Impaired fetal combined ventricular output in fetuses with cyanotic congenital heart disease (CHD) is associated with mortality, a new longitudinal study shows. The observational study also shows that cerebral blood flow and oxygen delivery to the fetus are associated with early language, cognitive and motor development later at 18 months. These findings were reported by Fu-Tsuen Lee, BSc, and Liquin Sun, MD, PhD, of the University of Toronto, and colleagues, in a manuscript published Monday online and in the April 2 issue of the Journal of the American College of Cardiology. In infants with birth defects, CHD is the leading cause of death. Early risk factors are important for determining neurodevelopmental (ND) impairments and mortality in this patient population. Circulatory disturbances many impact outcomes in fetuses with CHD, and these mechanisms are not fully understood. The investigators in this longitudinal study examined the relationship between hemodynamics in fetuses and early survival and ND outcomes in patients with cyanotic CHD. Late gestational fetal cardiovascular magnetic resonance (CMR) was performed on fetuses with cyanotic CHD to determine blood flow and oxygen content. The proxy for cerebral blood flow was superior vena cava (SVC) flow. Mortality at 18 months and the Bayley Scales of Infant Development-III assessment were the primary outcomes. Of the 144 fetuses with cyanotic CHD assessed, 12.5% died by 18 months. Reduced combined ventricular output (p=0.01), descending aortic flow (p=0.04) and umbilical vein flow (p=0.03) were associated with early mortality. ND outcomes were assessed in 71 of the surviving patients. The fetal hemodynamic variable most strongly associated with cognitive, language and motor outcomes was cerebral oxygen delivery (p<0.05). Additionally, fetal SVC flow predicted cognitive, language and motor outcomes (p<0.01), and was an independent predictor of cognitive (p=0.002) and language (p=0.04) outcomes post-diagnosis adjustment. Lessened SVC flow performed better than other fetal CMR and echocardiographic predictors of ND cognitive delays (receiver-operating characteristic curve area: 0.85; SE 0.05). The investigators said these results contribute new information in a growing body of research on patient risk factors for poor early ND outcomes. The authors acknowledged that their study was underpowered to perform detailed CHD subgroup analyses, which they said was a significant limitation of the present study. Overall, fetal hemodynamics in patients with cyanotic CHD were associated with early survival and ND outcomes. Reduced fetal CVO was associated with high rates of mortality and slower cognitive, language and motor development were predicted by reduced cerebral blood flow and oxygen delivery. In an accompanying editorial, Ashok Panigrahy, MD, of the UMPC Children’s Hospital of Pittsburgh, Jodie K. Votava-Smith, MD, of the Keck School of Medicine of USC, Los Angeles, and Daniel J. Licht, MD, of Children’s National Hospital, Washington, D.C., discussed prenatal factors in ND outcomes and the influence of CHD. They described the difficulties in studying fetal brain development and the complexities in this research field and highlighted the importance of refining data in this field of study. “These studies suggest that there is a need to develop an integrative ‘one-stop-shop’ fetal imaging protocol to include placenta and brain volumetry and hemodynamics,” the editorialists wrote. “Such protocols can be used to prognosticate which CHD patients have the highest clinical risk and would most benefit from resource allocation for surveillance of neurodevelopment and interventions to improve outcomes.” Sources: Lee F-T, Sun L, van Amerom JFP, et al. Fetal Hemodynamics, Early Survival, and Neurodevelopment in Patients With Cyanotic Congenital Heart Disease. J Am Coll Cardiol. 2024;83:1225-1239. Panigrahy A, Votava-Smith JK, Licht DJ. Need for ‘One-Stop-Shop’ Heart-Brain-Placental Imaging in Fetal Congenital Heart Disease: Fetal Hemodynamics Portend Neurodevelopmental Outcome. J Am Coll Cardiol. 2024;83:1240-1242. Image Credit: ibreakstock – stock.adobe.com