Extended fetal echocardiographic examination for detecting cardiac malformations in low risk pregnancies

The Utility of Screening Fetal Echocardiograms Following Normal Level II Ultrasounds in Fetuses with Maternal Congenital Heart Disease

INTRODUCTION

Fetal echocardiograms (F-echo) are recommended in all pregnancies when maternal congenital heart disease (CHD) is present, even if there was a prior level II ultrasound (LII-US) that was normal. The goal of this study was to evaluate if any diagnosis of a critical CHD was missed in a fetus with maternal CHD who had a normal LII-US.

METHODS

A retrospective chart review of all F-echoes where the indication was maternal CHD between 1/1/2015 to 12/31/2022 was performed. Fetuses were included if they had a LII-US that was read as normal and had an F-echo. Critical CHD was defined as CHD requiring catheterization or surgical intervention < 1 month of age.

RESULTS

A total of 296 F-echoes on fetuses with maternal CHD were evaluated, of which 175 met inclusion criteria. LII-US was performed at 19.8 ± 2.9 weeks gestational age and F-echo was performed at 24.2 ± 2.8 weeks gestational age. No patient with a normal LII-US had a diagnosis of a critical CHD by F-echo (negative predictive value = 100%). Evaluating those patients that had a negative LII-US, ten patients were diagnosed with non-critical CHD postnatally (negative predictive value = 94.3%). F-echo correctly diagnosed two of the ten missed LII-US CHD.

CONCLUSIONS

Critical CHD was not missed with a normal LII-US in this at risk population. F-echo also missed the majority of CHD when a LII-US was read as normal. A cost-benefit analysis of screening F-echo in fetuses with maternal CHD should be conducted if a normal LII-US has been performed.

Utility of Screening Fetal Echocardiograms at a Single Institution Following Normal Obstetric Ultrasound in Fetuses with Down Syndrome

Fetal echocardiograms (F-echo) are recommended in all pregnancies when the fetus has Down syndrome (DS) even if there was a prior obstetric scan (OB-scan) that was normal. The utility of a screening F-echo in this high-risk population when an OB-scan is normal is unknown. Goal of this study was to evaluate if any diagnosis of a critical congenital heart disease (CHD) was missed in a fetus with DS who had a normal OB-scan. Secondary goal was to determine if any CHD was missed postnatally when an OB-scan was read as normal. Retrospective chart review of all fetuses that had a F-echo whose indication was DS between 1/1/2010 to 6/30/2022 was performed. Fetuses were included if they had an OB-scan that was read as normal and had a F-echo. Postnatal transthoracic echocardiogram (pTTE) was reviewed when available. Critical CHD was defined as CHD requiring catheterization or surgical intervention < 1 month of age. One hundred twenty-two F-echo on fetuses with DS were evaluated, of which 48 met inclusion criteria. OB-scan was performed at 20.4 ± 4.5 weeks gestational age and F-echo was performed at 24.0 ± 4.6 weeks gestational age. No patient with a normal OB-scan had a diagnosis of a critical CHD by F-echo (n = 48, negative predictive value = 100%). Evaluating those patients that had an OB-scan and a pTTE (n = 38), 14 patients were diagnosed with CHD (muscular ventricular septal defect (VSD) n = 5, perimembraneous VSD n = 3, secundum atrial septal defect (ASD) n = 2, primum ASD n = 1, transitional atrioventricular septal defect (AVSD) n = 2, and aortic valve abnormality n = 1; negative predictive value = 63.2%). F-echo correctly diagnosed 4 of the 14 missed OB-scan CHD (perimembraneous VSD n = 2, muscular VSD n = 1, and transitional AVSD n = 1). Critical CHD was not missed with a normal OB-scan in this high-risk population. F-echo also missed the majority of CHD when an OB-scan was read as normal. The cost/benefit of screening F-echo in fetuses with DS should be evaluated if a normal OB-scan has been performed, considering all these patients would have a pTTE performed per guidelines.

First-Trimester Ultrasound Imaging for Prenatal Assessment of the Extended Cardiovascular System Using the Cardiovascular System Sonographic Evaluation Algorithm (CASSEAL)

INTRODUCTION AND OBJECTIVES

To compare fetal images obtained at the first- and second-trimester ultrasound scan when applying the Cardiovascular System Sonographic Evaluation Algorithm (CASSEAL).

METHODS

Using the CASSEAL protocol, nine sequential axial views were acquired in B-mode and color Doppler at the first- and second-trimester ultrasound scans, visualizing the main components of the extended fetal cardiovascular system. Images were compared qualitatively between both trimesters.

RESULTS

We obtained comparable images for all the nine axial views described in the CASSEAL protocol, with few differences and limitations.

CONCLUSIONS

The CASSEAL protocol is reproducible in the first trimester, and could help in the early detection of fetal cardiovascular abnormalities. It represents a promising additional tool in order to increase the CHD detection rate.

Application of Semiautomatic Fetal Intelligent Navigation Echocardiography (FINE) in Twin Pregnancies: Half the Work or Twice the Effort?

OBJECTIVE

To assess the performance of fetal intelligent navigation echocardiography (FINE, 5D Heart™) for automated volumetric investigation of the fetal heart in twin pregnancies.

METHODS

Three hundred twenty-eight twin fetuses underwent fetal echocardiography in the second and third trimesters. Spatiotemporal image correlation (STIC) volumes were obtained for a volumetric investigation. The volumes were analyzed using the FINE software, and the data were investigated regarding image quality and many properly reconstructed planes.

RESULTS

Three hundred and eight volumes underwent final analysis. 55.8% of the included pregnancies were dichorionic twin pregnancies, and 44.2% were monochorionic twin pregnancies. The mean gestational age (GA) was 22.1 weeks, and the mean maternal BMI was 27.3 kg/m². The STIC-volume acquisition was successful in 100.0% and 95.5% of cases. The overall depiction rates of FINE were 96.5% (twin 1) and 94.7% (twin 2), respectively (p = 0.0849, not significant). In 95.9% (twin 1) and 93.9% (twin 2), at least 7 planes were reconstructed properly (p = 0.6056, not significant).

CONCLUSION

Our results indicate that the FINE technique used in twin pregnancies is reliable. No significant difference between the depiction rates of twin 1 and twin 2 could be detected. In addition, the depiction rates are as high as those derived from singleton pregnancies. Due to the challenges of fetal echocardiography in twin pregnancies (i.e., greater rates of cardiac anomaly and more difficult scans), the FINE technique might be a valuable tool to improve the quality of medical care in those pregnancies.

Fetal intelligent navigation echocardiography (FINE) has superior performance compared to manual navigation of the fetal heart by non-expert sonologists

OBJECTIVES

Manual and intelligent navigation (i.e. fetal intelligent navigation echocardiography or FINE) by the operator are two methods to obtain standard fetal cardiac views from spatiotemporal image correlation (STIC) volumes. The objective was to compare the performance between manual and intelligent navigation (FINE) of the fetal heart by non-expert sonologists.

METHODS

In this prospective observational study, ten sonologists underwent formal training on both navigational methods. Subsequently, they were tested on their ability to obtain nine cardiac views from five STIC volumes of normal fetal hearts (19-28 gestational weeks) using such methods. The following parameters were determined for both methods: (1) success rate of obtaining nine cardiac views; (2) mean time to obtain nine cardiac views per sonologist; and (3) maximum number of cardiac views successfully obtained for each STIC volume.

RESULTS

All fetal cardiac images obtained from 100 STIC volumes (50 for each navigational method) were reviewed by an expert in fetal echocardiography. Compared to manual navigation, FINE was associated with a significantly: (1) higher success rate of obtaining eight (excluding the abdomen view) appropriate cardiac views (92-100% vs. 56-88%; all p<0.05); (2) shorter mean time (minute:seconds) to obtain nine cardiac views (2:11 ± 0:37 vs. 15:49 ± 7:44; p<0.0001); and (3) higher success rate of obtaining all nine cardiac views for a given STIC volume (86 vs. 14%; p<0.001).

CONCLUSIONS

When performed by non-expert sonologists, intelligent navigation (FINE) had a superior performance compared to manual navigation of the normal fetal heart. Specifically, FINE obtained appropriate fetal cardiac views in 92-100% of cases.

Maximal Reduction of STIC Acquisition Time for Volumetric Assessment of the Fetal Heart—Benefits and Limitations of Semiautomatic Fetal Intelligent Navigation Echocardiography (FINE) Static Mode

(1) Objective: To scrutinize the reliability and the clinical value of routinely used fetal intelligent navigation echocardiography (FINE) static mode (5DHeartStatic™) for accelerated semiautomatic volumetric assessment of the normal fetal heart. (2) Methods: In this study, a total of 296 second and third trimester fetuses were examined by targeted ultrasound. Spatiotemporal image correlation (STIC) volumes of the fetal heart were acquired for further volumetric assessment. In addition, all fetal hearts were scanned by a fast acquisition time volume (1 s). The volumes were analyzed using the FINE software. The data were investigated regarding the number of properly reconstructed planes and cardiac axis. (3) Results: A total of 257 volumes were included for final analysis. The mean gestational age (GA) was 23.9 weeks (14.3 to 37.7 weeks). In 96.9 (standard acquisition time, FINE standard mode) and 94.2% (fast acquisition time, FINE static mode) at least seven planes were reconstructed properly (p = 0.0961, not significant). Regarding the overall depiction rate, the standard mode was able to reconstruct 96.9% of the planes properly, whereas the static mode showed 95.2% of the planes (p = 0.0098). Moreover, there was no significant difference between the automatic measurement of the cardiac axis (37.95 + 9.14 vs. 38.00 + 8.92 degrees, p = 0.8827, not significant). (4) Conclusions: Based on our results, the FINE static mode technique is a reliable method. It provides similar information of the cardiac anatomy compared to conventional STIC volumes assessed by the FINE method. The FINE static mode has the potential to minimize the influence of motion artifacts during volume acquisition and might therefore be helpful concerning volumetric cardiac assessment in daily routine.

Prenatal Diagnosis of Double Aortic Arch: Associated Findings and Postnatal Clinical Outcomes

OBJECTIVES

The aim of this study is to share our experience in the prenatal diagnosis and characteristics of double aortic arc and neonatal consequences.

METHODS

We retrospectively analyzed 2153 fetal echocardiography reports between 2014 and 2019 years. Records of 14 fetuses with double aortic arc were examined. Prenatal and postnatal medical records, sonographic images, genetic reports, associated cardiac and extracardiac anomalies, and neonatal clinical results of affected fetuses were reviewed retrospectively.

RESULTS

DAA was isolated in 9 of 14 (64.2%) cases, while the other five cases had cardiac or extracardiac accompanying ultrasound findings. Three of cases (21.4%) were associated with other heart pathologies, including ventricular septal defect, double outlet right ventricle, and persistent left superior vena cava. In 10 cases (71.43%), the right aortic arch diameter was dominant. The left aortic arc was dominant in two cases and both arcs were symmetrical in the remaining two cases. 22q11 microdeletion was the only chromosomal abnormality and was detected in two of nine patients who accepted genetic analysis. Intrauterine fetal death occurred in two of the cases. After birth, in 58.3% (7/12) of the live born cases various degrees of symptoms. Surgical repair was performed with the division of the aorta to all symptomatic cases at different times according to severity of the complaints.

CONCLUSIONS

Since it can cause severe respiratory distress in the postnatal period and may accompany chromosomal anomalies, it is important to provide antenatal diagnosis of double aortic arc and adequate counseling to the family.

Usefulness of Postnatal Echocardiograms in Patients with Omphaloceles Who Previously Had a Normal Fetal Echocardiogram

INTRODUCTION

Neonates with omphaloceles routinely have a transthoracic echocardiogram (TTE) performed due to a high association with congenital heart defects (CHD). The utility of a TTE in these patients with a normal fetal echocardiogram is unknown. The primary objective of this study was to determine whether a critical CHD diagnosis was missed in patients with an omphalocele who had a normal fetal echocardiogram. The secondary objective of the study was to determine whether any CHD diagnosis was missed postnatally when a fetal echocardiogram was read as normal.

METHODS

A retrospective chart review was performed of patients with omphaloceles born between January 1, 2008, and June 30, 2020. Patients were included if they had a fetal echocardiogram that was read as normal and had a postnatal echocardiogram performed. Baseline demographics, postnatal data echocardiographic findings, and hospital course were collected. Critical CHD was defined as CHD requiring neonatal cardiac intervention.

RESULTS

Fifty-six fetal echocardiograms on patients with omphaloceles were performed, of which 24 patients met the inclusion criteria. No patient was diagnosed with a critical CHD postnatally (negative predictive value [NPV] = 100%). Two patients were diagnosed with ventricular septal defects (VSD) postnatally (NPV = 91.7%). One of the VSDs required closure with a patch at 4 months of life, while the other, a small muscular VSD, closed spontaneously within the first year of life. Both patients had a murmur on exam during their initial hospital stay. The patient that required surgery also had an abnormal electrocardiogram and chest X-ray. There were no mortalities due to cardiac causes in these patients.

CONCLUSION

Critical CHD was not missed on any patient with an omphalocele who had a normal fetal echocardiogram. All other patients with omphaloceles who had CHD diagnosed postnatally had an abnormal clinical finding on postnatal evaluation. The routine performance of a postnatal TTE in patients with an omphalocele who had a normal fetal echocardiogram may not be needed in those with a normal clinical workup. Further studies evaluating echocardiographic imaging recommendations are needed to maximize care and optimize resource allocation in this complex patient population.

Clinical utility of fetal echocardiography: an Egyptian center experience

BACKGROUND

The impact of early diagnosis of fetal cardiac abnormalities on the postnatal outcome has been controversial in literature. We aimed to evaluate the role of fetal echocardiography (FE) as a diagnostic tool for early detection and proper management of fetal cardiac abnormalities, study the indications of referral and detect the perinatal outcome in our institution.

RESULTS

This is a cross-sectional observational and descriptive study that included one hundred and one singleton pregnant women (101 fetuses) who were referred for FE over a period of one year. Indications for referral and perinatal risk factors were documented. FE and postnatal transthoracic echocardiography were done. Fetal cardiac abnormalities were detected in 46.5% of cases. Congenital heart defects (CHDs) in 34.6%, fetal arrythmias in 9.9%, cardiomyopathy in 2.9% and cardiac mass (Rhabdomyoma) in 1% (combined structural and rhythm abnormalities were observed in two fetuses). Of the CHDs, complex heart lesions were diagnosed in 57.1%, common atrioventricular canal in 28.6% and conotrunchal anomalies in 14.3%. Of the ten cases with fetal arrythmias, five fetuses had tachyarrhythmias, four had ectopics and one fetus had congenital heart block in association with maternal lupus. The indications for referral were abnormal obstetric ultrasound (52.5%), maternal medical illnesses (23.8%), multiple neonatal deaths (13.9%) and positive family history of CHD (10.9%). The number of fetuses with cardiac abnormalities was significantly higher than those without cardiac abnormalities in mothers not exposed to perinatal risk factors (p = 0.009) and was statistically lower in mothers exposed to perinatal risk factors (p = 0.005). FE showed 100% accuracy in diagnosing complex lesions, common atrio-ventricular canals, cono-truncal anomalies, cardiac masses and fetal arrhythmias. It missed two cases of tiny muscular ventricular septal defects and one case of aortic coarctation. Cases of fetal supraventricular tachycardia were successfully treated in-utero.

CONCLUSIONS

CHDs exist in fetuses with no underlying perinatal risk factors. FE can accurately diagnose most of the cardiac anomalies though few errors remain challenging (aortic coarctation). It also offers a good chance for successful early life-saving management of some types of fetal arrhythmia.

Feasibility of Semiautomatic Fetal Intelligent Navigation Echocardiography for Different Fetal Spine Positions: A Matter of "Time"?

OBJECTIVES

We investigated the feasibility of a semiautomatic approach for assessments of the fetal heart (fetal intelligent navigation echocardiography [FINE]) in cases of optimal and unfavorable fetal spine positions.

METHODS

In this study, a total of 1693 spatiotemporal image correlation volumes of first-, second-, and third-trimester fetuses were evaluated by experts using the FINE approach. The data were analyzed regarding proper reconstruction of the diagnostic cardiac planes depending on the fetal spine position.

RESULTS

A total of 1531 volumes were included. The volumes were divided into 4 groups depending on the fetal spine position: 5-7 o'clock, 4 + 8 o'clock, 3 + 9 o'clock, and 2 + 10 o'clock. In total, 93.2% of the diagnostic planes were displayed properly. Between 5 and 7 o'clock, 94.9% of the diagnostic planes were displayed properly. The correct depiction rates in the other groups were 92.4% (4 + 8 o'clock; n = 538; P = 0.0027), 88.3% (3 + 9 o'clock; n = 156; P < .0001), and 87.3% (2 + 10 o'clock; n = 41; P = .0139). In total, the highest dropout rates were found in the sagittal planes: ductal arch, 13.9%; aortic arch, 10.5%; and venae cavae, 12.0%.

CONCLUSIONS

Based on our results, the FINE technique is an effective method, but its feasibility depends on the fetal position. The use of this semiautomatic work flow-based approach supports evaluation of the fetal heart in a standardized manner. Semiautomatic evaluation of the fetal heart might be useful in facilitating the detection of fetal cardiac anomalies.

Initial fetal to initial postnatal echocardiogram in uncomplicated atrioventricular septal defects: Do significant changes occur?

BACKGROUND

Yield of serial echocardiography in fetuses with atrioventricular septal defects (fAVSD) has not been well defined. The goal of this study was to document if any major changes occurred from initial fetal to initial postnatal echocardiogram in uncomplicated fAVSD.

METHODS

fAVSD were excluded if initial fetal scan documented complex CHD or any concerns. Changes in ventricular function, valvular regurgitation, or diagnosis between first fetal and first postnatal echocardiogram were recorded.

RESULTS

Fifty-seven fAVSD met criteria. Ninety-six fetal echocardiograms were done in 57 patients. Initial fetal scan was performed at 24.3 ± 3.7 weeks of estimated gestational age. All fAVSD had normal function, 38 had no atrioventricular valve regurgitation (AVVR), and 19 had mild AVVR. First postnatal echocardiogram was performed at 6.3 ± 15.3 days. Fifty-six patients had normal function, 1 patient had mild dysfunction, 16 patients had no AVVR, 36 had mild AVVR, and 5 had moderate AVVR. Three patients (5%) had an improvement in AVVR by one degree, 27 patients (47%) had no change in AVVR, 24 patients (42%) had an increase in AVVR by one degree, and 3 patients (5%) had an increase in AVVR by two degrees. There was no major missed anatomical diagnosis from first prenatal to first postnatal echocardiogram.

CONCLUSION

In fAVSD that had no concerns on their initial fetal echocardiogram, the majority of patients had no major changes noted between their initial fetal echocardiogram and their first postnatal echocardiogram. Repeat fetal echocardiograms may not necessarily be needed in this cohort of patients.

The Evaluation of Fetal Cardiac Remote Screening in the Second Trimester of Pregnancy Using the Spatio-Temporal Image Correlation Method

We prospectively performed remote fetal cardiac screening using the spatio-temporal image correlation (STIC), and examined the usefulness and problems of remote screening. We performed heart screening for all pregnant women at four obstetrics clinics over the three years from 2009 to 2014. The STIC data from 15,404 examinations in normal pregnancies (16-27 weeks, median 25 weeks) were analyzed. Obstetricians and sonographer collected STIC data from four-chamber view images. Eight pediatric cardiologists analyzed the images offline. A normal heart was diagnosed in 14,002 cases (90.9%), an abnormal heart was diagnosed in 457 cases (3.0%), and poor images were obtained in 945 cases (6.1%). 138 cases had congenital heart disease (CHD) after birth, and severe CHD necessitating hospitalization occurred in 36 cases. We were not able to detect CHD by screening in 12 cases. The sensitivity and specificity of STIC in CHD screening was 50% and 99.5%, respectively. The sensitivity and specificity of STIC in screening for severe CHD was 82% and 99.9%, respectively. The STIC method was useful in fetal remote screening for CHD. However, the fact that > 10% of images that could not be analyzed by this method was a problem.

Low prenatal detection rate of valvar pulmonary stenosis: What are we missing?

OBJECTIVES

Critical pulmonary stenosis (PS) and pulmonary atresia with intact ventricular septum (PAIVS) require urgent neonatal intervention. Since PS may be more insidious than PAIVS during gestation, we hypothesized that neonates with PS would have lower rates of prenatal detection than PAIVS.

METHODS

We performed a retrospective chart review of all neonates who underwent diagnostic or interventional cardiac catheterization between 2000 and 2014 for critical PS or PAIVS. The rates of prenatal diagnosis were calculated for PS and PAIVS. Prenatal and postnatal echocardiographic data were reviewed.

RESULTS

178 patients met inclusion criteria: 91 with critical PS and 87 with PAIVS. The prenatal diagnosis rate for critical PS was lower than for PAIVS at 37% (34/91) vs 60% (52/87) (P = .003). At the time of diagnosis at a median gestational age of 25 weeks, the median TV z-score for patients with critical PS was larger than in PAIVS (-0.15 vs -3.0 P = .004).

CONCLUSION

Critical PS had a lower prenatal detection rate than PAIVS, likely due to a relatively normal 4-chamber view at the time of routine second trimester screening in patients with PS. Color flow Doppler of the outflow tracts may improve detection, since outflow tracts may appear normal by 2D imaging.

Behavior of fetal longitudinal myocardial fibers assessed by speckle tracking to obtain strain and strain rate values for low-risk pregnancies

Objective To analyze the behavior of fetal longitudinal myocardial fibers assessed by speckle tracking (STE) after fetal viability. Methods A cross-sectional study was performed in 156 women with normal singleton pregnancies from 22 to 31 weeks of gestation. Strain (S) and strain rate (SR) values were measured in both ventricles during the fetal cardiac cycle. The population was divided into five gestational age groups based on 2-week intervals. The correlations of maternal variables with the S and SR variables and intra-observer analysis were performed. Results There was a significant difference in the S and SR values of the left ventricle (LV) among the gestational age groups (P = 0.007). Significantly higher S and SR values were observed in early age groups demonstrating reductions in LV S and SR values at 26 weeks, followed by stabilization. For the right ventricle (RV), there was no significant difference between gestational age groups. Significant intra-observer agreement was observed for S values of the RV (P = 0.008) and LV (P = 0.0004) and SR values of the RV (P = 0.0001) and LV (P = 0.015). Conclusion Decreases in the S and SR values of the LV occurred after 26 weeks, followed by stabilization. No significant difference was observed in the S or SR value of the RV among the gestational age groups, and no significant association of any maternal variable evaluated with S and SR values was observed. Significant intra-observer agreement was obtained among the results.

Semiautomatic Fetal Intelligent Navigation Echocardiography Has the Potential to Aid Cardiac Evaluations Even in Less Experienced Hands

OBJECTIVES

To investigate the interobserver and intraobserver variability and corresponding learning curve in a semiautomatic approach for a standardized assessment of the fetal heart (fetal intelligent navigation echocardiography [FINE]).

METHODS

A total of 30 stored spatiotemporal image correlation volume data sets of second-trimester fetuses were evaluated by 3 physicians with different levels of expertise in fetal echocardiography by using the FINE approach. Data were analyzed regarding the examination time and proper reconstruction of the diagnostic cardiac planes. The completions and numbers of correct depictions of all diagnostic planes were evaluated by a blinded expert (time t0). To determine interobserver and intraobserver variability, the volumes were reassessed after a 4-week training interval (time t1).

RESULTS

All operators were able to perform the investigation on all 30 volumes. At t0, the interobserver variability between the beginner and both the advanced (P = .0013) and expert (P < .0001) examiners was high. Focusing on intraobserver variability at t1, the beginner showed a marked improvement (P = .0087), whereas in advanced and expert hands, no further improvement regarding proper achievement of all diagnostic planes could be noticed (P > .999; P = .8383). The beginner also showed improvement in the mean investigation time (t0, 82.8 seconds; t1, 73.4 seconds; P = .0895); nevertheless, the advanced and expert examiners were faster in completing the examination (t1, advanced, 20.9 seconds; expert, 28.3 seconds; each P < .0001).

CONCLUSIONS

Based on our results, the FINE technique is a reliable and easily learned method. The use of this semiautomatic work flow-based approach supports evaluation of the fetal heart in a standardized and time-saving manner. A semiautomatic evaluation of the fetal heart might be useful in facilitating the detection of fetal cardiac anomalies.

Usefulness of Postnatal Echocardiography in Patients with Down Syndrome with Normal Fetal Echocardiograms

The objective of this study is to evaluate if the diagnosis of a complex congenital heart disease (CHD) was missed in a patient with Down syndrome (DS) who had a fetal echocardiogram that was read as normal. Secondary goal of this study was to determine if any CHD was missed postnatally when a fetal echocardiogram was read as normal. A retrospective chart review of children with DS at Nationwide Children's Hospital whose birthdates were between 1/1/2010 and 12/31/2017 was performed. Patients were included if they had a fetal echocardiogram that was read as normal and also had a postnatal echocardiogram performed. One hundred twenty fetal echocardiograms on patients with DS were performed, of which 45 patients met the inclusion criteria. No patient was diagnosed with a complex CHD postnatally, with a negative predictive value = 100%. Thirteen patients were diagnosed with CHD postnatally, with a negative predictive value of 71.1%. All 13 patients had either a murmur (11) or an abnormal EKG (9). One patient died at 8 days of life due to pulmonary hypertension complications. Five patients had resolution of their CHD, 2 patients have near resolution, 2 patients are being followed for their atrial septal defects and 3 underwent intervention (septum primum surgical repair = 1, PDA catheter occlusion = 2). Complex CHD was not missed on any fetal echocardiograms performed on patients with DS. All the other patients who had CHD diagnosed postnatally had an abnormal finding on evaluation. Further studies evaluating echocardiographic imaging recommendations are needed to maximize care in this patient population.

Neonatal outcome of cases with isolated prenatal ventricular disproportion with a dominant right ventricle

OBJECTIVES

Isolated prenatal ventricular disproportion with a dominant right ventricle represents a challenge in decision-making for both physicians and pregnant women. In the current study, we sought to delineate the postnatal outcomes of these cases.

METHODS

This retrospective analysis included consecutive cases of isolated ventricular disproportion identified using complete fetal echocardiography at the Fetal Heart Center of Xinhua Hospital from January 2014 to October 2017. Postnatal cardiac outcome was examined using transthoracic echocardiography within the first 6 months after birth.

RESULTS

A total of 90 fetuses were included in the final analysis. The median gestational age (GA) at diagnosis was 29 weeks (range 24 to 36). At postnatal examination, cardiac malformations were detected in 39 cases (43.3%), including 25 (27.8%) cases of congenital cardiac septal defects, eight (8.9%) of persistent left superior vena cava, four (4.4%) of left-sided obstructive diseases, and one (1.1%) case of coronary fistula. Nineteen cases (21.1%) with fetal cardiac malformations had significant lower GA at diagnosis (P = .01) and greater right to left ventricle ratio (1.38 vs 1.30, P = .02). Neonatal surgical intervention was not required in any of the cases.

CONCLUSIONS

Isolated prenatal ventricular disproportion with a dominant right ventricle comprises minor postnatal cardiac malformations and doesn't require neonatal intervention.

[The left outflow tract: Normal features]

Congenital heart disease remains an important cause of perinatal morbidity and mortality. Screening for these is based on a good knowledge of normal fetal heart anatomy and ultrasound views to be performed. After recommending the use of the four chambers and the right outflow tract views in 2005, CNEOF proposes recently adding the left outflow tract assessment. The use of this one should sensitize the operator to the notion of sweeping essential to obtain all these views and make it possible to improve the detection of the conal VSD and conotruncal pathologies.

The Extended Fetal Cardiac Examination: Is It Feasible in a High-Risk Practice?

The aims of this study were to demonstrate the feasibility of obtaining additional cardiac views as proposed on an extended fetal cardiac examination and to see if there was any variation in individual components of that examination stratified by sonographer training, patient body habitus, or equipment. We retrospectively reviewed 200 consecutive detailed second-trimester high-risk fetal obstetric sonograms that included additional extended cardiac views. We analyzed the percentage of the time individual views were obtained, with variation based on (1) a sonographer with greater than 3 years of training compared with a group with 6 to 12 months of training, (2) 2 different ultrasound units, and (3) different body mass indices. Overall, the highest rate of visualization was achieved with the 4-chamber view (98.2%), whereas the 3-vessel tracheal view had the lowest percentage of visualization (40.2%), among the less experienced sonographers. Differences in successful completion of the extended cardiac views were not statistically different between the sonographer with a level of training greater than 3 years as compared with those with 6 to 12 months' training except for the 3-vessel tracheal view (P < 0.001). There is no statistically significant difference in our ultrasound equipment, when considering only inexperienced sonographers. Increasing body mass index had an inverse relationship with obtaining the components of the detailed cardiac examination. Using state-of-the-art ultrasound equipment and with focused additional training of obstetric sonographers, the majority of extended cardiac views can be obtained. There are exceptions.

Sonographer-Identified Barriers and Facilitators to Prenatal Screening for Congenital Heart Disease

Background: Fetal ultrasound screening for congenital heart disease has high detection rates in efficacy studies but not in practice. We investigated sonographers’ perspectives on barriers to screening and their association with intermediate measures of cardiac imaging. Methods: Barriers to fetal heart screening were identified in focus groups with obstetric sonographers. A web-based survey measured reported barriers and sonographers’ ability to interpret fetal heart screening images. Generalized linear random effect models assessed associations between barriers and image interpretation. Results: Four themes were identified: intrinsic barriers (self-efficacy), external barriers (time), informational needs, and provider and patient expectations. Among 224 sonographers surveyed, an average of 77.6% of fetal heart images were interpreted correctly. Perceptions about self-efficacy ( P = .03) and ease of performing imaging ( P = .01) were associated with accuracy of image interpretation. Conclusions: Several sonographer-identified barriers associated with image interpretation may be novel targets for improving prenatal detection of congenital heart disease.

A systematic review of prenatal screening for congenital heart disease by fetal electrocardiography

BACKGROUND

Congenital heart disease (CHD) is the most common severe congenital anomaly worldwide. Diagnosis early in pregnancy is important, but the detection rate by two-dimensional ultrasonography is only 65%-81%.

OBJECTIVES

To evaluate existing data on CHD and noninvasive abdominal fetal electrocardiography (ECG).

SEARCH STRATEGY

A systematic review was performed through a search of the Cochrane Library, PubMed, and Embase for studies published up to April 2016 using the terms "congenital heart disease," "fetal electrocardiogram," and other similar keywords.

SELECTION CRITERIA

Primary articles that described changes in fetal ECG among fetuses with CHD published in English were included.

DATA COLLECTION AND ANALYSIS

Outcomes of interest were changes in fetal ECG parameters observed for fetuses with congenital heart disease. Findings were reported descriptively.

MAIN RESULTS

Only five studies described changes observed in the fetal electrocardiogram for fetuses with CHD, including heart rate, heart rate variability, and PR, QRS, and QT intervals. Fetal ECG reflects the intimate relationship between the cardiac nerve conduction system and the structural morphology of the heart. It seems particularly helpful in detecting the electrophysiological effects of cardiac anatomic defects (e.g. hypotrophy, hypertrophy, and conduction interruption).

CONCLUSIONS

Fetal ECG might be a promising clinical tool to complement ultrasonography in the screening program for CHD.

Role of the 3-Vessel and Trachea View in Antenatal Detection of Tetralogy of Fallot

Prenatal diagnosis of tetralogy of Fallot remains less frequent compared to other major congenital heart defects. In this study, we examined how often the 3-vessel and trachea view was abnormal in a large series of prenatally diagnosed cases of tetralogy of Fallot. In addition, we compared its sensitivity to that of the traditional outflow tract views for detection of tetralogy of Fallot. We found that both views were abnormal in all fetuses with tetralogy of Fallot, showing reversed aortic-to-pulmonary valve and aortic arch isthmus-to-ductus arteriosus ratios in the outflow tract and 3-vessel and trachea views, respectively. However, as a single measured marker, the enlarged aortic arch isthmus on the 3-vessel and trachea view appears to be the most sensitive for tetralogy of Fallot.

A Review of Fetal Circulation and the Segmental Approach in Fetal Echocardiography

The incidence of congenital heart disease is generally estimated at 8 in 1000 live births. Fifty percent of these neonates will have “minor” defects—easily corrected with some intervention. The remainder will account for 30% of perinatal deaths and nearly 50% of lethal malformations in childhood. The purpose of this review is to outline essential guidelines for a thorough fetal echocardiogram and how it differs from the fetal cardiac imaging included as part of an obstetric sonographic examination. Specific values for both the anatomic and blood flow velocity measurements recommended are typically related to gestational age and method of acquisition. Multiple references exist in the literature that define these values.

Fetal cardiac interventions: clinical and experimental research

Fetal cardiac interventions for congenital heart diseases may alleviate heart dysfunction, prevent them evolving into hypoplastic left heart syndrome, achieve biventricular outcome and improve fetal survival. Candidates for clinical fetal cardiac interventions are now restricted to cases of critical aortic valve stenosis with evolving hypoplastic left heart syndrome, pulmonary atresia with an intact ventricular septum and evolving hypoplastic right heart syndrome, and hypoplastic left heart syndrome with an intact or highly restrictive atrial septum as well as fetal heart block. The therapeutic options are advocated as prenatal aortic valvuloplasty, pulmonary valvuloplasty, creation of interatrial communication and fetal cardiac pacing. Experimental research on fetal cardiac intervention involves technical modifications of catheter-based cardiac clinical interventions and open fetal cardiac bypass that cannot be applied in human fetuses for the time being. Clinical fetal cardiac interventions are plausible for midgestation fetuses with the above-mentioned congenital heart defects. The technical success, biventricular outcome and fetal survival are continuously being improved in the conditions of the sophisticated multidisciplinary team, equipment, techniques and postnatal care. Experimental research is laying the foundations and may open new fields for catheter-based clinical techniques. In the present article, the clinical therapeutic options and experimental fetal cardiac interventions are described.

How to Acquire Cardiac Volumes for Sonographic Examination of the Fetal Heart: Part 2

The effective performance of fetal cardiac examination using spatiotemporal image correlation (STIC) technology requires 2 essential steps: volume acquisition and postprocessing. An important prerequisite is training sonologists to acquire high-quality volume data sets so that when analyzed, such volumes are informative. This article is part 2 of a series on 4-dimensional sonography with STIC. Part 1 focused on STIC technology and its features, the importance of operator training/experience and acquisition of high-quality STIC volumes, factors that affect STIC volume acquisition rates, and general recommendations on performing 4D sonography with STIC. In part 2, we discuss a detailed and practical stepwise approach for STIC volume acquisition, along with methods to determine whether such volumes are appropriate for analysis.

Fetal Aortic Arch Anomalies: Key Sonographic Views for Their Differential Diagnosis and Clinical Implications Using the Cardiovascular System Sonographic Evaluation Protocol

Aortic arch anomalies are present in 1% to 2% of the general population and are commonly associated with congenital heart disease, chromosomal defects, and tracheaesophageal compression in postnatal life. The sonographically based detection of aortic arch anomalies lies in the 3-vessel and trachea view. Although highly sensitive, this view alone does not allow identification of the aortic arch branching pattern, which prevents an accurate diagnosis. The systematic addition of a subclavian artery view as part of a standardized procedure may be useful in the differential diagnosis of these conditions. We describe the sonographic assessment of fetal aortic arch anomalies by combining 2 fetal transverse views: the 3-vessel and trachea view and the subclavian artery view, which are included in the cardiovascular system sonographic evaluation protocol. We also review the sonographic findings and the clinical implications of fetal aortic arch anomalies.

Diagnostic Value of Fetal Echocardiography for Congenital Heart Disease: A Systematic Review and Meta-Analysis

Prenatal diagnosis of fetal congenital heart disease (CHD) has been shown to have a significant effect on prenatal and postnatal management and outcomes. However, the factors influencing the diagnostic accuracy and which pregnant trimester is the most adaptive for fetal heart disease remain uncertain despite of extensive researches. The aim of the present study was to evaluate the accuracy of echocardiography for detecting CHD and potential influence factors.We searched Chinese Biomedical Database (CBM), Medline, ISI Web of Knowledge, the Cochrane Library, and China National Knowledge Infrastructure (CNKI) to identify relevant studies from January 1, 1990 to August 13, 2015.Overall, the pooled sensitivity, specificity, diagnostic odds ratio, positive likelihood ratio, and negative likelihood ratio were 68.5% (95% confidence interval [CI], 66.8%-70.2%), 99.8% (95% CI, 99.7%-99.8%), 3026.9 (95% CI, 1417.9-6461.8), 659.41 (95% CI, 346.38-1255.3), and 0.246 (95% CI, 0.187-0.324) respectively (AUC = 0.9924). The pooled sensitivity of basic cardiac echocardiographic examination (BCEE), extended cardiac echocardiographic examination (ECEE), BCEE plus outflow tract view (BCEE + OTV), BCEE + OTV + 3VTV (BCEE plus outflow tract view plus three vessel and trachea view) for the prenatal diagnosis of CHD were 49.0%, 75.5%, 66.1%, and 83.7% respectively. The pooled sensitivity of the prenatal echocardiographic diagnosis of CHD during the first trimester, second trimester, the second to third trimester were 60.3%, 60.9%, and 77.4%, respectively. The pooled sensitivity of BCEE and ECEE for the prenatal diagnosis of CHD during the second to third trimester was significantly higher than that during the second trimester. The pooled sensitivity of the prenatal echocardiographic diagnosis of CHD for pregnancies with low risk, high risk, low and high risk, and unselected risk were 45.4%, 85.1%, 89.1%, and 66.2%, respectively. The sensitivity analysis was robust and risk level was significant source of heterogeneity. Deek test indicated no potential significant publication bias.Prenatal ultrasound is a powerful tool for the diagnosis of CHD; however, echocardiography has individual sensitivity for different gestation period, different levels of risk, and different echo-views.

Cardiovascular System Sonographic Evaluation Algorithm: A New Sonographic Algorithm for Evaluation of the Fetal Cardiovascular System in the Second Trimester

OBJECTIVES

To evaluate the reproducibility and feasibility of the new cardiovascular system sonographic evaluation algorithm for studying the extended fetal cardiovascular system, including the portal, thymic, and supra-aortic areas, in the second trimester of pregnancy (19-22 weeks).

METHODS

We performed a cross-sectional study of pregnant women with healthy fetuses (singleton and twin pregnancies) attending our center from March to August 2011. The extended fetal cardiovascular system was evaluated by following the new algorithm, a sequential acquisition of axial views comprising the following (caudal to cranial): I, portal sinus; II, ductus venosus; III, hepatic veins; IV, 4-chamber view; V, left ventricular outflow tract; VI, right ventricular outflow tract; VII, 3-vessel and trachea view; VIII, thy-box; and IX, subclavian arteries. Interobserver agreement on the feasibility and exploration time was estimated in a subgroup of patients. The feasibility and exploration time were determined for the main cohort. Maternal, fetal, and sonographic factors affecting both features were evaluated.

RESULTS

Interobserver agreement was excellent for all views except view VIII; the difference in the mean exploration time between observers was 1.5 minutes (95% confidence interval, 0.7-2.1 minutes; P < .05). In 184 fetuses (mean gestational age ± SD, 20 ± 0.6 weeks), the feasibility of all views was close to 99% except view VIII (88.7%). The complete feasibility of the algorithm was 81.5%. The mean exploration time was 5.6 ± 4.2 minutes. Only the occiput anterior fetal position was associated with a lower frequency of visualization and a longer exploration time (P < .05).

CONCLUSIONS

The cardiovascular system sonographic evaluation algorithm is a reproducible and feasible approach for exploration of the extended fetal cardiovascular system in a second-trimester scan. It can be used to explore these areas in normal and abnormal conditions and provides an integrated image of extended fetal cardiovascular anatomy.

Pediatric prenatal diagnosis of congenital heart disease

PURPOSE OF REVIEW

Fetal cardiology is a rapidly evolving field. Imaging technology continues to advance as do approaches to in-utero interventions and care of the critically ill neonate, with even greater demand for improvement in prenatal diagnosis of congenital heart disease (CHD) and arrhythmias.

RECENT FINDINGS

Reviewing the advances in prenatal diagnosis of CHD in such a rapidly developing field is a broad topic. Therefore, we have chosen to focus this review of recent literature on challenges in prenatal detection of CHD, challenges in prenatal counseling, advances in fetal arrhythmia diagnosis, and potential benefits to patients with CHD who are identified prenatally.

SUMMARY

As methods and tools to diagnose and manage CHD and arrhythmias in utero continue to improve, future generations will hopefully see a reduction in both prenatal and neonatal morbidity and mortality. Prenatal diagnosis can and should be used to optimize location and timing of delivery and postnatal interventions.

Second trimester cardiac diagnosis: screening standards and outcomes

Second trimester screening for congenital heart defects occurs during the routine 18-20 weeks' anomaly scan in many countries. Most congenital heart defects can be prenatally detected by experts in foetal echocardiography working in tertiary centres with high-risk pregnancies. Many studies, however, have shown that detection rates obtained by experts are not reproducible in the low-risk peripheral practices where most of the foetal screening takes place. As the majority of foetuses with congenital heart defects are born to mothers with no identifiable risk factors, it is important that widespread screening of the low-risk population occurs. To facilitate this, standard protocols have been introduced in several countries, but they are not universal and have differing sensitivities depending on the screening views advocated and the area studied. Initially, only performing the four-chamber view (basic scan) was advocated. By adding the outflow tract views (extended scan), three-vessel, and laterality views, the sensitivity of the examination can be significantly increased. Unfortunately, the sensitivity of these extended protocols still does not meet that obtainable in experienced hands, reflecting the additional skill required to obtain these extended views. Thus, close links are required between the tertiary centres and the screening centres to teach and maintain the skills required to obtain and interpret the required views, and to support the sonographer's commitment. Furthermore, an audit system is required to trace false-positive and -negative cases so that targeted interventions can be planned. This is important, as a missed case of prenatal congenital heart defect is potentially a missed opportunity to reduce postnatal morbidity and mortality.

Who should be referred? An evaluation of referral indications for fetal echocardiography in the detection of structural congenital heart disease

Although fetal echocardiography is a useful tool for earlier detection of congenital heart disease (CHD), no clear, evidence-based appropriate use criteria exist. This study aimed to determine those referral indications most predictive of CHD. A retrospective cohort study of fetal echocardiograms was conducted at a single tertiary care center. Binomial proportion tests were used to compare likelihoods of structural CHD detection based on primary indication with the general population prevalence of 0.8%. Fetal echocardiograms of 2,380 pregnancies were performed, with CHD detected in 29.3% of these pregnancies. Patients referred for suspected CHD on screening ultrasound had the highest prevalence of CHD. Of the women without a history of cardiac anomalies shown on screening ultrasound, those with extracardiac anomalies or known chromosomal abnormalities had the highest prevalence of CHD. Screening ultrasound currently is the most useful method for determining who should be referred for fetal echocardiography, with a high prevalence of CHD found. For women with normal cardiac screening ultrasound results, fetal factors such as extracardiac anomalies and chromosomal abnormalities are more predictive of CHD than maternal or familial factors.

Cost-effectiveness of prenatal screening strategies for congenital heart disease

OBJECTIVE

The economic implications of strategies to improve prenatal screening for congenital heart disease (CHD) in low-risk mothers have not been explored. The aim was to perform a cost-effectiveness analysis of different screening methods.

METHODS

We constructed a decision analytic model of CHD prenatal screening strategies (four-chamber screen (4C), 4C + outflow, nuchal translucency (NT) or fetal echocardiography) populated with probabilities from the literature. The model included whether initial screens were interpreted by a maternal-fetal medicine (MFM) specialist and different referral strategies if they were read by a non-MFM specialist. The primary outcome was the incremental cost per defect detected. Costs were obtained from Medicare National Fee estimates. A probabilistic sensitivity analysis was undertaken on model variables commensurate with their degree of uncertainty.

RESULTS

In base-case analysis, 4C + outflow referred to an MFM specialist was the least costly strategy per defect detected. The 4C screen and the NT screen were dominated by other strategies (i.e. were more costly and less effective). Fetal echocardiography was the most effective, but most costly. On simulation of 10 000 low-risk pregnancies, 4C + outflow screen referred to an MFM specialist remained the least costly per defect detected. For an additional $580 per defect detected, referral to cardiology after a 4C + outflow was the most cost-effective for the majority of iterations, increasing CHD detection by 13 percentage points.

CONCLUSIONS

The addition of examination of the outflow tracts to second-trimester ultrasound increases detection of CHD in the most cost-effective manner. Strategies to improve outflow-tract imaging and to refer with the most efficiency may be the best way to improve detection at a population level.

Feasibility of detection of the 3-vessel and trachea view using 3-dimensional sonographic volumes

OBJECTIVES

The purpose of this study was to investigate the ability to depict the 4-chamber and 3-vessel and trachea views of the fetal heart using 3-dimensional sonography.

METHODS

Three-dimensional color Doppler volumes of the fetal heart were acquired prospectively in 31 fetuses between 19 and 25 gestational weeks. The initial plane consisted of the 4-chamber view. Postprocessing included navigation within the volume solely in plane A in the caudal direction to visualize the stomach and in the cephalic direction to the plane of the 3-vessel and trachea view to visualize the pulmonary artery, the aorta, the V shape and color of the arches, the superior vena cava, and the trachea. The feasibility of showing these organs was evaluated.

RESULTS

The estimated time for volume acquisition and manipulation was about 60 seconds. The detection rates for the 4-chamber view, stomach, 3-vessel view, trachea, and V sign were 100%, 93.5%, 92.0%, 77.4%, and 83.9%, respectively, with interobserver agreement of 0.76 to 1.0.

CONCLUSIONS

We describe a simple technique in which a single sweep on 3-dimensional sonography starting at the level of the 4-chamber view can visualize the situs, stomach, 4-chamber view, and transverse view of the outflow tracts of the heart.

The fetal three-vessel and tracheal view revisited

The routine use of four-chamber screening of the fetal heart was pioneered in the early 1980s and has been shown to detect reliably mainly univentricular hearts in the fetus. Many conotruncal anomalies and ductal-dependent lesions may, however, not be detected with the four-chamber view alone and additional planes are needed. The three-vessel and tracheal (3VT) view is a transverse plane in the upper mediastinum demonstrating simultaneously the course and the connection of both the aortic and ductal arches, their relationship to the trachea and the visualization of the superior vena cava. The purpose of the article is to review the two-dimensional anatomy of this plane and the contribution of colour Doppler and to present a checklist to be achieved on screening ultrasound. Typical suspicions include the detection of abnormal vessel number, abnormal vessel size, abnormal course and alignment and abnormal colour Doppler pattern. Anomalies such as pulmonary and aortic stenosis and atresia, aortic coarctation, interrupted arch, tetralogy of Fallot, common arterial trunk, transposition of the great arteries, right aortic arch, double aortic arch, aberrant right subclavian artery, left superior vena cava are some of the anomalies showing an abnormal 3VT image. Recent studies on the comprehensive evaluation of the 3VT view and adjacent planes have shown the potential of visualizing the thymus and the left brachiocephalic vein during fetal echocardiography and in detecting additional rare conditions. National and international societies are increasingly recommending the use of this plane during routine ultrasound in order to improve prenatal detection rates of critical cardiac defects.

Fetal Intelligent Navigation Echocardiography (FINE): a novel method for rapid, simple, and automatic examination of the fetal heart

OBJECTIVE

To describe a novel method (Fetal Intelligent Navigation Echocardiography (FINE)) for visualization of standard fetal echocardiography views from volume datasets obtained with spatiotemporal image correlation (STIC) and application of 'intelligent navigation' technology.

METHODS

We developed a method to: 1) demonstrate nine cardiac diagnostic planes; and 2) spontaneously navigate the anatomy surrounding each of the nine cardiac diagnostic planes (Virtual Intelligent Sonographer Assistance (VIS-Assistance®)). The method consists of marking seven anatomical structures of the fetal heart. The following echocardiography views are then automatically generated: 1) four chamber; 2) five chamber; 3) left ventricular outflow tract; 4) short-axis view of great vessels/right ventricular outflow tract; 5) three vessels and trachea; 6) abdomen/stomach; 7) ductal arch; 8) aortic arch; and 9) superior and inferior vena cava. The FINE method was tested in a separate set of 50 STIC volumes of normal hearts (18.6-37.2 weeks of gestation), and visualization rates for fetal echocardiography views using diagnostic planes and/or VIS-Assistance® were calculated. To examine the feasibility of identifying abnormal cardiac anatomy, we tested the method in four cases with proven congenital heart defects (coarctation of aorta, tetralogy of Fallot, transposition of great vessels and pulmonary atresia with intact ventricular septum).

RESULTS

In normal cases, the FINE method was able to generate nine fetal echocardiography views using: 1) diagnostic planes in 78-100% of cases; 2) VIS-Assistance® in 98-100% of cases; and 3) a combination of diagnostic planes and/or VIS-Assistance® in 98-100% of cases. In all four abnormal cases, the FINE method demonstrated evidence of abnormal fetal cardiac anatomy.

CONCLUSIONS

The FINE method can be used to visualize nine standard fetal echocardiography views in normal hearts by applying 'intelligent navigation' technology to STIC volume datasets. This method can simplify examination of the fetal heart and reduce operator dependency. The observation of abnormal echocardiography views in the diagnostic planes and/or VIS-Assistance® should raise the index of suspicion for congenital heart disease.

Performance of different scan protocols of fetal echocardiography in the diagnosis of fetal congenital heart disease: a systematic review and meta-analysis

OBJECTIVE

The rapid progress in fetal echocardiography has lead to early detection of congenital heart diseases. Increasing evidences have shown that prenatal diagnosis could be life saving in certain cases. However, there is no agreement on which protocol is most adaptive diagnostic one. Thus, we use meta-analysis to conduct a pooled performance test on 5 diagnostic protocols.

METHODS

We searched PUBMED, EMBASE, the Cochrane Central Register of Controlled Trials and WHO clinical trails registry center to identify relevant studies up to August, 2012. We performed meta-analysis in a fixed/random-effect model using Meta-disc 1.4. We used STATA 11.0 to estimate the publication bias and SPSS 17.0 to evaluate variance.

RESULTS

We use results from 81 studies in 63 articles to analyze the pooled accuracy. The overall performance of pooled sensitivities of spatiotemporal image correlation (STIC), extend cardiac echography examination (ECEE) and 4 chambers view + outflow tract view + 3 vessels and trachea view (4 CV+OTV+3 VTV) were around 0.90, which was significant higher than that of 4 chambers view + outflow tract view or 3 vessels and trachea view (4 CV+OTV/3 VTV) and 4 chambers view (4 CV). Unfortunately the pooled specificity of STIC was 0.92, which was significant lower than that of other 4 protocols which reached at 1.00. The area under the summary receiver operating characteristic curves value of STIC, ECEE, 4 CV+OTV+3 VTV, 4 CV+OTV/3 VTV and 4 CV were 0.9700, 0.9971, 0.9983, 0.9929 and 0.9928 respectively.

CONCLUSION

These results suggest a great diagnostic potential for fetal echocardiography detection as a reliable method of fetal congenital heart disease. But at least 3 sections view (4 CV, OTV and 3 VTV) should be included in scan protocol, while the STIC can be used to provide more information for local details of defects, and can not be used to make a definite diagnosis alone with its low specificity.

Increasing the detection rate of congenital heart disease during routine obstetric screening using cine loop sweeps

OBJECTIVES

The purpose of this study was to demonstrate an increase in the detection rate of fetal cardiac defects using 2 cine loop sweeps.

METHODS

Image reviewers examined a series of 93 cases randomly sorted, including 79 studies with normal findings and 14 studies with abnormal findings. All of the images were assessed by 5 standard criteria. Cases were classified as normal, abnormal, or indeterminate. Reviewers using the conventional approach reviewed 3 still images: the 4-chamber, left ventricular outflow tract, and right ventricular outflow tract views. Reviewers using the cine loop sweeps viewed 2 grayscale sweeps through the fetal heart in real time. The image sequences were reviewed independently by 2 experts, 3 nonexperts, and 2 sonographers blinded to each others' results.

RESULTS

The cine loop sweeps had an increased detection rate of 38% for the nonexperts and 36% for the experts compared with the conventional approach. The cine loop sweeps allowed identification of all cardiac defects by at least 2 of the 7 reviewers; the percentage of cases with false-positive findings was 3.9%. With the conventional approach, 2 defects went undetected by all reviewers, and 4 defects were found by only 1 reviewer; the percentage of cases with false-positive findings was 5.4%.

CONCLUSIONS

The use of cine loop sweeps has the potential to increase the detection of fetal cardiac defects without increasing the rate of false-positive findings or increasing the interpretation and decision-making times.

'I-shaped' sign in the upper mediastinum: a novel potential marker for antenatal diagnosis of d-transposition of the great arteries

OBJECTIVES

To investigate the 'I-shaped' sign as a novel echocardiographic marker for antenatal diagnosis of d-transposition of the great arteries (dTGA) in routine cardiac examination, and to compare its prevalence in fetuses with dTGA, those with other congenital heart diseases (CHDs) and those with normal structural hearts.

METHODS

This retrospective evaluation involved 1134 fetuses undergoing echocardiography to screen for CHD over a 4-year period. I-shaped sign was defined as the characteristic appearance of the aortic arch, resembling the letter 'I', from the most anterior to the most posterior point of the descending aorta visible in the three vessels and trachea view. The frequency of this sign was evaluated in cases with dTGA, those with other cardiac defects and those with normal cardiac structures.

RESULTS

CHD was diagnosed in 671 (59.1%) cases, of which 31 (4.6%) had dTGA. I-shaped sign was observed in 30/31 (96.8%) cases of dTGA, compared with 31/640 (4.8%) cases with other cardiac anomalies, which included single ventricle with pulmonary atresia or severe pulmonary stenosis, hypoplastic left heart syndrome with aortic atresia, corrected transposition of the great arteries, and double outlet right ventricle with malposition of the great arteries. I-shaped sign was detected significantly more frequently in the dTGA group compared with the normal group and with the other CHDs group (both P < 0.001) and had 96.8% sensitivity and 97.1% specificity for diagnosis of dTGA. Importantly, I-shaped sign was never observed in fetuses with structurally normal hearts.

CONCLUSIONS

Detection on echocardiography of an extremely long vessel with a marked I-shape should raise suspicion of cardiac anomaly, especially dTGA. This marker may therefore aid in the prenatal diagnosis of dTGA during routine ultrasound examination.

Fetal diagnosis and imaging in cardiology

BACKGROUND

Fetal echocardiography plays a critical role in the diagnosis and management of structural, functional and rhythm-related fetal cardiovascular disease.

OBJECTIVES/METHODS

This article reviews the history of fetal echocardiography and the prenatal diagnosis of fetal cardiovascular disease as well as the evolution of the field of fetal cardiology. The clinical application of fetal echocardiography, including indications for referral, timing of referral and considerations in the diagnosis and serial assessment of fetal cardiovascular disease, is presented.

CONCLUSIONS

Newer directions in the field of fetal cardiology, including first trimester diagnoses and fetal intervention, will continue to expand its role in the evaluation and treatment of affected pregnancies in the future; however, equally as important are efforts to continue to improve prenatal detection rates.