Assessment of the Size and Shape of the 4-Chamber View and the Right and Left Ventricles using Fetal Speckle Tracking in Normal Fetuses at 17-24 Gestational Weeks

Introduction: The aim of the study was to establish normal reference values obtained by fetal speckle tracking analysis of the fetal heart between 17-24 weeks of gestation among Thai fetuses and compare the nomograms with previous studies. Methods: The 4-chamber view of the fetal heart in 79 normal fetuses was analyzed by speckle tracking analysis to determine the best-fit regression model. The 95% reference intervals and Z-score equations of fetal cardiac parameters were computed. Results: The end-diastolic length, width, area, and circumference of the 4-chamber view (4CV) as well as the ventricular end-diastolic length, 24-segment widths, and area were all increased as a function of gestational age (GA) and 5 fetal biometric parameters. In contrast, the global sphericity index (SI), 24-segment SI, and right ventricle/left ventricle width and area ratios did not change with GA or fetal biometric measurements. There were few differences in Z-score reference ranges of fetal cardiac measurements between the current study and previous studies conducted in different patient populations. Conclusion: Our study provided z-score and corresponding centile calculators, 5th and 95th centile reference tables, and corresponding graphs for evaluating the size and shape of the 4CV and the right and left ventricles using 6 independent variables between 17 and 24 weeks of gestation. These results provide normal reference ranges for future studies of fetuses with pathologies that may alter the size and shape of the 4-chamber view and ventricles.

Left Atrial Deformation And Risk of Transient Ischemic Attack And Stroke In Paroxysmal Atrial Fibrillation

Left atrial (LA) remodeling is closely related to cerebral stroke, but the relationship between impaired deformability of LA in early stages and stroke/TIA is not clear. The aim of this study was to evaluate the changes of LA deformability and its relationship with stroke/TIA events by using Speckle Tracking echocardiography. In 365 patients with paroxysmal atrial fibrillation (AF) (318, Non stroke/TIA; 47, stroke/TIA), comprehensive echocardiography was performed by using speckle tracking imaging to calculate mean LA longitudinal strain and strain rate values from apical four chamber view, apical two chamber view and apical three cavity view. The patients in stroke/TIA group had greater ages, a greater proportion of men and lower LA strain rate during left ventricular (LV) early diastole (SRE), and the difference was statistically significant(p<0.05). In the univariate linear regression analysis, the following clinical and conventional echocardiographic parameters each had a significant linear correlation with SRE(p<0.001), they were E/A ratio, LA volume index, body mass index, mean E/e′, LV ejection fraction, age, proportion of hypertension. Through a multiple linear regression analysis, the results show that there is a linear dependence between SRE and E/A ratio, LA volume index and Body mass index. The regression equation is y=-1.430-0.394X1+0.012X2+0.019X3(p<0.001) (y,SRE; X1,E/A ratio; X2,LA volume index; X3,Body mass index).In the multivariate logistic regression analyses, SRE and Sex ratio were independently risk factors stroke/TIA. (SRE, OR 2.945, 95% CI 1.092-7.943, p= 0.033; Sex, OR 0.462, 95% CI 0.230-0.930, p = 0.031)In patients with paroxysmal AF, SRE could reflect the impaired deformability of LA in early stages, and it was associated with the risk of stroke/TIA.

Deficient Myocardial Organization and Pathological Fibrosis in Fetal Aortic Stenosis—Association of Prenatal Ultrasound with Postmortem Histology

In fetal aortic stenosis (AS), it remains challenging to predict left ventricular development over the course of pregnancy. Myocardial organization, differentiation and fibrosis could be potential biomarkers relevant for biventricular outcome. We present four cases of fetal AS with varying degrees of severity and associate myocardial deformation on fetal ultrasound with postmortem histopathological characteristics. During routine fetal echocardiography, speckle tracking recordings of the cardiac four-chamber view were performed to assess myocardial strain as parameter for myocardial deformation. After pregnancy termination, postmortem cardiac specimens were examined using immunohistochemical labeling (IHC) of key markers for myocardial organization, differentiation and fibrosis and compared to normal fetal hearts. Two cases with critical AS presented extremely decreased left ventricular (LV) strain on fetal ultrasound. IHC showed overt endocardial fibro-elastosis, which correlated with pathological fibrosis patterns in the myocardium and extremely disturbed cardiomyocyte organization. The LV in severe AS showed mildly reduced myocardial strain and less severe disorganization of the cardiomyocytes. In conclusion, the degree of reduction in myocardial deformation corresponded with high extent to the amount of pathological fibrosis patterns and cardiomyocyte disorganization. Myocardial deformation on fetal ultrasound seems to hold promise as a potential biomarker for left ventricular structural damage in AS.

Prenatal detection of congenital heart disease - results of a Swedish screening program 2013–2017

Background This report evaluates results of a screening program on prenatal detection of congenital heart defects in a geographical cohort of western Sweden between January 1st, 2013 and June 31st, 2017. During the study period 88,230 children were born in VGR. Methods Retrospective data on pregnant women from the Västra Götaland region that were referred to fetal cardiologists in Gothenburg were retrieved. To determine prenatal detection rate, all neonates who underwent surgery or catheter intervention for a critical congenital heart defect born between January 1st, 2014 and December 31st, 2016 were included. The four-chamber view was implemented into the routine scan in 2009 and implementation of the ISUOG guidelines, including the outflow tracts, started in the region in 2015. Results 113 fetuses received a prenatal diagnosis of a major congenital heart defect. 89% of these were referred because of a suspected cardiac malformation and 88% were diagnosed before 22 completed weeks. 59% of the patients diagnosed before 22 completed weeks opted for termination of pregnancy. During 2014–2016, 61 fetuses had a prenatal diagnosis of a critical congenital heart defect and a further 47 were diagnosed after birth, hence 56% were diagnosed prenatally, 82% for those which had a combination with an extracardiac abnormality and/or chromosomal aberration compared to 50% if an isolated critical congenital heart defect was diagnosed. For single ventricle cardiac defects such as hypoplastic left heart syndrome, double inlet left ventricle and tricuspid atresia, the detection rate was 100%. The detection rate for transposition of the great arteries and coarctation of the aorta was 9 and 18% respectively. Conclusions 56% of all fetuses with a critical congenital heart defect were diagnosed prenatally during 2014–2016 and approximately 53% of all major congenital heart defects 2013–2017 as compared to 13.8% in 2009 in the same region. An increased focus towards the fetal heart in the routine scan improved the prenatal detection rate of major congenital heart defects. The detection of congenital heart defects affecting the four-chamber view seems sufficient, but more training is needed to improve the quality of the examination of the outflow tracts.

A Dense RNN for Sequential Four-Chamber View Left Ventricle Wall Segmentation and Cardiac State Estimation

The segmentation of the left ventricle (LV) wall in four-chamber view cardiac sequential image is significant for cardiac disease diagnosis and cardiac mechanisms study; however, there is no successful reported work on sequential four-chambered view LV wall segmentation due to the complex four-chamber structure and diversity of wall motion. In this article, we propose a dense recurrent neural network (RNN) algorithm to achieve accurately LV wall segmentation in a four-chamber view MRI time sequence. In the cardiac sequential LV wall process, not only the sequential accuracy but also the accuracy of each image matters. Thus, we propose a dense RNN to provide compensation for the first long short-term memory (LSTM) cells. Two RNNs are combined in this work, the first one aims at providing information for the first image, and the second RNN generates segmentation result. In this way, the proposed dense RNN improves the accuracy of the first frame image. What is more is that, it improves the effectiveness of information flow between LSTM cells. Obtaining more competent information from the former cell, frame-wise segmentation accuracy is greatly improved. Based on the segmentation result, an algorithm is proposed to estimate cardiac state. This is the first time that deals with both cardiac time-sequential LV segmentation problems and, robustly, estimates cardiac state. Rather than segmenting each frame separately, utilizing cardiac sequence information is more stable. The proposed method ensures an Intersection over Union (IoU) of 92.13%, which outperforms other classical deep learning algorithms.

Convolutional neural network for semantic segmentation of fetal echocardiography based on four-chamber view

The acute shortage of trained and experienced sonographers causes the detection of congenital heart defects (CHDs) extremely difficult. In order to minimize this difficulty, an accurate fetal heart segmentation to the early location of such structural heart abnormalities prior to delivery is essential. However, the segmentation process is not an easy task due to the small size of the fetal heart structure. Moreover, the manual task for identifying the standard cardiac planes, primarily based on a four-chamber view, requires a well-trained clinician and experience. In this paper, a CNN method using U-Net architecture was proposed to automate fetal cardiac standard planes segmentation from ultrasound images. A total of 519 fetal cardiac images was obtained from three videos. All data is divided into training and testing data. The testing data consist of 106 slices of the four-chamber segmentation tasks, i.e. atrial septal defect (ASD), ventricular septal defect (VSD), and normal. The segmentation of the post-processing method is needed to enhanced the segmentation result. In this paper, a combination technique with U-Net and Otsu thresholding gives the best performances with 99.48%-pixel accuracy, 96.73% mean accuracy, 94.92% mean intersection over union, and 0.21% segmentation error. In the future, the implementation of Deep Learning in the study of CHDs holds significant potential for identifying novel CHDs in heterogeneous fetal hearts.

Lancisi’s Sign: Giant C-V waves with Severe Tricuspid Regurgitation in Isolated Tricuspid Valve Prolapse

IIntroduction Isolated tricuspid valve prolapse (TVP) is a rare finding on transthoracic echocardiography. Right atrial enlargement or prominent ” v ” waves as a consequence of hemodynamic changes in severe tricuspid regurgitation (TR) are rarely seen with isolated TVP. Here is a case of isolated prolapse of anterior tricuspid leaflet presenting with giant C-V waves also known as Lancisi’s sign. Case Report A 66-year-old male presented with increasing exercise limitation and leg edema in recent months and was complaining about the persistent pulsation at his neck and elevated jugular venous pulse with prominent systolic pulsation that represents giant C-V waves, also known as ‘Lancisi’s sign’ consequence of severe TR due to isolated prolapse of the anterior leaflet.The patients’ symptoms resolved completely after tricuspid valve replacement. Discussion TVP is best defined at parasternal short axis view with more than 2 mm atrial displacement (AD) of leaflet/leaflets. TVP can also be detected from four chamber view with more than 2 mm AD or in right ventricular inflow view with more than 4 mm AD. As a consequence of TVP, the physiological jugular venous waveform alters due to severe TR.During severe TR; retrograde blood flow through right atrium during ventricular systole restrains x descent and produces a fusion of c and v waves that appears as a large pulsation in physical examination called as ‘Lancisi’s sign’ Conclusion ‘Lancisi’s sign’ is defined as a large visible systolic neck pulsation as a consequence of the c-v waves fusion by preventing x descent during severe TR.