Automated quantitative evaluation of fetal atrioventricular annular plane systolic excursion
Open accessAbstract
Objectives: The primary aim of this study was to evaluate the feasibility of automated measurement of fetal atrioventricular (AV) plane displacement (AVPD) over several cardiac cycles using myocardial velocity traces obtained by color tissue Doppler imaging (cTDI). The secondary objectives were to establish reference ranges for AVPD during the second half of normal pregnancy, to assess fetal AVPD in prolonged pregnancy in relation to adverse perinatal outcome and to evaluate AVPD in fetuses with a suspicion of intrauterine growth restriction (IUGR). Methods: The population used to develop the reference ranges consisted of women with an uncomplicated singleton pregnancy at 18–42 weeks of gestation ( n = 201). The prolonged‐pregnancy group comprised women with an uncomplicated singleton pregnancy at ≥ 41 + 0 weeks of gestation ( n = 107). The third study cohort comprised women with a singleton pregnancy and suspicion of IUGR, defined as an estimated fetal weight < 2.5 th centile or an estimated fetal weight < 10 th centile and umbilical artery pulsatility index > 97.5 th centile ( n = 35). Cineloops of the four‐chamber view of the fetal heart were recorded using cTDI. Regions of interest were placed at the AV plane in the left and right ventricular walls and the interventricular septum, and myocardial velocity traces were integrated and analyzed using an automated algorithm developed in‐house to obtain mitral (MAPSE), tricuspid (TAPSE) and septal (SAPSE) annular plane systolic excursion. Gestational‐age specific reference ranges were constructed and normalized for cardiac size. The correlation between AVPD measurements obtained using cTDI and those obtained by anatomic M‐mode were evaluated, and agreement between these two methods was assessed using Bland–Altman analysis. The mean Z ‐scores of fetal AVPD in the cohort of prolonged pregnancies were compared between cases with normal and those with adverse outcome using Mann–Whitney U ‐test. The mean Z ‐scores of fetal AVPD in IUGR fetuses were compared with those in the normal reference population using Mann–Whitney U ‐test. Inter‐ and intraobserver variability for acquisition of cTDI recordings and offline analysis was assessed by calculating coefficients of variation (CV) using the root mean square method. Results: Fetal MAPSE, SAPSE and TAPSE increased with gestational age but did not change significantly when normalized for cardiac size. The fitted mean was highest for TAPSE throughout the second half of gestation, followed by SAPSE and MAPSE. There was a significant correlation between MAPSE ( r = 0.64; P < 0.001), SAPSE ( r = 0.72; P < 0.001) and TAPSE ( r = 0.84; P < 0.001) measurements obtained by M‐mode and those obtained by cTDI. The geometric means of ratios between AVPD measured by cTDI and by M‐mode were 1.38 (95% limits of agreement (LoA), 0.84–2.25) for MAPSE, 1.00 (95% LoA, 0.72–1.40) for SAPSE and 1.20 (95% LoA, 0.92–1.57) for TAPSE. In the prolonged‐pregnancy group, the mean ± SD Z ‐scores for MAPSE (0.14 ± 0.97), SAPSE (0.09 ± 1.02) and TAPSE (0.15 ± 0.90) did not show any significant difference compared to the reference ranges. Twenty‐one of the 107 (19.6%) prolonged pregnancies had adverse perinatal outcome. The AVPD Z ‐scores were not significantly different between pregnancies with normal and those with adverse outcome in the prolonged‐pregnancy cohort. The mean ± SD Z ‐scores for SAPSE (−0.62 ± 1.07; P = 0.006) and TAPSE (−0.60 ± 0.89; P = 0.002) were significantly lower in the IUGR group compared to those in the normal reference population, but the differences were not significant when the values were corrected for cardiac size. The interobserver CVs for the automated measurement of MAPSE, SAPSE and TAPSE were 28.1%, 17.7% and 15.3%, respectively, and the respective intraobserver CVs were 33.5%, 15.0% and 17.9%. Conclusions: This study showed that fetal AVPD can be measured automatically by integrating cTDI velocities over several cardiac cycles. Automated analysis of AVPD could potentially help gather larger datasets to facilitate use of machine‐learning models to study fetal cardiac function. The gestational‐age associated increase in AVPD is most likely a result of increasing cardiac size, as the AVPD normalized for cardiac size did not change significantly between 18 and 42 weeks. A decrease was seen in TAPSE and SAPSE in IUGR fetuses, but not after correction for cardiac size. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Herling et al. found significant correlations between automated measurements of fetal atrioventricular plane displacement using cTDI versus anatomic M mode: mitral annular plane systolic excursion r=0.64 (P<0.001), septal annuar plane systolic excursion r=0.72 (P<0.001), and tricuspid annular plane systolic excursion r=0.84 (P<0.001).
“Herling et al. evaluated the correlation between automated measurement of fetal atrioventricular plane displacement using myocardial velocity traces obtained by color tissue Doppler imaging (cTDI) versus those obtained by anatomic M mode and found a significant correlation between mitral annular plane systolic excursion (r = 0.64; P < 0.001), septal annuar plane systolic excursion (r = 0.72; P < 0”
From Artificial intelligence in obstetric ultrasound: A scoping review. (2023) · cites this paper as [78]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
STATISTICAL METHODS FOR ASSESSING AGREEMENT BETWEEN TWO METHODS OF CLINICAL MEASUREMENT
Martin Bland, J., & Altman, D. (1986) · The Lancet · doi:10.1016/s0140-6736(86)90837-8 · Cited by 47,965 · see citing works
Measuring agreement in method comparison studies
Bland, J. M., & Altman, D. G. (1999) · Statistical Methods in Medical Research · doi:10.1177/096228029900800204 · Cited by 9,619 · see citing works
Intrauterine growth curves based on ultrasonically estimated foetal weights
Maršál, K., Persson, P., Larsen, T., Lilja, H., Selbing, A., & Sultan, B. (1996) · Acta paediatrica · doi:10.1111/j.1651-2227.1996.tb14164.x · Cited by 1,900 · see citing works
How to construct ‘normal ranges’ for fetal variables
Royston, P. J., & Wright, E. M. (1998) · Ultrasound in Obstetrics and Gynecology · doi:10.1046/j.1469-0705.1998.11010030.x · Cited by 482 · see citing works
Functional importance of the long axis dynamics of the human left ventricle.
Jones, C. J., Raposo, L., & Gibson, D. G. (1990) · Heart · doi:10.1136/hrt.63.4.215 · Cited by 367 · see citing works
Fetal cardiac output, distribution to the placenta and impact of placental compromise
Kiserud, T., Ebbing, C., Kessler, J., & Rasmussen, S. (2006) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.2832 · Cited by 275 · see citing works
Carlsson, M., Ugander, M., Mosén, H., Buhre, T., & Arheden, H. (2006) · American Journal of Physiology-Heart and Circulatory Physiology · doi:10.1152/ajpheart.01148.2006 · Cited by 266 · see citing works
Carlsson, M., Ugander, M., Heiberg, E., & Arheden, H. (2007) · American Journal of Physiology-Heart and Circulatory Physiology · doi:10.1152/ajpheart.01376.2006 · Cited by 206 · see citing works
Estimating Precision Using Duplicate Measurements
Hyslop, N. P., & White, W. H. (2009) · Journal of the Air & Waste Management Association · doi:10.3155/1047-3289.59.9.1032 · Cited by 181 · see citing works
Cardiac pumping and function of the ventricular septum.
Lundbäck, S. (1986) · PubMed · Cited by 156 · see citing works
Myocardial tissue Doppler and long axis function in the fetal heart
Gardiner, H. M., Pasquini, L., Wolfenden, J., Barlow, A., Li, W., Kulinskaya, E., & Henein, M. Y. (2005) · International Journal of Cardiology · doi:10.1016/j.ijcard.2005.10.029 · Cited by 128 · see citing works
Early changes in left ventricular subendocardial function after successful coronary angioplasty.
Henein, M. Y., Priestley, K., Davarashvili, T. I., Buller, N. P., & Gibson, D. G. (1993) · Heart · doi:10.1136/hrt.69.6.501 · Cited by 114 · see citing works
Cruz-Lemini, M., Crispi, F., Valenzuela‐Alcaráz, B., Figueras, F., Sitges, M., Gómez, O., Bijnens, B. H., & Gratacós, E. (2012) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.12374 · Cited by 91 · see citing works
Perinatal changes in cardiac geometry and function in growth‐restricted fetuses at term
Patey, O. V., Carvalho, J. S., & Thilaganathan, B. (2018) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.19193 · Cited by 82 · see citing works
Saltvedt, S., Almström, H., Kublickas, M., Reilly, M., Valentin, L., & Grünewald, C. (2004) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.1047 · Cited by 72 · see citing works
Acharya, G., Sitras, V., Erkinaro, T. M., Mäkikallio, K., Kavasmaa, T., Päkkilä, M., Huhta, J. C., & Rasanen, J. P. (2007) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.3977 · Cited by 59 · see citing works
Self-citationRight and left ventricular long‐axis function in the fetus using angular M‐mode
Carvalho, J. S., O’Sullivan, C. A., Shinebourne, E. A., & Henein, M. Y. (2001) · Ultrasound in Obstetrics and Gynecology · doi:10.1046/j.0960-7692.2001.00587.x · Cited by 56 · see citing works
Influence of body size and age on mitral ring motion
Wandt, B., Bojö, L., & Wranne, B. (1997) · Clinical Physiology · doi:10.1046/j.1365-2281.1997.00065.x · Cited by 56 · see citing works
Batterham, A. M., Shave, R., Oxborough, D., Whyte, G., & George, K. (2008) · European Journal of Echocardiography · doi:10.1093/ejechocard/jen114 · Cited by 51 · see citing works
Nomograms of Fetal Cardiac Dimensions at 18–41 Weeks of Gestation
García‐Otero, L., Gómez, O., Rodríguez‐López, M., Torres, X., Soveral, I., Sepúlveda-Martínez, Á., Guirado, L., Valenzuela‐Alcaráz, B., López, M., Martínez, J. M., et al. (2019) · Fetal Diagnosis and Therapy · doi:10.1159/000494838 · Cited by 49 · see citing works
Hobbins, J. C., Gumina, D. L., Zaretsky, M. V., Driver, C., Wilcox, A., & DeVore, G. R. (2019) · American Journal of Obstetrics and Gynecology · doi:10.1016/j.ajog.2019.06.008 · Cited by 43 · see citing works
Fetal Blood Velocity Waveforms In Normal Pregnancies
Åström, K., Eliasson, A. H., Hareide, J. H., & Maršál, K. (1989) · Acta Obstetricia Et Gynecologica Scandinavica · doi:10.3109/00016348909009907 · Cited by 39 · see citing works
Asgeirsson, D., Hedström, E., Jögi, J., Pahlm, U. S., Steding‐Ehrenborg, K., Engblom, H., Arheden, H., & Carlsson, M. (2017) · BMC Cardiovascular Disorders · doi:10.1186/s12872-017-0641-z · Cited by 27 · see citing works
Z-Score Reference Ranges for Angular M-Mode Displacement at 22-40 Weeks' Gestation
Mao, Y. K., Zhao, B., & Wang, B. (2016) · Fetal Diagnosis and Therapy · doi:10.1159/000446071 · Cited by 22 · see citing works
Peixoto, A. B., Bravo‐Valenzuela, N. J., Martins, W. P., Tonni, G., Mattar, R., Moron, A. F., Pares, D. B. S., & Júnior, E. A. (2020) · Journal of Perinatal Medicine · doi:10.1515/jpm-2020-0002 · Cited by 19 · see citing works
Longitudinal left ventricular function is globally depressed within a week of STEMI
Pahlm, U. S., Seemann, F., Engblom, H., Gyllenhammar, T., Halvorsen, S., Hansen, H. S., Erlinge, D., Atar, D., Heiberg, E., Arheden, H., et al. (2018) · Clinical Physiology and Functional Imaging · doi:10.1111/cpf.12521 · Cited by 16 · see citing works
Lee‐Tannock, A., Hay, K. E., Gooi, A., & Kumar, S. (2019) · Journal of Ultrasound in Medicine · doi:10.1002/jum.15177 · Cited by 16 · see citing works
Herling, L., Johnson, J., Ferm‐Widlund, K., Lindgren, P., Acharya, G., & Westgren, M. (2015) · Cardiovascular Ultrasound · doi:10.1186/s12947-015-0034-3 · Cited by 13 · see citing works
Self-citationAcharya, G. (2013) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.12542 · Cited by 9 · see citing works
Self-citationHerling, L., Johnson, J., Ferm‐Widlund, K., Bergholm, F., Elmstedt, N., Lindgren, P., Sonesson, S., Acharya, G., & Westgren, M. (2018) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.19037 · Cited by 8 · see citing works
Self-citationAutomated analysis of fetal cardiac function using color tissue Doppler imaging
Herling, L., Johnson, J., Ferm‐Widlund, K., Bergholm, F., Lindgren, P., Sonesson, S., Acharya, G., & Westgren, M. (2017) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.18812 · Cited by 7 · see citing works
Self-citation
Flagged first, then by citations
Cited by
Sorted by citations
Artificial intelligence in obstetric ultrasound: A scoping review.
Horgan, R., Nehme, L., & Abuhamad, A. (2023) · Prenatal Diagnosis · doi:10.1002/pd.6411 · Cited by 72 · see citing works
“001) measurements obtained by M‐mode and those obtained by cTDI.(78) Dozen et al.”
MethodJost, E., Kosian, P., Jimenez Cruz, J., Albarqouni, S., Gembruch, U., Strizek, B., & Recker, F. (2023) · Journal of Clinical Medicine · doi:10.3390/jcm12216833 · Cited by 44 · see citing works
“…Herling et al. analyzed the automated measurement of fetal atrioventricular plane displacement in US videos of cardiac cycles using color tissue Doppler [65], and Scharf et al. evaluated the automated assessment of the myocardial performance index as a tool to analyze fetal cardiac function [66].”
MethodAdvances in the Application of Artificial Intelligence in Fetal Echocardiography
Zhang, J., Xiao, S., Zhu, Y. C., Zhang, Z., Cao, H., Xie, M., & Zhang, L. (2024) · Journal of the American Society of Echocardiography · doi:10.1016/j.echo.2023.12.013 · Cited by 61 · see citing works
Türkyılmaz, G., Türkyılmaz, Ş., & Uygur, L. (2021) · Journal of obstetrics and gynaecology research · doi:10.1111/jog.15114 · Cited by 10 · see citing works
Role of artificial intelligence in congenital heart disease
Niyogi, S. G., Nag, D. S., Shah, M. M., Swain, A., Naskar, C., Srivastava, P., & Kant, R. (2025) · World Journal of Clinical Pediatrics · doi:10.5409/wjcp.v14.i3.105926 · Cited by 8 · see citing works
Assessment of fetal cardiac function in pregnant women with anemia: prospective case–control study
Ağaoğlu, Z., Tanaçan, A., Gurbuz, U., Ağaoğlu, M. Ö., Haksever, M., Okutucu, G., Kara, Ö., & Sahin, D. (2024) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.27637 · Cited by 5 · see citing works
Riva, A., Guerra, M., Gangi, S. D., Veronese, P., & Vida, V. L. (2024) · Clinical and Experimental Obstetrics & Gynecology · doi:10.31083/j.ceog5111244 · Cited by 6 · see citing works
Assessment of fetal cardiac functions in pregnant women with asthma
Koç, B. L., Oluklu, D., Hendem, D. U., Beşer, D. M., Besimoğlu, B., Tanaçan, A., Öcal, F. D., & Şahın, D. (2023) · Echocardiography · doi:10.1111/echo.15584 · Cited by 4 · see citing works
Zamprakou, A., Söderhult, I., Ferm‐Widlund, K., Ajne, G., Johnson, J., & Herling, L. (2023) · Acta Obstetricia Et Gynecologica Scandinavica · doi:10.1111/aogs.14722 · Cited by 3 · see citing works
Self-citationThomas, S., Erenbourg, A., Chang, M. H. Y., Ferreira, A. G. D. M. T., Stevenson, G. N., & Welsh, A. W. (2024) · Ultrasound · doi:10.1177/1742271x231215501 · Cited by 2 · see citing works
Ağaoğlu, Z., Tanaçan, A., Toptaş, G. R., Aktaş, B. A., Yıldız, E. G., Kara, O., & Şahın, D. (2024) · International Journal of Gynecology & Obstetrics · doi:10.1002/ijgo.15910 · Cited by 1 · see citing works
Erenbourg, A., Barber, T. J., Cecotti, V., Faiola, S., Fantasia, I., Stampaljia, T., Avnet, H., Radzymińska-Chruściel, B., Meriki, N., & Welsh, A. W. (2025) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-025-07145-7 · Cited by 1 · see citing works
Reference ranges for fetal tricuspid and mitral annular plane systolic excursions
Kanjak, J., Komwilaisak, R., Saksiriwuttho, P., Kongwattanakul, K., Chaiyarach, S., Duangkum, C., & Waidee, T. (2025) · Journal of Perinatal Medicine · doi:10.1515/jpm-2025-0189 · Cited by 1 · see citing works
Enhancing Fetal Cardiac Imaging With Artificial Intelligence
Martins, J. G., Horgan, R., & Sinkovskaya, E. S. (2025) · Clinical Obstetrics & Gynecology · doi:10.1097/grf.0000000000000992 · Cited by 1 · see citing works
Liu, H., Li, J., Cao, X., Wang, Y., Wen, D., Dong, F., Wang, J., & Li, T. X. (2023) · PeerJ · doi:10.7717/peerj.14702 · Cited by 1 · see citing works
Kiridi, E. K., Oriji, P. C., Ubom, A. E., Briggs, D. C., Ugwoegbu, J. U., Bosrotsi, P. Y., Addah, A. O., Abasi, I. J., Okechukwu, C., & Adesina, A. D. (2022) · International Journal of Radiology and Diagnostic Imaging · doi:10.33545/26644436.2022.v5.i4a.284
Assessment Of Fetal Cardiac Functions In Pregnant Women Wıth AsthmaPreprint
Koç, B. L., Oluklu, D., Hendem, D. U., Beşer, D. M., Besimoğlu, B., Tanaçan, A., Öcal, F. D., & Şahın, D. (2023) · doi:10.22541/au.167872057.74851799/v1
Current Applications of Artificial Intelligence in Obstetric Ultrasound
Li, Y., Cui, Y., Wu, Q., & Zhang, N. (2025) · Advanced ultrasound in diagnosis and therapy · doi:10.26599/audt.2025.250095
Impact of Preeclampsia Severity on Fetal MAPSE and TAPSE: A Prospective Case–Control Study
Gök, K., Baştan, M., Tüten, R., Özçil, M. D., Erdoğan, I., Özden, S., & Tüten, A. (2026) · Journal of Clinical Medicine · doi:10.3390/jcm15082952
方文伶, Hu, P., Jiang, X., Yu, R., Ma, J. J., Wang, N., Wu, T., Ye, L., Ruan, W., Jin, L., et al. (2026) · Echocardiography · doi:10.1111/echo.70526
Liang, H., Johnson, J., Lantto, J., Huhta, H., Haapsamo, M., Kokki, M., Voipio, H., Westgren, M., Bhide, A., Rasanen, J. P., et al. (2026) · Scientific Reports · doi:10.1038/s41598-026-66360-0
Self-citationErenbourg, A., Philip, M. E., Barber, T. J., Meriki, N., Faiola, S., Lops, G., Cecotti, V., Arcot, S., & Welsh, A. W. (2026) · Journal of Perinatal Medicine · doi:10.1515/jpm-2025-0729
- Authors
- Herling, L., Johnson, J., Ferm‐Widlund, K., Zamprakou, A., Westgren, M., & Acharya, G.
- Affiliations
- Karolinska University Hospital (SE)
- Corresponding author
- Herling, L.
- Venue
- Ultrasound in Obstetrics & Gynecology
- Publisher
- Wiley
- Published
- 2021-12
- Volume
- 58
- Issue
- 6
- Pages
- 853-863
- ISSN
- 0960-7692 (ISSN-L)
- 1469-0705
- OpenAlex
- W3169350714
- Cited by
- 22
- References
- 31
- Citations by year
- 2026: 4 · 2025: 5 · 2024: 5 · 2023: 6 · 2022: 1 · 2021: 1
- FWCI
- 2.34
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Ultrasound in Obstetrics and Gynecology (publishedVersion, cc-by)
- PubMed (publishedVersion)
- NORA - Norwegian Open Research Archives (submittedVersion, other-oa)
- Topics
- Health Sciences › Medicine › Epidemiology › Congenital Heart Disease Studies
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Function and Risk Factors
- Health Sciences › Medicine › Obstetrics and Gynecology › Pregnancy and preeclampsia studies
- Keywords
- color tissue Doppler imaging, mitral annular plane systolic excursion, tricuspid annular plane systolic excursion, fetal cardiac function, prolonged pregnancy, perinatal complications, fetal growth restriction, reference values
- MeSH terms
- Atrioventricular Node, Blood Flow Velocity, Feasibility Studies, Female, Fetal Growth Retardation, Fetal Heart, Gestational Age, Heart Ventricles, Humans, Pregnancy, Pulsatile Flow, Reference Values, Stroke Volume, Systole, Tricuspid Valve, Ultrasonography, Prenatal, Echocardiography, Doppler, Color, Fetal Weight, Ventricular Septum
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
