Single left superior vena cava: antenatal diagnosis, associated anomalies and outcomes

Prenatal Diagnosis and Classification of Type I Persistent Left Superior Vena Cava

OBJECTIVE

This study aimed to assess the utility of two-dimensional (2D) ultrasonography in diagnosing and classifying fetal type I persistent left superior vena cava (PLSVC).

METHODS

The diameter (D1) of the coronary sinus (CS) was measured in the four-chamber view and the diameter (D2) of the PLSVC was measured in the three-vessel trachea view; the ratio of the diameter of CS to PLSVC (D1/D2) and the ratio of gestational week (GA)/D1 and GA/D2 were calculated to analyze the correlation between measurement and classification of type I PLSVC.

RESULTS

Compared the parameter of Ia and Ib Group, the differences in D1, D2, GA/D1, and GA/D2 were statistically significant (P < .05). D1 and D2 are independent factors for the differential diagnosis of type I PLSVC, with odds ratios (OR) of 5.397 and 2.661, respectively, and both are statistically significant (P < .05). The nomogram model exhibited superior performance in diagnosing type I PLSVC, with the highest AUC value of 0.853, a sensitivity of 96.55%, and a specificity of 66.25%.

CONCLUSION

The combination of D1, D2, GA/D1, and GA/D2 is valuable for diagnosing and classifying fetal type I PLSVC, demonstrating significant clinical application value.

Prenatal MR Diagnosis of Total Anomalous Pulmonary Venous Connection and Related Brain Growth Changes

BACKGROUND

Prenatal diagnosis of total anomalous pulmonary venous connection (TAPVC) is challenging, and little is known about how it affects brain development.

PURPOSE

To evaluate the utility of fetal MRI to diagnose TAPVC and related brain growth changes.

STUDY TYPE

Retrospective case-control study.

POPULATION

Twenty-one fetuses (23.0 to 30.8 weeks, mean 26.4 weeks) with pre-natal MRI diagnosis of TAPVC. Post-natal images and surgery were available in 18 fetuses. Brain volumes in TAPVC fetuses were compared with age and sex matched 100 cases of normal controls and 38 fetuses with tetralogy of Fallot (TOF).

SEQUENCE

Single shot turbo spin echo sequence for evaluating fetal brain, and steady-state free precession (SSFP) sequence for evaluating fetal cardiovascular structures at 1.5 T.

ASSESSMENT

TAPVC type was determined by visualizing the drainage of the common pulmonary vein and dilated coronary sinus: supracardiac, intracardiac and infracardiac. The fetal pulmonary edema was evaluated, and fetal brain volumes were measured using automatic segmentation.

STATISTICAL TESTS

One-way analysis of variance and post hoc least square difference tests to evaluate differences in variables between TAPVC, TOF and control groups. A P value <0.05 was considered significant.

RESULTS

Of the 21 cases of TAPVC, 10 (47.6%) were identified as supracardiac, 8 (38.1%) as intracardiac, and 3 (14.3%) as infracardiac. Eighteen cases were confirmed by postnatal imaging and surgery; the remaining three cases had no confirmation. Six cases were associated with other cardiovascular abnormalities. Key MRI features of fetal TAPVC included a dilated coronary sinus and vertical vein. Fetal pulmonary edema was seen in six cases. Compared to controls, TAPVC fetuses had lower cerebellum and brainstem volumes and higher e-CSF, while had larger subcortical brain tissue, cerebellum, brainstem, e-CSF, and intracranial cavity volumes than those of TOF cases.

DATA CONCLUSION

Fetal MRI may be a useful modality for evaluating fetal TAPVC and altered brain development.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 3.

Prenatal Diagnosis and Postnatal Outcomes of Persistent Left Superior Vena Cava Associated With Mild Narrow Aorta: A Cohort Study

PURPOSE

To explore prenatal ultrasonic features and prognosis of the persistent left superior vena cava (PLSVC) complicated with mild narrow aorta.

MATERIALS AND METHODS

A retrospective study was conducted involving 1348 fetuses diagnosed with PLSVC prenatally between January 2016 and December 2019. Forty-five fetuses with PLSVC associated with mild narrow aorta were selected from the cohort as the study group and 79 fetuses with isolated PLSCV were recruited randomly as the control group. All clinical and ultrasound results, including images and parameters of cardiac structures, were reviewed retrospectively. General conditions, ultrasound (US) measurements, and fetal prognosis were compared between the groups.

RESULTS

Aorta valve diameter (AOD), Z-score of aorta valve (AODz-score), aortic isthmus diameter (AOIsD), and pulmonary diameter (PAD)/AOD were significantly different in study group than control group no matter in the second or third trimester. Thirty-eight fetuses in study group were born with favorable outcomes after long-term follow-up. A total of 13.16% (5/38) remain mild narrow aorta and 3 of them showed smaller left ventricle after 3 years follow up. Prenatal AODz-score in infants remains mild narrow aorta after 2 years aged was higher than ones' aorta return to normal (P = .01), especially when AODz-score >1.725. Moreover, when prenatal ratio of AOIsD/left subclavian artery was <1.12, it was more likely that the aorta would remain mildly narrow at age 2.

CONCLUSION

Fetuses diagnosed with PLSVC with mild narrow aorta had favorable prognosis. AODz-score and AOIsD/left subclavian artery may be two predictors that reveal the risk of a mildly narrowed aorta remaining after birth.

Association of Prenatally Diagnosed Isolated Single Left Superior Vena Cava and Postnatal Development of Coarctation of the Aorta

To report the prevalence of coarctation of the aorta (CoA) in fetuses with single left superior vena cava (SL-SVC) and to evaluate changes in echocardiographic measurements. Additionally, to report the prevalence of associated malformations. Retrospective observational study of fetuses diagnosed with SL-SVC between 2012 and 2021 at a tertiary fetal cardiology unit. In fetuses without intracardiac abnormalities, Z-scores of the ventricles, great arteries, and Doppler flow patterns are reported. We identified 47 fetuses with SL-SVC of which 8/47 (17%) had abnormal intracardiac anatomy. One fetus was lost to follow-up. Of those with normal intracardiac anatomy and postnatal follow-up (38), karyotype abnormalities were confirmed in 2/38 (5%) and ECA in 8/38 (21%). 33/38 were live-born. None developed CoA postnatally. Paired analysis of Z-scores between early and late scans of 24 fetuses showed that diameters of the right heart structures and Doppler flows of tricuspid valve increased significantly during pregnancy, while the left heart structures and flow patterns did not change. The median risk of CoA did not change between the early and the late scan. We did not observe CoA in this cohort. A degree of ventricular asymmetry was present, but this was due to right heart dominance rather than hypoplasia of left heart structures. This likely reflects redistribution of blood and does not appear to confer increased risk of CoA. Predictive models of the postnatal development of CoA which set the dimensions of right and left heart structures in relation might not be applicable in this situation.

Persistant Left Superior Vena Cava with and Without Right Superior Vena Cava: Significance of Prenatal Diagnosis

This study aims to define the associated anomalies with PLSVC, and to compare single PLSVC and bilateral superior vena cava in terms of accompanying anomalies and pregnancy outcomes. This was a retrospective study of the fetuses diagnosed with single and/or bilateral SVC at a tertiary fetal medicine center during 8 years. We detected 16 cases of single PLSVC and 84 cases of bilateral SVC. We found an association between the PLSVC and cardiac and extracardiac anomalies. Comparison between single PLSVC and BSVC cases revealed significant differences in the occurrence of heterotaxy and right isomerism. The study highlights the importance of prenatal diagnosis in PLSVC cases. Isolated PLSVC with situs solitus may be considered a benign finding, but larger studies are needed to understand the clinical implications of PLSVC in relation to chromosomal anomalies. Routine screening protocols should include three-vessel and trachea views to detect PLSVC.

Integrated analysis of comorbidity, pregnant outcomes, and amniotic fluid cytogenetics of fetuses with persistent left superior vena cava

BACKGROUND

Persistent left superior vena cava (PLSVC) is the most common venous system variant. The clinical characteristics and amniotic fluid cytogenetics of fetuses with PLSVC remain to be further explored.

AIM

To develop reliable prenatal diagnostic recommendations through integrated analysis of the clinical characteristics of fetuses with PLSVC.

METHODS

Cases of PLSVC diagnosed using prenatal ultrasonography between September 2019 and November 2022 were retrospectively studied. The clinical characteristics of the pregnant women, ultrasonic imaging information, gestational age at diagnosis, pregnancy outcomes, and amniocentesis results were summarized and analyzed using categorical statistics and the chi-square test or Fisher's exact test.

RESULTS

Of the 97 cases diagnosed by prenatal ultrasound, 49 (50.5%) had isolated PLSVC and 48 (49.5%) had other structural abnormalities. The differences in pregnancy outcomes and amniocentesis conditions between the two groups were statistically significant (P < 0.05). No significant differences were identified between the two groups in terms of advanced maternal age and gestational age (P > 0.05). According to the results of the classification statistics, the most common intracardiac abnormality was a ventricular septal defect and the most common extracardiac abnormality was a single umbilical artery. In the subgroup analysis, the concurrent combination of intra- and extracardiac structural abnormalities was a risk factor for adverse pregnancy outcomes (odds ratio > 1, P < 0.05). Additionally, all abnormal cytogenetic findings on amniocentesis were observed in the comorbidity group. One case was diagnosed with 21-trisomy and six cases was diagnosed with chromosome segment duplication.

CONCLUSION

Examination for other structural abnormalities is strongly recommended when PLSVC is diagnosed. Poorer pregnancy outcomes and increased amniocentesis were observed in PLSVC cases with other structural abnormalities. Amniotic fluid cytogenetics of fetuses is recommended for PLSVC with other structural abnormalities.

Clinical presentation, conventional/4D spatio-temporal image correlation imaging findings, pregnancy and early postnatal outcomes in fetuses having anomalies of systemic venous return in the absence of significant intracardiac defects: A retrospective study from two centres in Southern India

BACKGROUND

Recent advances in fetal ultrasound imaging, especially four-dimensional (4D) spatio-temporal image correlation techniques permit detailed evaluation of the fetal venous system and its abnormalities. In this report, we present the clinical presentation, conventional/4D spatio-temporal image correlation imaging findings, pregnancy, and early postnatal outcomes in fetuses having anomalies of systemic venous return in the absence of significant intracardiac defects from two centres in southern India.

OBJECTIVES

To report the clinical presentation, conventional/4D spatio-temporal image correlation imaging findings, pregnancy, and early postnatal outcomes in fetuses having anomalies of systemic venous return in the absence of significant intracardiac defects from two centres in Southern India.

METHODS

Retrospective study (October 2017 to March 2022). All fetuses referred with abnormal cardiac imaging findings who were diagnosed to have anomalies of systemic venous return in the absence of significant intracardiac defects were included. Imaging techniques like 2D with color and 4D spatio-temporal image correlation fetal imaging were used to evaluate systemic venous anomalies. Systemic venous anomalies were grouped into cardinal venous anomalies and umbilico-portosystemic venous anomalies.

RESULTS

Thirty-nine fetuses were included; this represented 4.4% of all cardiac anomalies diagnosed during the study period. Cardinal venous anomalies were seen in 29 fetuses (74%); the mean gestation age at diagnosis was 25.5 ± 3.4 weeks. Absent dilated coronary sinus was associated with anomalous drainage of superior caval vein through completely unroofed coronary sinus into the left atrium (n = 3) which resulted in cyanosis after birth in all infants. Among the three cases, one underwent surgery at 6 months of age due to a progressive increase in cyanosis (Spo2 78%) and others are awaiting surgery. A prenatal genetic evaluation was performed in 17 (58.6%). Cardinal venous anomalies were not associated with genetic abnormalities. Live births occurred in all fetuses with cardinal venous anomalies. Umbilico-portosystemic venous anomalies were seen in 10 (26%). The mean gestation age at diagnosis was 26.5 ± 4.5 weeks. Except in a fetus with the extrahepatic portosystemic shunt (umbilical vein to iliac vein), the genetic evaluation was normal in our cohort. Extracardiac anomalies (n = 3/10; 30%) were seen in both intra (n = 1) and extrahepatic portosystemic shunts (n = 2).

CONCLUSION

Anomalies of systemic venous return in the absence of significant intracardiac, extracardiac, and genetic abnormalities carried an overall favorable prognosis in our cohort. Precise characterization of anatomic details using advanced imaging techniques helps in the understanding of this complex three-dimensional anatomy and in the prognostication of these anomalies.