Prenatal diagnosis of persistent left superior vena cava and its associated congenital anomalies

Raghib Syndrome and Pulmonary Arterial Hypertension in a Pediatric Patient: Case Report and Literature Review

Background: Raghib syndrome is a rare malformation complex consisting of the drainage of the left superior vena cava (LSVC) into the left atrium, ostial atresia of the coronary sinus and an atrial septal defect (ASD). Case Report: This report aims to present the case of a child newly diagnosed with Raghib syndrome, complicated by pulmonary arterial hypertension, and to review previously published cases with the same diagnosis. A six-year-old female patient presented with signs and symptoms of heart failure (Ross III), reduced exercise tolerance and severe delay in stature and ponderal development. The imagistic work-up included echocardiography, followed by computer tomography (CT) and magnetic resonance imaging (MRI), through which a diagnosis of Raghib syndrome was established, complicated by pulmonary hypertension. As in other cases presented in the literature, MRI allowed for an accurate diagnosis, detecting the absent coronary sinus. The decision regarding the surgical closure of the ASD was made, with the patient having a favorable clinical evolution but with the persistence of elevated pulmonary artery pressure, for which Sildenafil therapy was instituted. Conclusions: The malformation complex consisting of an atrial septal defect, ostium atresia of the coronary sinus, uncovered coronary sinus, and persistent left superior vena cava, as identified through multiple imagistic investigations, was suggestive of the rare diagnosis of Raghib syndrome in this case. Among the limited number of cases of Raghib syndrome available in the literature, the present case is distinguished by the severity of the pulmonary artery hypertension at a very young age and in the absence of other concurrent cardiac malformations.

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.

Diagnostic accuracy of prenatal ultrasound in coarctation of aorta: systematic review and individual participant data meta-analysis

OBJECTIVE

To determine the diagnostic accuracy of prenatal ultrasound in detecting coarctation of the aorta (CoA).

METHODS

An individual participant data meta-analysis was performed to report on the strength of association and diagnostic accuracy of different ultrasound signs in detecting CoA prenatally. MEDLINE, EMBASE and CINAHL were searched for studies published between January 2000 and November 2021. Inclusion criteria were fetuses with suspected isolated CoA, defined as ventricular and/or great vessel disproportion with right dominance on ultrasound assessment. Individual participant-level data were obtained by two leading teams. PRISMA-IPD and PRISMA-DTA guidelines were used for extracting data, and the QUADAS-2 tool was used for assessing quality and applicability. The reference standard was CoA, defined as narrowing of the aortic arch, diagnosed after birth. The most commonly evaluated parameters on ultrasound, both in B-mode and on Doppler, constituted the index test. Summary estimates of sensitivity, specificity, diagnostic odds ratio (DOR) and likelihood ratios were computed using the hierarchical summary receiver-operating-characteristics model.

RESULTS

The initial search yielded 72 studies, of which 25 met the inclusion criteria. Seventeen studies (640 fetuses) were included. On random-effects logistic regression analysis, tricuspid valve/mitral valve diameter ratio > 1.4 and > 1.6, aortic isthmus/arterial duct diameter ratio < 0.7, hypoplastic aortic arch (all P < 0.001), aortic isthmus diameter Z-score of < -2 in the sagittal (P = 0.003) and three-vessel-and-trachea (P < 0.001) views, pulmonary artery/ascending aorta diameter ratio > 1.4 (P = 0.048) and bidirectional flow at the foramen ovale (P = 0.012) were independently associated with CoA. Redundant foramen ovale was inversely associated with CoA (P = 0.037). Regarding diagnostic accuracy, tricuspid valve/mitral valve diameter ratio > 1.4 had a sensitivity of 72.6% (95% CI, 48.2-88.3%), specificity of 65.4% (95% CI, 46.9-80.2%) and DOR of 5.02 (95% CI, 1.82-13.9). The sensitivity and specificity values were, respectively, 75.0% (95% CI, 61.1-86.0%) and 39.7% (95% CI, 27.0-53.4%) for pulmonary artery/ascending aorta diameter ratio > 1.4, 47.8% (95% CI, 14.6-83.0%) and 87.6% (95% CI, 27.3-99.3%) for aortic isthmus diameter Z-score of < -2 in the sagittal view and 74.1% (95% CI, 58.0-85.6%) and 62.0% (95% CI, 41.6-78.9%) for aortic isthmus diameter Z-score of < -2 in the three-vessel-and-trachea view. Hypoplastic aortic arch had a sensitivity of 70.0% (95% CI, 42.0-88.6%), specificity of 91.3% (95% CI, 78.6-96.8%) and DOR of 24.9 (95% CI, 6.18-100). The diagnostic yield of prenatal ultrasound in detecting CoA did not change significantly when considering multiple categorical parameters. Five of the 11 evaluated continuous parameters were independently associated with CoA (all P < 0.001) but all had low-to-moderate diagnostic yield.

CONCLUSIONS

Several prenatal ultrasound parameters are associated with an increased risk for postnatal CoA. However, diagnostic accuracy is only moderate, even when combinations of parameters are considered. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

A cohort study to investigate the potential indicators for prenatal echocardiographic detection of suspected coarctation of the aorta

Objectives

Suspected coarctation of the aorta (CoA) is a common fetal echocardiographic presentation. However, the prenatal findings did not indicate a satisfied accuracy in determining the truly CoA after birth, which made the prenatal diagnosis of CoA still as a critical challenge with high false positive rate. Thus, this research is aimed to distinguish the potential prenatal parameters influencing the fetal echocardiographic images and enhance the true positive diagnostic rate of CoA fetuses which require early clinical intervention in postnatal life.

Methods

A retrospective study had been designed and fetuses with suspected with CoA had been included from Jan 2016 to Dec 2021 in our center. The fetal echocardiography and related clinical information had been collected. And the postnatal diagnosis had been reached by echocardiography or CTA. Then, all the parameters had been analyzed by univariate analysis, and a multivariate logistic regression analysis was further involved to determine the independent parameters influencing the accuracy of diagnosis CoA fetuses. Moreover, such results had been validated by nomogram analysis and ROC curve.

Results

Among the included 44 liveborn infants who presented suspected CoA in fetal cardiac screening, 18 cases had been proved to be CoA postnatally (Group P). The true positive rate for this study was 40.9% (18/44). The abnormal atrial hemodynamic status (AAHs) and the gestational week of delivery (GWoD) were associated with the postnatal CoA confirmation among prenatal suspected fetuses. The ROC curve of predicting probability of the mode combined with two independent factors of absence of AAH and GWoD (AUC = 0.880, 95% CI 0.763-0.997) presented a satisfied efficacy in distinguishing postnatal positive CoA diagnosis. The nomogram plot had been be utilized in CoA prediction (model likelihood ratio test, p < 0.0001).

Conclusions

AAH and GWoD had been identified as independent factors of predictive accuracy in detecting postnatal CoA among prenatal suspected fetuses. The prediction mode based on nomogram scores could be used to predict the risk of occurring CoA fetuses.

Persistent left superior vena cava without right superior vena cava during fetal life

Enlarged coronary sinus detected during cardiac examination in the prenatal period is the first finding that raises suspicion for persistent left superior vena cava. In this report, a patient was presented who was referred with the prediagnosis of cor triatriatum sinister in the antenatal period and diagnosed with isolated persistent left superior vena cava (SVC).

Accidental Diagnosis of Isolated Persistent Left Superior Vena Cava After an Elective Central Venous Access Procedure for Chronic Hemodialysis: Clinical Implications and Precautions From a Case Report

Persistent left superior vena cava (PLSVC) is the most frequent thoracic venous anatomical variant in the general population. Isolated PLSVC, without formation of the right superior vena cava, is described in 10% of cases of PLSVC only. While it can be associated with congenital heart disease, arrhythmias, and premature death, adult patients with PLSVC are mostly asymptomatic, and the diagnosis is usually accidental. We present the case of a 72-year-old male with end-stage renal disease who was started on urgent hemodialysis through a temporary non-tunneled femoral central venous catheter (CVC) in the SLED (slow low-efficiency dialysis) modality and later remained dependent on hemodialysis. At this stage, placement of a tunneled CVC in the right internal jugular vein was necessary and fluoroscopy guidance was not available. There were no complications during the procedure, but postoperative conventional chest radiography revealed an inadequate positioning of the CVC tip in the left hemithorax, crossing the midline. Subsequently, the diagnosis of PLSVC was obtained by performing a thoracic angio-CT scan, confirming CVC tip positioning inside the PLSVC, and also excluded the presence of cardiac defects or additional anatomical variations of the great vessels of the thorax. Early evaluation for the creation of autologous vascular access was started under our care, and there were no mechanical or other complications associated with hemodialysis sessions during early follow-up after discharge.

Persistent Left Superior Vena Cava and Inferior Vena Cava Dual Drainage to Coronary Sinus: A Case Report

Dilation of the coronary sinus is often a result of excessive volume overload from congenital anomalies of systemic venous return to the heart. These abnormalities are often discovered incidentally later in life when a patient requires cardiac imaging, cardiac catheterization, or thoracic surgery. The most common abnormality is a persistent left superior vena cava. Inferior vena cava malformation is less common, yet several different anomalies can arise. The presence of persistent left superior vena cava or inferior vena cava anomalies requires further evaluation to rule out congenital heart disease in infants. Knowledge of technically challenging systemic venous anatomy is beneficial prior to procedures necessitating central venous access such as a central line, cardiac catheterization, and intracardiac device implantation. We present an unusual case of persistent LSVC and IVC both draining directly into a severely dilated coronary sinus that was diagnosed by fetal echocardiogram and later confirmed postnatally by transthoracic echocardiogram and computed tomography angiography. To our knowledge this is the second reported case of IVC drainage into the CS and the first case that reports this as a prenatal diagnosis.

Heterotaxy Syndrome with Increased Nuchal Translucency and Normal Karyotype Associated with Complex Systemic Venous Return. Ultrasound Diagnosis with Autopsy Correlation

Background: Prenatal ultrasound (US) detection of heterotaxy syndrome can be challenging, especially in identifying cardiovascular and associated anomalies. We present a new case of heterotaxy syndrome with anomalous systemic venous return (ASVR) fully displayed at autopsy. Case report: Left heterotaxy syndrome was diagnosed in a 19 weeks' of gestation fetus with right-sided stomach. The heart showed both ventricles with left morphology, a large ventricular septal defect, persistent left superior vena cava draining into the coronary sinus, ASVR with interrupted inferior vena cava (IVC) and azygous continuation. Autopsy dissection further identified the azygous draining into the left lower pulmonary vein (LLPV). Prenatal a-CGH on villous sampling showed 22q13.1 microduplication inherited from the father, not contributory to the phenotype. Conclusion/discussion: Heterotaxy syndrome requires US accuracy for anomaly identification, as they allow legal termination of pregnancy. Our case is unusual as IVC drained into the azygous vein and then into the LLPV.

Persistent Left Superior Vena Cava: Why is Prenatal Diagnosis Important?

ObjectiveTo investigate fetal anomalies and pregnancy outcomes in pregnancies with persistent left superior vena cava (PLSVC) to provide assistance in prenatal counseling.MethodsCases diagnosed with PLSVC between January 2015 and January 2020 were obtained from the hospital's electronic system and were analyzed retrospectively.ResultsTwenty-seven cases were analyzed. The prevalence of PLSVC among congenital heart diseases (CHD) was 6.9%. Conotruncal anomalies and renal anomalies were the most common accompanying cardiac and extracardiac anomalies, respectively. Chromosomal abnormality was detected in one fetus.In the postpartum period coarctation of aorta (CoA) was found in one fetus.ConclusionsWhen PLSVC is detected during prenatal ultrasonography, fetal anatomy should be carefully examined because of the anomalies that may accompany it. Prenatal genetic counseling should be given especially to cases with additional anomalies. In isolated cases, cardiac anatomy should be evaluated with repeated echocardiography because of the risk of CoA.

Persistent Left Superior Vena Cava Significance in Prenatal Diagnosis—Case Series

The persistent left superior vena cava (PLSVC) is a congenital heart anomaly reported in 0.3–0.5% of the general population and can be associated with congenital heart diseases in up to 8% of cases. Prenatal identification of PLSVC is important to prompt an extended cardiac and extracardiac fetal examination. We retrospectively reevaluated anomaly scans performed in our unit in a 2-year interval according to the national guidelines to evaluate the incidence of PLSVC and its association with prenatal morbidity. In our population, the incidence of PLSVC was 0.31%, and we found a low association with cardiac and extracardiac anomalies. The standard sections (three-vessel and trachea view, four-chamber view and outflow tract’s view) are insufficient to exclude cardiac anomalies whenever PLSVC is found. In our case series, only one newborn required postnatal surgery for total pulmonary vein anomaly, and at 2 years of life all babies had a normal evolution. Prenatal diagnosis of PLSVC can raise counseling issues; therefore, awareness of its good outcome when isolated and need for an extended examination to rule out other anomalies is very important.

Pictorial Essay: Understanding of Persistent Left Superior Vena Cava and Its Differential Diagnosis

Persistent left superior vena cava (PLSVC) is a rare congenital, thoracic, and vascular anomaly. Although PLSVCs generally do not have a hemodynamic effect, several types of PLSVC and some cardiac anomalies may manifest with clinical symptoms. The presence of PLSVC can render catheterization via left subclavian access difficult when placing a pacemaker or central venous catheter. As such, recognizing a PLSVC that is typically incidentally discovered can prevent complications such as vascular injury. Differentiating vessels found in a similar location as PLSVC is necessary when performing thoracic vascular procedures. This pictorial essay explains the multi-detector CT findings of a PLSVC, and provides a summary of other blood vessels that require differentiation during thoracic vascular procedures.

Prenatal persistent left superior vena cava in low population: Not a benign vascular anomaly

OBJECTIVE

The aim of this study is to identify prenatally diagnosed cases of persistent left superior vena cava (PLSVC) in our clinic, to evaluate the associated structural and chromosomal results, and to review their outcome.

MATERIALS AND METHODS

During a four-year period, patients with fetal PLSVC were detected by echocardiography. We reviewed medical records of these affected pregnancies, including maternal demographics, sonographic findings, chromosomal microarray results and pregnancy outcomes.

RESULTS

There were a total of 140 cases of fetal PLSVC. Eighty-nine fetuses (63.6%) had associated structural anomalies, while the remaining 51 fetuses (36.3%) had PLSVC as an isolated finding. In the non-isolated cases, cardiac anomalies were present in 72 fetuses (80.9%), and extracardiac abnormalities in 45 fetuses (50.6%). Among the 89 cases with non-isolated PLSVC, 12 cases had chromosomal abnormalities including 5 cases of aneuploidies. Among the 51 cases with isolated PLSVC, one pregnancy of chromosomal microduplication was detected.

CONCLUSION

Isolated PLSVC is a benign vascular anomaly in low risk population. However, the information about background risk of identifying an abnormal clinically significant CMA result should be conveyed to all pregnant women when they consults this vascular variation.

Clinical significance of prenatally diagnosed persistent left superior vena cava

AIMS

The aim of our study was to investigate the persistent left superior vena cava (PLSVC) cases diagnosed in the prenatal period in our clinic and to compare the obstetric and genetic outcomes of isolated PLSVC cases with cases accompanied by other cardiac or extracardiac anomalies.

METHODS

The cases diagnosed as PLSVC between January 2015 and January 2019 in our perinatology clinic were evaluated retrospectively. Patients were divided into two subgroups as isolated PLSVC and PLSVC accompanied by another anomaly. Furthermore, patients with extra anomalies were divided into three groups which are cardiac anomaly, extracardiac anomaly and those with both. The groups were compared in terms of genetic results and obstetric outcomes.

RESULTS

89 patients were included in our study. Cases with positive pregnancy outcomes were significantly higher in the isolated PLSVC group than with extra anomaly group (p<0.001). No karyotype anomaly was observed in the isolated group. Pregnancy results were significantly worse (postpartum demise, termination of pregnancy, in utero demise) in with both cardiac and extracardiac anomalies group (p<0.001). There was no significant difference between the groups in terms of karyotype results (p=0.535).

CONCLUSION

The diagnosis of PLSVC has gained importance and it can be made easier due to the fact that anatomic imaging can be performed in more detail. The isolated PLSVC cases have a very good prognosis. Obstetric outcomes vary according to the accompanying anomaly.

Fetal aortic coarctation: A combination of third-trimester echocardiographic parameters to improve the prediction of postnatal outcome

OBJECTIVES

This study aims to determine a combination of third-trimester echocardiographic parameters for improving the prenatal prediction of coarctation of the aorta (CoA) after birth.

METHODS

We included all cases of suspected CoA during fetal echocardiography performed in the second and/or third trimester of pregnancy at Gaslini Children's Hospital between January 2010 and December 2020. The last prenatal ultrasound evaluation was reviewed considering most of the echocardiographic criteria were already published for prenatal CoA diagnosis. Associated minor cardiac anomalies, such as a ventricular septal defect, persistent left superior vena cava (PLSCV), and redundant foramen ovale (FO) membrane, as well as postnatal outcomes, were reported. Initial perinatal management was defined based on the risk stratification of CoA during prenatal echocardiography. Neonates were divided into two groups depending on the presence or absence of CoA after birth.

RESULTS

A total of 91 fetuses with CoA suspicion were selected, of which 27 (30%) were confirmed with CoA after birth and underwent surgical repair. All cardiac parameters except redundant FO membrane and PLSCV showed a significant correlation with CoA. Statistical analysis confirmed that cardiovascular disproportion with right predominance carries an increased risk for occurrence of CoA, especially if already evident during the ultrasound evaluation in the second trimester. Aortic valve (AV) z-score and distal transverse aortic arch (TAA) z-score resulted as the best predictors of CoA after birth. The best cutoff point for CoA discrimination with ROC analysis was an AV z-score of -1.25 and a distal TAA z-score of -0.37. A total of 46% of those without CoA were diagnosed with a cardiac defect, which was not diagnosed in utero, pulmonary hypertension, or a genetic syndrome.

CONCLUSION

The current criteria for diagnosing CoA in utero allow accurate diagnosis of most severe cases but the rate of false positives remains relatively high for milder cases. A combination of anatomic and functional echocardiographic parameters might be used in stratifying the risk of CoA. We proposed the AV and the TAA diameter z-scores as the best predictors of CoA after birth. In addition, neonates without CoA deserve proper monitoring at birth because prenatal evidence of a significant cardiovascular discrepancy between the right and left cardiac structures has an inherent risk for additional morbidity postnatally.

Case Report: Candidate Genes Associated With Prenatal Ultrasound Anomalies in a Fetus With Prenatally Detected 1q23.3q31.2 Deletion

Background: Patients with deletions involving the long arm of chromosome 1 are rare, and the main aim of this study was to refine the genotype-phenotype correlation.

Case Report: In this report, a 28-year-old pregnant woman, gravida 2 para 1, at 25⁺⁴ weeks of gestation underwent ultrasound examination in our institute. The ultrasonographic findings of the fetus were as follows: (1) fetal growth restriction; (2) cleft lip and palate; (3) bilateral renal hypoplasia; (4) lateral ventriculomegaly; (5) single umbilical artery; (6) absent stomach; (7) coronary sinus dilatation with persistent left superior vena cava, ventricular septal defect and unroofed coronary sinus syndrome. Chromosomal microarray analysis of amniotic fluid from the fetus revealed a 28.025 Mb deletion in 1q23.3q31.2, spanning from position 164,559,675 to 192,584,768 (hg19).

Conclusion: Genotype-phenotype correlation might improve prenatal diagnosis of fetuses with chromosome 1q deletion. PBX1 could be a candidate gene for fetal growth restriction, renal hypoplasia and congenital heart disease. Fetal growth restriction was accompanied by decreased renal volume in the fetus. Combined with ultrasonic examination, the application of chromosomal microarray analysis will provide accurate prenatal diagnosis.

Prenatal diagnosis of persistent left superior vena cava, polyhydramnios and a small gastric bubble in a fetus with VACTERL association

OBJECTIVE

We reported a fetus that presenting with persistent left superior vena cava (PLSVC), polyhydramnios, and a small gastric bubble during prenatal examination and identified VACTERL association after birth.

CASE REPORT

A 34-year-old woman underwent amniocentesis at 18 weeks of gestation because of advanced maternal age and the result was normal. Subsequently, an ultrasound revealed single umbilical artery (SUA) at 21 weeks of gestation. She received a detailed fetal anatomy survey that presented the same findings and PLSVC. A small visible gastric bubble was noted at that time, and the other organs were unremarkable. Polyhydramnios was identified at 30 weeks of gestation and amnioreduction was subsequently performed at 32 weeks of gestation. However, polyhydramnios was persisted despite amnioreduction and intrauterine growth restriction was also detected. A cesarean section was performed because of fetal distress at 36 + 2 weeks, and a 1832-g female baby was delivered. Pre-axial polydactyly at left thumb, SUA and esophageal atresia with distal tracheoesophageal fistula (TEF) were identified after birth. The neonate died at age of 4 days because of surgical complication following esophageal anastomosis.

CONCLUSION

Prenatal diagnosis of PLSVC associated with polyhydramnios and a small gastric bubble may indicate esophageal atresia with TEF, and further examination for associated syndromes such as VACTERL association is warranted.

Persistent left superior vena cava: clinical importance and differential diagnoses

Persistent left superior vena cava (PLSVC) is the most common thoracic venous anomaly and may be a component of the complex cardiac pathologies. While it is often asymptomatic, it can lead to significant problems such as arrhythmias and cyanosis. Besides, it can cause serious complications during vascular interventional procedures or the surgical treatment of cardiac anomalies (CA). The clinical significance of PLSVC depends on the drainage site and the accompanying CA. In this article, we will describe the epidemiology, embryology, and anatomic variations of PLSVC. Possible accompanying CA and heterotaxy spectrum will be reviewed with the help of multidetector computed tomography (MDCT) images. Radiological pitfalls, differential diagnoses, and the clinical importance of PLSVC will be highlighted.

Gradual diagnosis and clinical importance of prenatally detected persistent left superior vena cava with absent right superior vena cava - a case report and literature review

Persistent left superior vena cava is a malformation of cardinal veins. We report a case of a secundigravida who had many fetal ultrasound examinations – first performed by an obstetrician (who described fetal mediastinum as “abnormal”), second by other obstetrician, who performed basic fetal echocardiographic examination and diagnosed persistent left superior vena cava. The woman was referred to a tertiary center for detailed fetal echocardiography. The diagnosis of persistent left superior vena cava with agenesis of the right superior vena cava was confirmed. The anomaly had no influence on fetal hemodynamic stability, fetal life, delivery and early postnatal period. After delivery, the neonate was under observation for further anomalies, aortic coarctation in particular. Prenatal and postnatal management was summarized. Literature review is presented.

Autopsy findings of an isolated persistent left superior vena cava in an intrauterine dead fetus

Persistent left superior vena cava (PLSVC) is one of the cardiac system abnormalities with a 0.3-0.5% incidence and caused by inadequate obliteration of the left anterior cardinal vein during embryonic development. Prognosis of PLSVC is generally assumed to be good if it is not accompanied by other cardiac system abnormalities. During the routine ultrasound control of a patient at 25th week of pregnancy at the Obstetrics and Gynecology Department of Mersin University, PLSVC anomaly was detected in an intrauterine fetus. Then, intrauterine death occurred and after removal of the deceased fetus, PLSVC diagnosis was confirmed by autopsy. According to the autopsy findings, right superior vena cava (SVC) and azygos vein were found in normal course. PLSVC opened into the right atrium via enlarged coronary sinus. There was no connection between the two SVCs. On the left side of posterior mediastinum, instead of hemiazygos or accessory hemiazygos veins, a vein symmetrical to azygos was opened into PLSVC, similar to the one on the right. No other cardiac anomaly associated with PLSVC or any other pathology in the other parts of body that could be responsible for death was discovered during autopsy. There was no evidence indicating that PLSVC played any role in intrauterine exitus of the present case. However, as mentioned in the literature, the ectopic beats in the atrium wall of patients with isolated PLSVC and enlarged coronary sinus may lead to pathologies in the conduction system of the heart. Considering the intrauterine death of an isolated PLSVC case associated with cardiac conduction pathologies, we recommend that the common assumption of 'isolated PLSVC is not associated with death' should be reviewed by studies on large series and even intrauterine cases should be closely monitored for cardiac arrhythmia.

Left Superior Vena Cava in the Fetus: A Rarely Isolated Anomaly

The frequency of chromosomal anomalies among fetuses with isolated persistent left superior vena cava (PLSVC) is still debated. The objective of the present study was to assess the prevalence of genetic and morphological anomalies identified in fetuses with PLSVC. We conducted a single-center retrospective study including all fetuses diagnosed with a PLSVC between 2010 and 2017. PLSVC was categorized as isolated or associated according to antenatal diagnosis of associated congenital heart defects, hypoplastic aortic isthmus, abnormal venous/arterial connections, and extracardiac anomalies. Among 229 fetuses diagnosed with PLSVC, 39 cases (17%) were strictly isolated and no syndromic/genetic anomaly or aortic coarctation was diagnosed. Seventy-two fetuses had a cardiovascular defect with a rate of genetic anomalies of 22%, 29 had an extracardiac malformation, and 89 had both an extracardiac and a cardiovascular defect. Among fetuses with abnormal development of the arterial/venous system as the only associated anomaly such as aberrant right subclavian artery or absent ductus venosus, 22% had a genetic anomaly. Overall, sixty-five fetuses or infants had a genetic concern, including 23 aneuploidies, 15 pathogenic micro-deletions/duplications, and 5 variants of unknown significance; 12 patients had VACTERL association, and 12 heterotaxy syndrome. Seven infants had an aortic coarctation diagnosed at birth.In conclusion, a thorough prenatal ultrasound examination is paramount, and the identification of variants of the venous/arterial system in addition to PLSVC should raise suspicion for genetic or morphologic abnormalities. Invasive prenatal diagnosis with array-CGH should be offered when PLSVC is non-isolated, after a detailed ultrasound evaluation in a tertiary center.

Neonatal outcome of cases with isolated prenatal ventricular disproportion with a dominant right ventricle

OBJECTIVES

Isolated prenatal ventricular disproportion with a dominant right ventricle represents a challenge in decision-making for both physicians and pregnant women. In the current study, we sought to delineate the postnatal outcomes of these cases.

METHODS

This retrospective analysis included consecutive cases of isolated ventricular disproportion identified using complete fetal echocardiography at the Fetal Heart Center of Xinhua Hospital from January 2014 to October 2017. Postnatal cardiac outcome was examined using transthoracic echocardiography within the first 6 months after birth.

RESULTS

A total of 90 fetuses were included in the final analysis. The median gestational age (GA) at diagnosis was 29 weeks (range 24 to 36). At postnatal examination, cardiac malformations were detected in 39 cases (43.3%), including 25 (27.8%) cases of congenital cardiac septal defects, eight (8.9%) of persistent left superior vena cava, four (4.4%) of left-sided obstructive diseases, and one (1.1%) case of coronary fistula. Nineteen cases (21.1%) with fetal cardiac malformations had significant lower GA at diagnosis (P = .01) and greater right to left ventricle ratio (1.38 vs 1.30, P = .02). Neonatal surgical intervention was not required in any of the cases.

CONCLUSIONS

Isolated prenatal ventricular disproportion with a dominant right ventricle comprises minor postnatal cardiac malformations and doesn't require neonatal intervention.

The gap between the aorta and the superior vena cava: A sonographic sign of persistent left superior vena cava and associated abnormalities

OBJECTIVES

To assess the distance between the right superior vena cava (SVC) and the aorta in fetuses with bilateral superior vena cava as a possible sonographic marker for this.

METHODS

This was a nested case-control study including 20 cases of bilateral SVC and 40 gestational age-matched controls. The distance between the right SVC and the aorta was measured at the level of the three-vessel trachea view in stored images, as well as the diameters of the aorta and the right SVC.

RESULTS

The distance between the aorta and the right SVC was significantly larger in the cases of a left SVC compared with controls, P < .001. A distance of 2.0 mm or more was found in 70% of the cases and 5% of the controls, with a gestational-age adjusted area under the receiver-operating characteristics (ROC) curve for the diagnosis of left SVC of 0.93 (95% CI 0.87-0.99). The aorta and the right SVC were significantly smaller in cases compared with controls, and there was a significant association with other cardiac and extracardiac abnormalities amongst cases of persistent left SVC.

CONCLUSION

An increased distance between the aorta and the right SVC is associated with the diagnosis of bilateral SVC.

Prenatal diagnosis of persistent left superior vena cava: a retrospective study of associated congenital anomalies

Objective:

To evaluate persistent left superior vena cava (PLSVC) cases according to associated cardiac, extracardiac, and chromosomal anomalies in the prenatal period and to review their outcomes.

Materials and Methods:

The data of patients with a prenatal diagnosis of PLSVC between January 2013 and December 2017 were reviewed retrospectively.

Results:

Data of 32 cases were reviewed. Nineteen (60%) cases were associated with cardiac defects, 5 (15%) were associated with both cardiac and extracardiac defects, and 8 (25%) had no associated anomalies. Two fetuses had karyotype anomalies. All patients with isolated PLSVC survived. Among the cases associated with extracardiac anomalies, cardiac anomalies, and with both extracardiac and cardiac anomalies, the survival rate was 40%, 40%, and 25%, respectively. Outcome was more favorable in cases with isolated PLSVC (100% vs. 40%).

Conclusion:

Prenatally diagnosed PLSVC is associated with cardiac and extracardiac anomalies in the majority of cases. The prognosis is good in isolated cases, but worsens when accompanied by cardiac or extracardiac anomalies.

Z-scores of early diastolic blood flow widths of mitral and tricuspid valves in normal fetuses and fetuses with dilated coronary sinus

Objectives: To establish Z-score models for early diastolic blood flow widths of mitral and tricuspid valves in normal fetuses and compare Z-scores and other blood flow dynamic parameters between normal fetuses and fetuses with dilated coronary sinus (CS). This study seeks to assess whether dilated CS affects cardiac structure or hemodynamics.Methods: One hundred twenty-nine normal fetuses (Group I) and 15 fetuses with dilated CS connected to persistent left superior vena cava (PLSVC) (Group II) were included in this study. Noncardiac biometrical parameters, including gestation age (GA), biparietal diameter (BPD), femoral length (FL), and heart area (HA), were obtained. Hemodynamic parameters, such as the early diastolic blood flow widths of mitral and tricuspid valves (MV-CDFI-Width, TV-CDFI-Width), velocity and time integral of blood flow (VTI), peak early and late diastolic velocity of mitral and tricuspid valves [peak early diastolic velocity of the mitral valve (MVE), peak late diastolic velocity of the mitral valve (MVA), peak early diastolic velocity of the tricuspid valve (TVE), peak late diastolic velocity of the tricuspid valve (TVA)], were measured.Results: Z-score models for MV-CDFI-Width and TV-CDFI-Width against noncardiac biometrical parameters were best described by linear regression analysis. The mean equations of MV-CDFI-Width against noncardiac biometrical parameters were 0.066 + (0.025 × GA), 0.169 + (0.084 × BPD), 0.213 + (0.106 × FL) and 0.533 + (0.028 × HA). The SD for MV-CDFI-Width against FL was estimated based on values from the following equation: -0.006 + (0.02 × FL). Other SDs were constants estimated as the standard deviations of the unscaled residuals. Z-scores and other blood flow dynamic parameters exhibited no statistically significant differences between Group I and Group II.Conclusions: This study demonstrated that dilated CS did not affect fetal hemodynamics of the mitral or tricuspid valves or cardiac structures. We also suggested that the causes of diminutive left heart or coarctation of the aorta might not be associated with dilated CS in fetuses with PLSVC.

Persistent Left Superior Vena Cava in Fetuses: An Autopsy Series

OBJECTIVE

To review fetal autopsy reports with persistent left superior vena cava (PLSVC) and identify its associations.

MATERIALS AND METHODS

Autopsy reports of all fetuses diagnosed with PLSVC in our center from January 2011 to December 2015 were reviewed. Fetuses less than 15 weeks gestational age along with autolyzed and damaged hearts were excluded from the study. The study group was compared with controls during this period.

RESULTS

Prenatal ultrasound detection rate of PLSVC was 13.06%. All the cases had associated anomalies of which 96% had extra cardiac anomalies and 67% had intrinsic cardiac defects among which septal defects were most common (39.6%). Anomalies of cardiovascular, respiratory, genitourinary and musculoskeletal, hypoplastic thymus and single umbilical artery were significantly higher in the study group.

CONCLUSION

This study emphasizes on the importance of improving the technical skill for imaging the three-vessel view as PLSVC seems to have significant associations.

Magnetic resonance imaging of fetal persistent left superior vena cava

This study aimed to evaluate the diagnostic accuracy of fetal magnetic resonance imaging (MRI) for persistent left superior vena cava (LSVC). Prenatal echocardiography (echo) and/or ultrasound (US) and MRI data for 49 fetuses with persistent LSVC, confirmed via postnatal diagnoses between January 2010 and October 2015, were retrospectively reviewed. All prenatal MRI was performed at 1.5 T. Imaging sequences included steady-state free-precession (SSFP), single-shot turbo spin echo (SSTSE), and other sequences. All 49 cases of fetal persistent LSVC were correctly diagnosed via MRI, but only 34 cases (69.4%) were correctly diagnosed via an initial US and/or echo before MRI. Of the 15 cases that were not correctly diagnosed via US and/or echo, 8 had congenital heart diseases (CHDs) and 7 were without CHDs; however, they were associated with extracardiac abnormalities or maternal obesity. Thirty-five cases were associated with other cardiovascular abnormalities; 8, with extracardiac abnormalities; and 6, with no associated condition. In 44 (89.8%) cases, the innominate veins were absent; the remaining cases had innominate veins. In 14.3% of patients (7 cases), the persistent LSVC drained directly into the atrium. Fetal MRI can detect persistent LSVC and play an adjunctive role along with US in the evaluation of persistent LSVC.

Array Characterization of Prenatally Diagnosed 15q26 Microdeletion and 2q37.1 Duplication: Report of a New Case with Multicystic Kidneys and Review of the Literature

We report on a molecular cytogenetic characterization of 15q26 deletion and 2q37.1 duplication in a fetus presenting with intrauterine growth restriction (IUGR), diaphragmatic hernia, multicystic kidneys, left kidney pyelectasis, and clubfeet. A terminal 15q26 deletion and a terminal 2q duplication of at least 10 and 9 Mb, respectively, derived from a maternal translocation, were found. The 15q26 deletion represents a contiguous gene deletion syndrome mainly characterized by IUGR, congenital diaphragmatic hernia, and less frequently kidney defects. This deletion encompasses the IGF1R and COUPTF2 genes, known to lead to fetal growth retardation syndrome. However, kidney malformations are less well known in such conditions, and to the best of our knowledge, no candidate gene has been proposed to date. Here, we review the literature of the 15q26 deletion syndrome and suggest that hypoplastic and multicystic kidneys, the most commonly observed anomalies in this condition, should be considered in the prenatal diagnosis setting. Based on COUPTF2 protein function, we hypothesize that its haploinsufficiency might be responsible for the renal pathology.

Does First-Trimester Screening Modify the Natural History of Congenital Heart Disease?

Background:

The study analyzed the impact of first-trimester screening on the spectrum of congenital heart defects (CHDs) later in pregnancy and on the outcome of fetuses and children born alive with a CHD.

Methods:

The spectrum of CHDs, associated comorbidities, and outcome of fetuses, either diagnosed with a CHD in the first trimester (Group I, 127 fetuses) or only in the second-trimester screening (Group II, 344 fetuses), were analyzed retrospectively between 2007 and 2013. Second-trimester fetuses diagnosed with a CHD between 2007 and 2013 were also compared with Group III (532 fetuses diagnosed with a CHD in the second trimester from 1996 to 2001, the period before first-trimester screening was introduced).

Results:

The spectrum of CHDs diagnosed in the first and second trimesters in the same time period differed significantly, with a greater number of comorbidities ( P <0.0001), CHDs with univentricular outcome ( P <0.0001), intrauterine deaths ( P =0.01), and terminations of pregnancy ( P <0.0001) in Group I compared with Group II. In Group III, significantly more cases of CHDs with univentricular outcome ( P <0.0001), intrauterine demise ( P =0.036), and early termination ( P <0.0001) were identified compared with fetuses diagnosed with CHDs in the second trimester between 2007 and 2013. The spectrum of CHDs seen in the second-trimester groups differed after first-trimester screening was implemented.

Conclusions:

First-trimester screening had a significant impact on the spectrum of CHDs and the outcomes of pregnancies with CHDs diagnosed in the second trimester. Early detection of severe forms of CHDs and significant comorbidities resulted in an increased pregnancy termination rate in the first trimester.

Persistent Left Superior Vena Cava

Persistent left superior vena cava (PLSVC) is a common cardiac anomaly associated with congenital heart diseases. A diagnosis of PLSVC usually warrants a detailed fetal echocardiography. Lesser known associations are the extra cardiac anomalies notably the upper airway and the gastrointestinal tract anomalies. We highlight here the importance of detailed fetal assessment for extra cardiac anomalies in addition to fetal echocardiography in fetuses diagnosed with PLSVC. We hereby present a preterm infant who presented with a triad of PLSVC, laryngeal atresia, and esophageal atresia.

Risk Factors for Coarctation of the Aorta on Prenatal Ultrasound: A Systematic Review and Meta-Analysis

BACKGROUND

Prenatal diagnosis of coarctation of the aorta (CoA) is still challenging and affected by high rates of false-positive diagnoses. The aim of this study was to ascertain the strength of association and to quantify the diagnostic accuracy of different ultrasound signs in predicting CoA prenatally.

METHODS

Medline, Embase, CINAHL, and Cochrane databases were searched. Random-effects and hierarchical summary receiver operating characteristic model meta-analyses were used to analyze the data.

RESULTS

Seven hundred ninety-four articles were identified, and 12 (922 fetuses at risk for CoA) articles were included. Mean mitral valve diameter z score was lower (P<0.001) and the mean tricuspid valve diameter z score was higher in fetuses with CoA than in those without CoA (P=0.01). Mean aortic valve diameter z score was lower in fetuses with CoA than in healthy fetuses (P≤0.001), but the ascending aorta diameter, expressed as z score or millimeters, was similar between groups (P=0.07 and 0.47, respectively). Mean aortic isthmus diameter z scores measured either in sagittal (P=0.02) or in 3-vessel trachea view (P<0.001) were lower in fetuses with CoA. Conversely, the mean pulmonary artery diameter z score, the right/left ventricular and pulmonary artery/ascending aorta diameter ratios were higher (P<0.001, P=0.02, and P=0.02, respectively) in fetuses with CoA in comparison with controls, although aortic isthmus/arterial duct diameter ratio was lower in fetuses with CoA than in those without CoA (P<0.001). The presence of coarctation shelf and aortic arch hypoplasia were more common in fetuses with CoA than in controls (odds ratio, 26.0; 95% confidence interval, 4.42-153; P<0.001 and odds ratio, 38.2; 95% confidence interval, 3.01-486; P=0.005), whereas persistent left superior vena cava (P=0.85), ventricular septal defect (P=0.12), and bicuspid aortic valve (P=0.14) did not carry an increased risk for this anomaly. Multiparametric diagnostic models integrating different ultrasound signs for the detection of CoA were associated with an increased detection rate.

CONCLUSIONS

The detection rate of CoA may improve when a multiple-criteria prediction model is adopted. Further large multicenter studies sharing the same imaging protocols are needed to develop objective models for risk assessment in these fetuses.

Systematic review and meta-analysis of persistent left superior vena cava on prenatal ultrasound: associated anomalies, diagnostic accuracy and postnatal outcome

OBJECTIVES

To quantify the prevalence of chromosomal anomalies in fetuses with persistent left superior vena cava (PLSVC), assess the strength of the association between PLSVC and coarctation of the aorta and ascertain the diagnostic accuracy of antenatal ultrasound in correctly identifying isolated cases of PLSVC.

METHODS

MEDLINE, EMBASE, CINHAL and the Cochrane databases were searched from the year 2000 onwards using combinations of keywords 'left superior vena cava' and 'outcome'. Two authors reviewed all abstracts independently. Quality assessment of the included studies was performed using the Newcastle-Ottawa Scale for cohort studies. The rates of the following outcomes were analyzed: chromosomal abnormalities; associated intracardiac anomalies (ICAs) and extracardiac anomalies (ECAs) diagnosed prenatally; additional ICAs and ECAs detected only at postnatal imaging or clinical evaluation but missed at prenatal imaging; and association of PLSVC and coarctation of the aorta. Meta-analyses of proportions were used to combine data.

RESULTS

In total, 2708 articles were identified and 13 (n = 501) were included in the systematic review. Associated ICAs and ECAs were detected at the prenatal ultrasound examination or at a follow-up assessment in 60.7% (95% CI, 44.2-75.9%) and 37.8% (95% CI, 31.0-44.8%) of cases, respectively. Chromosomal anomalies occurred in 12.5% (95% CI, 9.0-16.4%) of cases in the overall population of fetuses with PLSVC and in 7.0% (95% CI, 2.7-13.0%) of isolated cases. Additional ICAs and ECAs were detected only after birth and missed at ultrasound in 2.4% (95% CI, 0.5-5.8%) and 6.7% (95% CI, 2.2-13.2%) of cases, respectively. Coarctation of the aorta was associated with isolated PLSVC in 21.3% (95% CI, 13.6-30.3%) of cases.

CONCLUSIONS

PLSVC is commonly associated with ICAs, ECAs and chromosomal anomalies. Fetuses with isolated PLSVC should be followed up throughout pregnancy in order to rule out coarctation of the aorta. As most of the data in this review were derived from high-risk pregnancies, the rate of associated abnormalities is likely to be higher than that in the general population of fetuses with PLSVC, for which more data are needed. Revisión sistemática y metaanálisis de la persistencia de la vena cava superior izquierda en la ecografía prenatal: anomalías asociadas, precisión del diagnóstico y resultado postnatal RESUMEN OBJETIVOS: Cuantificar la prevalencia de anomalías cromosómicas en fetos con vena cava superior izquierda persistente (VCSIP), evaluar la solidez de la asociación entre la VCSIP y la coartación aórtica, y determinar la precisión del diagnóstico de la ecografía prenatal como método para identificar correctamente casos aislados de VCSIP. MÉTODOS: Se buscó en las bases de datos de MEDLINE, EMBASE, CINHAL y Cochrane artículos publicados desde el año 2000 en adelante, usando combinaciones de las palabras clave "vena cava superior izquierda" y "resultado". Dos de los autores revisaron de forma independiente todos los resúmenes encontrados. La evaluación de calidad de los estudios incluidos se realizó mediante la escala Newcastle-Ottawa para estudios de cohortes. Se analizaron las tasas de los siguientes resultados: anomalías cromosómicas; anomalías intracardíacas (AIC) y anomalías extracardíacas (AEC) asociadas diagnosticadas prenatalmente; AIC y AEC adicionales detectadas sólo en ecografías postnatales o mediante evaluación clínica, pero no observadas en ecografías prenatales; y la asociación entre la VCSIP y la coartación aórtica. Se utilizó un meta-análisis de proporciones para combinar los datos.

RESULTADOS

En total, se identificaron 2708 artículos y se incluyeron 13 (n = 501) en la revisión sistemática. En la ecografía prenatal o en una revisión de seguimiento se detectaron AIC y AEC asociadas en el 60,7% (IC 95%, 44,2-75,9%) y el 37,8% (IC 95%, 31,0-44,8%) de los casos, respectivamente. Se produjeron anomalías cromosómicas en el 12,5% (IC 95%, 9,0-16,4%) de los casos en la población general de fetos con VCSIP y en el 7,0% (IC 95%, 2,7-13,0%) de casos aislados. Las AIC y AEC adicionales sólo se detectaron después del nacimiento y en el 6,7% (IC 95%, 2,2-13,2%) de los casos, respectivamente. La coartación aórtica se encontró asociada con la VCSIP aislada en un 21,3% (IC 95%, 13,6-30,3%) de los casos.

CONCLUSIONES

La VCSIP está comúnmente asociada a AIC, AEC y anomalías cromosómicas. Los fetos con VCSIP aislada deben ser objeto de seguimiento durante todo el embarazo, con el fin de descartar la coartación aórtica. Como la mayoría de los datos de esta revisión proceden de embarazos de alto riesgo, es probable que la tasa de anomalías asociadas sea más alta que la de la población general de fetos con VCSIP, por lo que se necesitan más datos.

Prenatal Sonographic Predictors of Neonatal Coarctation of the Aorta

OBJECTIVES

To identify practical prenatal sonographic markers for the postnatal diagnosis of coarctation of the aorta.

METHODS

We reviewed the fetal echocardiograms and postnatal outcomes of fetal cases of suspected coarctation of the aorta seen at a single institution between 2010 and 2014. True- and false-positive cases were compared. Logistic regression analysis was used to determine echocardiographic predictors of coarctation of the aorta. Optimal cutoffs for these markers and a multivariable threshold scoring system were derived to discriminate fetuses with coarctation of the aorta from those without coarctation of the aorta.

RESULTS

Among 35 patients with prenatal suspicion of coarctation of the aorta, the diagnosis was confirmed postnatally in 9 neonates (25.7% true-positive rate). Significant predictors identified from multivariate analysis were as follows: Z score for the ascending aorta diameter of -2 or less (P = < .001), Z score for the mitral valve annulus of -2 or less (P= .033), Zscore for the transverse aortic arch diameter of -2 or less (P= .028), and abnormal aortic valve morphologic features (P= .026). Among all variables studied, the ascending aortic Z score had the highest sensitivity (78%) and specificity (92%) for detection of coarctation of the aorta. A multivariable threshold scoring system identified fetuses with coarctation of the aorta with still greater sensitivity (89%) and only mildly decreased specificity (88%).

CONCLUSIONS

The finding of a diminutive ascending aorta represents a powerful and practical prenatal predictor of neonatal coarctation of the aorta. A multivariable scoring system, including dimensions of the ascending and transverse aortas, mitral valve annulus, and morphologic features of the aortic valve, provides excellent sensitivity and specificity. The use of these practical sonographic markers may improve prenatal detection of coarctation of the aorta.

Intrathymic and other anomalous courses of the left brachiocephalic vein in the fetus

OBJECTIVE

The left brachiocephalic vein (LBCV), or innominate vein, connects the left jugular vein to the right superior vena cava. Its course is posterior to the thymus and directly anterior and superior to the aortic arch. Pediatric and adult cardiology studies have reported on the subaortic or retrotracheal courses of the LBCV and the presence of double LBCV. We observed recently in the fetus that the LBCV may have a course through the thymus (intrathymic) or be absent in the presence of a left superior vena cava. The aim of this study was to report the prevalence of isolated intrathymic and absent LBCV in normal fetuses undergoing second-trimester ultrasound screening, as well as the prevalence of other courses in association with cardiac anomalies.

METHODS

In the prospective part of this study, consecutive second-trimester ultrasound examinations were evaluated to assess the presence and course of the fetal LBCV. In the retrospective case-control part of this study, the databases of two fetal medicine centers were reviewed for cardiac anomalies and the pattern and prevalence of anomalous courses of the LBCV were reported.

RESULTS

One thousand four hundred and eighteen consecutive fetuses were examined prospectively. An intrathymic course of the LBCV with a typical bent shape was found in 1.76% (1 : 57) of cases and the absence of a LBCV in association with a persistent left superior vena cava (LSVC) was found in 0.28% (1 : 350). All fetuses with an isolated intrathymic course or absence of the LBCV had a normal outcome. Over a period of 4.5 years, a total of 1544 fetuses with cardiac malformations were reviewed at two centers. Among these, an anomalous course of the LBCV was noted in eight (0.5%) cases: six subaortic, one retrotracheal and one double LBCV.

CONCLUSION

An intrathymic LBCV is a common condition and appears to be a normal variant in the fetus. The prevalence of a LSVC in our screening population was similar to that reported in previous studies. Anomalous courses of the LBCV are seen occasionally in cases with cardiac malformation. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Persistent Left Superior Vena Cava Connected to the Coronary Sinus in the Fetus: Effects on Cardiac Structure and Flow Dynamics

Ventricular size discrepancy may be due to a persistent left superior vena cava (PLSVC) in utero. We sought to investigate for differences in cardiac structure measures and hemodynamics between fetuses with isolated PLSVC connected to the coronary sinus (CS) and normal. Fetuses diagnosed with isolated PLSVC in the second and third trimester were enrolled. We defined two groups: group 1, twenty-five fetuses in the second trimester (22-27 W + 6d); group 2, twenty-two fetuses in the third trimester (28-39 W + 6d). Fifty-three fetuses without intra-cardiac or extra-cardiac anomalies and gestation age-matched were divided into normal control groups: group 3, 28 fetuses in the second trimester; group 4, 25 fetuses in the third trimester. Parameters of cardiac structure and hemodynamics were measured, including: left- and right-side heart size, the diameter of foramen ovale, aorta (AO), aortic isthmus and pulmonary artery (PA), and ratios of cardiac structure RV/LV, RA/LA and PA/AO were calculated. Hemodynamic parameters measured included: flow velocity across mitral valve, tricuspid valve and foramen ovale. In the second trimester, the ratio of RV/LV and PA/AO of the PLSVC fetuses was significantly larger than normal, while the AO diameter, aortic isthmus diameter were smaller than normal (P < 0.05). However, in the third trimester, only the ratio of PA/AO of the PLSVC fetuses was significantly larger, and the aortic isthmus diameter was still smaller than normal (P < 0.05). Isolated PLSVC connecting to the CS is associated with differences in cardiac structure size from normal. These differences appear to diminish with gestational age. A dilated CS may have an influence on development of fetal left heart structures.

Anomalous Pulmonary Venous Return: Insights Into Prenatal Detection

OBJECTIVES

To review all cases of total anomalous pulmonary venous return (TAPVR) or partial anomalous pulmonary venous return (PAPVR) identified prenatally or postnatally at a single institution and to identify factors that may lead to a correct or missed diagnosis in both high- and low-risk fetuses on screening examinations.

METHODS

Fetal images from 16 cases of prenatally or postnatally diagnosed T/PAPVR were retrospectively reviewed to analyze factors that influenced interpretations and diagnoses.

RESULTS

Sixteen diagnoses of T/PAPVR were made, with a final number of 10 confirmed cases, 1 of which was PAPVR. Ten fetuses with a presumptive diagnosis of T/PAPVR before delivery were at an average gestational age of 24.7 weeks, with 5 cases diagnosed postnatally. None of the diagnoses of isolated TAPVR were made during a screening examination. Twelve of the pregnancies were complicated by complex cardiac defects, including 6 with heterotaxy syndromes. Of the 5 abnormal cases identified in the postpartum period, 3 had isolated TAPVR. In the 3 patients with isolated defects, prenatal echocardiography was not performed; the anatomy scan interpretations were confounded by multiple factors. In retrospect, there was no obvious sonographic evidence of TAPVR in these patients; however, color flow Doppler imaging of the pulmonary veins was not performed on any of them.

CONCLUSIONS

Although fetal echocardiography has improved the overall detection of TAPVR or PAPVR, this abnormality continues to elude prenatal diagnosis during screening in both low- and high-risk patients. We hypothesize that the use of color flow Doppler imaging in the 4-chamber view may assist in diagnosing TAPVR in screening low-risk patients, especially in those with difficult scans.

Clinical characteristics of prenatally diagnosed persistent left superior vena cava in low-risk pregnancies

Objective

To determine the incidence and clinical characteristics of persistent left superior vena cava (PLSVC) among low‐risk pregnancies. We have also compared electrocardiography (ECG) parameters of infants with PLSVC with those of normal controls.

Method

At our institute, fetal echocardiogram is routinely performed in the midtrimester. We retrospectively reviewed the records of prenatally diagnosed PLSVC cases from 2010 to 2014. The ECG findings in infants with isolated PLSVC were compared with those of age‐matched controls.

Results

Sixty‐five cases of fetal PLSVC were detected during the study period. It represents 0.36% (65/18 188) of all fetal echocardiographic examinations during the study period. Twenty cases (30.8%) had other cardiac anomalies, seven cases (10.8%) were associated with extracardiac anomalies, and four cases (6.2%) had both cardiac and extracardiac anomalies, whereas in 34 cases (52.3%), the anomaly was isolated. There were no significant differences in ECG parameters between neonates with PLSVC and normal controls.

Conclusion

Detection of PLSVC should prompt careful search for associated anomalies. Isolated PLSVC is a benign vascular anomaly and the outcomes are excellent. © 2016 The Authors. Prenatal Diagnosis published by John Wiley & Sons, Ltd.

What's Already Known About This Topic?

Persistent left superior vena cava (PLSVC) can be accurately diagnosed prenatally and can be associated with cardiac and extracardiac anomalies.

The significance of PLSVC when isolated is unclear.

What Does This Study Add?

We establish the incidence and clinical characteristics of PLSVC in low‐risk pregnancies.

Electrocardiographic parameters in neonates with PLSVC are similar to those of unaffected controls.

Absent right superior caval vein in situs solitus

Introduction In up to 0.07% of the general population, the right anterior cardinal vein obliterates and the left remains open, creating an absent right superior caval vein and a persistent left superior caval vein. Absent right superior caval vein is associated with additional congenital heart disease in about half the patients. We wished to study the consequences of absent right superior caval vein as an incidental finding on prenatal ultrasonic malformation screening. Material and methods This is a retrospective case series study of all foetuses diagnosed with absent right superior caval vein at the national referral hospital, Rigshospitalet, Denmark, from 2009 to 2012.

RESULTS

In total, five cases of absent right superior caval vein were reviewed. No significant associated cardiac, extra-cardiac, or genetic anomalies were found. Postnatal echocardiographies confirmed the diagnosis and there were no postnatal complications. All children were found to have healthy hearts at follow-up.

CONCLUSIONS

In all cases, the findings proved to be a benign condition with no clinical manifestations or complications. Although isolated absent right superior caval vein does not seem to affect the outcome, associated anomalies may be serious. Absent right superior caval vein should, therefore, prompt a search for additional malformations. Furthermore, the diagnosis of an isolated absent right superior caval vein is important, because knowledge of the anomaly can prevent future problems when invasive procedures are necessary.

Importance of Relationship between Ductus and Isthmus in Fetal Diagnosis of Coarctation of Aorta

BACKGROUND

The prenatal diagnosis of coarctation of aorta (CoA) can prove problematic, with relatively high false-positive and false-negative rates. This significantly impacts both prenatal counseling and postnatal management. We sought to evaluate a variety of prenatal echo indices to determine which would best predict neonatal CoA.

METHODS

Fetal echocardiograms of those with prenatal diagnosis of COA were analyzed for the following: diameter of cardiac valves, ascending aorta, distal transverse arch, aortic isthmus, and ductus; right (RV) and left ventricular (LV) length and end-diastolic area and isthmus-ductal angle (IDA). Ratios of RV: LV area, aortic: pulmonary valve diameter, mitral: tricuspid valve ratio (MV:TV ratio), and isthmus: ductal diameter (IDD) were calculated. These measures were compared between those with CoA after birth (CoA group) and those without (no CoA group).

RESULTS

Of the 62 subjects, 27 were in CoA and 35 in no CoA group. CoA group had a significantly smaller mitral valve, MV:TV ratio, IDD, and IDA compared to no CoA group. The ROC curves for each of these significant measures showed that mitral valve, IDD, and IDA had an AUC of 0.72, 0.80, and 0.83, respectively. Multiple variable model using at least two of these measures had 85% sensitivity and 60% specificity.

CONCLUSIONS

A smaller mitral valve, MV:TV ratio, IDD, and IDA are associated with development of neonatal coarctation. In cases with suspected prenatal diagnosis of CoA, careful evaluation of the relation between the isthmus and the ductus arteriosus using IDD and IDA may enhance the diagnostic accuracy of fetal echocardiograms.

Congenital Anomalies of Superior Vena Cava and their Implications in Central Venous Catheterization

Congenital anomalies of superior vena cava (SVC) are generally discovered incidentally during central venous catheter (CVC) insertion, pacemaker electrode placement, and cardiopulmonary bypass surgery. Persistent left SVC (PLSVC) is a rare (0.3%) anomaly in healthy subjects, usually asymptomatic, but when present and undiagnosed, it may be associated with difficulties and complications of CVC placement. In individuals with congenital heart anomalies, its prevalence may be up to 10 times higher than in the general population.

In this perspective, awareness of the importance of the incidental finding of PLSV during CVC placement is crucial. To improve knowledge of this rare but potentially dangerous condition, we describe the embryological origin of SVC, its normal anatomy, and possible congenital anomalies of the venous system and of the heart, including the presence of a right to left cardiac shunt. Diagnosis of PLSVC as well as the clinical complications and technical impact of SVC congenital anomalies for CVC placement are emphasized.

Fetal persistent left superior vena cava in cases with and without chromosomal anomalies

OBJECTIVES

The objectives of this study are to determine and compare the prevalence of persistent left superior vena cava (PLSVC) in chromosomally normal and abnormal fetuses and to evaluate the potential of PLSVC as a screening marker for chromosomal abnormalities.

METHODS

Women undergoing routine fetal sonographic examinations were evaluated once for the presence of PLSVC. PLSVC was diagnosed on the basis of the identification of an additional vessel in the left of the pulmonary artery in a three-vessel trachea view. Associated abnormalities, karyotypes, and outcomes were analyzed.

RESULTS

A total of 164 (0.7%, 164/25 171) cases of PLSVC were detected and successfully followed-up. The detection rates were 0.5% (81/17 535) and 1.1% (83/7636) in the low-risk and high-risk cases, respectively. The incidence of PLSVC was lower among the chromosomally or clinically normal (0.4%, 110/24 914) compared with chromosomally abnormal fetuses (7.8%, 20/257, p < 0.001). Additional defects were identified in 90% (18/20) of the PLSVC fetuses with chromosomal anomalies, a rate that was higher than those fetuses with chromosomal normal (61.8%, 68/110).

CONCLUSIONS

Persistent left superior vena cava is more common among chromosomally abnormal than normal fetuses, and PLSVC fetuses with other defects are more highly associated with chromosomal disorders than isolated PLSVC fetuses. Isolated PLSVC is a benign vascular anomaly and may not affect outcomes.