Fetal Cardiac Tumor: HDlive Flow Silhouette with Spatiotemporal Image Correlation and HDlive Features
Corresponding Author: Toshiyuki Hata, Department of Obstetrics and Gynecology, Miyake Clinic, Okayama, Japan; Department of Perinatology and Gynecology, Kagawa University Graduate School of Medicine, Takamatsu, Kagawa, Japan, Phone: +810878912174, e-mail: email@example.com
Received on: 06 February 2023; Accepted on: 15 March 2023; Published on: 30 June 2023
We present HDlive flow silhouette with spatiotemporal image correlation (STIC) and HDlive features of multiple fetal cardiac tumors at 28 weeks and 2 days of gestation. Fetal echocardiography showed multiple cardiac tumors in four chambers. Tortuous ductus arteriosus was also noted. HDlive flow revealed the spatial relationship between the tortuous ductus arteriosus and aorta. HDlive flow silhouette with STIC and HDlive clearly revealed intraventricular tumors and spatial blood flow dynamics of cardiac chambers and great vessels. HDlive depicted intraventricular tumor movements in real-time. There was no manifestation of cardiac failure. Fetal cardiac rhabdomyoma was strongly suspected. Cardiac tumors resolved 2 months later after delivery with the use of everolimus.
How to cite this article: Hata T, Kawahara T, Miyake T, et al. Fetal Cardiac Tumor: HDlive Flow Silhouette with Spatiotemporal Image Correlation and HDlive Features. Donald School J Ultrasound Obstet Gynecol 2023;17(2):117–120.
Source of support: Nil
Conflict of interest: Dr. Toshiyuki Hata is associated as the Scientific Editor of this journal and this manuscript was subjected to this journal’s standard review procedures, with this peer review handled independently of this Scientific Editor and his research group.
Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.
Keywords: Fetal cardiac tumor, HDlive, HDlive flow, HDlive flow silhouette, Tortuous ductus arteriosus, Spatiotemporal image correlation
The incidence of primary cardiac tumors was reported to be 0.0017–0.02% at autopsy in all age-groups1 and 0.25% in infants and young children.2 Among fetal primary cardiac tumors, rhabdomyoma is the most common (60%), followed by teratomas, fibromas, hemangiomas, and myxomas.3,4 About 40% of suspected fetal cardiac rhabdomyoma cases had a tuberous sclerosis complex (TSC).5 In other words, fetal cardiac rhabdomyoma may be the initial sign of TSC.6
Fetal echocardiography is the initial, main modality to diagnose fetal cardiac rhabdomyoma in utero.7 Three-dimensional (3D)/four-dimensional (4D) ultrasound has the advantage of providing more detailed information on fetal cardiac tumors.8 Visualization of the continuity, curvature, and localization of cardiac tumors is better with 3D/4D ultrasound. In the present case, we describe HDlive flow, HDlive flow silhouette with STIC, and HDlive features of multiple fetal cardiac tumors at 28 weeks and 2 days of gestation.
A 35-year-old pregnant Japanese woman, gravida 2, para 1, received a routine early third-trimester fetal screening at 28 weeks and 2 days of gestation. Fetal echocardiography showed multiple cardiac tumors in four chambers (Figs 1 and 2). Tortuous ductus arteriosus was also noted (Fig. 3). HDlive flow revealed the spatial relationship between the tortuous ductus arteriosus and aorta (Fig. 4). HDlive flow silhouette with STIC and HDlive clearly revealed intraventricular tumors with small ventricular septal defect and spatial blood flow dynamics of cardiac chambers, and great vessels (Figs 5 and 6). HDlive depicted intraventricular tumor movements in real-time (Figs 7 and 8). Fetal cardiac rhabdomyoma was strongly suspected. There was no other abnormal finding of the fetus, especially in the brain. Sizes of main tumors in both ventricles were gradually increasing with advancing gestation (left ventricle, 5.8 × 5.7 mm at 28 weeks and 2 days and 7.9 × 6.1 mm at 34 weeks; and right ventricle, 5.4 × 2.5 mm at 28 weeks and 2 days and 6.4 × 3.1 mm at 34 weeks), but there was no manifestation of cardiac failure during pregnancy.
A male newborn was vaginally delivered at 37 weeks and 6 days of gestation with a body weight of 2794 gm. The umbilical artery pH was 7.271. He had an Apgar score of 8/9 at 1 and 5 minutes, respectively. The administration of everolimus (0.1 mg/day) was decided due to the multiple inoperative cardiac tumors. The tumors resolved 2 months later after delivery with the use of everolimus. However, there was no manifestation of TSC except for cardiac tumors assessed by clinical symptoms and magnetic resonance imaging findings. The baby has been doing well since delivery.
HDlive can provide anatomically realistic images of normal and abnormal intracardiac anatomical structures of the fetus.9 HDlive flow (silhouette) can depict spatial relationships among great vessels and superior and inferior venae cavae in the normal fetal heart and congenital heart anomalies.10-13 In the present case, HDlive showed intraventricular tumor movements in real time. Moreover, HDlive flow silhouette with STIC and HDlive clearly demonstrated intraventricular tumors and spatial blood flow dynamics of cardiac chambers and great vessels. These new techniques may be adjunctive to conventional fetal echocardiography for the prenatal diagnosis of congenital heart anomalies.
Cardiac rhabdomyoma is accompanied by TSC at a rate of about 83.3%, especially when they are multiple.14 Fetal cardiac rhabdomyoma is the earliest sonographic sign of TSC.15,16 The prenatal diagnosis of TSC is based on major features, such as cardiac rhabdomyoma, subependymal nodules, and cortical/subcortical tubers.17 In the present case, multiple fetal cardiac rhabdomyoma were noted antenatally and TSC was strongly suspected. However, the cerebral abnormality could not be detected before or after delivery. Unfortunately, genetic testing for TSC was not conducted for either the neonate or family members in our case.
Everolimus is an mTOR inhibitor and its effective use for cardiac rhabdomyomas has been reported.18-20 In this case, everolimus therapy was started due to multiple inoperative cardiac tumors, although a definitive diagnosis of TSV was not made. Fortunately, cardiac tumors resolved 2 months later after delivery.
Isolated tortuous ductus arteriosus in a fetus has been reported and might be a transient, benign finding in utero.21-23 In the present case, tortuous ductus arteriosus was noted with cardiac tumors. The reason for the combination of tortuous ductus arteriosus and cardiac tumors (suspected cardiac rhabdomyoma) is currently unknown. Further studies are needed to identify the combination of tortuous ductus arteriosus and cardiac rhabdomyoma in TSC.
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