LETTER TO THE EDITOR

Three- and four-dimensional volume-rendered imaging of situsinversus totalis with inversion mode

Emiko Uketa • Keiji Hayashi • Megumi Ito •

Miki Sato • Toshiyuki Hata

Received: 17 October 2011 / Accepted: 16 February 2012 / Published online: 25 February 2012

� Springer-Verlag 2012

To the Editor

Situs inversus totalis (situs inversus with dextrocardia)

characterized by transposition of the abdominal viscera and

a right-sided heart, is a mirror-image of the normal anat-

omy. The incidence of situs inversus totalis is 0.01% [1].

In situs inversus totalis, the heart is structurally normal in

90–95%, in contrast to dextrocardia with situs solitus,

which involves a high incidence of structural cardiac

defects [2]. There have been a number of earlier reports on

the antenatal two-dimensional (2D) sonographic diagnosis

of situs inversus totalis during pregnancy [3]. However,

there has been no report on the three-dimensional (3D)

sonographic diagnosis of situs inversus totalis with an

inversion mode during pregnancy. This promoted us to

present antenatal diagnosis of situs inversus totalis

employing 3D/four-dimensional (4D) sonography with an

inversion mode.

A 29-year-old pregnant Japanese woman, gravida 2,

para 1, was referred to our ultrasound clinic because of a

right-sided heart and stomach at 24 weeks and 5 days of

gestation. 2D sonographic biometric measurements were

consistent with 25 weeks of gestation. 2D sonography

(Voluson E8, GE Healthcare, Milwaukee, WI, USA)

showed mirror-image dextrocardia and the mirror-image

arrangement of the stomach, spleen, and liver (Fig. 1). 3D/

4D sonography (Voluson E8, GE Healthcare, Milwaukee,

WI, USA) with an inversion mode clearly revealed a spa-

tial relationship among mirror-image cardiac structures, the

spine, and right-sided stomach (Fig. 2). Especially, the 3D

inversion mode facilitated the visualization of the rela-

tionship and course of the outflow tracts, thus helping the

physician to more effectively understand the spatial rela-

tionships between great vessels.

A healthy female infant weighing 3,554 g was delivered

vaginally at 41 weeks and 4 days of gestation. Echocardi-

ography and radiograph (Fig. 3) confirmed the prenatal

findings of situs inversus totalis. The neonate followed a

favorable course after delivery.

The inversion mode is a volume analysis approach to

3D/4D sonography for the visualization of fluid-filled fetal

structures [4]. Anechoic structures, such as the cardiac

chambers, vessel lumen, stomach, gallbladder, renal pelvis,

and bladder appear echogenic in the rendered images,

whereas structures that are normally echogenic before gray

scale inversion appear anechoic [5]. Therefore, the 3D/4D

inversion mode facilitates the visualization of the rela-

tionships and size of the fluid collections, thus helping the

sonographer to more effectively understand the spatial

relationships between fluid-filled structures [4]. In the

present case, the 3D/4D inversion mode was an adjunctive

tool to assist in the prenatal understanding of situs inversus

with dextrocardia, although conventional 2D sonography

can actually suggest the diagnosis.

The utility of 3D/4D sonography with an inversion

mode in the antenatal diagnosis of fetal cardiac anomalies

has been described in several reports [5–8]. In those

investigations, 4D sonography with an inversion mode

demonstrated real-time 3D angiographic features of fetal

cardiac outflow tracts in both normal and abnormal fetal

E. Uketa � K. Hayashi

Department of Obstetrics and Gynecology, Uchinomi Hospital,

44-95 Katajo-Kou, Shoudoshima-cho, Shouzu-gun,

Kagawa 761-4431, Japan

M. Ito � M. Sato � T. Hata (&)

Department of Perinatology and Gynecology,

Kagawa University School of Medicine, 1750-1 Ikenobe,

Miki, Kagawa 761-0793, Japan

e-mail: toshi28@med.kagawa-u.ac.jp

123

Arch Gynecol Obstet (2012) 286:533–535

DOI 10.1007/s00404-012-2264-z

hearts [8]. This technique assisted in the evaluation of

spatial relationships between the great vessels and both

ventricles, and 3D/4D inversion mode images are more

readily discernible than those obtained by conventional 2D

sonography. In our case, the 3D/4D inversion mode facil-

itated the visualization of mirror-image right-sided normal

cardiac structures. Moreover, the 3D/4D inversion mode

may be easier for less-experienced sonographers to learn

and make a diagnosis [8].

Conflict of interest The authors declare no conflict of interest.

References

1. eMedicine (2011) Medscape. Situs inversus imaging.

http://emedicine.medscape.com/article/413679-overview 23 Janu-

ary 2011

2. Marta MJ, Falcao LM, Saaverdra JA, Ravara L (2003) A case of

complete situs inversus. Rev Port Cardiol 22:91–104

3. Comstock CH, Smith R, Lee W, Kirk JS (1998) Right fetal cardiac

axis: clinical significance and associated findings. Obstet Gynecol

91:495–499

4. Hata T, Mori N, Tenkumo C, Hanaoka U, Kanenishi K, Tanaka H

(2011) Three-dimensional volume-rendered imaging of normal

Fig. 1 Left occipito-anterior position of the fetus at 24 weeks and

5 days of gestation. a Two-dimensional transverse view of the chest;

b two-dimensional transverse view of the abdomen. L fetal left,

R fetal right, Ao aorta, LA left atrium, Li liver, LV left ventricle, RAright atrium, RV right ventricle, S spleen, Sp spine, St stomach

Fig. 2 Three-dimensional reconstruction of the fetal chest and

abdomen using the inversion mode in a fetus with situs inversus

totalis. Mirror-image dextrocardia, the spine (Sp), and right-sided

stomach (St) are clearly shown. L fetal left, R fetal right, AAoascending aorta, AoA aortic arch, DA ductus arteriosus, DAodescending aorta, LV left ventricle, PA pulmonary artery, RV right

ventricle

Fig. 3 Neonatal chest-abdominal radiograph after birth. Mirror-

image dextrocardia and a right-sided stomach bubble are evident

534 Arch Gynecol Obstet (2012) 286:533–535

123

and abnormal fetal fluid-filled structures using inversion mode.

J Obstet Gynaecol Res 37:1754–1784

5. Goncalves LF, Espinoza J, Lee W, Nien JK, Hong JS, Santolaya-

Forgas J, Mazor M, Romero R (2005) A new approach to fetal

echocardiography. Digital casts of the fetal cardiac chambers and

great vessels for detection of congenital heart disease. J Ultrasound

Med 24:415–424

6. Dai SY, Inubashiri E, Hanaoka U, Kanenishi K, Yamashiro C,

Tanaka H, Yanagihara T, Hata T (2006) Three- and four-

dimensional volume-rendered imaging of fetal double-outlet right

ventricle using inversion mode. Ultrasound Obstet Gynecol

28:347–349

7. Araujo EJ, de Bussamra LC, Barros FSB, Britto ISW, Aoki T,

Pires CR, Nowak PM, Nardozza LMM, Moron AF (2008) Prenatal

diagnosis of Ebstein’s anomaly using spatio-temporal image

correlation (STIC) and inversion mode. Arch Gynecol Obstet

278:387–391

8. Hata T, Tanaka H, Noguchi J, Dai SY, Yamaguchi M, Yanagihata

T (2010) Four-dimensional volume-rendered imaging of the fetal

ventricular outflow tracts and great arteries using inversion mode

for detection of congenital heart disease. J Obstet Gynaecol Res

36:513–518

Arch Gynecol Obstet (2012) 286:533–535 535

123