THREE STEPS METHOD TO SCREEN CONGENITAL HEART DISEASE AT 11-13+6 WEEKS:VALIDATION OF A NEW HIGH DEFINITION IMAGING MODE TO DETECT FETAL CARDIAC STRUCTURES

THREE STEPS METHOD TO SCREEN CONGENITAL HEART DISEASE AT 11-13+6 WEEKS: VALIDATION OF A NEW HIGH DEFINITION IMAGING MODE TO DETECT FETAL CARDIAC STRUCTURES Objective We designed a prospective study to test the feasibility of the first level screening for cardiac defects at the time of Nuchal Translucency (NT) measurement using a new high definition blood flow imaging mode (e-flow). We also compare the quality of first level operators visualization both with B-Mode and e-flow mode. Methods 636 consecutive fetuses between 11 and 13 + 6 weeks referred for NT at San Paolo Hospital were examined by first level operators. In each fetus the cardiac morphology was studied in two sections, the four chambers view (transvers or apical) and great vessels sections (three vessels) visualized with B-mode and e-flow mode. The cardiac sections were independently and double blinded evaluated by first level operators and then by an expert echo-cardiographer. The operators evaluated the quality of imaging (good, sufficient or insufficient) and the cardiac morphology (normal, abnormal or suspicious). The tricuspid regurgitation was checked by color Doppler and e-flow. In the suspicious of cardiac anomaly the patient were referred to second level echocardiography. Neonatal follow up were collected by a telephone questioner. Efficacy of e-flow was evaluated as percentage of success in obtaining reliable images of the heart and the great vessels, and percentage of concordance between first level and expert supervisors operators evaluation. Results We analyzed 636 consecutive fetuses. Four chambers view was obtained in 89,5% (569/636) with B-Mode and in 99,8% (635/636) with e-flow mode. The quality of four chambers view for first operators with B-Mode was Good in 45,3% (258/569), Sufficient in 35% (199/569) and Insufficient in 19,7% (112/569). The same section with e-flow was valuated as Good in 78,3% (497/635), Sufficient in 20,8% (132/635) and Insufficient in 0,9% (6/635). The concordance of evaluation was respectively 52,5% (299/569) for B-Mode and 75,2% (478/635) for e-flow mode. A normal heart morphology was found in 89,7% (408/455) with B-Mode and in 98,1% (630/630) with e-flow mode while an abnormal heart morphology was found in 0,8% (4/455) with B-Mode and in 0,5% (3/630) with e-flow mode. A suspected abnormal heart was found in 9,5% (43/455) with B-Mode and in 1,4% (9/630) with e-flow mode. The concordance of evaluation of cardiac morphology was respectively 60% (273/455) for B-Mode and 88,4% (557/630) for e-flow mode. Three vessels view was obtained in 84% (534/636) with B-Mode and in 97,3% (619/636) with e-flow mode. The quality of three vessels view for first operators with B-Mode was Good in 20,1% (150/534), Sufficient in 31,3% (167/534) and Insufficient in 40,6% (217/534). The same section with e-flow was valuated as Good in 74,5% (461/619), Sufficient in 23,6% (146/619) and Insufficient in 4,1% (13/619). The concordance of evaluation was respectively 51,7% (276/534) for B-Mode and 69,9% (433/619) for e-flow mode. A normal three vessels morphology was found in 60,1% (262/436) with B-Mode and in 96,5% (579/600) with e-flow mode while an abnormal three vessels morphology was found in 0,4% (2/436) with B-Mode and in 0,3% (2/600) with e-flow mode. A suspected abnormal three vessels was found in 39,5% (172/436) with B-Mode and in 3,2% (19/600) with e-flow mode. The concordance of evaluation of three vessels morphology was respectively 56,2% (245/436) for B-Mode and 86,7% (520/600) for e-flow mode. Conclusions The percentage of visualization of four chambers and great vessels increases with the use of e-flow mode (89,5% vs 99,8% and 84% vs 97,3%) and the high concordance of evaluation of normality between the first and the second operators using the e-flow mode (60% vs 88,4% and 56,2% vs 86,7%) stress the feasibility of the first level screening for major cardiac defects at the time of Nuchal translucency screening.