Fetal MRI Reveals Altered Subplate Development in Congenital Heart Disease

Background: The subplate is a transient fetal brain compartment that provides an early foundation for downstream cerebral development. Congenital heart disease (CHD) alters fetal circulation and cerebral substrate delivery, but its impact on subplate development and whether resulting alterations relate to later neurodevelopmental outcomes remain unclear. Methods: In this retrospective observational cohort study, We used fetal MRI to quantify whole-brain, lobar, and regional (17 bilateral cortical regions) subplate volume and thickness to evaluate group differences between 76 fetuses with CHD and 62 typically developing (TD) fetuses scanned between 21-32 weeks of gestation, and estimated individualized deviations from TD developmental trajectories. Associations with fetal hemodynamic indices (substrate delivery score, cerebroplacental ratio [CPR]) and two-year neurodevelopmental outcomes (Bayley Scales of Infant and Toddler Development, N=46 CHD, N=37 TD) were explored. Results: Whole-brain subplate volume was lower in CHD, corresponding to a 5.7% reduction relative to age- and sex-expected values (p=0.003), but this difference was substantially attenuated after accounting for global brain volume (p=0.090). In contrast, regional analyses identified persistent spatially structured deviations beyond global scaling, most consistently involving posterior parietal, occipital and temporal regions, with a left-hemisphere bias in subplate thickness. Normative modelling demonstrated bidirectional regional deviations and increased inter-individual variability in CHD, with extreme subplate volume deviations enriched across 73% of cortical regions (p=0.009). Higher CPR was associated with lower SP thickness deviations, with the association strengthening after accounting for cerebral substrate delivery (p=0.010), although these analyses were exploratory. In CHD fetuses with postnatal follow-up, prenatal subplate deviations showed modest associations with neurodevelopmental outcomes, with right precuneus subplate thickness associated with receptive ({beta}=-11.87, q=0.017) and expressive ({beta}=-14.50, q=0.039) communication on the Bayley, after correction for multiple comparisons. Conclusions: Fetal subplate alterations in CHD are dominated by global reductions in brain growth but also include spatially heterogeneous and individually variable regional deviations beyond global scaling. Exploratory associations with fetal hemodynamics and postnatal neurodevelopment provide hypotheses for future studies investigating the developmental significance of these prenatal alterations.