Visualization of the arterial valve morphology and number of leaflets in a fetus with common arterial trunk by spatiotemporal image correlation imaging

Spatiotemporal imaging correlation (STIC) technology has been employed to visualize the fetal heart for close to two decades, but the additional value of the technology remains debatable. The value of the technology in identifying the morphology of the cardiac valves is being recognized. We report a 21-week gestational age fetus with common arterial trunk where STIC imaging enabled us to identify a bicuspid arterial valve.

Keywords: Common arterial trunk, fetal echocardiogram, STIC

How to cite this article:
Krishna MR, Senniyan UN. Visualization of the arterial valve morphology and number of leaflets in a fetus with common arterial trunk by spatiotemporal image correlation imaging. Ann Pediatr Card 2022;15:434-6
How to cite this URL:
Krishna MR, Senniyan UN. Visualization of the arterial valve morphology and number of leaflets in a fetus with common arterial trunk by spatiotemporal image correlation imaging. Ann Pediatr Card [serial online] 2022 [cited 2023 Jan 7];15:434-6. Available from: https://www.annalspc.com/text.asp?2022/15/4/434/367287

The introduction of spatiotemporal image correlation technique (STIC) was considered a breakthrough in imaging of the fetal heart.[1] Advancements in technology have resulted in a steady improvement in image quality. However, despite two decades of its existence, the clinical utility of the technique remains a topic of debate. Experts in congenital heart diseases (CHD) recognize that the technique offers very little additional diagnostic data over two-dimensional ultrasound and Doppler techniques in the hands of a skilled operator.[2]

The authors believe that the greatest utility of STIC imaging is the ability to better visualize the morphology of the cardiac valves. This provides important diagnostic and prognostic information in CHD where valve morphology is a key determinant of outcomes after the intervention.[3]

A primigravida mother was referred to us at 21 weeks of gestation for evaluation of a suspected CHD. The fetal echocardiogram was performed on a Philips EPIQ Elite ultrasound machine (Philips Medical Systems, Andover, MA, USA) with a V 9-2 mechanical volume transducer. There was usual arrangement of the abdominal organs and the atria. The heart was in the left hemithorax with the apex pointing to the left. The systemic and pulmonary venous drainage was normal. There was an adequate atrial communication in the oval fossa shunting right to left. The atrioventricular connections were concordant. The ventricles were balanced with normal ventricular function. There was a large malaligned perimembranous ventricular septal defect (VSD). A common arterial trunk arose from the ventricular mass overriding the VSD [[Figure 1]a and Video 1 [Additional file 1]]. This was an aortic dominance type of common trunk with the pulmonary arteries arising from the posterolateral surface of the common trunk [Figure 1b and Video 1]. The aortic arch was left-sided, and an arterial duct was not visualized.

Figure 1: (a) Two-dimensional ultrasound image of the fetus from a modified outflow tract view. The ventricles are balanced and there is a large mal-aligned ventricular septal defect. A single outflow tract (star) is seen over-riding the septal defect, (b) Two-dimensional ultrasound image of the fetus. The branch pulmonary arteries (arrows) are seen bifurcating from a common trunk. LA: Left atrium, LV: Left ventricle, RV: Right ventricle

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There was mild stenosis and mild incompetence of the valve of the common trunk [Figure 2]a and [Figure 2]b]. The 2D appearance raised the suspicion of a bicuspid valve. Hence, three-dimensional datasets were obtained by STIC both with and without color Doppler [Video 2 [Additional file 2]]. Reconstruction of the three-dimensional datasets confirmed a functionally bicuspid valve with fusion of two of the three leaflets [Figure 3]a, [Figure 3]b and Video 3 [Additional file 3]].

Figure 2: (a) Multiplanar rendered image of the heart obtained by STIC technology with color Doppler demonstrating aliasing of flow across the arterial valve (star) which suggests stenosis of the valve, (b) Multiplanar rendered image of the heart obtained by STIC technology with color Doppler demonstrating regurgitation of flow across the arterial valve (arrow). STIC: Spatiotemporal image correlation

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Figure 3: (a) A reconstructed image from a three-dimensional dataset of the fetal heart in diastole demonstrating the arterial valve leaflets (stars), (b) A reconstructed image from a three-dimesnional dataset of the fetal heart in systole demonstrating a functionally bicuspid valve due to fusion of the two anterior leaflets (arrow)

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STIC imaging permits surface rendering and multiplanar visualization of cardiac anatomy in the fetus. The value of STIC imaging in permitting offline expert analysis of cardiac abnormalities as well as a powerful teaching tool by creating libraries of fetal CHD has been recognized for some time.[2] Increasingly, the value of STIC imaging for the visualization of the morphology of the atrioventricular and semilunar valves is being recognized.[4-6] However, such efforts appear to be limited to a handful of high-volume centers with long-standing expertise in STIC imaging technology.

Adriaanse and colleagues attempted to measure the semilunar valve area and count the number of valve leaflets from more than 200 fetal datasets at various gestational ages.[6] They reported a >90% feasibility of measuring the area. When attempting to count the number of leaflets, they noticed that success was linked to the gestational age of the fetus with a higher probability at 19–24 weeks of gestation. The difficulty at advanced gestational ages was likely related to increased rib shadowing. When they extended their attempts to fetuses with CHD, they reported a similar high success rate in measuring valve area but did not attempt to count the number of leaflets. Our case highlights the feasibility of counting the number of leaflets and the valve morphology in fetuses with CHD

Our case illustrates the ability to demonstrate the semilunar valve morphology in fetuses with CHD. The quality of the dataset remains a major impediment to the widespread use of this technique. Even in the best centers, only around 80% of datasets were found to be of adequate quality for analysis.[6] It is likely that the numbers will be much lower in most centers performing fetal echocardiography. Improvement in technology to reduce noise during data acquisition could result in better datasets from less experienced operators and result in wider acceptance of this technology.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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3.Martínez-Quintana E, Portela-Torrón F. Truncus arteriosus and truncal valve regurgitation. Transl Pediatr 2019;8:360-2.

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5.Adriaanse BM, Uittenbogaard LB, Tromp CH, Schaefer SS, Heymans MW, van Vugt JM, et al. Prenatal examination of the area and morphology of the atrioventricular valves using four-dimensional ultrasound in normal and abnormal hearts. Prenat Diagn 2015;35:741-7.

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