Heikki Huhta1, Juulia Junno1, Mervi Haapsamo1, Tiina Erkinaro2, Pasi Ohtonen3, Lowell E Davis4, A Roger Hohimer4, Ganesh Acharya5,6, Juha Rasanen1,4,7. 1. Department of Obstetrics and Gynecology, University of Oulu, Oulu, Finland. 2. Department of Anesthesiology and Surgery, Oulu University Hospital, Oulu, Finland. 3. Division of Operative Care and Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Finland. 4. Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, USA. 5. Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Science, University of Norway and University Hospital of Northern Norway, Tromsø, Norway. 6. Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden. 7. Department of Obstetrics and Gynecology, Helsinki University Hospital, Helsinki, Finland.
Abstract
NEW FINDINGS: What is the central question of this study? The fetal aortic isthmus has an important physiological role, allowing communication between the left and right ventricular outputs, which are arranged in parallel. Can the aortic isthmus provide unrestrictive communication between the left and right ventricular circulations during occlusion of the ascending aorta? What is the main finding and its importance? During occlusion of the ascending aorta, fetal carotid artery perfusion pressure fell significantly, showing that the aortic isthmus failed to redirect blood flow and pressure from the ductus arteriosus to the aortic arch. This suggests that the aortic isthmus cannot provide unrestrictive communication between left and right ventricular circulations. The fetal aortic isthmus (AoI) allows communication between left (LV) and right ventricular (RV) outputs and represents an arterial watershed between the brachiocephalic (brain) and subdiaphragmatic (placenta) circulations. To understand the capability of the AoI to maintain the balance between the upper and lower body circulations, we performed a complete occlusion of the fetal ascending aorta in nine chronically instrumented sheep at near term gestation. We hypothesized that the occlusion would significantly decrease LV output and concomitantly increase RV output in order to maintain adequate systemic cardiac output and perfusion pressure to the fetal brain circulation through retrograde filling of the AoI. Fetal cardiac function and haemodynamics were assessed by pulsed and tissue Doppler at baseline, 15 and 60 min after occlusion of the ascending aorta and 15 min after occlusion was released. Carotid artery and jugular vein pressures were monitored. Occlusion of the ascending aorta increased (P < 0.002) RV output from [mean (SD)] 684 (369) to 907 (414) ml min-1 and decreased (P < 0.0001) LV output from 440 (136) to 40 (16) ml min-1 . Combined cardiac output decreased (P < 0.02) from 1125 (494) to 946 (417) ml min-1 . During occlusion, carotid artery mean pressure decreased from 32 (7) to 12 (7) mmHg (P < 0.0001). Systemic venous pressure was unaffected. Left ventricular systolic and diastolic function deteriorated during occlusion. Right ventricular systolic function improved, while diastolic dysfunction developed. Fetal carotid artery perfusion pressure decreased significantly during occlusion of the ascending aorta, demonstrating that AoI failed to redirect blood flow and pressure from the ductus arteriosus to the aortic arch. Our finding suggests that at near term gestation the aortic AoI cannot provide unrestrictive communication between LV and RV circulations.
NEW FINDINGS: What is the central question of this study? The fetal aortic isthmus has an important physiological role, allowing communication between the left and right ventricular outputs, which are arranged in parallel. Can the aortic isthmus provide unrestrictive communication between the left and right ventricular circulations during occlusion of the ascending aorta? What is the main finding and its importance? During occlusion of the ascending aorta, fetal carotid artery perfusion pressure fell significantly, showing that the aortic isthmus failed to redirect blood flow and pressure from the ductus arteriosus to the aortic arch. This suggests that the aortic isthmus cannot provide unrestrictive communication between left and right ventricular circulations. The fetal aortic isthmus (AoI) allows communication between left (LV) and right ventricular (RV) outputs and represents an arterial watershed between the brachiocephalic (brain) and subdiaphragmatic (placenta) circulations. To understand the capability of the AoI to maintain the balance between the upper and lower body circulations, we performed a complete occlusion of the fetal ascending aorta in nine chronically instrumented sheep at near term gestation. We hypothesized that the occlusion would significantly decrease LV output and concomitantly increase RV output in order to maintain adequate systemic cardiac output and perfusion pressure to the fetal brain circulation through retrograde filling of the AoI. Fetal cardiac function and haemodynamics were assessed by pulsed and tissue Doppler at baseline, 15 and 60 min after occlusion of the ascending aorta and 15 min after occlusion was released. Carotid artery and jugular vein pressures were monitored. Occlusion of the ascending aorta increased (P < 0.002) RV output from [mean (SD)] 684 (369) to 907 (414) ml min-1 and decreased (P < 0.0001) LV output from 440 (136) to 40 (16) ml min-1 . Combined cardiac output decreased (P < 0.02) from 1125 (494) to 946 (417) ml min-1 . During occlusion, carotid artery mean pressure decreased from 32 (7) to 12 (7) mmHg (P < 0.0001). Systemic venous pressure was unaffected. Left ventricular systolic and diastolic function deteriorated during occlusion. Right ventricular systolic function improved, while diastolic dysfunction developed. Fetal carotid artery perfusion pressure decreased significantly during occlusion of the ascending aorta, demonstrating that AoI failed to redirect blood flow and pressure from the ductus arteriosus to the aortic arch. Our finding suggests that at near term gestation the aortic AoI cannot provide unrestrictive communication between LV and RV circulations.