The in utero diagnosis of an interventricular septal cardiac rhabdomyoma by means of real-time-directed, M-mode echocardiography

Childhood tuberous sclerosis complex in southern Sweden: a paradigm shift in diagnosis and treatment

AIM

To investigate the complete clinical spectrum of individuals with paediatric tuberous sclerosis complex in southern Sweden and explore changes over time.

METHODS

In this retrospective observational study, 52 individuals aged up to 18 years at the study start were followed-up at regional hospitals and centres for habilitation from 2000 to 2020.

RESULTS

Cardiac rhabdomyoma was detected prenatally/neonatally in 69.2% of the subjects born during the latest ten years of the study period. Epilepsy was diagnosed in 82.7% of subjects, and 10 (19%) were treated with everolimus, mainly (80%) for a neurological indication. Renal cysts were detected in 53%, angiomyolipomas in 47%, astrocytic hamartomas in 28% of the individuals. There was a paucity of standardized follow-up of cardiac, renal, and ophthalmological manifestations and no structured transition to adult care.

CONCLUSION

Our in-depth analysis shows a clear shift towards an earlier diagnosis of tuberous sclerosis complex in the latter part of the study period, where more than 60% of cases showed evidence of this condition already in utero due to the presence of a cardiac rhabdomyoma. This allows for preventive treatment of epilepsy with vigabatrin and early intervention with everolimus for potential mitigation of other symptoms of tuberous sclerosis complex.

A case of surgically resected cardiac rhabdomyoma with progressive left ventricular outflow tract obstruction

Cardiac rhabdomyoma is the most prevalent cardiac tumors in the pediatric population, in close association with tuberous sclerosis complex. It is usually detected antenatally or postnatally by echocardiography. Clinical presentations depend greatly on the size and position of the tumor mass. Interestingly, rhabdomyoma has a propensity to regress spontaneously and is not usually operated upon, unless the patient becomes hemodynamically compromised. Herein, we report an unusual case of surgically treated cardiac rhabdomyoma in a baby boy presented at birth with a progressive enlarging intraventricular mass, complicated with left ventricular outflow tract obstruction 7 weeks later. Histopathological examination of the intracardiac mass revealed sheets of tumor cells with spider-like morphology (known as "spider cells"), confirmed the diagnosis of rhabdomyoma. Close disease monitoring of patient's hemodynamic status in a newly diagnosed cardiac rhabdomyoma is inevitable as the tumor, although rare, may progress.

Clinical and genetic description of patients with prenatally identified cardiac tumors

OBJECTIVE

Rhabdomyomas are the most common type of prenatal cardiac tumors. When isolated, 50% to 70% are related to the tuberous sclerosis complex (TSC). The aim of this study was to reinforce the importance of additional clinical data in patients with prenatal heart tumors.

METHODS

From 2010 to 2017, 10 prenatally detected cardiac tumors were referred to the Genetics Department, and a complete family history was taken. Postnatal echocardiographic and full clinical evaluation were completed. Next generation sequencing (NGS) of the TSC1 and TSC2 genes was performed.

RESULTS

The 10 cases were postnatally confirmed as rhabdomyomas. Four de novo and four family cases were detected, and only one patient was previously aware of the TSC diagnosis. Molecular analysis by NGS was performed in four patients with three TSC2 mutations, two of which were previously reported and one not.

DISCUSSION

Prenatal cardiac tumors are associated with TSC in 60% of cases. Prenatal diagnosis of cardiac tumors permits a further analysis of family members using the fetus as a clue for familial disease diagnosis.

Perinatal unusual rhabdomyoma location - case report and systematic reviews of the literature

Objective: To report a case of prenatal diagnosis of cardiac rhabdomyoma (CR) and neonatal surgical treatment as well as undertaking a systematic review of the literature to determine most frequent localization of CR, common signs and symptoms, associated pathologies, incidence of surgery, and prognoses for CR.Methods: We conducted systematic review of the literature on CR that were diagnosed and treated in the perinatal period, searching for English language articles in the PubMed/Medline database that were published within the past 20 years, using the following search terms: "cardiac rhabdomyoma"; "neonates"; "newborn"; "surgery".Results: Eighty-two studies were selected, but only 46 studies met the inclusion criteria. After birth, the majority of newborns were asymptomatic; however, murmurs and arrhythmia were also the two most prevalent signs of CR. The most prevalent location was the ventricles, corresponding to 40.3% of all cases, with 53% of these having a rhabdomyoma in the left ventricle. The incidence of multiple tumors was 56%, and in those cases the location of tumors was also most common in the ventricles. Tuberous sclerosis was the most commonly associated pathology, being present in 72% of cases of CR. Surgical treatment occurred in 27% of cases, and 3% of cases required surgery and prostaglandin. Regarding the perinatal outcome, 6% of cases resulted in fetal or neonatal death.Conclusion: CR are benign tumors which tend to spontaneously regress during early childhood but may have unfavorable outcomes in the presence of obstructive lesions and arrhythmias. Surgery is generally necessary in symptomatic patients.

Diagnosis of tuberous sclerosis complex in the fetus

Tuberous sclerosis complex is a dominantly inherited genetic disorder of striking clinical variability. It is caused by mutations in either TSC1 or TSC2 gene, which regulate cell growth and proliferation by inhibition of mTORC1 signaling. TS is characterized by the development of benign tumors in many tissues and organs and its neurological manifestations include epilepsy, autism, cognitive and behavioral dysfunction, and giant cell tumors. With mechanism-based mTOR inhibitors therapy now available for many of its manifestations, early diagnosis of TSC is very important in order to offer appropriate care, long-term surveillance and parental counseling. Fetal ultrasound and MRI imaging techniques have evolved and may capture even earlier the following TSC-associated lesions: cardiac rhabdomyomas, subependymal nodules, cortical tubers and renal cysts. Often these represent an incidental finding during a routine ultrasound. Furthermore, in the past decades prenatal molecular diagnosis of TSC has emerged as an important option for families with a known affected member; however, the existing evidence with regards to the clinical characteristics and long-term outcome of babies diagnosed prenatally with TSC is yet limited and the path that follows early TSC detection merits further research.

4D fetal echocardiography-An update

With the introduction of the electronic 4-dimensional and spatial-temporal image Correlation (e-STIC), it is now possible to obtain large volume datasets of the fetal heart that are virtually free of artifact. This allows the examiner to use a number of imaging modalities when recording the volumes that include two-dimensional real time, power and color Doppler, and B-flow images. Once the volumes are obtained, manipulation of the volume dataset allows the examiner to recreate views of the fetal heart that enable examination of cardiac anatomy. The value of this technology is that a volume of the fetal heart can be obtained, irrespective of the position of the fetus in utero, and manipulated to render images for interpretation and diagnosis. This article presents a summary of the various imaging techniques and provides clinical examples of its application used for prenatal diagnosis of congenital heart defects and abnormal cardiac function.

Rapid Regression of Prenatally Identified Intrapericardial Giant Rhabdomyomas with Sirolimus

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Giant cardiac rhabdomyomas were identified on fetal echocardiography.

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The rhabdomyomas were unusually located in the pericardial space.

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Rapid regression and hemodynamic improvement were seen with sirolimus therapy.

Prenatally Diagnosis and Outcome of Fetuses with Cardiac Rhabdomyoma - Single Centre Experience

BACKGROUND

Cardiac rhabdomyoma (CRs) are the most common primary tumour of the heart in infants and children. Usually are multiple and, basing on the location can cause a haemodynamic disturbance, dysrhythmias or heart failure during the fetal and early postnatal period. CRs have a natural history of spontaneous regression and are closely associated with tuberous sclerosis complex (TSC). It has an association with tuberous sclerosis (TS), and in those, the tumour may regress and disappear completely, or remain consistent in size.

AIM

We aimed to evaluate the prenatal diagnosis, clinical presentation and outcome of CRs and their association with TSC in a single centre. The median follow-up period was three years (range: 6 months - 5 years).

MATERIAL AND METHODS

We reviewed medical records of all fetuses diagnosed prenatally with cardiac rhabdomyoma covering the period January 2010 to December 2016 which had undergone detailed ultrasound evaluation at a single centre with limited technical resources.

RESULTS

Twelve fetuses were included in the study; mostly had multiple tumours and a total of 53 tumours were identified in all patients - the maximum was one fetus with16 tumours. All patients were diagnosed prenatally by fetal echocardiography. In two patient's haemodynamic disturbances during the fetal period was noted and pregnancies have been terminated. After long consultation termination of pregnancy was chosen by the parents in totally 8 cases. In four continuing pregnancies during the first year of live tumours regressed. TSC was diagnosed in all patients during the follow-up.

CONCLUSIONS

Cardiac rhabdomyoma are benign from the cardiovascular standpoint in most affected fetuses. An early prenatal diagnosis may help for an adequate planning of perinatal monitoring and treatment with the involvement of a multidisciplinary team. Large tumour size, the number of tumours and localisation may cause hydrops, and they are significantly associated with poor neonatal outcome.

Heart Tumors in 33 Fetuses - Review of Twenty-Two Years of the Single-Centre Experience

INTRODUCTION: Cardiac tumors (CT) have been diagnosed since the eighties of the last century. The three most commonly diagnosed types of CT are rhabdomyomas, teratomas and fibromas. Severe fetal disturbances, such as arrythmias, fetal hydrops, ventricular obstructions, may be associated with the heart tumor.

AIM OF THE STUDY: To present the key role of the echocardiographic examination in the perinatal care and to present some demographic changes in this population of the youngest patients.

MATERIAL AND METHODS: From the Filemaker database of the Department for Diagnosis and Prevention of Congenital Malformations, Polish Mother’s Memorial Hospital & Medical University of Lodz, all cases with prenatal diagnoses of cardiac tumor in singleton pregnancy were compiled over a 22-year period (1993–2015). 33 cases of heart tumors in fetuses had 72 fetal echo examinations. The average number of cases per year was 1,5 (range 1 – 5). The retrospective analysis of the material was performed using the Statistica package. The analysis included the assessment of the cardiovascular condition defined by Cardiovascular Profile Score, location and number of tumors; age, past obstetric history, place of residence of the mother, type of delivery and neonatal follow-up.

RESULTS: The number of fetuses with cardiac tumor cases did not increase during this period. The maternal age was 28,1 years (± 5,2 years) and was decreasing over time. The primigravidae constituted 60% of examined population. The history of past miscarriages was observed in 26% of women. The majority of tumors were detected and diagnosed in the third trimester – at mean 29,6 hbd, but the diagnosis was made earlier in the past decades (regression analysis, p=0,042). The average duration of pregnancy was 36,6 hbd (range: 27-42 hbd). There was no statistical difference between decades in term on pregnancy duration.

The cardiac tumors were more frequent in the female fetuses (71,4% to 28,6%; X2 test; p=0,006). The proportions between the groups of single and multiple tumors changed in last five years – currently the multiple tumors are more frequent (87,5%). The mortality in the group of single tumors was twice as high as in the group of multiple tumors. The percentage of cesarean sections between 1993 and 2005 was 67% and between 2006 and 2015 was 75% (p=0,63). The mortality of neonates with cardiac tumors declined over the period taken into account.

CONCLUSIONS: The perinatal care of the fetuses with cardiac tumors improved over last 20 years. The characteristics of analyzed population had shown that fetal CTs affected healthy, young mothers, more often primigravidae, more often female fetuses. The prevalence of CTs did not increase over time. The gestational age at the time of the diagnosis decreased, thus the period of fetal echo monitoring increased. However, the rate of cesarean sections also increased, which requires further studies and explanations.

Clinical value of prenatal echocardiographic examination in the diagnosis of fetal cardiac tumors

The aim of the present study was to explore the clinical value of prenatal echocardiographic examination in the diagnosis of fetal cardiac tumors. In total, the cases of 8 fetuses with fetal cardiac tumors, which were identified by prenatal ultrasound examination in The First Affiliated Hospital of Nanchang University between January 2012 and January 2014, were retrospectively analyzed. The size, shape, location, activity and hemodynamic changes of the lesions were described in detail, and the patients were followed up. Out of the 8 identified cases of fetal cardiac tumors, 2 fetuses contained tumors only in the left ventricular cavity and 6 fetuses contained tumors of the left and right ventricular cavities, interventricular septum and apex of the heart. Overall, 5 of the 8 female patients requested termination of the pregnancy and labor was induced. The fetuses were pathologically confirmed to possess rhabdomyoma. In addition, 1 patient was followed-up for 5 weeks, and the tumor in the fetal heart cavity was found to have enlarged and developed in multiple regions when follow-up was performed. The patient then requested termination of the pregnancy and labor was induced. The fetus was pathologically confirmed to possess rhabdomyoma. The remaining 2 patients insisted on continuation of the pregnancy and the fetuses were followed up during gestation and subsequent to birth by echocardiographic examination. Prenatal echocardiography may precisely position and diagnose occupying lesions of the fetal heart, which is of considerable value in clinical decision making and instruction for treatment.

Prenatal diagnosis and outcomes of fetal cardiac rhabdomyomas: evaluation of seven cases

In this case series, we aimed to determine the outcome of prenatally diagnosed fetal cardiac rhabdomyoma. This case series is a retrospective evaluation of seven cases of fetal cardiac rhabdomyoma determined during pregnancy. Only one of these cases has been associated with tuberous sclerosis (TS). Two of the cases had just a single tumor, whereas the others were found to have multiple tumors. Termination was performed to one fetus due to hydrops fetalis. The presence of risk factors of TS in a family and multifocal or large tumors, appears to be the most important factors affecting neonatal outcomes.

Right atrial cardiac rhabdomyoma with premature foramen ovale restriction: A case report

Fetal cardiac rhabdomyoma is the most common cardiac tumor in fetuses. However, this benign tumor can cause hemodynamic repercussions and intrauterine fetal mortality. The present study reports a case of rare fetal cardiac rhabdomyoma located in the right atrium, accompanied by premature restriction of the foramen ovale and moderate pericardial effusion, as determined by tomographic ultrasound imaging (TUI). Fetal mortality subsequently occurred late in the second trimester of pregnancy and the diagnosis was confirmed by pathology. The present study discusses the occurrence and diagnosis of this rare abnormality. TUI mode with spatio-temporal image correlation offline imaging provides the physician with clear views of abnormal intracardiac structures in the beating heart. With improvements in sonographic technology, the diagnosis of fetal cardiac rhabdomyoma may be easier and more accurate in the clinical arena.

Medical and surgical management of primary cardiac tumours in infants and children

Primary cardiac tumours in infants and children are extremely rare, with an estimated incidence of 0.2% according to echocardiographic studies. Owing to their rarity, there is very little literature available, and most knowledge is based on collections of case reports. Therefore, we reviewed retrospectively our 27 years of clinical experience on the overall management of cardiac tumours among children in order to improve not only our knowledge but also to provide others with information about the incidence, clinical presentation, management, and long-term outcome of this rare disease. Between April, 1982 and April, 2009, 52 children were diagnosed with cardiac tumours at our Institution. Medical records and follow-up echocardiographic evaluations were studied. The diagnosis was prenatal in 35% of the patients. The most frequent tumour types were rhabdomyomas (61.5%), fibromas (15.4%), and myxomas (5.8%). There were no cases of primary malignant tumours. All diagnoses were achieved using two-dimensional echocardiography, and for 12 patients a pathological analysis was carried out. A total of 41 patients (79%) were managed medically, whereas 11 (21%) patients underwent surgical treatment. At a mean follow-up of 7.2 ± 5.4 years, two patients died of complications related to cardiac transplantation; all the remaining patients are in excellent clinical condition. In conclusion, cardiac tumours in paediatric practice are usually clinically and histologically benign. Only a few cases need surgery. Up to one-third of the cardiac masses are detectable prenatally. Rhabdomyoma is the most common histotype, followed by fibroma and myxoma. The long-term prognosis is generally good.

Fetal arrhythmias associated with cardiac rhabdomyomas

BACKGROUND

Primary heart tumors in fetuses are rare and mainly represent rhabdomyomas. The tumors have a variable expression and can be associated with arrhythmias, including both wide and narrow QRS tachycardia. Although multiple Doppler techniques exist to assess fetal heart rhythm, it can be difficult to record precise electrophysiological abnormalities in fetal life.

OBJECTIVE

Investigations defining precise electrophysiological diagnosis were performed by using fetal magnetocardiography (fMCG).

METHODS

In addition to routine fetal echocardiography, fMCG was used to investigate electrophysiological rhythm patterns in a series of 10 fetuses with cardiac rhabdomyomas.

RESULTS

The mean gestational age of the fetuses was 28.6 ± 4.7 weeks. The multiple rhabdomyomas were mainly located in the right and left ventricles as well as around the atrioventricular groove. Arrhythmias or conduction abnormalities were diagnosed in all 10 patients, although only 6 of them were referred due to that indication. Remarkably, 80% (8 of 10) had associated Wolff-Parkinson-White pre-excitation. In addition, we found prominent P waves in 4 fetuses.

CONCLUSION

In fetuses with rhabdomyomas, a disease where rhythm pathology is common, precise electrophysiological diagnosis can now be made by fMCG. fMCG is complimentary to echocardiography for rhythm assessment and can detect conduction abnormalities that are not possible to diagnose prenatally with M-mode or pulsed Doppler ultrasound. Risk factor assessment using fMCG can support pregnancy management and postnatal treatment and follow-up.

Molecular genetic, cardiac and neurodevelopmental findings in cases of prenatally diagnosed rhabdomyoma associated with tuberous sclerosis complex

OBJECTIVE

Rhabdomyoma is the most common type of cardiac tumor in fetuses and is often associated with tuberous sclerosis complex (TSC) with neurologic sequelae. The purpose of this study was to investigate the cardiac and neurodevelopmental outcomes of fetal rhabdomyoma.

METHODS

We reviewed the clinical characteristics of 23 cases of cardiac rhabdomyoma diagnosed prenatally by fetal echocardiography at the Asan Medical Center between January 1998 and December 2009. We also reviewed postnatal results of brain magnetic resonance imaging, echocardiography, renal ultrasound examination and molecular genetic analysis to confirm the presence of cardiac rhabdomyoma with or without TSC.

RESULTS

Among 23 cases, outcome data were available for 17 (73.9%) and six cases (26.1%) were lost to follow-up. The survival rate was 100.0% (17/17). Among the 17 cases with outcome data, spontaneous tumor regression occurred in eight (47.1%), and no change in tumor size and number was observed in the remaining nine cases (52.9%). There was no evidence of long-term cardiac dysfunction caused by persisting rhabdomyomas, regardless of tumor size. TSC was found in nine patients (52.9%), of whom five (55.6%) showed neurodevelopmental morbidity. We identified mutations in one of the TSC1 or TSC2 genes in four of nine TSC infants whose parents allowed us to perform molecular genetic analysis. Three of these (75.0%) were found to have neurologic impairment. Seven (77.8%) of nine TSC cases were non-familial.

CONCLUSIONS

The overall outcome of isolated cardiac rhabdomyoma appears to be favorable. We suggest that systematic postnatal evaluation of TSC be performed even in cases of cardiac rhabdomyoma without a family history of TSC. Molecular characterization of TSC1 and TSC2 might be helpful in predicting short- and long-term neurodevelopmental outcomes.

Fetal cardiac rhabdomyoma with hydrops fetalis: report of 2 cases and literature review

Rhabdomyoma is the most common cardiac tumor in fetuses, often associated with the tuberous sclerosis complex, especially when multiple tumors and a positive family history of tuberous sclerosis are noted. The tumor is often benign and has a tendency to regress but may increase in size until the early third trimester. Fetal cardiac rhabdomyoma complicated by hydrops fetalis and leading to fetal death is rare. We report 2 cases of fetal cardiac rhabdomyoma with hydrops fetalis and provide a review of the literature.

Outcome of antenatally diagnosed cardiac rhabdomyoma: case series and a meta-analysis

OBJECTIVES

Rhabdomyoma, the most common primary fetal cardiac tumor, is often associated with tuberous sclerosis (TS). We aimed to evaluate outcome in cases diagnosed with fetal cardiac rhabdomyoma.

METHODS

This study presents 11 cases with fetal cardiac rhabdomyoma. In addition, all relevant published cases of antenatally diagnosed cardiac rhabdomyoma since 1982 were identified from MEDLINE. We evaluated the following risk factors associated with clinical impact and perinatal outcome: family history of TS, gestational age at diagnosis, tumor size, site and number of tumors, tumor progression, and associated intracardiac and extracardiac anomalies.

RESULTS

In this meta-analysis, 138 cases, including nine newly added by us, were categorized into Group A (107 live babies) and Group B (16 neonatal deaths and 15 intrauterine fetal deaths). Univariate analysis showed that large cardiac tumors (P < 0.0001), fetal dysrhythmia (P < 0.0001) and hydrops (P < 0.0001) were strong predictors of neonatal outcome. Tumor size >or= 20 mm (relative risk (RR), 20.6; 95% CI, 2.2-195.9; P = 0.009) and fetal dysrhythmia (RR, 13.6; 95% CI, 2.9-62.3; P = 0.001) were significantly associated with neonatal morbidity. TS, present in 85/133 (63.9%) cases, was significantly associated with multiple cardiac tumors (P < 0.0001) and family history of TS (P = 0.02).

CONCLUSIONS

Large tumor size and hydrops are significantly associated with poor neonatal outcome, whereas family history of TS and multiple fetal cardiac tumors are associated with TS. Any sonographic detection of a fetal cardiac tumor should warrant further investigation for the possible presence of associated disorders.

Prenatal diagnosis and management for a large fetal cardiac tumor complicated with hydrops fetalis

Fetal cardiac tumor is a rare disease, and its prognosis varies in relation to the complications such as arrhythmia and out-flow obstruction. Hydrops fetalis is one of severe complications that result in an unfavorable outcome. A case is presented herein of a large fetal cardiac tumor diagnosed at 28 weeks gestation. At 30 weeks gestation, the fetus complicated with hydrops fetalis because of impaired cardiac function. Increased peak systolic velocity in the ascending aorta and marked reversed flow in the ductus venosus were observed. Oral digoxin therapy was administered to the mother as a cardiotonic agent and the hydropic condition was immediately diminished. After normal delivery, the cardiac tumor gradually decreased in size and the infant developed normally, but required an antiarrhythmic drug. The case indicates that the in utero digoxin therapy could be a choice for hydrops fetalis caused by cardiac tumor.

Prenatal echocardiographic differential diagnosis of fetal cardiac tumors

OBJECTIVES

To present data on echocardiographic findings of fetal cardiac tumors and discuss their differential diagnoses.

METHODS

We retrospectively reviewed 14 cases of fetal echogenic cardiac mass diagnosed between 1990 and 2003; 12 were confirmed to be cardiac tumors and two were false-positive diagnoses. The echocardiographic characteristics examined included number, size, location and associated complications.

RESULTS

Eight fetuses had a single tumor and four fetuses had multiple tumors. The left ventricle was most often affected. Parents of eight fetuses opted for termination of pregnancy, one fetus died in utero and three affected fetuses survived. Histopathological examination revealed cardiac rhabdomyoma in six fetuses, fibroma in two, teratoma in two, lipoma in one and hemangioma in one. The pitfalls associated with prenatal echocardiographic diagnosis of cardiac tumors include: they may be too small to be visualized, intracardiac echogenic foci may mimic tumors, and echogenicity resulting from extracardiac structures or neoplasms near the heart may falsely appear as tumors.

CONCLUSION

Fetal cardiac tumors can be detected by echocardiography. However, differential diagnosis is important as this will affect prognosis and subsequent management.

Fetal rhabdomyoma: prenatal diagnosis, clinical outcome, and incidence of associated tuberous sclerosis complex

OBJECTIVES

We reviewed our institution's experience with fetal cardiac rhabdomyoma to document the clinical outcome and incidence of associated tuberous sclerosis complex (TSC) and compared our findings with those of patients diagnosed with cardiac rhabdomyoma after birth.

STUDY DESIGN

We reviewed the medical records of all cases diagnosed prenatally and postnatally with cardiac rhabdomyoma between January 1990 and June 2002.

RESULTS

Twenty fetuses with cardiac rhabdomyoma were diagnosed at 28.4+/-6.0 weeks' gestational age. Of 19 continued pregnancies, there was one spontaneous intrauterine death, and 18 were delivered at term. Although none had prenatal hemodynamic complications, after birth seven had cardiac symptoms requiring medical (n=4) or surgical intervention (n=3). On follow-up, 15 of 19 with available outcome had TSC (79%), including six with neurodevelopmental disease. Over the same period, 26 patients were diagnosed with cardiac rhabdomyoma postnatally. Most (77%) were referred for cardiac assessment after findings suggesting TSC. On follow-up, TSC was confirmed in 25 (96%), including 22 with neurodevelopmental disease. The incidence of cardiac symptoms and TSC was not statistically different between the prenatal and postnatal diagnosis groups.

CONCLUSIONS

Cardiac rhabdomyomas are benign from the cardiovascular standpoint in most affected fetuses. As observed in postnatally diagnosed cardiac rhabdomyoma, TSC is diagnosed in most cases of fetal cardiac rhabdomyoma.

Cardiac abnormalities associated with hydrops fetalis

Cardiovascular abnormalities are associated with hydrops fetalis in 26% of cases reported in the modern era. These include not only structural abnormalities, but also cardiac arrhythmias, failure, tumors, myopathy, infection, inflammation, infarction, and arterial calcification. Cardiac structural abnormalities may be causative or seen only in association with hydrops fetalis. Structural lesions that result in right atrial pressure or volume overload seem to be most commonly associated with hydrops fetalis. Fetal cardiac tumors, cardiomyopathy, myocarditis, myocardial infarction, and arterial calcification probably result in hydrops fetalis by a similar mechanism. Fetal tachyarrhythmia has been shown to result in elevation of atrial pressure and atrial natriuretic peptide. Fetal tachyarrhythmias are the most treatable of cardiac causes of hydrops fetalis. Fetal bradyarrhythmias are less easily treatable and less certainly a causative mechanism of hydrops fetalis.

Hydrops fetalis: role of the geneticist

The causes of hydrops fetalis are myriad. As a result of the advent of routine Rh screening, most cases are not currently related to Rh incompatibility. Genetic, metabolic, chromosomal, and syndromic causes are among the most frequently identified causes of nonimmune hydrops. The importance of determining the underlying cause of hydrops becomes evident once issues such as prognosis, specific treatment, and risk of recurrence are considered. The medical geneticist is highly qualified to assist in the evaluation of hydrops. Clinical geneticists have undergone training in a primary care specialty followed by intensive training in the diagnosis, management, and counseling of individuals and families with genetic, chromosomal, or multifactorial syndromes or birth defects. This training prepares the medical geneticist well to serve as a consultant when hydrops is diagnosed. As knowledge of the molecular genetic and metabolic basis of disease increases, utilization of genetics laboratories continues to increase dramatically. In addition to examining the child to look for dysmorphic features, the clinical geneticist can assist with the laboratory evaluation by coordinating testing with the cytogeneticist, molecular geneticist, and biochemical geneticist as appropriate. Increased awareness of the role of the geneticist in the evaluation of such patients should prove helpful to the physicians caring for such patients and the patients' families.

Diagnosis and management of fetal cardiac tumors: a multicenter experience and review of published reports

OBJECTIVES

We sought to determine the prevalence and natural history of cardiac tumors in patients referred for fetal echocardiography.

BACKGROUND

Cardiac tumors are rare; the prevalence, reported from autopsy studies of patients of all ages, varies from 0.0017% to 0.28%. Despite many case reports, the prevalence and natural history of fetal cardiac tumors are unclear.

METHODS

Fourteen thousand fetal echocardiograms recorded over an 8-year period in seven centers were available for retrospective review. Medical records and echocardiograms were studied to determine the reason for referral, family history of tuberous sclerosis, prenatal and postnatal course and tumor description and type.

RESULTS

Cardiac tumors were present in 19 pregnancies (0.14%). Gestational age at diagnosis ranged from 21 to 38 weeks. The most common indication for referral was a mass on an obstetric ultrasound study. The tumors were singular in 10 patients and multiple in 9. Tumor size ranged from 0.4 x 0.4 to 3.5 x 4 cm, and the majority of tumors were not hemodynamically significant. There were 17 patients with rhabdomyomas, 1 with a fibroma and 1 with an atrial hemangioma. Tuberous sclerosis complex was diagnosed in 10 patients. Partial or complete tumor regression was seen in eight patients; tumors were unchanged in five; and three required operation.

CONCLUSIONS

Fetal cardiac tumors, a rare condition, are often benign. The majority of tumors are rhabdomyomas, but not all fetuses with rhabdomyoma have tuberous sclerosis.

In Utero Diagnosis of Multiple Intracardiac Tumors

Obstetric ultrasound evaluation of the fetus should include routine imaging of the heart. The four-chamber view provides valuable information regarding the presence or absence of structural heart disease.' Fetal heart rate and rhythm are also studied as a routine part of the obstetric scan. Thus, dysrhythmias can be evaluated accurately. The finding of unsustained fetal atrial dysrhythmia is common and usually not associated with structural heart disease.2,3 This case report describes the ultrasound evaluation of a fetus with multiple intracardiac rhabdomyomas and an unsustained asymptomatic atrial dysrhythmia. This case emphasizes the importance of the basic four-chamber fetal cardiac view when scanning the fetal heart.

Incidence of tuberous sclerosis in patients with cardiac rhabdomyoma

Cardiac rhabdomyoma, a rare benign tumor often detected in infancy, is frequently associated with tuberous sclerosis. This association is commonly stated to occur in 50% of all cases of cardiac rhabdomyoma. Recently at our institution, the prenatal detection of a cardiac rhabdomyoma in a fetus at no known risk for tuberous sclerosis emphasized the need to determine the frequency of association in order to provide accurate diagnosis and counseling in such situations. After a review of reported cases and review of patients from our institution diagnosed to have cardiac rhabdomyoma, we estimate that 51-86% of cardiac rhabdomyomas are associated with tuberous sclerosis. We present the results of our literature and case review.

Fetal echocardiographic diagnosis of congenital heart disease

The delineation of the structural and functional abnormalities of the fetal heart by echocardiography has led to the emergence of a new and vital subspecialty, that of fetal cardiology. Its practitioners are from disciplines such as genetics, obstetrics, and pediatrics, the common interests of which in the well-being of the unborn child have converged as technologic advances in ultrasound have enabled detailed evaluation and sometimes treatment of fetal hemodynamic abnormalities. Each discipline forms an entry point for the identification and referral of the high-risk patient or fetus with a suspected abnormality. As has been shown obstetric cardiac screening of the general population with ultrasound provides the highest yield of cardiac malformations when suspicious findings are referred to a subspecialist in fetal cardiac sonography. As we study the pathogenesis of congenital defects, it is likely that hitherto unidentified high risk populations will be found. The future holds the possibility of meaningful surgical interventions that may change the dismal outcome of fetuses with certain, now lethal cardiac malformations. Patients with hydrops fetalis due to congenital complete heart block are almost certain to die. Intrauterine cardiac pacing has been attempted and is a potentially life-saving procedure. Patients in whom pulmonary underdevelopment occurs because of the cardiac enlargement associated with some types of pulmonary atresia could potentially benefit from intrauterine surgery such as valvotomy. Serial fetal echocardiographic examination of the developing heart with higher resolution equipment during the first trimester may one day pinpoint the exact moment of teratogenesis and lead to more specific treatments designed to restore normal embryogenesis. Such examinations will, when known to be safe themselves, at the very least significantly advance our knowledge of normal cardiac embryogenesis and pathogenesis.

Hydrops revisited: literature review of 1,414 cases published in the 1980s

This paper reviews 47 series of hydrops fetalis (804 cases) and 610 individual cases published since 1980. From this large number of cases, guidelines are derived for prenatal diagnosis and management.

Role of prenatal detection of cardiac tumours in the diagnosis of tuberous sclerosis--report of two cases

Tuberous sclerosis is an autosomal dominant disease with variable expression. Little is known about the intrauterine course of the disease and the fetal age at which specific abnormalities may be detected. The role of prenatal detection of cardiac tumours in the diagnosis of two fetuses at 28 and 32 weeks' gestation based on fetal echocardiography is discussed. The prenatal and postnatal course of the disease is described.

Prenatal detection of congenital heart disease: factors affecting obstetric management and survival

Our recent experience in the diagnosis and management of fetal congenital heart disease is presented. During an 18-month period from January 1985 to June 1986, 1757 fetal echocardiograms were performed on a total of 989 antenatal patients. Cardiac anomalies were accurately predicted in 74 cases, 34 of which were associated with extracardiac or chromosomal anomalies. Twenty-three pregnancies were electively terminated. Currently the survival rate for ongoing pregnancies is 17%. A false negative diagnosis was made in 16 cases, the majority involving minor anomalies with a good prognosis and a survival rate of 81%. Prenatal detection of congenital heart disease places the fetus at high risk for chromosomal and extracardiac anomalies. Congenital heart disease detectable during pregnancy is usually severe and associated with a poor long-term prognosis. Termination of the pregnancy may be a reasonable option if a severe anomaly is detected early in pregnancy.

Magnetic resonance and echocardiography in the investigation of cardiac tumour in an infant

An intracardiac tumour in an asymptomatic female infant was diagnosed by means of echocardiography and magnetic resonance. The natural history of this pathology in patients showing no symptoms of cardiac involvement is still unknown. The development of these modern diagnostic techniques, however, has made it easier to carry out longitudinal follow-up studies aimed at obtaining useful information about the prognosis and growth potentialities of these tumours.

Prenatal diagnosis of tuberous sclerosis: the use of fetal echocardiography

Fetal echocardiography was used to identify a cardiac rhabdomyoma in the second trimester. The combination of this finding with a maternal history of Tuberous Sclerosis allowed the patient and her family to make a more educated decision regarding termination of the pregnancy. Post mortem examination of the fetus confirmed the prenatal findings. This case report demonstrates the importance of ultrasound evaluation of the fetus at risk of recurrence of a genetic syndrome in which one or more anatomical defects might be seen.

Prenatal diagnosis of familial tuberous sclerosis following detection of cardiac rhabdomyoma by ultrasound

The authors report a case of tuberous sclerosis (TS), diagnosed by prenatal ultrasound, which was suspected by the detection of intracardiac tumours and confirmed by the family investigation. Cardiac rhabdomyomata can be visualized early on echography and must suggest this diagnosis. The place of genetic counselling and prenatal diagnosis in TS is examined.

Fetal tachycardia and intramyocardial tumors

The two-dimensional echocardiographic diagnosis of multiple cardiac rhabdomyomas and evaluation of tachycardia in a fetus are presented. Prenatal echocardiographic examination defined the extent of tumor involvement and mechanism of the tachycardia and demonstrated the lack of fetal hemodynamic compromise. Perinatal, clinical and therapeutic implications are discussed.

Echocardiographic incidence of cardiac rhabdomyoma in tuberous sclerosis

Cardiac rhabdomyoma occurs frequently in patients with tuberous sclerosis (TS). Although there have been case reports of detection of cardiac rhabdomyoma by 2-dimensional echocardiography, no study has examined the frequency of cardiac rhabdomyoma detected by cardiac ultrasound in patients with TS. Echocardiography was performed in 16 consecutive patients with TS. Physical examination revealed normal cardiac findings in each. Discrete areas of increased acoustic density were found in 8 of the 16 patients (50%). The maximum diameters ranged from 3 to 20 mm. Multiple areas were found in 3 of 8. The left ventricle was involved in 5 of the 8. Six masses were intracavitary and 8 were intramyocardial. No atrial masses were seen. Left ventricular size and function were normal. Although other tumors cannot be excluded, the diagnosis of cardiac rhabdomyoma is almost certain in these young patients with TS. The male predominance and the high incidence of intracavitary and left ventricular masses are similar to those in reported autopsy series, also supporting the diagnosis of cardiac rhabdomyoma. The prognosis and potential for growth of these masses are not known, but can be determined by longitudinal follow-up. Cardiac ultrasound should be considered for all patients with TS regardless of physical findings.

Ultrasonic patterns of a cardiac rhabdomyoma detected in utero

Echography performed on a healthy woman at the 30th week of an uneventful pregnancy demonstrated the presence of an intracardiac tumor protruding into the left ventricular cavity. In the early neonatal period a cardiovascular surgeon removed the mass which proved to be a rhabdomyoma. The authors stress the importance of these echographic findings in formulating plans for the management of pregnancy, delivery and proper therapeutic intervention.