Three-dimensional navigation inside a normal fetal heart in a virtual reality environment.

Three-dimensional navigation allows in a virtual reality environment across the fetal heart structures using glasses and joysticks. This technology allows virtual interactive discussions among multidisciplinary teams providing new perspectives on diagnosis and planning possible surgical corrections.

Prenatal Cardiac Ultrasound Markers of Outcomes in Ebstein's Anomaly: An International Multicenter Case Series.

This study aimed to analyze prenatal cardiac ultrasound markers of outcome in fetuses with Ebstein's anomaly (EA). From a retrospective database, 35 fetuses diagnosed with EA at fetal medicine centers in Brazil, Italy, and Poland were retrieved. The primary outcome was perinatal mortality. We analyzed prenatal cardiac ultrasound markers of outcomes and perinatal follow-up. Gestational age at diagnosis, extracardiac fetal anomalies, spontaneous fetal demise, and gestational age at each event were recorded. In postnatal survivors, data on cardiac surgery and short-term postoperative outcomes were collected. Our study included a cohort of 35 fetuses with EA (mean gestational age of 29.4 weeks), in which 6 fetuses were excluded due to termination of pregnancy (3), pregnancy still ongoing (2), and missed follow-up (1). Of the remaining 29 cases, severe tricuspid regurgitation and absence of anterograde pulmonary flow (pulmonary atresia) were observed in 88%. Significant cardiomegaly accounts for 58% of these data with a mean cardiothoracic ratio of 0.59. The cardiovascular profile (CVS) score ≤ 6 in six patients with one survival (4 fetal deaths, one stillbirth, and one survival). All fetuses with CVS score of 5 had intrauterine demise. Seventeen fetuses were born alive (53.1% of 29 cases). Of the remaining fetuses, one (1%) fetal was a stillbirth, six (20%) fetuses were neonatal deaths, and five (17%) fetuses were fetal deaths. Of the nineteen patients who underwent surgery to correct the cardiac defect, 17 survived after surgery. Among the survivors, biventricular cardiac repair was performed using the cone technique (da Silva's approach) in the majority of cases. We observed 2 abnormal karyotypes among in the remaining 29 fetuses. One of the patients with abnormal karyotype was a fetus with ascites and large for gestational age. The other patient with abnormal karyotype underwent cardiac surgery and progressed to neonatal death. Nine patients (25%) had extracardiac anomalies (genitourinary anomalies and single umbilical artery), being that 2 of them are alive and 4 died (2 had fetal and 2 neonatal death). Fetal EA is associated with high mortality. The most common prenatal marker associated with non-survival was CVP score ≤ 6. Fetuses that survived and underwent postnatal corrective surgery are significantly favorable outcomes.

Fetal transposition of the great arteries: 3D virtual and physical models from ultrasound datasets.

Transposition of the great arteries (TGA) is a cyanotic congenital heart disease characterized by ventriculoarterial discordance and atrioventricular concordance with the great arteries in a parallel relationship. Prenatal diagnosis of TGA has implications for postnatal outcomes, allowing for planned delivery and perinatal management. Three-dimensional virtual or physical models of fetal TGA allow better understanding of fetal cardiac anomalies by parents and interactive discussion among the multidisciplinary team (obstetricians, pediatricians, maternal-fetal specialists, pediatric cardiologists, and cardiovascular surgeons), as well as continuing medical education.

Fetal tetralogy of Fallot: Three-dimensional virtual and physical models from ultrasound scan data findings.

Three-dimensional reconstructions provide a spatial view of the congenital heart disease with a better understanding of the pathology for parents and allow interactive discussion among the medical team (maternal-fetal medicine specialist, neonatology, pediatric cardiology, and cardiovascular surgeon) and improve both objective knowledge and learner satisfaction for medical students.

Evaluation of cardiac contractility of fetuses from pregestational diabetes mellitus pregnancies by three-dimensional ultrasound.

OBJECTIVE: This study aimed to evaluate cardiac contractility in fetuses from pregestational diabetes mellitus pregnancies by three-dimensional ultrasound using spatiotemporal image correlation in rendering mode. METHODS: A retrospective cross-sectional study was performed on 40 fetuses from nondiabetic pregnancies and 28 pregestational diabetic pregnancies between 20 and 33 weeks and 6 days. Cardiac contractility was assessed by measuring the ventricular myocardial area in diastole subtracted from the ventricular myocardial area in systole. RESULTS: Pregestational diabetic pregnancies had a lower maternal age than nondiabetic pregnancies (26.7 vs. 39.9 years, p=0.019). Cardiac contractility in fetuses from diabetic and nondiabetic pregnancies was similar (p=0.293). A moderately positive and significant correlation was observed between gestational age and cardiac contractility (r=0.46, p=0.0004). A 1-week increase in gestational age was responsible for a 0.1386 cm2 increase in cardiac contractility. CONCLUSION: Cardiac contractility as evaluated by three-dimensional ultrasound using spatiotemporal image correlation in rendering mode showed no significant differences across fetuses with and without pregestational diabetes.

Ebstein anomaly: 3D virtual and physical models from obstetrical ultrasound data.

3D virtual and physical models from ultrasound scan data allow a 3D spatial view of congenital heart anomalies, interactive discussion among a multidisciplinary team, and improved parental counseling. To the best of our knowledge, this is the first description of 3D physical and virtual models of a fetal Ebstein anomaly.

Retrospective analysis of percutaneous intervention of the renal artery in transplanted kidneys in children and adolescents at a tertiary public hospital.

BACKGROUND: This study evaluated the long-term effects of percutaneous intervention in children and adolescents with transplant renal artery stenosis (TRAS). METHODS: Twenty patients had significant stenosis (>50%) and underwent percutaneous transluminal angioplasty (PTA/stenting) (TRAS group-intervention); 14 TNS (non-significant group -control) patients did not have significant stenosis (≤50%) and were treated clinically. The combined primary endpoints were death from all causes and late graft failure. The secondary endpoints were serum creatinine (SCr), systolic blood pressure (SBP), and diastolic blood pressure (DBP). RESULTS: No statistically significant difference was found between TRAS-Intervention(N = 20) and TNS groups-Control (N = 14) for these clinical parameters: deaths, 1 (5.0%) vs. 0 (0.0%) (p = 1.000) and graft loss, 4 (20.0%) vs. 2 (14.3%) (p = 1.000). For the secondary endpoints, after 1 month and 1 year the values of SCr, SBP, and DBP were similar between the two groups but not statistically significant. DISCUSSION: In the TRAS group (intervention), the stent implantation was beneficial for treating refractory hypertension and reducing blood pressure (BP) in children and adolescents. Despite the outcomes being similar in the two groups, it can be inferred that the patients in the TRAS group (intervention) would have had a worse outcome without the percutaneous intervention. CONCLUSION: TRAS treatment with stenting can be considered for children and adolescents. Because the sample in the present study comprised of only a specific population, further studies are needed for generalization. TRIAL REGISTRATION: The trial was registered at clinictrials.gov with trial registration number NCT04225338.

Prenatal diagnosis of fetal left ventricular diverticulum: 3D virtual and physical reconstruction models.

Congenital diverticulum is a very rare congenital heart disease. 3D virtual and physical models from ultrasound scan data provide a spatial visualization and better understanding of congenital heart disease to the parents and support possible surgical procedures.

Evaluation of cardiac contractility of fetuses from pregestational diabetes mellitus pregnancies by three-dimensional ultrasound

SUMMARY OBJECTIVE: This study aimed to evaluate cardiac contractility in fetuses from pregestational diabetes mellitus pregnancies by three-dimensional ultrasound using spatiotemporal image correlation in rendering mode. METHODS: A retrospective cross-sectional study was performed on 40 fetuses from nondiabetic pregnancies and 28 pregestational diabetic pregnancies between 20 and 33 weeks and 6 days. Cardiac contractility was assessed by measuring the ventricular myocardial area in diastole subtracted from the ventricular myocardial area in systole. RESULTS: Pregestational diabetic pregnancies had a lower maternal age than nondiabetic pregnancies (26.7 vs. 39.9 years, p=0.019). Cardiac contractility in fetuses from diabetic and nondiabetic pregnancies was similar (p=0.293). A moderately positive and significant correlation was observed between gestational age and cardiac contractility (r=0.46, p=0.0004). A 1-week increase in gestational age was responsible for a 0.1386 cm2 increase in cardiac contractility. CONCLUSION: Cardiac contractility as evaluated by three-dimensional ultrasound using spatiotemporal image correlation in rendering mode showed no significant differences across fetuses with and without pregestational diabetes.

Prenatal diagnosis of hypoplastic left heart syndrome: current knowledge / Diagnóstico pré-natal da síndrome hipoplásica do coração esquerdo: conhecimentos atuais

Abstract Hypoplastic left heart syndrome (HLHS) is characterized by underdevelopment of the left-sided heart structures. The prenatal diagnosis of this congenital heart disease is crucial because a newborn with undiagnosed HLHS often presents with clinical signs of low cardiac output once the ductus arteriosus begins to close. With that in mind, the aim of this article was to perform a non-systematic review focusing on the key ultrasound features that can be used in the prenatal diagnosis of HLHS. Severe forms of HLHS are characterized by a markedly abnormal four-chamber view of the fetal heart (small left atrium, hypoplastic left ventricle, or abnormal mitral valve). The left ventricular outflow tract view allows the degree of hypoplasia in the tract to be evaluated and the diameter of the ascending aorta to be measured. The Z-scores are intended to aid in the diagnosis and follow-up of HLHS. In mild forms of HLHS, a right ventricle/left ventricle length ratio > 1.28 was the strongest predictor of a univentricular outcome.

Resumo A síndrome do coração esquerdo hipoplásico (SCEH) é caracterizada pelo subdesenvolvimento das estruturas cardíacas do lado esquerdo. O diagnóstico pré-natal dessa cardiopatia congênita é crucial, uma vez que recém-nascido com SCEH não diagnosticado apresenta, frequentemente, sinais clínicos de baixo débito cardíaco, quando o canal arterial começa a se fechar. Por isso, o objetivo deste artigo foi realizar uma revisão não sistemática sobre as principais características ultrassonográficas que podem ser usadas no diagnóstico pré-natal da SCEH. As formas graves de SCEH são caracterizadas por plano de quatro câmaras marcadamente anormal (átrio esquerdo pequeno, ventrículo esquerdo hipoplásico, válvula mitral anormal) do coração fetal. A visualização da via de saída do ventrículo esquerdo permite a avaliação do grau de hipoplasia dessa via e a mensuração da aorta ascendente. Os escores Z têm como objetivo auxiliar no diagnóstico e acompanhamento da SCEH. Nas formas leves da SCEH, a relação comprimento do ventrículo direito/comprimento do ventrículo esquerdo > 1,28 foi a variável mais forte para identificar o desfecho univentricular.

Prenatal diagnosis of hypoplastic left heart syndrome: current knowledge.

Hypoplastic left heart syndrome (HLHS) is characterized by underdevelopment of the left-sided heart structures. The prenatal diagnosis of this congenital heart disease is crucial because a newborn with undiagnosed HLHS often presents with clinical signs of low cardiac output once the ductus arteriosus begins to close. With that in mind, the aim of this article was to perform a non-systematic review focusing on the key ultrasound features that can be used in the prenatal diagnosis of HLHS. Severe forms of HLHS are characterized by a markedly abnormal four-chamber view of the fetal heart (small left atrium, hypoplastic left ventricle, or abnormal mitral valve). The left ventricular outflow tract view allows the degree of hypoplasia in the tract to be evaluated and the diameter of the ascending aorta to be measured. The Z-scores are intended to aid in the diagnosis and follow-up of HLHS. In mild forms of HLHS, a right ventricle/left ventricle length ratio > 1.28 was the strongest predictor of a univentricular outcome.

A síndrome do coração esquerdo hipoplásico (SCEH) é caracterizada pelo subdesenvolvimento das estruturas cardíacas do lado esquerdo. O diagnóstico pré-natal dessa cardiopatia congênita é crucial, uma vez que recém-nascido com SCEH não diagnosticado apresenta, frequentemente, sinais clínicos de baixo débito cardíaco, quando o canal arterial começa a se fechar. Por isso, o objetivo deste artigo foi realizar uma revisão não sistemática sobre as principais características ultrassonográficas que podem ser usadas no diagnóstico pré-natal da SCEH. As formas graves de SCEH são caracterizadas por plano de quatro câmaras marcadamente anormal (átrio esquerdo pequeno, ventrículo esquerdo hipoplásico, válvula mitral anormal) do coração fetal. A visualização da via de saída do ventrículo esquerdo permite a avaliação do grau de hipoplasia dessa via e a mensuração da aorta ascendente. Os escores Z têm como objetivo auxiliar no diagnóstico e acompanhamento da SCEH. Nas formas leves da SCEH, a relação comprimento do ventrículo direito/comprimento do ventrículo esquerdo > 1,28 foi a variável mais forte para identificar o desfecho univentricular.

Area of the Fetal Ascending and Descending Aorta by Spatiotemporal Image Correlation in the Rendering Mode: Reproducibility and Comparison with Pregestational Diabetic Mothers.

Background: The objective of this study was to assess the ascending and descending aorta area measurements by three-dimensional (3D) ultrasound using spatiotemporal image correlation (STIC) in the rendering mode comparing these measurements with pregestational diabetic mothers and assessing the reproducibility of the method. Methods: We carried out a retrospective cross-sectional study with 58 normal and nine fetuses from pregestational diabetic mothers between 20 and 33 + 6 weeks of gestation. Fetal heart volumes were acquired at the level of four-chamber view to obtain the reconstructed planes for the ascending and descending aorta areas in the rendering mode. Linear regression was performed to assess the correlation between the fetal aorta areas and gestational age (GA). To assess the intra- and interobserver reproducibility, we used the concordance correlation coefficient (CCC). Results: The mean ascending and descending aorta areas were 0.12 (0.02-0.48) and 0.11 (0.04-0.39) cm2 in normal fetuses, respectively. There was a moderate positive correlation between GA and ascending aorta area measurements (0.005676*GA - 0.01283; r = 0.53, P < 0.0001) and strong positive correlation between GA and descending aorta area (0.01095*GA - 0.1581; r = 0.68, P < 0.0001). We observed a weak intra- and interobserver reproducibility with CCC ranging from 0.05 to 0.91. The mean difference in the ascending and descending aorta area measurements of normal and fetuses of pregestational diabetic mothers was -0.03 cm2 (P = 0.276) and -0.03 cm2 (P = 0.231), respectively. Conclusion: The fetal ascending and descending aorta area measurements obtained by 3D ultrasound using STIC in the rendering mode increased with GA in normal fetuses. The method showed weak intra- and interobserver reproducibility.

Right ventricular myocardial performance index (Tei) in premature infants

SUMMARY OBJECTIVE: The objective of this study was to evaluate the right ventricular myocardial performance index) based on echocardiography in very low birth weight premature neonates, close to hospital discharge. METHODS: This was a prospective cross-sectional study that included premature neonates with birth weight <1,500 g and gestational age <37 weeks at the Intermediate Neonatal Unit of Bonsucesso Federal Hospital from July 2005 to July 2006. The infants underwent two-dimensional color Doppler echocardiography, being the right ventricular myocardial performance index evaluated close to hospital discharge. We compared the neonatal and echocardiographic variables in neonates with and without bronchopulmonary dysplasia. RESULTS: A total of 81 exams were analyzed. The mean birth (standard deviation) weight and gestational age were 1,140 (235) g and 30 (2.2) weeks, respectively. The incidence of bronchopulmonary dysplasia was 32%. The mean right ventricle myocardial performance index (standard deviation) of the sample was 0.13 (0.06). We found a significant difference in aortic diameter [non-bronchopulmonary dysplasia 0.79 (0.07) vs. bronchopulmonary dysplasia 0.87 (0.11) cm, p=0.003], left ventricle in diastole [non-bronchopulmonary dysplasia 1.4 (0.19) vs. bronchopulmonary dysplasia 1.59 (0.21) cm, p=0.0006], ventricular septal thickness [non-bronchopulmonary dysplasia 0.23 (0.03) vs. bronchopulmonary dysplasia 0.26 (0.05) cm, p=0.032], and "a" measurement [(= sum of the isovolumetric contraction time, ejection time, and isovolumetric relaxation time) when calculating the myocardial performance index (p=0.01)]. CONCLUSION: Higher "a" interval in neonates with bronchopulmonary dysplasia suggests right ventricle diastolic dysfunction. We conclude that the right ventricle myocardial performance index is an important indicator both of ventricular function and for serial follow-up testing of very low birth weight premature neonates, especially those with bronchopulmonary dysplasia.

Tumores cardíacos pediátricos: características de imagens ecocardiográficas / Pediatric cardiac tumors: echocardiographic imaging features

Tumores cardíacos (TC) em crianças são lesões muito raras, mas seu diagnóstico é fundamental para a conduta adotada para o paciente. A ecocardiografia é a modalidade de imagem cardiovascular mais utilizada na prática clínica para o diagnóstico inicial de TC em pacientes pediátricos. Conhecer as características ecocardiográficas das TCs pode possibilitar um diagnóstico cada vez mais precoce e a identificação de sua etiologia mais provável. Os TCs primários e benignos são os mais frequentes na população pediátrica. Entre os TCs benignos, os mais frequentes em fetos e neonatos são rabdomiomas e teratomas. Em crianças e adolescentes, rabdomiomas e fibromas são os mais comuns. Neste artigo, descrevemos as características ecocardiográficas dos principais TCs em idades pediátricas.(AU)

Cardiac tumors (CTs) in children are very rare, but their diagnosis is crucial for patient management. Echocardiography is the most commonly used cardiovascular imaging modality in clinical practice for the initial diagnosis of CTs in pediatric patients. Knowing the echocardiographic characteristics of CTs can enable an increasingly early diagnosis and the identification of its most likely etiology. Primary and benign CTs are the most frequent types in the pediatric population. Among benign CTs, the most frequent in fetuses and neonates are rhabdomyomas and teratomas. In children and adolescents, rhabdomyomas and fibromas are more common. Here we describe the echocardiographic characteristics of the most common CTs in pediatric patients.(AU)

Spectral Doppler, tissue Doppler, and speckle-tracking echocardiography for the evaluation of fetal cardiac function: an update / Doppler espectral, Doppler tecidual e speckle-tracking para avaliação da função cardíaca fetal: uma revisão atualizada

Abstract The functional assessment of the fetal heart has been incorporated into cardiac ultrasound screening as a routine procedure, encompassing fetuses with and without structural heart diseases. It has long been known that various cardiac and extracardiac conditions, such as fetal growth restriction, fetal tumors, twin-to-twin transfusion syndrome, fetal anemia, diaphragmatic hernia, arteriovenous fistula with high cardiac output, and congenital heart diseases (valvular regurgitation and primary myocardial disease), can alter hemodynamic status and fetal cardiac function. Several ultrasound and Doppler echocardiographic parameters of fetal cardiovascular disease have been shown to correlate with perinatal mortality. However, it is still difficult to identify the signs of fetal heart failure and to determine their relationship with prognosis. The aim of this study was to review the main two-dimensional Doppler ultrasound parameters that can be used in the evaluation of fetal cardiac function, with a focus on how to perform that evaluation and on its clinical applicability.

Resumo A avaliação funcional do coração fetal foi incorporada ao rastreamento ultrassonográfico como procedimento de rotina, englobando fetos com e sem cardiopatias estruturais. Sabe-se, tradicionalmente, que várias condições cardíacas e extracardíacas podem alterar o estado hemodinâmico e a função cardíaca fetal, como restrição do crescimento fetal, tumores fetais, síndrome de transfusão feto-fetal, anemia fetal, hérnia diafragmática congênita, fístula arteriovenosa com alto débito cardíaco e cardiopatias congênitas (insuficiência valvar, doença primária do miocárdio). Vários parâmetros ecocardiográficos da doença cardiovascular fetal obtidos por ultrassonografia e Doppler têm sido correlacionados com a mortalidade perinatal. No entanto, ainda é difícil determinar a presença de sinais de insuficiência cardíaca fetal e sua relação com o prognóstico. Este estudo teve como objetivo revisar os principais parâmetros bidimensionais da ultrassonografia Doppler que podem ser utilizados na avaliação da função cardíaca fetal, com foco em como realizar essa avaliação e sua aplicabilidade clínica.

Taquicardia sinusal inapropriada: o papel da ecocardiografia fetal transvaginal: relato de caso / Inappropriate sinus tachycardia: the role of trasvaginal fetal echocardiography: case report / Taquicardia Sinusal Inapropiada: El papel de la Ecocardiografía Fetal Transvaginal ­ Relato del Caso

Introdução: A taquicardia sinusal inapropriada é rara na população em geral, tem maior prevalência em mulheres jovens e sua etiologia é desconhecida. Caracteriza-se por uma frequência cardíaca, persistentemente, elevada com uma resposta exagerada à atividade física. Objetivo: Relatar um caso raro de taquicardia sinusal inapropriada em fase precoce da gestação, enfatizando a importância da ecocardiografia fetal transvaginal. Relato de caso: Gestante encaminhada para realização de ecocardiografia transvaginal por taquicardia fetal persistente. Ao exame de nove semanas, o feto apresentava uma FC de 240 batimentos por minuto (bpm), com condução atrioventricular de um para um e sem sinais de hidropisia. Utilizados a digoxina e, posteriormente, o flecainide, ambos sem sucesso terapêutico. Iniciado sotatol com redução gradual e posterior normalização da FC fetal. O parto ocorreu a termo, concepto nasceu bem e evoluiu com taquicardia persistente. O eletrocardiograma realizado demonstrou onda P com morfologia de ritmo sinusal. As possíveis causas de taquicardia sinusal foram afastadas, confirmando assim o diagnóstico acima. Comentários: O autor reforça a importância da ecocardiografia fetal transvaginal para o diagnóstico e tratamento precoce de arritmias fetais, evitando complicações.

Introduction: The inappropriate sinus tachycardia is rare in the general population, more frequently affects young women, and its etiology is unknow. It is characterized by a persistently elevated cardiac frequency with na exaggerated response to physical activity. Objective: Report a rare case of inappropriate sinus tachycardia in the early phase of pregnancy and emphasize the importance of transvaginal fetal echocardiography. Case report: Pregnant referred due to persistente fetal tachycardia after obstretic ultrasonography. The transvaginal echocardiogram performed at 9 weeks' gestation showed a fetal heart rate of 240 beats min (bpm) with normal conduction from atria to ventricle (1:1)and no signal hydropsy. Digoxin therapy and Flecainide were used with no sucess. Sotatol use was chose when the fetal heart rate (HR) reduced to tolerable levels and then the number of heartbeats normalized at thirty six weeks gestation. The baby was born well at term and developed persistente tachycardia. The electrocardiogram performed showed P-ware morphology of sinus rhythm. Possible causes of sinus tachycardia were excluded, thus confirming the diagnosis above. Comments: The author describes the imortance of transvaginal fetal echocardiography for the diagnosis and early treatment of fetal arrhythmias avoiding complications.

Introducción: La taquicardia sinusal inapropiada es rara en la población en general, predomina mayormente en mujeres jóvenes y su etiología es desconocida. Se caracteriza por una frecuencia cardíaca, persistentemente, elevada con una respuesta exagerada a la actividad física. Objetivo: Relatar un caso raro de taquicardia sinusal inapropiada en fase precoz de la gestación, enfatizando la importancia de la ecocardiografía fetal transvaginal. Relato del caso: Gestante derivada para la realización del ecocardiograma transvaginal por taquicardia fetal persistente. En el examen de nueve semanas, el feto presentaba una FC de 240 latidos por minuto (lpm), con conducción aurículoventricular de uno para uno y sin señales de hidropesía. Se utilizó la digoxina y, posteriormente, el flecainide, ambos sin éxito terapéutico. Iniciado sotatol con reducción gradual y posterior normalización de FC fetal. El parto ocurrió a término, nació bien y evolucionó con taquicardia persistente. El electrocardiograma realizado demostró onda P con morfología de ritmo sinusal. Las posibles causas de taquicardia sinusal se eliminaron, confirmando así el diagnóstico señalado. Comentarios: El autor refuerza la importancia de la ecocardiografía fetal transvaginal para el diagnóstico y tratamiento precoz de arritmias fetales, evitando complicaciones