Prenatal diagnosis of ductal origin of distal pulmonary artery: presentation of three cases and literature review

Ductal origin of distal pulmonary artery (DODPA) is a rare congenital cardiovascular anomaly, with an incidence of approximately 1 in 200 000 people. It involves the proximal interruption of one pulmonary artery branch, with the distal part arising from the base of the brachiocephalic artery, via the ipsilateral ductus arteriosus (DA) and the intrapulmonary branch of the pulmonary artery is usually intact. If timely treatment is not provided after birth, it is very likely that, due to DA closure, severe hypoplasia will occur in the lung supplied by the abnormal pulmonary artery. Hence, prenatal diagnosis of DODPA is important to enable initiation of prostaglandin treatment and early rehabilitation of the affected lung. Herein, we report three cases of fetal DODPA diagnosed via two-dimensional (2D) ultrasonography combined with four-dimensional (4D) spatiotemporal image correlation. We also present a literature review, and explore the ultrasonographic findings and the importance of 2D and 4D ultrasonography in obtaining an accurate prenatal diagnosis of DODPA. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

New and advanced features of fetal intelligent navigation echocardiography (FINE) or 5D heart

Congenital heart disease (CHD) is the leading organ-specific birth defect, as well as the leading cause of infant morbidity and mortality from congenital malformations. Therefore, a comprehensive screening examination of the fetal heart should be performed in all women to maximize the detection of CHD. Four-dimensional sonography with spatiotemporal image correlation (STIC) technology displays a cine loop of a complete single cardiac cycle in motion. A novel method known as Fetal Intelligent Navigation Echocardiography (or FINE) was previously developed to interrogate STIC volume datasets using "intelligent navigation" technology. Such method allows the automatic display of nine standard fetal echocardiography views required to diagnose most cardiac defects. FINE considerably simplifies fetal cardiac examinations and reduces operator dependency. It has both high sensitivity and specificity for the detection of CHD. Indeed, FINE has been integrated into several commercially available ultrasound platforms.Recently, eight novel and advanced features have been developed for the FINE method and they will be described herein. Such features can be categorized based upon their broad goals. The first goal is to simplify FINE further, and consists of the following features: (1) Auto fetal positioning (or FINE align); (2) Skip points; (3) Predictive cursor; (4) Static mode volume; and (5) Breech sweep. The second goal is to allow quantitative measurements to be performed on the cardiac views generated by FINE: (6) Automatic cardiac axis; and (7) Cardiac biometry. Finally, the last goal is to improve the success of obtaining fetal echocardiography view(s); and consists of (8) Maestro planar navigation.

Right atrial isomerism diagnosed by STIC-HD live flow and autopsy: A case report

RATIONALE

Right atrial isomerism (RAI) is one of the most severe forms of congenital heart disease. This case of RAI was so complex that it incorporated 7 heart defects. It can be challenging to display the spatial relationship between different anatomical structures using conventional two-dimensional and color ultrasound (2D-Doppler imaging); therefore, we used spatio-temporal image correlation (STIC) and high definition live flow imaging technology to vividly display this case of RAI in a stereoscopic mode.

PATIENT CONCERNS

A 24-year-old woman was referred to our tertiary center at 24 weeks of gestation. The woman had difficult conceiving. Once pregnant, she was opposed to abortion, even if there was a possibility of deformity.

DIAGNOSIS

The fetus presented with an atrioventricular septal defect, persistent left superior vena cava, supra-cardiac total anomalous pulmonary venous connection (TAPVC), double outlet right ventricle, right ductus arteriosus, right aortic arch (RAA) with mirror image branching, and aortic arch dysplasia.

INTERVENTIONS

After consulting a pediatric cardiologist, the woman requested an abortion and consented to an autopsy.

OUTCOMES

Autopsy supported the echocardiographic findings.

LESSONS

Accurate diagnosis of RAI is essential for clinical and parent decision making. 2D-Doppler imaging combined with STIC-HD live flow can be used to visualize the spatial morphology of blood vessels, including the cardiac chambers and great vessels of the fetal heart, and smaller peripheral vessels.

Commercial 4-dimensional echocardiography for murine heart volumetric evaluation after myocardial infarction

BACKGROUND

Traditional preclinical echocardiography (ECHO) modalities, including 1-dimensional motion-mode (M-Mode) and 2-dimensional long axis (2D-US), rely on geometric and temporal assumptions about the heart for volumetric measurements. Surgical animal models, such as the mouse coronary artery ligation (CAL) model of myocardial infarction, result in morphologic changes that do not fit these geometric assumptions. New ECHO technology, including 4-dimensional ultrasound (4D-US), improves on these traditional models. This paper aims to compare commercially available 4D-US to M-mode and 2D-US in a mouse model of CAL.

METHODS

37 mice underwent CAL surgery, of which 32 survived to a 4 week post-operative time point. ECHO was completed at baseline, 1 week, and 4 weeks after CAL. M-mode, 2D-US, and 4D-US were taken at each time point and evaluated by two separate echocardiographers. At 4 weeks, a subset (n = 12) of mice underwent cardiac magnetic resonance (CMR) imaging to serve as a reference standard. End systolic volume (ESV), end diastolic volume (EDV), and ejection fraction (EF) were compared among imaging modalities. Hearts were also collected for histologic evaluation of scar size (n = 16) and compared to ECHO-derived wall motion severity index (WMSI) and global longitudinal strain as well as gadolinium-enhanced CMR to compare scar assessment modalities.

RESULTS

4D-US provides close agreement of ESV (Bias: -2.55%, LOA: - 61.55 to 66.66) and EF (US Bias: 11.23%, LOA - 43.10 to 102.8) 4 weeks after CAL when compared to CMR, outperforming 2D-US and M-mode estimations. 4D-US has lower inter-user variability as measured by intraclass correlation (ICC) in the evaluation of EDV (0.91) and ESV (0.93) when compared to other modalities. 4D-US also allows for rapid assessment of WMSI, which correlates strongly with infarct size by histology (r = 0.77).

CONCLUSION

4D-US outperforms M-Mode and 2D-US for volumetric analysis 4 weeks after CAL and has higher inter-user reliability. 4D-US allows for rapid calculation of WMSI, which correlates well with histologic scar size.

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.

An In-depth Perspective of Aortic Arch Branching in Fetal Vascular Rings Using Spatiotemporal Image Correlation Combined With High-definition Flow Imaging: Report of 4 Cases

On the basis of 2-dimensional fetal echocardiographic findings, we investigated 4 different fetal vascular ring cases using spatiotemporal image correlation (STIC) combined with high-definition (HD) flow imaging. An in-depth 3-dimensional perspective of aortic arch branching (ie, the brachiocephalic arteries) was created by application of glass body and HDlive flow rendering algorithms (GE Healthcare, Zipf, Austria). Additionally, complete (U- or O-shaped) or incomplete (C-shaped) vascular rings were clearly differentiated in utero, and articulations around the trachea and esophagus were more easily imaged. In conclusion, spatiotemporal image correlation combined with HD flow imaging could classify fetal vascular rings with accuracy and facilitate decision making during postnatal management.

4-D Intracardiac Ultrasound Vector Flow Imaging-Feasibility and Comparison to Phase-Contrast MRI

In vivo characterization of intracardiac blood velocity vector fields may provide new clinical information but is currently not available for bedside evaluation. In this paper, 4-D vector flow imaging for intracardiac flow assessment is demonstrated using a clinical ultrasound (US) system and a matrix array transducer, without the use of contrast agent. Two acquisition schemes were developed, one for full volumetric coverage of the left ventricle (LA) at 50 vps and a 3-D thick-slice setup with continuous frame acquisition (4000 vps), both utilizing ECG-gating. The 3-D vector velocity estimates were obtained using a novel method combining phase and envelope information. In vitro validation in a rotating tissue-mimicking phantom revealed velocity estimates in compliance with the ground truth, with a linear regression slope of 0.80, 0.77, and 1.03 for the , , and velocity components, and with standard deviations of 2.53, 3.19, and 0.95 cm/s, respectively. In vivo measurements in a healthy LV showed good agreement with PC-MRI. Quantitative analysis of energy loss (EL) and kinetic energy (KE) further showed similar trends, with peak KE at 1.5 and 2.4 mJ during systole and 3.6 and 3.1 mJ for diastole for US and PC-MRI. Similar for EL, 0.15- 0.2 and 0.7 mW was found during systole and 0.6 and 0.7 mW during diastole, for US and PC-MRI, respectively. Overall, a potential for US as a future modality for 4D cardiac vector flow imaging was demonstrated, which will be further evaluated in clinical studies.

Fetal Intelligent Navigation Echocardiography (FINE) Detects 98% of Congenital Heart Disease

OBJECTIVE

Fetal intelligent navigation echocardiography (FINE) is a novel method that automatically generates and displays 9 standard fetal echocardiographic views in normal hearts by applying intelligent navigation technology to spatiotemporal image correlation (STIC) volume data sets. The main objective was to determine the sensitivity and specificity of FINE in the prenatal detection of congenital heart disease (CHD).

METHODS

A case-control study was conducted in 50 fetuses with a broad spectrum of CHD (cases) and 100 fetuses with normal hearts (controls) in the second and third trimesters. Using 4-dimensional ultrasound with STIC technology, volume data sets were acquired. After all identifying information was removed, the data sets were randomly distributed to a different investigator for analysis using FINE. The sensitivity and specificity for the prenatal detection of CHD, as well as positive and negative likelihood ratios were determined.

RESULTS

The diagnostic performance of FINE for the prenatal detection of CHD was: sensitivity of 98% (49 of 50), specificity of 93% (93 of 100), positive likelihood ratio of 14, and negative likelihood ratio of 0.02. Among cases with confirmed CHD, the diagnosis with use of FINE completely matched the final diagnosis in 74% (37 of 50); minor discrepancies were seen in 12% (6 of 50), and major discrepancies were seen in 14% (7 of 50).

CONCLUSIONS

This is the first time the sensitivity and specificity of the FINE method in fetuses with normal hearts and CHD in the second and third trimesters has been reported. Because FINE identifies a broad spectrum of CHD with 98% sensitivity, this method could be used prenatally to screen for and diagnose CHD.

Feasibility assessment for successfully visualizing the fetal heart utilizing spatiotemporal image correlation

PURPOSE

Spatiotemporal image correlation (STIC) is an excellent imaging modality for observing the fetal heart. High-quality STIC volume data are needed for an antenatal anatomic survey to diagnose congenital heart disease. We aimed to clarify the causes of unsuccessful STIC volume data acquisition and describe a more accurate, efficient STIC examination.

METHODS

This cross-sectional study of 1124 women with fetuses assessed risk factors for unsuccessful acquisition of STIC volume data. Logistic regression analysis quantified the relation between unsuccessful acquisition and clinical variables, including maternal body mass index (BMI), shadowing artifacts due to unexpected fetal limb movement (SAU), estimated fetal weight (EFW), gestational age (GA), use of volume rendering images in four-dimensional ultrasonography (4D-US), fetal heart rate (FHR), maternal age, anterior placenta, and prior lower abdominal surgery.

RESULTS

STIC volume data acquisition was unsuccessful in 210 of 1124 (18.6%) cases. SAU, BMI ≥ 28 kg/m², not using volume rendering images in 4D-US, EFW ≥ 1300 g, and anterior placenta were independent risk factors for unsuccessful STIC data acquisition.

CONCLUSIONS

Avoiding SAU was the most important factor for accurate, efficient STIC evaluations for diagnosing congenital heart disease antenatally. The risk was not explained by lack of sonographer proficiency. Volume rendering images in 4D-US is a promising approach to successful acquisition of STIC volume data.

Intracardiac Vortex Dynamics by High-Frame-Rate Doppler Vortography-In Vivo Comparison With Vector Flow Mapping and 4-D Flow MRI

Recent studies have suggested that intracardiac vortex flow imaging could be of clinical interest to early diagnose the diastolic heart function. Doppler vortography has been introduced as a simple color Doppler method to detect and quantify intraventricular vortices. This method is able to locate a vortex core based on the recognition of an antisymmetric pattern in the Doppler velocity field. Because the heart is a fast-moving organ, high frame rates are needed to decipher the whole blood vortex dynamics during diastole. In this paper, we adapted the vortography method to high-frame-rate echocardiography using circular waves. Time-resolved Doppler vortography was first validated in vitro in an ideal forced vortex. We observed a strong correlation between the core vorticity determined by high-frame-rate vortography and the ground-truth vorticity. Vortography was also tested in vivo in ten healthy volunteers using high-frame-rate duplex ultrasonography. The main vortex that forms during left ventricular filling was tracked during two-three successive cardiac cycles, and its core vorticity was determined at a sampling rate up to 80 duplex images per heartbeat. Three echocardiographic apical views were evaluated. Vortography-derived vorticities were compared with those returned by the 2-D vector flow mapping approach. Comparison with 4-D flow magnetic resonance imaging was also performed in four of the ten volunteers. Strong intermethod agreements were observed when determining the peak vorticity during early filling. It is concluded that high-frame-rate Doppler vortography can accurately investigate the diastolic vortex dynamics.

Ventricular Diastolic Function in Normal Fetuses and Fetuses with Hb Bart's Disease Assessed by Color M-Mode Propagation Velocity using Cardio-STIC-M (Spatio-Temporal Image Correlation M-Mode)

Purpose: To determine whether ventricular diastolic dysfunction contributes to the pathogenesis of fetal cardiac failure due to fetal anemia using fetal Hb Bart's disease as a live model and cardio-STIC-M as a diagnostic tool. Materials and Methods: Color cardio-STIC volume datasets were acquired from fetuses at risk for Hb Bart's disease during 18 - 22 weeks of gestation and normal pregnancies and pregnancies with hydrops fetalis caused by Hb Bart's disease at 28 - 32 weeks. The volumes were analyzed off-line for velocity propagation (Vp) of the right and left ventricles to assess ventricular diastolic function using color cardio-STIC-M. Results: The Vp for the right and left ventricles was studied in fetuses at 18 - 22 weeks, including 64 normal fetuses (group 1) and 22 fetuses with Hb Bart's disease (group 2), and in fetuses at 28 - 32 weeks, including 22 normal fetuses (group 3) and 16 fetuses with Hb Bart's hydrops fetalis (group 4). The Vp of the fetuses in group 1 and group 2 was not significantly different. However, the Vp for the right and left ventricles in group 4 was significantly lower than in group 3 (19.02 vs. 9.78, p < 0.001; and 20.24 vs. 13.40, p < 0.001, respectively). The inter-observer variability had fair agreement with the intra-class correlation coefficient of 0.531 (95 % CI 0.393 - 0.646, p < 0.001). Conclusion: Hydrops fetalis secondary to fetal anemia is initially caused by hypervolemia rather than ventricular diastolic dysfunction while ventricular diastolic compromise is a late occurring consequence of persistent hypervolemia, different from the mechanism of hydropic changes caused by cardiac causes.

HDlive Silhouette Mode With Spatiotemporal Image Correlation for Assessment of the Fetal Heart

OBJECTIVES

The purpose of this article is to present our experience with normal and abnormal fetal cardiac structures reconstructed in the HDlive silhouette mode (GE Healthcare Japan, Tokyo, Japan) with spatiotemporal image correlation (STIC).

METHODS

Twenty-two fetuses with normal hearts and 1 fetus with a congenital heart anomaly (Ebstein anomaly) at 20 to 36 weeks' gestation were studied in the HDlive silhouette mode with STIC.

RESULTS

In normal fetal hearts, 4 cardiac chambers and crisscross arrangements of the pulmonary artery and aorta were clearly identified. This modality facilitated visualization of the relationships and course of the outflow and inflow tracts, thus helping the operators more effectively understand the spatial relationships among the cardiac chambers and vessels. The opening and closing of mitral, tricuspid, pulmonary, and aortic valves were ascertained in the en face view of both atrioventricular valves and great vessels. In the fetus with Ebstein anomaly, a low attachment of the tricuspid valve and an enlarged right atrium were evident.

CONCLUSIONS

The HDlive silhouette mode with STIC provides new visual experiences for physicians, owing to the anatomically clear depiction of fetal cardiac structures, and it may be an easier way to depict the spatial relationships among fetal cardiac chambers, great arteries, and veins.

Non-Invasive Evaluation of Heart Function with Four-Dimensional Echocardiography

Background

The aim of this study is to assess the accuracy and feasibility of left ventricular systolic function determined by four-dimensional echocardiography (4DE).

Methods

Latex balloons were sewn into the left ventricle (LV) of 20 freshly harvested pig hearts which were then passively driven by a pulsatile pump apparatus. Global longitudinal strain (GLS), global circumferential strain (GCS), global area strain (GAS) and left ventricular ejection fraction (LVEF) derived from 4DEand two-dimensional echocardiography (2DE)-derived LVEF were quantified at different stroke volumes (SV) 30–70 ml and correlated with sonomicrometry data.

Results

In all comparisons, GLS, GCS, GAS, 2DE-LVEF, and 4DE-LVEF demonstrated strong correlations with sonomicrometry data (r = 0.77, r = 0.89, r = 0.79, r = 0.93, r = 0.96, all P <0.001). Bland-Altman analyses showed slight overestimations of echo-derived GLS, GCS, 2DE-LVEF and 3DE-LVEF over sonomicrometry values (bias = 2.88, bias = 3.99, bias = 3.37, bias = 2.78, respectively). Furthermore, there is better agreement between GCS, 4D LVEF and sonomicrometry values compared with GLS and 2D LVEF.

Conclusion

Four-dimensional echocardiography accurately assesses LV function. GCS derived by 4DE is a potential alternative parameter to quantify LV systolic function.

Prenatal Visualization of the Pulmonary and Aortic Valves and Leaflets Is Feasible Using 4-Dimensional Sonography

OBJECTIVES

The purpose of this study was to determine whether the morphologic characteristics and area of the semilunar valves in healthy fetuses and fetuses with cardiac defects can be visualized by using spatiotemporal image correlation (STIC).

METHODS

Spatiotemporal image correlation volumes from 74 healthy fetuses were recorded in 5 examinations between the 15th and 36th weeks of pregnancy. Second, we recorded STIC volumes from 64 fetuses with various cardiac defects. The quality of the volumes was rated. The areas of the aortic and pulmonary valves were measured in systole by rendering the valves on 4-dimensional sonography. The number of leaflets was examined. Longitudinal data analysis using linear mixed models was performed.

RESULTS

Two hundred ninety-three volumes from normal hearts were examined. In 82.5%, the quality of the normal volumes was sufficient. Visualization of the valve opening was feasible in 96.1% of the normal hearts and 97.4% of the abnormal hearts. The success rate of visualization of the pulmonary and aortic valve leaflets was dependent on the gestational age, with the highest percentage (72.1% in normal hearts) at 19 to 24 weeks. Longitudinal regression analysis showed a positive relationship of the aortic and pulmonary valve areas with gestational age (P < .0001) and fetal biometric measurements (P < .0001). Fifty-eight abnormal volumes were examined. Cardiac defects with abnormal valve areas due to aortic and pulmonary stenosis could be clearly visualized by using STIC.

CONCLUSIONS

Examination of the morphologic characteristics of the semilunar valves using STIC is feasible, which is difficult when using 2-dimensional sonography. With increasing implementation of 4-dimensional sonography, the understanding of rendered images might be useful for anyone practicing fetal echocardiography.

Are Results of 4-D Ultrasound Angiography Examinations Dependent on the Doppler Technology Applied? Comparison of Results Obtained from an In Vivo Model

We aimed to evaluate the agreement of results obtained by 4-D spatio-temporal image correlation (STIC) angiography with two options of Doppler technology (power Doppler [PD] and high-definition flow [HDF]) from an ovary as an in vivo model. Thirty-eight ovaries were recorded by trans-vaginal ultrasound examination in the first part of the menstrual cycle. Two STIC sequences (4-D HDF and 4-D PD) were stored. Volumetric pulsatility index, volumetric resistance index and volumetric systolic/diastolic index for each of these sequences were calculated, and their mean values were compared and correlated. Agreement between 4-D HDF and 4-D PD was assessed using the intra-class correlation coefficient. Intra-class correlation coefficients for all three indices were high, but 95% confidence intervals and limits of agreement were wide. We conclude that both 4-D power Doppler and 4-D high-definition flow may be used for calculating volumetric pulsatility index, volumetric resistance index and volumetric systolic/diastolic index from a STIC sequence, at least in ovaries used as an in vivo model. However, values obtained by both methods cannot be used interchangeably.

4D Blood Flow Reconstruction Over the Entire Ventricle From Wall Motion and Blood Velocity Derived From Ultrasound Data

We demonstrate a new method to recover 4D blood flow over the entire ventricle from partial blood velocity measurements using multiple 3D+t colour Doppler images and ventricular wall motion estimated using 3D+t BMode images. We apply our approach to realistic simulated data to ascertain the ability of the method to deal with incomplete data, as typically happens in clinical practice. Experiments using synthetic data show that the use of wall motion improves velocity reconstruction, shows more accurate flow patterns and improves mean accuracy particularly when coverage of the ventricle is poor. The method was applied to patient data from 6 congenital cases, producing results consistent with the simulations. The use of wall motion produced more plausible flow patterns and reduced the reconstruction error in all patients.

Differential and linear insertion of atrioventricular valves: a useful tool?

OBJECTIVE

The differential insertion of the atrioventricular valves is the ultrasonographic representation of the more apical attachment of the tricuspid valve to the septum with respect to the mitral valve. A linear insertion is present when both valves form a linear continuum and has been suggested as a marker for atrioventricular septal defects (AVSDs). The objective of this study was to evaluate the anatomical substratum of differential and linear insertions of the atrioventricular valves in normal fetal hearts and fetal hearts with an AVSD.

METHODS

The extent and position of the fibrous skeleton and attachment of the atrioventricular valves to the septum were studied in histological sections of 17 normal hearts and four hearts with an AVSD from 10 + 0 weeks' gestation to 3 days postpartum with various immunohistochemical tissue markers. In addition, spatiotemporal image correlation (STIC) volumes of 10 normal hearts and STIC volumes of eight hearts with an AVSD at 13 + 6 to 35 + 5 weeks' gestation were examined.

RESULTS

The differential insertion of the atrioventricular valves was visible in normal hearts in the four-chamber plane immediately beneath the aorta, but nearer the diaphragm a linear insertion was found. In hearts with an AVSD, a linear appearance was observed in the four-chamber plane immediately beneath the aorta. Towards the diaphragm, however, first a differential insertion and, more caudally, a linear insertion was found.

CONCLUSIONS

Both differential and linear insertions can be found in normal fetal hearts and fetal hearts with AVSD, depending on the plane in which the four-chamber view is visualized. Therefore, measurement of the differential insertion is likely to be useful only in experienced hands.

First-trimester fetal cardiac examination using spatiotemporal image correlation, tomographic ultrasound and color Doppler imaging for the diagnosis of complex congenital heart disease in high-risk patients

OBJECTIVE

A four-dimensional (4D) fetal echocardiographic technique utilizing spatiotemporal image correlation, tomographic ultrasound imaging display (STIC-TUI echo) and color Doppler has previously been shown to be effective in displaying the examination planes constituting the extended cardiac examination. The aim of this study was to evaluate the performance of this first-trimester STIC-TUI echo technique in identifying complex congenital heart disease (CHD) in high-risk pregnancies.

METHODS

This was a prospective study of patients presenting at first-trimester screening who were at high risk for CHD owing to pregestational diabetes, in-vitro fertilization (IVF), increased nuchal translucency (NT) thickness, first-trimester tricuspid regurgitation or reversed ductus venosus (DV) a-wave, a previous child with CHD or who were on anticonvulsant medication. First-trimester STIC-TUI echo was performed, and the findings were correlated with second-trimester echocardiography and post-delivery echo findings in survivors.

RESULTS

One hundred and sixty-four fetuses from 152 patients were enrolled (77 diabetics, 38 IVF, 14 with increased NT, 23 cases of tricuspid regurgitation or reversed a-wave in the DV, 22 with prior CHD and two on anticonvulsants). STIC-TUI echo was abnormal in 20 (12%), showing atrioventricular canal defect (n = 9), hypoplastic left heart (n = 2), pulmonary stenosis (n = 2), right aortic arch (n = 1), interrupted aortic arch (n = 1), tricuspid atresia (n = 1), heterotaxy (n = 1), persistent truncus arteriosus (n = 1), double outlet right ventricle and ventricular septal defect (n = 1) and double inlet ventricle with transposition of the great arteries (n = 1). 85% of these anomalies were evident in the four-chamber view plane of the TUI display, and the remainder were diagnosed in the outflow tract planes with color Doppler imaging. In 13, CHD was isolated while seven had extracardiac anomalies. Thirteen fetuses had aneuploidy and all 13 underwent first-trimester termination of pregnancy. In the remaining seven, second-trimester echocardiography and neonatal echo/postmortem examination confirmed anomalies (two stillborn neonates, one neonatal death, four live births). Two cases of CHD missed by first-trimester STIC-TUI echo were diagnosed on second-trimester echo. Accordingly, first-trimester STIC-TUI echo had 91% sensitivity and 100% specificity for the detection of CHD.

CONCLUSIONS

First-trimester 4D echocardiography using a standardized application of STIC, TUI and color Doppler imaging is effective in displaying the imaging planes that are necessary for achieving the diagnosis of complex cardiac anomalies in high-risk patients. Optimal imaging of the four-chamber view with two-dimensional ultrasound is the major determinant of successful volume acquisition.

Imaging in fetal cardiology

Early detection and accurate diagnosis of fetal cardiac disease is a central approach in perinatal medicine. The purpose of this review is to evaluate current imaging modalities for the assessment of the fetal heart and its function. Conventional fetal 2D- and color-Doppler echocardiography as a screening tool as well as a diagnostic modality has been proven to be safe, easy and cost-effective for the diagnosis of structural heart disease. Cardiac function can be assessed by M-mode and intra- and extra-cardiac Doppler-echocardiography on a routine basis, but remains challenging in subclinical pathology. Tissue-Doppler, speckle tracking, dynamic three-dimensional (4D) echocardiography, and fetal cardiac magnetic resonance imaging are advanced modalities for the assessment of cardiac structure and function. Implementation of these new technologies is far from routine, but these approaches have already shown promising results and may allow a more detailed evaluation of cardiac function. In this review, we provide a brief overview of currently available techniques, and their benefits and limitations in the clinical assessment of the fetal heart.

Four-dimensional echocardiography with spatiotemporal image correlation and inversion mode for detection of congenital heart disease

The aim of this study was to evaluate the use of 4-D echocardiography with inversion mode and spatiotemporal image correlation (IM-STIC) in the detection of normal and abnormal fetal hearts. We retrospectively studied 112 normal fetuses and 16 fetuses with a confirmed diagnosis of congenital heart disease. Two volumes were acquired from each of the fetuses using transverse and sagittal sweeps. Volumes were reconstructed with IM-STIC. In normal fetuses, IM-STIC facilitated visualization of the interior structures of the fetal heart and great vessels. The visualization rates of intended planes obtained from IM-STIC 4D data ranged from 55% to 100%. In 16 fetuses with congenital heart disease, IM-STIC was able to display the cardiac malformations using digital casting. Some of the malformations were suspected during pre-natal 2-D echocardiography, and their pre-natal IM-STIC diagnoses were confirmed by post-natal echocardiography, surgery and/or autopsy. Hence, 4-D IM-STIC allows better visualization of complex congenital heart disease and should be considered a very useful addition to 2-D echocardiography.

Collaborative study of 4-dimensional fetal echocardiography in the first trimester of pregnancy

OBJECTIVES

Accumulating evidence supports a role for 2-dimensional fetal echocardiography in the first trimester of pregnancy for the identification of congenital heart defects. Our objective was to investigate the role of 4-dimensional (4D) sonography in the identification of congenital heart defects between 11 and 15 weeks of pregnancy.

METHODS

This study included 4 centers with expertise in first-trimester 4D fetal echocardiography. Fetuses with and without confirmed heart defects were evaluated between 11 and 15 weeks and their volume data sets were uploaded onto a centralized file transfer protocol server.

RESULTS

Forty-eight volume data sets from fetuses with normal (n = 17) and abnormal (n = 16) hearts were evaluated. Overall, the median (range) accuracy, sensitivity, and specificity, as well as the positive and negative likelihood ratios, for the identification of fetuses with congenital heart defects were 79% (77%-83%), 90% (70%-96%), 59% (58%-93%), 2.35 (2.05-9.80), and 0.18 (0.08-0.32), respectively.

CONCLUSIONS

(1) Four-dimensional fetal echocardiography can be performed in the first and early second trimesters of pregnancy; and (2) 4D volume data sets obtained from fetuses between 11 and 15 weeks can be remotely acquired and accurately interpreted by different centers.

Radial basis functions for combining shape and speckle tracking in 4D echocardiography

Quantitative analysis of left ventricular deformation can provide valuable information about the extent of disease as well as the efficacy of treatment. In this work, we develop an adaptive multi-level compactly supported radial basis approach for deformation analysis in 3D+time echocardiography. Our method combines displacement information from shape tracking of myocardial boundaries (derived from B-mode data) with mid-wall displacements from radio-frequency-based ultrasound speckle tracking. We evaluate our methods on open-chest canines (N=8) and show that our combined approach is better correlated to magnetic resonance tagging-derived strains than either individual method. We also are able to identify regions of myocardial infarction (confirmed by postmortem analysis) using radial strain values obtained with our approach.

Use of spatiotemporal image correlation at 11-14 weeks' gestation

OBJECTIVE

To assess prospectively the use of four-dimensional (4D) spatiotemporal image correlation (STIC) in the evaluation of the fetal heart at 11-14 weeks' gestation.

METHODS

The study involved offline analysis of 4D-STIC volumes of the fetal heart acquired at 11-14 weeks' gestation in a population at high risk for congenital heart disease (CHD). Regression analysis was used to investigate the effect of gestational age, maternal body mass index, quality of the 4D-STIC volume, use of a transvaginal vs transabdominal probe and use of color Doppler ultrasonography on the ability to visualize separately different heart structures. The accuracy in diagnosing CHD based on early fetal echocardiography (EFE) using 4D-STIC vs conventional two-dimensional (2D) ultrasound was also evaluated.

RESULTS

One hundred and thirty-nine fetuses with a total of 243 STIC volumes were included in this study. Regression analysis showed that the ability to visualize different heart structures was correlated with the quality of the acquired 4D-STIC volumes. Independently, the use of a transvaginal approach improved visualization of the four-chamber view, and the use of Doppler improved visualization of the outflow tracts, aortic arch and interventricular septum. Follow-up was available in 121 of the 139 fetuses, of which 27 had a confirmed CHD. A diagnosis based on EFE using 4D-STIC was possible in 130 (93.5%) of the 139 fetuses. Accuracy in diagnosing CHD using 4D-STIC was 88.7%, and the results of 45% of the cases were fully concordant with those of 2D ultrasound or the final follow-up diagnosis. EFE using 2D ultrasound was possible in all fetuses, and accuracy in diagnosing CHD was 94.2%. Five of the seven false-positive or false-negative cases were minor CHD.

CONCLUSIONS

In fetuses at 11-14 weeks' gestation, the heart can be evaluated offline using 4D-STIC in a large number of cases, and this evaluation is more successful the higher the quality of the acquired volume. 2D ultrasound remains superior to 4D-STIC at 11-14 weeks, unless volumes of good to high quality can be obtained.

First trimester two- and four-dimensional cardiac scan: intra- and interobserver agreement, comparison between methods and benefits of color Doppler technique

OBJECTIVE

To evaluate intra- and interobserver agreement for first-trimester fetal cardiac structural assessment, using two-dimensional (2D) ultrasound (2D-US) and 4D-US (4D spatiotemporal image correlation (STIC) technology), to compare the methods and to assess the advantages of adding color Doppler to each technique.

METHODS

Digital videoclips (B-mode and color Doppler) and 4D-STIC volumes (gray-scale and color Doppler) from 632 pregnancies with normal fetal hearts were acquired and stored at the time of detailed first-trimester ultrasound examination. Later analysis on a randomized sample of 100 cases was performed, targeting 11 cardiac structures and features. We compared visualization of fetal heart parameters using 2D-US vs 4D-US and gray-scale vs color Doppler imaging.

RESULTS

STIC volumes were considered satisfactory (adequate visualization of at least 8/11 parameters) in 78% of cases and 2D-US acquisitions in 89% of cases. The intra- and interobserver agreement was good for both 2D and 4D methods (kappa > 0.6), and the percentage overall agreement was very high using both methods (95%). 2D- and 4D-US identification of the fetal cardiac parameters did not differ significantly. The differences between gray-scale and color Doppler imaging were statistically significant in identifying similar key cardiac parameters, for both 2D- and 4D-US (P < 0.05).

CONCLUSION

Both 2D and 4D methods for assessing first-trimester heart parameters are feasible and repeatable within and between observers. Color Doppler adds valuable information to both methods.

Reliability of fetal thymus measurement in prediction of 22q11.2 deletion: a retrospective study using four-dimensional spatiotemporal image correlation volumes

OBJECTIVES

To evaluate the thymic-thoracic ratio (TT-ratio) method in assessment of the fetal thymus in normal fetuses and in those with cardiac abnormalities, in the presence or absence of 22q11.2 deletion.

METHOD

Database records were reviewed for cases of conotruncal and arch abnormalities found on fetal echocardiography between January 2007 and September 2011. The 22q11.2 deletion status was retrieved and cases in which this was not known were excluded from the analysis, as were fetuses with aneuploidy or other genetic disorders. An additional 55 normal fetuses were analyzed as a control group. The TT-ratio was measured retrospectively using stored spatiotemporal image correlation (STIC) volume datasets.

RESULTS

Sixty-nine fetuses with relevant cardiac diagnoses were identified and, of these, 18 (26%) had 22q11.2 deletion. The mean gestational age at diagnosis was 22 weeks. Significant pairwise differences, but also overlap, were observed between all three groups (i.e. fetuses with heart defects with and without the 22q11.2 deletion and controls). The mean TT-ratio was 0.44 in our normal control group and was significantly smaller in fetuses with 22q11.2 deletion, corresponding to previously published data. However, the mean TT-ratio in the group with conotruncal anomalies but without the 22q11.2 deletion was also smaller than that in controls, in contrast to previously published data. The TT-ratio was above the normal mean, regardless of fetal karyotype, in all cases of interrupted aortic arch.

CONCLUSION

The TT-ratio method is a feasible and potentially useful tool during detailed fetal heart assessment. However, the absolute measurement is not reliable for prediction of 22q11.2 deletion and the obtained results should therefore be interpreted with caution. Fetal karyotyping should be recommended in cases with conotruncal heart abnormalities, irrespective of the TT-ratio.

Accuracy, agreement, and reliability of fetal cardiac measurements using 4-dimensional spatiotemporal image correlation

OBJECTIVES

The purpose of this study was to evaluate the accuracy, agreement, and reliability of 4-dimensional sonography using spatiotemporal image correlation (STIC) in fetal cardiac measurements during the second and third trimesters.

METHODS

Four-dimensional cardiac STIC volumes were acquired from 150 low-risk singleton pregnancies at gestational ages of 18 to 38 weeks. A total of 11 dimensions of the fetal heart and great vessels were analyzed by two different observers. Accuracy was assessed by comparing the measurements acquired by 4-dimensional STIC with those determined by 2-dimensional echocardiography by calculating the mean error and mean percent error and depicted by Bland-Altman plots. Absolute agreement and reliability of STIC-based measurements were evaluated on the basis of an intraclass correlation coefficient (ICC).

RESULTS

For STIC-based measurements of cardiac dimensions, good accuracy was achieved by the two experienced observers (mean percent error, -3.10% to 0.87% for observer A; -2.49% to -0.33% for observer B), and absolute agreement was almost perfect (ICC, 95% confidence interval, 0.916-0.993 for observer A; 0.957-0.990 for observer B). Interobserver ICCs among the two observers were between 0.909 and 0.990 (95% confidence interval), whereas intraobserver ICCs for observer A were between 0.894 and 0.989, and those for observer B were between 0.893 and 0.985, showing no significant differences in the reliability of SITC with regard to observers.

CONCLUSIONS

Four-dimensional sonography with STIC is a feasible and accurate method for fetal cardiac dimension measurements in the second and third trimesters. It is in good agreement with 2-dimensional echocardiography and can be performed by different observers.

Evaluation of normal fetal pulmonary veins using B-flow imaging with spatiotemporal image correlation and by traditional color Doppler echocardiography

OBJECTIVE

The purpose of our report is to evaluate the use of color Doppler echocardiography (CDE) with four chamber view (4CV), scanning around left atrium, and four-dimensional echocardiography with B-flow imaging and spatiotemporal image correlation (4D BF-STIC) in detecting fetal pulmonary veins at 17 to 40 weeks' gestation.

METHODS

This was a prospective study. Color Doppler echocardiography with 4CV, scanning around left atrium, and 4D BF-STIC were used to detect the pulmonary veins in 460 normal fetuses at 17 to 40 weeks of gestation. Routine prenatal screening was used to confirm that the fetuses were in good health with no cardiac or extra cardiac anomalies. All patients underwent follow up at one year. Twenty-two patients were excluded from the study. The number of pulmonary veins visualized using each method was recorded and then compared in six subgroups according to gestational age.

RESULTS

Four-dimensional echocardiography with B-flow imaging and spatiotemporal image correlation was the best method to detect the greatest number of pulmonary veins between 17 and 31 weeks of gestation. Scanning around left atrium detected more pulmonary veins than the traditional 4CV method throughout the gestational period.

CONCLUSIONS

The scanning around left atrium method proved to be the most suited for detecting pulmonary veins in clinical practice. 4D BF-STIC was superior in detecting the greatest number of pulmonary veins before 32 gestational weeks, but had limited clinical usage because it was very time-consuming and experience-dependent. The 4D method should be considered as a complement to traditional two-dimensional sonography, because it facilitates understanding of the anatomy and the spatial relationships of the cardiac structures.

Four-dimensional sonography with spatiotemporal image correlation and tomographic ultrasound imaging in the prenatal diagnosis of anomalous pulmonary venous connections

OBJECTIVES

To determine whether the use of 4-dimensional (4D) sonography with spatiotemporal image correlation (STIC) and tomographic ultrasound imaging (TUI) can provide additional information with respect to 2-dimensional (2D) echocardiography in the prenatal diagnosis of anomalous pulmonary venous connections.

METHODS

The study population consisted of 10 cases that were initially suspected to have total or partial anomalous pulmonary venous connections by prenatal 2D echocardiography between January 2008 and April 2011. All 10 cases were further examined and analyzed by 4D sonography with STIC-TUI. Detailed postnatal surgery or autopsy was performed on all 10 fetuses.

RESULTS

Total anomalous pulmonary venous connections were found in 5 cases, and a partial connection was diagnosed in 1 fetus postnatally. The remaining 4 cases were confirmed to have normal pulmonary venous connections. Four of the 5 fetuses with anomalous pulmonary venous connections had an additional major cardiac defect; 1 fetus had an isolated connection. Anomalous drainage was supracardiac to the superior vena cava in 2 cases, cardiac to the coronary sinus in 3, and partially infracardiac to the portal vein in remaining case. The pulmonary venous connections were completely and correctly visualized with 2D echocardiography in 2 of the 10 cases, partially identified in 4, and not distinguished completely in 4. Four-dimensional sonography imaging with STIC-TUI clearly visualized the connections in 9 of the 10 cases, and the remaining case was partially identified.

CONCLUSIONS

Four-dimensional sonography with STIC-TUI facilitates visualization of pulmonary venous connections, thus supplying additional information with respect to 2D echocardiography in the prenatal diagnosis of anomalous pulmonary venous connections.

Comparison of ex-vivo high-resolution episcopic microscopy with in-vivo four-dimensional high-resolution transvaginal sonography of the first-trimester fetal heart

OBJECTIVE

To compare the capability of three-dimensional (3D) reconstructed images produced by high-resolution episcopic microscopy (HREM) with that of in-vivo four-dimensional high-resolution transvaginal sonography (4D-HRTVS) to discern morphological features of the first-trimester human fetal heart.

METHODS

This was a prospective study of fetal hearts between 9 and 14 weeks' gestation. For ex-vivo 3D analysis, 30 human fetal hearts (at 9 + 0 to 14 + 6 weeks) were retrieved from surgical terminations of pregnancy. The specimens were embedded in resin and episcopic ('block-face') imaging was used to obtain a digital volume dataset (HREM) using 3-micron slicing. 4D-HRTVS was performed in 28 separate pregnancies at 10 + 2 to 14 + 0 weeks using a Voluson E8 ultrasound machine with volumetric transvaginal RIC 6-12-MHz transducers. Heart volumes obtained by both methods were compared to assess their ability to demonstrate first-trimester cardiac morphology. Comparisons were made in the transverse and sagittal planes, and using volume rendering.

RESULTS

All hearts were structurally normal, although abdominal situs was not examined in the isolated hearts that underwent HREM. 4D-HRTVS demonstrated each of the complete five transverse cardiac views in 32-86% of cases. HREM showed four features unique to the first-trimester human heart: prominent atrial appendages, spiral ventricular arrangement, prominent coronary arteries and thickened arterial walls. 4D-HRTVS could demonstrate the first two, but ultrasound resolution was too poor to quantify wall thickness and demonstrate coronary arteries in the 3-5-mm diameter heart.

CONCLUSIONS

4D-HRTVS showed limited morphological features of the first-trimester fetal heart compared with HREM. HREM provides a gold standard of ex-vivo imaging against which developments in ultrasound resolution could be compared.

Interobserver agreement in detailed prenatal diagnosis of congenital heart disease by telemedicine using four-dimensional ultrasound with spatiotemporal image correlation

OBJECTIVE

To evaluate the clinical accuracy of four-dimensional (4D) echocardiography in the detailed prenatal diagnosis of congenital heart disease (CHD) in a telemedicine setting.

METHODS

Ten second-trimester spatiotemporal image correlation (STIC) volumes were sent to three observers in different tertiary care centers with expertise in 4D echocardiography. The 10 volumes were selected based on the type of diagnosis to cover a wide spectrum of CHD anomalies, and also included one normal fetal heart. Observers were asked to provide the diagnosis, the postprocessing modalities used and the time spent on examination, and to give a rating of the confidence for the diagnosis on a 5-point Likert scale. They were free to consult other colleagues, including pediatric cardiologists, but were blinded to the prenatal diagnosis and the neonatal outcome. A diagnostic scoring system was used to evaluate different aspects of the heart defects. The results were compared with neonatal echocardiography or postmortem findings ('gold standard').

RESULTS

In two cases all observers correctly diagnosed all details of the volume datasets. The observer with the best performance reached perfect agreement in six cases and nearly perfect agreement in three. The volumes were most frequently studied by sectional planes and were analyzed in a median time of 11.0 (range, 2.5-30.0) min. The median confidence score was 4.0 (range, 1.0-5.0).

CONCLUSIONS

In a telemedicine setting using STIC volumes, fetal cardiac anomalies can be diagnosed correctly by an expert. However, details required for adequate counseling and planning of postnatal care may be missed. STIC by telemedicine is a promising modality, although not accurate enough for exclusive use in clinical decision making regarding treatment, prognosis or termination of pregnancy.

The role of three-dimensional ultrasound in the diagnosis of fetal congenital anomalies: a review

The objective of this review was to establish whether three-dimensional (3D) and four dimensional (4D) ultrasonography adds diagnostic information to what is currently provided by two-dimensional (2D) ultrasound in the diagnosis of the most frequent fetal structural defects: congenital heart disease and central nervous system congenital anomalies. There are evidences suggesting that 3D ultrasound allows to reduce the operator dependency in the visualization of standard diagnostic planes, thus reducing the examination time require for the obstetric ultrasound examination, with minimal impact on the visualization quality of the anatomic landmarks. Furthermore, operators with minimal experience may record cardiac or brain volumes that can be successfully analyzed off-line locally or sent by internet to experts for remote review. As a consequence 3D ultrasonography promises to become the method of choice for diagnosis congenital structural defects.

Reference ranges for the fetal cardiac circumference derived by cardio-spatiotemporal image correlation from 14 to 40 weeks' gestation

OBJECTIVES

The purpose of this study was to construct reference ranges for the fetal cardiac circumference derived from volume data sets obtained by cardio-spatiotemporal image correlation.

METHODS

A prospective descriptive study was conducted on normal singleton pregnancies with certain dates from 14 to 40 weeks' gestation. All underwent cardio-spatiotemporal image correlation to acquire volume data sets for subsequent analysis. Cardiac circumferences were measured offline in a multiplanar view with 4-dimensional imaging software. The reference ranges were constructed against gestational weeks and the biparietal diameter as independent variables, using regression models for both the mean and SD.

RESULTS

A total of 678 satisfactory volumes were analyzed. Normal reference ranges for predicting means and SDs of the fetal cardiac circumference were established based on best-fitted equations. The mean cardiac circumference (millimeters) was modeled as a function of gestational age (weeks) and biparietal diameter (centimeters) as follows: cardiac circumference = -53.11 + 6.56 × gestational age - 0.035 × gestational age(2) (SD = 0.67 + 0.18 × gestational age) and -17.60 + 17.68 × biparietal diameter (SD = 1.651 + 0.61 × biparietal diameter). Equations for z score calculation were also provided, and percentile charts for predicting the cardiac circumference at various points of gestational age and biparietal diameter were constructed.

CONCLUSIONS

Normal reference ranges and z scores for the fetal cardiac circumference have been provided. These normative data may be useful tools for assessment of fetal cardiac size, especially in cardiomegaly due to fetal anemia.

A 10-Fr ultrasound catheter with integrated micromotor for 4-D intracardiac echocardiography

We developed prototype real-time 3-D intracardiac echocardiography catheters with integrated micromotors, allowing internal oscillation of a low-profile 64-element, 6.2-MHz phased-array transducer in the elevation direction. Components were designed to facilitate rotation of the array, including a low-torque flexible transducer interconnect and miniature fixtures for the transducer and micromotor. The catheter tip prototypes were integrated with two-way deflectable 10-Fr catheters and used in in vivo animal testing at multiple facilities. The 4-D ICE catheters were capable of imaging a 90° azimuth by up to 180° elevation field of view. Volume rates ranged from 1 vol/sec (180° elevation) to approximately 10 vol/sec (60° elevation). We successfully imaged electrophysiology catheters, atrial septal puncture procedures, and detailed cardiac anatomy. The elevation oscillation enabled 3-D visualization of devices and anatomy, providing new clinical information and perspective not possible with current 2-D imaging catheters.

Fetal cardiac ventricular volume, cardiac output, and ejection fraction determined with 4-dimensional ultrasound using spatiotemporal image correlation and virtual organ computer-aided analysis

OBJECTIVE

The objective of this study was to quantify fetal cardiovascular parameters using spatiotemporal image correlation (STIC) and virtual organ computer-aided analysis (VOCAL).

STUDY DESIGN

A cross-sectional study was performed in normal pregnancies (19-42 weeks) to evaluate ventricular volume, stroke volume (SV), cardiac output (CO), and ejection fraction (EF). The CO was also expressed as a function of estimated fetal weight and biometric parameters.

RESULTS

The following results were found: (1) 184 STIC datasets; (2) with advancing gestation, ventricular volume, SV, CO, and adjusted CO increased, whereas EF decreased; (3) right ventricular (RV) volume was larger than the left ventricular (LV) volume in systole (0.50 vs 0.27 mL; P < .001) and diastole (1.20 vs 1.03 mL; P < .001); (4) there were no differences between the LV and RV in SV, CO, or adjusted CO; and (5) LV EF was greater than the RV EF (72.2 vs 62.4%; P < .001).

CONCLUSION

Normal fetal cardiovascular physiology is characterized by a larger RV volume and a greater LV EF, resulting in similar LV and RV SV and CO.

Simple targeted arterial rendering (STAR) technique: a novel and simple method to visualize the fetal cardiac outflow tracts

OBJECTIVE

To describe a novel and simple technique—simple targeted arterial rendering (STAR)—to visualize the fetal cardiac outflow tracts from dataset volumes obtained with spatiotemporal image correlation (STIC) and applying a new display technology (OmniView).

METHODS

We developed a technique to image the outflow tracts by drawing three dissecting lines through the four-chamber view of the heart contained in a STIC volume dataset. Each line generated the following plane: (a) Line 1: ventricular septum en face with both great vessels (pulmonary artery anterior to the aorta); (b) Line 2: pulmonary artery with continuation into the longitudinal view of the ductal arch; and (c) Line 3: long-axis view of the aorta arising from the left ventricle. The pattern formed by all three lines intersecting approximately through the crux of the heart resembles a star. The technique was then tested in 50 normal fetal hearts at 15.3–40.4 weeks' gestation. To determine whether the technique could identify planes that departed from the normal images, we tested the technique in four cases with proven congenital heart defects (ventricular septal defect (VSD), transposition of great vessels, tetralogy of Fallot and pulmonary atresia with intact ventricular septum).

RESULTS

The STAR technique was able to generate the intended planes in all 50 normal cases. In the abnormal cases, the STAR technique allowed identification of the VSD, demonstrated great vessel anomalies and displayed views that deviated from what was expected from the examination of normal hearts.

CONCLUSIONS

This novel and simple technique can be used to visualize the outflow tracts and ventricular septum en face in normal fetal hearts. Inability to obtain expected views or the appearance of abnormal views in the generated planes should raise the index of suspicion for congenital heart disease involving the great vessels and/or the ventricular septum. The STAR technique may simplify examination of the fetal heart and could reduce operator dependency.

Added value of three-/four-dimensional ultrasound in offline analysis and diagnosis of congenital heart disease

OBJECTIVE

Many published studies have shown that application of three-dimensional (3D) and real-time 3D (4D) ultrasound modalities can improve certain aspects of fetal echocardiography, but have left open the question of whether these modalities improved the accuracy of prenatal detection of anatomical fetal cardiovascular malformations. We aimed to determine whether 3D/4D ultrasound improved diagnostic ability in cases of congenital heart disease (CHD).

METHODS

Women who attended for early- or midtrimester targeted organ scans had complete fetal echocardiography according to our five-planes protocol, as well as examination of the ductus venosus and longitudinal aortic arch planes, performed with 2D ultrasound combined with 2D color Doppler, spatiotemporal image correlation (STIC), STIC with color Doppler, and STIC with B-flow. Ultrasound data of cases of CHD were stored in a dedicated archive. Stored cases were anonymized and the list order was randomized. Stored 2D ultrasound cineloops and 4D ultrasound volumes were reviewed separately according to a standardized table of 23 specified structures on five required planes of visualization: the upper abdomen, four-chamber view, five-chamber view, pulmonary artery bifurcation view, and three vessels and trachea plane. Separate diagnoses were recorded and finally compared. Diagnoses were confirmed by pathological examination or neonatal echocardiography.

RESULTS

During the study period, 13 101 examinations were performed; 181 diagnoses of CHD were made. In 12 of these, 3D/4D ultrasound added to the accuracy of our diagnosis: one right aortic arch with anomalous branching; one transposition of the great arteries with pulmonary atresia diagnosed with tomographic ultrasound imaging (TUI); one segmental interrupted aortic arch diagnosed with TUI; one right ventricle aneurysm diagnosed with B-flow; two agenesis of ductus venosus to the coronary sinus diagnosed by multiplanar reconstruction (MPR) and B-flow; two total anomalous pulmonary venous connection diagnosed with MPR; and four ventricular septal defect (VSD) diagnosed with the aid of virtual planes. There were 12 missed diagnoses and no false-positive results.

CONCLUSIONS

3D/4D ultrasound modalities may have advantages in some aspects of fetal cardiovascular evaluation, however, overall 3D/4D ultrasound modalities had added value in only about 6% of cases of fetal anatomical cardiovascular anomalies.

Four-chamber view and 'swing technique' (FAST) echo: a novel and simple algorithm to visualize standard fetal echocardiographic planes

OBJECTIVE

To describe a novel and simple algorithm (four-chamber view and 'swing technique' (FAST) echo) for visualization of standard diagnostic planes of fetal echocardiography from dataset volumes obtained with spatiotemporal image correlation (STIC) and applying a new display technology (OmniView).

METHODS

We developed an algorithm to image standard fetal echocardiographic planes by drawing four dissecting lines through the longitudinal view of the ductal arch contained in a STIC volume dataset. Three of the lines are locked to provide simultaneous visualization of targeted planes, and the fourth line (unlocked) 'swings' through the ductal arch image (swing technique), providing an infinite number of cardiac planes in sequence. Each line generates the following plane(s): (a) Line 1: three-vessels and trachea view; (b) Line 2: five-chamber view and long-axis view of the aorta (obtained by rotation of the five-chamber view on the y-axis); (c) Line 3: four-chamber view; and (d) 'swing line': three-vessels and trachea view, five-chamber view and/or long-axis view of the aorta, four-chamber view and stomach. The algorithm was then tested in 50 normal hearts in fetuses at 15.3-40 weeks' gestation and visualization rates for cardiac diagnostic planes were calculated. To determine whether the algorithm could identify planes that departed from the normal images, we tested the algorithm in five cases with proven congenital heart defects.

RESULTS

In normal cases, the FAST echo algorithm (three locked lines and rotation of the five-chamber view on the y-axis) was able to generate the intended planes (longitudinal view of the ductal arch, pulmonary artery, three-vessels and trachea view, five-chamber view, long-axis view of the aorta, four-chamber view) individually in 100% of cases (except for the three-vessels and trachea view, which was seen in 98% (49/50)) and simultaneously in 98% (49/50). The swing technique was able to generate the three-vessels and trachea view, five-chamber view and/or long-axis view of the aorta, four-chamber view and stomach in 100% of normal cases. In the abnormal cases, the FAST echo algorithm demonstrated the cardiac defects and displayed views that deviated from what was expected from the examination of normal hearts. The swing technique was useful for demonstrating the specific diagnosis due to visualization of an infinite number of cardiac planes in sequence.

CONCLUSIONS

This novel and simple algorithm can be used to visualize standard fetal echocardiographic planes in normal fetal hearts. The FAST echo algorithm may simplify examination of the fetal heart and could reduce operator dependency. Using this algorithm, inability to obtain expected views or the appearance of abnormal views in the generated planes should raise the index of suspicion for congenital heart disease.

Fetal cardiac dimensions at 14-40 weeks' gestation obtained using cardio-STIC-M

OBJECTIVES

To establish normative reference ranges of fetal cardiac dimensions derived from volume datasets acquired using spatiotemporal image correlation with M-mode display (cardio-STIC-M).

METHODS

A cross-sectional study was undertaken on singleton pregnancies with normal fetuses and accurate gestational ages. Cardio-STIC volume datasets were acquired by experienced operators using a high-resolution ultrasound machine; these were maneuvered to obtain a four chamber-view with exactly horizontal interventricular septum (IVS). Cardiac dimensions were measured in STIC-M-mode using 4D View software.

RESULTS

A total of 657 measurements, at a rate of between 15 and 37 per week, were obtained. Normal reference ranges for biventricular outer diameter, left and right ventricular inner diameter, left and right ventricular wall thickness, IVS thickness, left to right ventricular diameter ratio and left and right ventricular shortening fractions were constructed based on best-fit equations as a function of gestational age, fetal head circumference and biparietal diameter. Thirty-four volume datasets of abnormal fetal hearts were also separately assessed, many of which showed abnormal cardiac dimensions.

CONCLUSIONS

This is the first report on normal ranges of fetal cardiac dimensions constructed using the new cardio-STIC-M technology. Preliminary evaluation suggests that these reference ranges may be a useful tool in the assessment of fetal cardiac abnormalities.

Volumetry of fetal hearts using 3D real-time matrix echocardiography - in vitro validation experiments and 3D echocardiographic studies in fetuses

PURPOSE

The aim of this study was to assess the feasibility, accuracy and reliability of 3D real-time echocardiography for fetal heart volumetry.

MATERIALS AND METHODS

Fifty unselected and consecutive fetuses, including 14 with cardiac malformations, were scanned prospectively using real-time 3D matrix technology and 2D echocardiography to determine ventricular volumes. Small phantoms as well as modified balloons (0.5 - 20 ml) were used to assess the validity of 2D and 3D distance, area and volume calculations and to study potential sources of error during data acquisition and analysis. The data was evaluated by two blinded observers.

RESULTS

In vitro, real-time 3D and 2D underestimated the actual volumes by -5.49 % (3D) and -6.86 % (2D). The intraobserver and interobserver variability were excellent. In vivo, real-time 3D was superior to 2D with regard to intraobserver and interobserver variability (mean coefficient of variation 8.28 % (3D) versus 13.96 % (2D), and mean intraclass correlation coefficient 0.997 (3D) versus 0.885 (2D) for left ventricular volumes). Similar to in vitro, in vivo 2D volumes were calculated smaller than 3D volumes (mean difference -0.39 to -0.94 ml). The ventricular volumes and stroke volumes increased exponentially with gestation. Secondary to poor imaging windows in advanced gestation or inadequate delineation of endocardial borders in small hearts at less than 19 weeks, 3D data could not be analyzed sufficiently in 6 / 50 fetuses.

CONCLUSION

Real-time 3D using a matrix transducer is a feasible, reliable and valid method for volume determination in the fetus beyond 19 weeks of gestation. If compared to 2D, real-time 3D echocardiography provides improved accuracy of cardiac volumetry, decreases intraobserver and interobserver variability and is a promising tool for the accurate assessment of cardiac size and function.

Satisfactory rate of postprocessing visualization of standard fetal cardiac views from 4-dimensional cardiac volumes acquired during routine ultrasound practice by experienced sonographers in peripheral centers

The aim of this study was to evaluate the feasibility of visualizing standard cardiac views from 4-dimensional (4D) cardiac volumes obtained at ultrasound facilities with no specific experience in fetal echocardiography. Five sonographers prospectively recorded 4D cardiac volumes starting from the 4-chamber view on 500 consecutive pregnancies at 19 to 24 weeks' gestation undergoing routine ultrasound examinations (100 pregnancies for each sonographer). Volumes were sent to the referral center, and 2 independent reviewers with experience in 4D fetal echocardiography assessed their quality in the display of the abdominal view, 4-chamber view, left and right ventricular outflow tracts, and 3-vessel and trachea view. Cardiac volumes were acquired in 474 of 500 pregnancies (94.8%). The 2 reviewers respectively acknowledged the presence of satisfactory images in 92.4% and 93.6% of abdominal views, 91.5% and 93.0% of 4-chamber views, in 85.0% and 86.2% of left ventricular outflow tracts, 83.9% and 84.5% of right ventricular outflow tracts, and 85.2% and 84.5% of 3-vessel and trachea views. The presence of a maternal body mass index of greater than 30 altered the probability of achieving satisfactory cardiac views, whereas previous maternal lower abdominal surgery did not affect the quality of reconstructed cardiac views. In conclusion, cardiac volumes acquired by 4D sonography in peripheral centers showed high enough quality to allow satisfactory diagnostic cardiac views.

Collaborative study on 4-dimensional echocardiography for the diagnosis of fetal heart defects: the COFEHD study

OBJECTIVE

Congenital anomalies are the leading cause of infant mortality in the United States, and congenital heart defects (CHDs) are the most common type of birth defects. Recently, 4-dimensional ultrasonography (4DUS) with spatiotemporal image correlation (STIC) has been introduced for fetal echocardiography. Accumulating evidence indicates that 4DUS with STIC may facilitate the examination of the fetal heart. Our objectives were to determine the accuracy of 4DUS for the diagnosis of CHDs and the agreement among centers.

METHODS

This study included 7 centers with expertise in 4D fetal echocardiography. Fetuses with and without confirmed heart defects were scanned between 18 and 26 weeks, and their volume data sets were uploaded onto a centralized file transfer protocol server. Intercenter agreement was determined using a κ statistic for multiple raters.

RESULTS

Ninety volume data sets were randomly selected for blinded analysis. Overall, the median (range) sensitivity, specificity, positive and negative predictive values, and false-positive and -negative rates for the identification of fetuses with CHDs were 93% (77%-100%), 96% (84%-100%), 96% (83%-100%), 93% (79%-100%), 4.8% (2.7%-25%), and 6.8% (5%-22%), respectively. The most frequent CHDs were conotruncal anomalies (36%). There was excellent intercenter agreement (κ = 0.97).

CONCLUSIONS

(1) Four-dimensional volume data sets can be remotely acquired and accurately interpreted by different centers. (2) Among centers with technical expertise, 4DUS is an accurate and reliable method for fetal echocardiography.

Accuracy of four-dimensional spatiotemporal image correlation echocardiography in the prenatal diagnosis of congenital heart defects

OBJECTIVE

To evaluate the accuracy of four-dimensional (4D) spatiotemporal image correlation (STIC) echocardiography for the diagnosis of fetal congenital heart disease (CHD) in a selected high-risk population.

METHODS

Three hundred and sixty-three pregnant women referred for suspected CHD on screening ultrasound were evaluated by means of conventional echocardiography between 14 and 41 weeks' gestation and 4D-STIC volumes were obtained (including gray-scale and color Doppler information). Stored volumes were analyzed, at least 1 year after they had been acquired, by examiners blinded to the patients' identities and outcomes. The STIC diagnoses were compared to those made on conventional two-dimensional echocardiography and the accuracy of diagnosis was assessed with respect to postnatal examination, or autopsy in cases of termination of pregnancy or perinatal death.

RESULTS

The mean gestational age at volume acquisition was 24 + 5 weeks. STIC evaluation was possible in 98% of cases. Twenty-one cases were lost to follow-up, with a total of 167 normal hearts and 175 cases of CHD diagnosed at postnatal evaluation. The overall accuracy, sensitivity, specificity and positive and negative predictive values of STIC in determining the presence or absence of CHD were 91.6, 94.9, 88.1, 89.7 and 94.0%, respectively. Absolute concordance with the final specific diagnosis among cases with confirmed CHD was 74.3% for STIC echocardiography, compared with 81.7% for real-time evaluation.

CONCLUSION

4D-STIC echocardiography performed by experienced operators can be used in fetuses at risk for cardiac anomalies in order to reliably provide reassurance of normality or to accurately diagnose major structural heart defects.

Reliability of fetal cardiac volumetry using spatiotemporal image correlation: assessment of in-vivo and in-vitro measurements

OBJECTIVE

To assess the reliability of measurement of fetal cardiac ventricular volume, stroke volume, and ejection fraction with four-dimensional ultrasound using spatiotemporal image correlation (STIC).

METHODS

Volume datasets were collected from two sources: 24 from fetuses over a range of gestational ages and 12 from a miniature balloon model. Datasets were analyzed by three observers, repeatedly in 12 fetal datasets and all balloon datasets. Volume calculations were obtained by manually tracing multiple parallel slices (three-dimensional (3D) slice method). Measurement error was assessed by calculating standard errors of measurement (SEM) and coefficients of variation (CV). Reliability was assessed by calculating interobserver and intraobserver intraclass correlation coefficients (ICC).

RESULTS

Measurement errors of balloon volumes were small and reliability was good (SEM <or= 0.07 mL, ICC 0.98-1.00). Fetal ventricle volume measurement error ranged from 0.09 to 0.20 mL and CV from 14.6 to 28.3%. Ventricular volume reliabilities for intra- and interobserver comparisons were greater than or equal to 0.94 and 0.75, respectively. Fetal stroke volume measurement error (SEM 0.17 mL), CV (21.9%) and reliability were measured (intraobserver ICC: left ventricle stroke volume (LVSV), 0.93 vs. right ventricle stroke volume (RVSV), 0.88; interobserver ICC: LVSV, 0.75 vs. RVSV, 0.86). The measurement error decreased with increasing operator experience. The reliability of ejection fraction calculations was poor (ICC < 0.7) for intra- and interobserver comparisons.

CONCLUSIONS

Volume measurements obtained with STIC and 3D slice methods using a balloon model were reliable. In the fetus, measurement errors decreased with increasing operator experience, and reliability was better for stroke volume than for ejection fraction.

Fetal interrupted aortic arch: 2D-4D echocardiography, associations and outcome

OBJECTIVES

To analyze fetal two-dimensional (2D) echocardiographic characteristics of interrupted aortic arch (IAA) and its different types, to explore whether the use of 4D ultrasound with B-flow imaging and spatiotemporal image correlation (STIC) can improve prenatal diagnostic accuracy, and to describe associations and outcome.

METHODS

The study comprised IAA fetuses examined exclusively by 2D conventional echocardiography during the period from 1994 to 2003, and those identified by conventional echocardiography and examined further by 4D ultrasound with B-flow imaging and STIC during the period January 2004 to July 2008, identified among fetuses examined at two referral centers for congenital heart defects (CHD). Postnatal follow-up was available in all cases. Karyotyping and fluorescent in-situ hybridization (FISH) analysis for the DiGeorge critical region (22q11.2) were performed in all cases.

RESULTS

Twenty-two cases of isolated IAA (15 Type B and seven Type A, seven and three of which, respectively, underwent B-flow imaging and STIC) were detected among 2520 cases of fetal CHD. In seven of the 15 Type B cases, a right subclavian artery arose anomalously (ARSA). 2D echocardiography failed to distinguish the type of IAA in only two cases and the ARSA in five of the seven cases. B-flow imaging and STIC successfully identified IAA types in all 10 cases examined and clearly visualized the origin and course of the ARSA, including cervical ones. FISH detected 22q11.2 microdeletion in 10 of the 15 Type B cases and an unusual association with Type A in one of the seven cases. Fetal/neonatal outcome included: eight terminations of pregnancy, one intrauterine death and four postoperative deaths in the neonatal period, and nine neonates were alive after surgery at a mean follow-up time of 58 months (range, 4 months-13 years).

CONCLUSION

Our results confirm the feasibility of prenatal characterization of IAA and its different types based on 2D echocardiographic examination, albeit with some limitations in the thorough assessment. 4D ultrasound with B-flow imaging and STIC can apparently facilitate visualization and detailed examination of the anatomical features of the IAA types, including visualization of the neck vessels, thus supplying additional information with respect to 2D sonography. As for the known association with microdeletion 22q11.2, our data indicate that Types A and B are distinct, there being a close association only with IAA Type B.

Intra- and interobserver repeatability of fetal cardiac examination using four-dimensional spatiotemporal image correlation in each trimester of pregnancy

OBJECTIVE

To assess the intra- and interobserver repeatability of the evaluation of fetal cardiac structures and measurements using spatiotemporal image correlation (STIC) technology in each trimester of pregnancy.

METHODS

Four-dimensional (4D)-STIC volumes from 150 low-risk pregnancies were acquired at first-, second- or third-trimester scan for later analysis by two different reviewers. A total of 19 items, including the evaluation of 14 structures as well as five measurements of the fetal heart, were evaluated. The reliability of qualitative variables was evaluated using Cohen's kappa and absolute agreement analysis while that of quantitative parameters was assessed using the intraclass correlation coefficient (ICC).

RESULTS

Forty-five, 47 and 47 STIC volumes were included in the final analysis from the first, second and third trimesters, respectively. For the evaluation of cardiac structures, good or excellent intra- and interobserver agreement (kappa > 0.6) was obtained in 12/14 and 9/14, respectively, while absolute agreement was > 90% for most structures evaluated. Regarding the quantitative cardiac measurements, ICC values were above 0.90 for all but cardiac axis (intraobserver ICC, 0.81 and interobserver ICC, 0.61). There were no significant differences in the repeatability values observed for qualitative or quantitative parameters among the trimesters of pregnancy.

CONCLUSION

Cardiac examination from 4D-STIC volumes showed a high repeatability between and within observers in each trimester of pregnancy.