PICTORIAL ESSAY

https://doi.org/10.5005/jp-journals-10009-2001
Donald School Journal of Ultrasound in Obstetrics and Gynecology
Volume 17 | Issue 4 | Year 2023

First-trimester HDlive Flow Features of Congenital Heart Anomalies

Toshiyuki Hata¹, Miyu Konishi², Tomomi Kawahara³, Takahito Miyake⁴

^1,4Department of Obstetrics and Gynecology, Miyake Clinic, Minami-ku, Okayama; Department of Perinatology and Gynecology, Kagawa University Graduate School of Medicine, Miki, Kagawa, Japan

^2,3Department of Obstetrics and Gynecology, Miyake Clinic, Minami-ku, Okayama, Japan

Corresponding Author: Toshiyuki Hata, Department of Obstetrics and Gynecology, Miyake Clinic, Minami-ku, Okayama; Department of Perinatology and Gynecology, Kagawa University Graduate School of Medicine, Miki, Kagawa, Japan, Phone: +810878912174, e-mail:
toshi28@med.kagawa-u.ac.jp; hata.toshiyuki@kagawa-u.ac.jp

Received: 16 July 2023; Accepted: 15 November 2023; Published on: 28 December 2023

ABSTRACT

HDlive Flow demonstrates three-dimensional (3D) cardiovascular structures with greater depth perception and dimension using a light source to create favorable lighting and shadowing effects. The supplemental usefulness of this technique for evaluation of the normal fetal heart and diagnosis of congenital heart anomaly in the second and third trimesters of pregnancy has been described. The potential advantages of HDlive Flow for the diagnosis of congenital heart anomaly need to be explored in the first trimester of pregnancy. In this pictorial essay, we present our experiences of the use of HDlive Flow to diagnose congenital heart anomalies in the first trimester of pregnancy.

How to cite this article: Hata T, Konishi M, Kawahara T, et al. First-trimester HDlive Flow Features of Congenital Heart Anomalies. Donald School J Ultrasound Obstet Gynecol 2023;17(4):277–281.

Source of support: Nil

Conflict of interest: None

Keywords: Congenital heart anomaly, First trimester, HDlive Flow, Prenatal diagnosis, Spatiotemporal image correlation

INTRODUCTION

HDlive Flow demonstrates three-dimensional (3D) cardiovascular structures with greater depth perception and dimension using a light source to create favorable lighting and shadowing effects.¹ The resolution of HDlive Flow is significantly better than that of conventional 3D/four-dimensional (4D) color/power Doppler ultrasound.² HDlive Flow with spatiotemporal image correlation (STIC) facilitates more precise evaluations of normal and abnormal fetal cardiac structures in the second and third trimesters of gestation.³–⁷ However, there have been only three investigations to assess normal fetal cardiac structures⁸ and diagnose congenital heart anomalies⁹^,¹⁰ with HDlive Flow in the first trimester of pregnancy. In this pictorial essay, we present our experiences of the use of HDlive Flow with STIC to diagnose congenital heart anomalies in the first trimester of pregnancy.

MATERIALS AND METHODS

During the 14-month period from April 2022 to May 2023, 408 first-trimester fetal screenings were performed at 11–13 + 6 weeks of gestation. Three congenital heart anomalies (0.74%) were identified during this screening period (Table 1). Fetal echocardiography, color Doppler, and HDlive Flow with STIC (GE Voluson E10 BT21 or GE Voluson Expert 22, GE Healthcare, Zipf, Austria) were used to assess fetal cardiac structures. The study was conducted following approval by the local Ethics Committee of Miyake Clinic, Okayama, Japan. Written informed consent was obtained from all patients after a full explanation of the aim of the study.

**Table 1:** Clinical characteristics of fetuses with congenital heart anomalies in the first trimester of pregnancy
Case	GA at examination (weeks)	MA (years)	Para	Maternal complication	Pregnancy method	NT (mm)	USG findings	DVRF	UARF	FHA diagnosis		Outcome (GA weeks)
Case	GA at examination (weeks)	MA (years)	Para	Maternal complication	Pregnancy method	NT (mm)	USG findings	DVRF	UARF	Fetal echo	HDlive Flow	Outcome (GA weeks)
1	12 + 4	30	1	None	Natural	12	Cystic hygroma Hydrops	(–)	(–)	Mitral atresia	Single ventricle RAF	IUFD 17w2d
2	13 + 4	29	1	None	Natural	8.4	Cystic hygroma Hydrops	(–)	(+)	HLH	HLH	IUFD 14w2d
3	13 + 5	29	0	None	Natural	3.6	Situs inversus Polysplenia	(+)	(–)	Vascular ring Common atrium VSD 2:1 AVB	Vascular ring ALSA AV	TOP 15w5d

ALSA, aberrant left subclavian artery; AV, azygos vein; AVB, atrioventricular block; DVRF, ductus venosus reverse flow; FHA, fetal heart anomaly; GA, gestational age; HLA, hypoplastic left heart; IUFD, intrauterine fetal death; MA, maternal age; NT, nuchal translucency; RAF, retrograde aortic flow; SUA, single umbilical artery; TOP, termination of pregnancy; UARF, umbilical artery reverse flow; USG, ultrasonography; VSD, ventricular septal defect

Volume datasets of the fetal heart were acquired with STIC, which employs automated transverse sweep of the anterior or lateral chest wall. Maximal sensitivity was ensured by setting the pulse repetition frequency to 0.9, 1.3, or 4 kHz and the wall motion filter to “mid 2 or low 1.” Using a curved array transabdominal transducer (RM6C or RM7C, GE Healthcare, Zipf, Austria), volume acquisition lasted 10–12.5 seconds. The acquisition angle was 20–25°. Thermal index (TI) was set at 0.3 or 0.5, and mechanical index (MI) ranged from 0.6 to 1.0. HDlive Flow with STIC data analysis was conducted by one experienced examiner Toshiyuki Hata (TH).

RESULTS

In the normal fetal heart at 13 weeks and 5 days of gestation, HDlive Flow clearly showed the crisscross arrangement of the pulmonary artery and aorta with a spatial three-vessel view (Fig. 1).

Fig 1: HDlive Flow image of a normal fetal heart at 13 weeks and 5 days of gestation. Ao, aorta; AoA, aortic arch; LV, left ventricle; PA, pulmonary artery; RA, right atrium; RV, right ventricle; SVC, superior vena cava

In a fetus with cystic hygroma (nuchal translucency = 12 mm) and hydrops fetalis (pericardial effusion, pleural effusion, and skin edema) at 12 weeks and 4 days of gestation, HDlive Flow revealed mitral atresia (Fig. 2). HDlive Flow demonstrated a single ventricle and retrograde aortic flow (Fig. 3). At 17 weeks and 2 days of gestation, intrauterine fetal death was confirmed. The parents did not consent to autopsy.

Fig 2: HDlive Flow image of four-chamber view of mitral atresia at 12 weeks and 4 days of gestation. LA, left atrium; LV, left ventricle; PE, pericardial effusion; PlE, pleural effusion; RA, right atrium; RV, right ventricle; SE, skin edema

Figs 3A and B: HDlive Flow image of mitral atresia at 12 weeks and 4 days of gestation. Ao, aorta; AoA, aortic arch; DA, ductus arteriosus; DAo, descending aorta; PA, pulmonary artery; RA, right atrium; RV, right ventricle; SVC, superior vena cava. (A) Anterior view; (B) Posterior view

In a fetus with cystic hygroma (nuchal translucency = 8.4 mm) and hydrops fetalis (ascites and skin edema) at 13 weeks and 4 days of gestation, a small left ventricle (LV) and atrium were noted (Fig. 4). HDlive Flow depicted a small ventricle (Fig. 5). Reverse flow of the umbilical artery was also evident (Fig. 6). At 14 weeks and 2 days of gestation, intrauterine fetal death was confirmed. Again, the parents did not consent to autopsy.

Fig 4: Four-chamber view of a hypoplastic left heart at 13 weeks and 4 days of gestation. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle; SE, skin edema

Fig 5: HDlive Flow image of a small LV at 13 weeks and 4 days of gestation. RV, right ventricle; PA, pulmonary artery

Fig 6: Reverse flow of an umbilical artery at 13 weeks and 4 days of gestation

In a fetus with increased nuchal translucency (3.6 mm) and ductus venosus reverse flow at 13 weeks and 5 days of gestation, two-dimensional sonography showed a ventricular septal defect, common atrium, and right-sided stomach with polysplenia (Fig. 7). Radiant flow revealed a common atrium and vascular ring (Fig. 8). M-mode echocardiography depicted 2:1 atrioventricular block (Fig. 9). HDlive Flow clearly demonstrated a vascular ring with an aberrant subclavian artery and azygous vein (Fig. 10). The parents decided to terminate the pregnancy and induced abortion was conducted at 15 weeks and 5 days of gestation.

Figs 7A and B: Situs ambiguous at 13 weeks and 5 days of gestation. CA, common atrium; LV, left ventricle; RV, right ventricle; S, spleen; Sp, spine; St, stomach; VSD, ventricular septal defect. (A) Four-chamber view; (B) Abdominal transverse view

Figs 8A and B: Radiant flow images of a congenital heart anomaly at 13 weeks and 5 days of gestation. Ao, aorta; AoA, aortic arch; DA, ductus arteriosus; DK, diverticulum of Kommerell; CA, common atrium; LV, left ventricle; PA, pulmonary artery; RV, right ventricle; VSD, ventricular septal defect. (A) Four-chamber view; (B) Three-vessel view

Fig 9: M-mode echocardiogram of 2:1 atrioventricular block. A, atrial contraction; V, ventricular contraction

Fig 10: HDlive Flow image of the vascularity at 13 weeks and 5 days of gestation. ALSA, aberrant left subclavian artery; Ao, aorta; AoA, aortic arch; AV, azygous vein; DA, ductus arteriosus; DAo, descending aorta; DK, diverticulum of Kommerell; LV, left ventricle; PA, pulmonary artery; RV, right ventricle

DISCUSSION

HDlive Flow provided additional, useful information for evaluating fetal cardiac structures, especially great vessel and major vein abnormalities in the normal heart and congenital heart anomalies.¹^,⁵^,¹⁰–¹⁵ Only a few studies reported the advantages of HDlive Flow for diagnosing congenital heart anomalies in the first trimester of pregnancy.⁹^,¹⁰ In this pictorial essay, HDlive Flow also clearly showed unique characteristics of first-trimester congenital heart anomalies. HDlive Flow may improve our ability to diagnose congenital heart anomalies and become an adjunctive tool in addition to conventional fetal echocardiography in the first trimester of pregnancy. Further studies involving a larger sample size are needed to confirm the usefulness of HDlive Flow for diagnosing first-trimester congenital heart anomalies.

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