Rightward convexity of the great vessel arising from the anterior ventricle: a novel fetal marker for transposition of the great arteries

The use of cardiac ultrasound imaging in first-trimester prenatal diagnosis of congenital heart diseases

This study aims to explore ultrasound (US) cardiac and echocardiographic features that may enable the early diagnosis of various major congenital heart diseases (CHDs). Focusing on providing useful US tools for this assessment, high resolution of US cardiac images of various CHDs, such as hypoplastic left heart syndrome, conotruncal anomalies, and univentricular heart, were evaluated. Results show that early US detection of most major CHDs is feasible during first-trimester ultrasonography cardiac evaluation. Concerns about safety issues, findings on early fetal cardiovascular hemodynamics, and cardiac lesions that can progress during the course of pregnancy were also discussed.

Early detection of significant congenital heart disease: The contribution of fetal cardiac ultrasound and newborn pulse oximetry screening

Fetal cardiac and newborn pulse oximetry screening has greatly facilitated the detection of cardiac abnormalities, which may be serious with potentially dire neonatal consequences. The prenatal diagnosis of a serious cardiac abnormality allows the attending obstetrician to organise the much safer in-utero transfer of the fetus for delivery at a tertiary centre, particularly if there is evidence of a duct-dependent lesion that may require the infusion of Prostaglandin E1 to maintain duct patency pending surgical intervention. Newborn pulse oximetry alerts the paediatrician that the baby may have a significant cardiac abnormality, which warrants further elucidation prior to discharge, rather than for the baby to represent unwell a few days later. Despite these advances, serious cardiac abnormalities may be missed on screening. Their detection then falls back onto the clinical acumen of the attending paediatrician/family physician to review the history, carefully elicit and evaluate the clinical signs further aided by whatever investigations that may be available at the birthing hospital, frequently less resourced than the tertiary centres. At the outset, a brief synopsis is provided of the clinical findings that may point to a cardiac abnormality. That is followed by a critical review of the accuracy of prenatal and newborn pulse oximetry screening with emphasis on the lesions that may be missed. Suggestions are made as to how to improve the diagnostic accuracy.

Prenatal diagnosis of transposition of the great arteries: an updated review

Simple transposition of the great arteries (TGA) is a cyanotic heart disease that accounts for 5% to 7% of all congenital heart diseases. It is commonly underdiagnosed in utero, with prenatal detection rates of less than 50%. Simple TGA is characterized by ventriculoarterial discordance, atrioventricular concordance, and a parallel relationship of TGA. The prenatal diagnosis of TGA influences postnatal outcomes and therefore requires planned delivery and perinatal management. For these reasons, it is important to identify the key ultrasound markers of TGA to improve the prenatal diagnosis and consequently provide perinatal assistance. The presence of two vessels instead of three in the three-vessel tracheal view, a parallel course of TGA, and identification of the origin of each of TGA are the key markers for diagnosing TGA. In addition to the classical ultrasound signs, other two-dimensional ultrasound markers such as an abnormal right convexity of the aorta, an I-shaped aorta, and the "boomerang sign" may also be used to diagnose TGA in the prenatal period. When accessible, an automatic approach using four-dimensional technologies such as spatio-temporal image correlation and sonographically-based volume computer-aided analysis may improve the prenatal diagnosis of TGA. This study aimed to review the ultrasound markers that can be used in the antenatal diagnosis of TGA, with a focus on the tools used by ultrasonographers, the obstetric and fetal medicine team, and perinatal cardiologists to improve the diagnosis of this condition.

The Fetal 3-Vessel Views: An Illustrative Case-Based Tutorial

In 2018, the American Institute of Ultrasound in Medicine revised its obstetric Practice Parameter for the second-trimester fetal anatomic survey. The 2018 Practice Parameter recommends incorporation of the 3-vessel view and 3-vessel and trachea view "if technically feasible." Sonographers and other medical providers may require additional training and education to develop greater proficiency in obtaining and interpreting these views. This pictorial essay, including ultrasound images alongside their respective schematic diagrams, provides an up-to-date, practical, and clinically oriented review of the 3-vessel view and 3-vessel and trachea view and their most common presentations in the context of congenital heart disease.

Apparent normal arrangement pattern of three-vessel view in a fetus with transposition of great arteries and L-malposed aorta

Transposition of great arteries (TGA) is more commonly associated with D-malposition of great arteries where anterior aorta produces characteristic “I” sign in the three-vessel view (3VV) in fetal heart imaging. We describe two cases with TGA and L-malposition of aorta where 3VV imaging showed an apparently normal arrangement of vessels while outflow tract imaging proved vital in diagnosing transposition anatomy. Apparently, normal 3VV in the presence of disproportionate vessel caliber and inability to produce normal outflow images should raise the suspicion. Attempts should be made to produce views to show great arteries originating from respective ventricles to rule out ventriculoarterial discordance and to complete segmental analysis.

How to Acquire Cardiac Volumes for Sonographic Examination of the Fetal Heart: Part 2

The effective performance of fetal cardiac examination using spatiotemporal image correlation (STIC) technology requires 2 essential steps: volume acquisition and postprocessing. An important prerequisite is training sonologists to acquire high-quality volume data sets so that when analyzed, such volumes are informative. This article is part 2 of a series on 4-dimensional sonography with STIC. Part 1 focused on STIC technology and its features, the importance of operator training/experience and acquisition of high-quality STIC volumes, factors that affect STIC volume acquisition rates, and general recommendations on performing 4D sonography with STIC. In part 2, we discuss a detailed and practical stepwise approach for STIC volume acquisition, along with methods to determine whether such volumes are appropriate for analysis.

The fetal three-vessel and tracheal view revisited

The routine use of four-chamber screening of the fetal heart was pioneered in the early 1980s and has been shown to detect reliably mainly univentricular hearts in the fetus. Many conotruncal anomalies and ductal-dependent lesions may, however, not be detected with the four-chamber view alone and additional planes are needed. The three-vessel and tracheal (3VT) view is a transverse plane in the upper mediastinum demonstrating simultaneously the course and the connection of both the aortic and ductal arches, their relationship to the trachea and the visualization of the superior vena cava. The purpose of the article is to review the two-dimensional anatomy of this plane and the contribution of colour Doppler and to present a checklist to be achieved on screening ultrasound. Typical suspicions include the detection of abnormal vessel number, abnormal vessel size, abnormal course and alignment and abnormal colour Doppler pattern. Anomalies such as pulmonary and aortic stenosis and atresia, aortic coarctation, interrupted arch, tetralogy of Fallot, common arterial trunk, transposition of the great arteries, right aortic arch, double aortic arch, aberrant right subclavian artery, left superior vena cava are some of the anomalies showing an abnormal 3VT image. Recent studies on the comprehensive evaluation of the 3VT view and adjacent planes have shown the potential of visualizing the thymus and the left brachiocephalic vein during fetal echocardiography and in detecting additional rare conditions. National and international societies are increasingly recommending the use of this plane during routine ultrasound in order to improve prenatal detection rates of critical cardiac defects.