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American Institute of Ultrasound in Medicine <strong>Proceedings</strong> J Ultrasound Med 32(suppl):S1–S134, 2013Conclusions—The vast majority (94%) of unstable hips becamestable on FU examination; 91% of these hips were morphologicallynl at initial US, while 9% were morphologically abnl at the initial study butbecame morphologically nl on FU. Approximately 6% of total hips analyzedremained unstable on FU, 4% of these being morphologically nlhips. While these findings can be comforting to parents whose babies havehip instability, they also support the current practice of obtaining FU sonogramsuntil stability is achieved.1538513 Neonatal Ovarian Cysts: Can Sonography Predict Torsion?Dinesh Chinchure, 1 * Chiou Li Ong 2 1 Diagnostic Radiology,Khoo Teck Puat Hospital, Singapore; 2 Diagnostic Imaging, K.K. Women’s and Children’s Hospital, SingaporeObjectives—The purpose of this study was to evaluate whethersonography can predict torsion in neonatal ovarian cysts.Methods—Seven surgically proven cases of neonatal ovariancysts were included in this retrospective study. The patients were dividedinto 2 groups: torsion and nontorsion. These 7 patients were evaluated forclinical presentation, sonographic features, and surgical and pathologic findings.The findings on follow-up sonography after surgery were also noted.Results—The sonographic appearance was variable. Of the 4cases with torsion, 2 lesions had internal echoes with a “fishnet appearance.”The other 2 lesions were predominantly cystic on sonography withinternal echoes and echogenic nodules. A calcific focus was present in 1of these echogenic nodules. One of the cysts had a fluid-fluid level. In thenontorsion group, only 1 of the lesions had a mixed echogenic appearance.The other 2 lesions were cystic with low-level internal echoes in 1of the cysts. The surgical procedure performed in the torsion group wassalpingo-oophorectomy in 2 patients and oophorectomy in 1 patient. In 1patient, cystectomy was attempted without success. In the nontorsiongroup, only cystectomy was performed with preservation of normalovaries, which was confirmed on follow-up sonography.Conclusions—The sonographic features of cysts with a fishnetappearance, a fluid-debris level, and echogenic nodules favor torsion. Theformer sign has so far not been described as a sonographic predictor forneonatal ovarian torsion.1539741 Sonographic Evaluation of Pediatric Skeletal Lesions: Is ItWorthwhile?Henrietta Kotlus Rosenberg,* Neil Lester Radiology, MountSinai Medical Center, New York, New York USAObjectives—To demonstrate how ultrasound (US) may serveas a readily available, cost-effective, noninvasive, nonionizing, practicaltool for the evaluation of a variety of skeletal abnormalities in the pediatricage range.Methods—We reviewed the clinical and imaging findings in31 patients in whom US demonstrated abnormalities related to the skeletalsystem, excluding patients with hip joint effusions or developmentaldysplasia of the hip.Results—US proved useful in the following situations: evaluationof a hard superficial immobile mass (osteoma shin; 1), absent medialend clavicle on x-ray in the region of a neck mass (US showed an aneurysmalbone cyst in the medial end clavicle; 1), to determine if a soft tissuemass involves adjacent bone (nodular fasciitis surrounding the clavicularhead; 1), diagnosis and follow-up of fracture (displaced/nondisplaced) in aninfant (4), diagnosis of osteomyelitis in patients with cellulitis (4), questionof fracture underlying cephalohematoma or subgaleal hematoma (4),rib mass (osteochondroma; 1; or a mass in costochondral junctions: contourdeformities in the costochondral cartilage; 6), firm posterior knee mass(Baker’s cyst; 1), firm anterior knee mass (septated cystic mass in the suprapatellaregion due to rheumatoid disease; 1), immobile hard scalp mass dueto an epidermoid cranial vault (1), painful mass in the occipital bone withsoft tissue components extending through the skull externally and internallydue to Langerhan’s histiocytosis (1), indeterminate mass in the clavicleclinically thought to be posttraumatic sequelae, resolved on follow-up(1), assessment of craniosynostosis (3), ad differentiation of a pathologic entityfrom a normal anatomic structure (lump on the back of a slender babyproven to be a normal posterior spinous process; 1).Conclusions—US is worthwhile for evaluation of a wide rangeof pediatric skeletal abnormalities and helps determine if the a lesion is onethat is “touch” or “don’t touch.” To maximize diagnostic accuracy, the imagershould have thorough knowledge of the clinical history, physical findings,and laboratory and other imaging findings. In equivocal cases or inthose patients in whom the field of view is insufficient for complete visualizationof an obvious lesion or if malignancy is suspected, US serves totriage those patients in whom further imaging is necessary.1539575 Evaluation of Automated Multiplanar 3-/4-DimensionalSonography in Prenatal Diagnosis of Conotruncal CardiacDefects: Analysis of 150 CasesElena Sinkovskaya,* Sharon Horton, Anna Klassen, AlfredAbuhamad Division of Maternal-Fetal Medicine, EasternVirginia Medical School, Norfolk, Virginia USAObjectives—The aim of this study was to assess potential clinicalapplicability of automated multiplanar imaging (AMI) in prenatal detectionof conotruncal heart defects.Methods—Detailed 2D echocardiography was performed in75 fetuses with normal cardiac anatomy and 75 fetuses with conotruncalheart anomalies between 18 and 23 weeks’ gestation by a trained sonographer.In addition, 3D/spatiotemporal image correlation volumes of thefetal chest were acquired at the level of the 4-chamber view. Two volumedata sets per case (with and without color Doppler) were included in thestudy. The initial scan was interpreted and reported based on the 2D images.The volume data sets were independently reviewed offline usingAMI software by a pediatric cardiologist with experience in fetal heart assessment.The diagnostic value, image quality, as well as time for acquisitionand reading of AMI were evaluated and compared with the original2D report. The prenatal diagnosis was confirmed in all cases by postnatalechocardiography, angiography, operative findings, or autopsy.Results—A summary of the results is provided in Table 1.Conclusions—The developed software demonstrates an excellentdisplay of the diagnostic landmarks of conotruncal defects withappropriate image quality in most cases. This should help improve the detectionof these heart anomalies in the future. Automated sonography alsohas the potential for improving the efficiency of ultrasound imaging byreducing the time needed to complete an ultrasound examination, therebyresulting in increased throughput of ultrasound laboratories.Table 1Parameter 2D AMI PAcquisition time, min 16 ± 4 0.3 ± 0.1
American Institute of Ultrasound in Medicine <strong>Proceedings</strong> J Ultrasound Med 32(suppl):S1–S134, 20131540606 Fetal Diagnosis of Hypoplastic Left Heart: Associations andOutcomes in the Current EraRoland Axt-Fliedner, 1 * Christian Enzensberger, 1 MelanieVogel, 2 Jan Weichert, 4 Ulrich Gembruch, 5 Ute Germer, 6Thomas Kohl, 3 Martin Krapp, 7 Jan Degenhardt 1 1 Divisionof Prenatal Medicine, 2 Division of Pediatric Cardiology,3German Center for Fetal Surgery and Minimally InvasiveTherapy, University of Giessen & Marburg, Giessen, Germany;4Division of Prenatal Medicine, University of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany; 5 Division ofPrenatal Medicine, University of Bonn, Bonn, Germany;6Center for Prenatal Medicine, Caritas Krankenhaus St Josef,Regensburg, Germany; 7 Center for Endocrinology andReproductive and Prenatal Medicine, Amedes Hamburg, Hamburg,GermanyObjectives—Hypoplastic left heart (HLH) is one of the mostcommon forms of cardiac abnormality detectable during gestation by fetalechocardiography. Antenatal diagnosis allows for appropriate counselingand time to consider treatment options. We report the actual outcome dataafter fetal diagnosis of HLH.Methods—We conducted a retrospective analysis of the outcomein all cases with HLH from 1994 to 2011 presenting in fetal life at2 tertiary referral centers for prenatal diagnosis and pediatric cardiology.Results—One hundred five cases were included, and the overallsurvival was 40.9% (43/105) after prenatal diagnosis. There was an81.1% survival rate in infants undergoing surgery and a 64.1% survivalrate from an intention-to-treat position. Two neonates died due to tamponadeand cardiac arrest following balloon septostomy and 1 neonatefrom sepsis before surgery. Extracardiac anomalies occurred in 3 fetusesand karyotype anomalies in 7 fetuses (18.9%). In 4 of 5 babies born withadditional extracradiac or karyotype anomalies, parents opted for compassionatecare. The first had trisomy 13; the second had trisomy 18; thethird neonate presented with spina bifida; and the fourth presented with hydronephrosisand pulmonary atresia. Termination of pregnancy took placein 17 cases (16.1%).Conclusions—Thorough antenatal evaluation should includekaryotyping and detailed extracardiac and intracardiac assessment to accuratelypredict the risks of surgery. Prenatal counseling might be modifiedafter the exclusion of additional anomalies. These data provideup-to-date information for parental counseling.1539318 Fetal Pulmonary Venous Flow and a Restrictive ForamenOvale in Hypoplastic Left HeartRoland Axt-Fliedner, 1 * Jan Degenhardt, 1 Melanie Vogel, 2Jan Weichert, 4 Ulrich Gembruch, 5 Thomas Kohl, 3 ChristianEnzensberger 1 1 Division of Prenatal Medicine, 2 Division ofPediatric Cardiology, 3 German Center for Fetal Surgery andMinimally Invasive Therapy, University of Giessen & Marburg,Giessen, Germany; 4 Division of Prenatal Medicine, Universityof Schleswig-Holstein, Campus Luebeck, Luebeck, Germany;5Division of Prenatal Medicine, University of Bonn, Bonn,GermanyObjectives—Hypoplastic left heart (HLH) with intact or restrictiveinteratrial communication (HLH- IAS/RAS) is associated withhigh mortality rates. The objective was to correlate pulmonary venous(PV) Doppler spectra and direct foramen ovale (FO) assessment with theneonatal need for early atrial septostomy (EAS) and neonatal outcome.Methods—We reviewed all prenatal echocardiograms andoutcomes of 51 fetuses with HLH and information about the interatrialcommunication between 1994 and 2011. IAS/RAS was defined as asmall/absent interatrial shunt on 2D imaging. Three PV Doppler spectrawere observed: type A, continuous forward flow with a small a-wave reversal;type B, continuous forward flow with increased a-wave reversal;and type C, brief to-and-fro flow.S30Results—Three of 51 neonates with the type C PV flow patternand suspicion of IAS/ RAS on 2D evaluation required EAS. In 1 fetus, PVflow changed from type B to type C spectra throughout gestation. Fetuseswith type C spectra showed 71.4% survival after 30 days compared to92.3% in fetuses with type A spectra. Short-term survival after EAS was33%.Conclusions—The prenatal PV flow pattern and 2D evaluationof the FO size help in identifying the fetus at risk for neonatal EASand patient selection for fetal cardiac intervention. Most late secondtrimestervalues will not change over time.1538894 The Fetal-Maternal Vascular Impedance Index: A PotentialNew Tool for Characterization of Fetal CirculatoryHealthDebbra Soffer,* Margaret McCann, Xi Liu, Zhiyun Tian,Jack Rychik Fetal Heart Program, Children’s Hospital ofPhiladelphia, Philadelphia, Pennsylvania USAObjectives—Fetal circulatory health is often determined bycharacterization of (1) umbilical arterial blood flow, (2) cerebrovascularblood flow, or (3) the ratio between the two. However, these measures ignorethe maternal contribution to placental perfusion. We sought to investigatethe utility of the fetal-maternal vascular impedance index(FMVI), a new measure of vascular characterization that incorporates fetalcerebrovascular, umbilical, and maternal uterine circulations in assessingoverall fetal well-being.Methods—Doppler interrogation of the fetal middle cerebralartery (MCA), umbilical artery (UA), and right maternal uterine artery(UTA) was performed and vascular impedance calculated for each throughthe pulsatility index (PI). Three groups of gestationally age-matched subjectswere studied: (1) normal controls, (2) fetuses with maternal diabetes(MD), and (3) fetuses with a severe form of congenital heart disease(CHD), hypoplastic left heart syndrome (HLHS). The FMVI was calculatedas the (MCA PI – UA PI)/UTA PI.Results—Mean and SD data are listed in Table 1. There wasno difference in gestational age between the 3 groups. The MCA PI for theMD group was no different than for normal; however, HLHS was significantlylower (P < .05). There was no difference in the UA PI or UTA PIbetween the 3 groups. The FMVI for the MD group was significantlylower (P < .05) and for the HLHS group was markedly lower (P < .001),than normal.Conclusions—The FMVI is an index of relative vascular impedancebetween the fetal cerebrovasculature, UA, and maternal contributionto placental flow, which varies from normal in MD and complexCHD. Vascular impedance is naturally highest in the MCA, followed bythe UA, and lowest in the UTA. The FMVI evaluates this natural trend,which may aid in detecting subtle circulatory alterations that are not evidentby analysis of individual PI values alone.Table 1Gestationaln Age, wk MCA PI UA PI UTA PI FMVINormal 47 23.2 (3.7) 1.99 (0.38) 1.25 (0.19) 0.92 (0.38) 0.97 (0.63)MD 54 23.5 (4.8) 1.92 (0.39) 1.30 (0.29) 0.91 (0.36) 0.73 (0.73)HLHS 29 24 (3.4) 1.85 (0.31) 1.34 (0.26) 0.89 (0.21) 0.62 (0.49)
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Page 7 and 8: 2013 AIUM Award WinnersJoseph H. Ho
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