Echogenic cardiac foci

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Diagnosis:
Cardiac echogenic foci are not uncommon findings during fetal echocardiographic examination. They are located at the fetal ventricles and have similar echogenicity to the surrounding bone tissue Echogenic intracardiac foci were seen in the apical 4-chamber view in 100% and in the lateral 4-chamber view in only 30% (5). Most echogenic cardiac foci are located in an area of the left ventricle. However, echogenic cardiac foci can also be found in the right ventricle. In about 93% of cases, they are located in the left ventricle and in 5% in the right ventricle; and bilateral in 2% (9).

Prevalence:
The incidence of echogenic cardiac foci in 2nd trimester ultrasounds ranges from 0.17% to 7.4% (2,3,7,9).

Etiology:
Increased local mineralization or calcification of papillary muscles and chordae tendinae are thought to be the cause and the formation of calcium or other minerals in the ventricles is thought to be the cause of the increased echoing that leads to echogenic cardiac foci. As evidence of this, a study of the heart tissue of unborn children with Down syndrome found a significantly increased calcification. Histological studies have shown these foci to be due to mineralization within a papillary muscle (10).

Differential diagnosis :
In the differential diagnosis these structures must be always differentiated from thrombi or cardiac tumours.

Associated anomalies:
Echogenic foci in the heart have become an increasingly frequent ultrasound finding. As with many ultrasound findings, there is controversy about the significance of the foci. There is conflicting evidence, however, as to whether echogenic foci in the heart lead to an increased risk for Down syndrome. That is, some studies have found that there is no increased risk (1), whereas others have found that unborn children with echogenic cardiac foci are four times more likely to have Down syndrome. Many studies suggest that unborn children with echogenic cardiac foci have about a 1% chance of having Down syndrome IN 2003 Prefumo and AL report that : An association exists between first trimester nuchal translucency and second trimester cardiac echogenic foci. Then the Risk calculation algorithms for trisomy 21 based on nuchal translucency thickness should not use cardiac foci as an independent marker (4).

Prognosis:
Echogenic cardiac foci are not an unusual or abnormal finding in an echocardiography of the heart. In fact, up to 7.4% of unborn children have echogenic cardiac foci when the mother is in the second trimester. The vast majority of children with echogenic cardiac foci are born normal and intacardiac foci found in low-risk patients are not associated with a significant increase in the risk of cardiac anomalies (7). This is especially the case for the children of mothers who are under 35 years of age. Several reports recently indicated an association with chromosomal trisomies, particularly that of trisomy 21 (6) and Intracardiac echogenic foci increase the risk of Down syndrome five- to seven-fold. This information should be considered in the decision making for amniocentesis in conjunction with the woman's background risk8.

Many of the cases of echogenic cardiac foci go away by themselves by the time the child is born. In more than half of the cases regress before 5 years of age and are not associated with significant intracardiac or extracardiac anomalies (11).

References 1:
Schechter AG, Fakhry J, Shapiro LR, Gewitz MH : In utero thickening of the chordae tendinae. A cause of intracardiac echogenic foci. J Ultrasound Med. 1987 Dec;6(12):691-5.
2. Dildy GA, Judd VE, Clark SL : Prospective evaluation of the antenatal incidence and postnatal significance of the fetal echogenic cardiac focus: a case-control study. Am J Obstet Gynecol. 1996 Oct;175(4 Pt 1):1008-12.
3. Homola J : [Are echogenic foci in fetal heart ventricles insignificant findings?] [Article in Czech] . Ceska Gynekol. 1997 Oct;62(5):280-2.
4. Prefumo F, Presti F, Thilaganathan B, Carvalho JS : Association between increased nuchal translucency and second trimester cardiac echogenic foci. Obstet Gynecol. 2003 May;101(5 Pt 1):899-904.
5. Ranzini AC, McLean DA, Sharma S, Vintzileos AM : Fetal intracardiac echogenic foci: visualization depends on the orientation of the 4-chamber view. J Ultrasound Med. 2001 Jul;20(7):763-6.
6. Wax JR, Philput C : Fetal intracardiac echogenic foci: does it matter which ventricle?. J Ultrasound Med. 1998 Mar;17(3):141-4; quiz 145-6.
7. Wolman I, Jaffa A, Geva E, Diamant S, Strauss S, Lessing JB, Yaron Y: Intracardiac echogenic focus: no apparent association with structural cardiac abnormality. Fetal Diagn Ther. 2000 Jul-Aug;15(4):216-8.
8. Sotiriadis A, Makrydimas G, Ioannidis JP: Diagnostic performance of intracardiac echogenic foci for Down syndrome: a meta-analysis. Obstet Gynecol. 2003 May;101(5 Pt 1):1009-16.
9. Petrikovsky BM, Challenger M, Wyse LJ : Natural history of echogenic foci within ventricles of the fetal heart. Ultrasound Obstet Gynecol. 1995 Feb;5(2):92-4.
10. Tennstedt C, Chaoui R, Vogel M, Goldner B, Dietel M : Pathologic correlation of sonographic echogenic foci in the fetal heart. Prenat Diagn. 2000 Apr;20(4):287-92.
11. Liu HH, Lin MT, Chang CC, Wang JK, Wu MH, Shyu MK, Lee CN, Hsieh FJ: Postnatal outcome of fetal cardiac echogenic foci. J Formos Med Assoc. 2002 May;101(5):329-36.