Diagnosis of congenital heart disease by early and second-trimester fetal echocardiography

First-Trimester Ultrasound Screening in Routine Obstetric Practice

Technologic advances and ultrasonographer-physician experience in fetal imaging have led to significant improvements in our ability to distinguish between normal and abnormal fetal structural development in the latter part of the first trimester. As a critical component of pregnancy care, assessment of fetal anatomy at the end of the first trimester with a standardized imaging protocol should be offered to all pregnant patients regardless of aneuploidy screening results because it has been demonstrated to identify approximately half of fetal structural malformations. Early identification of abnormalities allows focused genetic counseling, timely diagnostic testing, and subspecialist consultation. In addition, a normal ultrasound examination result offers some degree of reassurance to most patients. Use of cell-free DNA alone for aneuploidy screening while foregoing an accompanying early anatomic evaluation of the fetus will result in many anomalies that are typically detected in the first trimester not being identified until later in pregnancy, thus potentially diminishing the quality of obstetric care for pregnant individuals and possibly limiting their reproductive options, including pregnancy termination.

The clinical value of color ultrasound screening for fetal cardiovascular abnormalities during the second trimester: A systematic review and meta-analysis

BACKGROUND

This meta-analysis aimed to investigate the diagnostic value of color ultrasound screening for fetal cardiovascular abnormalities during the second trimester in China.

METHODS

A literature search was conducted to evaluate the clinical value of color ultrasound screening for fetal cardiovascular abnormalities during the second trimester using English and Chinese databases. Numerical values for sensitivity and specificity were obtained from false-negative, false-positive, true-negative, and true-positive rates, presented alongside graphical representations with boxes marking the values and horizontal lines showing the confidence intervals. Summary receiver operating characteristic (SROC) curves were applied to assess the performance of the diagnostic tests. Data were processed using Review Manager 5.3.

RESULTS

Four studies (151 patients with fetal cardiovascular abnormalities and 3397 undiagnosed controls) met our evaluation criteria. The sensitivity was 0.91 and 0.96, respectively, and the specificity was 1.00. The Area Under the Curve (AUC) from the SROC curves was >90%; therefore, it was classified as excellent. Furthermore, there were 6 types of fetal cardiovascular abnormalities, and the pooled screening rate of atrioventricular septal defects was the highest.

CONCLUSION

Our meta-analysis showed that the use of color ultrasound during the second trimester can be an excellent diagnostic tool for fetal cardiovascular abnormalities.

Evaluation fetal heart in the first and second trimester: Results and limitations

Background

Cardiac heart defects affect nearly 6-12 per 1000 live births in the general population and are more frequent than common trisomies.

Aim

To assess the efficacy and technical limitations of first-trimester fetal heart evaluation in the 11-14^th-weeks' scan and comparison with the second-trimester anatomical exam by ultrasound.

Material and Method

Between April 2015 and July 2020, medical records and ultrasound data of 3295 pregnancies who underwent first-trimester fetal anatomy exams by ultrasound were reviewed retrospectively. All ultrasound exams were performed by the same two operators (TUKD, OP) with transabdominal transducers. Fetal situs, four-chamber view, outflow tracts, and three-vessel trachea view are the cornerstones of first-trimester fetal heart examination. Conventional grayscale mode and high-definition power Doppler mode were utilized. The same operators re-examined all cases between the 18 and 23 weeks of gestation by ISUOG guidelines.

Results

We performed a combined transvaginal and transabdominal approach for only 101 cases (3.06%). The mean maternal age was 31.28 ± 4.43, the median gestational age at the first-trimester ultrasound exam was 12.4 weeks, and the median CRL was 61.87 mm (range was 45.1-84 mm). Even combined approach situs, cardiac axis, and four-chamber view could not be visualized optimally in 28 cases (0.7%). Outflow tracts were visualized separately in 80% (2636 in 3295) cases. Three vessel-trachea views were obtained in 85.4% (2814 in 3295) cases by high-definition Doppler mode. There were 47 fetuses with cardiac defects in 3295 pregnancies with the known pregnancy outcome. Ten cases had abnormal karyotype results. Thirty-two fetuses with cardiac anomalies (9.7 in 1000 pregnancies) were detected in the first-trimester examination, and the remaining 15 (4.55 in 1000 pregnancies) cases were diagnosed in the second-trimester examination. The prevalence of congenital cardiac anomalies was 14.25 in 1000 pregnancies. Fifteen cases were missed in the first-trimester exam. Also, ten fetuses which had abnormal cardiac findings in the first-trimester exam were not confirmed in the second-trimester exam. Sensitivity, specificity, positive, and negative predictive values were calculated as 65.3%, 99.7%, 66.8%, and 99.67%, respectively.

Conclusion

Late first-trimester examination of the fetus is feasible and allows earlier detection of many structural abnormalities of the fetus, including congenital heart defects. Suspicious and isolated cardiac abnormal findings should be re-examined and confirmed in the second-trimester exam. Previous abdominal surgery, high BMI, and subtle cardiac defects can cause missed cardiac abnormalities.

Prenatal detection of congenital heart disease at 12-13 gestational weeks: detailed analysis of false-negative cases

OBJECTIVES

To report on the early detection of congenital heart disease (CHD) in low- and high-risk populations managed at our hospital; and perform a detailed analysis of false-negative diagnoses, in order to derive possible recommendations on how to reduce their incidence.

METHODS

This was a retrospective observational study analyzing cases which underwent an ultrasound examination at the end of the first trimester at the Fetal Medicine and Surgery Unit of Gaslini Children's Hospital, Genoa, Italy, in the period January 2015 to December 2021. The study population included both low-risk pregnancies that underwent standard first-trimester combined screening and high-risk ones referred to our unit because of a positive combined test or suspicion of fetal anomalies raised in a regional community hospital. For each case, the following variables were retrieved and analyzed: number of fetuses, maternal body mass index, gestational age at first-trimester screening, whether the pregnancy was low or high risk, nuchal translucency thickness (normal or > 99th  centile), type of CHD, associated extracardiac anomalies, karyotype and pregnancy outcome. For low-risk pregnancies, suspicion of CHD was also recorded. In low-risk cases, sonographic cardiac screening comprised evaluation of the four-chamber view (grayscale and color/power Doppler) and three-vessel-and-trachea view (color/power Doppler). High-risk cases underwent early fetal echocardiography. False-negative cases were categorized according to likely cause of the missed diagnosis, as follows: human factor; technical factor; acoustic-window factor.

RESULTS

Gestational age at ultrasound ranged from 12 + 0 to 13 + 6 weeks (crown-rump length (CRL), 50.1-84.0 mm) in the low-risk group and from 11 + 5 to 13 + 6 weeks (CRL, 45.1-84.0 mm) in the high-risk group. Over the 7-year study period, 7080 pregnancies were evaluated in the first trimester. Of these, 6879 (7167 fetuses) were low-risk and 201 were high-risk cases. In the low-risk group, there were 30 fetuses with CHD (including 15 major and 15 minor CHD), yielding a prevalence of 4.2/1000 (2.1/1000 for major CHD). Nine of the 30 CHD cases were suspected at screening ultrasound (7/15 major CHD). Excluding cases in which the CHD would not be expected to be associated with a modification of the screening views and would therefore not be detectable on screening ultrasound, 7/12 cases of major CHD were detected, corresponding to a sensitivity of 58.3%. Among the 201 high-risk cases, there were 46 fetuses with CHD (including 44 major and two minor CHD), of which 43 were detected, corresponding to a sensitivity for early fetal echocardiography of 93.5%, or 97.7% if the two cases that were unlikely to be detectable on first-trimester screening were excluded. Analysis of the 11 (of 24) false-negative cases that would be expected to be picked up on screening views revealed that human error (image interpretation and/or scanning approach) was involved in all 11 cases and technical factors (excessive color priority (color-balance function) and/or incorrect plane alignment) were present in two. There was impairment of the acoustic window (associated with maternal obesity and/or twin gestation) as a cofactor in five of the 11 cases.

CONCLUSIONS

The sensitivity for detection of major CHD of early cardiac screening in low-risk pregnancy is under 60%, partly due to the natural history of CHD and, it seems, partly relating to human error and technical issues with image quality. Factors associated with false-negative diagnoses may be categorized into three types: human error, technical factors and acoustic-window impairment. We recommend: appropriate assessment with fetal posterior spine; that sufficient time is spent on assessment of the fetal situs; and that color/power Doppler settings are adapted to the individual case. A lower threshold for referring doubtful cases for early fetal echocardiography should be adopted in cases of maternal obesity and in twin gestation. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

First-trimester ultrasound detection of fetal heart anomalies: systematic review and meta-analysis

OBJECTIVES

To determine the diagnostic accuracy of ultrasound at 11-14 weeks' gestation in the detection of fetal cardiac abnormalities and to evaluate factors that impact the detection rate.

METHODS

This was a systematic review of studies evaluating the diagnostic accuracy of ultrasound in the detection of fetal cardiac anomalies at 11-14 weeks' gestation, performed by two independent reviewers. An electronic search of four databases (MEDLINE, EMBASE, Web of Science Core Collection and The Cochrane Library) was conducted for studies published between January 1998 and July 2020. Prospective and retrospective studies evaluating pregnancies at any prior level of risk and in any healthcare setting were eligible for inclusion. The reference standard used was the detection of a cardiac abnormality on postnatal or postmortem examination. Data were extracted from the included studies to populate 2 × 2 tables. Meta-analysis was performed using a random-effects model in order to determine the performance of first-trimester ultrasound in the detection of major cardiac abnormalities overall and of individual types of cardiac abnormality. Data were analyzed separately for high-risk and non-high-risk populations. Preplanned secondary analyses were conducted in order to assess factors that may impact screening performance, including the imaging protocol used for cardiac assessment (including the use of color-flow Doppler), ultrasound modality, year of publication and the index of sonographer suspicion at the time of the scan. Risk of bias and quality assessment were undertaken for all included studies using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool.

RESULTS

The electronic search yielded 4108 citations. Following review of titles and abstracts, 223 publications underwent full-text review, of which 63 studies, reporting on 328 262 fetuses, were selected for inclusion in the meta-analysis. In the non-high-risk population (45 studies, 306 872 fetuses), 1445 major cardiac anomalies were identified (prevalence, 0.41% (95% CI, 0.39-0.43%)). Of these, 767 were detected on first-trimester ultrasound examination of the heart and 678 were not detected. First-trimester ultrasound had a pooled sensitivity of 55.80% (95% CI, 45.87-65.50%), specificity of 99.98% (95% CI, 99.97-99.99%) and positive predictive value of 94.85% (95% CI, 91.63-97.32%) in the non-high-risk population. The cases diagnosed in the first trimester represented 63.67% (95% CI, 54.35-72.49%) of all antenatally diagnosed major cardiac abnormalities in the non-high-risk population. In the high-risk population (18 studies, 21 390 fetuses), 480 major cardiac anomalies were identified (prevalence, 1.36% (95% CI, 1.20-1.52%)). Of these, 338 were detected on first-trimester ultrasound examination and 142 were not detected. First-trimester ultrasound had a pooled sensitivity of 67.74% (95% CI, 55.25-79.06%), specificity of 99.75% (95% CI, 99.47-99.92%) and positive predictive value of 94.22% (95% CI, 90.22-97.22%) in the high-risk population. The cases diagnosed in the first trimester represented 79.86% (95% CI, 69.89-88.25%) of all antenatally diagnosed major cardiac abnormalities in the high-risk population. The imaging protocol used for examination was found to have an important impact on screening performance in both populations (P < 0.0001), with a significantly higher detection rate observed in studies using at least one outflow-tract view or color-flow Doppler imaging (both P < 0.0001). Different types of cardiac anomaly were not equally amenable to detection on first-trimester ultrasound.

CONCLUSIONS

First-trimester ultrasound examination of the fetal heart allows identification of over half of fetuses affected by major cardiac pathology. Future first-trimester screening programs should follow structured anatomical assessment protocols and consider the introduction of outflow-tract views and color-flow Doppler imaging, as this would improve detection rates of fetal cardiac pathology. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Discordant congenital heart defects in monochorionic twins: Risk factors and proposed pathophysiology

A six-fold increase in congenital heart defects (CHD) exists among monochorionic (MC) twins compared to singleton or dichorionic twin pregnancies. Though MC twins share an identical genotype, discordant phenotypes related to CHD and other malformations have been described, with reported rates of concordance for various congenital anomalies at less than 20%. Our objective was to characterize the frequency and spectrum of CHD in a contemporary cohort of MC twins, coupled with genetic and clinical variables to provide insight into risk factors and pathophysiology of discordant CHD in MC twins. Retrospective analysis of all twins receiving prenatal fetal echocardiography at a single institution from January 2010 –March 2020 (N = 163) yielded 23 MC twin pairs (46 neonates) with CHD (n = 5 concordant CHD, n = 18 discordant CHD). The most common lesions were septal defects (60% and 45.5% in concordant and discordant cohorts, respectively) and right heart lesions (40% and 18.2% in concordant and discordant cohorts, respectively). Diagnostic genetic testing was abnormal for 20% of the concordant and 5.6% of the discordant pairs, with no difference in rate of abnormal genetic results between the groups (p = 0.395). No significant association was found between clinical risk factors and development of discordant CHD (p>0.05). This data demonstrates the possibility of environmental and epigenetic influences versus genotypic factors in the development of discordant CHD in monochorionic twins.

Area of the right atrium of the fetal heart and its significance in fetuses with tricuspid regurgitation

OBJECTIVES

The first aim was to develop a nomogram for the area of the right atrium (ARA) of the fetal heart in uncomplicated singleton pregnancies. The second aim was to assess diagnostic indices of ARA to distinguish between tricuspid regurgitation (TR) with and without concomitant congenital heart defect (CDH).

METHODS

The study was conducted between 2014 and 2019. Fetal echocardiography was performed on fetuses with and without TR. For the first aim, ARA was measured in 460 fetuses without proven structural and chromosomal abnormalities, and for the second aim, ARA was measured in 1077 fetuses with TR.

RESULTS

A nomogram for the ARA of fetuses with normal hearts was developed. TR was observed in 4.5% (1077/23,771) of euploid fetuses; 4.3% (1020/23,771) of fetuses had TR without a concomitant CHD, and 0.2% (57/23,771) fetuses had TR with a concomitant CHD. No significant differences in ARAs were found between fetuses with normal hearts without TR (n = 22,694) and fetuses with TR without CHD (n = 1020; p = .751). Fetuses with TR and CHDs had different ARA than fetuses with normal hearts without TR and fetuses with TR without CHD (p < .0005 in both cases).

CONCLUSIONS

ARA seems to be an auxiliary marker to distinguish the presence of CHD in fetuses with TR.

Tetralogy of Fallot and Outlet Ventricular Septal Defect with Anterior Malalignment Detected at Early Fetal Echocardiography

OBJECTIVES

To examine the evolution of tetralogy of Fallot (TOF) and outlet ventricular septal defect (VSD) with anterior malalignment (am) from the initial diagnosis at early fetal echocardiography through the gestation and to evaluate the impact of the first-trimester scan on the outcome.

METHODS

We identified cases of TOF or outlet VSD with am diagnosed before 16 weeks' gestation. For all cases, prenatal data and pregnancy outcomes were evaluated. In continuing pregnancies, the evolution in severity of the disease was assessed.

RESULTS

Fifty-one fetuses with TOF or outlet VSD with am were diagnosed at early fetal echocardiography. Parents opted for termination of pregnancy in all 23 cases associated with additional anomalies. In 2 of 28 continuing pregnancies, there was an intrauterine death. In the remaining 26, there was progression in severity in 7 (by 20-22 weeks in 3 cases and during the third trimester in the remaining 4).

CONCLUSIONS

TOF and outlet VSD with am diagnosed before 16 weeks' gestation can progress in severity throughout pregnancy in over one-quarter of cases. In addition, a high proportion of cases diagnosed in the first trimester may have associated extracardiac anomalies, with a significant impact on clinical management and on the rate of early termination of pregnancy.

Performance of First-Trimester Fetal Echocardiography in Diagnosing Fetal Heart Defects: Meta-analysis and Systematic Review

OBJECTIVES

Early fetal echocardiography is becoming increasing common during the nuchal translucency scan period. The aim of this meta-analysis was to assess the accuracy of first-trimester fetal echocardiography in diagnosing congenital heart defects (CHDs).

METHODS

The databases of PubMed, Embase, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature were systematically searched for the candidate articles, and the references of included studies were also examined. We recorded the characteristics of the included studies and assessed the quality of each study by the Quality Assessment of Diagnostic Accuracy Studies tool. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the curve (AUC) were calculated with Meta-Disc version 1.4 software (Ramón y Cajal Hospital, Madrid, Spain). We also evaluated the publication bias by using Stata version 12.0 software (StataCorp, College Station, TX).

RESULTS

This meta-analysis included 18 studies with 26,201 fetal hearts. The overall pooled sensitivity, specificity, PLR, and NLR were 0.750, 0.999, 392.95, and 0.277, respectively. The DOR and AUC were 1736.0 and 0.9331. The pooled sensitivity, specificity, PLR, NLR, DOR, and AUC for major CHDs were 0.838, 1.000, 725.69, 0.203, 5084.8, and 0.9617.

CONCLUSIONS

First-trimester fetal echocardiography had high value in diagnosing CHDs, especially major CHDs.

Fetal Anatomic Imaging Between 11 and 14 Weeks Gestation

Fetal imaging between 11 and 14 weeks is a standard component of prenatal risk assessment for aneuploidy. Evaluating the fetus during this gestational age window provides the opportunity to reliably examine anatomic structures. Using a defined imaging protocol, approximately 50% of major abnormalities can be detected. Some abnormalities should almost always be detected, some may be detected on occasion and others are not currently detectable. Imagers must be familiar with embryologic patterns of development and natural history of anomalies. Patients must be informed of the limitations of early anatomic evaluation. Currently, early anatomic evaluation does not replace the standard second trimester evaluation.

Efficacy of prenatal diagnosis of major congenital heart disease on perinatal management and perioperative mortality: a meta-analysis

BACKGROUND

There is no consensus on the effectiveness of prenatal diagnosis except for hospitalized outcomes. Hence, a meta-analysis of published literature was conducted to assess the effect of prenatal diagnosis.

METHODS

Literature review has identified relevant studies up to December 2013. A meta-analysis was performed according to the guidelines from the Cochrane review group and the PRISMA statement. Studies were identified by searching PubMed, Embase, the Cochrane Central Register of Controlled Trials and World Health Orgnization clinical trials registry center. Meta-analysis was performed in a fixed/random-effect model using Revman 5.1.1 according to the guidelines from the Cochrane review group and the PRISMA guidelines.

RESULTS

The results from 13 cohort studies in 12 articles were analyzed to determine the optimal treatment with the lower rate of perioperative mortality in prenatal diagnosis. The superiority of a prenatal diagnosis has been proven because the surgical procedure could be done in the early neonatal period (95% CI, -0.76, -0.40). The prenatal diagnosis has also remarkably reduced the preoperative and postoperative mortality rates in cases of transposition of the great arteries (95% CI=0.06, 0.80; 95% CI=0.01, 0.82, respectively), as well as the overall results with all subtypes (95% CI=0.18, 0.94; 95% CI=0.46, 0.94, respectively).

CONCLUSIONS

Prenatal diagnosis is effective in perinatal management with an earlier intervention for major congenital heart disease, but only results in a reduced perioperative mortality in cases of transposition of the great arteries. Further investigations are required to evaluate the effect of prenatal diagnosis on life quality during a long-term follow-up.

Safety Indices during Fetal Echocardiography at the Time of First-Trimester Scan Are Machine Dependent

The aim of our study was to evaluate the thermal index (TI) and mechanical index (MI), during the assessment of the fetal heart at the time of first-trimester scan, with different ultrasound machines. This was part of an observational study conducted in patients undergoing routine first-trimester screening. Cases were examined with Voluson E8 or 730Pro scanners using 2–8 MHz transabdominal probes. TI and MI were retrieved from the saved displays while in gray mode, color flow mapping and pulsed-wave (PW) Doppler examinations of the fetal heart and also from the ductus venosus (DV) assessment. We evaluated 552 fetal cardiac examinations, 303 (55%) performed with Voluson E8 and 249 (45%) with Voluson 730Pro ultrasound machines. The gray-scale exam of the heart and the PW Doppler DV assessment had TI values significantly lower for the Voluson E8 group (median, 0.04 vs. 0.2 and 0.1 vs. 0.2, respectively). The MI values from gray-scale and color flow mapping of the heart were significantly lower (median, 0.6 vs, 1.2 and 0.7 vs. 1) and for PW Doppler exam of the tricuspid flow were significantly higher (median 0.4 vs. 0.2) in the Voluson E8 group. The TI values from Doppler examinations of the heart, either color flow or PW imaging and MI values from DV assessment were not significantly different between the two groups. A different (newer) generation of ultrasound equipment provides lower or at least the same safety indices for most of the first-trimester heart examinations.

Acoustic output measured by thermal and mechanical indices during fetal echocardiography at the time of the first trimester scan

We measured acoustic output, expressed as the thermal index (TI) and mechanical index (MI), during fetal echocardiography at the time of the first trimester scan. TI and MI were retrieved from the saved displays during gray-mode, high-definition color flow Doppler and pulsed-wave Doppler (tricuspid flow) ultrasound examinations of the fetal heart and from the ductus venosus assessment. A total of 399 fetal cardiac examinations were evaluated. There was a significant increase in TI values from B-mode studies (0.07 ± 0.04 [mean ± SD]) to color flow mapping (0.2 ± 0.0) and pulsed-wave Doppler studies (0.36 ± 0.05). The TI from ductus venosus assessment (0.1 ± 0.01) was significantly lower than those from Doppler examinations of the heart. MI values from B-mode scans (0.65 ± 0.12) and color flow mapping (0.71 ± 0.11) were comparable, although different, and both values were higher than those from pulsed-wave Doppler tricuspid evaluation (0.39 ± 0.03). There were no differences in MI values from power Doppler assessment between the tricuspid flow and ductus venosus. Safety indices were remarkably stable and were largely constant, especially for color Doppler (TI), tricuspid flow (MI) and ductus venosus assessment (TI, MI). We acquired satisfactory Doppler images and/or signals at acoustic levels that were lower than the actual recommendations and never reached a TI of 0.5.

Factors affecting the feasibility of routine first-trimester fetal echocardiography

OBJECTIVES

The purpose of our study was to assess the factors that may improve the feasibility of routine fetal echocardiography at the time of the first-trimester scan.

METHODS

In this prospective study, we included 616 healthy singleton fetuses. Examinations were performed transabdominally by a single sonographer at the beginning of his training in first-trimester screening. The fetal heart was examined by high-definition color Doppler imaging to obtain the 4-chamber view, right and left ventricular outflow tracts, and 3-vessel and trachea view. Logistic regression was used to investigate the effect on the ability to visualize different cardiac structures.

RESULTS

The frequency of successful heart examinations increased significantly with the number of scans performed (P < .05). The sonographer needed 180 examinations before he could successfully examine the heart in at least 80% of cases. Significant factors that increased the probability of adequate echocardiography were the length of the heart examination and the experience of the sonographer (P< .05) but not transducer-heart distance, maternal body mass index, fetal crown-rump length, placenta interposition, or restrictive fetal position. Visualization of the left ventricular outflow tract could be improved by increasing the experience of the sonographer and decreasing the transducer-heart distance. Also, visualization of the 3-vessel and trachea view depended on the length of the heart examination, the experience of the sonographer, an anterior position of the placenta, and a restrictive fetal position.

CONCLUSIONS

Competence in color flow mapping assessment of the fetal heart at gestational ages of 11 weeks to 13 weeks 6 days is achieved only after extensive supervised training.

Detection of fetal structural anomalies in a basic first-trimester screening program for aneuploidy

OBJECTIVES

The purpose of this study was to determine whether first-trimester aneuploidy screening sonography initially performed by credentialed sonographers was useful for detecting fetal anomalies between 11 and 14 weeks' gestation.

METHODS

We conducted a retrospective cohort study of consecutive patients referred to a private ultrasound facility between January 1, 2008, and June 30, 2012, for measurement of the nuchal translucency (NT) and crown-rump length as part of a screening protocol for aneuploidy. Patients were included if there was at least 1 live fetus with a crown-rump length between 34 and 84 mm. No specific anatomic imaging protocol was followed. The presence of anomalies was based on the sonographic report and review of the medical record. The absence of anomalies was based on the report from the anatomic survey. Anomalies were categorized as lethal, major, and minor. The anomaly category and gestational age at diagnosis (≤14 versus >14 weeks) were compared.

RESULTS

An NT scan was performed on 9692 fetuses. Anatomic surveys were done on 9077 (93.7%) of these fetuses at a mean of 18 weeks' gestation. Anomalies were detected in 180 fetuses (1.8%): 50 (0.5%) at the NT scan and 130 (1.3%) at the anatomic scan. Overall, 46 of 111 fetuses (41.4%) with major or lethal anomalies were detected at the NT scan. Two suspected abnormalities at the NT scan were not present at the anatomic scan.

CONCLUSIONS

First-trimester aneuploidy screening sonography initially performed by credentialed sonographers can identify a substantial proportion of major and lethal anomalies.

Relationship between isolated mild tricuspid valve regurgitation in second-trimester fetuses and postnatal congenital cardiac disorders

OBJECTIVES

In most cases, the clinical importance of fetal isolated mild tricuspid valve regurgitation is not known. This study evaluated the relationship between fetal isolated mild tricuspid regurgitation in the general obstetric population and postnatal congenital cardiac disorders.

METHODS

Detailed fetal echocardiography was done between 18 and 24 weeks' gestation to detect tricuspid regurgitation and to exclude complicated cardiac defects. Routine second-trimester targeted organ scans were also performed to exclude extracardiac defects. Follow-up was done until birth. After birth, the cardiac anatomy of the neonates was examined by echocardiography. The association between fetal isolated mild tricuspid regurgitation and postnatal congenital cardiac disorders was assessed by logistic regression analysis.

RESULTS

No major cardiac disorders were found postnatally. Some minor disorders were found, including a patent foramen ovale, atrial septal defects, a patent ductus arteriosus, and small ventricular septal defects. Fetuses with isolated mild tricuspid regurgitation had a significantly higher likelihood of having ventricular septal defects (odds ratio, 5.80; P = .027) or a patent foramen ovale with atrial septal defects and a patent ductus arteriosus (odds ratio, 11.61; P = .007). There was no significant association between tricuspid regurgitation and an isolated patent foramen ovale or a patent foramen ovale with atrial septal defects in neonates.

CONCLUSIONS

Fetuses with isolated mild tricuspid regurgitation in the second trimester did not have a higher incidence of major cardiac disorders after birth. The presence of isolated mild tricuspid regurgitation may be an indication of minor postnatal congenital cardiac disorders.

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.

Multimodality Imaging in Congenital Heart Disease: an Update

The increasing number of survivors of congenital heart disease (CHD) has been paralleled by advancement of imaging modalities used for the ongoing assessment of these patients. There has been a large body of literature describing new approaches to non-invasive assessment of CHD. We will review new applications of well established as well as novel techniques for the management and understanding of CHD.