Persistent right umbilical vein in isomerism

Can Fetal Heterotaxy Syndrome Be Diagnosed Through Prenatal Ultrasound in the First Trimester (GA 11+0-13+6 Weeks)?

OBJECTIVE

To investigate the value of prenatal ultrasonography in the diagnosis and classification of fetal heterotaxy syndrome (HS) in the first trimester (gestational age 11+0-13+6 weeks).

METHODS

A retrospective analysis of data from 31 HS fetuses prenatally diagnosed with HS. Diagnoses were confirmed by follow-up prenatal ultrasound and in some cases postnatal ultrasound or autopsy. Data were collected on ultrasound characteristics of left atrial isomerism (LAI) and right atrial isomerism (RAI) in the first trimester, follow up ultrasounds, pregnancies outcomes, and postnatal ultrasound or autopsy findings, if available.

RESULTS

In total, 23cases of HS were diagnosed in the first trimester, and 8 cases were missed during the GA 11+0-13+6 weeks ultrasound. The sensitivity, specificity, false positive rate, false negative rate, positive predictive value, and negative predictive value of prenatal ultrasound examination for fetal HS were 74.19%, 100%, 0, 25.80%, 100%, and 99.98%, respectively. The main and common manifestations of fetal HS included abnormal positioning of the stomach and heart and positioning of the stomach and umbilical vein (UV) on different sides, combined with complete atrioventricular septal defect (AVSD), double outlet of the right ventricle (DORV) and other CHDs. Compared with RAI, fetuses with LAI in the first trimester of pregnancy were more prone to bradycardia and ductus venous (DV) a-wave inversion (p < 0.05). Among the 31 HS cases, only 6 pregnancies were continued, resulting in one neonatal death and five liveborns with a good prognosis.

CONCLUSION

Ultrasound performed during GA 11+0-13+6 weeks can be an effective tool for diagnosing fetal HS, particularly when significant cardiovascular anomalies are present. However, fetal LAI without complex intracardiac malformations is more likely to be missed in diagnosis during the first trimester. Most cases of HS diagnosed in early pregnancy are associated with major intracardiac anomalies and result in termination of pregnancies.

Chromosomal Aberrations in Fetuses With Isolated Persistent Right Umbilical Vein-A Nationwide Study

OBJECTIVE

To evaluate the prevalence of chromosomal aberrations in fetuses with isolated PRUV in a nationwide cohort with 1st-trimester screening for aneuploidies.

METHOD

A retrospective study including all pregnancies in Denmark with a due date between 2010 and 2022. We retrieved all cases from patient files, where we searched for "PRUV" in the conclusion field. All retrieved cases were manually assessed to determine if PRUV was present, associated anomalies were present, and genetic tests were performed including results. Additional data on postnatal genetics were retrieved from the Danish Cytogenetic Central Registry.

RESULTS

A total of 262 cases with PRUV were retrieved, of which 19 (7.3%) had associated malformations. Among the isolated cases, 119 (49.0%) had a prenatal invasive genetic test that consisted of CMA, and 5 cases had an NIPT (2.1%): All tests were normal or showed low risk for aneuploidies, respectively. None of the children born with PRUV had a postnatal genetic test performed.

CONCLUSION

We found no chromosomal aberrations in fetuses with isolated or non-isolated PRUVs. Isolated PRUV does not seem associated with a higher incidence of chromosomal aberrations, so parents can be reassured. However, since PRUV was associated with other malformations in 7% of cases, thorough scans are needed.

In-utero evaluation of the fetal umbilical-portal venous system among fetuses with persistent right umbilical vein: Two-and three-dimensional ultrasonographic study

OBJECTIVE

The aim of this study was to describe the anatomy of the portal system in fetuses with persistent right umbilical vein (PRUV).

METHODS

Prospective observational study of fetuses diagnosed with PRUV. All patients underwent a comprehensive portal system anatomy scan supplemented by two-dimensional (2D) and three-dimensional (3D) color doppler modalities.

RESULTS

29 fetuses with PRUV were studied. We perceived an identical anatomical pattern in 28 fetuses. The right umbilical vein drains to the portal sinus (future right portal vein, RPV), which has a configuration of a left portal vein (LPV) in the normal left portal system, with three emerging branches: inferior (RPVi), medial (RPVm) and superior (RPVs). The RPV then courses to the left, towards the stomach to the point of the bifurcation of the main portal vein (MPV) to become the left portal vein. The LPV has an RPV configuration in a normal portal system with anterior (LPVa) and posterior (RPVp) branches. This anatomical layout mimics a mirror image of the normal anatomy of left portal system.

CONCLUSION

PRUV has unique umbilical portal venous anatomy, which is a mirror image of the normal left portal system. It can be demonstrated prenatally and serve as an additional tool for prenatal diagnosis of PRUV.

Cardiac Laterality: Surgical Results of Right Atrial Isomerism

Right atrial isomerism (RAI) is a complex entity with varying diagnostic and treatment outcomes due to its rarity. Treatment options range from palliative to corrective surgeries, resulting in heterogeneous outcomes. The aim of this study was to analyze the results obtained after cardiac surgery in patients with RAI. A retrospective study was conducted, including patients diagnosed with RAI who underwent cardiac surgery. Their follow-up was from 1 January 2010 to 31 March 2020. Demographic characteristics and perioperative conditions were described. Thirty-eight patients were included, the median age was 4 years (IQR 2-9.2) and 57.9% were men. The main diagnoses were atrioventricular canal (63.2%) and pulmonary stenosis (55.3%). The most common surgical procedures were modified Blalock-Taussig shunt (65.8%) and total cavopulmonary connection with an extracardiac conduit fenestrated without cardiopulmonary bypass (15.9%). We did not find any factors associated with negative outcomes in these patients. The overall survival was 86.8%, with a better outcome in those who did not require reintubation (log rank, p < 0.01). The survival of RAI was similar to other centers. Individuals with RAI should be evaluated rigorously to determine an adequate repair strategy, considering high morbidity and mortality.

[Isomorfismo cardiaco: Una perspectiva multidisciplinaria]

Atrial isomerism describes complex anatomical findings with defects in the determination of lateralization; being a rare situation, with a prevalence of 1 in every 10.000 to 20.000 live births, with an incidence of up to 4% of all cardiac malformations. The diagnosis can be made in the neonatal age; however, clinical presentation is nonspecific. Depending on the spectrum of malformations, complex and invasive diagnostic tools may be required. Treatment is varied and can range from palliative surgery in view of univentricular physiology to total correction surgery for biventricular repair.