Guidelines and Recommendations for Performance of the Fetal Echocardiogram: An Update from the American Society of Echocardiography

Feasibility of fetal cardiac biometry measurement at 11-14 weeks scan - a cross-sectional study

OBJECTIVE

To study the feasibility of fetal cardiac biometry measurement between 11 and 14 weeks in low-risk singleton pregnancies.

METHODS

A cross-sectional study was conducted at a single tertiary care center between June 2022 and March 2024 in 129 singleton low-risk mothers in the South Indian population. All subjects included in the study underwent early fetal echocardiography at 11-14 weeks of gestation. The parameters interrogated were the heart length, heart width, heart circumference and area, chest circumference, ventricular chamber length and width, the transverse diameter of aortic and pulmonary annulus, and the transverse diameter of aortic isthmus.

RESULTS

In our study, the success rate of measuring the fetal heart biometry was 33% at 11 weeks, 72% at 12 weeks, and 77% at 13 weeks, respectively. Measurements of outflow tracts and aortic isthmus were difficult. The exclusion of aortic isthmus diameter from the biometric parameters increased the success rate to 50% at 11; weeks, and 80% at 12 and 13 weeks, respectively. Maternal body mass index, any abdominal scar from previous surgeries, and position of placenta had no statistically significant correlation with feasibility of cardiac biometry.

CONCLUSIONS

Our study showed early fetal cardiac biometry is feasible. These measurements can be a helpful tool in the generation of nomograms for the population which can aid early identification of congenital cardiac defects, their follow-up and prognostication.

Normal fetal echocardiography ratios - a multicenter cross-sectional retrospective study

OBJECTIVES

Normal fetal echocardiography ratios reflect blood flow balance and developmental patterns, providing a basis for more accurate diagnosis and prediction of congenital heart disease in fetuses. Despite its significance, standardized studies with ample samples are lacking. We aim to establish reference ranges for fetal cardiac structural parameters and hemodynamics using extensive multicenter data, including 11 ratios, and to clarify how these ratios change with gestational age.

METHODS

This is a multicenter cross-sectional retrospective study. 23,313 normal fetal echocardiographic examinations were enrolled from three medical centers. Analysis included 11 fetal cardiac-related ratios, such as right/left heart diameter ratio, mitral and tricuspid valve E/A-wave velocity ratio. To determine the reference ranges for various ratios across different gestational ages, a nonparametric quantile regression model, which does not presuppose normality, was utilized. The study investigated how the ratios change with gestational age by examining nonparametric regression plots and their first and second derivatives.

RESULTS

We established normal percentile reference ranges for 11 ratios at each gestational day. Analysis of ratio changes across gestation reveals several key patterns: The right heart system consistently dominates, with the right heart/left heart internal diameter ratio accelerating from 21.7 weeks of gestation; throughout fetal development, the E/A ratio of the mitral and tricuspid valves initially remains below one but increases progressively with gestational age, both reaching their maximum growth rates at week 25.7.

CONCLUSIONS

This study provides new references for routine obstetric screening, may enhance the understanding of the growth and developmental patterns of normal fetal hearts.

Utility of Screening Fetal Echocardiograms Following Normal Level II Ultrasounds in Fetuses with Siblings with Congenital Heart Disease

INTRODUCTION

In pregnancies when congenital heart disease (CHD) is present in siblings, fetal echocardiograms (F-echo) are recommended, regardless if there was a prior level II ultrasound (LII-US) that was normal. The goal of this study was to evaluate if any diagnosis of a critical congenital heart disease (CHD) was missed in a fetus who had a sibling with CHD, when a normal LII-US was documented.

METHODS

Retrospective chart review of all F-echo where the indication was sibling with CHD between January 1, 2019 and December 31, 2023 was performed. Fetuses were included if they had a LII-US that was read as normal and had a F-echo. Critical CHD was defined as CHD requiring catheterization or surgical intervention < 1 month of age.

RESULTS

A total of 187 F-echo on fetuses who had a sibling with CHD were evaluated, of which 113 met inclusion criteria. LII-US was performed at 21.1 ± 3.3 weeks gestational age and F-echo was performed at 25.4 ± 3.1 weeks gestational age. No patient with a normal LII-US had a diagnosis of a critical CHD by F-echo (negative predictive value = 100%). Six patients that had a negative LII-US were diagnosed with non-critical CHD or cardiac issues postnatally (negative predictive value = 94.7%). F-echo correctly diagnosed two of the six missed LII-US CHD.

CONCLUSION

Critical CHD was not missed with a normal LII-US in this at-risk population. F-echo also missed the majority of CHD when a LII-US was read as normal. The cost/benefit of screening F-echo in fetuses with siblings with CHD should be evaluated if a normal LII-US has been performed. Larger studies are needed to determine if these findings remain consistent.

The reference ranges for fetal ductus venosus flow velocities and calculated waveform indices and their predictive values for right heart diseases

OBJECTIVES

This study endeavors to establish comprehensive normal reference ranges and Z score formulas for ductus venosus (DV) flow velocity parameters and calculated waveform indices across different gestational ages in low-risk fetuses. Furthermore, we aim to validate the predictive capabilities of these Z score calculation formulas in fetuses with diverse right heart diseases.

METHODS

A total of 8,953 singleton low-risk fetuses and 70 fetuses diagnosed with different types of right heart diseases were retrospectively enrolled. The DV blood flow velocities during the cardiac cycle (ventricular systolic wave velocity [S], ventricular diastolic wave velocity [D], atrial contraction wave velocity [A], and time-averaged maximum velocity [Tamx]) and calculated waveform indices (preload index [PLI], peak velocity index [PVI], pulsatility index [PI], S/A, and S/D) were obtained. Ninety low-risk fetuses were randomly selected as the control group to verify the predictive value of the Z score model for fetuses with different types of right heart diseases.

RESULTS

As gestational age increased (16-39 weeks), the mean values of S, D, A, and Tamx progressively increased; conversely, the mean values of PLI, PVI, PI, and S/A decreased, respectively, and the median value of S/D remained stable. The Z score-transformed A, PLI, PVI, PI, and S/A could serve as predictors of overall right heart diseases. Different DV Doppler parameter Z scores exhibited varying predictive values for different subtypes of right heart diseases.

CONCLUSIONS

Normal reference ranges and corresponding Z score calculation formulas for DV hemodynamic parameters were established, which have demonstrated significant diagnostic values in identifying right heart diseases.

Transversal cardiac diameter is increased in fetuses with dextro-transposition of the great arteries older than 28th weeks of gestation

OBJECTIVES

In majority of congenital heart defects the size of the fetal heart is normal (without cardiomegaly). Aim of this study was to establish normal ranges of fetal transversal cardiac diameter (4CV TW ED) and to compare fetal dextro-transposition of the great arteries (d-TGA) with normal ranges for 4CV TW ED.

METHODS

Retrospectively of 3,553 records we analyzed and included 1,154 healthy singleton fetuses as a control group. Consecutive percentiles for 4CV TW ED diameter according to the gestational age (GA) were calculated. 74 fetuses with d-TGA were analyzed in 3rd trimester.

RESULTS

The -2, -1, +1 and +2 Z-scores of 4CV TW ED between weeks 18 and 37 of gestation were calculated. In the group of fetuses with d-TGA 68 % of them had 4CV TW ED > +2 Z-score fitted for GA. Rashkind procedure during first 24 h after birth was performed in 63 % cases. Increased 4CV TW ED was more frequently seen in fetuses who needed Rashkind procedure after birth, but without statistical significance.

CONCLUSIONS

4CV TW ED measurement during the third trimester scans as a cardiac screening tool in obstetrical practice may potentially help to detect d-TGA and indicate further echocardiographic examination in case of d-TGA suspicion. 4CV TW ED was not helpful to predict the necessity for neonatal Rashkind procedure.

Combination Diagnostics In Vivo: Dual-Mode Ultrasound/NIR Fluorescence Imaging with Neodymium- and Thulium-Doped Graphene Quantum Dots

The combination of two biomedical imaging techniques, fluorescence and ultrasound imaging, can uniquely offer enhanced anatomical visualization, sensitivity, and specificity necessary for improved diagnostic accuracy in detecting small tumors, tracing therapeutic delivery, and guiding biopsies. This work aims to harness the advantages of highly deterministic fluorescence imaging and deeply penetrating ultrasound diagnostics in neodymium- and thulium-doped graphene quantum dot (Nd-NGQD and Tm-NGQD) ultrasound/near-infrared (NIR) fluorescence contrast agents. These biocompatible nanostructures are tested for dual-mode fluorescence/ultrasound imaging in vivo in live sedated BALB/c mice as well as in animal organs. Injected intravenously (IV), Tm-NGQDs and Nd-NGQDs exhibit ultrasound enhancement and NIR fluorescence in the liver, spleen, and kidneys. The best agreement is achieved between the two techniques in the liver at 12 h for Tm-NGQDs and in the liver at 24 h, in the spleen at 6 h, and in the kidneys at 12 h for Nd-NGQDs, suggesting the optimal timeline for imaging. IP-injected Nd-NGQDs demonstrate a greater consistency between ultrasound enhancement and NIR fluorescence within 1-48 h time points in all imaged organs. Metal-doped GQD contrast agents developed for the first time in this work hold significant promise for dual-mode ultrasound-fluorescence imaging, paving the way for improved diagnostics and therapeutic monitoring.

Reproducibility Challenges in Fetal Cardiac Function Analysis with 2D Speckle-Tracking Echocardiography: Insights from FetalHQ

Background/Objectives: Functional assessment of the fetal heart remains a significant challenge in contemporary perinatology due to the absence of a universally accepted gold standard for such evaluations. The aim of this study was to evaluate the reproducibility of parameters derived from two-dimensional speckle-tracking echocardiography (2D STE) using the FetalHQ software. Methods: We enrolled 87 pregnant women between 19 and 23 weeks of gestation who were undergoing mid-trimester screening at the Provincial Hospital Complex in Kielce. Two independent operators acquired 5 s cine-loops of four-chamber views (4CVs) according to a standardized protocol. Reproducibility was assessed by examining intra- and interobserver variability using the intraclass correlation coefficient (ICC) for several cardiac parameters, including the global sphericity index (GSI), global longitudinal strain (GLS), stroke volume (SV), and fractional area change (FAC). Results: Reproducibility varied substantially across the assessed parameters. The highest intraobserver reproducibility was observed for the 4CV GSI (ICC > 0.9). Moderate intraobserver reproducibility (ICCs ranging from 0.5 to 0.75) was noted for left ventricular (LV) parameters, such as end-diastolic area, end-systolic area, end-diastolic volume, and end-systolic volume. Interobserver variability demonstrated higher ICC values, with excellent reproducibility (ICC > 0.9) for the 4CV GSI and LV volume measurements. Good reproducibility (ICCs between 0.75 and 0.9) was observed for specific left ventricular segmental strain indices, whereas other parameters showed moderate to poor reproducibility (ICC < 0.5). Conclusions: Two-dimensional speckle-tracking echocardiography (2D STE) using FetalHQ exhibits variable reproducibility, which is influenced by the choice of parameters, operator experience, and technical factors. This method holds potential for fetal cardiac assessment; however, additional research is required to improve its predictive accuracy and streamline the evaluation process for routine clinical application.

Impact of COVID-19 on Prenatal Diagnosis and Surgical Outcomes of Congenital Heart Disease: Fetal Heart Society and Society of Thoracic Surgeons Collaborative Study

BACKGROUND

Fetal echocardiography is the mainstay of prenatal diagnosis of congenital heart disease. The COVID-19 pandemic led to shifts in triage of prenatal services. Our objective was to evaluate the impact of COVID-19 restrictions on prenatal diagnosis, surgical outcomes, and disparities in neonatal critical congenital heart disease (CCHD) management in the United States during the pandemic's first year.

METHODS AND RESULTS

A multi-institutional retrospective cohort study compared neonatal CCHD outcomes (requiring surgery within 60 days of birth) 1 year prior (prepandemic era) and during the peak pandemic era, supplemented by a Fetal Heart Society survey assessing regional practice changes. Data on prenatal diagnosis, demographics, outcomes, and 2020 state Area Deprivation Index were analyzed using Wilcoxon rank sum and χ2 tests. The survey, completed by 72 fetal cardiologists from 9 US census regions, showed 75% of institutions implemented restrictions by March 2020, affecting triage, referrals, and number of prenatal cardiology visits. Compared with CCHD neonates born prepandemic (n=4637), those born during the pandemic (n=1806) had a higher proportion of prenatal diagnosis (66% versus 63%, P<0.05). There were no significant differences in complications or mortality, but pandemic-era neonates had longer hospital stays. During the pandemic, CCHD neonates had a more disadvantaged Area Deprivation Index and had surgery at hospitals located in more advantaged regions.

CONCLUSIONS

Although pandemic-driven care delivery adjustments affected perinatal cardiology referrals and triage, prenatal diagnosis, perioperative outcomes, and survival remained robust. The management of CCHD demonstrates health care resilience, maintaining core prenatal and perioperative care. Regional variations highlight the need for targeted strategies to address disparities during health care crises.

"Triangle Method" for Evaluating the Morphological Characteristics of the Aortic Arch in Healthy Mid-to-Late Pregnancy Fetuses

OBJECTIVES

This study aimed to apply the 2-dimensional grayscale ultrasound "triangle method" to evaluate the morphology of the aortic arch in healthy mid-to-late pregnancy fetuses.

METHODS

A total of 317 healthy singleton fetuses at 20-38+6 weeks of gestation were assessed. Using the long-axis view of the aortic arch, the "triangle method" was employed to measure the aortic arch length (sum of the 2 sides of a triangle), width, height, and angle. The aortic arch tortuosity (length/width) and height-to-width ratio were calculated. Healthy reference values for these morphological parameters were established, and their relationship to gestational age (GA) and cardiac valve annuli was explored.

RESULTS

The length, width, and height of the aortic arch in healthy mid-to-late pregnancy fetuses increased significantly with GA (P < .05). Instead, no significant correlation was observed between GA or cardiac valve annuli and the aortic arch angle, tortuosity, or height-to-width ratio (P > .05), whose corresponding reference values were 69.2 ± 6.1°, 1.7 ± 0.1, and 0.7 ± 0.1, respectively.

CONCLUSIONS

The aortic arch angle, tortuosity, and height-to-width ratio in healthy mid-to-late pregnancy fetuses remain relatively stable during development.

Comparison of fresh and glutaraldehyde-treated autologous pericardial patch in tricuspid valve repair: A long-term porcine study

OBJECTIVE

Autologous pericardium (AP), the most common repair material used in tricuspid valve (TV) repair, has variable clinical outcomes with different treatments. To test this, we performed a long-term implantation porcine study to systematically evaluate the performance of fresh AP (FAP) and glutaraldehyde-treated AP (GAP) in TV repair.

METHODS

Twenty-six Bama pigs were to undergo TV septal leaflet repair and chordae tendineae reconstruction using FAP patches (n = 6), GAP patches (n = 6), and half-half mixed AP patches (n = 14) under cardiopulmonary bypass. Heart and TV function were evaluated by echocardiograph and laboratory methods immediately, 1, 3, and 9 months postimplant. Implanted AP was evaluated 9 months after operation by morphologic, histologic, and calcification examination. Outcomes were compared using t tests and mixed-effects linear regression analysis.

RESULTS

All 26 animals underwent successful TV operations and survived 9 months after the operation. Echocardiographic analysis indicated comparable heart functions over the follow-up period but TV regurgitation class with GAP was significantly higher (P = .03) than the other 2 groups 1 month postoperation. After 9 months, the length of leaflets of pigs in the FAP and GAP groups were statistically reduced by 30.21% and 47.40%, respectively (P < .01). Patch thickness in the FAP and GAP groups increased 4.98 times and 7.21 times and were statistically significant (P = .02). The lengths of chordae tendineae in FAP and GAP groups were reduced by 61.19% and 25.96%, respectively (P < .01). Compared with the GAP group, FAP group pigs demonstrated a more homogenous contribution of collagen and elastic fibers in Elastica-van Gieson staining and less calcification in von Kossa staining. Hematoxylin and eosin staining and scanning electron microscopy showed comparable endothelial cell layers on FAP and GAP patches. The mean tissue calcium content of FAP and GAP patches was 19.32 ± 1.67 mg/g and 56.10 ± 3.75 mg/g, respectively (P < .01).

CONCLUSIONS

AP is a reliable material for TV repair. An oversized FAP patch proved to be a better option in tricuspid leaflet repair, whereas GAP performed better in TV chordae tendineae reconstruction.

Application Value of Myocardial Segmental Thickness Variability Measured by Echocardiography in Distinguishing Ischemic and Nonischemic Dilated Cardiomyopathy

PURPOSE

The aim of this study is to evaluate the clinical value of myocardial segmental thickness variability (STV) measured by echocardiography in distinguishing ischemic cardiomyopathy (ICM) from nonischemic dilated cardiomyopathy (NIDCM).

METHODS

This study included 120 patients diagnosed with dilated cardiomyopathy, divided into ICM (n = 43) and NIDCM (n = 77) groups based on coronary angiography. Traditional echocardiographic parameters, STV, and regional wall motion abnormalities (RWMA) were compared. The diagnostic value of STV was assessed using receiver operating characteristic (ROC) curve analysis.

RESULTS

There were no significant differences in traditional echocardiographic parameters between the groups. The NIDCM group had a significantly higher mean STV compared to the ICM group. An STV threshold of 0.768 provided a sensitivity of 86.0% and a specificity of 94.8% for distinguishing ICM from NIDCM. Combining STV with RWMA improved diagnostic accuracy.

CONCLUSION

STV measured by echocardiography is a valuable, noninvasive tool for differentiating between ICM and NIDCM, offering high sensitivity and specificity. This approach enhances diagnostic precision, supporting its use in clinical practice to guide appropriate treatment strategies.

Utility of serial fetal echocardiograms in detecting in-utero changes for single-ventricle lesions: an 11-year experience

OBJECTIVE

Current guidelines in fetal echocardiography recommend serial evaluation every 4 weeks for single-ventricle lesions. However, there are limited data on the type and frequency of in-utero cardiac changes seen on fetal echocardiograms (FEs) based on the type of single-ventricle lesion. We aimed to evaluate the utility of serial FEs in detecting cardiac changes during gestation and how these changes impact postnatal management.

METHODS

We performed a retrospective review of all FEs for fetuses diagnosed with a single-ventricle lesion at the Children's Healthcare of Atlanta, between January 2012 and January 2023. All patients included in the study had two or more FEs and were evaluated for in-utero cardiac changes based on eight cardiac categories: atrioventricular (AV) valve regurgitation; systemic ventricular dysfunction; ductus arteriosus flow; atrial-level restriction; umbilical artery Doppler pattern; umbilical vein Doppler pattern; evidence of hydrops; and evidence of arrhythmias. All in-utero cardiac changes were classified into three categories: improving, worsening or critical. Any changes noted on serial FEs that altered the fetal cardiac diagnosis were also recorded. Fisher's exact test was used to determine whether the proportion of fetuses with in-utero cardiac changes differed significantly between different segmental findings and single-ventricle lesion subtype.

RESULTS

A total of 721 FEs were performed for 248 patients over the 11-year study period. The majority of fetuses had hypoplastic left heart syndrome (HLHS) (63.7%) and most changes were seen in the third trimester (median gestational age, 29.3 (range, 17.4-38.4) weeks). In-utero cardiac changes observed on serial FEs were reported in 38 (15.3%) fetuses, with a total of 42 changes noted throughout the study period. However, only eight (3.2%) fetuses had a critical change that impacted perinatal management. All eight fetuses had HLHS, of which the majority developed hydrops (4/8) or atrial-level restriction (3/8). In addition, there were 34 non-critical changes seen in 30 (12.1%) fetuses, largely in the form of intermittent premature atrial contractions, AV valve regurgitation or ventricular dysfunction. There were 12 (2.5%) follow-up FEs that resulted in a change to the fetal cardiac diagnosis, confirmed by postnatal echocardiography.

CONCLUSION

In fetuses with single-ventricle lesions, there was a low rate of in-utero cardiac changes that led to alterations in perinatal management. However, fetuses with HLHS were most likely to develop critical changes affecting delivery-room management, often in the form of atrial-level restriction and/or evolving hydrops. It is important to consider these factors when considering the timing of visits for families who face a prenatal diagnosis of a single-ventricle lesion. © 2025 International Society of Ultrasound in Obstetrics and Gynecology.

Simplified First-Trimester Fetal Cardiac Screening Protocol for Low-Risk Pregnancies: Enhancing Efficiency and Accuracy

Introduction

Congenital heart defects (CHDs) are among the most prevalent congenital anomalies and are frequently detected in pregnancies classified as low-risk, rather than in high-risk groups. Advancements in ultrasound technology have heightened the emphasis on first-trimester fetal cardiac screening. However, due to the small size of the fetal heart at this stage, significant challenges persist, underscoring the need for simplified and reproducible protocols that can be effectively applied on a population-wide scale.

Methods

This paper describes a screening approach centred on the four-chamber view (4CV) and three-vessel tracheal view (3VTV) with colour Doppler imaging. This includes optimisation of ultrasound machine settings and the use of transabdominal and transvaginal approaches to enhance visualisation.

Results

Evidence demonstrates a CHD detection rate of 76% in low-risk populations, with a 95% success rate in obtaining the necessary views.

Discussion and Conclusion

Operator expertise and familiarity with cardiac anomalies are critical for accurate detection. The early identification of CHDs enables informed decision-making regarding pregnancy management. A simplified protocol for first-trimester cardiac screening offers a promising tool for the early identification of CHDs, enabling timely referral and intervention. To optimise detection rates and clinical outcomes, continuous professional education and systematic auditing processes are indispensable for practitioners performing early fetal cardiac screening.

Artificial intelligence based automatic classification, annotation, and measurement of the fetal heart using HeartAssist

This study evaluated the feasibility of HeartAssist, a novel automated tool designed for classification of fetal cardiac views, annotation of cardiac structures, and measurement of cardiac parameters. Unlike previous AI tools that primarily focused on classification, HeartAssist integrates classification, annotation and measurement capabilities, enabling a more comprehensive fetal cardiac assessment.Cardiac images from fetuses (gestational ages 20-40 weeks) were collected at Asan Medical Center between January 2016 and October 2018. HeartAssist was developed using convolutional neural networks to classify 10 cardiac views, annotate 26 structures, and measure 43 parameters. One expert performed manual classifications, annotations, and measurements, which were then compared to HeartAssist outputs to assess feasibility. A total of 65,324 images from 2,985 fetuses were analyzed. HeartAssist achieved 99.4% classification accuracy, with recall, precision, and F1-score of 0.93, 0.95, and 0.94, respectively. Annotation accuracy was 98.4%, while the automatic measurement success rate was 97.6%, with an error rate of 7.62% and caliper similarity of 0.613. HeartAssist is a reliable tool for fetal cardiac screening, demonstrating high accuracy in classifying cardiac views and annotating structures, with comparable outcomes in measuring cardiac parameters. This tool could enhance prenatal detection of congenital heart disease and improve perinatal outcomes.

Indications for fetal echocardiography: consensus and controversies among evidence-based national and international guidelines

OBJECTIVE

Fetal echocardiography (FE) is an indication-driven examination for pregnant women with a fetus at high risk for congenital heart disease (CHD). Several familial, maternal and fetal factors are reported to increase the risk of CHD. The aim of this study was to highlight the existing differences in recommended indications for FE among recently published guidelines and consensuses of experts.

METHODS

Guidelines and expert consensuses published from January 2008 to October 2023 were identified through a systematic literature search. FE guidelines and consensus statements were excluded if not written in the English language and if indications for FE were not reported. All familial, maternal and fetal risk factors for CHD reported in the consensuses and guidelines were listed and comparisons were made between documents. The agreement or disagreement for each risk factor between guidelines and consensuses was classified as: complete agreement (all analyzed documents reported the same indication); partial agreement (all documents considered a risk factor as an indication, but with inconsistency in its definition); or complete disagreement (inconsistency between documents for the considered risk factor as an indication).

RESULTS

Six guidelines and expert consensuses that met the inclusion criteria were identified. Overall, a total of 17 risk factors were identified as an indication for FE. Complete agreement was reached for 3/17 (17.6%) risk factors, all of which are fetal risk factors (suspected CHD at the anomaly scan, presence of major fetal extracardiac abnormality and non-immune hydrops fetalis). Partial agreement was recorded for 8/17 (47.1%) risk factors (family history of CHD, increased nuchal translucency, multiple gestation, maternal diabetes mellitus, maternal phenylketonuria, maternal infection, maternal autoimmune disease and autoantibody positivity, and teratogen exposure). Complete disagreement was recorded for 6/17 (35.3%) risk factors (inherited genetic disease associated with CHD, fetal genetic anomaly, suspected abnormality of heart rate or rhythm, first-trimester sonographic markers of CHD, abnormality of umbilical cord and venous system, and use of assisted reproductive technology).

CONCLUSIONS

Areas of controversy regarding which CHD risk factors warrant FE were greater in quantity than were the areas of consensus. An internationally standardized agreement would be valuable for physicians and guideline developers. For many risk factors, further evidence is needed to justify their use as an indication for FE. © 2025 International Society of Ultrasound in Obstetrics and Gynecology.

The Pandemic Effect: Secondary Impact on the Diagnosis of Clinically Significant Congenital Heart Disease and Role of Deprivation Index

We sought to determine the impact of the COVID-19 on prenatal diagnosis (PND) of clinically significant congenital heart disease (CHD) and the role of socioeconomic status (SES), complexity of diagnosis, and proximity to advance testing. This single-center retrospective study evaluated 2 eras of infants (COVID (born July 1, 2020-July 31, 2023) and pre-COVID (born June 1, 2017-July 1, 2020) who had cardiac surgery in the first year of life. 512 infants, 292 in pre-COVID era and 220 in COVID era with no significant difference in the rate of prenatal care (PNC) or PND in the COVID era (88%/42%) versus pre-COVID era (93%/48%) (χ2 = 3.22, p = 0.07, χ2 = 1.9, p = 0.17). Distance from advanced testing had no influence on PND in the COVID era [55% close versus 53% further away (χ2 = 2, p = 0.65)]. When evaluating SES with income per zip code, the higher SES group had increased PND during the pandemic compared to both pre-COVID era and low SES group. However, social deprivation index (SDI) based on zip code showed the higher SES group had a decrease in PND rates. Both metrics showed no change in PND in the lower SES group during COVID. COVID-19 had no significant change in the PND of clinically significant CHD during the pandemic. The differing SES results using income versus SDI of patient zip codes suggest that barriers to PND is multifactorial. The discrepancy in PND reflects poor referral rates to advanced testing, highlighting the importance of educating frontline healthcare professionals to improve outcomes.

Suboptimal Imaging on Obstetric Ultrasound Should Prompt Early Referral for Fetal Echocardiography

Recent studies suggest that suboptimal cardiac imaging on routine obstetric anatomy ultrasound (OB-scan) is not associated with a higher risk for congenital heart disease (CHD) and, therefore, should not be an indication for fetal echocardiography (F-echo). We aim to determine the incidence of CHD in patients referred for suboptimal imaging in a large catchment area, including regions that are geographically distant from a tertiary care center. We conducted a retrospective chart review of patients referred to Seattle Children's Hospital (SCH) and SCH Regional Cardiology sites (SCH-RC) from 2011 to 2021 for F-echo with the indication of suboptimal cardiac imaging by OB-scan. Of 454 patients referred for suboptimal imaging, 21 (5%) of patients were diagnosed with CHD confirmed on postnatal echo. 10 patients (2%) required intervention by age one. Mean GA at F-echo was significantly later for suboptimal imaging compared to all other referral indications (27.5 ± 3.9 vs 25.2 ± 5.2 weeks, p < 0.01). Mean GA at F-echo was also significantly later at SCH-RC compared to SCH (29.2 ± 4.6 vs 24.2 ± 2.9 weeks; p < 0.01). In our experience, CHD in patients referred for suboptimal imaging is higher (5%) than previously described, suggesting that routine referral for is warranted. Furthermore, while suboptimal imaging was associated with a delayed F-echo compared to other indications, this delay was most striking for those seen at regional sites. This demonstrates a potential disparity for these patients and highlights opportunities for targeted education in cardiac assessment for primary providers in these regions.

Advancements in prenatal diagnosis and management of hypoplastic left heart syndrome: A multidisciplinary approach and future directions

Hypoplastic left heart syndrome is a severe congenital defect involving underdeveloped left-sided cardiac structures, leading to significant mortality and morbidity. Prenatal diagnosis using fetal ultrasound and echocardiography enables early detection, family counseling, and improved clinical decision-making. Advanced prenatal interventions, such as fetal aortic valvuloplasty and atrial septostomy, show promise but require careful patient selection. A multidisciplinary approach involving obstetricians, neonatologists, and pediatric cardiologists is vital for effective management. Future directions include refining imaging techniques, such as three-dimensional ultrasound, cardiovascular magnetic resonance imaging, and exploring bioengineering solutions, stem cell therapies, and genetic research. These advancements aim to improve therapeutic options and address current limitations, including transplant scarcity and postoperative complications. Although surgical innovations have improved survival rates, challenges remain, including neurological risks and long-term hemodynamic issues. Ongoing research and technological advancements are essential to enhance outcomes and quality of life for hypoplastic left heart syndrome patients.

Second trimester echocardiography

Fetal echocardiography involves a comprehensive cardiac assessment aiming to make a complete structural examination of the heart as well as to detect signs of cardiovascular adaptation to different insults. For the former, this assessment entails expert's evaluation of the anatomy of the heart including additional views beyond the five axial views used in cardiac screening examinations and always complemented with colour and pulsed Doppler. Echocardiography may accurately diagnose most congenital heart defects in fetal life, which enables adjusting the perinatal management. For the latter, echocardiography encompasses cardiac morphometric assessment to identify signs of cardiac remodeling indicative of cardiac adaptation in structure, shape, and size in response to underlying diseases, and cardiac functional assessment to detect signs of systolic and/or diastolic dysfunction. The most used parameters to study the systolic function (stroke volume, cardiac output, ejection fraction, fractional shortening, and mitral and tricuspid annular plane systolic excursion), diastolic function (characteristics of flow in the precordial veins and through the atrioventricular valves) and global myocardial function (myocardial performance index) will be discussed in this review.

A novel diagnostic model for fetal coarctation of the aorta with ventricular septal defect

BACKGROUND

Our study aimed to develop a novel diagnostic model for fetal coarctation of the aorta with ventricular septal defect(CoA/VSD).

METHODS AND RESULTS

We respectively included 70 fetuses with suspected CoA/VSD(January 2017-June 2023). After birth, 26 fetuses (26/47, 55.3 %) were confirmed to be true-positive CoA/VSD (TP-CoA/VSD), 21 cases had only VSDs without CoA, namely false-positive CoA/VSD (FP-CoA/VSD), and the remaining 23 fetuses were excluded due to additional major malformations, multiple pregnancies or other reasons. Large VSDs and doubly committed subarterial VSDs were more prevalent in true coarctation fetuses(all p < 0.05). Among morphological parameters of echocardiography, the aortic isthmus (AoI)/VSD ratio had the highest area under the curve (AUC) of 0.81 (95 % CI: 0.68-0.94, p < 0.001) and cutoff value of ≤0.67. Three new diagnostic models were constructed by adding different functional variables, namely left ventricular longitudinal strain(LVLS), LV ejection fraction, and LV fractional area of change to the morphological variable AoI/VSD ratio. The diagnostic model of AoI/VSD ratio and LVLS had the highest AUC of 0.96 (95 % CI: 0.86-1.00; p < 0.001). In addition, risk stratification revealed a high risk of prenatal CoA/VSD when the risk probability was greater than 0.80, which required early medical counseling and intervention.

CONCLUSIONS

In fetuses suspected with having CoA/VSD, myocardial strains of both ventricles were lower in true CoA group. Additionally, a diagnostic model of new morphological parameter AoI/VSD ratio and functional variable LVLS, was highly valuable in diagnosing fetal CoA/VSD.

Transitional Care for Adult Patients with Congenital Heart Disease

The prognosis of congenital heart disease (CHD) has improved, and most patients now reach adulthood. Owing to residual disease and comorbidities, it is recommended that adult CHD (ACHD) patients transition to adult care for lifelong monitoring and treatment. However, this transition period can be challenging for CHD patients owing to obstacles such as independence from their parents and establishing self-management. To achieve a seamless shift from pediatric to adult care and ensure continuity, it is important to educate and motivate patients appropriately, and an established transition system is needed that involves collaboration between CHD specialists and healthcare providers across medical specialties. The present review describes the epidemiology of ACHD and notable points in patient care as the background of transition. The concepts and an overview of transition systems, educational systems, and potential lapses in the care of their relevant causes are then provided with supporting evidence.

Incidence of Fetal Arrhythmia Before and During the COVID-19 Pandemic: A Single-Center Experience

Fetal arrhythmias are rare and carry significant morbidity and mortality without appropriate treatment. Initial reports exist of fetal arrhythmia in the setting of maternal COVID-19 infection. Our study sought to evaluate incidence of fetal arrhythmia before and during the COVID-19 pandemic at our institution. This retrospective cohort study from a tertiary care fetal cardiac center utilized the institutional REDCap database to search fetal arrhythmia diagnostic codes. Medical records of mother-fetus dyads were reviewed and data were collected on diagnoses, gestational age, treatment regimen, and postnatal outcomes. Patients were divided into pre-COVID and peri-COVID segments. 8368 total pregnancies were evaluated during the 7.3 years of study period. Forty-five patients (0.5%) had a significant fetal arrhythmia and were included in this study: 19 (42%) in the pre-COVID-19 group and 26 (58%) in the peri-COVID-19 group. No patients had associated congenital heart disease. There was a notable increase in the incidence of fetal supraventricular tachycardia (SVT) (1.82 per 1000 vs 2.65 per 1000 pregnancies) and complete heart block (1.04 per 1000 vs 1.77 per 1000 pregnancies) but no apparent change in other tachyarrhythmias during the COVID era. The proportion of antibody-mediated complete heart block increased from 50 to 87.5%. There was also an increase in the percentage of SVT patients requiring postnatal treatment during COVID-19 (53.8% vs 62.5%). Our experience shows an increased incidence of some fetal arrhythmia diagnoses during the COVID-19 pandemic. Additional multi-center studies will be necessary to fully evaluate the increased burden of fetal arrhythmias during the COVID-19 era as well as to elucidate etiology.

Initiating a Fetal Cardiac Program from Scratch in Low- and Middle-Income Countries: Structure, Challenges, and Hopes for Solutions

Although fetal cardiac programs are well established in developed countries, establishing an efficient program in low- and middle-income countries (LMICs) is still considered a significant challenge. Substantial obstacles usually face the initiation of fetal cardiac service from scratch in LMICs. The primary structural frame of a successful fetal cardiac program is described in detail, emphasizing the required team members. The potential challenges for starting fetal cardiac services in LMICs include financial, awareness-related, prenatal obstetric screening, sociocultural, psychosocial, and social support factors. These challenges could be solved by addressing these barriers, such as collecting funds for financial support, raising awareness among families and health care providers, telemedicine, building international health partnerships, modifying training protocols for fetal cardiologists and sonographers, and initiating support groups and social services for families with confirmed fetal cardiac disease. Initiating a successful fetal cardiac program requires multi-aspect structural planning. The challenges for program initiation require diverse efforts, from modified training and promoting awareness of care providers and the community to governmental and nonprofit organizations' collaborations for proper building and utilization of program resources.

Impact of the Fetal Echocardiogram on Maternal Depression and Well-Being

Fetal echocardiography allows for prenatal diagnosis of congenital heart disease (CHD). The objective of this study is to assess for the impact of fetal echocardiogram on levels of well-being and depression in pregnant women. Adult pregnant women carrying a fetus < 31-week gestational age were enrolled in the prospective observational study from February 2022 to June 2022. These subjects were split into two cohorts: those with CHD and those without CHD. Surveys were distributed prior to the fetal echocardiogram, six weeks later and six weeks after delivery. These surveys consisted of the Edinburgh Postpartum Depression Scale (EPDS) and questions about topics, such as anxiety and social support. Of the 152 subjects enrolled, 14 women had a fetus with CHD and 138 women had a fetus without CHD. Initial EPDS scores were elevated for the study population compared to the general population. Six weeks later, EPDS scores remained elevated. For the post-partum surveys, the EPDS scores were decreased below the rate of the general population for the group without CHD and similar to the general population rate for the CHD group. Anxiety, worry, and guilt remained low for both groups after the initial survey. Counseling from the pediatric cardiologist may help decrease anxiety and worry. Social support, like support groups, may be helpful for women carrying a fetus with CHD.

Approaching Universal Prenatal Detection of Significant Cardiovascular Malformations in Nevada

OBJECTIVE

To report our recent experience with prenatal detection of significant cardiovascular malformations (CVMs) in Nevada's state-wide maternal population receiving prenatal care.

METHODS

We queried our databases for those with significant CVMs diagnosed pre- or postnatally between May 1, 2021, and April 30, 2024. We defined CVMs as those that required, would have required, or will likely require a therapeutic procedure in the first 12 months. Additionally, we included those with atrioventricular and ventriculoarterial discordance and left isomeric situs, both unaccompanied by additional CVMs, and congenital complete heart block. We defined routine prenatal care as obstetric care, which included at least one fetal anatomical survey ultrasound.

RESULTS

We identified 390 cases of significant CVMs. Of the 390 cases, 359 (92%) had prenatal care over the three-year observation period, with prenatal detection rates for the three 12-month intervals: 76% (87/115), 87% (94/108), and 95% (129/136) respectively (p < 0.001 by chi-square). A total of 310 prenatal diagnoses were made from comprehensive fetal echocardiograms performed on 8397 pregnant women at maternal-fetal-medicine centers.

CONCLUSION

To our knowledge, these results represent the highest prenatal detection rate for significant CVMs, in a state-wide maternal population in the United States.

Decoding Hearts: Genetic Insights and Clinical Strategies in Congenital Heart Disease

Structural congenital heart disease (CHD) represents a heterogeneous group of cardiac anomalies of variable embryologic and molecular origins. A basic understanding of the genetics implicated in nonsyndromic (isolated) and syndromic structural CHD can better inform management decisions and family counseling. When a fetus or neonate develops CHD as a result of a genetic cause, it can be due to a mutation or a monogenic, oligogenic, or polygenic pathogenic variant. In this review, we summarize basic cardiac embryology in the context of genetic signaling pathways and proteins that are commonly implicated in syndromic and nonsyndromic structural CHD. We also provide an overview of the basic genetic evaluation in infants with common syndromic structural CHD.

Screening for Structural Heart Defects: A Single-Center Retrospective Cost Analysis for Fetal Echocardiography in Adults with Congenital Heart Disease

Fetal echocardiography (FE) is recommended for parents with congenital heart disease (pCHD) due to a 3-6% recurrence risk of congenital heart disease (CHD). This study aimed to evaluate the cost of FE for detecting neonatal CHD in pCHD. FE data were collected between 12/2015 and 12/2022. Parents were stratified by CHD complexity: "simple" (class I) and "complex" (class II/III). Cost analysis compared universal FE with selective FE following a positive level II screening anatomical ultrasound (SAU). Primary outcomes included the cost and number needed to screen (NNT) to detect one case of neonatal CHD. Of 419 pCHD cases, 48 were analyzed separately due to additional FE indications. Among the remaining 371 cases (73% maternal, 27% paternal; mean maternal age: 31 years), 14 postnatal CHD cases were detected (3.8%). Recurrence rates were 1.9% for simple pCHD (n = 156) and 5.1% for complex pCHD (n = 215). Universal FE increased the cost of detecting neonatal CHD. The cost per detected case was $267,157 for simple CHD (NNT = 560) and $135,125 for complex CHD (NNT = 288). The lower sensitivity of SAU reduced the cost of universal FE. In this single-center cohort, the recurrence risk of CHD in pCHD is higher than in the general population, particularly in complex cases. Universal screening in simple pCHD is costlier with high-sensitivity SAU. Targeted screening in complex pCHD may offer a better cost-to-risk ratio, highlighting the need for early detection to improve outcomes. The cost effectiveness is dependent on local SAU sensitivity rates.

Assessment of right ventricular endocardial fibroelastosis in fetuses with critical pulmonary stenosis and pulmonary atresia with intact ventricular septum

Background

This study aimed to assess right ventricular (RV) endocardial fibroelastosis (EFE) in fetuses with critical pulmonary stenosis (CPS) and pulmonary atresia with intact ventricular septum (PA-IVS) and to investigate the implications of RV EFE for circulatory outcomes.

Methods

Fetal echocardiographic data from July 2018 to January 2021 were collected. Three reviewers independently graded EFE based on the presence and extent of endocardial echogenicity. Since this is a novel study on grading RV EFE, intra- and interobserver comparisons were performed. The associations among EFE severity, anatomic variables, and late-gestational circulatory outcomes were analysed.

Results

Eighty-one patients with RV EFE were identified. By consensus, EFE severity was assessed as Grade 1 (n = 66, 81.5%) or Grade 2 (n = 15, 18.5%). At the first consultation, RV sphericity values were greater in Grade 2 EFE fetuses than in Grade 1 EFE fetuses, implying more severe noncompliance and worse diastolic function. From the first consultation to late gestation, significant differences were observed in the changes in the tricuspid/mitral valve (TV/MV) annulus diameter (P = 0.042) and TV z-score (P = 0.001) between the Grade 1 and Grade 2 RV EFE groups. Among the ten patients who underwent fetal cardiac intervention (FCI), the restoration of the TV z-score was more significant in Grade 2 RV EFE fetuses than in Grade 1 EFE fetuses. Among Grade 2 EFE cases, fetuses who underwent FCI exhibited greater changes in the right/left ventricular (RV/LV) long-axis dimension, TV/MV, and RV sphericity compared to non-FCI fetuses, indicating that FCI benefited Grade 2 EFE fetuses by restoring the development of ventricular structure.

Conclusions

This study graded RV EFE in fetuses with CPS/PA-IVS, shedding light on its implications for circulatory outcomes. FCI offered benefits in Grade 2 RV EFE patients, suggesting its potential to preserve cardiac development in affected fetuses with CPS/PA-IVS.

Influence of pre-existing maternal diabetes mellitus on fetal myocardial performance index and systolic-to-diastolic duration ratio: a prospective cohort study

OBJECTIVE

To evaluate the influence of pre-existing maternal diabetes mellitus on fetal myocardial performance index and systolic-to-diastolic duration ratio.

METHODS

Prospective cohort study included 179 pregnant women between 20 and 36w6d, divided into 3 groups: Group 1 (120, normal), Group 2 (31, type 1 diabetes mellitus), and Group 3 (28, type 2 diabetes mellitus). Systolic-to-diastolic duration ratio was calculated as the sum of isovolumic contraction time and ejection time divided by the sum of isovolumic relaxation time and ventricular filling time. Spectral Doppler was used to assess left ventricle systolic-to-diastolic duration ratio. Tissue Doppler was used to assess right ventricular filling time. Using spectral Doppler, left ventricle myocardial performance index was calculated as the sum of isovolumic contraction time and isovolumic relaxation time divided by ejection time.

RESULTS

Pre-existing maternal diabetes mellitus had a significant influence on fasting glucose levels (p < 0.001), left ventricle isovolumic contraction time (p < 0.001), left ventricle ejection time (p = 0.025), and left ventricle myocardial performance index (p < 0.001). Group 2 had higher left ventricle isovolumic contraction time (0.036 vs. 0.031 sec, p = 0.001) and left ventricle myocardial performance index (0.487 vs. 0.453, p = 0.003) compared with Group 1. Group 3 showed higher left ventricle myocardial performance index (0.492 vs. 0.449, p = 0.006) and lower left ventricle ejection time (0.161 vs. 0.169 sec, p = 0.038) than Group 1. Left ventricle systolic-to-diastolic duration (p = 0.704), right ventricle systolic-to-diastolic duration ratio' (p = 0.757), left ventricle isovolumic contraction time (p = 0.163), left ventricle ejection time (p = 0.093), and left ventricle myocardial performance index (p = 0.087) were not useful parameters in predicting composite neonatal outcomes.

CONCLUSION

Pre-existing maternal diabetes mellitus had significant influence on fetal left ventricle myocardial performance index, but no effect on systolic-to-diastolic duration ratio. Systolic-to-diastolic duration ratio was not useful in predicting adverse perinatal outcomes.

Noninvasive assessment of myocardial perfusion using ultrafast ultrasound: clinical study for congenital heart disease

Aims

Myocardial perfusion impacts cardiac function following surgical repair of critical congenital heart disease (CCHD). Temporal variation assessment of myocardial blood volume throughout the cardiac cycle can be a surrogate for perfusion. Ultrafast power Doppler (UPD) is an ultrasound imaging technique capable of noninvasively quantifying myocardial blood volume changes. The objective of this study is to demonstrate the feasibility of perioperative transthoracic UPD assessment and to determine if UPD reflects physiologic changes in myocardial perfusion.

Methods and results

Five neonatal transposition of the great arteries (TGA) undergoing arterial switch operation (ASO), five hypoplastic left heart syndrome (HLHS) undergoing Stage 1 palliation (S1P), and five age/weight-matched controls were prospectively recruited. Transthoracic UPD acquisitions were performed before/after operations. Segmental perfusion in right/left ventricles (RV/LV) was assessed. The controls' myocardial perfusion patterns are visually similar to published human references for both ventricles. Systolic/diastolic myocardial perfusion differences were modified by ASO in the RV (P = 0.03) but not for LV (P = 0.99). For HLHS patients, no difference after S1P was observed in either the RV (P = 0.16) nor the LV (P = 0.51).

Conclusion

For TGA patients, the perfusion profile of the myocardium seems to be directly influenced by the intracavitary pressure (directly driving coronary perfusion pressure), namely if it was the systemic or sub-pulmonary ventricle. Our data suggests that UPD could noninvasively quantify myocardial perfusion variation. Myocardial perfusion patterns change in CCHD according to their haemodynamic and surgical status. Correlation with clinical outcomes requires further study.

Artificial Intelligence in Fetal and Pediatric Echocardiography

Echocardiography is the main modality in diagnosing acquired and congenital heart disease (CHD) in fetal and pediatric patients. However, operator variability, complex image interpretation, and lack of experienced sonographers and cardiologists in certain regions are the main limitations existing in fetal and pediatric echocardiography. Advances in artificial intelligence (AI), including machine learning (ML) and deep learning (DL), offer significant potential to overcome these challenges by automating image acquisition, image segmentation, CHD detection, and measurements. Despite these promising advancements, challenges such as small number of datasets, algorithm transparency, physician comfort with AI, and accessibility must be addressed to fully integrate AI into practice. This review highlights AI's current applications, challenges, and future directions in fetal and pediatric echocardiography.

Effects of high-intensity interval and moderate-intensity continuous training on ambulatory blood pressure and cardiovascular outcomes in older adults with hypertension (HEXA Study): study protocol for a randomised trial

INTRODUCTION

Approximately two-thirds of Brazilian older adults have hypertension. Aerobic training is the first-line non-pharmacological therapy for hypertension. However, the effects of different aerobic training approaches on ambulatory blood pressure in older adults are uncertain. Here, we present the study protocol for the HEXA Study, which aims to investigate the effects of high-intensity interval (HIIT) and moderate-intensity continuous training (MICT) on 24-hour ambulatory blood pressure and cardiovascular outcomes in older adults with hypertension.

METHODS AND ANALYSIS

This is a single-centre, randomised, three-arm, parallel superiority trial with a 1:1:1 ratio. The trial is conducted with blinded outcome assessors and statistical analysts. 66 inactive older adults with hypertension aged 60-80 years without a history of major adverse cardiovascular events will be randomly assigned to one of the following groups: (1) HIIT (3 months; 3× week); (2) MICT (3 months; 3× week); (3) health education programme (control; 3 months; 1× week). Exercise training sessions involve rating of perceived exertion-based outdoor moderate walking, brisk walking and/or jogging. The primary outcome is 24-hour ambulatory blood pressure. Secondary cardiovascular outcomes are resting blood pressure, cardiorespiratory fitness, pulse wave velocity, carotid intima-media thickness, heart rate variability and cardiac function/structure. All outcomes are measured at baseline and after a 3-month period. In addition, feelings of pleasure/displeasure, adherence and safety are reported.

ETHICS AND DISSEMINATION

All procedures were approved by the Research Ethics Committee of the Onofre Lopes University Hospital (protocol, CAAE 07191019.8.0000.5292) and are executed in compliance with the Declaration of Helsinki. Additionally, the procedures adhered to Resolution 466/2012 issued by the Brazilian National Health Council for research involving human subjects.

TRIAL REGISTRATION NUMBER

Brazilian Registry of Clinical Trials (ID: RBR-4ntszb).

Feto-maternal indicators of cardiac dysfunction as a justification for the cardiac origins for pre-eclampsia

While the pathophysiology of pre-eclampsia has been postulated as being secondary to placental dysfunction, a cardiac origin has more recently been proposed. Although an association between fetal congenital cardiovascular disease and pre-eclampsia has been demonstrated, no precise pathophysiologic mechanism for this association has been described. This review highlights the current biophysical (including echocardiography and Doppler indices) and biochemical (including proteomic, metabolomic and genetic/transcriptomic) markers of cardiac dysfunction that have been investigated in maternal and fetal cardiac disease and their overlap with predictors of pre-eclampsia.   Common pathways of inflammatory and anti-angiogenesis imbalance, endothelial damage, and oxidative stress have been demonstrated in both cardiovascular disease and pre-eclampsia and further investigation into these pathways could help to elucidate the common pathophysiologic mechanisms linking these disorders.

Fetal Echocardiography From 10 to 15 Weeks of Gestation-Reliability, Genetic Associations, and Outcomes

INTRODUCTION

There is increasing demand for accurate early fetal cardiac disease (FCD). We assessed the accuracy of early fetal echo (EFE) conducted in our high-volume fetal cardiac program and reviewed the spectrum of FCD, associated genetic anomalies, and outcomes encountered.

METHODS

We identified all EFEs performed from 10+0 to 15+6 weeks of gestation from 2009 to 2021. We compared findings at EFE to fetal echo at ≥18+0 weeks or autopsy and documented genetic testing results for all FCD cases. For those with discrepancy between EFE and later exam, the discrepancy impact was reviewed. A score was used to quantify the anatomy assessed.

RESULTS

A total of 1,662 EFEs were performed in 1,387 pregnancies; all but 41 were considered diagnostic. Fetal cardiac disease was diagnosed at EFE in 130, including 101 major, 12 minor, 13 other FCD, and 4 arrhythmias. In 14/130 with FCD, endovaginal imaging was undertaken, which increased the score (1.6/9 vs 3.5/9; P = .049). Thirty-five of 130 had repeat EFE, which increased the score (5.2/9 vs 7.4/9, P < .0001). Fetal loss occurred before confirmation of FCD in 16 and termination in 64, and 11 were lost to follow-up. Thirty-nine had autopsy and/or fetal echo ≥18+0: 35 had FCD confirmed, and 4 had resolution. Of the 35 confirmed FCD, 27 had no, 7 minor, and 1 major change. Of 1,489 with normal EFE, later echo demonstrated FCD in 14: 3 major and 11 minor. In 16, FCD evolved, including 4 arrhythmias and 12 with progressive FCD. Sensitivity, specificity, and positive and negative predictive values of EFE in identifying major FCD were 92.9%, 100%, 100%, and 99.7%, respectively. In cases with FCD, 85.4% had genetic testing, of whom 71% (60.8% of the total) had abnormal results.

CONCLUSIONS

In our experience, EFE permits accurate diagnosis and exclusion of most FCD. Endovaginal imaging and repeat EFE studies improved the ability to visualize structures adequately.

Systematic Review and Meta-analysis of Prenatal Risk Factors for Congenital Heart Disease: Part 1, Maternal Chronic Diseases and Parental Exposures

BACKGROUND

There is considerable heterogeneity in studies on prenatal risk factors for congenital heart diseases (CHDs). We performed a meta-analysis of all nongenetic factors of CHDs. This report presents results of factors related to maternal chronic diseases and parental exposures.

METHODS

A systematic search encompassing concepts of CHD and risk factors was used, using the following inclusion criteria: (1) original peer-reviewed articles, (2) quantifying the effects of risk factors for CHDs, (3) between 1989 and 2022. Pooled odds ratios (ORs) and 95% confidence interval (CI) were calculated using a random-effect model.

RESULTS

Inclusion criteria were met for 170 studies. There was an association between being overweight or obese and CHDs (OR, 1.26; 95% CI, 1.15-1.37), with a dose-effect relationship. Pregestational diabetes (PGDM) was associated with CHDs (OR, 3.51; 95% CI, 2.86-4.3), without difference between type 1 and type 2 PGDM. The effect size of gestational diabetes was less than that of PGDM (OR, 1.38; 95% CI, 1.18-1.61). There was an association between CHDs and pre-eclampsia (OR, 2.01; 95% CI, 1.32-3.05), paternal smoking (OR, 1.32; 95% CI, 1.03-1.70), and alcohol use (OR, 1.50; 95% CI, 1.08-2.08). A smaller association was found with maternal smoking and advanced maternal age.

CONCLUSIONS

There exists robust evidence for increased risk of CHD in the presence of obesity, maternal diabetes, maternal smoking, and increased maternal age. The effect sizes were relatively modest, except for PGDM. The robustness of the evidence decreased when CHDs were divided into subgroups or when the analyses were restricted to severe CHDs.

New Fetal Sonographic Marker to Rule Out Total Anomalous Pulmonary Venous Return: Color Doppler Drainage From Pulmonary Vein to Atrium to Ventricle (CDDVAV)

Many cases of total anomalous pulmonary venous return (TAPVR) present with life-threatening pulmonary venous obstruction within hours following delivery. As a result, prenatal detection represents an important approach to optimizing outcome. Unfortunately, TAPVR remains one of the most challenging major forms of congenital heart disease to detect prenatally; most cases elude diagnosis until postnatal life, despite the widespread recognition of multiple fetal two-dimensional (2D) and color Doppler sonographic markers. This commentary demonstrates that even the 2D and color Doppler appearance of pulmonary venous drainage to the left atrium may be seen in cases of TAPVR. Accordingly, we describe, for the first time, a novel color Doppler fetal sonographic marker to rule out TAPVR.

Evaluation of fetal heart size, morphology and function with fetal growth restriction using fetal HQ

BACKGROUND

Fetal growth restriction (FGR) is associated with various perinatal complications. Limited research has focused on the fetal heart in the context of FGR. This study aimed to investigate the application value of fetal heart quantification (HQ) technology in evaluating the size, morphology, and function of the heart in FGR.

METHODS

A total of 31 fetuses diagnosed with FGR in our hospital from April 2022 to May 2024 were included, alongside another 31 normal fetuses matched for gestational age as the control group. Ultrasound Doppler parameters of the middle cerebral artery (MCA), umbilical artery (UA), venous catheter, and fetal HQ parameters were collected for comparative analysis, and perinatal data were followed up.

RESULTS

Fetuses with FGR exhibited significant differences in various parameters of the MCA and UA compared to the control group (P < 0.05). The four-chamber view end-diastolic transverse width, end-diastolic area, left ventricular (LV) end-diastolic area, end-systolic area, end-systolic length, end-diastolic volume, end-systolic volume, and right ventricular (RV) end-systolic area in the FGR group were significantly lower than those in the control group (P < 0.05). In the 24-segment analysis, the LV fractional shortening in the FGR group was greater than in the control group at segments 12 to 14, while the end-diastolic diameter (ED) at segments 5 to 13 of the LV and segments 1 to 14 of the RV were smaller than those in the control group, with statistical significance (P < 0.05). Analysis of each subgroup indicated that fractional shortening (FS) in the early-onset group was significantly greater than in the late-onset group at RV segments 2 to 8. LV-ED at segments 1 to 15 and RV-ED at segments 1 to 16 were significantly smaller in the early-onset group than in the control group, and LV ED segments 20 to 21 were significantly smaller in the early-onset group compared to the late-onset group (P < 0.05). FS in the mild group was significantly larger than in the normal group at LV segments 10 to 16. The severe group exhibited significantly smaller LV segment 2 to 11 ED and the mild group showed smaller RV segments 1 to 13 compared to the control group (P < 0.05).

CONCLUSIONS

Fetal HQ is a promising technique for evaluating the cardiac function, size, and morphology in cases of FGR.

Recommendations for the training and practice of fetal cardiology from the Association of European Paediatric Cardiology

Prenatal detection of cardiac abnormalities has increased significantly over the past few decades, such that fetal cardiology has developed into a sub-specialty of paediatric and congenital cardiology. As this speciality develops further and extends across Europe and more globally, it is important to standardize the requirements for training and subsequent practice, to optimize prenatal diagnosis and perinatal care. In addition to the knowledge and technical skills required to make a correct diagnosis, the counseling of families after diagnosis and the planning of appropriate perinatal management is equally important. The aim of these recommendations is to provide a framework for both basic and advanced training for paediatric cardiologists wishing to practice as fetal cardiologists, as well as highlighting requisites for a fetal cardiology service. All aspects regarding training in fetal cardiology and service provision are addressed including diagnosis, counseling and management.

Aortic isthmus flow reversal in fetal coarctation of the aorta and the associated factors

INTRODUCTION

The aim of this study was to investigate the presence of aortic isthmus flow reversal and its associated factors in fetuses with positive and false-positive coarctation of the aorta (CoA) compared with normal controls.

MATERIAL AND METHODS

Pregnant women with fetuses suspected of CoA and normal control were enrolled, and these women experienced prenatal ultrasound scan and followed up for 6 months after birth to confirm the presence of CoA. All the ultrasound parameters were analyzed.

RESULTS

A total of 134 pregnant women were enrolled, with 43 CoA-positive fetuses and 91 CoA false-positive fetuses, and 334 matched pregnant women were enrolled in the control group. Aortic isthmus flow reversal occurred in 28 (65.1%) fetuses in the CoA-positive group, significantly (p < 0.05) more than in the false-positive (37 or 40.7%) or control group (64 or 19.2%). Aortic isthmus flow reversal was mostly in the full systole (n = 17 or 60.7%) or late systole and early-middle diastole (n = 10 or 35.7%) in the CoA-positive fetuses (n = 27 or 96.4%), significantly (p < 0.001) different from that in the false-positive or control group. The aortic isthmus flow reversal peak systolic velocity (PSV), flow volume, and ratio of reversed flow/forward flow were significantly (p < 0.05) increased in the CoA-positive and false-positive groups than in the control group. The aortic isthmus flow reversal incidence was significantly (p < 0.05) correlated with the middle cerebral artery (MCA) PSV in the total three groups or in the false-positive group but was significantly (p < 0001) negatively correlated with the MCA resistance index (RI) in the CoA-positive group. The incidence of the aortic isthmus flow reversal was significantly (p < 0.05) positively correlated with the umbilical artery (UA) RI in the false-positive group and with the UA RI in the total three groups. Independently associated factors for aortic isthmus flow reversal were isthmic flow volume/CCO (combined cardiac output) in the CoA-positive group.

CONCLUSIONS

Reversal of flow in the aortic isthmus is much more common in true-positive cases of CoA as compared to controls, and isthmic flow reversal in the full systolic phase only suggests presence of CoA. The aortic isthmic reversed flow volume accounts for over half of the isthmic forward flow volume in the CoA-positive fetuses than in the normal controls.

Bovine aortic arch: a potential indicator that may not serve in prenatal diagnosis - a study based on fetal anatomy, genetics, and postnatal clinical outcomes

OBJECTIVE

To investigate the structural abnormalities, genetic results, and postnatal clinical outcomes of fetuses with bovine aortic arch (Bovine Aortic Arch, BAA) to provide a basis for prenatal counseling and management.

METHODS

A retrospective analysis was conducted on 216 fetuses diagnosed with bovine aortic arch through prenatal ultrasound screening at the First Affiliated Hospital of Anhui Medical University and the No.901 Hospital of the Joint Service of the People's Liberation Army from January 2019 to February 2023. Their family history of genetic diseases, prenatal screening results, and postnatal follow-up data were collected. The fetuses were divided into an isolated BAA group (n = 192) and a non-isolated BAA group (n = 24). Chromosomal karyotyping and copy number variation (CNV) testing were conducted, and statistical analysis was performed using SPSS 22.0 software.

RESULTS

Of the 216 fetuses with BAA, 192 were isolated BAA (88.89%), and 24 were non-isolated BAA (11.11%). Among the isolated BAA fetuses, only 1 case (0.52%) had chromosomal karyotype and pathogenic CNV abnormalities. Among the non-isolated BAA fetuses, 4 cases (16.67%) had chromosomal or CNV abnormalities, but the overall risk was low. The postnatal outcomes of isolated BAA fetuses were good (99.48%), while 79.17% of non-isolated BAA fetuses had good postnatal outcomes.

CONCLUSION

Most BAA fetuses are isolated, with a very low incidence of chromosomal abnormalities and pathogenic CNVs, and have good postnatal outcomes. The clinical value of isolated BAA is limited, and invasive prenatal diagnosis is not recommended for low-risk populations. Prenatal screening should focus on the risk of concurrent severe structural anomalies and chromosomal abnormalities.

Characterizing phenotypic data of Peromyscus leucopus compared to C57BL/6J Mus musculus and diversity outbred (DO) Mus musculus

Translational research is commonly performed in the C57B6/J mouse strain, chosen for its genetic homogeneity and phenotypic uniformity. Here, we evaluate the suitability of the white-footed deer mouse (Peromyscus leucopus) as a model organism for aging research, offering a comparative analysis against C57B6/J and diversity outbred (DO) Mus musculus strains. Our study includes comparisons of body composition, skeletal muscle function, and cardiovascular parameters, shedding light on potential applications and limitations of P. leucopus in aging studies. Notably, P. leucopus exhibits distinct body composition characteristics, emphasizing reduced muscle force exertion and a unique metabolism, particularly in fat mass. Cardiovascular assessments showed changes in arterial stiffness, challenging conventional assumptions and highlighting the need for a nuanced interpretation of aging-related phenotypes. Our study also highlights inherent challenges associated with maintaining and phenotyping P. leucopus cohorts. Behavioral considerations, including anxiety-induced responses during handling and phenotyping assessment, pose obstacles in acquiring meaningful data. Moreover, the unique anatomy of P. leucopus necessitates careful adaptation of protocols designed for Mus musculus. While showcasing potential benefits, further extensive analyses across broader age ranges and larger cohorts are necessary to establish the reliability of P. leucopus as a robust and translatable model for aging studies.

Safety and feasibility pilot study of continuous low-dose maternal supplemental oxygen in fetal single ventricle heart disease

OBJECTIVE

Fetuses with single ventricle physiology (SVP) exhibit reductions in fetal cerebral oxygenation, with associated delays in fetal brain growth and neurodevelopmental outcomes. Maternal supplemental oxygen (MSO) has been proposed to improve fetal brain growth, but current evidence on dosing, candidacy and outcomes is limited. In this pilot study, we evaluated the safety and feasibility of continuous low-dose MSO in the setting of SVP.

METHODS

This single-center, open-label, pilot phase-1 safety and feasibility clinical trial included 25 pregnant individuals with a diagnosis of fetal SVP. Participants self-administered continuous MSO using medical-grade oxygen concentrators for up to 24 h per day from the second half of gestation until delivery. The primary aim was the evaluation of the safety profile and feasibility of MSO. A secondary preliminary analysis was performed to assess the impact of MSO on the fetal circulation using echocardiography and late-gestation cardiovascular magnetic resonance imaging. Early outcomes were assessed, including perinatal growth and preoperative brain injury, and neurodevelopmental outcomes were assessed at 18 months using the Bayley Scales of Infant and Toddler Development 3rd edition, and compared with those of a contemporary fetal SVP cohort (n = 217) that received the normal standard of care (SOC).

RESULTS

Among the 25 participants, the median maternal age at conception was 35 years, and fetal SVP diagnoses included 16 with right ventricle dominant, eight with left ventricle dominant and one with indeterminate ventricular morphology. Participants started the trial at approximately 29 + 2 weeks' gestation and self-administered MSO for a median of 16.1 h per day for 63 days, accumulating a median of 1029 h of oxygen intake from enrolment until delivery. The only treatment-associated adverse events were nasal complications that were resolved typically by attaching a humidifier unit to the oxygen concentrator. No premature closure of the ductus arteriosus or unexpected fetal demise was observed. In the secondary analysis, MSO was not associated with any changes in fetal growth, middle cerebral artery pulsatility index, cerebroplacental ratio or head-circumference-to-abdominal-circumference ratio Z-scores over gestation compared with SOC. Although MSO was associated with changes in umbilical artery pulsatility index Z-score over the study period compared with SOC (P = 0.02), this was probably due to initial baseline differences in placental resistance. At late-gestation cardiovascular magnetic resonance imaging, MSO was not associated with an increase in fetal cerebral oxygen delivery. Similarly, no differences were observed in neonatal outcomes, including preoperative brain weight Z-score and brain injury, mortality by 18 months of age and neurodevelopmental outcomes at 18 months of age.

CONCLUSIONS

This pilot phase-1 clinical trial indicates that low-dose MSO therapy is safe and well tolerated in pregnancies diagnosed with fetal SVP. However, our protocol was not associated with an increase in fetal cerebral oxygen delivery or improvements in early neurological or neurodevelopmental outcomes. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Assisted reproductive technology and the risk of fetal congenital heart disease: insights from a tertiary-care referral center

PURPOSE

To investigate whether congenital heart diseases exhibit higher rates in pregnancies achieved through assisted reproductive technology (ART) compared to natural conception.

METHODS

In this retrospective cohort study, multinomial logistic regression was employed to analyze the relationship between categories of congenital heart diseases and three conception groups (IVF, ICSI, and natural pregnancies). The main outcome measures are risks of congenital heart disease categories in IVF and ICSI groups using the natural group as reference. We selected fetuses referred for fetal echocardiography to IRCCS Policlinico Sant'Orsola, Bologna, between January 2005 and November 2023, diagnosed with congenital heart diseases.

RESULTS

We categorized the congenital heart diseases into six groups based on anatomical and embryological criteria. The estimated risk of left ventricular outflow tract, valvular, conotruncal, and atrioventricular septal defects was lower in the IVF group compared to natural conception. The estimated risk of valvular and atrioventricular septal defects was lower in the ICSI group vs natural. Conversely, the risk for right heart anomalies was higher both in the IVF and ICSI groups compared to natural conception. Heart rhythm diseases were more frequent in IVF pregnancies. When comparing ART methods, valvular defects, conotruncal defects, and right heart anomalies were more frequently observed in the ICSI group, while atrioventricular septal defects were more common in the IVF group.

CONCLUSION

Significant differences were found in the occurrence of congenital heart diseases in pregnancies conceived through IVF and ICSI, versus those conceived naturally, underscoring the importance of further studying the underlying mechanisms of these associations.

A comparative study of fetal cardiovascular assessment: utilizing Doppler ultrasound gated MRI and echocardiography with detailed analysis using five axial views

Objectives

To investigate the diagnostic performance of fetal cardiovascular magnetic resonance imaging (MRI) using Doppler ultrasound (DUS) gating for the evaluation of the standardized five axial views in comparison with fetal echocardiography.

Methods

In this prospective study 29 pregnant women (median: 34.4 weeks of gestation) underwent fetal cardiovascular MRI using DUS gating at 3 Tesla. The standardized five axial views in prenatal screening (fetal abdomen, four-chamber view, left ventricular outflow tract, right ventricular outflow tract, and three-vessel view) were independently assessed and analysed by both fetal MRI and fetal echocardiography on the same day. Image analysis included qualitative assessment and quantitative measurements of cardiovascular structures. MR image quality was assessed using a 4-point scale (from 1 = low to 4 = excellent). Postnatal echocardiography was performed for validation.

Results

17/28 fetuses (60.7%) had pathological findings [16 congenital heart defect (CHD), one diaphragmatic hernia] in prenatal echocardiography. One fetus was excluded due to severe motion. Overall sensitivity and specificity in detecting fetal cardiac abnormalities was 88% and 100%, respectively, for fetal MRI and 100% and 100% for fetal echocardiography. MR image quality for evaluation of cardiac structures was high with a mean score of 2.8 (±0.8) (score 4: 15.9%, score 3: 53.8%, score 2: 19.3%, score 1: 11%). Quantitative measurements did not differ between fetal cardiovascular MRI and fetal echocardiography (all p > 0.05).

Conclusion

Diagnostic performance of fetal cardiovascular MRI using DUS gating was comparable to fetal echocardiography. Fetal cardiovascular MRI using DUS gating might be a valuable diagnostic adjunct for the prenatal evaluation of CHD.

Unraveling fetal venous disorders: An integrated approach in fetal echocardiography and their clinical significance

OBJECTIVE

Fetal venous system malformations frequently coincide with cardiac or extracardiac anomalies. This study explores our experience with an integrated fetal echocardiography approach and analyzes the characteristics and outcomes of fetal venous system disorders.

MATERIALS AND METHODS

We conducted a retrospective study with 7048 pregnant women (7255 fetuses) who underwent complete two-dimensional (2D) fetal echocardiographic examinations. We primarily employed an integrated 2D approach. Three-/four-dimensional (3D/4D) spatiotemporal image correlation was supplemental. Fetal venous disorders were classified into 3 groups: cardinal (Group 1), umbilical and vitelline (Group 2), and pulmonary (Group 3) systems, based on embryological-anatomical considerations. Maternofetal data were recorded alongside imaging diagnoses.

RESULTS

Congenital venous malformations were identified in 98 fetuses, yielding a prevalence of 1.35% (98/7255). Six participants had coexisting venous disorders from different groups. Group 1 included 48 fetuses with persistent left superior vena cava (LSVC) and 3 others (unidentified brachiocephalic vein, left inferior vena cava (IVC), and interrupted IVC with azygous continuation to SVC). Group 2 had 39 fetuses with persistent right umbilical vein and 7 with umbilical-portal-ductus venosus disorders. Group 3 had 7 fetuses with pulmonary venous return disorders. Group 2 showed the most favorable outcomes (alive and without neonatal death), while Group 3 exhibited the poorest. Associated cardiac defects were observed in 43.1% of Group 1, 8.7% of Group 2, and 57.1% of Group 3 (P < 0.001), displaying a broad spectrum of non-specific anomalies. Meanwhile, Group 2 had a greater occurrence of a single venous disorder (93.5%) compared to Group 1 (88.2%) and Group 3 (57.1%) (P = 0.020).

CONCLUSION

Our approach offers an integrated strategy for assessing the fetal venous system during fetal echocardiography, providing multiple views to characterize venous anomalies. The presence of a fetal venous disorder may indicate the coexistence of more severe abnormalities, and the prognosis depends on associated anomalies or the venous disorders per se.

Review of speckle tracking analysis to measure the size, shape, and contractility of the fetal heart in fetuses with congenital heart defects

Evaluation of the fetal heart involves two approaches. The first describes a screening protocol in which the heart is imaged in transverse planes that includes the four-chamber view (4CV), left and right outflow tracts, and the 3-vessel-tracheal view. The second approach is a fetal echocardiogram that requires additional cardiac images as well as evaluating ventricular function using diagnostic tools such as M-mode and pulsed Doppler ultrasound. Speckle tracking analysis of the ventricular and atrial endocardium of the fetal heart has focused primarily on computing longitudinal global strain. However, the technology enabling this measurement to occur has recently been adapted to enable the clinician to obtain numerous additional measurements of the size, shape, and contractility of the ventricles and atrial chambers. By using the increased number of measurements derived from speckle tracking analysis, we have reported the ability to screen for tetralogy of Fallot, D-transposition of the great arteries (D-TGA), and coarctation of the aorta by only imaging the 4CV. In addition, we have found that measurements derived from speckle tracking analysis of the ventricular and atrial chambers can be used to compute the risk for emergent neonatal balloon atrial septostomy in fetuses with D-TGA. The purpose of this review is to consolidate our experience in one source to provide perspective on the benefits of speckle tracking analysis to measure the size, shape, and contractility of the ventricles and atria imaged in the 4CV in fetuses with congenital heart defects.