Marina Maccagnano Zamith

Heart stroke volume, cardiac output, and ejection fraction in 265 normal fetus in the second half of gestation assessed by 4D ultrasound using spatio-temporal image correlation

Objectives. The aim of this study was to establish nomograms for fetal stroke volume (SV), cardiac output (CO), and ejection fraction (EF) using four-dimensional ultrasound with spatio-temporal image correlation (STIC) modality. Methods. The fetal heart was scanned using STIC modality, starting with classic four-chamber view plane, during fetal quiescence with abdomen uppermost, at an angle of 20–30°, without color Doppler flow mapping. In post-processing virtual organ, computer-aided analysis technique was used to obtain a sequence of six sections of each ventricular volume in end-systolic volume (ESV) and end-diastolic volume (EDV). The SV (SV = EDV–ESV), CO (CO = SV × fetal heart rate), and EF (EF = SV/EDV) for each ventricle were then calculated. Intra- and interobserver agreement were then calculated. Results. Two hundred sixty-five fetuses, ranging in gestational age (GA) from 20 to 34+6 weeks, were included in the study. The left and right SV and CO increased exponentially with gestation and EF remained fairly stable through gestational. Mean left and right SV increased from 0.211 ml and 0.220 ml at 20 weeks to 1.925 ml and 2.043 ml, respectively, at 34 weeks. Mean left and right CO increased from 30.25 ml/min and 31.52 ml/min at 20 weeks to 268.49 ml/min and 287.80 ml/min, respectively, at 34 weeks. Both left and right mean EF remained constant at around 0.63 with advancing GA. Nomograms were created for LSV, RSV, LCO, RCO, LEF, and REF vs. gestational age. Intra- and interobserver agreement reached 95%. Conclusions. Four-dimensional ultrasound using STIC represents a simple and reproducible method for estimating fetal cardiac function. STIC seems to overcome many of the pitfalls of conventional ultrasound methods and has the potential to become the method of choice.

O papel da translucência nucal no rastreamento de cardiopatias congênitas

OBJECTIVE Assess the accuracy of the nuchal translucency (NT) measurement between 11 and 13 weeks and 6 days of gestation as a sonographic marker to screen for congenital heart defects (CHD). METHODS This is a multi-center retrospective study in which singleton gestations of euploid fetuses were analyzed. NT measurement was performed in the first trimester examination when the fetal crown-rump length (CRL) was 45 to 84 mm, according to the criteria established by the Fetal Medicine Foundation. The cases were followed up to one month postpartum to assess the presence of CHD. RESULTS Three thousand six hundred and sixty four gestations were analyzed, of which twenty newborn infants had some congenital heart defect up to the first month of life (prevalence of 0.55%). The median NT in fetuses with CHD was 1.70 mm, and 1.60 mm in fetuses without CHD. However no statistically significant difference was observed between the two medians (Mann-Whitney test, p > 0.05). The NT sensitivity to detect CHD ranged from 15% to 20%, with a probability of false positive cases of 86.4% to 97.9%, depending on the cut-off point used. Odds ratio for CHD was high when compared to the classical indications for fetal echocardiography, ranging from 4.7 to 33.7, according to the cut-off point used. CONCLUSION Despite the low sensitivity of the test, increased NT is an important risk factor for CHD, and should be included in the strategy of prenatal screening for these diseases.

Reference curve of the fetal ventricular septum area by the STIC method: preliminary study

FUNDAMENTO: A deteccao precoce de alteracoes septais, tais como a hipertrofia septal comumente presente em fetos de maes diabeticas, contribuiria para a reducao das altas taxas de mortalidade infantil. OBJETIVO: Determinar intervalos de referencia para a area do septo interventricular fetal por meio da ultrassonografia tridimensional (US3D) utilizando o metodo STIC (Spatio-Temporal Image Correlation). METODOS: Realizou-se um estudo de corte transversal com 69 gestantes normais entre a 18a e 33a semanas de gestacao. Utilizou-se como referencia o plano de quatro câmaras com a ROI (Regiao de Interesse) posicionada a partir dos ventriculos, sendo a area do septo delimitada de modo manual. Para se avaliar a correlacao da area do septo interventricular com a idade gestacional (IG), construiram-se diagramas de dispersao e calculou-se o coeficiente de correlacao de Pearson (r), sendo o ajuste realizado pelo coeficiente de determinacao (R2). Foram calculadas medias, medianas, desvios-padrao (dp), valores maximo e minimo. Para o calculo da reprodutibilidade intraobservador, utilizou-se o coeficiente de correlacao intraclasse (CCI). Obteve-se a medida da espessura do septo interventricular e ela foi correlacionada com a IG e a area septal obtida pelo modo renderizado em 52 pacientes utilizando-se o CCI. RESULTADOS: A area do septo interventricular foi altamente correlacionada com a idade gestacional (r = 0,81), e a media aumentou de 0,47 cm2 na 18a para 2,42 cm2 na 33a semana de gestacao. A reprodutibilidade intraobservador foi excelente com CCI = 0,994. Nao se observou correlacao significativa entre a medida do septo interventricular e a IG (R² = 0,200), assim como nao houve correlacao com a area do septo obtida pelo modo renderizado com CCI = 0,150. CONCLUSAO: Intervalos de referencia para a area do septo interventricular entre a 18a e 33a semanas de gestacao foram determinados e se mostraram altamente reprodutiveis.BACKGROUND Early detection of septal changes such as septal hypertrophy commonly present in fetuses of diabetic mothers would help reduce the high rates of infant mortality. OBJECTIVE Determine reference ranges for the fetal ventricular septal area through three-dimensional ultrasound (US3D) using the STIC method (Spatio-Temporal Image Correlation). METHODS We conducted a cross-sectional study with 69 pregnant women between the 18th and 33rd weeks of pregnancy. We used as a reference the four-chamber plane with the ROI (Region of Interest) positioned from the ventricles; the septum area were manually marked. To assess the correlation of the interventricular septum area with gestational age (GA), we constructed scatter plots and calculated Pearsons correlation coefficient (r), and the adjustment was performed by the coefficient of determination (R²). We calculated averages, medians, standard deviations (sd), as well as maximum and minimum values. To calculate the intraobserver reproducibility, we used the intraclass correlation coefficient (ICC). The interventricular septum thickness was measured and it was correlated with gestational age and the septal area rendered in 52 patients using the ICC. RESULTS The interventricular septum area was highly correlated with gestational age (r = 0.81), and the average increased from 0.47 cm² in the 18th week to 2.42 cm² in the 33rd of gestation. The intraobserver reproducibility was excellent with ICC = 0.994. No significant correlation was observed between the interventricular septum measurement and the GA (R² = 0.200), as well as there was no correlation with the septal area rendered with ICC = 0.150. CONCLUSION Reference intervals for the interventricular septum area between the 18th and the 33rd pregnancy week were determined to be highly reproducible.

Screening of Congenital Heart Diseases by Three‐Dimensional Ultrasound Using Spatiotemporal Image Correlation: Influence of Professional Experience

To evaluate the feasibility of the use of spatiotemporal image correlation (STIC) as a screening program for congenital heart disease and the influence of professional experience in those examinations.

Assessment of the fetal mitral and tricuspid valves areas development by three-dimensional ultrasonography.

PURPOSE: to evaluate the areas of the atrioventricular valves (tricuspid and mitral) of normal fetuses by the use of three-dimensional ultrasound (3DUS) and the spatiotemporal image correlation (STIC) method. METHODS: a cross-sectional study was conducted on 141 women between the 18th and the 33rd week of pregnancy. Cardiac volumes were measured with a volumetric transabdominal transducer attached to the Voluson 730 Expert equipment. The four chamber plane was used as reference, with the region of interest (ROI) positioned from the ventricles, and the area of the valves was obtained manually. To determine the correlation of the areas with gestational age, scatter plots were constructed and the Pearson correlation coefficient (r) was calculated. Means, medians, standard deviations (SD) and maximum and minimum values were calculated. The simple linear regression model was used to determine reference ranges of valve areas according to the gestational age by the Altman method, with the level of significance set at p<0.05. To calculate the intraobserver reproducibility, we used the intraclass correlation coefficient (ICC) and the Bland-Altman graph. RESULTS: the mitral and tricuspid valve areas were correlated to the gestational age (r=0.80 for the tricuspid and r=0.79 for the mitral valve) and the mean value of the tricuspid and mitral valves increased from 0.22±0.10 cm2 and 0.23±0.10 cm2 on the 18th week to 0.92±0.29 cm2 and 1.08±0.41 cm2 on the 33rd of pregnancy, respectively. The intraobserver reproducibility resulted in an ICC=0.993 (95%CI 0.987; 0.996) and the mean difference was 0.01 cm2 (SD±0.2 cm2 and CI95%±0.4 cm2). CONCLUSION: reference intervals for the areas of the mitral and tricuspid valve between the 18th and the 33rd week of gestation were determined and proved to be highly reproducible.PURPOSE to evaluate the areas of the atrioventricular valves (tricuspid and mitral) of normal fetuses by the use of three-dimensional ultrasound (3DUS) and the spatiotemporal image correlation (STIC) method. METHODS a cross-sectional study was conducted on 141 women between the 18th and the 33rd week of pregnancy. Cardiac volumes were measured with a volumetric transabdominal transducer attached to the Voluson 730 Expert equipment. The four chamber plane was used as reference, with the region of interest (ROI) positioned from the ventricles, and the area of the valves was obtained manually. To determine the correlation of the areas with gestational age, scatter plots were constructed and the Pearson correlation coefficient (r) was calculated. Means, medians, standard deviations (SD) and maximum and minimum values were calculated. The simple linear regression model was used to determine reference ranges of valve areas according to the gestational age by the Altman method, with the level of significance set at p<0.05. To calculate the intraobserver reproducibility, we used the intraclass correlation coefficient (ICC) and the Bland-Altman graph. RESULTS the mitral and tricuspid valve areas were correlated to the gestational age (r=0.80 for the tricuspid and r=0.79 for the mitral valve) and the mean value of the tricuspid and mitral valves increased from 0.22 ± 0.10 cm² and 0.23 ± 0.10 cm² on the 18th week to 0.92 ± 0.29 cm² and 1.08 ± 0.41 cm² on the 33rd of pregnancy, respectively. The intraobserver reproducibility resulted in an ICC=0.993 (95%CI 0.987; 0.996) and the mean difference was 0.01 cm² (SD ± 0.2 cm² and CI95% ± 0.4 cm²). CONCLUSION reference intervals for the areas of the mitral and tricuspid valve between the 18th and the 33rd week of gestation were determined and proved to be highly reproducible.

Fetal cardiac function assessed by spatio-temporal image correlation

BackgroundThree-dimensional (3D) and four-dimensional (4D) ultrasound have been proposed to be valuable tools for the examination of fetal heart. Spatio-temporal image correlation (STIC) is a technique that adds a time component to 3D ultrasound imaging of the fetal heart, so we can evaluate cardiac structures as a 4D cine sequence containing information of one full cardiac cycle. STIC gives the investigator the opportunity to freeze the displayed cardiac loop in end-diastolic and end-systolic phases. By STIC, 3D measurements of both the left and right ventricle can be used to calculate fetal heart stroke volume, cardiac output and ejection fraction, and expressions of cardiac function. The ultimate goal of STIC technique is to improve fetal cardiac function analysis by decreasing the dependency on operator skills required by two-dimensional ultrasound.ContextIn this article, we describe literature practical approach for the examination of the fetal heart function using 4D ultrasound by STIC technique.

Nova bandagem ajustável das artérias pulmonares na Síndrome de Hipoplasia de Câmaras Esquerdas

Objective: Hypoplastic left heart syndrome remains a challenge for worldwide surgeons. Initial palliation employing bilateral pulmonary artery banding along with ductal stent implantation and atrial septostomy has been proposed as an alternative approach. However, the surgically placed bands are fixed and may become inadequate after sternum closure or with somatic growth of the patient. We describe the first case in which a neonate with hypoplastic left heart syndrome was initially managed using a mini banding system that allows for fine percutaneous adjustments of pulmonary blood flow. Method: Through a mid sternotomy, a 5 day-old neonate underwent bilateral pulmonary artery banding using this new system combined with placement of a main pulmonary artery to innominate artery shunt. Results: The patient had an uneventful postoperative course. Three percutaneous adjustments of the banding system were necessary to keep the arterial oxygen saturation in the 75%-85% range. On the 48 th day of life, she was

Assessment of modified myocardial performance index in foetuses with growth restriction

AIM To evaluate the modified myocardial performance index (Mod-MPI) in foetuses with growth restriction and compare this index with appropriate for gestational age foetuses. MATERIAL AND METHODS A prospective cross-sectional case-control study was conducted involving 76 singleton foetuses between 24 and 34 weeks of gestation divided into three groups (24 appropriate growth foetuses, 30 foetuses with estimated weight between the 3rd and 10th percentiles and 22 foetuses with estimated weight < 3rd percentile, according to the Hadlock table). The Mod-MPI was obtained in the plane of the four chamber view, and the spectral Doppler sample volume was placed in the lateral wall of the aorta, close to the mitral valve. Doppler of umbilical artery was normal in all cases. Analysis of variance (ANOVA) was used to compare the groups and the intra-class correlation coefficient (ICC) was used to assess intra- and inter-observer reproducibility. RESULTS The mean Mod-MPI in the groups of appropriate for gestational age, estimated weight between the 3rd and 10th percentiles, and estimated weight < 3rd percentile was 0.32 +/- 0.05, 0.35 +/- 0.05 and 0.36 +/- 0.06, respectively; there was no statistical difference between the groups (p = 0.072). There was good intra- and inter-observer reproducibility (ICC = 0.726 and 0.760, respectively). CONCLUSION Mod-MPI was not significantly different between foetuses appropriate for gestational age and those with growth restriction. Mod-MPI proved to be a feasible and reproducible technique.

Curva de referência da área do septo interventricular fetal pelo método STIC: estudo preliminar

FUNDAMENTO: A deteccao precoce de alteracoes septais, tais como a hipertrofia septal comumente presente em fetos de maes diabeticas, contribuiria para a reducao das altas taxas de mortalidade infantil. OBJETIVO: Determinar intervalos de referencia para a area do septo interventricular fetal por meio da ultrassonografia tridimensional (US3D) utilizando o metodo STIC (Spatio-Temporal Image Correlation). METODOS: Realizou-se um estudo de corte transversal com 69 gestantes normais entre a 18a e 33a semanas de gestacao. Utilizou-se como referencia o plano de quatro câmaras com a ROI (Regiao de Interesse) posicionada a partir dos ventriculos, sendo a area do septo delimitada de modo manual. Para se avaliar a correlacao da area do septo interventricular com a idade gestacional (IG), construiram-se diagramas de dispersao e calculou-se o coeficiente de correlacao de Pearson (r), sendo o ajuste realizado pelo coeficiente de determinacao (R2). Foram calculadas medias, medianas, desvios-padrao (dp), valores maximo e minimo. Para o calculo da reprodutibilidade intraobservador, utilizou-se o coeficiente de correlacao intraclasse (CCI). Obteve-se a medida da espessura do septo interventricular e ela foi correlacionada com a IG e a area septal obtida pelo modo renderizado em 52 pacientes utilizando-se o CCI. RESULTADOS: A area do septo interventricular foi altamente correlacionada com a idade gestacional (r = 0,81), e a media aumentou de 0,47 cm2 na 18a para 2,42 cm2 na 33a semana de gestacao. A reprodutibilidade intraobservador foi excelente com CCI = 0,994. Nao se observou correlacao significativa entre a medida do septo interventricular e a IG (R² = 0,200), assim como nao houve correlacao com a area do septo obtida pelo modo renderizado com CCI = 0,150. CONCLUSAO: Intervalos de referencia para a area do septo interventricular entre a 18a e 33a semanas de gestacao foram determinados e se mostraram altamente reprodutiveis.BACKGROUND Early detection of septal changes such as septal hypertrophy commonly present in fetuses of diabetic mothers would help reduce the high rates of infant mortality. OBJECTIVE Determine reference ranges for the fetal ventricular septal area through three-dimensional ultrasound (US3D) using the STIC method (Spatio-Temporal Image Correlation). METHODS We conducted a cross-sectional study with 69 pregnant women between the 18th and 33rd weeks of pregnancy. We used as a reference the four-chamber plane with the ROI (Region of Interest) positioned from the ventricles; the septum area were manually marked. To assess the correlation of the interventricular septum area with gestational age (GA), we constructed scatter plots and calculated Pearsons correlation coefficient (r), and the adjustment was performed by the coefficient of determination (R²). We calculated averages, medians, standard deviations (sd), as well as maximum and minimum values. To calculate the intraobserver reproducibility, we used the intraclass correlation coefficient (ICC). The interventricular septum thickness was measured and it was correlated with gestational age and the septal area rendered in 52 patients using the ICC. RESULTS The interventricular septum area was highly correlated with gestational age (r = 0.81), and the average increased from 0.47 cm² in the 18th week to 2.42 cm² in the 33rd of gestation. The intraobserver reproducibility was excellent with ICC = 0.994. No significant correlation was observed between the interventricular septum measurement and the GA (R² = 0.200), as well as there was no correlation with the septal area rendered with ICC = 0.150. CONCLUSION Reference intervals for the interventricular septum area between the 18th and the 33rd pregnancy week were determined to be highly reproducible.

OP07.07: Ventricular volumetry, heart stoke volume, cardiac output and ejection fraction obtained by STIC: comparison between fetal sex

Objectives: The ductus arteriosus (DA) emerged from the pulmonary trunk and connects with the descending aorta. The normal Doppler evaluation depends on gestational age and the pulsatility index (PI) must be greater than 1.9. Anatomical and functional problems can occur as aneurysm of DA and DA with restrictive flow. DA anatomical changes can be caused by changes in blood flow and / or morphology of DA especially in the last trimester. Methods: Description of cases: 10 cases of anatomical changes of DA in fetuses with gestational age (GA) ranging from 28 to 37 weeks: 2 aneurysms DA (diameters of 5 and 8 mm) and 8 with morphological alteration with elongated, tortuous duct but with normal diameter with no points of constriction. Doppler flow changes was present with systolic velocity > 155 cm/s IP ranging from 1.7 to 2.5. Predominance of right heart chambers and tricuspid regurgitation was presented in 3 fetuses. ControI examinations were performed weekly or every two weeks. Results: Four women were found on routine obstetric ultrasound and three with suspected restrictive DA in previous fetal echo. One patient presented an excessive intake of grape juice, no use of drugs NSAIDs. All newborns born at term without significant symptoms and evolved with spontaneous closure of the DA. Conclusions: Changes of morphology in DA can be identified in the third trimester mainly because in this period the arteries and cardiac output pressures are greater and the proliferation of the intima occurs in DA preparing for postnatal closure. Evaluation with Doppler mainly using the PI help in the differential diagnosis of restrictive ductus arteriosus.