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\begin{document}

\title{Visualisation of the arterial valve morphology and number of leaflets in
a fetus with common arterial trunk by Spatio-Temporal Image Correlation
(STIC) imaging}



\author[1]{Mani Ram Krishna}%
\author[1]{Usha Nandhini Sennaiyan}%
\affil[1]{Amrita Institute of Medical Sciences}%


\vspace{-1em}



  
  \date{May 17, 2024}


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\selectlanguage{english}
\begin{abstract}
Spatio-temporal 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.%
\end{abstract}%



\sloppy


\textbf{Visualisation of the arterial valve morphology and number of
leaflets in a fetus with common arterial trunk by Spatio-Temporal Image
Correlation (STIC) imaging}

\emph{STIC imaging of arterial valve morphology in congenital heart
disease}

Mani Ram Krishna and Usha Nandhini Senniyan

Tiny Hearts Fetal and Pediatric Cardiac Clinic

R.K. Hospital for Women and Children

Thanjavur, India

Correspondence to

Dr Mani Ram Krishna

Dr R.K. Hospital for Women and Children

No 7, V.O.C. Nagar

Thanjavur-613007

Tamil Nadu, India

E-mail: mann\_comp@hotmail.com

Data availability statement: Additional data regarding the case is
available with the authors and will be provided on request

Abstract

Spatio-temporal 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.

Introduction

The introduction of spatio-temporal image correlation technique (STIC)
was considered a breakthrough in imaging of the fetal heart(1).
Advancements in technology has resulted in a steady improvement in the
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 recognize that the technique offers very
little additional diagnostic date 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 congenital
heart diseases (CHD) where valve morphology is a key determinant of
outcomes after intervention(3).

We report a fetus with common arterial trunk identified at 21 weeks
gestational age. A bicuspid arterial valve was suspected on
two-dimensional ultrasound and confirmed by reconstruction of the STIC
dataset.

Clinical Details

A primi-gravida mother was referred to us at 21 weeks of gestation for
evaluation of a suspected CHD. The growth of the fetus was appropriate
for gestational age and there were no major extra-cardiac anomalies.

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 were normal. There was an
adequate atrial communication in the oval fossa shunting right to left.
The atrio-ventricular connections were concordant. The ventricles were
balanced with normal ventricular function. There was a large mal-aligned
peri-membranous ventricular septal defect (VSD). A common arterial trunk
arose from the ventricular mass over-riding the VSD (Fig 1A and Video
1). This was an aortic dominance type of common trunk with the pulmonary
arteries arising from the postero-lateral surface of the common trunk
(Fig 1B and Video 1). The aortic arch was left sided, and an arterial
duct was not visualized.

There was mild stenosis and mild incompetence of the valve of the common
trunk (Fig 2A and 2B). 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). Reconstruction of the
three-dimensional datasets confirmed a functionally bicuspid valve with
fusion of two of the three leaflets (Fig 3A and B, Video 3).

Discussion

STIC imaging permits surface rendering and multi planar 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 congenital heart diseases
has been recognized for some time(2). Increasingly, the value of STIC
imaging for visualization of the morphology of the atrio-ventricular and
semilunar valves(4-6). Authors have focused on measurement of the valve
area as well as counting the number of leaflets. However, such efforts
appear to be limited to a handful of high-volume centers with long
standing expertise in STIC imaging technology.

Nomograms have been published for the measurement of semilunar valve
dimensions from multi-planar datasets obtained by STIC imaging(7).
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 greater than 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 CHS

As short- and medium-term outcomes after congenital cardiac surgery has
improved over the recent decades, the focus has shifted to very
long-term outcomes extending into adulthood. It is being recognized that
most re-interventions in adult survivors of congenital heart disease
involve operations of the cardiac valves(8). This is best exemplified by
common arterial trunk in which long term outcomes appear to be directly
related to the degree of arterial valve dysfunction(9). The imaging of
the valve morphology hence represents a very important prognostic
information for counseling the expectant members and is likely best
achieved in the 19--24-week gestational age period.

Our case illustrates the ability to demonstrate the semilunar valve
morphology in fetuses with congenital heart disease. The quality of the
dataset remains a major impediment to 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.

Compliance with ethical standards

Funding: This work did not involve any external funding

Conflict of Interest: The authors report no conflict of interest with
regards to this work

Ethical approval: This article does not contain any studies with human
participants or animals performed by any of the authors. Informed
consent was obtained

References

1. DeVore GR, Falkensammer P, Sklansky MS, Platt LD. Spatio-temporal
image correlation (STIC): new technology for evaluation of the fetal
heart. Ultrasound Obstet Gynecol. 2003;22(4):380-7.

2. Shen O, Yagel S. The added value of 3D/4D ultrasound imaging in fetal
cardiology: has the promise been fulfilled? Ultrasound Obstet Gynecol.
2010;35(3):260-2.

3. Martinez-Quintana E, Portela-Torron F. Truncus arteriosus and truncal
valve regurgitation. Transl Pediatr. 2019;8(5):360-2.

4. Yagel S, Benachi A, Bonnet D, Dumez Y, Hochner-Celnikier D, Cohen SM,
et al. Rendering in fetal cardiac scanning: the intracardiac septa and
the coronal atrioventricular valve planes. Ultrasound Obstet Gynecol.
2006;28(3):266-74.

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(8):741-7.

6. Adriaanse BM, Uittenbogaard LB, Tromp CH, Heymans MW, van Vugt JM,
Haak MC. Prenatal Visualization of the Pulmonary and Aortic Valves and
Leaflets Is Feasible Using 4-Dimensional Sonography. J Ultrasound Med.
2016;35(3):497-504.

7. Tongprasert F, Srisupundit K, Luewan S, Sirichotiyakul S, Piyamongkol
W, Wanapirak C, et al. Reference ranges of fetal aortic and pulmonary
valve diameter derived by STIC from 14 to 40 weeks of gestation. Prenat
Diagn. 2011;31(5):439-45.

8. Holst KA, Dearani JA, Burkhart HM, Connolly HM, Warnes CA, Li Z, et
al. Risk factors and early outcomes of multiple reoperations in adults
with congenital heart disease. Ann Thorac Surg. 2011;92(1):122-8;
discussion 9-30.

9. Russell HM, Pasquali SK, Jacobs JP, Jacobs ML, O'Brien SM, Mavroudis
C, et al. Outcomes of repair of common arterial trunk with truncal valve
surgery: a review of the society of thoracic surgeons congenital heart
surgery database. Ann Thorac Surg. 2012;93(1):164-9; discussion 9.

Figure Legends

Figure 1A -- 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 (LA -- left atrium, LV --
left ventricle, RV- right ventricle)

Figure 1B -- Two-dimensional ultrasound image of the fetus. The branch
pulmonary arteries (arrows) are seen bifurcating from a common trunk

Figure 2A -- multi-planar rendered image of the heart obtained by
spatio-temporal image correlation (STIC) technology with color Doppler
demonstrating aliasing of flow across the arterial valve (star) which
suggests stenosis of the valve

Figure 2B - multi-planar rendered image of the heart obtained by
spatio-temporal image correlation (STIC) technology with color Doppler
demonstrating regurgitation of flow across the arterial valve (arrow)

Figure 3A -- A reconstructed image from a three-dimensional dataset of
the fetal heart in diastole demonstrating the arterial valve leaflets
(stars)

Figure 3B -- 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)

Video 1 -- A cine echocardiogram loop demonstrating the arterial trunk
arising from the ventricular mass with the branch pulmonary arteries
arising from the lateral surface of the common trunk

Video 2 -- A reconstructed three-dimensional dataset using STIC
technology with color Doppler demonstrating stenosis and regurgitation
of the arterial valve

Video 3- A reconstructed three-dimensional dataset using STIC technology
demonstrating the functionally bicuspid arterial valve with fusion of
the two anteriorly located leaflets\selectlanguage{english}
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