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The normal reference ranges of fetal left ventricular Mod-MPI based on the cross-sectional data with the manual and automatic measurements
Source publication
Objectives
The primary aim of this study was to establish the normal reference ranges of the fetal left ventricular (LV) Modified Myocardial Performance Index (Mod-MPI). A secondary aim was to evaluate the agreement between manual and automatic measurements for fetal Mod-MPI.
Design
A prospective, multicentre, cross-sectional study.
Participants...
Citations
... One of the large-sample studies reporting the normal ranges of fetal mMPI is based on cross-sectional data from 730 women conducted in Spain [12]. Another study was conducted in China, involving 2,081 women with singleton pregnancies [13]. ...
... There was a notable variance in reference values across the studies [12,13]. On the other hand, Hernandez-Andrade et al. reported that the reference value was 0.35 for the 19th week and 0.37 for the 39th week of gestation [5]. ...
Introduction: Fetal ventriculomegaly, the most commonly identified abnormality of the fetal central nervous system (CNS), has been associated with elevated levels of the modified myocardial performance index (mMPI). However, the impact of other CNS pathologies on mMPI has not yet been evaluated. This study aimed to investigate whether there were changes in the myocardial performance index of fetuses with CNS pathologies without congenital heart diseases.
Methods: A total of 126 singleton pregnant women were included in this study. Sixty-three fetuses had fetal CNS abnormalities of acrania, anencephaly, encephalocele, Dandy-Walker malformation, hydrocephalus, and meningocele. The control group consisted of 63 healthy and gestational age-matched fetuses. All ultrasonographic examinations were done in the second trimester of gestation. The data related to the characteristics of pregnant women were evaluated, and fetal left ventricular mMPI was obtained by ultrasound scan.
Results: The study and the control group participants were not significantly different by means of pregnancy characteristics. The mean mMPI was higher in the fetal CNS malformation group compared to the control groups (0.39±0.02 vs. 0.45±0.04, P<0.001). The mean mMPI value was similar for fetuses with both closed and open calvarium defects of fetal CNS malformation.
Conclusion: Fetal CNS anomalies may be associated with prenatal cardiac dysfunction. Moreover, this relationship might be independent of the type of fetal CNS malformation, whether a closed or open calvarium defect.
... There is a wide variation in the quoted reference values of the MPI to date-which are still inconsistent-ranging from 0.35 to 0.60 as the mean values. Therefore, a significant correlation between the MPI and the gestational age (GA) is controversially debated in the current literature [1,8,15,18,20,23,[26][27][28][29][30][31][32][33]. The Mod-MPI is less dependent on factors that impair image acquisition and quality than the other methods used for assessing fetal cardiac function (e.g., maternal BMI, anterior placenta, oligohydramnios), is less dependent on fetal anatomy and position or precise imaging and, by incorporating only time intervals, is less prone to artifacts such as fetal movements. ...
... As a result of the highly heterogeneous measurement techniques used so far, with priority given to the lack of standard criteria regarding caliper placement, clinicians are currently confronted with a wide variation in the quoted reference values for the MPI to date-which still lack consistency-ranging from 0.35 to 0.60 as the mean values. The values of the RV-Mod-MPI for both operators corresponded with this expected distribution pattern and increased with GA (Figure 3), even though a significant correlation between the MPI and GA has been controversially discussed in the current literature [1, 8,15,18,20,23,[26][27][28][29][30][31][32][33]. The present values of the RV-Mod-MPI were very similar to those of Kang et al., who investigated the clinical value of the MPI+™ tool for the assessment of cardiac function in TTTS. ...
(1) Objectives: In utero functional cardiac assessments using echocardiography have become increasingly important. The myocardial performance index (MPI, Tei index) is currently used to evaluate fetal cardiac anatomy, hemodynamics and function. An ultrasound examination is highly examiner-dependent, and training is of enormous significance in terms of proper application and subsequent interpretation. Future experts will progressively be guided by applications of artificial intelligence, on whose algorithms prenatal diagnostics will rely on increasingly. The objective of this study was to demonstrate the feasibility of whether less experienced operators might benefit from an automated tool of MPI quantification in the clinical routine. (2) Methods: In this study, a total of 85 unselected, normal, singleton, second- and third-trimester fetuses with normofrequent heart rates were examined by a targeted ultrasound. The modified right ventricular MPI (RV-Mod-MPI) was measured, both by a beginner and an expert. A calculation was performed semiautomatically using a Samsung Hera W10 ultrasound system (MPI+™, Samsung Healthcare, Gangwon-do, South Korea) by taking separate recordings of the right ventricle’s in- and outflow using a conventional pulsed-wave Doppler. The measured RV-Mod-MPI values were assigned to gestational age. The data were compared between the beginner and the expert using a Bland-Altman plot to test the agreement between both operators, and the intraclass correlation was calculated. (3) Results: The mean maternal age was 32 years (19 to 42 years), and the mean maternal pre-pregnancy body mass index was 24.85 kg/m2 (ranging from 17.11 to 44.08 kg/m2). The mean gestational age was 24.44 weeks (ranging from 19.29 to 36.43 weeks). The averaged RV-Mod-MPI value of the beginner was 0.513 ± 0.09, and that of the expert was 0.501 ± 0.08. Between the beginner and the expert, the measured RV-Mod-MPI values indicated a similar distribution. The statistical analysis showed a Bland-Altman bias of 0.01136 (95% limits of agreement from −0.1674 to 0.1902). The intraclass correlation coefficient was 0.624 (95% confidence interval from 0.423 to 0.755). (4) Conclusions: For experts as well as for beginners, the RV-Mod-MPI is an excellent diagnostic tool for the assessment of fetal cardiac function. It is a time-saving procedure, offers an intuitive user interface and is easy to learn. There is no additional effort required to measure the RV-Mod-MPI. In times of reduced resources, such assisted systems of fast value acquisition represent clear added value. The establishment of the automated measurement of the RV-Mod-MPI in clinical routine should be the next level in cardiac function assessment.
... In practice, the assessment is usually accomplished using conventional two-dimensional ultrasound, Doppler, and M-mode echocardiography, possibly successfully performed even as early as late first trimester [25]. The commonly used methods for the evaluation of fetal cardiac function are described below [26][27][28][29] and summarized in Table 1. Based on this review, for clinical purposes in actual practice, fetal cardiovascular assessment for FHF should include cardiac size, hydropic signs, umbilical artery (UA) Doppler, myocardial performance index (MPI) or modified Tei index, E/A waveform analysis, the presence of atrioventricular valve (AV) regurgitation, shortening fraction, middle cerebral artery (MCA) Doppler, ductus venosus (DV) waveforms, and umbilical vein (UV). ...
... Additionally, some limitations in clinical translation, such as a poorly standardized technique with variations, ultrasound machine settings, cursor placement, and need of training, can result in significantly different MPI values [64]. Many reference ranges of fetal MPI are available for clinical use [27,65,66]. ...
Fetal heart failure (FHF) is a condition of inability of the fetal heart to deliver adequate blood flow for tissue perfusion in various organs, especially the brain, heart, liver and kidneys. FHF is associated with inadequate cardiac output, which is commonly encountered as the final outcome of several disorders and may lead to intrauterine fetal death or severe morbidity. Fetal echocardiography plays an important role in diagnosis of FHF as well as of the underlying causes. The main findings supporting the diagnosis of FHF include various signs of cardiac dysfunction, such as cardiomegaly, poor contractility, low cardiac output, increased central venous pressures, hydropic signs, and the findings of specific underlying disorders. This review will present a summary of the pathophysiology of fetal cardiac failure and practical points in fetal echocardiography for diagnosis of FHF, focusing on essential diagnostic techniques used in daily practice for evaluation of fetal cardiac function, such as myocardial performance index, arterial and systemic venous Doppler waveforms, shortening fraction, and cardiovascular profile score (CVPs), a combination of five echocardiographic markers indicative of fetal cardiovascular health. The common causes of FHF are reviewed and updated in detail, including fetal dysrhythmia, fetal anemia (e.g., alpha-thalassemia, parvovirus B19 infection, and twin anemia-polycythemia sequence), non-anemic volume load (e.g., twin-to-twin transfusion, arteriovenous malformations, and sacrococcygeal teratoma, etc.), increased afterload (intrauterine growth restriction and outflow tract obstruction, such as critical aortic stenosis), intrinsic myocardial disease (cardiomyopathies), congenital heart defects (Ebstein anomaly, hypoplastic heart, pulmonary stenosis with intact interventricular septum, etc.) and external cardiac compression. Understanding the pathophysiology and clinical courses of various etiologies of FHF can help physicians make prenatal diagnoses and serve as a guide for counseling, surveillance and management.
... There is no universal reference range and guidelines for normal Mod-MPI values. Normal reference ranges of fetal Mod-MPI still show wide variations in recent studies,[29][30][31][32][33] reported due to heterogeneous study populations, possibly other maternal or fetal characteristics, and differences in measurement techniques. Comparable29,31,32 or totally different30,33 Mod-MPI values from ours have been cited in the literature.Following delivery, infants with growth restriction are more likely to have significantly prolonged NICU stay as compared to appropriately grown infants and this finding is closely related to the severity of FGR.34 ...
... Normal reference ranges of fetal Mod-MPI still show wide variations in recent studies,[29][30][31][32][33] reported due to heterogeneous study populations, possibly other maternal or fetal characteristics, and differences in measurement techniques. Comparable29,31,32 or totally different30,33 Mod-MPI values from ours have been cited in the literature.Following delivery, infants with growth restriction are more likely to have significantly prolonged NICU stay as compared to appropriately grown infants and this finding is closely related to the severity of FGR.34 In our study, late-onset FGR and SGA infants were more likely to be admitted to NICU during the postnatal period as compared to healthy control patients. ...
Background:
Fetal growth disturbance can be associated with cardiac dysfunction. This study aimed to assess the modified myocardial performance index in growth-restricted and appropriate for gestational age fetuses and evaluate both its prognostic value in perinatal period and also its association with adverse perinatal outcomes.
Methods:
Totally 131 pregnant women were included in this prospective study. Of these, 56 cases were in study group with a diagnosis of small fetus and 75 cases were in control group with a diagnosis appropriately grown fetus. Fetal echocardiography was performed in all pregnant women to measure modified myocardial performance index. Umbilical, middle cerebral and uterine artery Doppler ultrasound parameters were measured in the study group. Small fetuses were categorized into 2 subgroups of late-onset fetal growth restriction and small for gestational age.
Results:
Modified myocardial performance index was significantly higher in small fetuses compared to controls (0.45 vs. 0.37, P <.001). Newborn intensive care unit admission rates were significantly higher in small fetuses than in controls (chi-square test, P <.001). The highest mean modified myocardial performance index was recorded in the late-onset fetal growth restriction subgroup (0.45 vs. 0.41 vs. 0.37). The sensitivity and specificity of modified myocardial performance index in predicting adverse outcomes at a cut-off value of 0.41 were 63% and 75%, respectively. There was a significant negative correlation between modified myocardial performance index values and birth weights.
Conclusions:
We found higher left fetal heart modified myocardial performance index values in small fetuses indicating the presence of prenatal cardiac dysfunction. Fetal myocardial performance deteriorates in concordance with severity of growth restriction. Modified myocardial performance index can also be used to predict adverse perinatal outcomes among growth-restricted fetuses.
... The high IRT value in the EOPE group is another parameter that indicates diastolic dysfunction in these fetuses. In a recently published study evaluating >2000 fetuses, the longitudinal reference ranges of fetal cardiac Doppler parameters were determined according to the weeks of gestation (25) . According to the study results, the mean values of fetal cardiac Doppler parameters and the 5 th and 95 th percentile values were similar in the mean ultrasound weeks of our EOPE and LOPE groups. ...
Objective:
To compare the maternal serum catestatin (CST) levels in pregnant women with preeclampsia (PE) and with normal blood pressure and evaluate the relationship between the maternal serum CST levels and fetal cardiac functions.
Materials and Methods:
This cross-sectional study was conducted on 27 women with early-onset PE (EOPE), 28 women with late-onset PE (LOPE), and 28 healthy pregnant women. Maternal serum CST levels were measured using the enzyme-linked immunosorbent assay kits. Fetal cardiac functions were evaluated using the cardiac Doppler.
Results:
Maternal serum CST levels were lower in the EOPE group; however, no statistically significant difference was found between the groups. Compared with the other two groups, a statistically significant difference was found in the fetal E/A ratio and myocardial performance index (MPI) values of the EOPE group (p=0.013, p=0.002, p=0.005, p<0.001, respectively). The fetal E/A ratio was positively correlated with the maternal serum CST levels in both the PE and control groups (p<0.001, p<0.001). The fetal isovolumetric relaxation time and MPI values were negatively correlated with maternal serum CST levels in both the PE and control groups (p<0.001, p=0.001, p<0.001, and p=0.002, respectively).
Conclusion:
Lower CST levels are associated with fetal cardiovascular dysfunction, thus CST can be a critical biochemical marker in fetal cardiac function evaluation.
Introduction:
The modified myocardial performance index (mod-MPI) is a noninvasive Doppler-derived metric used to evaluate fetal cardiac function. However, the reference ranges for mod-MPI in normal fetuses are not clearly defined, which limits the use of this technology in fetuses with potential cardiac compromise. Thus, we aimed to perform a systematic review and meta-analysis of published mod-MPI reference ranges across gestation.
Methods:
The published literature was systematically searched, and all published articles in any language that provided values for the left ventricular mod-MPI obtained in low-risk, singleton fetuses were considered eligible for further review. All retrieved titles and abstracts were independently reviewed by two researchers. Mean and standard deviation by gestational week was extracted or calculated from published data. DerSimonian-Laird random-effects models were used to estimate pooled means and 95% confidence intervals (CIs).
Results:
The search resulted in 618 unique citations, of which 583 did not meet inclusion criteria, leaving 35 abstracts selected for full-text review. Review of the references of these 35 articles identified another 5 studies of interest. Of the 40 articles reviewed, six met inclusion criteria. There was significant heterogeneity seen in the mod-MPI results reported. Mod-MPI increased as pregnancy progressed in all studies. The pooled mean mod-MPI at 11 weeks' gestation was 0.400 (95% CI 0.374-0.426) and increased to 0.585 (95% CI 0.533-0.637) at 41 weeks' gestation. The increase was linear in 5 of 6 studies, while in 1 study, the mod-MPI was stable until 27 weeks' gestation, and then increased throughout the third trimester. Despite all having trends increasing over pregnancy, there was no study in which all the weekly means fell within the pooled 95% CI.
Conclusion:
While mod-MPI does increase over gestation, the true "reference ranges" for fetuses remain elusive. Future efforts to further optimize calculation of time intervals possibly via automation are desperately needed to allow for reproducibility of this potentially very useful tool to assess fetal cardiac function.
Artificial intelligence (AI) has gained prominence in medical imaging, particularly in obstetrics and gynecology (OB/GYN), where ultrasound (US) is the preferred method. It is considered cost effective and easily accessible but is time consuming and hindered by the need for specialized training. To overcome these limitations, AI models have been proposed for automated plane acquisition, anatomical measurements, and pathology detection. This study aims to overview recent literature on AI applications in OB/GYN US imaging, highlighting their benefits and limitations. For the methodology, a systematic literature search was performed in the PubMed and Cochrane Library databases. Matching abstracts were screened based on the PICOS (Participants, Intervention or Exposure, Comparison, Outcome, Study type) scheme. Articles with full text copies were distributed to the sections of OB/GYN and their research topics. As a result, this review includes 189 articles published from 1994 to 2023. Among these, 148 focus on obstetrics and 41 on gynecology. AI-assisted US applications span fetal biometry, echocardiography, or neurosonography, as well as the identification of adnexal and breast masses, and assessment of the endometrium and pelvic floor. To conclude, the applications for AI-assisted US in OB/GYN are abundant, especially in the subspecialty of obstetrics. However, while most studies focus on common application fields such as fetal biometry, this review outlines emerging and still experimental fields to promote further research.
Diagnostic ultrasound (DUS) has been in use for over half a century in medicine with clear benefits. It has become an indispensable tool in obstetrics and gynecology due to its relatively low cost, immediate results availability, and perceived safety. Most pregnant women have several ultrasound examinations during their pregnancies. In addition, patients undergoing Artificial Reproductive Technologies (ART) receive serial scans of the developing follicles during ovulation induction and in the earliest stages of gestation. The record of safety of DUS is excellent, with no epidemiological studies demonstrating harmful effects in human fetuses. The ultrasound beam, however, as it crosses tissues, induces two effects: an indirect effect, where the acoustic energy is transformed into heat (thermal effect) and a direct non-thermal or mechanical effect, secondary to the alternance of positive and negative pressures. From 1976 to 1992, the acoustic output of ultrasound machines for fetal use was allowed to be increased from 94 to 720 mW/cm2. Because of the two best recognized biological effects of ultrasound (thermal and non-thermal), two indices were introduced to allow the clinical end user an assessment of the risk: the thermal index or TI and the mechanical index or MI. The first trimester is a time of maximal fetal susceptibility to external factors, and usage of ultrasound in early pregnancy has become ubiquitous and is ever expanding. This includes Doppler, a modality with very high acoustic output. Regrettably, knowledge of health providers who utilize ultrasound is lacking and to guarantee safety, education of the end users is vital on precautions to limit the possible hazards of exposure of the follicles/ova and the fetus at early stages of gestation. To this effect, DUS should be used only when medically indicated, keeping the exam as short as possible, at lowest possible output for diagnostic accuracy (As Low As Reasonably Achievable [ALARA] principle) and maintaining TI and MI below 1.KeywordsBioeffectsDopplerFetusFirst trimesterMechanical indexPregnancyRiskSafetyTeratologyThermal indexUltrasound
