Objective: To establish normal reference intervals of the fetal left modified myocardial performance index (MPI) with the use of stringent criteria for delimitation of the time periods. Study Design: A cohort of consecutive singleton fetuses was created including at least 20 fetuses for each completed week of gestation between 11 and 41 weeks. The isovolumetric contraction time (ICT), isovolumetric relaxation time (IRT), and ejection time (ET) were calculated using the clicks of the mitral and aortic valves as landmarks, and the MPI was calculated as follows: (ICT + IRT)/ET. Normal reference ranges for the MPI and its individual components were constructed by means of regression analysis of the mean and standard deviation against gestational age (GA). Results: A total of 730 fetuses were included. After a natural logarithmic transformation, a third degree cubic polynomial model (loge mean MPI = 0.0477 × GA – 0.002565 × GA2 + 0.000043 × GA3 –1.22, with GA measured in weeks) was selected to fit our data. There was a progressive increase in the mean MPI from 11 weeks (mean, 0.39; 95th centile, 0.51) to 41 weeks (mean, 0.55; 95th centile, 0.78) of gestation. While the mean ICT and IRT values increased with GA from 25 to 32 ms and from 39 to 51 ms, respectively, the ET showed an initial increase until 30 weeks and a progressive decrease thereafter. Conclusion: Normative references of left modified MPI from 11 to 41 weeks of gestation are provided, which could be useful in the assessment of cardiac function in fetuses.

Barker DJ: The intrauterine origins of cardiovascular disease. Acta Paediatr Suppl 1993;82(suppl 391):93–99, discussion 100.
Lau C, Rogers JM: Embryonic and fetal programming of physiological disorders in adulthood. Birth Defects Res C Embryo Today 2004;72:300–312.
Tutschek B, Schmidt KG: Techniques for assessing cardiac output and fetal cardiac function. Semin Fetal Neonatal Med 2011;16:13–21.
Clur SA, Oude Rengerink K, Mol BW, Ottenkamp J, Bilardo CM: Fetal cardiac function between 11 and 35 weeks’ gestation and nuchal translucency thickness. Ultrasound Obstet Gynecol 2011;37:48–56.
Huggon IC, Turan O, Allan LD: Doppler assessment of cardiac function at 11–14 weeks’ gestation in fetuses with normal and increased nuchal translucency. Ultrasound Obstet Gynecol 2004;24:390–398.
Van Mieghem T, Klaritsch P, Done E, Gucciardo L, Lewi P, Verhaeghe J, Lewi L, Deprest J: Assessment of fetal cardiac function before and after therapy for twin-to-twin transfusion syndrome. Am J Obstet Gynecol 2009;200:400.e1–400.e7.
Raboisson MJ, Fouron JC, Lamoureux J, Leduc L, Grignon A, Proulx F, Gamache S: Early intertwin differences in myocardial performance during the twin-to-twin transfusion syndrome. Circulation 2004;110:3043–3048.
Ichizuka K, Matsuoka R, Hasegawa J, Shirato N, Jimbo M, Otsuki K, Sekizawa A, Farina A, Okai T: The Tei index for evaluation of fetal myocardial performance in sick fetuses. Early Hum Dev 2005;81:273–279.
Crispi F, Hernandez-Andrade E, Pelsers MM, Plasencia W, Benavides-Serralde JA, Eixarch E, Le Noble F, Ahmed A, Glatz JF, Nicolaides KH, Gratacos E: Cardiac dysfunction and cell damage across clinical stages of severity in growth-restricted fetuses. Am J Obstet Gynecol 2008;199:254.e1–254.e8.
Hernandez-Andrade E, Crispi F, Benavides-Serralde JA, Plasencia W, Diesel HF, Eixarch E, Acosta-Rojas R, Figueras F, Nicolaides K, Gratacos E: Contribution of the myocardial performance index and aortic isthmus blood flow index to predicting mortality in preterm growth-restricted fetuses. Ultrasound Obstet Gynecol 2009;34:430–436.
Comas M, Crispi F, Cruz-Martinez R, Martinez JM, Figueras F, Gratacos E: Usefulness of myocardial tissue Doppler vs. conventional echocardiography in the evaluation of cardiac dysfunction in early-onset intrauterine growth restriction. Am J Obstet Gynecol 2010;203:45.e1–45.e7.
Cruz-Martinez R, Figueras F, Benavides-Serralde A, Crispi F, Hernandez-Andrade E, Gratacos E: Sequence of changes in myocardial performance index in relation with aortic isthmus and ductus venosus Doppler in fetuses with early-onset intrauterine growth restriction. Ultrasound Obstet Gynecol 2011;38:179–184.
Hernandez-Andrade E, Crispi F, Benavides-Serralde A, Figueras F, Gratacos E: Contribution of the modified myocardial performance index and aortic isthmus blood flow index to refine prediction of mortality in preterm intrauterine growth restricted fetuses. Ultrasound Obstet Gynecol 2009;34:430–436.
Cruz-Martinez R, Figueras F, Benavides-Serralde A, Crispi F, Hernandez Andrade E, Gratacos E: Sequence of changes in myocardial performance index in relation with aortic isthmus and ductus venosus Doppler in fetuses with early-onset intrauterine growth restriction. Ultrasound Obstet Gynecol 201;38:179–184.
Van Mieghem T, Gucciardo L, Done E, Van Schoubroeck D, Graatsma EM, Visser GH, Verhaeghe J, Deprest J: Left ventricular cardiac function in fetuses with congenital diaphragmatic hernia and the effect of fetal endoscopic tracheal occlusion. Ultrasound Obstet Gynecol 2009;34:424–429.
Inamura N, Taketazu M, Smallhorn JF, Hornberger LK: Left ventricular myocardial performance in the fetus with severe tricuspid valve disease and tricuspid insufficiency. Am J Perinatol 2005;22:91–97.
Wong ML, Wong WH, Cheung YF: Fetal myocardial performance in pregnancies complicated by gestational impaired glucose tolerance. Ultrasound Obstet Gynecol 2007;29:395–400.
Russell NE, Foley M, Kinsley BT, Firth RG, Coffey M, McAuliffe FM: Effect of pregestational diabetes mellitus on fetal cardiac function and structure. Am J Obstet Gynecol 2008;199:312.e1–312.e7.
Api O, Emeksiz MB, Api M, Ugurel V, Unal O: Modified myocardial performance index for evaluation of fetal cardiac function in pre-eclampsia. Ultrasound Obstet Gynecol 2009;33:51–57.
Crispi F, Comas M, Hernandez-Andrade E, Eixarch E, Gomez O, Figueras F, Gratacos E: Does pre-eclampsia influence fetal cardiovascular function in early-onset intrauterine growth restriction? Ultrasound Obstet Gynecol 2009;34:660–665.
Tei C, Ling LH, Hodge DO, Bailey KR, Oh JK, Rodeheffer RJ, Tajik AJ, Seward JB: New index of combined systolic and diastolic myocardial performance: a simple and reproducible measure of cardiac function – a study in normals and dilated cardiomyopathy. J Cardiol 1995;26:357–366.
Hernandez-Andrade E, Lopez-Tenorio J, Figueroa-Diesel H, Sanin-Blair J, Carreras E, Cabero L, Gratacos E: A modified myocardial performance (Tei) index based on the use of valve clicks improves reproducibility of fetal left cardiac function assessment. Ultrasound Obstet Gynecol 2005;26:227–232.
Friedman D, Buyon J, Kim M, Glickstein JS: Fetal cardiac function assessed by Doppler myocardial performance index (Tei index). Ultrasound Obstet Gynecol 2003;21:33–36.
Hernandez-Andrade E, Figueroa-Diesel H, Kottman C, Illanes S, Arraztoa J, Acosta-Rojas R, Gratacos E: Gestational-age-adjusted reference values for the modified myocardial performance index for evaluation of fetal left cardiac function. Ultrasound Obstet Gynecol 2007;29:321–325.
Van Mieghem T, Gucciardo L, Lewi P, Lewi L, Van Schoubroeck D, Devlieger R, De Catte L, Verhaeghe J, Deprest J: Validation of the fetal myocardial performance index in the second and third trimesters of gestation. Ultrasound Obstet Gynecol 2009;33:58–63.
Rozmus-Warcholinska W, Wloch A, Acharya G, Cnota W, Czuba B, Sodowski K, Skrzypulec V: Reference values for variables of fetal cardiocirculatory dynamics at 11–14 weeks of gestation. Ultrasound Obstet Gynecol 2010;35:540–547.
Comas M, Cruz-Martinez R, Crispi F, Figueras F, Gratacos E: Cardiac dysfunction is present in small for gestational age fetuses with normal umbilical artery Doppler. Ultrasound Obstet Gynecol 2010;36(suppl 1):5.
Crispi F, Bijnens B, Figueras F, Bartrons J, Eixarch E, Le Noble F, Ahmed A, Gratacos E: Fetal growth restriction results in remodeled and less efficient hearts in children. Circulation 2010;121:2427–2436.
Robinson HP, Fleming JE: A critical evaluation of sonar ‘crown-rump length’ measurements. Br J Obstet Gynaecol 1975;82:702–710.
Figueras F, Meler E, Iraola A, Eixarch E, Coll O, Figueras J, Francis A, Gratacos E, Gardosi J: Customized birthweight standards for a spanish population. Eur J Obstet Gynecol Reprod Biol 2008;136:20–24.
Royston P, Wright EM: How to construct ‘normal ranges’ for fetal variables. Ultrasound Obstet Gynecol 1998;11:30–38.
Tsutsumi T, Ishii M, Eto G, Hota M, Kato H: Serial evaluation for myocardial performance in fetuses and neonates using a new Doppler index. Pediatr Int 1999;41:722–727.
Chen Q, Sun XF, Liu HJ: Assessment of myocardial performance in fetuses by using Tei index (in Chinese). Zhonghua Fu Chan Ke Za Zhi 2006;41:387–390.
Eidem BW, Edwards JM, Cetta F: Quantitative assessment of fetal ventricular function: establishing normal values of the myocardial performance index in the fetus. Echocardiography 2001;18:9–13.
Falkensammer CB, Paul J, Huhta JC: Fetal congestive heart failure: correlation of Tei-index and cardiovascular-score. J Perinat Med 2001;29:390–398.
Raboisson MJ, Bourdages M, Fouron JC: Measuring left ventricular myocardial performance index in fetuses. Am J Cardiol 2003;91:919–921.
Snijders RJ, Thom EA, Zachary JM, Platt LD, Greene N, Jackson LG, Sabbagha RE, Filkins K, Silver RK, Hogge WA, Ginsberg NA, Beverly S, Morgan P, Blum K, Chilis P, Hill LM, Hecker J, Wapner RJ: First-trimester trisomy screening: nuchal translucency measurement training and quality assurance to correct and unify technique. Ultrasound Obstet Gynecol 2002;19:353–359.
Eto G, Ishii M, Tei C, Tsutsumi T, Akagi T, Kato H: Assessment of global left ventricular function in normal children and in children with dilated cardiomyopathy. J Am Soc Echocardiogr 1999;12:1058–1064.
Ichihashi K, Yada Y, Takahashi N, Honma Y, Momoi M: Utility of a Doppler-derived index combining systolic and diastolic performance (Tei index) for detecting hypoxic cardiac damage in newborns. J Perinat Med 2005;33:549–552.
Burrell JH, Boyn AM, Kumarasamy V, Hsieh A, Head SI, Lumbers ER: Growth and maturation of cardiac myocytes in fetal sheep in the second half of gestation. Anat Rec A Discov Mol Cell Evol Biol 2003;274:952–961.
Agata Y, Hiraishi S, Oguchi K, Misawa H, Horiguchi Y, Fujino N, Yashiro K, Shimada N: Changes in left ventricular output from fetal to early neonatal life. J Pediatr 1991;119:441–445.
Huang J, Hove-Madsen L, Tibbits GF: Na+/Ca2+ exchange activity in neonatal rabbit ventricular myocytes. Am J Physiol Cell Physiol 2005;288:C195–C203.
Clur SA, Oude Rengerink K, Ottenkamp J, Bilardo CM: Cardiac function in trisomy 21 fetuses. Ultrasound Obstet Gynecol 2011;37:163–171.
Cruz-Martinez R, Figueras F, Jaramillo JJ, Meler E, Mendez A, Hernandez-Andrade E, Gratacos E: Learning curve for Doppler measurement of fetal modified myocardial performance index. Ultrasound Obstet Gynecol 2011;37:158–162.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.