AIUM Practice Parameter for the Performance of Fetal Echocardiography.

American society of echocardiography guidelines and standards for performance of the fetal echocardiogram

is a multidisciplinary association dedicated to advancing the safe and effective use of ultrasound in medicine through professional and public education, research, development of parameters, and accreditation.

The American Institute of Ultrasound in Medicine (AIUM) is an educational, scientific, and professional society concerned with the advancement of the art and science of ultrasound in medicine and research. To promote this mission, the AIUM is pleased to publish, in conjunction with the American College of Radiology (ACR), the updated Standard for Performance of an Ultrasound Examination of the Abdomen or Retroperitoneum. We are indebted to the many volunteers who contributed their time, knowledge, and energy to bringing this document to completion.The AIUM represents the entire range of clinical and basic science interests in medical diagnostic ultrasound and with hundreds of volunteers, the AIUM has promoted the safe and effective use of ultrasound in clinical medicine for 50 years. This document, and others like it, will continue to advance this mission.Clinical Standards of the AIUM are intended to provide the medical ultrasound community with guidelines for the performance and recording of high quality ultrasound examinations. The standards reflect what the AIUM considers the minimum criteria for a complete examination in each area, but are not intended to establish a legal standard of care. AIUM accredited practices are expected to generally follow the standards with the recognition that deviations from the standards will be needed in some cases depending on patient needs and available equipment. Practices are encouraged to go beyond the standards to provide additional service and information as needed by their referring physicians and patients.

Objective To observe characters in isolated complete vascular ring (CVR) fetuses and to evaluate the trachea area (TA) and vascular ring area (VRA) changes by fetal echocardiography. Methods Ninety-two fetuses with isolated complete vascular ring were diagnosed by fetal echocardiography prenatally and confirmed by postnatal echocardiography, from August 2010 to November 2015 in the Department of Ultrasound in Beijing Anzhen Hospital and Fetal Heart Disease Maternal Fetal Medicine Research Important Laboratories. The VRA and TA were measured at the three vessel-trachea view, and the parameters were compared. Results The TA was decreased in vascular ring fetuses compared with normal fetuses [(5.27±1.49) mm2 vs (2.39±1.26) mm2]. The VRA of vascular ring fetuses was (48.92±19.10) mm2. Right aortic arch and left ductus arteriosus formed ʺUʺ shaped in 77 cases. Double aortic arch formed ʺOʺ shaped or ʺλʺ shaped in 15 cases. Conclusions Fetal echocardiography can accurately diagnosed isolated complete vascular ring. The TA decreased in vascular ring fetuses compared with normal fetuses. Key words: Echocardiography; Fetal; Vascular ring; Trachea

First-trimester fetal heart evaluation: time to move forward.

Objective To quantitatively study the correlation of the distance of pulmonary valve to pulmonary artery bifurcation (DPVB) of normal fetuses in second and late trimester with the fetal biometric parameters using fetal echocardiography. Methods The distances of pulmonary valve to pulmonary artery bifurcation in end-systole (DPVBs) and in end-diastole (DPVBd) were measured in a standard short axis view or right ventricular outflow tract view using fetal echocardiography on 419 normal fetuses. The gestation ages ranged from 20 to 35+ weeks. Fetal non-cardiac biometric parameters including biparietal diameter (BPD), femoral length (FL) and gestation age (GA) based on menstrual age, pulmonary valve annulus diameters (PA) at end-systole were measured. The correlation between DPVBs, DPVBd and non-cardiac biometric parameters were analyzed. Results In normal fetuses, the DPVBs was (1.14±0.24)cm with a range of 0.67 to 1.61 cm, the DPVBd was (0.93±0.20)cm with a range of 0.53 to 1.33 cm. The DPVBs and DPVBd were increased with the growth of GA, and were positively correlated with GA, BPD, FL and PA (r=0.827, 0.798, 0.793, 0.769; 0.802, 0.764, 0.773 and 0.771, respectively, all P<0.001). The linear regression equations between DPVBs, DPVBd and GA, BPD, FL, PA were: Y=0.054×GA-0.369, Y=0.184×BPD-0.179, Y=0.217×FL+ 0.011, Y=1.602×PA+ 0.156, Y=0.045×GA-0.330, Y=0.152×BPD-0.157, Y=0.182×FL-0.018, Y=1.380×PA+ 0.080. Conclusions In normal fetuses, the DPVBs and DPVBd increase with the growth of GA, and have good correlation with GA, BPD, FL and PA, respectively. Normal reference ranges of DPVBs and DPVBd have been provided. These normative data may become a new tool for assessment of fetal heart, especially has potential applications in screening of complex congenital heart defects. Key words: Echocardiography; Fetus; Developmental biology; Distance of pulmonary valve to pulmconary artery bifurcation

ABSTRACTObjectiveTo evaluate the performance of color and bidirectional power Doppler ultrasound combined with Fetal Intelligent Navigation Echocardiography (FINE) in examining the fetal heart.MethodsA prospective cohort study was conducted of fetuses in the second and third trimesters with a normal heart or with congenital heart disease (CHD). One or more spatiotemporal image correlation (STIC) volume datasets, combined with color or bidirectional power Doppler (S‐flow) imaging, were acquired in the apical four‐chamber view. Each successfully obtained STIC volume was evaluated by STICLoop™ to determine its appropriateness before applying the FINE method. Visualization rates for standard fetal echocardiography views using diagnostic planes and/or Virtual Intelligent Sonographer Assistance (VIS‐Assistance®) were calculated for grayscale (removal of Doppler signal), color Doppler and S‐flow Doppler. In four cases with CHD (one case each of tetralogy of Fallot, hypoplastic left heart and coarctation of the aorta, interrupted inferior vena cava with azygos vein continuation and asplenia, and coarctation of the aorta with tricuspid regurgitation and hydrops), the diagnostic potential of this new technology was presented.ResultsA total of 169 STIC volume datasets of the normal fetal heart (color Doppler, n = 78; S‐flow Doppler, n = 91) were obtained from 37 patients. Only a single STIC volume of color Doppler and/or a single volume of S‐flow Doppler per patient were analyzed using FINE. Therefore, 60 STIC volumes (color Doppler, n = 27; S‐flow Doppler, n = 33) comprised the final study group. Median gestational age at sonographic examination was 23 (interquartile range, 21–27.5) weeks. Color Doppler FINE generated nine fetal echocardiography views (grayscale) using (1) diagnostic planes in 73–100% of cases, (2) VIS‐Assistance in 100% of cases, and (3) a combination of diagnostic planes and/or VIS‐Assistance in 100% of cases. The rate of generating successfully eight fetal echocardiography views with appropriate color and S‐flow Doppler information was 89–100% and 91–100% of cases, respectively, using a combination of diagnostic planes and/or VIS‐Assistance. However, the success rate for the ninth echocardiography view (i.e. superior and inferior venae cavae) was 33% and 30% for color and S‐flow Doppler, respectively. In all four cases of CHD, color Doppler FINE demonstrated evidence of abnormal fetal cardiac anatomy and/or hemodynamic flow.ConclusionsThe FINE method applied to STIC volumes of normal fetal hearts acquired with color or bidirectional power Doppler information can generate successfully eight to nine standard fetal echocardiography views (via grayscale, color Doppler or power Doppler) in the second and third trimesters. In cases of CHD, color Doppler FINE demonstrates successfully abnormal anatomy and/or Doppler flow characteristics. Published 2017. This article is a U.S. Government work and is in the public domain in the USA. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

The objective of this study was to establish the echocardiographic modality that best correlates with electrical events in the fetal heart. No documentation on the relationship between electrical events recorded with a surface ECG and fetal M-mode or Doppler echocardiographic measurements is available. The following ultrasound tracings were recorded simultaneously with a surface ECG on six exteriorized near-term fetal lambs: 1) M-mode echocardiography of atrial and ventricular contractions; and 2) Doppler flow velocity waveforms in the right superior vena cava (SVC) either alone or 3) in association with those of the ascending aorta. In the SVC, the onset of the retrograde A wave and the beginning of the forward wave during ventricular systole were used as markers for the start of the P wave and QRS complex, respectively. For the simultaneous SVC and ascending aorta tracings, the beginnings of the A and of the aortic ejection waves were used as markers. On average, the atrioventricular interval was 84 ms longer than the PR interval with the M-mode, corresponding to an increase of 107%. A similar observation was made for the simultaneous Doppler signals from SVC and ascending aorta, but the difference between the atrioventricular and PR intervals was smaller, averaging 35 ms. When the SVC Doppler was taken alone, no significant difference was found between atrioventricular and ventriculoatrial compared with PR and RP intervals, respectively, and a strong correlation was found between the two methods of measurement, both for the atrioventricular (r = 0.91) and ventriculoatrial (r = 0.89) intervals. Doppler interrogation of the SVC alone and, to a lesser degree, of the SVC and ascending aorta are reliable indirect markers for the timing of electrical events of the fetal lamb heart in sinus rhythm.

Although the fetus usually is assessed echocardiographically at midtrimester, modem equipment makes it possible to examine the fetal heart much earlier in pregnancy. This cross-sectional study, conducted in 584 unselected fetuses, was planned to determine whether it is feasible to make 2-dimensional echocardiography of the fetal heart a part of routine first-trimester screening and to formulate reference ranges for cardiac structure at 11 weeks to 13 weeks plus 6 days of gestation. All were viable intrauterine pregnancies. Crown-rump length (CRL), which reflects gestational age, ranged from 41 to 78 mm. A single obstetrician performed all echocardiograms, lasting no longer than 20 minutes, using a 5-to 7.5-MHz vaginal transducer to confirm viability, measure CRL and nuchal translucency, and examine the structure of the heart and great vessels. The 4 cardiac chambers and outflow tracts were well visualized in 67% of examinations. Satisfactory views of all structures in the fetal heart, including a longitudinal view of the aortic arch and ductal arch, were obtained in 43%, 56%, and 62% of fetuses, respectively, at 11, 12, and 13 weeks gestation (58% overall). Reference ranges were derived from measurements of the cardiac ventricles, their outflow tracts, and the ratio of cardiac circumference to thoracic circumference in relation to CRL. There were 6 cardiac malformations among the fetuses. An atrioventricular septal defect was identified at 13 weeks and a case of hypoplastic left heart syndrome was identified at 18 weeks during a follow-up examination done because of an unsatisfactory 4-chamber view and enlarged NT. There were also 4 fetuses with ventricular septal defects, but none were identified prenatally. It is feasible to examine the fetal heart echocardiographically, using the transvaginal approach, at 11 weeks to 13 weeks plus 6 days gestation. It is not yet clear, however, that this can be made part of routine first-trimester ultrasound screening.

ObjectiveThe 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.MethodsWe 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.ResultsWe 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.ConclusionThese 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.

Giants in Obstetrics and Gynecology Series: Philippe Jeanty, MD, PhD, a pioneer in the study of fetal anatomy, biometry, growth, and congenital anomalies

We present the latest HDlive echocardiographic studies on the fetal heart using spatiotemporal image correlation (STIC). Fetal HDlive echocardiography with the use of new skin-like colors provides sonographers and physicians with a natural and anatomically realistic appearance of the fetal heart. Moreover, HDlive images provide entirely new visual experiences for obstetricians and pediatric cardiologists owing to the anatomically realistic depiction of the normal fetal heart and fetal congenital anomalies in utero. This novel technique may assist in the evaluation of the fetal cardiac anatomy, and offer potential advantages relative to conventional two-, three-, and four-dimensional fetal echocardiography. HDlive may be an important modality in future fetal cardiac research and in the evaluation of fetal congenital heart disease. How to cite this article Hata T, Kanenishi K, Hanaoka U, Tanaka H. HDlive of the Fetal Heart. Donald School J Ultrasound Obstet Gynecol 2014;8(3):266-272.

Objective To evaluate the clinical significance of prenatal ultrasonography in diagnosis of retroaortic left innominate vein(LINV). Methods Thirty fetus with retroaortic LINV were involved,including 17 cases of isolated retroaortic LINV and 13 cases of complicated retroaortic LINV. Three-vessel and trachea (3VT) view was focused in the routine second trimester ultrasound screening to observe whether LINV existing or not. And then the transducer was rotated to the fetal sagittal view to assess the relationship between LINV and aortic arch and the convergence of left subclavian vein and left internal jugular vein into the LINV. Results The characteristic feature of retroaortic LINV was the LINV converge into right superior vena cava (SVC) under the aortic arch,not above the aortic arch. The most important plane to detect the retroaortic LINV was the 3VT view,which revealed the abnormal vein lying to the left of pulmonary artery. The abnormal vein then could be traced and revealed its connection with the right SVC beneath the aortic arch on the transverse plane inferior to the 3VT view and on the fetal sagittal plane. Conclusions The whole course of retroaortic LINV can be revealed by ultrasound prenatally,which can not only account for the abnormal vein to the left of pulmonary artery on 3VT view,but also play an important role in surgery decision and future cardiac intervention treatment. Key words: Echocardiography; Fetus; Heart defects,congenital; Retroaortic left innominate vein

Introduction: The presence of a double aortic arch (DAA) is manifested by compressive symptoms, requiring surgery. DAA cases are classified as either complete or incomplete type. DAA and a right aortic arch with mirror image branching (mRAA) have a similar configuration to the first branch artery. The first branch of the mRAA is the left brachiocephalic artery, which appears to be the same as that of an incomplete DAA due to blood flow interruption. The present retrospective study aimed to evaluate the differences between DAA and mRAA by fetal echocardiography. Methods: This single retrospective cohort study included all patients diagnosed with complete DAA, incomplete DAA, or mRAA at our facility between 2010 and 2022. The patients were diagnosed with complete DAA, incomplete DAA, or mRAA after birth and remaining fetal echocardiograms. The patients were divided into the DAA (complete DAA: n = 4, incomplete DAA: n = 3) and mRAA (n = 4) groups. The following three outcomes were compared: (1) angle between the right aortic arch and first branch (RF angle), (2) ratio of height to width of the region bounded by the aortic arch, first branch of the aortic arch, and descending aorta, and (3) maximum tracheal diameter on a three-vessel trachea view. Results: The incomplete DAA cases were difficult to diagnose via fetal echocardiography. On fetal echocardiography, the RF angle was significantly steeper in the DAA group than in the mRAA group (median 57° [36°–69°] vs. 75° [62°–94°]; p < 0.05). The DAA and RAA groups showed no significant differences in the ratio of height to width of the region bounded by the aortic arch, first branch of the aortic arch, and descending aorta (median 0.57 [0.17–0.68] vs. 0.73 [0.56–1.0]) and maximum tracheal diameter (median 2.5 [1.4–3.3] vs. 3.2 [2.8–3.5] mm). The cut-off value for the presence of DAA was an RF angle <71°. Conclusion: The DAA group (complete and incomplete DAA) had a significantly steeper RF angle than the mRAA group. Therefore, RF angle measurement could improve the fetal diagnosis and postnatal prognosis of DAA.

To study the value of detecting fetal congenital heart disease (CHD) using the five transverse planes technique of fetal echocardiography. Nine hundred and eighty-two high-risk pregnancies for fetal CHD were included in this study, the fetal heart was scanned with the five transverse planes technique of fetal echocardiography described by Yagel, autopsy was conducted when pregnancy was terminated. Blood from fetal heart was collected for fetal chromosome analysis. A close follow-up was given for normal fetal heart pregnancies and neonatal echocardiography was performed to check the accuracy of prenatal diagnosis. (1) Forty-six cases (4.68%) were found to have fetal heart abnormalities in this study, 69.56% of them were diagnosed by single four-chamber view, another 30.43% fetal CHD were found by combining other views; (2) Forty-one parents of prenatal fetuses with CHD chose to terminate pregnancy, thirty-two of them gave consent to conduct autopsy, 93.75% of which yielded unanimous conclusion between prenatal fetal echocardiography and autopsy; (3) Thirty-two of 46 cases underwent fetal chromosome analysis, 8 cases (25%) were found to have abnormal chromosome; (4) Five cases were found to have right ventricle and atrium a little bigger than those on the left side, with the unequal condition being the same after birth, but there were no clinical manifestations and they are healthy for the time being; (5) Nine hundred and thirty-six cases were not found with abnormality in this study, but one case was diagnosed with ventricular septal defect after birth, one case was diagnosed with patent ductus arteriosus, one case had atrial septal defect after birth. (1) The detected CHD rate was 4.68% by screening fetal heart with five transverse planes according to Yagel's description of high risk population basis for CHD. The coinciding rate of prenatal diagnosis and autopsy was 93.75%; (2) The sensitivity of detecting fetal heart abnormality is 92%, the specificity is 99.6% using the five transverse planes technique of fetal echocardiography; (3) Fetuses with mild or moderate disproportion of right and left side in the heart are potentially healthy babies.