Introdução: O Doppler tecidual (DT) surgiu como uma técnica ecocardiográfica para registro das velocidades do miocárdio e evoluiu para a determinação da deformação miocárdica regional com medida do strain rate (SR) e strain longitudinal e radial unidimensionais. Nosso objetivo foi determinar padrões de normalidade em neonatos e analisar seqüencialmente esses índices em períodos de alta e baixa resistência vascular pulmonar. Casuística e Método: Selecionaram-se 55 crianças com idade média de 20,14 ± 14,0 horas, constituindo o Grupo I (G I). Um segundo exame foi realizado em 30 crianças que retornaram após 31,9 ± 2,9 dias de vida, constituindo o Grupo II (G II). As velocidades do DT pulsado foram obtidas em cortes transversais (R) e longitudinais (L) do ventrículo esquerdo (VE) em posições apical 4 e 2 câmaras e no VD (paredes livre e inferior). Foram medidas velocidades sistólicas (onda Sm), diastólica inicial (Em), diastólica final (Am) de pico e a relação Em/Am. Pelo menos três ciclos cardíacos consecutivos com taxa de quadros/s superior a 300 foram digitalmente obtidos nos cortes mencionados e analisados posteriormente utilizando programa específico para medida das curvas de SR/strain e seus componentes sistólico, diastólico inicial e final. Resultados: As velocidades demonstraram gradiente bem definido com redução progressiva na direção base-ápice do coração. As velocidades do VD foram superiores às do VE quando comparadas com as medidas nas paredes septal (S), anterior (A) e lateral (L). No GI verificamos diferença significativa entre as medidas do SR/strain sistólicos do segmento basal da parede S em relação à apical (-1,90 ± 0,61, - 25,90 ± 4,90 vs -1,66 ± 0,25, - 24,23 ± 3,08), p=0,04 e p=0,02 e do segmento médio em relação ao apical (p=0,01 e 0,02). A avaliação regional do VD demonstrou strain sistólico maior no segmento médio em relação ao basal (-33,20 ± 6,34 vs -28,38 ± 4,90, p=0,00) e em relação ao segmento apical (-33,20 ± 6,34 vs -31,95 ± 5,06, p=0,021). Os valores absolutos de SR/strain e todos os seus componentes foram maiores na direção R quando comparados com a L (SR sistólico 2,99 ± 0,78 s-1 vs (-)1,90 ± 0,60 s-1 strain sistólico 49,72% ± 12,86% vs (-) 25,86% ± 4,83 p=0,00). Quando comparamos os GI e GII verificamos redução do strain sistólico do VE na direção R e L nas paredes S, L e A em todos os segmentos. O SR sistólico reduziu apenas na porção basal da parede L (-1,91 ± 0,46 s-1 vs - 1,71 ± 0,33 s-1, p=0,02). O VD apresentou no GII aumento significativo do strain sistólico e diastólico inicial em todos os segmentos e paredes. O SR sistólico também apresentou aumento dos valores nos segmentos basal e médio de sua parede livre e na parede inferior. A correlação entre a onda Sm e SR/strain sistólicos não foi significativa. Conclusão: Os índices regionais de deformação miocárdica constituem técnica clínica reproduzível em neonatos e podem monitorar alterações seqüenciais fisiológicas da circulação neonatal precoce e tardia. São mais robustos que as velocidades na quantificação da função regional. / Background: Color Doppler myocardial imaging (CDMI) has emerged as an echocardiographic technique for determining myocardial velocities and has been further developed to allow the determination of one-dimension regional longitudinal and radial strain rate (SR)and strain. Our goal was to determine normal values in neonates and sequentially analyse these indices in periods of high and low pulmonary vascular resistance. Study population and methods: Fifty-five term newborns with mean age of 20.14 ± 14.0 hours were selected to be part of Group I (GI). A second echo study was performed on 30 children that had returned with 31.9 ± 2.9 days after birth, being Group II (GII). Pulsed wave Doppler tissue velocities (PWDTV) were obtained in short axis (R) and longitudinal (L) axis of the left ventricle (LV) in apical 4 and 2 chamber view and in 4 and 2 chamber of the right ventricle (RV), including RV free lateral and inferior walls. Peak systolic (Sm), peak early diastolic (Em) and peak late diastolic (Am) motion velocities and Em/Am ratio were measured. At least three consecutive cardiac cycles with frame rate more than 300 fps were stored in digital format from the mentioned views for offline analysis by using dedicated software for measuring peak systolic and peak early and late diastolic SR/strain. Results: PWTDV have shown a well-defined gradient with progressive peak reduction from base to apex. RV velocities were higher than those of the LV whem compared to septal (S), anterior (A) and lateral (L) walls. In GI there was a significant difference between systolic SR/strain measurement of basal S segment in relation to apical (-1.90 ± 0.61, -25.90 ± 4.90 vs -1.66 ± 0.25, - 24.23 ± 3.08), p=0.04 e p=0.02 and from the mid in relation to the apical segment (p=0.01 e 0.02). Regional RV longitudinal function showed that systolic strain recorded from the mid segment was significantly higher than that recorded from the basal segment (-33.20 ± 6.34 vs -28.38 ± 4.90, p=0.00) and that from the apical segment (-33.20 ± 6.34 vs ?31.95 ± 5.06, p=0.021). The absolute and all components of SR/strain were significantly higher in R direction when compared to the L ones (systolic SR 2.99 ± 0.78 s-1 vs (-)1.90 ± 0.60 s-1 systolic strain 49.72% ± 12.86% vs (-)25.86% ± 4.83 p=0.00). When comparing data from GI and GII, we noticed reduction of LV systolic strain in the second group for both R and L, in all segments of S, L and A walls. Systolic SR showed reduction of the values in GII only in the basal segment of the L wall (-1.91 ± 0.46 s-1 vs ?1.71 ± 0.33s-1, p=0.02). Regional RV function showed systolic and early diastolic strain significantly higher in all segments of wall in GII. Systolic SR also showed higher values in the basal and mid segments of RV free lateral and inferior wall in GII when comparing to GI. The correlation between peak systolic velocity Sm and peak systolic SR/strain was not significant. Conclusion: Regional myocardial deformation indices are reproducible clinical techniques in neonates and can monitor physiological sequential circulatory changes of the early and late neonatal period. They are more robust than velocities in the quantification of the regional myocardial function.

Environ 42% de la mortalité infantile dans le monde résulte des cardiopathies congénitales. Un tiers de ces cardiopathies nécessitent la reconstruction de la voie de sortie du cœur droit par des procédures chirurgicales utilisant des dispositifs inertes sans potentiel de croissance. Par conséquence, des réinterventions, parfois nombreuses, sont nécessaires, avec une importante morbi-mortalité. Le projet européen TEH-TUBE a pour objectif de créer un nouveau dispositif implantable de reconstruction de la voie de sortie du cœur droit, sous la forme d’un tube valvé en polymère biorésorbable biofonctionnalisé, afin de permettre la reconstruction in vivo d’une néo-voie de sortie du cœur droit autologue, vivante et douée d’un potentiel de croissance. Ce projet consiste tout d’abord à sélectionner le meilleur couple polymère/biofonctionnalisation en comparant in vitro et in vivo dans modèle expérimental de petit animal différents polymères et techniques de biofonctionnalisation. Dans l’intervalle, le design du tube valvé sera évalué afin de confectionner un dispositif compétent et continent en position de voie de sortie du cœur droit. Une fois ces deux étapes abouties, le tube valvé produit en fonction du couple polymère/biofonctionnalisation préalablement sélectionné sera testé dans un modèle de gros animal en croissance, i.e. l’agneau, afin d’analyser les capacités de régénération in vivo, de compétence hémodynamique et de potentiel de croissance du dispositif. Afin de mettre en place les protocoles de comparaison des polymères et de la biofonctionnalisation, nous avons sélectionné trois polymères biorésorbables de grade non clinique : un polyuréthane [PU], un polyhydroxyalkanoate (le poly(3-hydroxybutyrate-co-3- hydroxyvalerate-co-4-hydroxyvalerate) [PHBVV]), et le polydioxanone [PDO]), ainsi que deux techniques de biofonctionnalisation, par ensemencement de cellules souches de tissu adipeux (adipose-derived stem cells [ADSCs]) ou par greffe peptidique de RGD. Ces polymères ont été testés in vitro (prolifération et viabilités cellulaires d’ADSC ensemencées) et in vivo après la mise en place d’un modèle expérimental de remplacement partiel de veine cave inférieure (VCI) chez 53 rats Wistar (comparaison des trois polymères) et 31 rats imuno-déficients nude (comparaison du meilleur polymère biofonctionnalisé par ADSC ou RGD). Les résultats ont été analysés par cytométrie en flux, test de viabilité cellulaire au MTT, imagerie, histologie, immunohistochimie et ELISA. Le PDO a montré les meilleures propriétés in vitro en termes de viabilité et prolifération cellulaire et a été sélectionné pour l’étape de comparaison des biofonctionnalisation. Six semaines après implantation sur la VCI, les imageries réalisées n’ont pas retrouvé de sténose, de dilatation ou de thrombose au niveau des sites d’implantation des patchs. A trois mois, tous les polymères présentaient une couche continue de cellules endothéliales mais seuls le PDO et le PHBVV présentaient une couche continue de cellules musculaires lisses. Le PU était le siège d’une réaction inflammatoire granulomateuse importante. La comparaison des techniques de biofonctionnalisation par ADSC et RGD n’a pas montré de différence significative, avec une reconstruction de la VCI par un néo-tissu similaire à une paroi de VCI native. Cette première partie a permis non seulement de valider les protocoles in vitro de comparaison des polymères et de mettre au point un modèle animal fiable et reproductible, mais aussi de montrer qu’une biofonctionnalistion peptidique peut être aussi efficace qu’une biofonctionnalisation cellulaire, permettant d’éviter la culture cellulaire et l’ensemencement des dispositifs, potentiellement sources de contamination et de fabrication plus compliquée (...). / Approximately 42% of infant mortality in the world is due to congenital heart diseases (CHD). One third of these CHD require surgical reconstruction of the right ventricular outflow tract (RVOT). Actual available devices for RVOT reconstruction are inerts without growth potential. Therefore, reinterventions are inevitable with a subsequent morbi-mortality.The European TEH TUBE project aims to create a new implantable device for RVOT reconstruction, a bioresorbable polymeric biofunctionnalized valved tube, to allow in vivo reconstruction of a living autologous neo-RVOT with a growth potential. This project aims to select the best polymer/biofunctionnalization couple by comparing in vitro and in vivo in a rat animal model different polymers and biofunctionnalization techniques. In the meantime, the design of the valved tube will be evaluated to produce a competent and continent device for RVOT replacement. Once these two steps will be complete, a valved tube made of the selected polymer/biofunctionnalization couple will be tested in a growing big animal model, i.e. in lambs, to analyse its in vivo regeneration potential, hemodynamic competences and growth potential. Three non-clinical grade bioresorbable polymers : a polyurethane [PU], a polyhydroxyalkanoate (poly(3-hydroxybutyrate-co-3- hydroxyvalerate-co-4-hydroxyvalerate) [PHBVV]), and the polydioxanone [PDO]), and two biofunctionnalization techniques, either by cell seeding of adipose-derived stem cells (ADSC) or by peptide grafting (RGD) were selected to implement the experimental protocol. Polymers were tested in vitro (cellular viability and proliferation of seeded ADSC) and in vivo after implementing an experimental model of partial replacement of the inferior vena cava (IVC) in 53 Wistar rats (polymer comparison) and 31 immuno-deficient nude rats (comparison of biofunctionnalization with ADSC or RGD on the selected polymer). Results were analysed using flow cytometry, cellular viability with the MTT test, imaging, histology, immunohistochemistry and ELISA.PDO displayed the best in vitro properties in terms of cellular viability and proliferation and was selected for the biofunctionnalization comparison step. Six weeks after implantation, imaging of the implanted IVC revealed no stenosis, dilatation or thrombosis in the area of patch implantation. At three months, all polymers presented with a continuous layer of endothelial cells but only PDO and PHBVV polymer had a continuous layer of smooth muscle cells. An important inflammatory granulomatous reaction was encountered with the PU. Comparison of biofunctionnalization by either ADSC or RGD failed to detect any significative difference, with an IVC reconstruction similar to the native IVC architecture.This first part did not only allow to validate both in vitro and in vivo experimental protocols, and implement a reproducible animal model, but also allowed to reveal that peptide biofunctionnalization can be as efficient as cellular biofunctionnalization. This will allow us to avoid cell therapy and cell seeding for the device biofunctionnalization, as it can be source of contamination and harder to produce. The methodological tools thus defined were then used for the next step. As to preserve the required confidentiality of the TEH TUBE project, selection criteria of the clinical grade bioresorbable polymers and their exact composition will not be revealed, and the polymers will be anonymized. Ninety Wistar rats underwent a partial replacement of the IVC, and were distributed in 3 polymer groups of 30 animals each : polymer A, polymer B and polymer C. Five rats of each polymer group were sacrificed two weeks after implantation, the other specimen at 3 months after receiving an imaging of the operated IVC by Doppler echography. No significative stenosis or dilatation was found by echographic examination (...).

Background: Patients with d-transposition of the great arteries after Senning or Mustard procedure are at increased risk for arrhythmias. Especially atrial arrhythmias represent a major threat in this patient population. Early detection of clinical and subclinical arrhythmias may prevent major cardiac events. Therefore, this study aimed to evaluate the ability of the Medtronic REVEAL LINQ to detect atrial arrhythmias in adult patients after atrial switch procedure and compare the effectiveness of detecting clinically relevant arrhythmias to conventional Holter monitoring. METHODS: The database of the Heart Center Leipzig, Department for pediatric cardiology was analyzed for patients after atrial switch procedure and implantation of a Medtronic REVEAL LINQ (Medtronic Inc., Minneapolis, Minnesota). After informed consent was obtained, patients were followed up for 1 year including Holter ECG tracings and device interrogation every 3 months. In addition, symptoms were determined using a standardized questionnaire completed by the patient. RESULTS: The analysis is based on 10 patients aged 34.5 years (range 27-46 years), of which 8 had a Senning - and 2 had a Mustard procedure. The comparison of the number of arrhythmia episodes detected by Holter and LINQ showed significantly more detected episodes using LINQ (p 0.014). Data showed that no therapy adjustments were recorded as a consequence of Holter ECG findings, whereas two changes in medication were documented due to arrhythmia detection via LINQ. When analyzing possible correlations between subjective symptoms reported in the standardized questionnaire and the number of episodes documented, there was a significant correlation of subjective symptoms and arrhythmia episodes in LINQ (p 0.014), whereas no correlation could be demonstrated between subjective symptoms and the number of episodes detected by Holter monitoring (p 0.394). CONCLUSION: In patients after Senning or Mustard procedure, the Medtronic REVEAL LINQ seems to be superior in the identification of subclinical arrhythmia burden in comparison to standard Holter ECG.

Congenital heart disease is the most common birth defect globally, affecting both children and their families. Twenty –five percent of children experiencing a CHD birth defect are diagnosed with complex CHD (cCHD), signifying critical heart dysfunction requiring one or more open-heart surgeries during the first year of life. With medical advances, cCHD survival rates have almost tripled in the last three decades. This has resulted in an increase in the number of morbidities associated with cCHD, which is drastically impacting the need to support quality of life outcomes for a child with cCHD and their family. The two most prevalent unaddressed risks for quality of life outcomes in the cCHD population are child and caregiver mental health and child's neurodevelopmental disabilities. Congenital heart disease is the most common birth defect globally, affecting both children and their families. Twenty-five percent of children experiencing a CHD birth defect are diagnosed with complex CHD (cCHD), signifying critical heart dysfunction requiring one or more open-heart surgeries during the first year of life. With medical advances, cCHD survival rates have almost tripled in the last three decades. This has resulted in an increase in the number of morbidities associated with cCHD, which is drastically impacting the need to support quality of life outcomes for a child with cCHD and their family. The two most prevalent unaddressed risks for quality of life outcomes in the cCHD population are child and caregiver mental health and child's neurodevelopmental disabilities. The present study sought to address the relationship between caregiver knowledge of cCHD developmental challenges (i.e., outcomes related to neurodevelopmental disabilities, mental health, and provider quality-care approach) and children's and caregiver's quality of life outcomes, inclusive of academic functioning ability of children with cCHD, children with cCHD and their caregivers' mental health functioning, and the overall satisfaction with the nature of the healthcare provider of the child with cCHD. A total sample size of N = 46 participants were included in the current study. Results that caregivers' knowledge of cCHD risks to quality of life outcomes explained a much greater percentage of the variance in caregiver satisfaction with healthcare providers (R2 = 0.350, p < 0.001) compared to number of surgical interventions (R2 = 0.058, p = 0.047). Clinical implications and implementation for use of a holistic, integrated approach are strengthened by the study findings.

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Contexte : L’objectif primaire de l’étude est de décrire les issues maternelles cardiaques, périnatales et obstétricales des femmes enceintes avec cardiopathie congénitale. L’objectif secondaire porte sur l’application des scores prédictifs de complications cardiaques (score ZAHARA 1 et classification modifiée de l’Organisation mondiale de la Santé) dans notre population. Méthodologie : Nous avons mené une étude descriptive de type série de cas incluant 408 grossesses de 283 patientes avec cardiopathies congénitales ayant accouchées au Centre Hospitalier Universitaire Sainte-Justine, entre 1992 et 2013. La collecte de données a été réalisée à partir des dossiers médicaux. Les issues périnatales sur les plans obstétrical et néonatal ont été décrites. La comparaison des scores de complications cardiaques a été réalisée avec le test de Pearson Chi carré. Résultats: Notre cohorte à faible risque de complications était composée de 405 grossesses (99,3%) de classes fonctionnelles New York Heart Association I et II. La proportion de complications obstétricales était de 49,0% (200 grossesses), dont 16,9% d’admissions aux soins pour surveillance étroite en post-partum, 12,7% de diabète gestationnel et 11,3% d’hémorragie du post-partum. Les complications fœtales ou néonatales ont compliqué 148 grossesses (36,3%). Les fréquences de petit poids selon l’âge gestationnel (16,6%) et de prématurité (14,9%) étaient significativement plus élevées que celles rencontrées dans la population générale. Seulement 4,7% des grossesses (19 grossesses) ont compliqué d’un évènement cardiovasculaire. La classification modifiée de l’Organisation mondiale de la Santé estimait bien le risque de complications cardiaques, sauf pour la classe à haut risque (IV). Conclusions: Les patientes atteintes de cardiopathies congénitales sont plus à risque de complications obstétricales et périnatales que la population obstétricale générale, tels les accouchements vaginaux assistés, l’hémorragie du post-partum, la prématurité et le petit poids de naissance inférieur au 10e percentile. La classification modifiée de l’Organisation mondiale de la Santé semblait adéquate dans la prévision d’évènements cardiaques, mais le score ZAHARA 1 reste un bon outil complémentaire dans l’évaluation du pronostic de la grossesse. / Background: The aim of the study was to describe cardiac maternal outcomes as long as perinatal and obstetrical morbidities of pregnant women with congenital heart disease. Secondary outcome was to validate predictive cardiovascular events risk scores (ZAHARA 1 score and modified World Health Organization classification) in our population. Methods: We conducted a case series study including 408 pregnancies of 283 women with congenital heart disease, who delivered at Sainte-Justine Hospital in Montreal (Canada) from 1992 to 2013. Data were collected from chart review. Perinatal issues were described. Comparison of cardiac risk scores was analysed using Chi square test. Results: Our low-risk cohort was composed of 405 pregnancies (99.3%) with New York Heart Association functional classes I or II. Obstetrical complications rates among women with congenital heart disease was 49.0% (200 pregnancies), such as intensive care admission for close monitoring (16.9%), gestational diabetes (12.7%) and post-partum haemorrhage (11.3%) which are higher than the general obstetrical population. Furthermore, offspring complications occurred in 148 pregnancies (36.3%); the rates of small for gestational age (16.6%) and preterm delivery (14.9%) were significantly higher than general population. Only 4.7% pregnancies (19 pregnancies) were complicated by a cardiac event. The modified World Health Organization classification gave the best overview of cardiac prognostic during the pregnancy, except for the highest risk class (IV). Conclusions: Compared to Canadian obstetrical population, pregnant women with congenital heart disease had higher rates of assisted vaginal delivery, post-partum haemorrhage, preterm delivery and birth weight lower than the 10th percentile. The modified World Health Organization classification risk seemed better to predict cardiovascular events, while ZAHARA 1 score is complementary in the evaluation of prognosis of pregnancy.

Minha experiência clínica atendendo gestantes com diagnóstico de cardiopatia fetal pôde propiciar a observação de alterações na condição emocional das pacientes que se mantinham em acompanhamento psicológico no hospital de Cardiologia, que passou a recebê-las desde o período pré-natal até o nascimento do bebê, para que estes fossem submetidos às intervenções cardíacas necessárias. Esta percepção motivou a pesquisa sobre a natureza destas repercussões emocionais uma vez que a gestação é considerada um período de transição e de crise para a mulher, no qual precisa se reorganizar emocionalmente devido às mudanças com a vinda do filho, bem como às expectativas e idealizações inerentes. O objetivo foi identificar as repercussões emocionais mais significativas a partir de aspectos da psicodinâmica das gestantes, visando contribuir para a assistência a esta população. O método utilizado foi o clínico qualitativo, tendo como instrumentos: a entrevista semidirigida e as técnicas projetivas, Desenho da Figura Humana (DFH) e Teste de Apercepção Temática (TAT). Foi realizada a análise de conteúdo, conforme Bardin, de uma sessão de atendimento psicológico, gravada, com o consentimento das participantes, e transcrita posteriormente. Os resultados confirmaram a presença de repercussões emocionais significativas, dentre elas: os sentimentos de impotência e de posse em relação ao bebê, sentimento de culpa pelo diagnóstico fetal, angústia de morte, desamparo, não aceitação do diagnóstico e medo do desconhecido. A partir da análise psicodinâmica, identificou-se também: as principais ansiedades das gestantes - conhecer o bebê, de separação e do parto; os mecanismos de defesa atuantes - negação, regressão, identificação, racionalização e idealização- e as principais formas de enfrentamento - confiança na equipe, acreditar que a barriga é a forma possível de proteção do bebê, controle emocional, busca de conhecimento sobre a cardiopatia, identificação com outros pais na mesma situação e oferecimento de ajuda a estes, e a fé. No DFH destacaram-se: a inclinação das figuras femininas e masculinas, que pode estar relacionado à tentativa de manter um equilíbrio corporal em virtude das modificações físicas ao final da gestação; a assimetria apresentada em metade dos desenhos, analisada como possível forma de expressar a percepção das anomalias corporais dos bebês, embora a cardiopatia não possa ser visualmente observada, pode se relacionar às fantasias sobre a aparência do bebê malformado. No TAT perceberam-se importantes conflitos como dependência x independência e maternidade x afiliação, com o uso de mecanismos de defesa tais como a regressão, racionalização e idealização. Concluiu-se que o diagnóstico de cardiopatia fetal traz intensas repercussões emocionais, relacionadas às fantasias de morte sobre o nascimento do filho, sendo atribuída ao parto uma representação simbólica ainda mais angustiante que nas gestações comuns ou não caracterizadas como de alto risco, pois parece ser vivenciada inicialmente como uma situação quase-certa de morte, o que torna importante que o acompanhamento psicológico seja oferecido nas instituições de saúde, por todo o ciclo gravídico-puerperal / My clinical experience serving pregnant women with diagnosis of fetus with heart disease made it possible to observe changes in the emotional condition of the patients who remained in counseling in the Cardiology Hospital, which has been admitting them from the prenatal period to childbirth, so that they were subjected to the necessary cardiac interventions. This realization led to research into the nature of these emotional repercussions since pregnancy is considered a period of transition and crisis to the woman, who needs emotional restructuring due to changes related to the child\'s coming, and the inherent expectations and idealizations. The objective was to identify the most significant emotional repercussions from the psychodynamic aspects of pregnant women, in order to contribute to their assistance. The research followed a clinical-qualitative method, with the following instruments: semi-structured interviews and projective techniques, the Human Figure Drawing Test (HFD) and Thematic Apperception Test (TAT). Content analysis was carried out according to Bardin during psychological counseling sessions, recorded with the consent of the participants, and later transcribed. The results confirmed the presence of significant emotional repercussions, such as: feelings of powerlessness and possession over the baby, guilt over fetal diagnosis, death anxiety, helplessness, denial and fear of the unknown. The psychodynamic analysis also identified: the main anxieties of pregnant women knowing the baby, separation and childbirth; the active defense mechanisms denial, regression, identification, rationalization and idealization; and the main coping mechanisms confidence in the team, belief in the bellys protection, emotional control, pursuit of knowledge about the disease, identification with other parents in similar situations and the ability to extend help to them, and faith. HFD highlighted: the angle of the female and male figures, which may be related to trying to maintain body balance because of physical changes at the end of pregnancy; the asymmetry identified in half of the drawings, analyzed as a possible way to express the perception of bodily abnormalities of babies which, even in the absence of visual observation of the abnormalities, can relate to fantasies about the appearance of a malformed baby. TAT showed important conflicts such as dependence vs. independence and motherhood vs. affiliation with the use of defense mechanisms such as regression, rationalization and idealization. The research concludes that the diagnosis of fetal heart disease causes intense emotional distress, related to death fantasies during childbirth with childbirth having a more distressing symbolic representation than during ordinary or low-risk pregnancies, since it seems to be early experienced as a situation of almost certain death, which makes it important that health institutions offer psychological counseling throughout the pregnancy and childbirth