Fetal Doppler Echocardiographic Assessment Predicts Severe Postnatal Obstruction in Total Anomalous Pulmonary Venous Connection

Abstract

Background: Obstructed total anomalous pulmonary venous connection (TAPVC) is a form of critical congenital heart disease that usually requires urgent postnatal intervention. Knowing which patients have severe obstruction can aid delivery planning. The authors previously developed a novel quantitative metric of pulmonary venous flow, the pulmonary venous variability index (PVVI). The aim of this study was to test the hypothesis that fetal PVVI and vertical vein Doppler velocities are associated with severe pulmonary vein obstruction postnatally.

Methods: A retrospective cohort study of neonates with prenatally diagnosed TAPVC was performed. Patients who underwent fetal echocardiography at the Children's Hospital of Philadelphia with Doppler interrogation of the vertical vein were included for analysis. Twenty-nine patients met criteria (21 with heterotaxy, 18 with supracardiac TAPVC). The latest gestation fetal echocardiogram was used. Severe pulmonary vein obstruction was defined as preoperative death or urgent surgery or catheter-based intervention (first day of life). Measurements of PVVI, defined as (maximum velocity - minimum velocity)/mean velocity, were made offline. Wilcoxon rank sum models were used to assess the associations of severe obstruction and PVVI and maximum, mean, and minimum velocities.

Results: The mean gestational age at the latest fetal echocardiographic examination was 35 weeks (range, 30-39 weeks). Twelve of the 29 patients (41%) met criteria for severe pulmonary vein obstruction. Lower PVVI was associated with greater risk for severe pulmonary venous obstruction (P = .008). The maximum, mean, and minimum velocities in the vertical vein were all significantly associated with severe pulmonary venous obstruction (P = .03, P = .03, and P = .007, respectively). Qualitative assessment of obstruction was not significantly associated with the outcome. Interobserver reliability for all vertical vein Doppler metrics was high (intraclass correlation coefficient > 0.9).

Conclusions: Fetal PVVI and maximum, mean, and minimum velocities are associated with severe postnatal pulmonary vein obstruction in TAPVC. Accurate prediction of obstructed TAPVC could allow safer delivery planning. Further research with larger sample sizes is needed to identify the ideal cutoff values for these Doppler measures.

Keywords: Congenital heart disease; Fetal echocardiography; Prenatal diagnosis; Pulmonary venous obstruction; Total anomalous pulmonary venous connection.

Figure 1

TAPVC vertical vein Doppler patterns. The Doppler tracing at the top shows a Doppler signal from a fetus with unobstructed TAPVC, demonstrating phasic variability, which translates to a high PVVI. The Doppler tracing at the bottom is obstructed and does not show phasic variability, leading to a low PVVI.

Figure 2

Vertical vein Doppler characteristics versus severe pulmonary venous obstruction. Box-and-whisker plots are shown comparing the association of V_max, V_min, and V_mean in the vertical vein, as well as the PVVI, with severe pulmonary vein obstruction.

Figure 3

Doppler characteristics versus gestational age. Scatterplots demonstrating the fetal Doppler measures in the vertical vein are plotted over gestational age. Red dots represent patients without severe obstruction, and blue dots represent patients with severe pulmonary vein obstruction.