Rania Habib, MD, DDS (Host): The American Heart Association estimates that 1 percent of babies born in the U.S. have a congenital heart defect. Traditionally, fetal heart conditions in these 40,000 plus patients are diagnosed via ultrasound. The Heart Center at Children's Health is a leader in care for children with heart conditions and they serve as one of the few centers in the country offering fetal cardiac MRIs. This is Pediatric Insights, Advances and Innovations with Children's Health, where we explore the latest in pediatric care and research.

I'm your host, Dr. Rania Habib. Joining me today are two Pediatric Cardiologists at Children's Health who are also Assistant Professors at UT Southwestern, Dr. Mansi Gaitonde and Dr. Munes Fares. They are here to discuss how radiation free fetal cardiac MRIs are used to help diagnose fetal heart conditions and guide treatment for critical postnatal interventions.

Welcome to the podcast. We are so excited to have you both on this panel discussion.

Munes Fares, MD: Hi.

Mansi Gaitonde, MD: Thank you for having us.

Host: Yes, we're so excited to delve into this very exciting topic. To begin, I would like you to share how widely available fetal cardiac MRIs are and why is Children's Health one of the few centers offering this and being a leader in fetal cardiac imaging.

Munes Fares, MD: So, I'll take this one. You know, fetal cardiac MRI is a recently developed technology. So we do MRIs for adults and kids, but we don't necessarily do fetal cardiac MRI. So fetal MRI, it's existed for a long time, but it's always been challenging to image a very fasting heartbeat in a fetus and get really good images in the fetus.

So it is a very recently developed technology, very few centers that has developed that technology. And there is a lot of methods that led to creating this very unique technology where you need to not only get image of a really small structure the size of a thumbnail, but also you really need to synchronize the imaging with the heartbeat of the fetus and that specifically needs a device, the adopter device to be available, to be able to image the heart of the fetus. So it's a really recent and newly developed technology.

Host: Okay. That's wonderful. Can you share the fetal safety guidelines in collaboration with the Society for Cardiovascular Magnetic Resonance and Fetal Heart Society for adopting fetal cardiac MRIs? Specifically, how is this safe for mom and baby?

Mansi Gaitonde, MD: So this is one of the most exciting parts about this technology is that we're able to collaborate with other institutions across the world. In Europe, they have had several more years of experience, with fetal cardiovascular imaging. If you historically go back, fetal MRI has been done for a couple of decades and then kind of transitioned to the U.S. We're a little bit behind compared to our European friends. And then consequently, you know, over the last 5 to 10 years, they have started doing this and in the United States, a few centers have been able to adopt what they've learned in terms of imaging the fetal heart, and being able to acquire these new devices that allow us to obtain the fetal heart rate and extrapolate the fetal ECG. And these are new things that we have now.

When we look at all the studies on fetal MRI imaging and their safety; MRI is a radiation free type of imaging. And we prefer to do this in the third trimester, but the studies that have been shown, because it's radiation free, we have limited amounts of risk to the mom and baby. We make sure that the heating that can be associated with MR imaging is limited, so we take all of that into account so that there's not excessive heating of the fetus, and we operate this at lower levels, and we're taking all that into account as well as the comfort of the mother and the overall gestational age, which we do in a slightly older gestation. We wouldn't really be offering this in like the first trimester, or really the early second trimester, but mostly targeted to the third trimester, and when you look at the studies on fetal MR, just for the body, there's been safety shown in that when it's done in a skilled way. Additionally, we're not using contrast agents in the baby, or in the mother, and there is probably limited information about the use of this in a fetus, but the scans, I think, as what's sort of adopted, that there are not official guidelines that have yet been published, and we're working on those. Likely that contrast in the use of these MRIs is probably not going to be recommended just because of the unknowns.

So that's one way we try to make these tests more safe. And then finally, we have the Fetal Heart Society as well as the Society for Cardiovascular Magnetic Resonance. And, with the different centers across the country that have started doing this, I think collaboration is such an important part in the United States.

This includes advocating for dedicated ICD codes for fetal cardiovascular MRI, which currently don't exist. So it does help to have other people who are doing this, whether they're in San Diego or Toronto or, Colorado; we rely on our friends, and especially when we come up with questions about techniques, it's always good to bounce things off one another.

Host: Absolutely. Now, we know that the gold standard of care up until this point has been ultrasound to diagnose congenital heart defects. So why is this technology helpful in the prenatal and postnatal management of fetuses with suspected congenital heart defects?

Munes Fares, MD: The way we look at this is cardiac MRI is not going to replace echocardiogram or fetal ultrasound. It's going to augment and it's going to help the fetal ultrasound. So in multiple, examples, one is sometimes the imaging with fetal echo or the ultrasound can be limited due to a lot of reasons; the fetal position, the body habitus, a lot of reasons can make those images a little bit limited. Fetal cardiac MRI may be able, as we progress with the technology, to actually be an alternative method of imaging. The other aspect that fetal cardiac MRI can really help is in cases where there is a very complex congenital heart disease and truly for the family and the physicians that are going to take care of that baby with a very significant congenital heart disease, it's really important to make sure that we understand the full spectrum and the full prognosis of that baby. A lot of times we're faced with not only that the heart hasn't developed completely well, sometimes in very specific cases like hypoplastic left heart syndrome with intact septum, not only the heart, is a one chamber, but also the way from the lungs down to the heart is not well developed, which makes the lungs also not completely developed.

Having the fetal cardiac MRI will also help you not only look at the heart, but also look at the lung and assess the lung edema or swelling and make sure it's not very significant to the point where you really may end up changing plan and really having that type of data helps the family meet with the specific specialists where they're prepared not only, with the plans, but also emotionally and just having a really good understanding of what their fetus is going through and how is the birth plan and delivery is going to look like.

Host: I'm sure that's extremely helpful for the family to have that full understanding and be able to see the images in real time, as you can show them, so that it causes a little less stress because I can't imagine the stress, you know, that those parents are under when they receive that diagnosis. Can you speak to the technical complexities of these images and the team of experts who are involved in interpreting the results?

Mansi Gaitonde, MD: I feel that we're so lucky here to have a really strong Fetal Heart Center. And not only do we have the team, which are the fetal cardiologists, like Dr. Fares and myself that perform fetal echocardiograms, but through collaboration, we have radiologists who are trained in fetal imaging and we rely on them to help us with interpretation of brain imaging and the lung imaging and or placental imaging that might be important and relevant in the type of congenital heart disease that's there.

And so we're so thankful that we have those other experts as part of our team. Our families are still being seen by our comprehensive Fetal Heart Center, which can involve the fetal care team with consultation with intensivists and surgeons, geneticists, social worker, looking at perinatal maternal stress.

There's a lot of different things that are really like a multidisciplinary aspect to our fetal care. And then we are also even more lucky that we have a physicist who is part of our cardiovascular MRI team. And we couldn't have done any of this without him. Because whenever we run into a problem, we get his advice on how to fIx what is challenging about a specific scenario with the fetus.

For example, a neonatal heart is about the size of a strawberry. This isn't, you know, a full term baby. So, early on in gestation, you have to go smaller and smaller. We're talking about raspberries now. So, this is what we're trying to image and we're also trying to gait this heart and assess systole, diastole, and how the heart is moving. And then we don't use sedation in these scans. So we position the mother in the best way possible, so that she's still comfortable. But that we have our Doppler device and it's targeted as much towards the baby as possible. And the baby is still free to move inside the mother. So we're kind of combating the fetal motion, which some babies can be calmer than others.

 When you think about if you've been pregnant and you go to your ultrasound and you see the screen and everything's kind of blown up on the screen, but that's really not the size of how small these structures are. So we are using these new technologies to image very, very small structures.

And so it really is a multidisciplinary team, which I think over years and years, we're going to make this imaging beautiful and find amazing uses for it. And these are the things that you know, we are investigating, which specific heart conditions is it really the most useful? And as we go along, I hope that we just continue to work with the industry and improve all these aspects that can make the technical complexities less of a problem for us as we go along.

So definitely going to be a work in progress and I think probably both Dr. Fares and I have thought about the plan for this since our fellowship training. It was always something that I wanted to do, and I feel really grateful that we have the opportunity to finally bring it to life and, you know, have it go live for people to order this test and talk with us so we can better diagnose and help prognosticate these different fetal heart conditions.

Host: Absolutely, and I love how you highlighted that, you know, it's a really multidisciplinary approach. Dr. Gaitonde, how long do these MRIs typically take?

Mansi Gaitonde, MD: So we keep the scan under 60 minutes. On average, it's about 45 minutes, and we do take that into account. We're so lucky that our technicians are experienced in fetal MRI imaging, so they know how to help the mom going through pregnancy, especially in the third trimester, being very uncomfortable. And that's so useful, being able to help our pregnant mothers.

Host: Are there any reasons why a patient would not be able to undergo a fetal cardiac MRI?

Munes Fares, MD: Not necessarily to be honest. The major challenges that we see sometimes, which is specifically claustrophobia, where you're really scared of going into the tunnel of the cardiac MRI. We are really lucky here. We have one of the largest MRI scanners, so the bore size is really large, where we've actually had referrals from outside where they send patients that have significant claustrophobia. The scanner size we have is very comfortable.

Host: What is the Health Center's hope for the future of fetal cardiac imaging at Children's Health?

Munes Fares, MD: One is to continue to improve our imaging and using fetal cardiac MRI to really have a fully functioning clinical service to be able to provide that service for all the patients that needs it. We're hoping to continue that research effort and developing more sequences to make that technology more helpful and more meaningful down the road as we use it more. We're not going to stop at just using the MRI. We're going to continue like just we do in our cardiac MRI program as we always try and lead the field and continue to develop it.

So we're hoping down the road to see even more use to it and more advancement in this technology.

Host: It's absolutely fantastic to hear you guys lead the charge in this type of technology. I'd like to end by giving you each a moment to add any last minute thoughts for our audience today.

Mansi Gaitonde, MD: Yes, I just want to thank, first of all, our maternal fetal medicine colleagues who have been really open and accepting of this technology, and when we've recommended it's ordering, and they've been excited about it, and we couldn't do this without them. I feel like same with the director of the Fetal Heart Center, which is Dr. Ikemba. She's also so excited to help us further this part of the Fetal Heart Center. So I think just with the whole team and having support from our chief, Dr. Madsen, I think we're just very lucky and we just hope that if you have any questions, if you are someone who deals with pregnant women or deals with fetuses and congenital heart disease, and you have any patients that you have questions about, I think Dr. Fares and I would be happy to talk with you in detail about whether this test would be beneficial for your patient or not. We want to provide a service that's useful and we are so happy to take any referrals that people have questions about and see what else we can provide for your patients.

Munes Fares, MD: I would like to say that we're also very grateful working with Dr. Sain and Dr. Greel from the director of MRI. They have created our interventional cardiac MRI environment here, which was really helpful to have because we're not only set up to do MRI, but we're also set up to do interventional MRI which made a fetal cardiac MRI really feasible to have everybody trained to do complex and unusual tasks in the MRI environment. We're working on getting a 0.5 Tesla Cardiac MRI in our Heart Center, which I think is going to push the fetal MRI even further with less safety concerns and less worries about any of the theoretical side effects of the MRI.

So I think I'm very, very excited about that as well. And I share same words that Mansi said. We're very lucky to be in the Fetal Heart Center and the Heart Center in general. Everybody has been really, really supportive.

Host: The future is definitely bright at Children's Health and the Heart Center. So we really appreciate your time today and to our audience for listening to Pediatric Insights, Advances and Innovations with Children's Health, where we explore the latest in pediatric care and research. You can find more information at childrens.com/fetalhealth, and if you found this podcast helpful, please rate and review or share the episode, and please follow Children's Health on all of your social channels. I'm Dr. Rania Habib, wishing you well.