{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,18]],"date-time":"2026-09-18T17:24:45Z","timestamp":1789752285449,"version":"4.0.1"},"reference-count":23,"publisher":"Wiley","license":[{"start":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T00:00:00Z","timestamp":1788134400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T00:00:00Z","timestamp":1788134400000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"funder":[{"DOI":"10.13039\/501100004587","name":"Instituto de Salud Carlos III","doi-asserted-by":"publisher","award":["PI13\/02769"],"award-info":[{"award-number":["PI13\/02769"]}],"id":[{"id":"10.13039\/501100004587","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100004587","name":"Instituto de Salud Carlos III","doi-asserted-by":"publisher","award":["PI24\/00734"],"award-info":[{"award-number":["PI24\/00734"]}],"id":[{"id":"10.13039\/501100004587","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100012818","name":"Comunidad de Madrid","doi-asserted-by":"publisher","award":["MAGERIT\u2010CMTEC\u20102024\/COM\u201044"],"award-info":[{"award-number":["MAGERIT\u2010CMTEC\u20102024\/COM\u201044"]}],"id":[{"id":"10.13039\/100012818","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["J of Ultrasound Medicine"],"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>To evaluate the feasibility, transferability, and implementation performance of the cardiovascular system sonographic evaluation algorithm (CASSEAL), a structured 3\u2009\u00d7\u20093 sequential framework for second\u2010trimester ultrasound assessment of the extended fetal cardiovascular system, in a multicenter screening setting.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      This prospective multicenter observational study included unselected singleton and twin pregnancies examined between 18 and 22\n                      <jats:sup>+6<\/jats:sup>\n                      \u2009weeks' gestation. After standardized training, operators completed an initial implementation phase (first 30 examinations) followed by a validation phase (\u226550 additional examinations). The CASSEAL algorithm consists of sequential acquisition of 9 axial planes organized into infracardiac, cardiac, and supracardiac territories within a structured 3\u2009\u00d7\u20093 framework. The primary outcome was complete visualization of all 9 views. Secondary outcomes included examination time, factors associated with incomplete visualization, and exploratory screening performance using absence of normality in \u22651 axial view as the screening criterion.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      A total of 1494 fetal examinations performed by 15 operators across 7 centers were analyzed. Complete visualization of all 9 views increased from 78% in the implementation phase to 84% in the validation phase (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u2009.01). Mean examination time decreased significantly after completion of the learning phase (8.0\u2009\u00b1\u20096.4 versus 5.8\u2009\u00b1\u20093.9\u2009minutes;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u2009.001). In multivariable analysis, the validation phase independently reduced the likelihood of incomplete visualization (adjusted OR, 0.65;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u2009.01), whereas higher maternal body mass index (adjusted OR, 1.06 per kg\/m\n                      <jats:sup>2<\/jats:sup>\n                      ;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u2009.001) and anterior fetal spine position (adjusted OR, 3.95;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u2009.001) increased this risk. Thirty\u2010six fetuses (2.4%) had confirmed cardiovascular anomalies, vascular variants, or relevant ultrasound markers. Exploratory screening performance estimates based on available prenatal and postnatal follow\u2010up suggested high specificity and negative predictive value, although sensitivity estimates should be interpreted cautiously because systematic postnatal echocardiography was not available.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The CASSEAL algorithm demonstrates high feasibility, a short learning curve, and robust multicenter reproducibility for structured second\u2010trimester evaluation of the extended fetal cardiovascular system. The integrated 3\u2009\u00d7\u20093 sequential framework may facilitate standardized assessment of supracardiac, cardiac, and infracardiac territories in routine multicenter screening practice.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/jum.70422","type":"journal-article","created":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T11:56:41Z","timestamp":1788177401000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Multicenter Implementation and Validation of the Structured 3 \u00d7\u20093\n                    <scp>CASSEAL<\/scp>\n                    Framework for Second\u2010Trimester Assessment of the Extended Fetal Cardiovascular System"],"prefix":"10.1002","author":[{"given":"Coral Bravo","family":"Arribas","sequence":"first","affiliation":[{"name":"Department of Public and Maternal and Child Health, Faculty of Medicine and Health Sciences Complutense University of Madrid  Madrid Spain"},{"name":"Department of Obstetrics and Gynecology University Hospital Gregorio Mara\u00f1\u00f3n  Madrid Spain"},{"name":"Research Group Pathophysiology of Women, Pregnancy, Childbirth and Puerperium Instituto de Investigaci\u00f3n Sanitaria Gregorio Mara\u00f1\u00f3n  Madrid Spain"},{"name":"Maternal and Infant Research Investigation Unit Alonso Family Foundation (UDIMIFFA)  Madrid Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0529-9892","authenticated-orcid":false,"given":"Cristina Mart\u00ednez","family":"Payo","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology University Hospital Puerta de Hierro  Madrid Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Teresa \u00c1lvarez","family":"Mart\u00edn","sequence":"additional","affiliation":[{"name":"Research Group Pathophysiology of Women, Pregnancy, Childbirth and Puerperium Instituto de Investigaci\u00f3n Sanitaria Gregorio Mara\u00f1\u00f3n  Madrid Spain"},{"name":"Maternal and Infant Research Investigation Unit Alonso Family Foundation (UDIMIFFA)  Madrid Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mar\u00eda Jos\u00e9 Rodr\u00edguez","family":"Su\u00e1rez","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology Hospital La Mancha Centro  Alc\u00e1zar de San Juan Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5869-4450","authenticated-orcid":false,"given":"Jara Pascual","family":"Macho","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology University Hospital Miguel Servet  Zaragoza Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Esther","family":"Tello","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology University Hospital Nuestra Se\u00f1ora del Prado  Talavera de la Reina Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mar\u00eda \u00c1ngeles Anaya","family":"Baz","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology University Hospital Ciudad Real  Ciudad Real Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cristina S\u00e1nchez","family":"Rojo","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology Hospital Central de la Defensa  Madrid Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ana","family":"Pomares","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology Hospital Central de la Defensa  Madrid Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2915-7162","authenticated-orcid":false,"given":"Ana G\u00f3mez","family":"Manrique","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology University Hospital Puerta de Hierro  Madrid Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria Moreno","family":"Cid","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology Hospital La Mancha Centro  Alc\u00e1zar de San Juan Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Miguel Ruiz de Azuaga","family":"Ballesteros","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology University Hospital Puerta de Hierro  Madrid Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ana M Rubio","family":"Lorente","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology Hospital La Mancha Centro  Alc\u00e1zar de San Juan Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yolanda Nieto","family":"Jim\u00e9nez","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology University Hospital Puerta de Hierro  Madrid Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mar\u00eda","family":"del Carmen Garrido S\u00e1nchez","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology University Hospital Nuestra Se\u00f1ora del Prado  Talavera de la Reina Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ana","family":"Granados","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology University Hospital Nuestra Se\u00f1ora del Prado  Talavera de la Reina Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8190-8680","authenticated-orcid":false,"given":"Yolanda","family":"Cu\u00f1arro","sequence":"additional","affiliation":[{"name":"Department of Public and Maternal and Child Health, Faculty of Medicine and Health Sciences Complutense University of Madrid  Madrid Spain"},{"name":"Department of Obstetrics and Gynecology Complejo Hospitalario Universitario de Vigo  Vigo Spain"},{"name":"Research and Innovation in Maternal\u2010Perinatal Medicine and Gynecology Galicia Sur Health Research Institute (IIS Galicia Sur). SERGAS\u2010UVIGO  Vigo Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ricardo P\u00e9rez","family":"Fdez\u2010Pacheco","sequence":"additional","affiliation":[{"name":"Department of Public and Maternal and Child Health, Faculty of Medicine and Health Sciences Complutense University of Madrid  Madrid Spain"},{"name":"Department of Obstetrics and Gynecology University Hospital Gregorio Mara\u00f1\u00f3n  Madrid Spain"},{"name":"Research Group Pathophysiology of Women, Pregnancy, Childbirth and Puerperium Instituto de Investigaci\u00f3n Sanitaria Gregorio Mara\u00f1\u00f3n  Madrid Spain"},{"name":"Maternal and Infant Research Investigation Unit Alonso Family Foundation (UDIMIFFA)  Madrid Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6320-2668","authenticated-orcid":false,"given":"Juan De Le\u00f3n","family":"Luis","sequence":"additional","affiliation":[{"name":"Department of Public and Maternal and Child 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