The fetal heart: from early life to the after life
votino, carmela (2010) The fetal heart: from early life to the after life. [Tesi di dottorato] (Inedito)
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Congenital heart disease (CHD) with an incidence of about 6 to 8 per 1000 live birth is a leading cause of infant mortality. Prenatal detection of CHD allows in utero referral to tertiary care centers witch plays an important role in improving perinatal care. Fetal echocardiography (FE) is an easily accessible real-time technique and provides a relatively high sensibility in detecting major CHD in second trimester screening programs. The recent use of nuchal translucency, ductus venosus and tricuspid flow during the first trimester of pregnancy allows selecting a higher risk population of CHD, early referral to specialists and subsequently detection of abnormalities even as early as the first trimester. The first chapter of this thesis will review the current literature on the use of first trimester fetal echocardiography. The second chapter will be more dedicated specifically to the use of high frequency ultrasound linear probes as well as the e-flow on improving the ability to visualise cardiac anatomy in the first trimester of pregnancy. Although FE is the screening modality of choice for cardiac evaluation, there are circumstances during which ultrasound was reported to have some limitations such as oligohydramnios, advanced gestation due to bone ossification, fetal position, maternal abdominal wall scar and maternal obesity. The latest was shown to impair correct visualisation of cardiac anatomy in about half of the cases. That led us as well as others searching for alternative techniques in imaging the fetal heart. The third chapter of this thesis will evaluate the feasibility of studying the fetal heart using MR imaging with its steady-state free precession (SSFP) sequences. Despite the technological advances in antenatal diagnosis and screening, the role of perinatal autopsy in confirmation or refuting an antemortem diagnosis is undisputed. However, an increased number of parents simply refuse traditional fetal autopsy. Added to that, conventional autopsy is sometimes limited due to fetal size, maceration and autolysis, thus not allowing adequate examination. As a consequence, alternative techniques of postmortem assessment had to be developed. The last part of this thesis will dedicate 3 chapters in studying alternative technique of non invasive autopsy. In chapter 4, we will focus on studying the acceptance and the confidence of reporting fetal virtuopsy as compared to conventional necropsy in our population. We will first study what factors influenced the refusal of conventional necropsy. Subsequently, we will study the confidence of virtuopsy using a whole-body MRI at 1.5 T. Since accuracy of conventional post-mortem MRI at 1.5 T for organs such as the heart is shown to be poor, in chapters 5 and 6 we studied the use of angiography and of high field MRI at 9.4 T in fetuses in the second half, respectively the first half of pregnancy.
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