Mark Sklansky

Spatio‐temporal image correlation (STIC): new technology for evaluation of the fetal heart

Spatio‐temporal image correlation (STIC) is a new approach for clinical assessment of the fetal heart. It offers an easy to use technique to acquire data from the fetal heart and to aid in visualization with both two‐dimensional and three‐dimensional (3D) cine sequences. The acquisition is performed in two steps: first, images are acquired by a single, automatic volume sweep. Second, the system analyzes the image data according to their spatial and temporal domain and processes an online dynamic 3D image sequence that is displayed in a multiplanar reformatted cross‐sectional display and/or a surface rendered display. The examiner can navigate within the heart, re‐slice, and produce all of the standard image planes necessary for a comprehensive diagnosis. The advantages of STIC for use in evaluation of the fetal heart are as follows: the technique delivers a temporal resolution which corresponds to a B‐mode frame rate of approximately 80 frames/s; it provides the examiner with an unlimited number of images for review; it allows for correlation between image planes that are perpendicular to the main image acquisition plane; it may shorten the evaluation time when complex heart defects are suspected; it enables the reconstruction of a 3D rendered image that contains depth and volume which may provide additional information that is not available from the thin multiplanar image slices (e.g. for pulmonary veins, septal thickness); it lends itself to storage and review of volume data by the examiner or by experts at a remote site; it provides the examiner with the ability to review all images in a looped cine sequence. Copyright

Diagnosis and Treatment of Fetal Cardiac Disease A Scientific Statement From the American Heart Association

Background— The goal of this statement is to review available literature and to put forth a scientific statement on the current practice of fetal cardiac medicine, including the diagnosis and management of fetal cardiovascular disease. Methods and Results— A writing group appointed by the American Heart Association reviewed the available literature pertaining to topics relevant to fetal cardiac medicine, including the diagnosis of congenital heart disease and arrhythmias, assessment of cardiac function and the cardiovascular system, and available treatment options. The American College of Cardiology/American Heart Association classification of recommendations and level of evidence for practice guidelines were applied to the current practice of fetal cardiac medicine. Recommendations relating to the specifics of fetal diagnosis, including the timing of referral for study, indications for referral, and experience suggested for performance and interpretation of studies, are presented. The components of a fetal echocardiogram are described in detail, including descriptions of the assessment of cardiac anatomy, cardiac function, and rhythm. Complementary modalities for fetal cardiac assessment are reviewed, including the use of advanced ultrasound techniques, fetal magnetic resonance imaging, and fetal magnetocardiography and electrocardiography for rhythm assessment. Models for parental counseling and a discussion of parental stress and depression assessments are reviewed. Available fetal therapies, including medical management for arrhythmias or heart failure and closed or open intervention for diseases affecting the cardiovascular system such as twin–twin transfusion syndrome, lung masses, and vascular tumors, are highlighted. Catheter-based intervention strategies to prevent the progression of disease in utero are also discussed. Recommendations for delivery planning strategies for fetuses with congenital heart disease including models based on classification of disease severity and delivery room treatment will be highlighted. Outcome assessment is reviewed to show the benefit of prenatal diagnosis and management as they affect outcome for babies with congenital heart disease. Conclusions— Fetal cardiac medicine has evolved considerably over the past 2 decades, predominantly in response to advances in imaging technology and innovations in therapies. The diagnosis of cardiac disease in the fetus is mostly made with ultrasound; however, new technologies, including 3- and 4-dimensional echocardiography, magnetic resonance imaging, and fetal electrocardiography and magnetocardiography, are available. Medical and interventional treatments for select diseases and strategies for delivery room care enable stabilization of high-risk fetuses and contribute to improved outcomes. This statement highlights what is currently known and recommended on the basis of evidence and experience in the rapidly advancing and highly specialized field of fetal cardiac care.

The ‘spin’ technique: a new method for examination of the fetal outflow tracts using three‐dimensional ultrasound

The prenatal detection of congenital heart defects remains one of the most difficult challenges for the sonologist/sonographer when performing the second‐ or third‐trimester screening examination. The four‐chamber view has been used for a number of years as the primary screening image for detection of heart defects, but the inclusion of the right and left outflow tracts increases the detection of cardiac malformations. One of the difficulties, however, is obtaining and interpreting two‐dimensional images of the outflow tracts. This paper reviews a new technique using three‐dimensional (3D) multiplanar imaging that allows the examiner to identify the outflow tracts within a few minutes of acquiring the 3D volume dataset by rotating the volume dataset around the x‐ and y‐axes.

Prenatal screening for congenital heart disease using real-time three-dimensional echocardiography and a novel 'sweep volume' acquisition technique

Conventional prenatal screening for congenital heart disease (CHD) involves a time‐consuming and highly operator‐dependent acquisition of the four‐chamber view and outflow tracts. By acquiring the entire fetal heart instantaneously as a single volume, real‐time three‐dimensional echocardiography (RT3DE) may facilitate fetal cardiac screening.

ACCF/AHA/AAP recommendations for training in pediatric cardiology

SUMMARY It is vital to the future intellectual health of cardiovascularmedicine and the welfare of pediatric patients with cardiovas-cular disease that all future pediatric cardiologists be familiarwith the principles and tools of research. Training in researchrequires the intense involvement of productive and establishedinvestigators. Those trainees preparing for a career in investi-gative cardiology require a carefully developed but flexibleeducational plan that will permit them to be successful in theirresearch careers over an extended period. REFERENCES 1. Sonnenblick EH, Ryan TI, Starke RD. Task force 7: training incardiovascular research. J Am Coll Cardiol 1995;25:25–8.2. Roberts R, Alexander RW, Loscalzo J, Williams RS. Task force 7:training in cardiovascular research. Available at: http://www.acc.org/clinical/training/cocats2.pdf 2002. Accessed August 10, 2004.3. NHLBI Task Force Report on Pediatric Cardiovascular Diseases.Available at: http://www.nhlbi.nih.gov/resources/docs/pediatric_cvd.pdf.Accessed August 10, 2004.

Real-time 3-dimensional fetal echocardiography with an instantaneous volume-rendered display early description and pictorial essay

Objective. Random fetal motion, rapid fetal heart rates, and cumbersome processing algorithms have limited reconstructive approaches to 3‐dimensional fetal cardiac imaging. Given the recent development of real‐time, instantaneous volume‐rendered sonographic displays of volume data, we sought to apply this technology to fetal cardiac imaging. Methods. We obtained 1 to 6 volume data sets on each of 30 fetal hearts referred for formal fetal echocardiography. Each volume data set was acquired over 2 to 8 seconds and stored on the systems hard drive. Rendered images were subsequently processed to optimize translucency, smoothing, and orientation and cropped to reveal “surgeons eye views” of clinically relevant anatomic structures. Qualitative comparison was made with conventional fetal echocardiography for each subject. Results. Volume‐rendered displays identified all major abnormalities but failed to identify small ventricular septal defects in 2 patients. Important planes and views not visualized during the actual scans were generated with minimal processing of rendered image displays. Volume‐rendered displays tended to have slightly inferior image quality compared with conventional 2‐dimensional images. Conclusions. Real‐time 3‐dimensional echocardiography with instantaneous volume‐rendered displays of the fetal heart represents a new approach to fetal cardiac imaging with tremendous clinical potential.

Advances in Fetal Cardiac Imaging

During the past 25 years, two-dimensional imaging of the fetal heart has evolved into a sophisticated and widely practiced clinical tool, but most heart disease still goes undetected until sometime after birth, despite routine fetal ultrasound evaluations. Over the next 25 years, tremendous advances in fetal cardiac imaging, including three-dimensional imaging, promise to revolutionize both the prenatal detection and diagnosis of congenital heart disease. Image resolution continues to improve year after year, allowing earlier (10-15 week) visualization of the fetal heart, as well as the detection of subtle valvar abnormalities that may progress to serious forms of ventricular hypoplasia at term. However, fetal cardiac imaging remains constrained by limited sonographic windows. To improve the prenatal detection of congenital heart disease, outflow tracts are increasingly included along with the routine screening four-chamber view. However, while the four-chamber view resides within a single plane, lending itself to tomographic evaluation with two-dimensional ultrasound, the outflow tracts (and most forms of congenital heart disease) do not reside within a single plane. For these and other reasons, three-dimensional imaging of the fetal heart ultimately may improve the detection of outflow tract abnormalities, and facilitate comprehension of complex forms of congenital heart disease. Finally, other imaging modalities, including but not limited to Doppler tissue imaging and magnetic resonance imaging, continue to evolve and to complement two- and three-dimensional sonographic imaging of the fetal heart. As a result of these ongoing advances in the prenatal detection and assessment of congenital heart disease, these are exciting and glorious times for the field of fetal cardiac imaging.

ACCF/AHA/AAP recommendations for training in pediatric cardiology: A report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence (ACC/AHA/AAP Writing Committee to Develop Training Recommendations for Pediatric Cardiology)

SUMMARY It is vital to the future intellectual health of cardiovascularmedicine and the welfare of pediatric patients with cardiovas-cular disease that all future pediatric cardiologists be familiarwith the principles and tools of research. Training in researchrequires the intense involvement of productive and establishedinvestigators. Those trainees preparing for a career in investi-gative cardiology require a carefully developed but flexibleeducational plan that will permit them to be successful in theirresearch careers over an extended period. REFERENCES 1. Sonnenblick EH, Ryan TI, Starke RD. Task force 7: training incardiovascular research. J Am Coll Cardiol 1995;25:25–8.2. Roberts R, Alexander RW, Loscalzo J, Williams RS. Task force 7:training in cardiovascular research. Available at: http://www.acc.org/clinical/training/cocats2.pdf 2002. Accessed August 10, 2004.3. NHLBI Task Force Report on Pediatric Cardiovascular Diseases.Available at: http://www.nhlbi.nih.gov/resources/docs/pediatric_cvd.pdf.Accessed August 10, 2004.

Outcomes of critical congenital heart disease requiring emergent neonatal cardiac intervention.

The aim of this study was to evaluate outcomes for neonates with critical congenital heart disease (CHD) requiring emergent neonatal cardiac intervention (ENCI).

Prenatal diagnosis of congenital heart disease: impact of mode of delivery on neonatal outcome

We sought to evaluate the impact of mode of delivery (MOD) on early outcome for neonates diagnosed prenatally with major forms of congenital heart disease (CHD).