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Int J Clin Exp Med 2016;9(7):13000-13006
www.ijcem.com /ISSN:1940-5901/IJCEM0010589
Original Article
Continuously transverse scanning of fetal heart for
comprehensive cardiac evaluation
Yuntao Li, Qiuyan Pei, Jianguo Li, Zhenjuan Yang, Si Chen
Department of Obstetric Ultrasonography, Peking University People’s Hospital, Beijing 100044, China
Received May 23, 2015; Accepted July 11, 2015; Epub July 15, 2016; Published July 30, 2016
Abstract: Objective: To investigate the feasibility of the screening method of continuously transverse scan for comprehensive cardiac evaluation. Case Report: After pretreating, 5 cases of normal fetal heart samples were cut
transversely and serially to produce 60 μm thick sections. Then the sections were obsverated and macroshotted
by a digital camera to obtain serial images. The typical anatomical cross-sections that could display steadily and
reflect the characteristics of auricular vein connection, atrioventricular connection, ventricular artery connection
and vessels of bottom of the heart were chosen from the database. And simultaneously, 105 cases of fetal heart
were scanned transversely by fetal echocardiography (FECG) during second trimester. The detection rate of the typical section above was analyzed. In the database of the 5 normal fetal hearts, the typical sections were conformed
to the standards mentioned above. The typical sections were the sections of coronary sinus, four-chamber, outflow
tract of left ventricle, outflow tract of right ventricle and the transverse-section of ductal arches and aortic arch.
During the transverse scan of the 105 cases fetal heart examination, the detection rate of the sections above was
100%, except for the coronary sinus, with the presenting rate of 79%. Conclusion: The anatomical cross-section
image database of normal fetal heart provides the anatomical basis to transverse scan of fetal heart. The highly
detection rate of the typical sections during the 105 cases fetal heart examination has further proved the feasibility
of transversely scanning method.
Keywords: Fetal heart, transverse scan, anatomical cross-section, database
Introduction
The rate of congenital heart deformation (CHD)
among the live-born infants and children is
4‰-13‰ [1-3] and it is the main reason for the
death of infants [4-6]. Examining CHD before
giving birth can improve the management in
the perinatal period and promote the prognosis
of fetus [7-9]. As a result, (the birth rate) the
rate of seriously complicated CHD fetus can be
reduced [10]. At present, the FECG is the main
way to diagnosis fetal CHD prenatally. In second trimester, as the fetal costa ossification is
inconspicuous and free from the influence of
air in lung, the fetal cardiac anatomical structure from arbitrary angles is continuously
observed by getting away from the spinal column [11].
There for the fetal FECG can be much simplified
compared with the adult (FECG) [12-14]. In
2001, Israel scholar Yagel et al [15] raised the
method of continuously horizontal scan to
examine the fetal echocardiography (FECG) by
the five short-axis views, which included abdominal transverse section, four-chamber section,
five-chamber section (the section of outflow
tract of left ventricle), the section of outflow
tract of right ventricle and the three vessel and
trachea (3VT) plane [15]. In 2008, the fetal
ultrasonic cardiogram team of the International
Society of Ultrasound in Obstetrics and
Gynecology (ISUOG) has already published a
consensus [16]. It put forward that fetal ultrasonic cardiogram examination should at least
includes the examination of the sections of
four-chamber, the outflow tract section of left
ventricle, the outflow tract section of right ventricle and the section of the 3VT plane. At the
same time, it estimated pulmonary venous connection and held the idea that the method of
continuously horizontal scan of fetal heart can
accomplish the examination above. During the
Continuously transverse scanning of fetal heart for comprehensive cardiac evaluation
progress of horizontal scan, if the sections
mentioned above can be clearly presented and
correctly evaluated, it would be no need of
examining other special sections [17].
least show the auricular vein connection, atrioventricular connection, atrioventricular septum,
ventricular artery connection, and vessels of
bottom of the heart.
The method of continuously transverse scan of
fetal heart is accepted by more and more scholars, however up to now, there has been no any
relevant anatomy research [18]. In this
research, we established 10 cases cross-sections anatomical databases of the normal fetal
heart with the layer of thickness 60 μm in
22-26 weeks from which we chose typical
cross-sections of the fetal heart that appeared
stably and could reflect the characteristics of
auricular vein connection, atrioventricular connection, ventricular artery connection and vessels of bottom of the heart. Simultaneously, we
transversely scanned the 105 fetal heart cases
and analyzed the detection rate of the sections
above and further investigate the feasibility of
the method of continuously transverse scan of
fetal heart.
105 fetuses of 22-26 weeks were randomly
chosen. The GE VOLUSON four-dimensional
Doppler ultrasound instrument was applied
and the ultrasound instrument whose frequency of volume transducer was 4~8 MHz. Then
the obstetric procedures was started with
power less than <100 Mw/cm2. Letting the
pregnant woman take supine or lateral position, verify fetal age by observing the biparietal
diameter, head circumference, abdomen circumference and femur length. From (the transverse view of the upper abdomen) the crosssection of enterocoelia, except for successively
presenting the typical sections above, the section of enterocoelia was added as the section
to be observed with the method of continuously
horizontal scan of fetal heart. At the same time,
the sections of the 3VT were obtained when the
section of ductal arches is horizontal and the
probe leans slightly to the fetal right shoulder.
Then every typical section was saved.
Material and methods
For the induced labor CHD fetal heart samples,
along the left sternal border, the skin and the
subcutaneous tissue to the pleura were incised.
According to different size of the fetus, the
length of the cut was about 3 cm to 4 cm, than
they were fixed with 4% formaldehyde for 4 to 8
weeks. Along with the original cut, the chest
from xiphoid to suprasternal fossa was opened
and the thoracic viscera was taken out, then
they were fixed with formaldehyde for 2 to 4
weeks. According to the biggest size that the
freezing microtome could cut, 0.5 cm outside
the margin of the left and right lateral heart, the
two sides of lung tissue were cut. Then the
remained samples were put into the organic
glass cases (4×4.5×4.5 cm or 5×5.5×5.5 cm)
vertically and poured into OCT to submerge the
samples. After four hours in the refrigerator at
-25 c, the content was removed and fixed it in
the freezing microtome. From the apex to the
bottom, the samples were cut serially with a
freezing microtome to produce 60 μm thick
sections. The slices were then macroshot with
a digital camera (Canon EOS 5D; camera lens,
SIGMA 70 mm 1:2.8 DG MACRO) to obtain serial images of the section planes. And the 5 anatomical image databases of normal fetal heart
cross-section were established. In these 5
database images, the typical anatomical crosssections were chose, which could stably and at
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By comparing the detection rate of the typical
cross-sections that established in the anatomical image database of normal fetal heart crosssection when the 105 fetal heart cases were
horizontally scanned, the feasibility of the
method of continuously horizontal scan of fetal
heart was investigated.
Results
In this research, 5 cases anatomical image
databases of normal fetal heart cross-section
were built. The thickness of section was 60 μm,
the pixel of image was 3888×2592 and the format of anatomical image databases was JPEG.
The capacity of anatomical image databases
was respectively 2.21, 2.72, 1.94, 2.89, 2.56
GB and the hanatomical image databases
included respectively 793, 803, 898, 769 and
751 cross-sections. The 5 image databases
could show the typical anatomical sections and
could reflect the auricular vein connection,
atrioventricular connection, atrioventricular
septum, ventricular artery connection, the sections of four-chamber, the outflow tract section
of left ventricle, the outflow tract section of
right ventricle, cross section of aortic arch and
ductus arch. The vessels of bottom of the heart
Int J Clin Exp Med 2016;9(7):13000-13006
Continuously transverse scanning of fetal heart for comprehensive cardiac evaluation
Figure 1. Typical anatomical sections of normal fetal
heart. A. Coronary sinus section; B. Four-chamber
view; C. Left ventricular outflow tract section; D.
Right ventricular outflow tract section; E. The threevessel section; F. The ductal arch cross-section; G.
The aortic arch section.
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Int J Clin Exp Med 2016;9(7):13000-13006
Continuously transverse scanning of fetal heart for comprehensive cardiac evaluation
During the continuous horizontally scanning of the 105
fetal heart cases, the presenting rate of the sections
above was 100%, except for
the coronary sinus, with the
presenting rate of 79%. The
echocardiography was showed in Figure 2.
Discussion
In this research, the fetal
samples were fixed in the
formaldehyde and the heart
specimens were cut serially
with part of thoracic cavity,
to maintain the natural state
of the heart as far as possible. Meanwhile, the database with the layer of thick
60 μm was proved to be the
thinnest heart section database at present. It not only
could present the atrioventricular cavity and large vascular structures, but also
could present the valve,
chordae tendineae and other
tiny structures, that could be
applied into the anatomical
research of fetal heart as
well as FECG.
Figure 2. Typical echocardiography of the fetal heart cases. A. The abdominal
cross-section; B. The coronary sinus section; C. The four-chamber view; D. The
left ventricular outflow tract section; E. The right ventricular outflow tract section; F. The three vessel view; G. The ductus arteriosus arch cross-section or
three-vessel trachea view; H. The aortic arch cross-section.
were coronary sinus section (Figure 1). The presenting rate is 100%.
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The five cases anatomical
image database of normal
fetal heart cross-section,
From the apex to the bottom,
The
typical
anatomical
cross-sections showing the
auricular vein connection,
atrioventricular connection,
ventricular artery connection, vessels of bottom of the
heart was coronary sinus
section, the sections of fourchamber, the outflow tract
section of left ventricle, the
outflow tract section of right
ventricle, the cross section
of ductus arch and aortic
arch. They include all the
short axis view that was put
forward by Yagels except for
the 3VT plane.
The cross-section of aortic arch is the highest
anatomical structure in the thoracic. The secInt J Clin Exp Med 2016;9(7):13000-13006
Continuously transverse scanning of fetal heart for comprehensive cardiac evaluation
ond one is the section of ductal arches. As they
cannot appear in the same section, the cross
section of the fetal database cannot show the
3VT plane. However, during the progress of
continuous horizontally scan of the 105 fetal
hearts, when the cross-section of ductal arche
appears, the probe slightly leans to the right
shoulder of the fetus and we can see the 3VT
plane. The detection rate is 100%. The 3VT
plane shows the section of ductus arch and
aortic arch. Compared with, it is much easier to
observe the inner diameter ratio and the positional relationship, and also helpful to diagnose
the transverse coarctation of Aorta and the
malformation of arterial ring. As a result, this
research also suggests to use the 3VT plane to
instead of the independent sections of ductus
arch and aortic arch [19, 20]. Being one section
of the continuously scanned sections of fetal
heart, it can help to observe the great vessels
structure of fetal heart.
The database of anatomical cross-section
images of the normal fatal hearts doesn’t
include upper abdomen transverse view.
However, during the continuously scanning of
100 fetuses, upper abdomen transverse view
appears stably. Compared with other sections,
it is much easier to be obtained and recognized. Its normal presenting excludes the atrial
trans, inferior vena cava interruption, Azygos
vein ectopic drainage and other kinds of CHD.
Besides, this kind of malformation is with poor
prognosis and always companied with serious
malformation in other system. For example,
asplenia syndrome and so on. And its ultrasonic appearance lacks of specialty. As a result, it
is very easy to omit it. The unshow of inferior
vena cava and the abnormal expending of azygos vein can provide information to this kind of
malformation [21].
During the continuous horizontally scanning of
the 105 fetal hearts, we can see upper abdomen transverse view, the sections of fourchamber, the outflow tract section of left ventricle, the outflow tract section of right ventricle
and the 3VT plane as well as the cross-sections
of the ductus arch and the aortic arch. The
detection rate of the sections above is 100%
while the detection rate of coronary sinus is
79%, which is lower than the former ones.
Though the detection rate of coronary sinus
section is low, it doesn’t fail to be the observing
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section of continuously horizontal scan.
Normally, when the fetal coronary sinus is narrow, the section of coronary sinus is very hard
to be seen. However, when the venous return is
abnormal, for example, in the case of intracardiac type drainage pulmonary vein abnormalities, forever left cavity malformation, the coronary sinus would be expended abnormally. As a
result, the ultrasound examination is much
easier [22]. Thus, during the continuous scan of
fetal heart, its unshow is normal in the coronary sinus section.
The database of cross-sectional anatomical
images of normal fetal heart provides the anatomical basis to the method of continuously
transverse scan of fetal heart. During the horizontally scan of 105 fetal hearts, the high presenting rate of the sections above further
proves the feasibility of the method of continuously horizontal scan of fetal heart.
In the western developed countries, some of
the antenatal diagnosis centers have already
regarded the continuously scan of fetal heart
as a kind of fetal ultrasonic cardiogram and
applied into the antenatal diagnosis [18].
Among them, the sections of four-chamber, the
outflow tract section of left ventricle, the outflow tract section of right ventricle, the 3VT
plane are greatly applied. Sydney royal hospital,
British medical Mr Willy and children and some
other hospitals also regard the section of
enterocoelia as a common examining section
when they examine the sections of four-chamber, the outflow tract section of left ventricle,
the outflow tract section of right ventricle, the
3VT plane [23]. However, no scholar has regarded the coronary sinus section as one of the
common examining section yet.
The method of continuous scan of fetal heart
greatly simplifies the fetal ultrasonic cardiogram technology and is very easy to be popularized. The difficulty of fetal ultrasonic cardiogram is not the obtaining of sections; instead, it
is the standardization and accurate evaluation
of the sections. During the continuous scan,
the obtaining of standard sectional images can
not only help to analyze, but also can help to
remote diagnose.
In conclusion, the anatomical image database
of normal fetal heart cross-section has provided anatomical foundation for the continuous
scan of fetal heart. During the horizontally scan
Int J Clin Exp Med 2016;9(7):13000-13006
Continuously transverse scanning of fetal heart for comprehensive cardiac evaluation
of 105 fetal hearts, the high presenting rate of
the sections above further proves the feasibility
of the method of continuously horizontal scan
of fetal heart. The method of continuous scan
of fetal heart not only simplifies the fetal ultrasonic cardiogram technology, but also helps to
standardize the images. Besides, it also makes
the remote diagnose more convenient.
Disclosure of conflict of interest
[9]
[10]
[11]
None.
Address correspondence to: Dr. Qiuyan Pei,
Department of Obstetric Ultrasonography, Peking
University People’s Hospital, Beijing 100044, China.
Tel: +86-18801137169; Fax: +86-10-88324270;
E-mail: [email protected]
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