2023

Characteristics and outcomes of fetal ventricular

aneurysm and diverticulum: combining the use
of a new technique, fetalHQ
Liqing Zhao† , Pengfei Wu† , Xianting Jiao, Minjie Zhang, Wenhao Jing, Yurong Wu* and Sun Chen*
Department of Pediatric Cardiology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of
Medicine, Shanghai, China
Volume 11 - 2023 | https://doi.org/10.3389/fped.2023.1165972

Objectives
Congenital ventricular aneurysms or diverticulum (VA/VD) are rare cardiac anomalies with lack prenatal
evaluation data. The present study aimed to provide the prenatal characteristics and outcomes from a tertiary
center and the use of new techniques to evaluate the shape and contractility of these fetuses.

Methods
Ten fetuses were diagnosed with VA or VD, and 30 control fetuses were enrolled. Fetal echocardiography was
performed to make the diagnosis. The prenatal echo characteristics and follow-up data were carefully reviewed.
The shape and contractility measurements of the four-chamber view (4CV) and both ventricles were measured
and computed using fetal fetal heart quantification (HQ)

Results
A total of 10 fetuses were enrolled, including 4 cases of left ventricular diverticulum, 5 cases of left ventricular
aneurysm, and 1 case of right ventricular aneurysm (RVA). Four cases chose to terminate the pregnancy. The RVA
was associated with a perimembranous ventricular septal defect. Two cases had fetal arrhythmia, and one case
had pericardial effusion. After birth, one case underwent surgical resection at five years old. The 4CV global
sphericity index (SI) of free-wall located ventricular outpouching (VO) was significantly lower than the apical
ones and the control group (p < 0.01). Four of five apical left VOs had significant higher (>95th centile) SI in base
segments, and three of four left VOs in the free-wall had significant lower (< 5th centile) SI in the majority of 24
segments. Compared to the control group, the left ventricle (LV) global longitudinal strain, ejection fraction, and
fractional area change were significantly decreased (p < 0.01), while the LV cardiac output of the cases was in the
normal range. The transverse fraction shortening of the affected segments of ventricles was significantly lower
than the other ventricle segments (p < 0.01).
Conclusions
FetalHQ is a promising technique to evaluate the shape and contractility of congenital ventricular aneurysm
and diverticulum.

JB24769XX
 2022

It is all about clear borders: reliability of speckle-

tracking analysis with and without using the
Quiver techniqu
R. Charach, A. Nahum, S.M. Cohen, M. Lipschuetz, D.V. Valsky, S. Yagel
First published: 14 September 2022 https://doi.org/10.1002/uog.254904

Objectives
The measurement of the left fetal ventricle (LV) and right ventricle (RV) size, shape, contractility, and LV function is
feasible using FetalHQ® speckle-tracking analysis. However, defining ventricle borders accurately might be
challenging. This study aimed to compare the interobserver reliability of non-quiver with the quiver technique for the
above cardiac parameters.

Methods
For the purpose of reliability analysis, a sample of scans was analysed with Quiver (n=23 pts) and without Quiver (n=
27) by two examiners who were blinded to the other's work. All four chamber images were obtained according to the
Fetal HQ® consensus guideline. Each examiner chose an AVI file for analysis from the stored patient exam, without
knowledge of which AVI file was selected by the other examiner for that patient. Individual reports were created per
patient and per examiner. Global Strain (GS), Fractional area change (FAC), global sphericity index (GSI), and left
ventricle (LV) function were compared between the two individual examiners. Intraclass correlation coefficient (ICC)
analysis with a two-way mixed model was performed. ICC results <0.5 indicated poor reliability; 0.5 to 0.75 indicate
moderate reliability, values from 0.75 to 0.9 indicate good reliability.

Results
In the exams analysed with Quiver, good reliability was observed for the LV stroke volume and LV cardiac output
measures (0.789;0.763, respectively) and moderate reliability in the LV ejection fraction and LV MAPSE– lateral
measures (0.670 and 0.640, respectively). Other parameters had ICC results below 0.5. In the without-Quiver dataset,
good reliability was shown for LV fractional area change and GSI (ICC 0.758 and 0.764, respectively), and moderate
reliability was shown for LV and RV Global Strain (0.649 and 0.502, respectively) and RV fractional area change (0.579).

Conclusions
Our experience showed good interobserver reliability for LV cardiac function measurements. However, the Quiver
technique did not improve the interobserver reliability for cardiac GS, FAC, and GSI.

JB24769XX
 2022

2D speckle-tracking assessment of biventricular

strain in fetuses with aortic stenosis

M. Bennasar, L. Nogue, G. Gaeta, C. Mula, N. Masoller, J. Martínez, E. Gratacós, F. Crispi, O. Gómez

First published: 14 September 2022 https://doi.org/10.1002/uog.25484

Objectives
To assess biventricular global longitudinal strain (GLS) in fetuses with aortic stenosis (AoS) using 2D speckle-
tracking echocardiography (STE) by FetalHQ® and to compare it to healthy fetuses.

Methods
A prospective cohort study including 13 fetuses with AoS (53% critical, 46% mild) at diagnosis (21-38weeks of
gestation), and 39 healthy controls matched by gestational age and estimated fetal weight at scan. Basic fetal scan
and advanced echocardiography were performed and 3 seconds 4 chamber view clips were obtained for 2D-STE
analysis. Biventricular GLS were assessed and strain curves were automatically displayed by the software.

Results
Maternal and perinatal characteristics were similar in both groups. Mean gestational age at diagnosis was 27±5.5
weeks. While right ventricular GLS was preserved in fetuses with AoS (AoS mean −19.26%±2.89 versus controls
−18,58%±3.08, p=0,487), left ventricular GLS was significantly reduced in AoS cases as compared to controls (AoS
−11.21%±10.17 versus controls 20.17%±3.59, p=0.008) as shown in figure 1.

Conclusions
Fetuses with AoS showed reduced left GLS with preserved right strain. Future studies are warranted to assess the
potential utility of strain analysis for the diagnosis and prognosis of AoS.

JB24769XX
 2022

Evaluation of Fetal Cardiac Geometry and

Contractility in Gestational Diabetes Mellitus by
Two-Dimensional Speckle-Tracking Technology

Peina Huang, MD, Youbin Deng, PhD , Ling Feng, PhD, Yiping Gao, MD, Xueqing Cheng, MD, Hongyun Liu, PhD

Received October 26, 2021, from the Depart�ment of Medical Ultrasound, Tongji Hospital, Tongji Medical
College, Huazhong University of Science and Technology, Wuhan, China (P.H., Y.D., Y.G., X.C., H.L.); and
Depart�ment of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University
of Science and Technology, Wuhan, China (L.F.). Manuscript accepted for publication April 3, 2022.
Address correspondence to Hongyun Liu, PhD, Tongji Hospital, Tongji Medical College, Huazhong
University of Science and Technology, 1095 Jiefang Avenue, Wuhan 430030, China.

Objectives
Gestational diabetes mellitus (GDM) is the most common meta�bolic disease that occurs during pregnancy
and may result in fetal cardiac dys�function. Our study aimed to assess the cardiac function in fetuses of
mothers with GDM by a quantitative analysis software based on speckle-tracking echocardiography.

Methods
Forty-nine fetuses exposed to GDM and 50 normal fetuses were enrolled, and fetal echocardiography
were performed and analyzed in this pro�spective cross-sectional study. We compared cardiac
systolic function between the two groups using fetal cardiac quantitative analysis software.

Results
In the GDM group, left ventricular (24 � 4 versus 28 � 4, P < .001) and right ventricular global longitudinal
strain (23 � 4 versus 26 � 4, P = .002) and right ventricular free wall strain (26 � 6 versus 29 � 5, P = .006) were
sig�nificantly lower compared with the control group, whereas there was no signifi�cant difference in global
spherical index (1.2 � 0.1 versus 1.2 � 0.1, P = .425). Additionally, 24-segment transverse fraction shortening
of the right ventricle was more impaired than the left, and the segments with reduced fraction shortening
were mainly located in the mid and apical sections of the right ventricle, and midsection of the left
ventricle..
Conclusions
Fetuses exposed to GDM may have cardiac dysfunction before the onset of cardiac morphologic
abnormalities, and the right ventricle is more vul�nerable than the left during fetal development..

JB24769XX
 2022

Evaluation of Fetal Cardiac Geometry and

Contractility in Gestational Diabetes Mellitus by
Two-Dimensional Speckle-Tracking Technology

Roxana Gireadă 1 , Demetra Socolov 1,2 , Elena Mihălceanu 1,2, Ioan Tudor Lazăr 1,2, Alexandru Luca 2 Roxana
Matasariu 1,2,* , Alexandra Ursache 1,2,*, Iuliana Bujor 1 , Tiberiu Gireadă 1 , Vasile Lucian Boiculese 3 and Răzvan
Socolov 1,4

1 Department of Obstetrics and Gynecology, University of Medicine and Pharmacy ‘Gr. T. Popa’,
700115 Ia¸si, Romania - 2 Department of Obstetrics and Gynecology, Cuza Vodă Hospital, 700038 Ia¸si, Romania - 3
Department of Medical Informatics and Biostatistics, University of Medicine and Pharmacy ‘Gr. T. Popa’, - 700115
Ia¸si, Romania- 4 Department of Obstetrics and Gynecology, Elena Doamna Hospital, 700398 Ia¸si, Romania *
Correspondence: roxanamatasariu@yahoo.com (R.M.); carpalecsandra@yahoo.com (A.U.)

Background
The most commonly known cardiac effect of gestational diabetes mellitus (GD) in the fetus is hypertrophic
cardiomyopathy, but recent studies show that it is preceded by subclinical cardiac dysfunction. This study aimed to
assess the effect of GD on fetal cardiac geometry and contractility by two-dimensional speckle-tracking technology.

Methods
We performed a prospective observational study that included 33 pregnant patients with GD and 30 healthy
individuals. For all fetuses, a four-chamber 3 s cine-loop was recorded and analyzed with Fetal Heart Quantification
(fetalHQ), a novel proprietary speckle-tracking software. The following cardiac indices were calculated: global
sphericity index (GSI), global longitudinal strain (GLS), fractional area change (FAC), and 24-segment end-diastolic
diameter (EDD), fractional shortening (FS), and sphericity index (SI) for both ventricles. Demographic and cardiac
differences between the two groups were analyzed, as well as intra-rater and inter-rater reliability.

Results
There were significant changes in right ventricular FAC and FS for segments 4–24 in fetuses exposed to GD (−1 SD,
p < 0.05). No significant differences were detected for GSI, GLS, EDD, or SI for either ventricle.

Conclusions
Fetuses exposed to GD present impaired right ventricular contractility, especially in the mid and apical segments.

JB24769XX
2022

Feasibility of 4D-Spatio Temporal Image

Correlation (STIC) in the Comprehensive
Assessment of the Fetal Heart Using fetalHQ

Laura Nogué 1 , Olga Gómez 1,*, Nora Izquierdo 1 , Cristina Mula 1 , Narcís Masoller 1 , Josep M.
Martínez 1 , Eduard Gratacós 1 , Greggory Devore 2,3 , Fàtima Crispi 1 and Mar Bennasar 1

1 BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant
Joan de Déu, 08950 Barcelona, Spain; nogue@clinic.cat (L.N.); nizquierdo@clinic.cat (N.I.);
mula@clinic.cat (C.M.); masoller@clinic.cat (N.M.); jmmarti@clinic.cat (J.M.M.); gratacos@clinic.cat
(E.G.); fcrispi@clinic.cat (F.C.); bennasar@clinic.cat (M.B.) 2 Fetal Diagnostic Centers, Pasadena, CA
91105, USA; grdevore@gmail.com 3 Department of Obstetrics and Gynecology, David Geffen School of
Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA * Correspondence:
ogomez@clinic.cat; Tel.: +34-93-227-9904

Abstract:

Fetal Heart Quantification (fetalHQ) is a novel speckle tracking software that permits the study of global and regional
ventricular shape and function from a 2D four-chamber-view loop. The 4D-Spatio Temporal Image Correlation
(STIC) modality enables the offline analysis of optimized and perfectly aligned cardiac planes. We aimed to evaluate
the feasibility and reproducibility of 4D-STIC speckle tracking echocardiography (STE) using fetalHQ and to compare
it to 2D STE. We conducted a prospective study including 31 low-risk singleton pregnancies between 20 and 40
weeks of gestation. Four-chamber view volumes and 2D clips were acquired with an apex pointing at 45◦ and with a
frame rate higher than 60 Hz. Morphometric and functional echocardiography was performed by fetalHQ. Intra-
and interobserver reproducibility were evaluated by the intraclass correlation coefficient (ICC). Our results showed
excellent reproducibility (ICC > 0.900) for morphometric evaluation (biventricular area, longitudinal and transverse
diameters). Reproducibility was also good (ICC > 0.800) for functional evaluation (biventricular strain, Fractional
Area Change, left ventricle volumes, ejection fraction and cardiac output). On the contrary, the study of the
sphericity index and shortening fraction of the different ventricular segments showed lower reproducibility (ICC <
0.800). To conclude, 4D-STIC is feasible, reproducible and comparable to 2D echocardiography for the assessment
of cardiac morphometry and function.

JB02535XX
2022

Cardiac Size, Shape, and Ventricular Contractility

in Fetuses at Sea Level With an Estimated Weight
Less-than 10th Centile

Wesley Lee MD, Lauren M. Mack RDMS, MPH, Roxanna Miremadi RDMS, Betul Yilmaz Furtun MD, Haleh Sangi-
Haghpeykar PhD, Greggory R. DeVore MD
First published: 10 February 2022 https://doi.org/10.1002/jum.15954
This study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development
(1R01HD097756-01A1). The Authors also express appreciation for additional resources and technical assistance
from GE Healthcare.

Objectives
To investigate cardiac size, shape, and ventricular contractility in fetuses with estimated fetal weight (EFW) <10th
centile at sea level (Houston).

Methods
A prospective ultrasound study examined 37 fetuses with EFW <10th centile at sea level. High-frequency cine clips
were used to evaluate the 4-chamber view including end-diastolic measurements and global sphericity index. The
size, shape, and contractility of both ventricles were analyzed with speckle tracking methods. Z scores were
calculated using the mean ± standard deviation (SD) derived from normal controls. Measurements were abnormal
if their Z score values were <−1.65 or >+1.65. The proportion of small fetuses with abnormal parameters was
compared to normal reference ranges. Results were compared to a similar published study of small fetuses at
higher altitude in Denver.

Results
About one-third of Houston fetuses with EFW <10th centile had enlarged globular shaped 4-chamber hearts with
increased right ventricle (RV) area, RV basal-apical length, RV base width, and left ventricle (LV) basal-apical length
measurements. Bilateral ventricular hypertrophy was often present. An increased proportion of Houston fetuses
had increased ventricular contractility. However, decreased ventricular contractility was more prevalent for
higher altitude fetuses.

Conclusions
Third trimester fetuses at sea level, with an EFW <10th centile, were often associated with enlarged and globular-
shaped hearts. They had increased global and longitudinal ventricular contractility as compared to controls.
Higher altitude fetuses also had enlarged globular-shaped hearts but with a greater proportion of cases having
decreased ventricular contractility as compared to the sea level cohort.

JB02535XX
2022

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

Anuwutnavin S. a · Russameecharoen K.a · Ruangvutilert P.a · Viboonchard S.a · Sklansky M.b · DeVore G.R.c,d
aDivision of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj

Hospital, Mahidol University, Bangkok, Thailand bDivision of Pediatric Cardiology, Department of Pediatrics, UCLA
Mattel Children’s Hospital, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA cDivision of Maternal-
Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles,
CA, USA dFetal Diagnostic Centers, Pasadena, CA, USA
Fetal Diagn Ther 2022;49:41–51
https://doi.org/10.1159/000521378

Introduction
The aim of the study was to establish normal reference values obtained by fetal speckle tracking analysis of the fetal
heart between 17 and 24 weeks of gestation among Thai fetuses and compare the nomograms with previous
studies.

Methods
The 4-chamber view (4CV) 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 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 4CV and ventricles.

JB02535XX
2022

Cardiac Function Assessment in Fetuses With

Ductus Arteriosus Constriction: A Two-
Dimensional Echocardiography and fetalHQ
Study
Jing Ma, 1 , 2 , 3 , † Haiyan Cao, 1 , 2 , 3 , † Liu Hong, 1 , 2 , 3 , † Juanjuan Liu, 1 , 2 , 3 Xiaoyan Song, 1 , 2 , 3 Jiawei
Shi, 1 , 2 , 3 Yi Zhang, 1 , 2 , 3 Li Cui, 1 , 2 , 3 Li Zhang,corresponding author 1 , 2 , 3 , * and Mingxing
Xiecorresponding author 1 , 2 , 3 , *

1Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and
Technology, Wuhan, China 2Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
3Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China corresponding author Corresponding
author. Edited by: Ornella Milanesi, University of Padua, Italy Reviewed by: Jan Degenhardt, Praenatal Plus-
Center for Prenatal Medicine and Genetics, Germany; Gulten Tacoy, Gazi University, Turkey Front Cardiovasc
Med. 2022; 9: 868675. Published online 2022 Jul 26. doi:
10.3389/fcvm.2022.868675

Background
Fetal ductal constriction (DC) is associated with excessive polyphenol-rich food (PRF) consumption during
pregnancy. However, the effect of this hemodynamic change on fetal cardiac function still needs to be
elucidated. Therefore, this study aimed to evaluate the cardiac function of fetuses with PRF-related DC and to
describe serial observations of cardiac function changes.
Methods
We compared the traditional echocardiographic indices, including morphological, hemodynamic, and
functional parameters, between study fetuses and controls. For global and segmental deformation analysis of
the left and right ventricles, fetalHQ with the speckle-tracking technique was used to calculate sphericity
index (SI), global longitudinal strain (GLS), fractional shortening (FS), fractional area change (FAC), etc. In
addition, follow-up data were compared with the generalized linear model.

Results
A total of 60 DC fetuses and 60 gestational-matched controls were enrolled in our study, with 20 DC fetuses
undertaking a follow-up echocardiogram after 2–3 weeks. Compared with controls, there was a distinct
decrease in right ventricular GLS (RVGLS) (−13.39 ± 3.77 vs. −21.59 ± 2.51, p < 0.001), RVFAC (22.20 ± 9.56 vs.
36.01 ± 4.84, p < 0.001), left ventricular GLS (LVGLS) (−19.52 ± 3.24 vs. −23.81 ± 2.01 p < 0.001), and LVFAC
(39.64 ± 7.32 vs. 44.89 ± 4.91, p = 0.004). For 24-segment FS analysis, DC fetuses showed lower FS in left
ventricular (LV) segments 18–24, with no difference in LV segments 1–17. Right ventricular (RV) FS in segments
4–23 was also reduced in the DC group. The 24-segment SI analysis indicated significantly lower SI in DC than
those in controls for LV segments 1–14 and RV segments 19–24. We found that the pulsatility index (PI) of
ductus arteriosus (DA) was an independent variable for RVGLS (β = −0.29, p = 0.04). In 20 DC fetuses with
follow-up echocardiograms, no obvious difference in myocardial deformation was found between the initial
examination and follow-up data.
Conclusion
Left and right ventricular performances were both impaired in DC fetuses, along with a series of
morphological and hemodynamic changes. Although the state of DA constriction improved on second
examinations, cardiac function was not completely restored.
JB02535XX
2021

Recent Topics in Fetal Echocardiography

Toshiyuki Hata1 , Aya Koyanagi2 , Riko Takayoshi3 , Takahito Miyake4

1,4Department of Obstetrics and Gynecology, Miyake Clinic, Okayama, Japan; Department of Perinatology and
Gynecology, Kagawa University Graduate School of Medicine, Kagawa, Japan 2,3Department of Obstetrics and
Gynecology, Miyake Clinic, Okayama, Japan Corresponding Author: Toshiyuki Hata, Department of Obstetrics and
Gynecology, Miyake Clinic, Okayama, Japan; Department of Perinatology and Gynecology, Kagawa University
Graduate School of Medicine, Kagawa, Japan, Phone: +81-(0)87-891-2174, e-mail: toshi28@med.kagawa-u.ac.jp How
to cite this article: Hata T, Koyanagi A, Takayoshi R, et al. Recent Topics in Fetal Echocardiography. Donald School J
Ultrasound Obstet Gynecol 2021;15(3):259–265. Donald School Journal of Ultrasound in Obstetrics and Gynecology
(2021): 10.5005/jp-journals-10009-1717

Abstract

Recent advances in fetal echocardiography are HDlive Flow (silhouette) and fetalHQ. HDlive Flow (silhouette) provides
novel visual experiences for operators due to the spatial visualization of fetal cardiac structures and allows examiners
to easily understand the spatial relationships among fetal cardiac chambers, great arteries, and veins. HDlive Flow
(silhouette) may become an important diagnostic tool for the assessment of the normal fetal heart and congenital heart
anomaly. fetalHQ consists of a 24-segment sphericity index (SI) and fractional shortening (FS). Fetal 24-segment SI can
measure cardiac remodeling and the diastolic shape, whereas 24-segment FS can evaluate the fetal cardiac function
and ventricular contractility. Fetal 24-segment SI and FS using fetalHQ may become useful diagnostic modalities in
clinical practice. In this review article, we present the latest state-of-the-art HDlive Flow (silhouette) and fetalHQ of
normal and abnormal fetal hearts. We also discuss the present and future applicability of these novel techniques to
assess normal and abnormal fetal hearts. HDlive Flow (silhouette) and fetalHQ may become important modalities in
future research on the fetal heart.

JB02535XX
 2021

Speckle Tracking Analysis to Evaluate the Size,

Shape, and Function of the Atrial Chambers in
Normal Fetuses at 20–40 Weeks of Gestation

Greggory R. DeVore, MD , Berthold Klas, BS, Gary Satou, MD, Mark Sklansky, MD

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at
UCLA, Los Angeles, CA, USA (G.R.D.); Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
(G.R.D.); Fetal Diagnostic Centers, Pasadena, Tarzana, and Lancaster, CA, USA (G.R.D.); TomTec, Munich, Germany (B.K.);
and Division of Pediatric Cardiology, Department of Pediatrics, Mattel Children’s Hospital UCLA, David Geffen School of
Medicine at UCLA, Los Angeles, CA, USA (G.S., M.S.). Manuscript accepted for publication October 31, 2021J Ultrasound
Med 2021; 9999:1–17 | 0278-4297 | www.aium.org

Objective
Objectives—The purpose of this study was to use speckle tracking analysis to evaluate the size, shape, and function of
the atrial chambers in normal fetuses and develop a z-score calculator that can be used in future studies in fetuses at
risk for cardiovascular disease.

Methods
The control group consisted of 200 normal fetuses examined between 20 and 40 weeks of gestation in which speckle
tracking analysis of right (RA) and left (LA) atrial chambers was performed. The atrial end-diastolic and end-systolic
endocardial borders for each chamber were identified from which measurements of atrial length, width, area, and
volume were computed. Equations were derived using fractional polynomial regression analysis to compute z-score
equations.

Results
The LA end-diastolic volume, RA and LA end-diastolic area, length, base width, and mid-chamber widths increased with
gestational age and fetal size. Left atrial emptying and ejection volumes increased with gestational age and fetal size.
The fractional area change was significantly less for the RA than the LA. The LA base and mid-chamber fractional
shortening were significantly greater than the RA. There was a significant difference between the RA and LA global
contractile strain.

Conclusion
Mean and standard deviation equations for each of the measurements described in this study were computed to
create a z-score calculator that can be utilized in the clinical environment when evaluating fetuses with suspected
atrial pathology that could alter the size, shape, and function of the atrial chambers.

JB02535XX
2021

Evaluation of Fetal Cardiac Size and Shape

A New Screening Tool to Identify Fetuses at Risk
for Tetralogy of Fallot
Greggory R. DeVore, MD , Gary M. Satou, MD, Yalda Afshar, MD , Danielle Harake, MD, Mark Sklansky, MD

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, UCLA,
California, Los Angeles, USA (G.R.D., Y.A.); and Division of Pediatric Cardiology, Department of Pediatrics, UCLA Mattel
Children’s Hospital, David Geffen School of Medicine at UCLA, California, Los Angeles, USA (G.M.S., D.H., M.S.).
doi:10.1002/jum.15639 J Ultrasound Med 2021; 9999:1–12

Objective
Prenatal detection rates for tetralogy of Fallot (TOF) vary between 23 and 85.7%, in part because of the absence of
significant structural abnormalities of the 4-chamber view (4CV), as well as the relative difficulty in detection of
abnormalities during the screening examination of the outflow tracts. The purpose of this study was to evaluate
whether the 4CV and ventricles in fetuses with TOF may be characterized by abnormalities of size and shape of these
structures

Methods
This study retrospectively evaluated 44 fetuses with the postnatal diagnosis of TOF. Measurements were made from
the 4CV (end-diastolic length, width, area, global sphericity index, and cardiac axis) and the right (RV) and left (LV)
ventricles (area, length, 24-segment transverse widths, sphericity index, and RV/LV ratios). Logistic regression analysis
was performed to identify variables that might separate fetuses with TOF from normal controls

Results
The mean gestational age at the time of the last examination prior to delivery was 28 weeks 5 days (SD 4 weeks, 4
days). The mean z-scores were significantly lower in fetuses with TOF for the 4CV and RV and LV measurements of size
and shape. Logistic regression analysis identified simple linear measurements of the 4CV, RV, and LV that had a
sensitivity of 90.9 and specificity of 98.5% that outperformed the 4CV cardiac axis (sensitivity of 22.7%) as a screening
tool for TOF.

Conclusions
Measurements of the 4CV, RV, and LV can be used as an adjunct to the outflow tract screening examination to
identify fetuses with TOF.

JB02535XX
2021

Evaluation of the sphericity index of the fetal

heart during middle and late pregnancy using
fetalHQ
Yingchun Luo, Fang Xiao, Can Long, Haiyan Kuang, Meiping Jiang, Cheng Zhou, Qi Cui, Yamei Ye,
Shuai Zhang and Meixiang Zhang

Department of Ultrasound, The Maternal and Child Health Care Hospital of Hunan Province,
Changsha, Hunan, China

THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE

https://doi.org/10.1080/14767058.2021.1940934

Objective
To explore the feasibility of the fetal heart quantitative technique (fetalHQ) for evaluatingthe sphericity index (SI)
of the fetal heart during middle and late pregnancy.

Methods
Ninety-six normal fetuses in middle and late gestation who underwent systemic ultrasoundexamination in the
Department of Ultrasound of the Maternal and Child Health Care Hospital of Hunan Province in November 2020 were enrolled,
and dynamic images of the four-chamberviewofthefetalheartwerecollected.Thecorrelationbetweentheglobalsphericityindex(GSI),
ventricular24-segmentSI,andgestationalage (GA)wasanalyzed,andthedifferences between the left and right ventricular 24-
segment SI were compared.

Results
The success rate of fetalHQ analysis was 93.75%. There was no significant linear correllation between GSI and
ventricular 24-segment SI and GA (all ps > .05). The differences in SI between segments 1 and 9 and 15 and 24 in
the left and right ventricles were statistically significant (all ps < .05), while the differences in SI between segments
10 and 14 were not statistically significant (all ps > .05). In segments 1–9, the SI of the right ventricle was smaller
than that of the left ventricle, indicating that the right ventricle was significantly more spherical than the left
ventricle. In segments 15–24, the opposite was true.

Conclusions
fetalHQ is a simple and reliable method for evaluating the GSI and 24-segment SI
of the left and right ventricles. It can provide some theoretical basis for the clinical quantitative evaluation of
fetal heart geometry and lay a foundation for the quantitative evaluation of fetal heart function in cases of
structural and functional abnormalities.

JB16546XX
2021

Evaluation of prenatal changes in fetal cardiac

morphology and function in maternal diabetes
mellitus using a novel fetal speckle-tracking
analysis: a prospective cohort study
Dong Wang, Caixia Liu, Xinyu Liu, Ying Zhang* and Yu Wang* Department of Ultrasound, Shengjing Hospital of
China Medical University, No. 36 Sanhao Street, Heping District, Shenyang 110004, China
Wang et al. Cardiovasc Ultrasound (2021) 19:25
https://doi.org/10.1186/s12947-021-00256-z

Background
Due to metabolic changes in the second trimester and the increasing number of pregnant women
with obesity and advanced maternal age, the incidence of gestational diabetes mellitus (GDM) remains high. This
study aimed to evaluate the efects of GDM on fetal cardiac morphology and function, and to determine
whether these changes increase with increasing estimated fetal weight (EFW).

Methods
Fifty-eight women with GDM (GDM group) and 58 women with a healthy pregnancy (control group) were included
in this prospective observational cohort study. Each group included subgroups of 31 pregnant women with a
gestational age between 24+0 weeks and 27+6 weeks as well as 27 pregnant women with a gestational age
between 28+0 weeks and 40+0 weeks. For all fetuses, a cine of 2–3 s in the four-chamber view was obtained, and
online speckle-tracking analysis was performed using the GE Automatic Fetal Heart Assessment Tool (fetalHQ;
GeneralElectric Healthcare Ultrasound, Zipf, Austria) to measure the global sphericity index (GSI), global
longitudinal strain (GLS), fractional area change (FAC), 24-segment sphericity index (SI), and 24-segment end-
diastolic diameter of the left ventricle (LV) and right ventricle (RV). Data were analyzed using the independent t-
test and Wilcoxon rank-sum test, as applicable.
Results
The GDM group (mean HbA1c value was 5.3±0.57 mmol/L) showed a lower GSI value than the control group (1.21
vs. 1.27, P=0.000), which indicated a rounder shape of the heart. In addition, fetuses in the GDM group
demonstrated signifcant impairment in cardiac function compared to those in the control group (LV-GLS:
-18.26% vs. -22.70%, RV-GLS: -18.52% vs. -22.74%, LV-FAC: 35.30% vs. 42.36%, RV-FAC: 30.89% vs. 36.80%;
P=0.000 for all). Subgroup analyses according to gestational age (24+0–27+6 weeks and 28+0–40+0 weeks)
showed that the statistical diferences were retained between the GDM and control groups in each subgroup.

Conclusions
Fetuses of women with GDM present with signs of biventricular systolic dysfunction according to deformation
analysis using fetalHQ. Additionally, the heart had a rounder shape in the GDM group than in the controlgroup. This
study showed that fetalHQ can be used to assess fetal cardiac morphology and function easily and quickly, and
the efects of GDM on fetal cardiac morphology and function appeared from the second trimester. Thus, whether
earlier and stricter clinical intervention was necessary remained to be further studied. Furthermore, future studies
will need to supplement the efects of blood glucose levels on GLS, FAC, GSI, and 24-segment SI. Additionally, the
long-term follow-up after birth should also be improved to observe the infuence of changes in the indicators on
the prognosis.
JB16546XX
2021

Evaluation of fetal cardiac functions in the

setting of maternal diabetes: Application of the
global spherical index, global strain and
fractional area change by the speckle tracking
technique
Yan Song a,b , Hong Yin b , Wen Wang b , Yu-fen Zou b , De-quan Liu b , Ge Zhang b , Xiao-ping Ji a, aDepartment of
Cardiology, Qilu Hospital of Shandong University, Jinan 250012, China bDepartment of Ultrasound, Shandong
Maternal and Child Health Hospital, Jinan 250014, China

European Journal of Obstetrics & Gynecology and Reproductive Biology 264 (2021) 162–167
https://doi.org/10.1016/j.ejogrb.2021.07.004
2215-1532/2021 Elsevier B.V.
Objective
To evaluate ventricular contractility and profile heart deformations in fetuses of hyperglycemic mothers using the Speckle
tracking imaging (STI). The fractional area change (FAC), global longitudinal strain (GLS) and global sphericity index (GSI) of the
4-chamber view (4-CV) were computed

Method
Dynamic 4-CV images of 60 fetuses exposed to maternal diabetes (MD) and 60 controls were retrospectively collected between 19 and
37 weeks of gestation. Speckle-tracking analysis was used to compute and compare GSI, GLS and FAC of the right ventricle (RV) and
the left ventricle (LV) between the groups. By definition, GSI was the ratio of the epicardial basal–apical length in end-diastole (BAL) to
the overall transverse length of RV and LV in end-diastole (TL). The FAC was calculated by dividing the difference between end-
diastolic area and end-systolic area by the end-diastolic area. Similarly, the GLS of the RV and LV was obtained by dividing the
difference between the endocardial length in end-systole and endocardial length in end-diastole to the endocardial length in end-
diastole. Data for conventional echocardiographic parameters, standard biological measurements of fetus and maternal baseline
characteristics were also recorded and compared between the groups. Linear regression analysis was performed to assess the
association between age, BMI and the inter-ventricular septum thickness (IVST).

Results
Gestational age at the time of examination did not differ significantly between the control and gestational diabetes group (p =
0.74). In fetuses exposed to MD, the thickness of the IVS was higher while the FAC of RV, GLS of RV and the GSI were all
significantly lower. The FAC and global strain of LV generally decreased with progress in gestation but the difference between the
two groups was not statistically significant.
Conventional echocardiography in fetuses exposed to MD revealed a lower mitral E/A ratio and a larger myocardial performance
index (MPI) of the RV and LV. Although the annular plane systolic excursion (MAPSE), tricuspid annular plane systolic excursion
(TAPSE) and septal annular plane systolic excursion (SAPSE) were also lower in this group, the difference was not statistically
significant compared to fetuses of the control group. No regression relationship between age, BMI and IVST were noticed in any
group.
Conclusion
This study found that diastolic dysfunction among fetuses of gestational diabetic mothers is accompanied by global cardiac
deformation and functional decrease of the RV in systole in the second and third trimester. The GSI, global strain and FAC acquired
by SRI can be used as convenient and reliable quantitative parameters in the assessment of cardiac function in fetuses exposed to
gestational diabetes.

JB16546XX
2021

Comparing the Non-Quiver and Quiver Techniques

for Identification of the Endocardial Borders Used
for Speckle-Tracking Analysis of the Ventricles of
the Fetal Heart
Greggory R. DeVore MD, Gary Satou MD, Mark Sklansky MD
First published: 11 November 2020 https://doi.org/10.1002/jum.15561

Abstract
This study compared the non-quiver with the quiver technique for identifying the end-systolic and end- diastolic
endocardium of the fetal right ventricle (RV) and left ventricle (LV) used for speckle-tracking analysis. Bland–Altman and t
test analyses showed no significant differences in measurements between the techniques for the RV and LV. The
difference in the time required to perform the non-quiver analysis was significantly longer (P<.001) for the RV and LV than
the quiver technique. The quiver technique allows the examiner to efficiently identify the endocardial borders of the fetal
heart compared with the non-quiver method

JB17342XX
2021

Evaluation of fetal cardiac function in maternal

gestational diabetes mellitus by speckle tracking
echocardiography
Peina Huang -Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology Youbin Deng - Tongji
Hospital of Tongji Medical College of Huazhong University of Science and Technology Ling Feng - Tongji Hospital of Tongji Medical
College of Huazhong University of Science and Technology Yiping Gao - Tongji Hospital of Tongji Medical College of Huazhong
University of Science and Technology Xueqing Cheng - Tongji Hospital of Tongji Medical College of Huazhong University of Science
and Technology Hongyun Liu - Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology DOI:
https://doi.org/10.21203/rs.3.rs-761354/v1

Abstract
The aim of this study was to assess the cardiac function in fetuses of mothers with gestational diabetes mellitus (GDM) by using
fetalHQ, a quantitative analysis software for the assessment of fetal cardiac function based on speckle tracking
echocardiography. In this prospective cross-sectional study, 49 fetuses exposed to GDM and 50 normal fetuses were enrolled and
fetal echocardiography were performed and analyzed. In the GDM group, left ventricular (24 ± 4 vs. 28 ± 4, p < 0.001) and right
ventricular global longitudinal strain (23 ± 4 vs. 26 ± 4, p = 0.002) and right ventricular free wall strain (26 ± 6 vs. 29 ± 5, p = 0.006)
were significantly lower compared with the control group, whereas there was no significant difference in global spherical index
(1.2 ± 0.1 vs. 1.2 ± 0.1, p = 0.425). Additionally, 24-segment transverse fraction shortening of the right ventricle was more impaired
than the left and the segments with reduced fraction shortening were mainly located in the mid and apical sections of the right
ventricle, and mid section of the left ventricle. In conclusion, fetuses exposed to GDM may have cardiac dysfunction before the
onset of cardiac morphologic abnormalities, and the right ventricle is more vulnerable than the left during fetal development.

Introduction
Gestational diabetes mellitus (GDM) is the most common metabolic disease that occurs during pregnancy, affecting 9.3–25.5% of
pregnant women [1]. Previous studies have shown that GDM adversely affects the structure and function of the fetal heart and fetal
cardiac dysfunction may occur even the fetal heart is structurally normal [2, 3]. Fetal echocardiography is the most commonly used
method to evaluate and monitor fetal cardiac function at present because of its noninvasiveness, low cost and radiation free to
mother and fetus.

M-mode echocardiography is a simple and effective method for the assessment of fetal cardiac function by calculating the
fractional shortening (FS), but it has limitations. It has been testified that the endocardial wall of the ventricle in the systolic period
does not move vertically, but tangentially to the center of the chamber, so FS calculated by traditional M-mode echocardiography
does not represent the systolic displacement at the same endocardial segment [4]. Hence, the results of studies on left ventricular
FS calculated by M-mode echocardiography between GDM fetuses and normal fetuses need to be further evaluated or validated
[5–7]. Strain imaging, which is based on the principle of two-dimensional speckle tracking, is an emerging noninvasive ultrasonic
technique for quantitative analysis of cardiac deformation and has been widely used in pediatric and adult cardiology. Since there
have been many studies on the effects of GDM in fetal cardiac deformation, no consensus has yet been reached. The results of
different studies were controversial, which might be caused by diverse ultrasound equipment and the different diagnostic criteria

Page 1 JB17115XX
 used for GDM [8–11]. According to Miranda et al. [7], peak right ventricular global longitudinal systolic strain was lower in
fetuses of mothers with GDM or pregestational diabetes than control by using proprietary special speckle tracking software
(EchoPAC) but there was no difference in strain values for the left ventricle. By contrast, Patey et al. [9] found GDM fetuses had
significantly higher values of left and right ventricular using the same software. Rolf, et al. [10] and Wang et al. [11] showed that
maternal GDM would impair the left and right ventricular segmental longitudinal strain in fetuses (software: QLab, AFI,
respectively). Obviously, these studies have some limitations. These softwares used for assessing cardiac deformation in the
aforementioned studies were originally developed for adult hearts and were more prone to errors due to the small fetal heart
size and fast heart rates when applied to assess fetal heart function [10]. A special quantitative analysis software called
fetalHQ for the assessment of fetal cardiac function is now commercially available. The principle of fetalHQ is also based on
speckle tracking and strain values can be calculated by tracking the endocardium motion. Meanwhile, the ventricular
endocardium is divided into 49 points which starts from the insertion of the atrioventricular valve on the lateral wall and traces
down to the apex and goes up to the insertion of the atrioventricular valve on the interventricular septum, which results in 24
transverse segments defined as 2 points opposite each other. Thus, 24-segment transverse ventricular FS can be calculated
[4]. It overcomes the limitation of traditional M-mode echocardiography for the measurement of FS by using speckle tracking
technique to track the systolic displacement of the same endocardial segment. The objective of this study is to evaluate the
cardiac function in fetuses exposed to GDM by using fetalHQ.

Material and Methods Study

Population
In this prospective cross-sectional study, we recruited 75 pregnant women with GDM (GDM group) and
50 normal pregnant women (control group) between 20 and 40 weeks gestation from July 2020 to January 2021. All subjects
were single pregnancies and had completed fetal systemic ultrasound examination prior to fetal echocardiography. Exclusion
criteria for both groups were maternal type 2 diabetes mellitus, chronic inflammatory disease, thyroid disease, hypertension,
kidney disease, fetal cardiac or extracardiac malformation, fetal arrhythmia, fetal growth restriction and fetal chromosomal
abnormality. Referral reasons for control group included advanced age, adverse pregnancy history, family history of congenital
heart disease and intracardiac echogenic focus. GDM was diagnosed if one or more of the following criteria was met: fasting
plasma glucose ≥5.11mmol/L, 1h plasma glucose ≥9.99mmol/L, and 2h plasma glucose ≥8.49mmol/L with a
75-g oral glucose tolerance test. Finally, 26 cases were ruled out (4 fetuses with congenital heart defects, 8 GDM pregnant
women complicated with thyroid disease, and 14 with poor image quality) and 49 pregnant women with GDM and 50
normal pregnant women were included in this study.

The study protocol was approved by the Medical Ethics Committee of Tongji Hospital, Tongji Medical College,
Huazhong University of Science and Technology (TJ-IRB20210312) and informed consent was obtained from each
participant before their enrollment in the study

Maternal characteristics
Clinical characteristics, including maternal age, date of last menstruation, gestational age (calculated by the last menstrual
period), number of pregnancies, parity, and medical past history, laboratory test results, and medical treatment were
collected from electronic medical records. After recording the present clinical
characteristics, all subjects underwent standard fetal echocardiography and myocardial strain assessment..

Fetal echocardiography
Fetal echocardiography was performed on Voluson E10 ultrasound machine (GE Healthcare, Tiefenbach, Austria) equipped
with either an EM6C or RM6C transducer. First, a comprehensive fetal echocardiographic examination was carried out to rule
out congenital heart defects according to the recommendations of the International Society of Ultrasound in Obstetrics and
Gynecology (ISUOG) [12]. Then, the image was optimized to make the borders between the blood pool and endocardium clear
and the standard four-chamber view was acquired as saved as a 3-second loop with frame rate of 72-85 Hz with minimized
maternal respiration and fetal movement interferences.

Page 2 JB17115XX
Materials and Methods continued

Fetal cardiac function analysis

Cardiac function analysis was performed using the machine build-in software fetalHQ which was activated by
pressing Ventricular Shape and Contractility in the fetalHQ menu. Fetal cardiac end-diastolic and end-systolic time were determined
from the M-mode tracing of the tricuspid annulus. On the end-systolic image of four-chamber view, the septal and lateral
atrioventricular valve insertion points and the apex were identified for the selected right or left ventricle. The machine build-in
automated tracking algorithm outlined the endocardium in successive frames throughout the cardiac cycle. After the tracking quality
was verified (with subsequent manual adjustment of the region of interest if necessary), endocardial motion was analyzed by speckle
tracking to calculate the global longitudinal strain (GLS) of the left and right ventricles and strain of right ventricular free wall (Figure 1).
In the meantime, the following parameters were calculated through fetalHQ: fractional area change (%) = [(end diastolic area - end
systolic area)/ end diastolic area] *100; FS (%) = [(end diastolic transverse length - end systolic transverse length)/ end diastolic
transverse length] *100. In addition, global sphericity index (GSI) was calculated with the widest transverse length (orthogonal to the
longest length from the epicardial borders at the widest part of the four-chamber view) divided by the longest length (from the
epicardial border of the posterior mid atrial wall to the apical epicardial border of the ventricles). Left and right ventricular sphericity
index (SI) were calculated with the end-diastolic widest transverse length divided by the basal-apical length of the right or left ventricle.
Since the left and right ventricles were divided into 24 transverse segments for the calculation of FS, segments 1-8, 9-16 and 17-24 were
subsequently defined as basal, mid and apical sections, respectively.
.

Statistical analysis
Data were analyzed with SPSS 19.0 (IBM, Armonk, NY, USA). Continuous data were tested for normality (Shapiro Wilk test). Normally
distributed data were expressed as mean ± standard deviation and non-normally distributed data were expressed as median and
interquartile interval. For comparation between groups, independent T test was performed for normally distributed data and non-
parametric test was performed for non-normally distributed data. All statistical tests were two tailed, and p value <0.05 was
considered statistically significant.
.

Conclusions
In conclusion, cardiac systolic function of fetuses exposed to GDM is significantly impaired and abnormal cardiac function may
occur before morphologic change. Through a comprehensive, noninvasive cardiac segmental functional assessment, we
speculate reasonably that the right ventricle is more vulnerable than the left during fetal development and the mid and apical
sections tend to be affected earlier than the basal.
Furthermore, 24-segment transverse FS might be a sensitive indicator to evaluate cardiac systolic function in fetuses, but it need to
be validated in larger studies.

Page 3 JB17115XX
2021

Novel Speckle Tracking Analysis Showed

Excellent Reproducibility for Size and Shape of
the Fetal Heart and Good Reproducibility for
Strain and Fractional Shortening
Huntley E.S.a · Hernandez-Andrade E.a · Soto E.a · DeVore G.b,c· Sibai B.M.a Fetal
Diagn Ther- https://doi.org/10.1159/000517625

aDepartment of Obstetrics and Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at
Houston (UTHealth),Houston, TX, USA
bFetal Diagnostic Centers, Pasadena, CA, USA
cDepartment of Obstetrics and Gynecology, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA

Introduction
This study aimed to evaluate reproducibility and agreement of fetal cardiac shape and deformation using
fetalHQ.

Methods
Fifty normal fetuses at 20–38 weeks of gestation were evaluated. Two operators independently selected an optimal
cardiac cycle using FetalHQ®™software for speckle tracking analysis. Intra- and interobserver correlation coefficient
and limits of agreement for cardiac shape and deformation were estimated.

Results
Global cardiac markers: high correlation (r = 0.98) and agreement (mean difference, standard deviation [MD, SD]
5.07, 75.8) for ventricular area; moderate correlation (r = 0.78) and agreement (MD, SD: 0.016, 0.08) for global sphericity
index (SI) and for left ventricle (LV) global strain (r = 0.65; MD, SD: −4.48, 11.9); and low but still significant correlation (r
= 0.58) and agreement (MD, SD: −3.77, 12.27) for right ventricle (RV) global strain. For individual ventricular
parameters: high correlation for LV ([median r; range] 0.98; 0.93–0.99) and RV (r = 0.98; 0.97–1.0) SI, and for LV (r = 0.92:
0.56–0.99) and RV (r = 0.96; 0.67–0.99) end diastolic diameters; moderate correlation for LV fractional shortening (r =
0.53; 0.87–0.98); and no significant correlation for RV fractional shortening (r = 0.36; 0.32–0.97). Inter- and
intraobserver correlation and agreement were similar for all evaluated parameters.

Conclusion
Speckle tracking analysis of the fetal heart provides reliable estimations of global and LV shape and deformation.
Low correlation in the RV can be related to anatomical structures such as the moderator band.

JB17088XX
2021

Fetal cardiac geometry and function in

pregnancies with well-controlled gestational
diabetes mellitus using fetalHQ
Yunyu Chen, Qin Chen, Yingheng Wu, Haiyu Wang, Qiyun Fan, Wenjia Lei, Rui Zhang, Yongen Liang & Hongying
Wang - Department of Medical Ultrasonics, Guangzhou Women and Children’s Medical Center, Guangzhou
Medical University, Guangzhou, China

The Journal of Maternal-Fetal & Neonatal Medicine https://doi.org/10.1080/14767058.2021.1973996

Objective
To determine whether abnormal cardiac shape and ventricular global, transverse, and longitudinal
contractility are present in fetuses of women with well-controlled GDM

Methods
A prospective observational study was performed on 80 fetuses of women with well-controlled GDM and 90 control
fetuses. Using fetalHQ, a new speckle-tracking technique, cardiac shape, global contractility, transverse
contractility, and longitudinal contractility were calculated. The number and percentage of fetuses with z score
values below 5th or above 95th were computed.

Results
Compared with controls, there were no significant differences in the frequency of cardiac geometric abnormalities in
GDM fetuses. Despite good glycemic control, 60.0% of fetuses in the well-controlled GDM group had one or more
types of global, longitudinal, and transverse contractility abnormalities of one or both ventricles, but more frequent
on the right ventricle (RV, 50%). The most frequent abnormality of the RV occurred in the transverse contractility
(35%), followed by abnormalities of global contractility (25%), and longitudinal contractility (21.3%), compared with
controls. The left ventricle (LV) analysis demonstrated that the percentage of study fetuses with only transverse
contractility abnormality (18.8%) was significantly higher.

Conclusion
Despite good glycemic control, abnormal ventricular contractility was present in fetuses of women with GDM, but
more frequent in the RV. For both the RV and LV, transverse ventricular contractility abnormality were more prevalent
than abnormal global and longitudinal contractility. Fetuses of women with GDM should be evaluated for ventricular
contractility abnormality and have more follow-ups despite good glycemic control.

JB17088XX
2021

Impact of gestational diabetes mellitus on

fetal cardiac morphology and function: cohort
comparison of second and third-trimester
fetuses
L. YOVERA1,2, M. ZAHARIA1,2, T. JACHYMSKI1, O. VELICU-SCRABA1,2, C. CORONEL1,2,
C. DE PACO MATALLANA2, G. GEORGIOPOULOS1, K. H. NICOLAIDES1 and M. CHARAKIDA1,3
1Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King’s College Hospital,
London, UK; 2Hospital Cl´ınico Universitario Virgen de la Arrixaca, Institute for Biomedical Research of Murcia, IMIB-
Arrixaca, Murcia, Spain; 3School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK

Ultrasound Obstet Gynecol 2021; 57: 607–613

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.22148

Objective
To assess differences in cardiac morphology and function in fetuses of mothers with gestational diabetes
mellitus (GDM) compared to controls, and to assess whether, in women with GDM, fetal cardiac changes are
accentuated with advancing gestational age.

Method
We studied 112 women with GDM and 224 women with uncomplicated pregnancy at 24–40 weeks’ gestation. In all
fetuses, a standard four-chamber oblique view was obtained, and offline speckle-tracking analysis was performed to
measure right and left endocardial global longitudinal strain (GLS) and tricuspid and mitral annular plane systolic
excursion. Global sphericity index was also calculated. Echocardiographic parameters were compared between
GDM fetuses and controls at two gestational time periods of 24 + 0 to 32 + 0 weeks and 32 + 1 to 40 + 1 weeks.

Results
At 24 + 0 to 32 + 0 weeks, we phenotyped 43 fetuses from mothers with GDM and 71 from uncomplicated
pregnancies, and, at 32 + 1 to 40 + 1 weeks, we phenotyped 69 fetuses from mothers with GDM and 153 from women
with uncomplicated pregnancy. In fetuses of mothers with GDM, compared to controls, right ventricular functional
indices were consistently lower both at 24 + 0 to 32 + 0 weeks and at 32 + 1 to 40 + 1 weeks. Right ventricular GLS was
reduced in the GDM group at 24 + 0 to 32 + 0 weeks (adjusted mean difference, 0.7%; 95% CI, 0.3–1.1%) and at 32 + 1
to 40 + 1 weeks (adjusted mean difference, 0.9%; 95% CI, 0.6–1.1%). Fetal left ventricular global longitudinal function
was similar in GDM pregnancies compared with controls, with the exception of the contractility of the left ventricular
basal segment, which was reduced. Global sphericity index was reduced in GDM pregnancies only at 32 + 1 to 40 + 1
weeks (adjusted mean difference, −0.4; 95% CI, −0.7 to 0.1).

Conclusion
The offspring of women with GDM are at high risk for development of cardiovascular disease in childhood and early
adulthood. Our study demonstrates that GDM is associated with a reduction mainly in fetal right ventricular function,
compared to controls, and this response is not exaggerated with increasing gestational age. Further studies are
needed to determine whether fetuses with the observed alterations in cardiac function are those at highest risk for
subsequent development of cardiovascular disease.
JB17088XX
2021

Evaluation of novel fetalHQ technique, for

comprehensive cardiac function assessment of
fetal anemia
H. Avnet, B. Weisz, A. Weissmann-Brenner, E. Kassif, Y. Yinon
Institute of Obstetrics and Gynecological Imaging and Fetal Therapy, Sheba Medical Centre and Sackler School of
Medicine, Tel Aviv University, Tel HaShomer, Israel
ISUOG 2020
VP14.09

Objective
Fetal anemia MCA monitoring, particularly with recurrent IUTs is limited. Current fetal cardiac function ultrasound
techniques have limited validation. fetalHQ uses speckle-tracking to comprehensively evaluate the size, shape, and
contractility of the fetal heart. We aim to evaluate the clinical applicability of this modality for assessing fetal anemia.

Method
A prospective, longitudinal study. 41 scans from 16 pregnancies with anemia requiring IUT. FetalHQ was acquired
at pre-anemia routine scan and pre- and post-recurrent IUTs. Using a Voluson E10 machine, optimised to enhance
the blood pool-endocardium border and maximise framerate. 2D, 3-second cine clips of the 4CV while apex at 3 or
9 o’clock +/- 45◦ were stored. End-diastolic (ED) length and width recorded. Endocard traced by placing apex,
lateral and septal valve insertion points; automated analysis tracked wall movement throughout the cardiac
cycle. Postnatal blood count collected.

Results
Gravida 16-35 weeks with Rh/Kell disease or Parvo, observed 1-8 times in pregnancy, underwent 1-4 IUTs. FetalHQ
acquisition and analysis rate was 100%; mean analysis time was 4.3 minutes. Analysis simultaneously derived multiple
measurements, including z-scores and percentiles compared to reference ranges and displayed in a clear graphic
visualisation. Global analysis included 4CV size and sphericity index (SI). Lt and Rt ventricle analysis included ED and ES
diameter, fractional shortening, strain and
SI. Lt ED and ES volume and ejection fraction were computed. Fetuses typically showed early changes; Rt and Lt
ventricles dilated with progress of the disease, heart became more globular displaying decreased SI (Rt>Lt) and
finally fetus became compromised with decreased contractility (Rt>Lt). After IUTs partial reverse in Rt ventricle
diameter, Lt and Rt fractional shortening and Rt SI alteration was noted.

Conclusion
fetalHQ conducts an easy, fast, and comprehensive cardiac function evaluation, provides precise information for the
clinician to better understand, early-detect and manage fetal anemia.

JB17088XX
 2020

Improve d de te ction of coarctation of the aorta

using spe ckle tracking analysis of the fe tal heart
using the last examination prior to delivery
Greggory R. DeVore M.D.; Caitlin Haxel M.D.; Gary Satou M.D.; Mark Sklansky M.D.; Michelle J. Pelka M.D.; Pei Ni
Jone M.D.; Bettina F. Cuneo M.D.; Ultrasound in Obstetrics & Gynecology https://doi.org/10.1002/uog.21989

Objective
The false-positive rate for prenatal diagnosis of CoA commonly exceeds 50%, with an accurate detection rate of <50%.
This study was conducted to determine if the sensitivity and false-positiverate (FPCoA) for prenatal detection of CoA
could be reduced by evaluating the fetal epicardialsize and shape of the four-chamber view (4CV) and the endocardial
right (RV) and left (LV) ventricular size, shape, and contractility.

Methods
This was a retrospective case series of 108 fetuses with suspected prenatal diagnosis of CoA by pediatric cardiologists
using traditional diagnostic criteria. Postnatal evaluation distinguished those fetuses who subsequently required CoA
surgery (true positives) from those that were FPCoA. Postnatal cardiac abnormalities were identified for each group. The
prenatal evaluation measured the 4CV end-diastolic epicardial area, length, width, and sphericity index. Speckle tracking
analysis was used to compute the endocardial RV and LV end-diastolic area, length, 24-segment sphericity index, 24-
segment transverse width, and the following functional parameters:(1) fractional area change; (2) global, lateral, and
septal strain; (3) basal-apical, lateral, and septal wall fractional shortening; (4) RV and LV annular plane systolic excursion,
(4) 24-segment transverse width fractional shortening, and (5) LV stroke volume, cardiac output, and ejection fraction. In
addition, the RV/LV end-diastolic area ratio was computed. Using a control group of 200 normal fetuses, the mean and
standard deviation for each of the above cardiac measurements were used to compute the Z-scores for each of the 108
study fetuses. Once the Z-scores were computed for each fetus, logistic regression analysis was performedon the Z-
score values for the 108 fetuses to identify variables that separated the CoA from the FPCoA.

Results
The RV/LV area ratio was 80% (N=43) for the CoA fetuses and 76% (N=41) for the FPCoA fetuses. Fetuses with CoA had a
significantly greater number of associated cardiac abnormalities (93%, N=50) compared to the FPCoA (61%, 33/54),
P<0.001. The most common associated malformations were a bicuspid aortic valve (CoA 46%, N=25; FPCoA 22%, N=12;
P<0.01 ), aortic arch hypoplasia (CoA 31%, N=17; FPCoA 11%, N=6; P<0.01), ventricular septal defects (CoA 33%, N=18;
FPCoA 11%; N=6; P>05), and a mitral valve abnormality (CoA 30%, N=16); FP CoA 4%, N=2;
P<0.001). Logistic regression identified 28 variables that correctly identified 96% (52/54) of fetuses who had CoA, with a
false-positive rate of 4% (N=2/54) and a false-negative rate of 4% (2/54). The variables included the size of the 4CV, size
and shape of the RV and LV, and abnormal contractility of the RV and LV. The area under the receiver operating curve
was 0.98 (SE 0.023; 95% confidenceinterval 0.84 to 1). There was no significant differencein the percent of fetuses with
RV/LV area disproportion between fetuses with CoA and FPCoA.

Conclusions
Speckle tracking analysis of multiple ventricular measurements may be helpful to separatefetuses that are suspected to
have CoA prenatally.

JB63351XXao
2020

Cardiac Measurements of Size and Shape in

Fetuses With Absent or Reversed End-Diastolic
Velocity of the Umbilical Artery and Perinatal
Survival and Severe Growth Restriction Before
34 Weeks’ Gestation
Greggory R. DeVore, MD , Percy Pacora Portella, MD, Edgar Hernandez Andrade, MD, Lami Yeo, MD, Roberto Romero,
MD First published: 30 October 2020; https://doi.org/10.1002/jum.15532

Objective
The purpose of this study was to evaluate the end-diastolic size and shape of the 4-chamber view as well as the
right ventricle (RV) and left ventricle (LV) in growth-restricted fetuses before 34 weeks’ gestation with absent or
reversed end-diastolic velocity of the umbilical artery and compare the results between those with perinatal
deaths and those who survived the neonatal period.

Methods
Forty-nine fetuses with growth restriction and absent or reversed end-diastolic velocity of the umbilical artery
were studied. The size, shape, and sphericity index of the 4-chamber view, RV, and LV were assessed. The number
and percentage of fetuses with z score values of less than −1.65 and greater than
1.65 were computed.

Results
Of the 49 fetuses, there were 13 perinatal deaths (27%) and 36 (63%) neonatal survivors. Measurements that
were unique for neonatal survivors were an increased RV apical transverse width and decreased measurements of
the following: LV and RV widths, LV and RV areas, as well as RV sphericity indices.

Conclusions
Fetuses with a smaller RV and LV size and area and those with a globular-shaped RV were at significantly lower
risk for perinatal death.

JB01431XX
2020

Comparing the Non-Quiver and Quiver

Techniques for Identification of the Endocardial
Borders Used for Speckle-Tracking Analysis of
the Ventricles of the Fetal Heart
Greggory R. DeVore, MD , Gary Satou, MD, Mark Sklansky, MD
First published: 11 November 2020 https://doi.org/10.1002/jum.15561

Abstract

This study compared the non-Quiver with the Quiver technique for identifying the e nd- systolic and end diastolic
endocardium of the fetal right ventricle (RV) and left ventricle (LV) used for spe ckle - tracking analysis. Bland–Altman
and t test analyses showed no significant differences in measurements between the techniques for the RV and LV.
The difference in the time required to perform the non- Quiver analysis was significantly longer (P< .001) for the RV
and LV than the Quiver technique. The Quiver technique allows the examiner to efficiently identify the endocardial
borders of the fetal heart compared with the non-Quiver method.

JB01431XX
 2020

Evaluation of cardiac function in the recipient

twin in successfully treated twin-to-twin
transfusion syndrome using a novel fetal
speckle-tracking analysis
Anna L. Harbison Jay D. Pruetz Stephen Ma Mark S. Sklansky Ramen H. Chmait Greggory R. DeVore First
published: 05 October 2020 https://doi.org/10.1002/pd.5835

Objective
This study was designed to evaluate ventricular size, shape, and function in recipient twins following laser therapy for
twin-twin transfusionsyndrome (TTTS), using novel speckle-tracking techniques.

Methods
This retrospective study enrolled patients that underwent fetal laser surgery for TTTS and had fetal
echocardiograms (FE) performed pre ‐ and post‐ operatively (op), with adequate resolution in the 4‐ chamber
view for analysis, using a spe ckle ‐ tracking software, to compute the size, shape, and function of both the right
(RV) and left (LV) ventricles. Values were indexed to published normal values. Pre‐ and post‐ laser Z‐ score
values for each of the measurements were compared using the Student's t‐ test, with significance defined as P
<0.05.

Results
Fifteen TTTS candidate pregnancies that underwent laser therapy between 2010 and 2017, with adequate pre‐and
post‐ op FE, were selected for the analysis. Post‐ op FE at 28.5±8.3days showed a significant decrease in RV base
dimension, increased LV base dimension, and improvements in many functional measurements: LV global and free
wall strain, LV fractional area change, LV basal‐ apical fractional change, and LV and RV 24‐ segment fractional
shortening (FS) of the basal segments.

Conclusions
Cardiac remodeling, following laser surgery in TTTS recipient twins, was demonstrated in the basal portion
of both the RV and LV with improved biventricular function.

JB01431XX
 2020

Main Patterns of Fetal Cardiac Remodeling

Fàtima Crispi a Álvaro Sepúlveda-Martínez a, b Francesca Crovetto a Olga Gómez a Bart Bijnens c, d
Eduard Gratacós a

Fetal Medicine Research Center, BCNatal – Barcelona Center for Maternal-Fetal and Neonatal Medicine
(Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia Obstetricia i Neonatologia, Institut
d’Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Centre for Biomedical Research on Rare
Diseases (CIBER- ER), Barcelona, Spain; b Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital
Clínico de la Universidad de Chile, Santiago de Chile, Chile; c ICREA, Barcelona, Spain; d IDIBAPS,
Barcelona, Spain

Abstract
The heart is a central organ in the fetal adaptation to an adverse environment. Fetal cardiac changes may persist
postnatally and increase the risk of cardiovascular disease in adulthood. Knowledge about fetal cardiac
structural as well as functional remodeling has radically improved over the last few years. As it occurs in
postnatal life, the fetal heart remodels – changing its structure and shape – to adapt to an insult. Several
conditions have been reported to be associated with fetal cardiac remodeling including intrauterine growth
restriction, diabetes, exposure to antiretroviral drugs, conception by assisted reproductive technologies,
pulmonary stenosis, and other congenital heart diseases. Here we summarized the main observable patterns of
cardiac remodeling, i.e., globular shape, hypertrophy without dilation, and hypertrophy with cardiomegaly. We
discuss the potential pathophysiology behind different types of remodeling. Defining precisely the distinct
patterns of fetal cardiac remodeling is critical for advancing in the understanding of fetal cardiovascular
programming and its consequences on adult health, and potentially for the design of preventive strategies that
might have an impact on long-term cardiovascular health.

JB01431XX
2019

Quantitative Evaluation of the Fetal Right

and Left Ventricular Fractional Area Change
Using Speckle Tracking Technology
DeVore GR, Klas B, Satou G, Sklansky M. Quantitative Evaluation of the Fetal Right and Left Ventricular
Fractional Area Change Using Speckle Tracking Technology.
Ultrasound Obstet Gynecol. 2019 Feb;53(2):219-228

OBJECTIVES
The purpose of this study was to me asure the fractional are a change (FAC) of the right and left
ve ntricle s in normal fe tal he arts be twe e n 20 and 40 we e ks of ge station using speckle- tracking
software.
METHODS
The 4-chamber view of the fetal heart was obtained in 200 control fetuses between 20 and 40 weeks of gestation.
The FAC was computed from the ventricular areas [((end-diastolic area) - (end-systolic area)/(end-diastolic area))
x 100] for the right and left ventricles and regressed against 7 independent biometricand age variables. The FAC
was correlated with longitudinal fractional shortening (LFS) [((end-diastolic longitudinal length) - (end-systolic
longitudinal length) /(end-diastolic longitudinal length)) x 100] obtained from the mid ventricular basal- apical
lengths of the right and left ventricular chambers and the transversefractional shortening (TFS) [((end-diastolic
transverselength) - (end-systolic transverselength)/(end- diastolic transverselength)) x 100] from three
transversepositions (base, mid, apical) located within each ventricular chamber. To evaluatepotential clinical
utility, the FAC, LFS, and TFS results were examined in 9 fetuses with congenital heart defects (CHD).

RESULTS
Regression analysis demonstratedsignificant associations between the FAC and the biometricand age
independent variables (R2= 0.13 - 0.15). The FAC was significantly correlated with the LFS (R2 =0.18 to 0.28)
and TFS (R2 = 0.13 to 0.33). The 9 fetuses with CHD illustratedthe interrelationship between the FAC, LFS,
and TFS when identifyingabnormal ventricular function.
CONCLUSIONS
This study reports results from measuring the FAC of the right and left ventricles, and demonstratesa
correlation with longitudinal fractional shortening (LFS) and transversefractional shortening (TFS).

JB59717XXaa
2019

Quantitative evaluation of fetal right and left

ventricular fractional area change using
speckle-tracking technology

DeVore GR, Klas B, Satou G, Sklansky M Quantitative evaluation of fetal right and left ventricular
fractional area change using speckle-tracking technology
2019 Feb;53(2):219-228. doi: 10.1002/uog.19048

Objectives
To me asure , using spe ckle -tracking te chnology, the fractional are a change (FAC) of the right and left
ve ntricle s in normal fe tal he arts be twe e n 20 and 40 we e ks of gestation..

Methods
The four-chamber view of the fetal heart was obtained in 200 normal fetuses between 20 and 40 weeks of
gestation. FAC was computed from the ventricular areas (((end-diastolic area - end-systolic area)/end-diastolic
area) × 100) for the right and left ventricles and regressed against seven independent biometric and age
variables. FAC was correlated with longitudinal fractional shortening (LFS) (((end-diastolic longitudinal length -
end-systolic longitudinal length)/end-diastolic longitudinal length) × 100) obtained from the mid-ventricular
basal-apical lengths of the right and left ventricular chambers and with transverse fractional shortening (TFS)
(((end-diastolic transverse length - end-systolic transverse length)/end- diastolic transverse length) × 100) from
three transverse positions (base, mid, apical) located within each ventricular chamber. To evaluate potential
clinical utility, FAC, LFS and TFS results were examined in nine fetuses with a congenital heart defect (CHD)

Findings
Regression analysis demonstrated significant associations between FAC and the independent biometric and
age variables (R2 = 0.13-0.15). FAC was significantly correlated with LFS (R2 = 0.18-0.28)and TFS (R2 =
0.13-0.33). Examination of the fetuses with CHD revealed that six of the nine had abnormal FAC Z-score values
for the index pathological ventricle. When abnormal LFS and TFS values were compared to the FAC in these
fetuses, the FAC was either abnormally low or normal.

Conclusions
This study re ports re sults from me asuring the FAC of the right and le ft ve ntricle s and
de monstrates a correlation with LFS and TFS. Copyright © 2018 ISUOG. Published by John Wiley &
Sons Ltd.

JB50561XXeq
2019

Evaluation of Fetal Left Ventricular Size and

Function Using Speckle-Tracking and the
Simpson Rule

DeVore GR, Klas B, Satou G, Sklansky M. Evaluation of Fetal Left Ventricular Size and Function Using
Speckle-Tracking and the Simpson Rule.
J Ultrasound Med. 2019 May;38(5):1209-1221

OBJECTIVES
This study was conducted to evaluate left ventricular (LV) size and function in healthy fetuses and to test
a cohort of fetuses at risk for abnormal function using speckle- tracking software.
METHODS
Two hundred control fetuses were examined between 20 and 40 weeks' gestation. With the use of offline
speckle-tracking software, the end-diastolic and end-systolic volumes were measured and the following
computed: strokevolume (SV), SV per kilogram, cardiac output (CO), CO per kilogram, and ejection fraction.
These were regressed against 7 independent variables related to the size, weight, and age of the fetuses. Five
fetuses with risk factors for LV dysfunctionwere examined to sample the validity of the data from the control
group.
RESULTS
The R2 values for measurements of the end-diastolic volume, SV, and CO correlated with the 7 independent
variables of fetal size and age (0.7-0.78), whereas the SV/kg, CO/kg, and ejection fraction had lower R2 values
(0.02-0.1). The measurements were normally distributed (Shapiro-Wilke > 0.5). The 5 fetuses at risk for abnormal
LV function had measurements of LV size and function that were consistent with the expected pathologic
condition.
CONCLUSIONS

Speckle tracking can provide a comprehensive evaluation of the size and function of the fetal LV.

JB50561XXay
2019

Assessment of ventricular contractility in

fetuses with an estimated fetal weight less
than the tenth centile
DeVore GR, Gumina DL, Hobbins JC. Assessment of ventricular contractility in fetuses with an estimated fetal weight less
than the tenth centile. Am J Obstet Gynecol 2019.0002-9378 https://doi.org/10.1016/j.ajog.2019.05.042

Objectives
To determine whether abnormal global, transverse, and longitudinal ventricular contractility of the heart in fetuses with an
estimated fetal weight <10th centile is present, irrespective of Doppler studies of the umbilical artery and cerebroplacental ratio.

Methods
This was a retrospective study of 50 fetuses with an estimated fetal weight <10th centile that were classified based on Doppler
results from the pulsatility indices of the umbilical artery and middle cerebral artery, and the calculated cerebroplacental ratio
(pulsatility indices of the umbilical artery/middle cerebral artery).Right and left ventricular measurements were categorized into3
groups: (1) global ventricular contractility (fractionalarea change), (2) transverse ventricular contractility (24-segment transverse
fractionalshortening), and (3) Basale apical longitudinal contractility (longitudinal strain, longitudinal displacement fractional
shortening, and basal lateral and septal wall annular plane systolic excursion). Z scores for the above measurements were computed
for fetuses with an estimated fetal weight <10th centile using the mean and standard deviation derived from normal controls.
Ventricular contractility measurements were considered abnormal if their Z score values were <5th centile (z score <e1.65) or >95th
centile (Z score >1.65), de pending on the specific ventricular measurement.

Findings
The average gestational age at the time of the examination was 32 weeks 4 days (standard deviation 3 weeks 4 days). None of the 50
study fetuses demonstrated absent or reverse flow of the umbilical artery Doppler waveform. Eighty-eight percent (44/50) of fetuses
had one or more abnormal measurements of cardiac contractility of 1 or both ventricles. Analysis of right ventricular contractility
demonstrated 78% (39/50) to have 1 or more abnormal measurements, which were grouped as follows: global contractility 38%
(19/50), transverse contractility 66% (33/ 50); and longitudinal contractility 48% (24/50). Analysis of left ventricular contractility
demonstrated 1 or more abnormal measurements in 58% (29/ 50) that were grouped as follows: global contractility 38% (19/50);
transverse contractility 40% (20/50); and longitudinal contractility 40% (20/50). Of the 50 study fetuses, 25 had normal pulsatility index
of the umbilical artery and cerebroplacental ratios, 80% of whom had 1 or more abnormalities of right ventricular contractility and 56%
of whom had 1 or more abnormalities of left ventricular contractility. Abnormal ventricular contractility for these fetuses was present in
all 3 groups of measurements; global, transverse, and longitudinal. Those with an isolated abnormal pulsatility index of the umbilical
artery (n¼11) had abnormalities of transverse contractility of the right ventricular and global contractility in the left ventricle. When an
isolated cerebroplacental ratio abnormality was present, the right ventricle demonstrated abnormal global, transverse, and
longitudinal contractility, with the left ventricle only demonstrating abnormalities in transverse contractility. When both the pulsatility
index of the umbilical artery and cerebroplacental ratio were abnormal (3/50), transverse and longitudinal contractility measurements
were abnormal for both ventricles, as well as abnormal global contractility of the left ventricle.

Conclusions
High rates of abnormal ventricular contractility were present in fetuses with an estimated fetal weight <10th centile, irrespective of the
Doppler findings of the pulsatility index of the umbilical artery, and/or cerebroplacental ratio. Abnormalities of ventricular contractility
were more prevalent in transverse measurements than global or longitudinal measurements. Abnormal transverse contractility was
more common in the right than the left ventricle. Fetuses with estimated fetal weight <10 may be considered to undergo assessment of
ventricular contractility, even when Doppler measurements of the pulsatility index of the umbilical artery, and cerebroplacental ratio
are normal.

JB70046XX
 2019

Fetal cardiac rhabdomyomas treated with

maternal sirolimus

Ilina D. Pluym Mark Sklansky Joyce Y. Wu Yalda Afshar Kerry Holliman Greggory R. Devore
Ayanna Walde n Lawrence D. Platt Deborah Krakow
First published: 19 November 2019 https://doi.org/10.1002/pd.5613

OBJECTIVE
To review the pathophysiology of rhabdomyomas and the emerging option of prenatal treatment of fetal cardiac
rhabdomyomas.

METHODS
We present a case of fetal rhabdomyomas causing significant hemodynamic compromise that received in utero
treatment of maternal sirolimus. Genetic amniocentesis confirmed a TSC2 mutation. A treatment program was
initiated with a 10- mg loading dose titrated to a goal maternal trough of 10 to 15 ng/dL. In order to follow fetal
cardiac function, a sophisticated method of speckle tracking echocardiography was used before and after treatment.
Obstetric ultrasound was used to monitor fetal growth, and clinical surveillance, echocardiography, and brain MRI
were used to monitor postnatal growth and development through 6 months of neonatal life.

RESULTS
Sirolimus was initiated from 28 to 36 weeks of gestation with improvement of cardiac status. During this period,
intrauterine growth restriction developed. Postnatally, the infant has had stable rhabdomyomas and cardiac function
without reinitiating sirolimus. Brain MRI demonstrated scattered cortical tubers and subependymal nodules, and the
infant has not had seizure-like activity. At 6 months of age, the infant has achieved appropriate developmental
milestones.

CONCLUSIONS
In counseling cases of prenatal onset large obstructing rhabdomyomas and cardiac compromise, in utero
sirolimus treatment can be considered

JB02535XX
2019

Aortic Coarctation: A Comprehensive

Analysis of Shape, Size, and Contractility of
the Fetal Heart
DeVore GR1, Jone PN2, Satou G3, Sklansky M3, Cuneo BF2,4
Fetal Diagn Ther. 2020;47(5):429-439

BACKGROUND

An integrated assessment of the size and shape of the 4-chamber view (4-CV) and right and left ventricles (RV and LV) as
well as the function of the RV and LV in fetuses with coarctation of the aorta (CoA) has not yet been conducted.

OBJECTIVES
We evaluated the size and shape of the 4-CV, RV, and LV, and function of the RV and LV, to identify a profile for fetuses
with CoA when compared to a control population.

METHODS
50 CoA fetuses were compared to 200 controls. This was a retrospective case series comparing the 4-CV of CoA fetuses
and controls. The 4-CV end-diastolic area, length, width, and sphericity index were measured to determine the
configuration of the 4-CV. Speckle-tracking analysis was used to compute the RV and LV end-diastolic area, length, 24-
segment sphericity index, 24-segment transverse width, and the following functional parameters: (1) fractional area
change; (2) global, lateral, and septal strain; (3) basal- apical, lateral, and septal annular displacement and fractional
shortening; and (4) 24-segment transverse width fractional shortening. Using 5 and 95% reference intervals, the CoA fetal
measurements were classified; from these, the odds ratio was computed between the fetuses with CoA and the controls.
p<
0.05 was considered significant.

RESULTS
In fetuses with CoA, the 4-CV was spherical in shape, increased in area and width, and decreased in length. Abnormal
CoA sphericity indices reflected a flatter LV and a more spherical RV. The LV area, length, and width, and RV length were
decreased. The transverse width of the RV was increased. RV and LV global, longitudinal, and transverse contractility
were depressed.

CONCLUSIONS
The results demonstrate previously unappreciated differences in the shape, size, and function of the heart in
fetuses with CoA. These differences may assist examiners in identifying fetuses with CoA.

JB63351XXai
2019

Speckle Tracking of the Basal Lateral and Septal

Wall Annular Plane Systolic Excursion of the Right
and Left Ventricles of the Fetal Heart

DeVore GR, Klas B, Satou G, Sklansky M. Speckle Tracking of the Basal Lateral and Septal Wall Annular Plane
Systolic Excursion of the Right and Left Ventricles of the Fetal Heart.J Ultrasound Med. 2019 May;38(5):1309- 1318.
doi: 10.1002/jum.14811. Epub 2018 Sep 12

OBJECTIVE
Annular plane systolic excursion (APSE) has been evaluated for the right (RV) and left (LV) ventricles using M-mode
echocardiography. This study examined APSE using 2- dimensional speckle tracking (2DST) of the lateral and
septal annuli of the RV and LV in normal fetuses.
METHODS
Two hundred normal fetuses were prospectivelyexamined between 20 and 40 weeks' gestation, in which the end-
diastolic and end-systolic lengths were measured from the apex to the insertion of the annuli into the lateral and
septal walls of the RV and LV using 2DST. Subtracting the end-systolic from the end-diastolic length resulted in the
APSE measurement. The APSE values from the ventricular and septal locations were regressed against biometric
and gestationalage independent variables, and the mean and standard deviationcomputed using fractional
polynomial analysis. Within-subject repeated measures of variance were used to compare results within and
between the right ventricular and left ventricular basal APSE values.
RESULTS
When regressed against the independent variables the R2 for the APSE of the right ventricular lateral wall ranged from
0.39 to 0.40, the left ventricular lateral wall 0.29 to 0.31, the right ventricular septal wall 0.22 to 0.40, and the left
ventricular septal wall 0.05 to 0.07. There was a significant difference (P < .001) for APSE between the right ventricular
and left ventricular lateral wall and their respective septal annuli, the left ventricular and right ventricular lateral wall
annuli, and the left ventricular and right ventricular septal annuli.
CONCLUSIONS
The right ventricular and left ventricular lateral and septal wall APSE can be computed using 2DST and are
associated with changing fetal biometricand age measurements.

B63351XXai
2019

Size and shape of the four-chamber view of

the fetal heart in fetuses with an estimated
fetal weight less than the tenth centile

Greggory R. DeVore; John C. Hobbins, MD; Diane L. Gumina, MS; Michael V. Zaretsky, MD; Camille Driver, MA; Annabelle Wilcox,
BA; American Journal of Obstetrics & Gynecology 495.e9

BACKGROUND:
Fetuses with an estimated fetal weight below the 10th centile have an increased risk of adverse perinatal and long-term outcomes
as well as increased rates of cardiac dysfunction, which often alters cardiac size and shape of the 4-chamber view and the
individual ventricles. As a result, a simple method has emerged to screen for potential cardiac dysfunction in fetuses with
estimated fetal weights <10th centile by measuring the size and shape of the 4-chamber view and the size of the ventricles.

OBJECTIVE:
To de termine the numbe r of fe tuse s with an abnormal size and shape of the 4-chambe r vie w and size of the ve ntricle s in
fetuses with an estimated fetal weight <10th centile.

MATERIALS ANDMETHODS:
This was a retrospective study of 50 fetuses between 25 and 37 weeks of gestation with an estimated fetal weight <10th centile. Data
from their last examination were analyzed. From an end-diastolic image of the 4-chamber view, the largest basal apical length and
transverse width were measured from their corresponding epicardial borders. This allowed the 4-chamber view area and global
sphericity index (4- chamber view length/4-chamber view width) to be computed. In addition, tracing along the endocardial borders
with speckle tracking software enabled measurements of the right and left ventricular chamber areas and the right ventricle/left
ventricle area ratios to be computed. Doppler waveform pulsatility indices from the umbilical
(umbilical artery pulsatility index) and middle cerebral arteries (middle cerebral artery pulsatility index) were analyzed, and the
cerebroplacental ratio (middle cerebral artery pulsatility index/umbilical artery pulsatility index) computed. Umbilical artery
pulsatility indices
>90th and cerebroplacental ratios <10th centile were considered abnormal. Using data from the control fetuses, the centile for each
of the cardiac measurements was categorized by whether it was <10th or >90th centile, depending upon the measurement.

RESULTS
Of the 50 fetuses with estimated fetal weight <10th centile, 50% (n = 25) had a normal umbilical artery pulsatility index and
cerebroplacental ratio. These fetuses had significantly more (P < 0.02 to <0.0001) abnormalities of the size and shape of the 4-
chamber view than controls. In all, 44% had a 4-chamber view area >90th centile, 32% had a 4-chamber view global sphericity index
<10th centile, 56% had a 4-chamber view width >90th centile, and 80% had 1 or more abnormalities of size and/or shape. The
remaining 50% of fetuses (n = 25) had abnormalities of 1 or both for the umbilical artery pulsatility index and/or cerebroplacental
ratio. These fetuses had significantly higher rates of abnormalities (P <0.05 to <0.0001) than controls for the following 4-chamber view
measurements: 36% had a 4-chamber view area >90th centile; 28% had a 4-chamber view global sphericity index <10th centile; and
68% had a 4-chamber view width >90th centile. Only those fetuses with an abnormal umbilical artery pulsatility index had significant
changes in ventricular size; 56% had a left ventricular area <10th centile; 28% had a right ventricular area <10th centile; 36% had right
ventricular/left ventricular area ratio >90th centile. One or more of the above abnormal measurements were present in 92% of the
fetuses.

Continued next page

1/2 JB63351XXao
2019

Size and shape of the four-chamber view of

the fetal heart in fetuses with an estimated
fetal weight less than the tenth centile

Greggory R. DeVore; John C. Hobbins, MD; Diane L. Gumina, MS; MichaelV. Zaretsky, MD; Camille Driver, MA; Annabelle Wilcox,
BA; American Journalof Obstetrics & Gynecology 495.e9

CONCLUSIONS
Higher rates of abnormalities of cardiac size and shape of the 4-chamber view were found in fetuses with an estimated fetal weight
<10th centile, regardless of their umbilical artery pulsatility index and cerebroplacental ratio measurements. Those with normal
umbilical artery pulsatility index and an abnormal cerebroplacental ratio had larger and wider measurements of the 4-chamber
view. In addition, the shape of the 4-chamber view was more globular or round than in controls. These fetuses may have an
increased risk of perinatal complications and childhood and/or adult cardiovascular disease. Screening tools derived froma the 4-
chamber view, acting as surrogates for ventricular dysfunction, may identify fetuses who could benefit from further comprehensive
testing and future preventive interventions.

1/2 JB63351XXao
2018

Longitudinal Annular Systolic Displacement

Compared to Global Strain in Normal Fetal
Hearts and Those With Cardiac Abnormalities

DeVore GR, Klas B, Satou G, Sklansky M. Longitudinal Annular Systolic Displacement Compared to Global
Strain in Normal Fetal Hearts and Those With Cardiac Abnormalities. J UltrasoundMed. 2018
May;37(5):1159-1171.

OBJECTIVES
The purpose of this study was to comparea new technique that measures the midventricular
basal-apical longitudinal diastolic and systolic lengths, computes the longitudinal displacement
fractional shortening, and compares it to global strain.
METHODS
Two hundred control fetuses were examined between 20 and 40 weeks' gestation, in whom the longitudinal
displacement fractional shortening was computed from end- diastolic and end-systolic lengths measured from
the apex to the mid portion of the distance between the level of the basal lateral and septal walls using 2-
dimnsional speckle tracking. In addition, global strain was computed using speckle tracking. A correlation
analysis was used to compare the longitudinal displacement fractional shortening to global strain. The
longitudinaldisplacement fractional shortening of the right ventricle(RV) and left ventricle (LV) was measured in
10 fetuses with heart abnormalities.
RESULTS
The longitudinal displacement fractional shortening for the RV (mean ± SD, 22.94% ± 4.73%) and LV
(21.05% ± 4.21%) was independent of gestational age and other biometric growth parameters, as was
global strain (RV, -22.7% ± 4.07%); LV, -22.93% ± 3.52%). The RV longitudinal displacement fractional
shortening was greater than that of the LV (P <
.024). The correlations between the longitudinal displacement fractional shorteningand
global strain were 0.95 for the RV and 0.97 for the LV. Comparing the longitudinal displacement
fractional shorteningand global strain in fetuses with abnormal cardiac findings showed concordant
findings in 9 of 10 fetuses.
CONCLUSIONS
The RV and LV longitudinal displacement fractional shortening can be computed from 2- dimensional
images of the 4-chamber view and correlated with global strain. The longitudinal displacement fractional
shortening was significantly greater for the RV than the LV and was abnormal in fetuses with RV and LV
cardiac abnormalities.

JB59717XXaa
2018

24-segment sphericity index: a new technique

to evaluate fetal cardiac diastolic shape

DeVore GR, Klas B, Satou G, Sklansky M. 24-segment sphericity index: a new te chnique to evaluate fetal
cardiac diastolic shape. UltrasoundObstet Gynecol. 2018 May;51(5):650- 658

OBJECTIVE
Because of parallel circulation in the fetus and the differential effect that various disease states may have
on the shape of the right and left ventricles, this study was conducted to evaluate the sphericity index (SI)
of 24 transversesegments distributed from the base to the apex of each of the ventricular chambers.

METHODS
Two hundred control fetuses were examined between 20 and 40 weeks of gestation. The displacement of the
ventricular endocardium during the cardiac cycle was computed using offline speckle-tracking software. From
the ASCII output of the analysis, we analyzed 24 end-diastolic transversesegments, distributed from the base to
the apex of each ventricle, as well as the end-diastolic mid-basal-apical length. The SI was computedfor each
of the 24 segments by dividing the mid-basal-apical length by the transverselength for each segment.
Regression analysis was performed against biometricmeasurements and gestational age according to last
menstrual period and ultrasound. Eight fetuses, in which the four-chamber view appeared subjectivelyto
demonstratechamber disproportion, were evaluated as examples to demonstratethe utility of this technology.

RESULTS
The SI for each segment was independent of gestational age and fetal biometric measurements. The SI of the
right ventricle was significantly (P < 0.001) lower than that of the left ventricle for segments 1-18, suggesting that
the right ventricle was more globular in shape than was the left ventricle at the base, mid and a portion of the
apical segments of the chamber. Fetuses with various cardiac structuralabnormalities and abnormal fetal
growth had abnormal SI values that reflected either a more globular or a more flattened ventricular chamber.

CONCLUSION
Determination of SI for each of 24 segments of the fetal right and left ventricles provides a comprehensive
method to examine the shape of the ventricular chambers

JB59717XXaa
2018

Twenty-four Segment Transverse Ventricular

Fractional Shortening: A New Technique to
Evaluate Fetal Cardiac Function

DeVore GR, Klas B, Satou G, Sklansky M. Twenty-four Segment TransverseVentricular Fractional

Shortening: A New Technique to Evaluate Fetal Cardiac Function. J Ultrasound Med. 2018
May;37(5):1129-1141.

OBJECTIVES
Because of variousfetal and maternal disease states, this study was conducted to evaluate the fractional
shorteningof 24 transversesegments distributed from the base to the apex of the ventricular chambers.
METHODS
Two hundred control fetuses were examined between 20 and 40 weeks' gestation. The transverse
displacement of the ventricular endocardium during the cardiac cycle was computed by using offline
software. From the outputof the analysis, 24 end-diastolic and end-systolic segments were measured
from the base (segment 1) to the apex (segment
24) of the right and left ventricles, and the fractional shortening was computed: [(end- diastolic length -
end-systolic length)/end-diastolic length] × 100. Examples of fetal cardiovascular abnormalities were
selected to demonstratethe utility of this technique.
RESULTS
The fractional shortening for each segment was independent of gestational age and fetal biometric
measurements. There was no significant difference in fractional shortening for segments 1 to 5 between the
right and left ventricles. However, the fractional shortening of the left ventricle was significantly greater (P
< .0001) than that of the right ventricle for segments 6 to 24, suggesting that the mid and apical segments of the
left ventricle have increased displacement toward the center of the chamber compared to the right ventricle.
Fetuses with various cardiac structuralabnormalities had abnormal fractional shortening values.

CONCLUSIONS
The fractional shortening of 24 segments of the right and left ventricles provides a
comprehensive method to examine the contractility of the ventricular chambers.

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2018

Comprehensive Evaluation of Fetal Cardiac

Ventricular Widths and Ratios Using a 24-
Segment Speckle Tracking Technique

Greggory R. DeVore MD , Bettina Cuneo MD , Berthold Klas BS , Gary Satou MD , Mark Sklansky MD,
Comprehensive Evaluation of Fetal Cardiac Ventricular Widths and Ratios Using a 24-Segment Speckle
Tracking Technique, First published: 02 October 2018, https://doi.org/10.1002/jum.14792

Objectives
This study was conducte d to e valuate the 24-se gme nt transve rse widths of the right and le ft ventricles
distribute d from the base to the ape x of the ventricular chambe rs and compute the right ventricular
(RV)/le ft ve ntricular (LV) ratios for each segment.
Methods
Two hundred control fetuses were examined between 20 and 40 weeks’ gestation. Using offline speckle-
tracking software, the 24 end-diastolic transverse widths were computed and the RV/LV ratios were regressed
against 7 independent variables related to the size, weight, and age of the fetuses. Five fetuses with
coarctation of the aorta and 5 fetuses with pulmonary stenosis were examined to exemplify the utility of
these measurements.
Findings
The 24-segment transverse widths were associated with changes in fetal size, weight, and age. Regression
equations were developed to describe these changes with R2 values between .5 and .82. The measurements
were normally distributed (Shapiro-Wilk > 0.5). The RV/LV ratio for the 24 segments did not strongly correlate (R2
= .001 to –.2) with fetal size, weight, or gestational age. Fetuses with coarctation of the aorta and pulmonary
stenosis demonstrated characteristic changes in the 24-segment transverse widths and the RV/LV ratios in the
basal (segments 1–8), mid (segments 9–16) and apical (segments 17–
24) sections of the ventricles.
Conclusions
The 24-se gme nt transve rse widths of the right and le ft ve ntricle s and the RV/LV ratios provide a
compre he nsive me thod to e xamine the width of the ventricular chambers.

JB50561XXbf
2018

Right and left ventricular 24-segment

sphericity index is abnormal in small- for-
gestational-age fetuses
DeVore GR, Zaretsky M, Gumina DL, Hobbins JC. Right and left ventricular 24-segment sphericity index is
abnormal in small-for-gestational-age fetuses. UltrasoundObstet Gynecol. 2018 Aug;52(2):243-249.
OBJECTIVE
Fetuses with growth restriction have been reported to have an abnormal sphericity index (SI), which is
indicative of the shape of the ventricular chambers of the heart. Our aim was to evaluate the SI for 24
transverse segments distributed from base to apex of the right (RV) and left (LV) ventricles to determine
whether, in small-for-gestational-age(SGA) fetuses, the SI is abnormal at locations other than the basal
segment.
METHODS
We evaluated 30 SGA fetuses between 25 and 37 weeks of gestation. SI was computed for both ventricles by
dividing the end-diastolic mid-basal-apical length by each of 24 end-diastolic transverse segmental widths, from
base (Segment 1) to apex (Segment 24). For each ventricle, the Z-score and centile for the SI from each of the 24
segments were computed using the mean and SD from published equations. The 24-segment method, defining
abnormal SI as values
< 10th centileor > 90th centile, was compared with that of using only the basal segment by chi- square
analysis to determine the number of fetuses identified with an abnormal SI.
RESULTS
In 23 of the 30 (77%) SGA fetuses, at least one of the 24 transverse segments in one or both ventricles had an
abnormal SI; in 17% of cases, both ventricles were affected, in 23% of cases only the RV was involvedand in 37% of
cases only the LV was involved. Compared with the 24- segment model, significantly fewer fetuses with an
abnormal SI were identified using only basal Segment 1, from the RV base (58%, 7/12; P < 0.01) or only Segment
12, in the mid portion of the RV (50%, 6/12; P < 0.005). Combining measurementsof Segment 1 and Segment 12
from the RV identified 83% of fetuses with at least one abnormal SI and was not significantly different from using
the 24- segment model. Similarly, significantly fewer fetuses with an abnormal SI were identified using only LV
basal Segment 1 (63%, 10/16; P < 0.006) or only Segment 12, in the mid portion of the LV (75%, 12/16; P < 0.03),
when compared with the 24-segment model.
Combining measurements of both LV Segment 1 and Segment 12 identified 81% (13/16) of fetuses with
an abnormal SI and was not significantly different from using the 24-segment model.
CONCLUSION
The 24-segment SI of RV and LV provides a comprehensive method with which to examine the shape of the
ventricular chambers and identifies more SGA fetuses with an abnormal SI than are identified using only the
basal segment SI.

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2017

Area of the fetal heart's four-chamber view: a

practical screening tool to improve detection
of cardiac abnormalities in a low-risk
population
DeVore GR, Satou G, Sklansky M. Area of the fetal heart's four-chamber view: A practical screening tool to
improve detection of cardiac abnormalities in a low-risk population.
Prenat Diagn. 2017 Feb;37(2):151-155.

OBJECTIVE
The objective of this article is to evaluatewhether the area of the four-chamber view of the fetal heart
computed from two orthogonal diameters could be used to screen for cardiac malformations.
METHODS
Two hundred control fetuses were examined between 20 and 40 weeks of gestation. The end-diastolic area
was computed from the orthogonal basal-apicaland transversediameters obtained from the four-chamber
view. Regression analysis of the computed area versus six independent variables was performed between 20
and 40 weeks. Fetuses with major heart defects were identified from a low-riskpopulation of 4352 fetuses
undergoing second-trimester or third-trimester screening ultrasound. The end-diastolic area was derived and
the Z-score and centile computed. An area greater than the 95th centile was considered to be abnormal.

RESULTS
From the screening population, the incidence of major heart defects was 2.8/1000. Of the 12 fetuses with
major heart defects, 50% (6/12) demonstratedan area greater than the 95th centile. Of the fetuses with an
enlarged heart, 66% (4/6) had outflow tract abnormalities.
CONCLUSIONS
Measurements of the orthogonal basal-apical and transverse diameters can be used to compute the area of
the four-chamber view. Fetuses with major heart defects who have an enlarged heart can be identified using
this technique.

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2017

Computing the Z Score and Centiles for Cross-

sectional Analysis: A Practical Approach

DeVore GR. Computing the Z Score and Centiles for Cross-sectional Analysis: A Practical
Approach. J Ultrasound Med. 2017 Mar;36(3):459-473.

Although Z scores have been reported in the literature, one of the problems for the nonstatistician is
understanding the systematic approach used to compute the predicted mean and standard deviation,
components of the Z score equation, which may vary as the independent variable changes over time (eg,
gestational age). This review focuses on a step- by-step analysis using linear, quadratic, and fractional
polynomials to compute the mean and standard deviation as a function of a continuous independent variable.
Once the mean and standard deviation are computed, the Z score and centile can be derived and Z score
calculators created that enable investigators to implement the results in the laboratory and/or clinical setting.

JB59717XXaa
2017

Abnormal Fetal Findings Associated With a

Global Sphericity Index of the 4-Chamber View
Below the 5th Centile

DeVore GR, Satou G, Sklansky M. Abnormal Fetal Findings Associated With a Global Sphericity Index of the
4-Chamber View Below the 5th Centile. J UltrasoundMed. 2017 Nov; 36(11): 2309-2318

OBJECTIVES
The purpose of this study was to evaluatethe global sphericity index (GSI) of the 4- chamber view
and correlate the results with abnormal ultrasound findings.
METHODS
The epicardial end-diastolic basal-apical length (BAL) and transverselength (TL) of the 4- chamber view were
measured to compute the GSI (BAL/TL) in 200 control fetuses between 20 and 40 weeks' gestation. Three
hundred study fetuses were prospectivelyexamined between 17 and 39 weeks' gestation. The GSI, Z score, and
centile were computed for each of the fetuses.
RESULTS
The GSI (1.233; SD, 0.0953) in the control fetuses was independent of gestational age. Eighteen percent of the
study fetuses (55 of 300) had a GSI below the 5th centile (<1.08), of whom 96% (53 of 55) had additional abnormal
ultrasound findings. Fetuses with an estimated fetal weight below the 10th centile had a significantly (P < .05)
higher rate of an umbilical artery Doppler pulsatilityindex above the 95th centile (27%versus17.7%), a middle
cerebral artery Doppler pulsatilityindex below the 5th centile(27% versus 0%), an abnormal cerebroplacental
ratio (27% versus 4.5%), and an amniotic fluid index of less than 5 cm (36% versus 9%). The TL was significantly
increased compared with the BAL in fetuses with cardiac dysfunction, irrespectiveof the estimatedfetal weight.

CONCLUSIONS
An abnormal GSI below the 5th centileis associated with abnormal fetal ultrasoundfindings.

JB59717XXaa
2017

Evaluation of the right and left ventricles: An

integrated approach measuring the area,
length, and width of the chambers in normal
fetuses
De Vore GR, Klas B, Satou G, Sklansky M. Evaluation of the right and left ve ntricle s: An integrated
approach me asuring the are a, le ngth, and width of the chambers in normal fetuses. Prenat Diagn.
2017 Dec;37(12):1203-1212.

INTRODUCTION
The purpose of this study was to simultaneouslymeasure with speckle tracking software the end-diastolic
ventricular area (A), basal transverse width (BW), mid-chamber transverse width (MW), and basal-apical length
(BAL) in normalfetuses and those with pathology.
METHODS
The 4-chamber view of the fetal heart was obtained in 200 control fetuses between 20 and 40 weeks of
gestation and in 9 third-trimester fetuses with heart malformations. The mean and standard deviation for the
A, BW, MW, and BAL were computed from the control fetuses and Z scores computed from the 9 fetuses with
cardiac malformations.
RESULTS
The A, BAL, BW, and MW were correlated with 7 somatic and age-independent variables (R2 = .63-.85). The
highest R2 values occurred for the head circumference, estimatedfetal weight, and ultrasound mean
gestational age (.82-.85). Z-score values and centiles from the 9 fetuses with cardiac malformations
suggested that the A, BW, MW, and BAL were below or above the 5th and 95th centiles as expected for the
corresponding ventricular
pathology.
CONCLUSIONS
This study reports an integrated approach to evaluatethe end-diastolic size of the right and left
ventricular chambers and demonstratedclinical utility in fetuses with cardiac malformations.

JB59717XXaa
2016

Fetal Heart Size: A Comparison Between the

Point-to-Point Trace and Automated Ellipse
Methods Between 20 and 40 Weeks'
Gestation

DeVore GR, Tabsh K, Polanco B, Satou G, Sklansky M. Fetal Heart Size: A Comparison Between the
Point-to-Point Trace and Automated Ellipse Methods Between 20 and 40 Weeks' Gestation. J
UltrasoundMed. 2016 Dec;35(12):2543-2562.

OBJECTIVES
To evaluate whether the global area and circumference of the heart varies between two measurement
techniques: the point-to-point trace and the electronic ellipse methods.
METHODS
The epicardial border of the 4-chamber view was measured in 200 fetuses between 20 and 40 weeks' gestation,
from which the area and circumference using the point-to-point trace and electronic ellipse were measured.
Analysis of variance, correlation, and regression analysis using fractional polynomials and 7 independent
variables (head circumference, biparietal diameter, abdominalcircumference, femur length, estimatedfetal
weight, mean ultrasound gestational age, and last menstrualperiod gestational age) were performed.

RESULTS
The correlation between the mean ultrasound gestationalage and last menstrualperiod gestational age was
0.9880 (5% confidence limit,0.9716; 95% confidence limit,0.9880), with an R2 of 0.9762. The R2 value for the 7
independent variables regressed against the area and circumference using the point-to-point trace and
electronic ellipse methods range d between 0.885 and 0.965. Comparison of Z scores between this study and
previous publications demonstratedthat there were differences and similarities, depending on whether the area
or circumference was measured.
CONCLUSIONS
This study shows high R2 values when comparing measurementsof the area and circumference
against 7 independent variables, irrespectiveof whether the point-to- point trace or the electronic
ellipse method was used to obtain the measurements. A calculator to evaluatethe area and
circumference is provided, using 7 independent variables from which Z scores and percentiles for
individual measurements can be compute

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2016

Two-Dimensional Speckle Tracking of the

Fetal Heart: A Practical Step-by- Step
Approach for the Fetal Sonologist
DeVore GR, Polanco B, Satou G, Sklansky M. Two-Dimensional Speckle Tracking of the Fetal Heart: A
Practical Step-by-Step Approach for the Fetal Sonologist. J Ultrasound Med. 2016 Aug;35(8):1765-81.

Various approaches to 2-dimensional speckle tracking have been used to evaluateleft ventricular
function and deformationin the fetus, child, and adult. In 2015, because of differences in imaging
devices and analytical programs, the cardiology community published a consensus document
proposing standards for pediatric/adult deformation imaging using
2-dimensional speckle tracking. The understanding and application of deformation imaging in the
fetus have been limited by a lack of uniform software,terminology,techniques, and display. This
article provides a practical, step-by-step approach for deformation analysis of
the fetal heart using offline software that is independent of specific ultrasound vendors.

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