Skip to main content Accessibility help

Foetal echocardiographic assessment of borderline small left ventricles can predict the need for postnatal intervention

  • Roland W. Weber (a1) (a2), Ricardo Ayala-Arnez (a1), Merna Atiyah (a1), Yousef Etoom (a1), Cedric Manlhiot (a1), Brian W. McCrindle (a1), Edward J. Hickey (a1), Edgar T. Jaeggi (a1) and Lynne E. Nield (a1)...



We sought to prospectively determine foetal echocardiographic factors associated with neonatal interventions in borderline hypoplastic left ventricles.


Foetuses were included who had a left ventricle that was 2–4 standard deviations below normal for length or diameter and had forward flow across the mitral and aortic valves. Factors associated with an intervention in the first month of life or no need for intervention were sought using univariate and multivariate logistic regression models.


From 2005 to 2008, 47 foetuses meeting the criteria had an additional diagnosis (+foetal coarctation/+transverse arch hypoplasia): atrioventricular septal defect 7 (+2/+0), double outlet right ventricle 2 (+0/+0), Shone's complex 19 (+9/+4), and ventricular disproportion 19 (+13/+11; 4 both). There were seven pregnancies terminated, three foetal demises, and five had compassionate care. There were 32 livebirths that either had a biventricular repair (n = 20, n = 2 dead), univentricular palliation (n = 2, both alive), or no intervention (n = 9). Overall survival of livebirths to 6 months of age was 79%. Factors associated with early intervention on first foetal echocardiogram were: obstructed or retrograde arch flow (p = 0.08, odds ratio 3.3), coarctation (p = 0.05, odds ratio 11.4), and left ventricle outflow obstruction (p = 0.05, odds ratio 12.5). Neonatal factors included: Shone's diagnosis (p = 0.02, odds ratio 4.9), bicuspid aortic valve (p = 0.005, odds ratio 11.7), and larger tricuspid valve z-score (p = 0.05, odds ratio 3.6). A neonatal factor associated with no intervention was a larger mitral valve z-score (mean −3.8 versus −4.2 intervention group, p = 0.04, odds ratio 2.8).


The need for early intervention in foetuses with borderline hypoplastic left ventricle can be predicted by foetal echocardiography.


Corresponding author

Correspondence to: Dr L. E. Nield, MD, The Hospital for Sick Children, Labatt Family Heart Centre, 555 University Avenue, Toronto, Ontario, Canada M5G 1X8. Tel: +1 416 813 6141; Fax: +1 416 813 5857; E-mail:


Hide All
1. Corno, AF. Borderline left ventricle. Eur J Cardiothorac Surg 2005; 7: 6773.
2. Cohen, MS, Rychik, J. The small left ventricle: How small is too small for biventricular repair? Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 1999; 2: 189202.
3. Holzer RJ, Cheatham JP. Therapeutic cardiac catheterisation. In: Moss AJ, Allen HD, Driscoll DJ (eds.). Moss and Adam's Heart Disease in Infants, Children and Adolescents, 7th edn. Lippincott Williams & Wilkins, Philadelphia, 2008, p 374.
4. Justino, H, Pedra, C, Freedom, RM, Benson, LN. Congenital aortic valve stenosis or reurgitation. In: Freedom RM, Yoo SJ, Mikailian H, Williams WG (eds.). The Natural and Modified History of Congenital Heart Disease. Blackwell, New York, 2003, pp 138141.
5. Tchervenkov, CI, Tahta, SA, Jutras, LC, Béland, MJ. Biventricular repair in neonates with hypoplastic left heart complex. Ann Thorac Surg 1998; 66: 13501356.
6. Pitkänen, OM, Hornberger, LK, Miner, SE, et al. Borderline left ventricles in prenatally diagnosed atrioventricular septal defect or double outlet right ventricle: echocardiographic predictors of biventricular repair. Am Heart J 2006; 152: 163.e1–7.
7. Hickey, EJ, Caldarone, CA, Blackstone, EH, et al. Critical left ventricular outflow tract obstruction: the disproportionate impact of biventricular repair in borderline cases. J Thorac Cardiovasc Surg 2007; 134: 14291436.
8. Serraf, A, Piot, JD, Bonnet, N, et al. Biventricular repair approach in ducto-dependent neonates with hypoplastic but morphologically normal left ventricle. J Am Coll Cardiol 1999; 33: 827834.
9. Hornberger, LK, Sanders, SP, Rein, AJ, Spevak, PJ, Parness, IA, Colan, SD. Left heart obstructive lesions and left ventricular growth in the mid-trimester fetus: a longitudinal study. Circulation 1995; 15: 15311538.
10. Quartermain, MD, Cohen, MS, Dominguez, TE, Tian, Z, Donaghue, DD, Rychik, J. Left ventricle to right ventricle size discrepancy in the fetus: the presence of critical congenital heart disease can be reliably predicted. J Am Soc Echocardiogr 2009; 22: 12961301.
11. Brown, DL, Durfee, SM, Hornberger, LK. Ventricular discrepancy as a sonographic sign of coarctation of the fetal aorta: how reliable is it? J Ultrasound Med 1997; 16: 9599.
12. Schneider, C, McCrindle, BW, Carvalho, JS, Hornberger, LK, McCarthy, KP, Daubeney, PE. Development of Z-scores for fetal cardiac dimensions from echocardiography. Ultrasound Obstet Gynecol 2005; 26: 599605.
13. Shone, JD, Sellers, RD, Anderson, RC, Adams, P Jr, Lillehey, CW, Edwards, JE. The developmental complex of “parachute mitral valve,” supravalvular ring of left atrium, subaortic stenosis, and coarctation of aorta. Am J Cardiol 1963; 11: 714725.
14. Lofland, GK, McCrindle, BW, Williams, WG, et al. Critical aortic stenosis in the neonate: a multi-institutional study of management, outcomes, and risk factors. Congenital Heart Surgeons Society. J Thorac Cardiovasc Surg 2001; 121: 1027.
15. Brauner, R, Laks, H, Drinkwater, DC Jr, Shvarts, O, Eghbali, K, Galindo, A. Benefits of early surgical repair in fixed subaortic stenosis. J Am Coll Cardiol 1997; 30: 18351842.
16. Schwartz, ML, Gauvreau, K, Geva, T. Predictors of outcome of biventricular repair in infants with multiple left heart obstructive lesions. Circulation 2001; 104: 682687.
17. Matsui, H, Mellander, M, Roughton, M, Jicinska, H, Gardiner, HM. Morphological and physiological predictors of fetal aortic coarctation. Circulation 2008; 118(8): 17931801.
18. Hinton, RB Jr, Martin, LJ, Tabangin, ME, Mazwi, ML, Cripe, LH, Benson, DW. Hypoplastic left heart syndrome is heritable. J Am Coll Cardiol 2007; 53: 15901595.
19. Zhong, TP. Zebrafish genetics and formation of embryonic vasculature. Curr Top Dev Biol 2005; 71: 5381.
20. Phoon, CK, Silverman, NH. Conditions with right ventricular pressure and volume overload, and a small left ventricle: “hypoplastic” left ventricle or simply a squashed ventricle? J Am CollCardiol 1997; 30(6): 15471553.
21. Rudolph, AM. Congenital Diseases of the Heart, 3rd edn. Wiley-Blackwell, West Sussex, United Kingdom, 2009, pp 296297.
22. Allan, LD, Chita, SK, Anderson, RH, Fagg, N, Crawford, DC, Tynan, MJ. Coarctation of the aorta in prenatal life: an echocardiographic, anatomical, and functional study. Br Heart J 1988; 59: 356360.
23. Grosse-Wortmann, L, Yun, TJ, Al Radi, O, et al. Borderline hypoplasia of the left ventricle in neonates: insights for decision-making from functional assessment with magnetic resonance imaging. J Thorac Cardiovasc Surg 2008; 136: 14291436.
24. Rhodes, LA, Colan, SD, Perry, SB, Jonas, RA, Sanders, SP. Predictors of survival in neonates with critical aortic stenosis. Circulation 1991; 84: 23252335.
25. Parsons, MK, Moreau, GA, Graham, TP Jr, Johns, JA, Boucek, RJ Jr. Echocardiographic estimation of critical left ventricular size in infants with isolated aortic valve stenosis. J Am Coll Cardiol 1991; 18: 10491055.
26. Manganaro, L, Savelli, S, Di Maurizio, M, et al. Fetal MRI of the cardiovascular system: role of steady-state free precession sequences for the evaluation of normal and pathological appearances. Radiol Med 2009; 114: 852870.


Foetal echocardiographic assessment of borderline small left ventricles can predict the need for postnatal intervention

  • Roland W. Weber (a1) (a2), Ricardo Ayala-Arnez (a1), Merna Atiyah (a1), Yousef Etoom (a1), Cedric Manlhiot (a1), Brian W. McCrindle (a1), Edward J. Hickey (a1), Edgar T. Jaeggi (a1) and Lynne E. Nield (a1)...


Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed