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Four-Dimensional Sonography With
Spatiotemporal Image Correlation and
Tomographic Ultrasound Imaging in
the Prenatal Diagnosis of Anomalous
Pulmonary Venous Connections
Ruan Peng, MD, Hong-Ning Xie, PhD, Liu Du, MD, Hui-Juan Shi, PhD, Ju Zheng, PhD, Yun-Xiao Zhu, PhD
Received November 17, 2011, from the Depart-
ment of Ultrasonic Medicine, Fetal Medical Cen-
ter (R.P., H.-N.X., L.D., J.Z., Y.-X.Z.), and
Department of Pathology (H.-J.S.), First Affiliated
Hospital of Sun Yat-Sen University, Guangzhou,
China. Revision requested December 5, 2011.
Revised manuscript accepted for publication
March 31, 2012.
This study was supported by research
grant 81071166 from the National Scientific
Foundation Committee of China and grants
2009B080701061 and 2008A03020108 from
the Guangdong Provincial Department of Science
and Technology.
Address correspondence to Hong-Ning Xie,
PhD, Department of Ultrasonic Medicine, Fetal
Medical Center, First Affiliated Hospital of Sun
Yat-Sen University, 58 Zhongshan Er Rd, 510080
Guangzhou, Guangdong, China.
E-mail: hongning_x@126.com
Abbreviations
4D, four-dimensional; STIC, spatiotemporal
image correlation; 2D, 2-dimensional; TUI,
tomographic ultrasound imaging
©2012 by the American Institute of Ultrasound in Medicine | J Ultrasound Med 2012; 31:1651–1658 | 0278-4297 | www.aium.org
ORIGINAL RESEARCH
Objectives—To determine whether the use of 4-dimensional (4D) sonography with
spatiotemporal image correlation (STIC) and tomographic ultrasound imaging (TUI)
can provide additional information with respect to 2-dimensional (2D) echocardiog-
raphy in the prenatal diagnosis of anomalous pulmonary venous connections.
Methods—The study population consisted of 10 cases that were initially suspected to
have total or partial anomalous pulmonary venous connections by prenatal 2D echocar-
diography between January 2008 and April 2011. All 10 cases were further examined
and analyzed by 4D sonography with STIC-TUI. Detailed postnatal surgery or autopsy
was performed on all 10 fetuses.
Results—Total anomalous pulmonary venous connections were found in 5 cases, and a
partial connection was diagnosed in 1 fetus postnatally. The remaining 4 cases were con-
firmed to have normal pulmonary venous connections. Four of the 5 fetuses with anom-
alous pulmonary venous connections had an additional major cardiac defect; 1 fetus had
an isolated connection. Anomalous drainage was supracardiac to the superior vena cava
in 2 cases, cardiac to the coronary sinus in 3, and partially infracardiac to the portal vein
in remaining case. The pulmonary venous connections were completely and correctly
visualized with 2D echocardiography in 2 of the 10 cases, partially identified in 4, and
not distinguished completely in 4. Four-dimensional sonography imaging with STIC-
TUI clearly visualized the connections in 9 of the 10 cases, and the remaining case was
partially identified.
Conclusions—Four-dimensional sonography with STIC-TUI facilitates visualization
of pulmonary venous connections, thus supplying additional information with respect to 2D
echocardiography in the prenatal diagnosis of anomalous pulmonary venous connections.
Key Words—anomalous pulmonary venous connection; congenital heart disease; 4-dimen-
sional sonography; spatiotemporal image correlation; tomographic ultrasound imaging
T he prenatal detection of congenital heart disease is feasible,
and most common heart malformations can be detected
with fetal echocardiography. Unfortunately, some impor-
tant diseases, such as anomalous pulmonary venous connections and
atrial septal defects, are often missed. An anomalous pulmonary
venous connection is a rare type of congenital heart disease, through
constitutes 4.9% of all congenital heart diseases with an incidence of
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Peng et al—Prenatal Diagnosis of Anomalous Pulmonary Venous Connections
1 per 14,700 neonates.1 In a total anomalous pulmonary
venous connection, all pulmonary veins drain directly or
indirectly into the right atrium, whereas in a partial anom-
alous pulmonary venous connection, 1 or more, but not
all, of the pulmonary veins connect to the right atrium or
tributary of the systemic circulation.
The prognosis of an anomalous pulmonary venous
connection is influenced by the accuracy of prenatal diag-
nosis. If surgical repair cannot be performed promptly, the
prognosis is poor. Thus, the prenatal diagnosis of an anom-
alous pulmonary venous connection is expected to improve
the outlook of affected fetuses. Four-dimensional (4D)
sonography and spatiotemporal image correlation (STIC)
have been suggested to provide a substantial contribu-
tion to the identification of congenital heart diseases.2–5
Spatiotemporal image correlation is a technique that allows
the acquisition of cardiac volumes. These volume data sets
can then be displayed and analyzed in multiple rendering
modes and be used to detect cardiac defects. Multiple ren-
dering modes have been shown to supply additional
information over that provided by 2-dimensional (2D)
sonography in the prenatal diagnosis of complex congen-
ital heart diseases.5 Spatiotemporal image correlation with
tomographic ultrasound imaging (TUI) allows complete
sequential analysis of cardiac structures to be displayed on
a single panel by showing all echocardiographic transverse
sections at the same time.4 Turan et al6 confirmed that the
STIC-TUI technique enables a detailed segmental cardiac
evaluation of the normal fetal heart in the first trimester.
Power Doppler imaging is an extremely useful tool for
detecting tiny veins,7 especially pulmonary veins, and helps
determine the precise location for pulsed Doppler interro-
gation. The TUI modality and power Doppler imaging
could be combined together and may be helpful for iden-
tifying anomalous pulmonary venous connections.
Thus, we report a series of fetuses who were initially
suspected to have anomalous pulmonary venous connec-
tions on the basis of 2D echocardiography and in whom
we attempted to evaluate the use of 4D sonography with
STIC-TUI can supply additional information for prenatal
diagnosis of anomalous pulmonary venous connections.
Materials and Methods
This study was conducted at a single tertiary center for pre-
natal care between January 2008 and April 2011. The study
population consisted of cases that had an initially diagno-
sis of total or partial anomalous pulmonary venous con-
nections by prenatal 2D echocardiography. Fetuses with
heterotaxy syndrome or an unconfirmed diagnosis (lost to
1652
follow-up or necropsy not performed) were excluded from
the analysis. Written informed consent was obtained from
all patients, and the study was approved by the Ethical
Committee of the institution.
The prenatal diagnostic criteria of anomalous pul-
monary venous connections is as follows1: an anomalous
pulmonary venous connection should be suspected when 1
or more pulmonary veins cannot be visualized entering the
left atrium in the 4-chamber apical view, with a wide gap
between the posterior wall of the left atrium and the
descending aorta; the left ventricle is smaller than the right
ventricle; and the ascending or descending vertical vein can
be visualized in the 3-vessel and tracheal view or transverse
abdominal view as an additional vessel or pulmonary veins
directly connecting to the right atrium.
Two-dimensional fetal echocardiography was per-
formed in all cases with an ultrasound system equipped
with pulsed, continuous, and color Doppler capability (GE
Healthcare, Kretztechnik, Zipf, Austria). Anomalous pul-
monary venous connections were diagnosed, and then
after 2D examination, the cardiac volume data sets were
acquired with STIC and power Doppler imaging using
automatic sweeps through the fetal thorax. Volume data
sets were acquired with an original plane from the apical
4-chamber, transverse 4-chamber, or sagittal view of the
aortic arch. The volume data sets were stored for analysis,
and the best gray-scale and power Doppler volumes illus-
trating the cardiac defects were selected for analysis.
Analysis of the recorded volume data sets was performed
offline on a personal computer using dedicated software
(4D View version 7.0; GE Healthcare). Offline TUI was
applied using the 4D View software, and the TUI images
were displayed in a 3 × 3 format. The analyst was blinded to
the diagnosis by 2D echocardiography. The interslice dis-
tance was adjusted according to the gestational age, and the
necessary planes for diagnosing could be visualized. The 2
ventricles, 2 atria, and great arteries were visualized, and the
pulmonary venous connections were scrutinized. We
looked for the presence of a confluent vein behind the left
atrium or a vertical vein draining into the superior vena
cava, the innominate vein, or the portal vein. If too many
unnecessary windows were shown, the interslice distance
or the x-, y-, or z-axis was slightly adjusted finely until the
pulmonary venous connections could be visualized.
The diagnosis was confirmed in all cases by postnatal
surgery or autopsy. All autopsies were performed within
12 hours after termination of pregnancy.
The accuracy of visualization of the pulmonary
venous connections between 2D sonography and 4D
sonography with STIC-TUI was compared by a χ2 test or
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Peng et al—Prenatal Diagnosis of Anomalous Pulmonary Venous Connections
Fisher exact test. The statistical analysis was performed
with SPSS version 16.0 software (SPSS Inc, Chicago, IL).
P < .05 was considered statistically significant.
Results
Over 4 years, we were able to provide second- and third-
trimester screening for 23,765 fetuses. Six hundred ninety-
two with congenital heart diseases were identified; 12 of the
692 were suspected to have anomalous pulmonary venous
connections (without heterotaxy syndrome). Two of these
12 fetuses were lost to follow-up. Six fetuses were confirmed
to have anomalous pulmonary venous connections by
postnatal surgery or autopsy; the remaining 4 fetuses did
not have anomalous connections. Four fetuses had isolated
total anomalous pulmonary venous connections, and 2
(1 fetus with a total connection and 1 with a partial con-
nection) had coexisting cardiac defects. The 3 fetuses with
cardiac total anomalous pulmonary venous connections
(Figure 1) showed anomalous drainage into the coronary
sinus, whereas the 2 fetuses with supracardiac total con-
nections (Figure 2) showed drainage into the superior
vena cava. The remaining case was shown to have a partial
connection, and the anomalous drainage was infracardiac
to the portal vein.
The mean maternal age was 27 years (range, 23–32
years). The mean gestational age at the time of diagnosis
was 27 weeks (range, 21–32 weeks). Twenty-eight vol-
umes were acquired for these 10 cases, and more than 2
volume data sets were acquired for each case. The median
interslice distance was 3.3 mm (range, 2.4–4.1 mm). The
median time for offline TUI analysis was 5 minutes (range,
1–11 minutes).
Amniocentesis or cordocentesis was performed on 4
fetuses, all of whom had normal karyotypes. A summary of
the 2D and 4D echocardiographic findings and the results
of postnatal autopsy or surgery for the 10 cases are listed
in Table 1.
In these 10 fetuses with initial diagnoses of anomalous
pulmonary venous connections by 2D echocardiography,
the connections were completely and correctly visualized on
2D echocardiography in 2 cases and partially identified in 4,
whereas the connections were completely misdiagnosed in
4 cases. Four-dimensional sonography with STIC-TUI
clearly visualized the pulmonary venous connections in 9
of the 10 cases, and the remaining case was partially identi-
fied. The difference between 2D echocardiography and the
4D STIC-TUI technique with respect to visualization of
the pulmonary venous connections was significant accord-
ing to the χ2 test (P = .006).
J Ultrasound Med 2012; 31:1651–1658
Discussion
Because anomalous pulmonary venous connections are very
rare lesions, their prenatal diagnosis has been the subject of
a few case reports.8–10 The prognosis of fetuses with anom-
alous pulmonary venous connections is affected by the
presence of cardiac or extracardiac malformations and the
accuracy of the prenatal diagnosis. The long-term prognosis
is optimized by accurate prenatal diagnosis and early sur-
gical repair, which are especially important for fetuses with
an obstructed pulmonary venous return because they can
present with severe decompensation soon after birth.
However, the low sensitivity of fetal echocardiography for
detecting anomalous pulmonary venous connections has
been emphasized, and the main reason leading to the low
detection rate is that cardiac anatomic changes are not sub-
stantial. In this study, only 6 fetuses (0.87%) were confirmed
to have anomalous pulmonary venous connections by post-
natal surgery or autopsy among 692 cases with congenital
heart diseases, and isolated total connections accounted
for 0.57% of the congenital heart diseases cases, a finding
comparable to the results of Allan and Sharland8 (0.17%)
and Volpe et al9 (0.67%); the rate was slightly decreased
with respect to the postnatal reports.
The direct signs of an anomalous pulmonary venous
connection are as follows: the 4 pulmonary veins do not
connect to the left atrium and a confluent vessel behind
the left atrium, which receives the pulmonary veins; then
the vertical vein goes upward to the inferior vena cava
(supracardiac type) or downward to the portal vein system
(infracardiac type); or the pulmonary veins drain directly
into the right atrium or through the coronary sinus to the
right atrium (cardiac type). The indirect signs of anomalous
pulmonary venous connection are as follows: a smaller left
atrium and ventricle, a wide gap between the posterior wall
of the left atrium and the descending aorta, and an anomalous
vein in the 3-vessel and tracheal view. With 2D echocar-
diography, the pulmonary veins were correctly detected in
only 2 cases in which they connected to the coronary sinus
(cases 1 and 2), whereas pulmonary venous connections
were partially identified in 4 cases (cases 3–6). An obstructed
pulmonary venous system caused difficulty in visualizing
the pulmonary venous drainage in case 3. The confluence
of 2 inferior pulmonary veins behind the left atrium was so
inconspicuous that we misdiagnosed a partial anomalous
pulmonary venous connection with 2D echocardiography
in case 4. With respect to case 5, complex cardiac malfor-
mations made partial pulmonary veins difficult to identify,
whereas in case 6, the tortuous superior vena cava caused
an artifact involving the upper pulmonary vein drainage.
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Peng et al—Prenatal Diagnosis of Anomalous Pulmonary Venous Connections

A B

Figure 1. A, Four-dimensional echocardiogram of a 32-week fetus with

a totally anomalous pulmonary venous connection (cardiac type). The
top left window shows a sagittal view of the fetal thorax with the lines
corresponding to the views displayed in the other windows as follows:
window –3, upper abdominal view; windows –2 and –1, planes slightly
inferior to the 4-chamber view showing pulmonary veins connecting to
the confluent vessel and drainage into the coronary sinus; window 0,
apical 4-chamber view showing the smaller left atrium and no pulmonary
venous connection; window 1, outlet of the left ventricle; window 2, out-
let of the right ventricle; and window 3, 3-vessel and trachea view. Ao
indicates aorta; CS, coronary sinus; LA, left atrium; LPV, left pulmonary
vein; PA, pulmonary artery; RA, right atrium; and RPV, right pulmonary
vein. B, Postnatal autopsy of this fetus. The 4 pulmonary veins did not
connect to the left atrium, and the dilated coronary sinus drained into
the right atrium. CS indicates coronary sinus; LA, left atrium; LV, left ven-
tricle; RA, right atrium; and RV, right ventricle.

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Peng et al—Prenatal Diagnosis of Anomalous Pulmonary Venous Connections

A B

Figure 2. A, Four-dimensional echocardiogram of a 27-week fetus with

a total anomalous pulmonary venous connection (supracardiac type).
The top left window shows a sagittal view of the fetal thorax with the lines
corresponding to the views displayed in the other windows as follows:
window –3, plane of the fetal neck showing the dilated innominate vein;
window –2, 3-vessel and trachea view showing the vertical vein adja-
cent to the pulmonary artery; windows –1 and 0, planes slightly supe-
rior to the 4-chamber view showing pulmonary veins connecting to the
confluent vessel; and windows 1–3, pulmonary veins that could not be
seen connected to the left atrium in the 4-chamber view. Ao indicates
aorta; C, confluent vessel; LPV, left pulmonary vein; RPV, right pulmonary
vein. B, Postnatal autopsy of this fetus. The pulmonary veins connected
to the confluent vessel (vertical vein) behind the atrium, and the ascend-
ing vertical vein drained into the left innominate vein. IV indicates innom-
inate vein; LPV1, upper left pulmonary vein; LPV2, inferior left pulmonary
vein; RPV1, upper right pulmonary vein; RPV2, inferior right pulmonary
vein; and VV, vertical vein.

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Peng et al—Prenatal Diagnosis of Anomalous Pulmonary Venous Connections

Table 1. Patient Demographics and Sonographic Acquisition Parameters

Visualization of Visualization of
Associated PVs on 2D PVs on 4D Results of
Case GA, wk Outcome Malformations Echocardiography Sonography With STIC-TUI Surgery/Autopsy

1 32 TOP None Smaller LA; PV drainage Smaller LA; enlarged CS; Cardiac TAPVC;
to cyst in LA PV drainage to CS PVs connected to CS
2 28 TOP Smaller LV; PVs joined into PVs joined into confluence Cardiac TAPVC;
mitral atresia; confluence located located behind RA, PVs connected to
coarctation of behind RA, through through CS to RA CS; HLHS; ASD
aorta CS to RA
3 31 TOP None Right heart dominant; Right heart dominant; Supracardiac TAPVC;
PAs and PVs not seen; PVs could not be visualized PVs connected to IV;
PV obstruction entering LA; VV behind LA PV obstruction
4 27 Surgery None 1 of right and left PVs ASD; PVs joined into Supracardiac TAPVC;
2 mo connected to IV by VV; confluence located PVs connected to IV;
after birth other PVs to LA behind LA and drained ASD
into IV through VV
5 21 TOP Dextrocardia; PVs drained into VV; 2 upper PVs drained into Infracardiac PAPVC;
tricuspid atresia; descending VV right-sided morphologic LA; 2 inferior PVs to
pulmonary atresia; entered liver 2 inferior PVs drained into portal vein; isolated
persistent left left portal vein through VV; dextrocardia; HRHS;
SVC IV flow from right to left persistent left SVC; ASD
6 24 TOP None 4 PVs joined into CS to PVs joined into CS to RA Cardiac TAPVC;
RA; 1 PV directly to RA PVs connected to CS
7 24 TOP Viscera inversus, PVs ambiguous to Smaller LA; foramen ovale Viscera inversus,
right heart identify and close to LA bulging into LA; right heart dominant;
dominant; but difficult to identify PVs connected to LA partial AVSD; restrictive
partial AVSD relationship between foramen ovale;
LA and dilated CS normal PV connections
8 27 TOP Mitral atresia; Enlarged CS; Restrictive foramen ovale; Restrictive foramen
HLHS; SUA PVs joined into CS; PVs joined together ovale; PVs drained to
bidirectional pulmonary and entered into LA; venous channel and LA;
venous Doppler obstructed LA obstructed LA
waveform and only venous
sinus ostium in wall
9 23 TOP Pulmonary atresia; Anomalous vein PVs connected to LA; Pulmonary atresia;
VSD; overriding entering RA behind vein behind cardiac VSD; overriding aorta;
aorta cardiac base; base was SVC normal PV connections
suspected PAPVC
10 21 TOP Dextrocardia; Atria inversus; Isolated dextrocardia; Isolated dextrocardia;
aberrant left PA atrioventricular atria solitus; left PA origin atria solitus; left PA origin
discordant connection; from right PA; left PA sling from right PA; left PA sling
APVC; IVC, SVC, and (surrounding the trachea); (surrounding the trachea);
PVs entered into normal venous-atrial normal PV connections
left-sided atrium connection
APVC indicates, anomalous pulmonary venous connection; ASD, atrial septal defect; AVSD, atrioventricular septal defect; CS, coronary sinus; 4D,
4-dimensional; GA, gestational age; HLHS, hypoplastic left heart syndrome; HRHS, hypoplastic right heart syndrome; IV, innominate vein; IVC, infe-
rior vena cava; LA, left atrium; LV, left ventricle; PA, pulmonary artery; PAPVC, partial anomalous pulmonary venous connection; PV, pulmonary vein; RA,
right atrium; STIC, spatiotemporal image correlation; SUA, single umbilical artery; SVC, superior vena cava; TAPVC, total anomalous pulmonary
venous connection; 2D, 2-dimensional; TOP, termination of pregnancy; TUI, tomographic ultrasound imaging; VSD, ventricular septal defect; and
VV, vertical vein.

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Peng et al—Prenatal Diagnosis of Anomalous Pulmonary Venous Connections
Four cases of suspected anomalous pulmonary venous
connections were confirmed to be normal connections
postnatally; all 4 cases had coexisting cardiac defects.
Because of the restrictive foramen ovale, the left atrium was
smaller, and the pulmonary venous flow was decreased so
that the pulmonary venous connections were difficult to
detect in cases 7 and 8. Mitral atresia, left atrium obstruction,
foramen ovale flow from the left atrium to the right atrium,
and a bidirectional pulmonary venous Doppler waveform
were present in case 8. Case 9 had tetralogy of Fallot, and
the tortuous superior vena cava produced a partial anom-
alous pulmonary venous connection artifact. In case 10,
the pulmonary venous connection to the left atrium was
not recognized because of dextrocardia caused by a left pul-
monary artery sling. In our opinion, a search for pulmonary
venous drainage should be made in the presence of asso-
ciated cardiac anomalies. Otherwise, indirect signs, such
as right ventricular dominance and enlargement of the
right atrium, coronary sinus, or superior vena cava, may
falsely lead to a diagnosis of an anomalous pulmonary
venous connection.8 The sole detection of indirect signs
does not warrant the diagnosis of an anomalous pulmonary
venous connection. Indeed, the diagnosis of an anomalous
pulmonary venous connection requires complete visualiza-
tion of the connection. With 2D echocardiography, however,
it is difficult to detect all of the pulmonary venous drainage
because the 4 pulmonary veins are not in a single panel.
Spatiotemporal image correlation has been shown to
improve the visualization of small vessels with low-flow
velocity and to contribute to a better understanding of car-
diovascular anatomy and hemodynamic peculiarities of the
fetal heart.2–5 Volume data sets are acquired with STIC
using automatic sweeps through the fetal thorax, and then
cardiac volumes are displayed as a single real-time cardiac
cycle played in a cine loop. The loop may also be played in
slow motion or stopped at any time for detailed analysis of
specific phases of the cardiac cycle. With the volume data
sets, each of the scan planes, especially the planes not
obtained by 2D echocardiography but pertinent to the
diagnosis of complex congenital heart diseases, can be
moved and rotated while maintaining the synchronized
cardiac loop. Volpe et al9 showed that 4D sonography with
B-flow imaging and STIC could clearly visualize the anom-
alous pulmonary venous confluence and the draining ver-
tical vein in all 4 of their cases and made a conclusion that
4D sonography with B-flow imaging and STIC is appar-
ently able to facilitate identification of the anatomic fea-
tures of total anomalous pulmonary venous connections.
Lee et al11 reported a case with a supracardiac total anom-
alous pulmonary venous connection and displayed the
J Ultrasound Med 2012; 31:1651–1658
“starfish” sign for showing the vertical vein with B-flow and
STIC imaging. That appearance is a useful direct sign for
diagnosis of total anomalous pulmonary venous connections.
In our study, offline evaluation of the volume data sets
acquired with STIC-TUI could identify the pulmonary
venous connections in the 6 cases with anomalous con-
nections and the 4 false-positive cases, and the diagnostic
accuracy was significantly improved by 4D sonography
with respect to 2D echocardiography. In case 3, although
pulmonary venous flow could not be identified because of
obstruction, an anomalous pulmonary venous connection
was suspected, and a confluent vessel behind the left atrium
was visualized after the STIC-TUI evaluation was performed.
In cases 6 and 9, pulmonary vein confluence could be
revealed after rotation volumes. In 2 other cases associated
with a restrictive foramen ovale (cases 7 and 8), the pul-
monary venous connections to the smaller left atrium were
identified by sequential evaluation of volumes. This find-
ing was also true for case 10 with coexisting dextrocardia
created by a left pulmonary artery sling. Discrimination
between the left and right atriums was accomplished after
adjustment and rotation of the cardiac volume data sets, and
the normal pulmonary venous connection was recognized
on 4D sonography with STIC-TUI. The sequential ana-
lytical approach could be performed with STIC-TUI for
detecting congenital heart diseases and anatomic detail12;
thus, STIC-TUI provided an efficient approach to this
complicated anomaly and identifying the pulmonary
venous connections.
In our study, termination of pregnancy was chosen in 9
of these 10 cases, whereas only 1 case continued pregnancy
(case 4). With 2D echocardiography, we initially mistakenly
concluded that this case was a supracardiac partial anom-
alous pulmonary venous connection. After volume data
sets were acquired, analysis of the data was performed with
the 4D View software, and all of the pulmonary veins
joined into the confluence located behind the left atrium
and drained into the innominate vein through the vertical
vein on STIC-TUI. Echocardiography confirmed that the
fetus had an isolated total anomalous pulmonary venous
connection and did not have extracardiac anomalies after
birth. The neonate underwent corrective surgery 2 months
after birth. The additional information supplied by 4D
sonography and STIC-TUI was important for immediate
postnatal corrective surgery.
In this investigation, the objective was not to directly
compare the visualization of pulmonary venous connec-
tions on 2D echocardiography and STIC-TUI. However,
our investigation confirmed that the use of 4D sonography
supplies useful information for evaluation of pulmonary
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Peng et al—Prenatal Diagnosis of Anomalous Pulmonary Venous Connections

venous connections and allows the course and size of each 12. Devore GR, Polanko B. Tomographic ultrasound imaging of the fetal
pulmonary vein to be assessed; this additional information heart: a new technique for identifying normal and abnormal cardiac
may have correlations with postnatal surgical procedures. anatomy. J Ultrasound Med 2005; 24:1685–1696.
Nonetheless, the limitations of 4D sonography should be
recognized. For example, the STIC volumes will be of poor
quality or incomplete in the third trimester because of the
increased mineralization of the ribs and maternal weight, or
body movements will alter the quality of the images.

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