Fetal Intelligent Navigation Echocardiography (FINE) Detects 98% of Congenital Heart Disease

Abstract

Objective: Fetal intelligent navigation echocardiography (FINE) is a novel method that automatically generates and displays 9 standard fetal echocardiographic views in normal hearts by applying intelligent navigation technology to spatiotemporal image correlation (STIC) volume data sets. The main objective was to determine the sensitivity and specificity of FINE in the prenatal detection of congenital heart disease (CHD).

Methods: A case-control study was conducted in 50 fetuses with a broad spectrum of CHD (cases) and 100 fetuses with normal hearts (controls) in the second and third trimesters. Using 4-dimensional ultrasound with STIC technology, volume data sets were acquired. After all identifying information was removed, the data sets were randomly distributed to a different investigator for analysis using FINE. The sensitivity and specificity for the prenatal detection of CHD, as well as positive and negative likelihood ratios were determined.

Results: The diagnostic performance of FINE for the prenatal detection of CHD was: sensitivity of 98% (49 of 50), specificity of 93% (93 of 100), positive likelihood ratio of 14, and negative likelihood ratio of 0.02. Among cases with confirmed CHD, the diagnosis with use of FINE completely matched the final diagnosis in 74% (37 of 50); minor discrepancies were seen in 12% (6 of 50), and major discrepancies were seen in 14% (7 of 50).

Conclusions: This is the first time the sensitivity and specificity of the FINE method in fetuses with normal hearts and CHD in the second and third trimesters has been reported. Because FINE identifies a broad spectrum of CHD with 98% sensitivity, this method could be used prenatally to screen for and diagnose CHD.

Keywords: 4-dimensional; cardiac; fetal heart; prenatal diagnosis; spatiotemporal image correlation; ultrasound.

Figure 1

Application of the FINE method to a fetus with a normal heart. Nine normal cardiac diagnostic planes in a single template are shown with the unique feature of automatic labeling (through intelligent navigation) of each plane, anatomic structures, fetal left and right sides, and cranial and caudal ends (also see Video 1). The labeling is distinctive because it stays with the corresponding anatomical structure(s), even as the image is increased or decreased in size. A indicates transverse aortic arch; Ao, aorta; Desc., descending; IVC, inferior vena cava; LA, left atrium; LV, left ventricle; P, pulmonary artery; PA, pulmonary artery; RA, right atrium; RV, right ventricle; RVOT, right ventricular outflow tract; S, superior vena cava; SVC, superior vena cava; and Trans., transverse

Figure 2

Application of the FINE method to a fetus with tetralogy of Fallot at 23 weeks' gestation (diagnostic planes or VIS‐Assistance with automatic labeling are shown; also see Video 2). Six echocardiographic views were abnormal and demonstrate the typical features of this cardiac defect. The 3‐vessels and trachea view shows a narrow pulmonary artery caused by stenosis, while the transverse aortic arch is prominent. There is a “Y‐shaped” appearance of the great vessels. As is commonly noted in conotruncal abnormalities, the 4‐chamber view appeared normal in the diagnostic plane; however, VIS‐Assistance demonstrates a large ventricular septal defect (not shown here). The 5‐chamber view shows a ventricular septal defect. The left ventricular outflow tract view shows an overriding aorta, dilated aortic root, and ventricular septal defect. In the short‐axis view of great vessels/right ventricular outflow tract (obtained via VIS‐Assistance), the pulmonary artery is narrow with a tortuous ductus arteriosus. There is difficulty in visualizing a normal ductal arch. In the aortic arch view, the aortic root is dilated and there is a prominent ascending aorta. A indicates transverse aortic arch; Ao, aorta; Desc., descending; IVC, inferior vena cava; LA, left atrium; LV, left ventricle; P, pulmonary artery; PA, pulmonary artery; RA, right atrium; RV, right ventricle; RVOT, right ventricular outflow tract; S, superior vena cava; SVC, superior vena cava; and Trans., transverse.

Figure 3

Application of the FINE method to a fetus with coarctation of the aorta at 24 weeks' gestation (diagnostic planes or VIS‐Assistance with automatic labeling are shown; also see Video 3). Seven echocardiographic views are abnormal. The 3‐vessels and trachea view shows a narrow transverse aortic arch. In the 4‐chamber view, the left side of the heart is smaller than the right side; however, the left ventricle is apex forming. The right side of the heart appears enlarged, with the right ventricle being moderately dilated and hypertrophied. The 5‐chamber view shows similar findings to that of the 4‐chamber view. In addition, there is a narrow aortic root. The left ventricular outflow tract view shows a narrow aorta (obtained via VIS‐Assistance). In the short‐axis view of great vessels/right ventricular outflow tract, the cross‐section of the aorta is small compared to the pulmonary artery. The enlarged right atrium is apparent. The ductal arch view demonstrates that the cross‐section of the aorta is small compared to the pulmonary artery. In the aortic arch view, the coarctation is demonstrated as hypoplasia and narrowing of the transverse aortic arch as well as in the isthmus region. A indicates transverse aortic arch; Ao, aorta; Desc., descending; IVC, inferior vena cava; LA, left atrium; LV, left ventricle; P, pulmonary artery; PA, pulmonary artery; RA, right atrium; RV, right ventricle; RVOT, right ventricular outflow tract; S, superior vena cava; SVC, superior vena cava; and Trans., transverse.

Figure 4

VIS‐Assistance of the left ventricular outflow tract view in a 19‐week fetus with hypoplastic left heart, double outlet right ventricle, transposition of the great vessels, and fetal stomach on the right side (also see Video 4). The abnormal diagnostic plane (left panel) demonstrates a single vessel arising from the right ventricle that is consistent with the pulmonary artery due to its bifurcation. A second vessel could not be clearly identified. However, when VIS‐Assistance is activated (right panel), automatic navigational movements now demonstrate a second vessel (aorta) that is rightward and anterior and exiting the right ventricle. These 2 vessels are parallel and side by side, consistent with transposition. AO indicates aorta; PA, pulmonary artery; and RV, right ventricle.