Fetal Ventricular Longitudinal Strain Does Not Predict Neonatal Hypoxemia in D-Transposition of the Great Arteries: A Prospective Multi-Center Study by the Fetal Heart Society Research Collaborative

Q: What are the key findings of this study?

Fetal ventricular longitudinal strain was not associated with preoperative neonatal hypoxemia (occurring in 37%) or balloon atrial septostomy (57%) in 79 fetuses with D-TGA and intact septum.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: D-transposition of the great arteries with intact ventricular septum (TGA/IVS) (n=79). Intervention: Fetal ventricular longitudinal strain and strain rate (LV LS, RV LS, RV free wall strain, LV SR, RV SR) vs. Neonates without postnatal preoperative hypoxemia and historical normal fetal controls. Primary outcome: Preoperative neonatal hypoxemia (defined as PaO2 < 30 mmHg or SpO2 < 75% between 5 minutes after birth and prior to balloon atrial septostomy or cardiac surgery).

Q: What does this research mean for the field?

Fetal ventricular longitudinal strain does not predict preoperative neonatal hypoxemia or the need for balloon atrial septostomy in neonates with D-transposition of the great arteries and intact ventricular septum. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Jacqueline Shuplock; Joyce T. Johnson; David N. Schidlow; Mary T. Donofrio; Angela McBrien; Lisa K. Hornberger; Chella A. Palmer; Ron Reeder; Bettina Francesca Cuneo; Peter N. Dean; Lisa W. Howley; Catherine Ikemba; Caroline K. Lee; Erik C. Michelfelder; Anita J. Moon‐Grady; Sheetal R. Patel; Shabnam Peyvandi; Rajesh Punn; Jill J. Savla; Amee Shah; Shreya S. Sheth; Jonathan H. Soslow; Heather Sun; Amy Svenson; Ann L. Kavanaugh-McHugh

doi:10.21203/rs.3.rs-11197059/v1

Key result

Fetal ventricular longitudinal strain fails to predict neonatal hypoxemia or septostomy in D-TGA.

n=79

Why the study?

Neonates with transposition of the great arteries and intact ventricular septum can develop life-threatening hypoxemia after birth, yet reliable fetal echocardiographic markers of postnatal hypoxemia were lacking.

Does fetal echocardiographic ventricular longitudinal strain and strain rate predict preoperative neonatal hypoxemia or the need for balloon atrial septostomy in fetuses prenatally diagnosed with D-transposition of the great arteries and intact ventricular septum?

Key Points

To evaluate whether fetal ventricular longitudinal strain measurements can predict postnatal hypoxemia or the requirement for balloon atrial septostomy in neonates with transposition of the great arteries and intact ventricular septum.
Ventricular longitudinal strain and strain rate were measured from fetal echocardiograms (median gestational age 34 6/7 weeks) in N=79 fetuses with adequate four-chamber views.
Primary outcome was preoperative neonatal hypoxemia; secondary outcome was the performance of balloon atrial septostomy (BAS).
Postnatal hypoxemia occurred in 29 of 79 neonates (37%) and BAS was performed in 45 of 79 (57%), with no statistically significant differences in fetal longitudinal strain between neonates who developed hypoxemia and those who did not, or between those who underwent BAS and those who did not.
Right ventricular free wall strain was significantly higher than left ventricular longitudinal strain in fetuses with TGA/IVS (p = 0.025), whereas overall left and right ventricular longitudinal strain were similar (p = 0.332).
Both left and right ventricular longitudinal strain were significantly higher in fetuses with TGA/IVS compared with published normative data (LV LS mean Z-score -0.27, p < 0.001; RV LS mean Z-score -0.53, p < 0.001).

Study Design

Type

Cohort (n=79)

Blinding

Investigators performing strain measurements were blinded to outcome

Multicenter

Yes

Structured PICO

Does fetal echocardiographic ventricular longitudinal strain and strain rate predict preoperative neonatal hypoxemia or the need for balloon atrial septostomy in fetuses prenatally diagnosed with D-transposition of the great arteries and intact ventricular septum?

P

Population

79 fetuses prenatally diagnosed with D-transposition of the great arteries and intact ventricular septum (median gestational age 34 6/7 weeks at echocardiography) enrolled across 18 North American centers and followed through hospital discharge.

E

Exposure

Fetal echocardiographic ventricular strain analysis, including left and right ventricular systolic longitudinal strain (LV LS, RV LS), right ventricular free wall strain (RV FWS), and left and right ventricular strain rate (LV SR, RV SR), performed on the last 2D fetal echocardiogram (4-chamber view) prior to delivery using TomTec 2D Cardiac Performance Analysis software.

C

Comparator

Comparison between neonates who developed preoperative postnatal hypoxemia (n=29) versus those who did not (n=50), those who underwent balloon atrial septostomy (BAS, n=45) versus those who did not (n=34), and comparison against previously published normative data from gestational age-matched fetuses without congenital heart disease.

O

Outcome

Profound pre-operative neonatal hypoxemia, defined as lowest PaO2 < 30 mmHg or SpO2 < 75% recorded between 5 minutes after birth and prior to balloon atrial septostomy (BAS) or cardiac surgery.hard clinical

Fetal ventricular longitudinal strain and strain rate do not predict postnatal hypoxemia or the need for balloon atrial septostomy in fetuses with D-transposition of the great arteries and intact ventricular septum, underscoring that delivery planning for all affected fetuses should include preparations for urgent septostomy.

Limitations

Variability across centers in clinical practice and indications/timing for performing balloon atrial septostomy
Difficulty capturing true preoperative oxygenation status because arterial catheters were often placed after stabilization or BAS, and SpO2 measurement site (pre- vs post-ductal) was not consistently recorded
Suboptimal image quality, unstandardized fetal heart orientation, and potential endocardial border dropout could falsely underestimate strain values
Frame rates of exported DICOM clips (often defaulting to 30 frames per second) were lower than the recommended >80-90 frames per second
Poor or uncertain inter-rater reliability for LV strain rate and RV strain measurements
Vendor, platform, and ultrasound machine heterogeneity across the 18 participating centers
Variability across centers in clinical practice regarding the decision to perform and timing of balloon atrial septostomy (BAS).
Difficulties capturing true preoperative hypoxemia status: indwelling arterial catheters for PaO2 were often placed after stabilization or BAS, and the site of SpO2 (pre- vs post-ductal) was not captured on all subjects.
Suboptimal image quality with low axial/lateral resolution and inability to standardize the orientation of the fetal heart prior to strain analysis, potentially causing imaging dropout of endocardial borders and falsely underestimating strain values.
Lower than recommended frame rates (many exported at default DICOM 30 frames per second rather than >80-90 frames per second), which could falsely underestimate true strain values.
Poor or uncertain inter-rater reliability for LV strain rate and RV strain measurements across investigators.

Implication

Fetal strain does not aid preoperative risk prediction in TGA/IVS; leaves open the need for alternative echocardiographic markers in prospective studies.

Abstract

Introduction : Neonates with transposition of the great arteries (TGA) and intact ventricular septum (IVS) can develop life-threatening hypoxemia after birth. There are no known reliable fetal echocardiographic markers of postnatal hypoxemia. Using a large, multi-center prospectively recruited cohort, we analyzed fetal ventricular strain and its association with postnatal hypoxemia. Material and Methods: Eighteen centers enrolled maternal-fetal dyads. Fetal ventricular longitudinal strain and strain rate measurements were obtained. The primary outcome measure was preoperative neonatal hypoxemia. The secondary outcome measure was reported need for balloon atrial septostomy (BAS). Intra- and inter-rater reliability was assessed. Fetal longitudinal strain was compared to normative data from a previously published study evaluating strain in fetuses without congenital heart disease. Results : Longitudinal strain was performed on 79 fetuses with TGA/IVS. Of those, 29 (37%) developed postnatal hypoxemia. A BAS was performed in 45 (57%). There was no statistically significant difference in fetal longitudinal strain between those with postnatal hypoxemia and those without. Similarly, fetal longitudinal strain did not differ among those who received a BAS and those who did not. Among fetuses with TGA/IVS, while right and left ventricular longitudinal strain was similar, right ventricular free wall strain was significantly higher than left ventricular longitudinal strain. Compared to the previously published normative data, longitudinal strain for both ventricles were significantly higher in fetuses with TGA/IVS. Conclusion : This prospective multi-center study identified no association between fetal longitudinal strain and postnatal hypoxemia or need for BAS in neonates with TGA/IVS, highlighting the importance of delivery planning for all fetuses with TGA to include preparations for BAS.

Discussion

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Cite This Study

Shuplock et al. (2026) conducted a cohort in D-transposition of the great arteries with intact ventricular septum (TGA/IVS) (n=79). Fetal ventricular longitudinal strain and strain rate (LV LS, RV LS, RV free wall strain, LV SR, RV SR) vs. Neonates without postnatal preoperative hypoxemia and historical normal fetal controls was evaluated on Preoperative neonatal hypoxemia (defined as PaO2 < 30 mmHg or SpO2 < 75% between 5 minutes after birth and prior to balloon atrial septostomy or cardiac surgery). Fetal ventricular longitudinal strain was not associated with preoperative neonatal hypoxemia (occurring in 37%) or balloon atrial septostomy (57%) in 79 fetuses with D-TGA and intact septum.

synapsesocial.com/papers/6ae682a3e432e7a5c4ef35f6 https://doi.org/10.21203/rs.3.rs-11197059/v1

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Fetal Ventricular Longitudinal Strain Does Not Predict Neonatal Hypoxemia in D-Transposition of the Great Arteries: A Prospective Multi-Center Study by the Fetal Heart Society Research Collaborative

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

Fetal Ventricular Longitudinal Strain Does Not Predict Neonatal Hypoxemia in D-Transposition of the Great Arteries: A Prospective Multi-Center Study by the Fetal Heart Society Research Collaborative

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

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