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Spatio-Temporal Image Correlation: Three-Dimensional Imaging for Fetal Cardiac Screening and Congenital Heart Disease Assessment

André Malho et al. Renato Silveira Ximenes Nathalie Jeanne Bravo-Valenzuela Edward Araujo Júnior

Heart defects are among the most common congenital malformations, occurring in 4 to 12 per 1,000 live births, depending on the population studied. Congenital heart disease (CHD) is an important cause of mortality related to birth defects. Therefore, prenatal diagnosis of CHD is crucial to improve the prognosis associated with this disease. In this scenario, the development of prenatal cardiac ultrasound screening programs serves as crucial tools that have increased the early detection of CHD. These programs achieve this by adding the ventricular outflow tract and superior mediastinum views (three vessels – 3V and 3V with trachea) to the standard four-chamber (4C) view when scanning the cardiac ultrasound.

The development of advanced imaging technologies, such as three- and four-dimensional (3D/4D) ultrasound and Spatio-Temporal Image Correlation (STIC), has improved the quality of ultrasound images of the fetal heart with a positive impact on the diagnosis of cardiac malformations. The 4D-STIC technology allows the capture of thousands of cardiac images using a 3D volumetric transducer by a single 7.5 to 15-second slow-motion scan of the 4C view of the fetal heart. The acquired 3D/4D volumes contain a “block” of information of the complete cardiac cycle that can be stored for later off-line navigation of the fetal heart, allowing detailed analysis of cardiac anatomy by the sonographer, or sent via Internet link for analysis by experts in tertiary centers.

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Maternal restriction of polyphenols and fetal ductal dynamics in normal pregnancy: an open clinical trial

Paulo Zielinsky et al. Antônio Luiz Piccoli Jr. Izabele Vian Ana Maria Zílio … Alexandre Antônio Naujorks Luiz Henrique Nicoloso Carolina Weiss Barbisan Stefano Busato Mauro Lopes Caroline Klein

BACKGROUND:We have recently demonstrated reversal of fetal ductal constriction after dietary maternal restriction of polyphenol-rich foods (PRF), due to its inhibitory action on prostaglandin synthesis. OBJECTIVE: To test the hyphotesis that normal third trimester fetuses also improve ductus arteriosus dynamics after maternal restriction of polyphenols. METHODS: Open clinical trial with 46 fetuses with gestational age (GA) > 28 weeks submitted to 2 Doppler echocardiographic studies with an interval of at least 2 weeks, being the examiners blinded to maternal dietary habits. A validated food frequency questionnaire was applied and a diet based on polyphenol-poor foods (<30mg/100mg) was recommended. A control group of 26 third trimester fetuses was submitted to the same protocol. Statistics used t test for independent samples. RESULTS: Mean GA was 33±2 weeks. Mean daily maternal estimated polyphenol intake (DMPI) was 1277mg, decreasing to 126mg after dietary orientation (p=0.0001). Significant decreases in systolic (SDV) and diastolic (DDV) ductal velocities, and RV/LV diameters ratio, as well as increase in ductal PI were observed [DSV=1.2±0.4m/s (0.7-1.6) to 0.9±0.3m/s (0.6-1.3) (p=0.018); DDV=0.21±0.09m/s (0.15-0.32) to 0.18±0.06m/s (0.11-0.25) (p=0.016); RV/LV ratio =1.3±0.2 (0.9-1.4) to 1.1±0.2 (0.8-1.3) (p=0.004); ductal PI=2.2±0.03 (2.0-2.7) to 2.4±0.4(2.2-2.9) (p=0.04)]. In the control group, with GA of 32±4 weeks, there were no significant differences in DMPI, mean SDV, DDV, PI and RV/LV ratio. CONCLUSION: The oriented restriction of third trimester maternal ingestion of polyphenol-rich foods for a period of 2 weeks or more improve fetal ductus arteriosus flow dynamics and right ventricular dimensions.

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Reference curve of the fetal ventricular septum area by the STIC method: preliminary study

Liliam Cristine Rolo et al. Luciano Marcondes Machado Nardozza Edward Araujo Júnior Christiane Simioni … Marina Maccagnano Zamith Antonio Fernandes Moron

BACKGROUND: Early detection of septal changes such as septal hypertrophy commonly present in fetuses of diabetic mothers would help reduce the high rates of infant mortality. OBJECTIVE: Determine reference ranges for the fetal ventricular septal area through three-dimensional ultrasound (US3D) using the STIC method (Spatio-Temporal Image Correlation). METHODS: We conducted a cross-sectional study with 69 pregnant women between the 18th and 33rd weeks of pregnancy. We used as a reference the four-chamber plane with the ROI (Region of Interest) positioned from the ventricles; the septum area were manually marked. To assess the correlation of the interventricular septum area with gestational age (GA), we constructed scatter plots and calculated Pearson’s correlation coefficient (r), and the adjustment was performed by the coefficient of determination (R²). We calculated averages, medians, standard deviations (sd), as well as maximum and minimum values. To calculate the intraobserver reproducibility, we used the intraclass correlation coefficient (ICC). The interventricular septum thickness was measured and it was correlated with gestational age and the septal area rendered in 52 patients using the ICC. RESULTS: The interventricular septum area was highly correlated with gestational age (r = 0.81), and the average increased from 0.47 cm² in the 18th week to 2.42 cm² in the 33rd of gestation. The intraobserver reproducibility was excellent with ICC = 0.994. No significant correlation was observed between the interventricular septum measurement and the GA (R² = 0.200), as well as there was no correlation with the septal area rendered with ICC = 0.150. CONCLUSION: Reference intervals for the interventricular septum area between the 18th and the 33rd pregnancy week were determined to be highly reproducible.

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Morphological basis for the study of the interatrial septum in the human fetus

Hugo Becker Amaral et al. Paulo Zielinsky Aron Ferreira da Silveira Ijoni Costabeber … Luiz Henrique Nicoloso Olmiro Cezimbra de Souza Filho Marcelo Salum João Luiz Manica Juliana Silveira Zanettini Ane Micheli Costabeber

OBJECTIVE: To describe morphological features of the interatrial septum in normal fetuses, especially foramen ovale (FO) and septum primum (SP), in order to compare septum primum excursion with foramen ovale diameter. METHODS: Septum primum excursion (SPE) toward the left atrium (LA) and foramen ovale diameter (FOD) were measured in the hearts of ten formaldehyde-fixed human fetuses ranging from 28 to 36 weeks of gestation. Histological sections were obtained from the foramen ovale (FO), septum primum (SP), septum secundum (SS), left atrium (LA), and right atrium (RA). RESULTS: FOD and SPE measurements were the following: FOD 3.1-3.5 mm and SPE 2.8-3.1 mm in three fetuses with presumed gestational age (GA) of 28 weeks; FOD 3.3-3.5 mm, and SP excursion 4.0-5.0 mm in four fetuses with presumed GA of 34 weeks, plus FOD 3.3-4.5 mm and SPE 6.0-9.0 in three fetuses with presumed GA of 36 weeks. Cardiac muscular fibers were identified in both the septum primum and secundum. CONCLUSION: Based on its muscular components, it may be suggested that SP is active in character, influencing blood flow through the FO, SP mobility, and its excursion into the LA.

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Prenatal study of fetal endocardial hyperrefringence and its relation to maternal toxoplasmosis

Luiz Henrique Soares Nicoloso et al. Tiene Zingano Henke Paulo Zielinsky

OBJECTIVE: To compare a group of fetuses whose mothers had acute or recent toxoplasmosis with a group of fetuses whose mothers had no systemic disease, analyzing the presence of changes in endocardial refringence. METHODS: This study assessed 91 fetuses of mothers diagnosed with acute or recent toxoplasmosis, detected by seroconversion or the presence of elevated IgM and IgG titers, confirmed through the IgM-capture ELISA. They were compared with a control group comprising 182 fetuses selected from a low-risk population participating in a prenatal screening program for heart diseases. RESULTS: No significant difference was observed between the mean gestational (29.2±4.6 weeks; 29.2±4.6 weeks) and maternal (25.7±6.7 years; 26±5.4 years) ages in the 2 groups. Areas of endocardial hyperechogenicity were observed in 69 fetuses whose mothers had toxoplasmosis (75.8%) and in only 6 fetuses of the control group (3.3%) (P<0.001). In 52 patients of the group studied (75.4%), endocardial hyperrefringence was diffuse, and, in 17 (24.3%), it was focal. In the control group, focal distribution was observed in 5 fetuses (83.3%). CONCLUSION: The prenatal echocardiographic image of focal or diffuse endocardial hyperrefringence is more prevalent in pregnancies with maternal toxoplasmosis than in the healthy ones, and an association between fetal endocardial hyperechogenicity and maternal disease exists.

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Fetal supraventricular tachyarrhythmias. Experience of a fetal cardiology reference center

Paulo Zielinsky et al. Rejane F. Dillenburg Gustavo G. de Lima Lúcia P. Zimmer

PURPOSE: To describe the presentation, diagnosis and treatment of fetal supraventricular tachyarrhythmias in a series of fetuses followed in a tertiary Fetal Cardiology Center. METHODS: Twenty-five fetuses with diagnosis of supraventricular tachyarrhytmia were reported from January 1989 to October 1997, among 3117 pregnant women referred for fetal cardiac evaluation. RESULTS: There were 17 fetuses with the diagnosis of supraventricular tachycardia (SVT) and 8 patients with atrial flutter (AF). Gestational age ranged from 26 to 40 weeks. Twelve patients were hydropic at presentation (6 with SVT and 6 AF). Four fetuses with SVT showed structural abnormalities (two with Ebsten’s anomaly and two with VSD). All patients were admitted to the Fetal Cardiology Unit for monitoring and treatment. Among 17 fetuses with SVT, twelve showed good response to digoxin administration, but this drug was not useful in any of the patients with flutter. In two patients with SVT and in six with AF, the pregnancy was interrupted to perform post-natal cardioversion. The mortality rate was 3/17 in the SVT group (including 2 patients with ebstein’s anomaly and 0/8 in the flutter group) CONCLUSION: Fetal supraventricular tachyarrithmias are rare in the general population. Nevertheless, the fetus may present with severe heart failure and death. Considering the satisfactory therapeutic response, accurate diagnosis and early treatment of these conditions are extremely important.

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Spatio-Temporal Image Correlation: Three-Dimensional Imaging for Fetal Cardiac Screening and Congenital Heart Disease Assessment

Maternal restriction of polyphenols and fetal ductal dynamics in normal pregnancy: an open clinical trial

Reference curve of the fetal ventricular septum area by the STIC method: preliminary study

Morphological basis for the study of the interatrial septum in the human fetus

Prenatal study of fetal endocardial hyperrefringence and its relation to maternal toxoplasmosis

Fetal supraventricular tachyarrhythmias. Experience of a fetal cardiology reference center

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