Medical education in fetal echocardiography for OB/GYN residents.

Introduction: Second-trimester fetal screening for congenital heart defects (CHD) included in routine obstetric care provides relevant information for decision making. The aim of this study was to describe the clinical practice of prenatal detection of CHD in terms of the process and results. Methods: The characteristics and results of ultrasound screening for major CHD were documented using data provided by hospitals for a national survey in Spain over the period of 2004–2006. Sixty-seven percent of eligible centers (56/83), covering 36% of total births nationwide, responded to the survey; 33 of these returned complete data regarding the screening results. Results: The number of major CHD occurring in the centers which provided data with results of screening was 1,060. The overall prenatal detection rate of major CHD was 65.7% (95% CI 57.8–74.7), but the detection rate in the routine second-trimester scan was 52.6% (95% CI 45.6–60.8). In 61% of these cases the parents chose to terminate the pregnancy. Two independent predictors of increased detection by center were identified: first, the uniformity and systematic character of the examination of the heart showing at least the 4-chamber view and outflow tracts (prevalence ratio 1.3, 95% CI 1.0–1.8) and second, the local availability of specialists in fetal echocardiography (prevalence ratio 1.4, 95% CI 1.1–1.9). Conclusions: The detection of major CHD in the first half of pregnancy has an important impact on parental decision making. The prenatal screening program for CHD should be globally strengthened in terms of qualifications and methodological approaches. To improve its performance locally, close collaboration with fetal heart specialists should be promoted.

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. isuog GUIDELINES ISUOG Practice Guidelines (updated): fetal cardiac screening The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) is a scientific organization that encourages sound clinical practice and high-quality teaching and research related to diagnostic imaging in women's healthcare. The ISUOG Clinical Standards Committee (CSC) has a remit to develop Practice Guidelines and Consensus Statements as educational recommendations that provide healthcare practitioners with a consensus-based approach, from experts, for diagnostic imaging. They are intended to reflect what is considered by ISUOG to be the best practice at the time at which they are issued. Although ISUOG has made every effort to ensure that Guidelines are accurate when issued, neither the Society nor any of its employees or members accepts liability for the consequences of any inaccurate or misleading data, opinions or statements issued by the CSC. The ISUOG CSC documents are not intended to establish a legal standard of care, because interpretation of the evidence that underpins the Guidelines may be influenced by individual circumstances, local protocol and available resources. Approved Guidelines can be distributed freely with the permission of ISUOG (

Fetal heart defects: Potential and pitfalls of first-trimester detection

To perform a cost-effectiveness analysis of different follow-up strategies for non-obese and obese women who had incomplete fetal cardiac screening for major congenital heart disease (CHD). Three decision-analytic models, one each for non-obese, obese and Class-III-obese women, were developed to compare five follow-up strategies for initial suboptimal fetal cardiac screening. The five strategies were: (1) no follow-up ultrasound (US) examination but direct referral to fetal echocardiography (FE); (2) one follow-up US, then FE if fetal cardiac views were still suboptimal; (3) up to two follow-up US, then FE if fetal cardiac views were still suboptimal; (4) one follow-up US and no FE; and (5) up to two follow-up US and no FE. The models were designed to identify fetuses with major CHD in a theoretical cohort of 4 000 000 births in the USA. Outcomes related to neonatal mortality and neurodevelopmental disability were evaluated. A cost-effectiveness willingness-to-pay threshold was set at US$100 000 per quality-adjusted life year (QALY). Base-case and sensitivity analysis and Monte-Carlo simulation were performed. In our base-case models for all body mass index (BMI) groups, no follow-up US, but direct referral to FE led to the best outcomes, detecting 7%, 25% and 82% more fetuses with CHD in non-obese, obese and Class-III-obese women, respectively, compared with the baseline strategy of one follow-up US and no FE. However, no follow-up US, but direct referral to FE was above the US$100 000/QALY threshold and therefore not cost-effective. The cost-effective strategy for all BMI groups was one follow-up US and no FE. Both up to two follow-up US with no FE and up to two follow-up US with FE were dominated (being more costly and less effective), while one follow-up US with FE was over the cost-effectiveness threshold. One follow-up US and no FE was the optimal strategy in 97%, 93% and 86% of trials in Monte-Carlo simulation for non-obese, obese and Class-III-obese models, respectively. For both non-obese and obese women with incomplete fetal cardiac screening, the optimal CHD follow-up screening strategy is no further US and immediate referral to FE; however, this strategy is not cost-effective. Considering costs, one follow-up US and no FE is the preferred strategy. For both obese and non-obese women, Monte-Carlo simulations showed clearly that one follow-up US and no FE was the optimal strategy. Both non-obese and obese women with initial incomplete cardiac screening examination should therefore be offered one follow-up US. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Pulse oximetry screening (POS) has been shown to be an effective, non-invasive investigation that can detect up to 50–70% of previously undiagnosed congenital heart defects (CHDs). The aims of this study were to assess the accuracy of POS in detection of CHDs and its impact on clinical practice. All eligible newborn infants born between 1 Jan 2015 and 31 Dec 2019 in a busy regional neonatal unit were included in this prospective observational study. A positive POS was classified as two separate measurements of oxygen saturation < 95%, or a difference of > 2% between pre- and post-ductal circulations. Overall, 23,614 infants had documented POS results. One hundred eighty nine (0.8%) infants had a true positive result: 6 had critical CHDs, 9 serious or significant CHDs, and a further 156/189 (83%) infants had significant non-cardiac conditions. Forty-three infants who had a normal POS were later diagnosed with the following categories of CHDs post-hospital discharge: 1 critical, 15 serious, 20 significant and 7 non-significant CHDs. POS sensitivity for detection of critical CHD was 85.7%, whereas sensitivity was only 33% for detection of major CHDs (critical and serious) needing surgery during infancy; specificity was 99.3%.Conclusion: Pulse oximetry screening showed moderate to high sensitivity in detection of undiagnosed critical CHDs; however, it failed to detect two-third of major CHDs. Our study further emphasises the significance of adopting routine POS to detect critical CHDs in the clinical practice. However, it also highlights the need to develop new, innovative methods, such as perfusion index, to detect other major CHDs missed by current screening tools.What is Known:• Pulse oximetry screening is cost effective, acceptable, easy to perform and has moderate sensitivity and high specificity in detection of critical congenital heart defects.• Pulse oximetry screening has been implemented many countries including USA for detection of critical congenital heart defects, but it is not currently recommended by the UK National Screening Committee.What is New:• To our knowledge, this is the first study describing postnatal detection and presentation of all the infants with congenital heart defects over a period of 5 years, including those not detected on the pulse oximetry screening, on the clinical practice. • It emphasises that further research required to detect critical congenital heart defects and other major CHDs which can be missed on the screening tools currently employed in clinical practice.

AIUM Practice Parameter for the Performance of Fetal Echocardiography.

Background: Prenatal diagnosis of cardiac defects in fetus is of paramount importance to enable a better monitoring of heart defects and to allow planning a proper management. We reported our experience on fetal heart echocardiography in a great referral heart center in Iran with the approach to assessment of the diagnostic value of this tool for detecting Congenital Heart Diseases (CHDs). Methods: This retrospective cohort study included 234 pregnant women attended at a great referral heart center in Tehran, Iran between 2012 and 2016 for heart abnormalities screening. All women were evaluated by trans-abdominal fetal echocardiography from 12 weeks of gestation to term and after birth. Results: Fetal echocardiography showed different types of CHDs in 5.9%. CHDs detected in 9.9% of neonates by echocardiography after birth. The most common heart abnormalities detected was VSD in 4.3%. Considering echocardiography findings after birth as the reference, fetal echocardiography had a sensitivity of 92.8%, a specificity of 66.6%, a positive predictive value of 59.8%, a negative predictive value of 86.6%, and an accuracy of 84.1% for detection of heart defects. Conclusion: Fetal heart echocardiography is a sensitive tool for detection of CHDs, but its specificity is moderate.

ABSTRACTPurposeTo determine the diagnostic accuracy of standardized first trimester (11+0–14+0 weeks of gestation) fetal echocardiography (FE) for the detection of congenital heart defects (CHDs).MethodsPregnant women who underwent FE in the first trimester at a tertiary center between November 2021 and December 2022 were included in this retrospective study. In the first trimester, FE; heart position with cardiac axis, heart rhythm, four‐chamber view with two distinct ventricles, left ventricular outflow tract view, and three vessel trachea view were evaluated. CHDs were grouped as mild (do not require treatment or can be easily treated without affecting the child in the long term) and severe (expected to require surgery or cardiac catheterization, may affect the child in the long term) according to their severity.ResultsA total of 311 pregnant women were included in the study, and 22 (7.1%) fetuses were diagnosed with CHDs. Of the 22 fetuses, 6 (27.3%) had severe CHDs, and 16 (72.7%) had mild CHDs. All severe CHDs were correctly diagnosed on first trimester FE. The sensitivity of first trimester FE for overall CHDs was 54.5%, and specificity was 100%. The performance of first trimester FE in the diagnosis of severe CHDs was excellent, with 100% sensitivity and 100% specificity.ConclusionFirst trimester FE has high detection rates for early diagnosis of severe CHDs. Standardized first trimester FE may allow early diagnosis of fetuses with CHDs and contribute to the appropriate management of these pregnancies.

Fetal MRI and prenatal diagnosis of congenital heart defects

Special statement: Proposed quality metrics to assess accuracy of prenatal detection of congenital heart defects

Introduction: Since the origin of Medicine in 4th BC. Century research has taught us that learning and practicing preventive medicine is properly the best method to prevent disease from happening in the first place. Preventive health care must be planned and executed ahead of time, even when illness/ disease, is absent, especially for those that are common and fаtal. Among neonates and infants, congenital heart disease (CHD) is responsible for the largest proportion of mortality caused by birth defects. Actual numbers of patients and mortality resulting from CHD reportedly is increasing. In the developed world the treatment of CHD has escalating costs for health care systems and private covered patients, while in low-income countries it is not always available. Prevention is urgently needed to tackle the increasing needs.&#x0D; Aim: To present the current practice in preventing/early detecting CHD and justify why pulse oximetry is the best available, early detecting postnatal screening test we currently have.&#x0D; Methods: The existing in use preventing/early detecting methods for avoiding or early diagnosing CHD are: 1. Eliminate the maternal risk factors by obtaining a good level of health and medical surveillance during pregnancy. 2. Avoiding teratogenic agents, 3. Detecting risk factors from Family History, 4. Delivering a balanced Nutrition during Pregnancy 5. Obtaining at least an experienced 4-chamber view and outflow tracts imaging during the 20-weeks anomaly scan. 6. Fetal Echocardiography when indicated 7. Postnatal evaluation by experienced Pediatricians. 8. Pulse Oximetry, screening test after 72 hours post-delivery in term babies. 9. Hyperoxia test when indicated.&#x0D; Conclusion: Although CHD’s are the most common, high morbidity and mortality, congenital malformations, we still lack a single, easy to apply, non-invasive and low-cost screening test, for early detection. The current preventive methods must be combined to counterbalance the CHD prevalence. Meanwhile, they are costly and partially accessible. The most advantageous method for minimizing CHD deaths worldwide seems to be currently, pulse oximetry combined with clinical assessment.&#x0D; Original publication: Petropoulos AC. Prevention and Early Detection of Congenital Heart Defects. Where do we Stand. J Cardiol 2018, 2(1): 000111.

Introduction: Since the origin of Medicine in 4th BC. Century research has taught us that learning and practicing preventive medicine is properly the best method to prevent disease from happening in the first place. Preventive health care must be planned and executed ahead of time, even when illness/ disease, is absent, especially for those that are common and fаtal. Among neonates and infants, congenital heart disease (CHD) is responsible for the largest proportion of mortality caused by birth defects. Actual numbers of patients and mortality resulting from CHD reportedly is increasing. In the developed world the treatment of CHD has escalating costs for health care systems and private covered patients, while in low-income countries it is not always available. Prevention is urgently needed to tackle the increasing needs.&#x0D; Aim: To present the current practice in preventing/early detecting CHD and justify why pulse oximetry is the best available, early detecting postnatal screening test we currently have.&#x0D; Methods: The existing in use preventing/early detecting methods for avoiding or early diagnosing CHD are: 1. Eliminate the maternal risk factors by obtaining a good level of health and medical surveillance during pregnancy. 2. Avoiding teratogenic agents, 3. Detecting risk factors from Family History, 4. Delivering a balanced Nutrition during Pregnancy 5. Obtaining at least an experienced 4-chamber view and outflow tracts imaging during the 20-weeks anomaly scan. 6. Fetal Echocardiography when indicated 7. Postnatal evaluation by experienced Pediatricians. 8. Pulse Oximetry, screening test after 72 hours post-delivery in term babies. 9. Hyperoxia test when indicated.&#x0D; Conclusion: Although CHD’s are the most common, high morbidity and mortality, congenital malformations, we still lack a single, easy to apply, non-invasive and low-cost screening test, for early detection. The current preventive methods must be combined to counterbalance the CHD prevalence. Meanwhile, they are costly and partially accessible. The most advantageous method for minimizing CHD deaths worldwide seems to be currently, pulse oximetry combined with clinical assessment.&#x0D; Original publication: Petropoulos AC. Prevention and Early Detection of Congenital Heart Defects. Where do we Stand. J Cardiol 2018, 2(1): 000111.

Objective To explore the sensitivity and specificity of fetal intelligent navigation echocardiography(FINE, 5D Heart) in the prenatal detection of congenital heart defect(CHD), and to compare its diagnostic performance with spatiotemporal image correlation(STIC) loop (STICloop). Methods A total of 250 pregnant women having a singleton pregnancy in the second and third trimesters from April 2018 to May 2019 in Sir Run Run Shaw Hospital, Zhejiang University College of Medicine were enrolled in this prospective study. 2D ultrasound diagnosis has been made before acquiring STIC volume data set. After the appropriateness of each volume data set was preliminarily determined, all identifying informations were concealed and the appropriate volumes were randomly distributed to less experienced sonographer for analysis using 5D Heart software. The sensitivity and specificity, positive and negative likelihood ratios, as well as area under the receiver operating characteristic curve (AUC) of the two methods were determined respectively, and the differences between the two methods were statistically analyzed. Results The diagnostic performance of 5D Heart for the prenatal detection of CHD was: sensitivity of 95.45% (105/110), specificity of 94.29% (132/140), positive likelihood ratio of 16.72, negative likelihood ratio of 0.05, and AUC of 0.95, respectively. Among cases with confirmed CHD, the 5D Heart diagnosis completely matched the final diagnosis in 77.27% (85/110). The diagnostic performance of STICloop for the prenatal detection of CHD was: sensitivity of 90.91% (100/110), specificity of 92.86% (130/140), positive likelihood ratio of 12.73, negative likelihood ratio of 0.10, and AUC of 0.92. The sensitivity and secificity of 5D Heart in diagnosing CHD were both higher than 90%, and it could successfully detect a broad spectrum of severe fetal CHD. Among cases with confirmed CHD, even the STICloop diagnosis completely matched the final diagnosis in 61.81%(68/110), its diagnostic accuracy was relatively lower than 5D Heart (P=0.013). However, there were no statistical differences between the two methods in sensitivity and specificity(all P>0.05). Conclusions The sesitivity and specifity of 5D Heart in diagnosis CHD were both higher than 90%, and it could successfully detect a broad spectrum of severe fetal CHD. STICloop could be used for preliminary screening of CHD, as it has the same high sensitivity and specificity as 5D Heart. Further examination may be recommended when fetal heart abnormalities are suspected. Key words: Echocardiography; Congenital heart defect; Fetal intelligent navigation echocardiography; Spatiotemporal image correlation

To examine the feasibility and performance of implementing a standardized fetal cardiac scan at the time of a routine first-trimester ultrasound scan. A retrospective, single-center study in an unselected population between March 2021 and July 2022. A standardized cardiac scan protocol consisting of a four-chamber and 3-vessel trachea view with color Doppler was implemented as part of the routine first-trimester scan. Sonographers were asked to categorize the fetal heart anatomy. Data were stratified into two groups based on the possibility of evaluating the fetal heart. The influence of maternal and fetal characteristics and the detection of major congenital heart disease were investigated. A total of 5083 fetuses were included. The fetal heart evaluation was completed in 84.9%. The proportion of successful scans increased throughout the study period from 76% in the first month to 92% in the last month. High maternal body mass index and early gestational age at scan significantly decreased the feasibility. The first-trimester detection of major congenital heart defects was 7/16, of which four cases were identified by the cardiac scan protocol with no false-positive cases. First-trimester evaluation of the fetal heart by a standardized scan protocol is feasible to implement in daily practice. It can contribute to the earlier detection of congenital heart defects at a very low false positive rate.

LinkedComment:UltrasoundObstetGynecol2020;55:747-757.