The investigators present their experience with normal fetal cardiac structures and congenital heart anomalies reconstructed using 4-dimensional color Doppler with glass-body rendering mode and spatiotemporal image correlation. Two normal fetuses and 6 fetuses with congenital heart anomalies (1 case each of ventricular septal defect, Ebstein’s anomaly, hypoplastic left heart syndrome, and ductus arteriosus aneurysm and 2 of double-outlet right ventricle) at 26 to 36 weeks’ gestation were studied using 4-dimensional color Doppler with glass-body rendering mode. In normal fetal hearts, blood flow through the 4 cardiac chambers and crisscross arrangements of the pulmonary artery and aorta were clearly recognized. In the fetus with a ventricular septal defect, significant shunt flow through the defect between the left and right ventricles was evident. In the fetus with Ebstein’s anomaly, giant tricuspid regurgitant flow was noted. In the fetus with hypoplastic left heart syndrome, large tricuspid regurgitant flow was identified. In the fetuses with double-outlet right ventricles, large aortas and small pulmonary arteries leaving the right ventricles in parallel were clearly shown. In the fetus with a ductus arteriosus aneurysm, an enlarged ductus arteriosus following the pulmonary artery was clearly depicted. In conclusion, fetal 4-dimensional color Doppler may assist in the evaluation of spatial relations between the great vessels and both ventricles and differences in the sizes of the great vessels and cardiac chambers.
Highlights
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Two normal fetuses and 6 fetuses with congenital heart anomalies at 26 to 36 weeks’ gestation were studied using 3D and 4D color Doppler with glass-body rendering mode.
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In normal fetal hearts, blood flow through the 4 cardiac chambers and crisscross arrangements of the pulmonary artery and aorta were clearly recognized.
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In a fetus with a VSD, significant shunt flow through the VSD between the left and right ventricles was evident.
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In a fetus with Ebstein’s anomaly, giant tricuspid regurgitant flow was noted. In a fetus with HLHS, large tricuspid regurgitant flow was identified.
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In 2 fetuses with double-outlet right ventricles, large aortas and small pulmonary arteries leaving the right ventricles in parallel were clearly shown.
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In a fetus with a ductus arteriosus aneurysm, enlarged ductus arteriosus following the pulmonary artery was clearly depicted.
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Fetal 3D and 4D color Doppler may assist in the evaluation of spatial relations between the great vessels and both ventricles and differences in the sizes of the great vessels and cardiac chambers.
There has been a variety of rendering modes of 3-dimensional (3D) and 4-dimensional (4D) fetal echocardiography with spatiotemporal image correlation (STIC), such as tomographic ultrasound imaging, B-flow, inversion mode, color and power Doppler, and HDlive (GE Healthcare, Little Chalfont, UK), for the evaluation of fetal cardiac structures in normal hearts and those with congenital anomalies. Regarding color/power Doppler STIC, the color Doppler multiplanar view or tomographic ultrasound imaging, 4D color Doppler en face views with glass-body rendering, and 3D and 4D HD-Flow (GE Healthcare) with or without glass-body rendering have been used to evaluate normal and abnormal fetal cardiac structures. There have been only a few reports on real-time 3D color Doppler fetal echocardiographic features of congenital heart anomalies. However, to the best of our knowledge, there has been no study of 4D color Doppler fetal echocardiographic evaluation of normal and abnormal hearts. We present our experience with normal fetal cardiac structures and congenital heart anomalies reconstructed using 4D color Doppler with glass-body rendering mode and STIC.
Methods
Two normal fetuses and 6 fetuses with congenital heart anomalies (1 case each of ventricular septal defect [VSD], Ebstein’s anomaly, hypoplastic left heart syndrome, and ductus arteriosus aneurysm and 2 of double outlet right ventricle) at 26 to 36 weeks’ gestation were studied using 4D color Doppler with glass-body rendering mode and STIC (Voluson E8; GE Healthcare). The glass-body rendering mode is based on the simultaneous display of gray and color Doppler images, and it allows demonstration, at the same time, of ventricular filling and crossing of the great arteries, without changing the scanning plane. Volume data sets of the fetal heart were acquired with STIC, which uses automated transverse and longitudinal sweeps of the anterior chest wall. Using a curved-array transducer (4 to 8 MHz), volume acquisition lasted 10 to 12.5 seconds. Acquisition angles ranged from 25° to 45°. One to 4 recordings were obtained using a transabdominal 4D probe. Fetal movement necessitated repeat volume acquisition to obtain satisfactory data. The fetus was monitored using conventional 2-dimensional (2D) sonography before 4D color Doppler with glass-body rendering mode and STIC examination in each subject. The 4D color Doppler with glass-body rendering display of the fetal heart was produced after 2D sonographic examinations. The data set was stored on a 700-megabyte CD-R and could be retrieved for further analysis. All volume data for each subject were examined, and optimal images were selected for further analysis. The study was approved by the local ethics committee of Kagawa University Graduate School of Medicine, and standardized written informed consent was obtained from each patient.
The 4D reconstruction was carried out using 4D color Doppler with glass-body rendering mode and STIC. All sonographic examinations were performed by 1 examiner (T.H.) for the data reported here.
Results
In normal fetal hearts, blood flow through the 4 cardiac chambers and crisscross arrangements of the pulmonary artery and aorta were clearly recognized in real-time in systole and diastole ( Figure 1 ). Moreover, blood flow from the right to the left atrium through the foramen ovale was noted. In the fetus with a VSD, significant bidirectional shunt flows through the VSD between the left and right ventricles were evident ( Figure 2 ). In the fetus with Ebstein’s anomaly, giant right atrial flow and turbulent tricuspid regurgitant flow were noted. In the fetus with hypoplastic left heart syndrome, large tricuspid regurgitant flow was identified. Small left ventricular flow was also noted. In the fetuses with double-outlet right ventricles, large aortas and small pulmonary arteries leaving the right ventricles in parallel were clearly shown ( Figure 3 ). In the fetus with a ductus arteriosus aneurysm, a crisscross arrangement of the pulmonary artery and aorta was identified, and an enlarged ductus arteriosus following the pulmonary artery was clearly depicted using 2D sonography, 2D color Doppler, and 4D color Doppler with glass-body rendering ( Figure 4 ). Four-dimensional color Doppler with glass-body rendering images seemed to be more readily discernible than those obtained by conventional 2D sonography and 2D color Doppler in the evaluation of spatial relations between the great vessels and both ventricles and differences in the sizes of the great vessels and cardiac chambers.
