Hostname: page-component-594f858ff7-7tp2g Total loading time: 0 Render date: 2023-06-09T12:10:53.427Z Has data issue: false Feature Flags: { "corePageComponentGetUserInfoFromSharedSession": true, "coreDisableEcommerce": false, "corePageComponentUseShareaholicInsteadOfAddThis": true, "coreDisableSocialShare": false, "useRatesEcommerce": true } hasContentIssue false

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

Published online by Cambridge University Press:  05 April 2012

Roland W. Weber
The Hospital for Sick Children, Labatt Family Heart Centre, Toronto, Ontario, Canada Division of Cardiology, University Children's Hospital, University of Zurich, Zurich, Switzerland
Ricardo Ayala-Arnez
The Hospital for Sick Children, Labatt Family Heart Centre, Toronto, Ontario, Canada
Merna Atiyah
The Hospital for Sick Children, Labatt Family Heart Centre, Toronto, Ontario, Canada
Yousef Etoom
The Hospital for Sick Children, Labatt Family Heart Centre, Toronto, Ontario, Canada
Cedric Manlhiot
The Hospital for Sick Children, Labatt Family Heart Centre, Toronto, Ontario, Canada
Brian W. McCrindle
The Hospital for Sick Children, Labatt Family Heart Centre, Toronto, Ontario, Canada
Edward J. Hickey
The Hospital for Sick Children, Labatt Family Heart Centre, Toronto, Ontario, Canada
Edgar T. Jaeggi
The Hospital for Sick Children, Labatt Family Heart Centre, Toronto, Ontario, Canada
Lynne E. Nield*
The Hospital for Sick Children, Labatt Family Heart Centre, Toronto, Ontario, Canada
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:



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.

Original Article
Copyright © Cambridge University Press 2012

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)


1. Corno, AF. Borderline left ventricle. Eur J Cardiothorac Surg 2005; 7: 6773.CrossRefGoogle Scholar
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.CrossRefGoogle Scholar
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.Google Scholar
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.CrossRefGoogle Scholar
5. Tchervenkov, CI, Tahta, SA, Jutras, LC, Béland, MJ. Biventricular repair in neonates with hypoplastic left heart complex. Ann Thorac Surg 1998; 66: 13501356.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle Scholar
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle Scholar
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
17. Matsui, H, Mellander, M, Roughton, M, Jicinska, H, Gardiner, HM. Morphological and physiological predictors of fetal aortic coarctation. Circulation 2008; 118(8): 17931801.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle Scholar
19. Zhong, TP. Zebrafish genetics and formation of embryonic vasculature. Curr Top Dev Biol 2005; 71: 5381.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
21. Rudolph, AM. Congenital Diseases of the Heart, 3rd edn. Wiley-Blackwell, West Sussex, United Kingdom, 2009, pp 296297.CrossRefGoogle Scholar
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
24. Rhodes, LA, Colan, SD, Perry, SB, Jonas, RA, Sanders, SP. Predictors of survival in neonates with critical aortic stenosis. Circulation 1991; 84: 23252335.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed