#5 Tricuspid and Mitral Inflow Doppler

E/A ratio refers to the ratio of the two peaks in flow velocity observed over the atrioventricular valves during diastole

The E-wave is the early, passive diastolic filling, which is dependent on ventricular wall relaxation

The A-wave is the active diastolic filling known as the ‘atrial kick’

Pulsed-wave (PW) Doppler, with the cursor set on or just below the AV valve in a four-chamber view (optimal angle of interrogation is parallel 0 to 20 degrees)

Case #5

Tricuspid valve dysplasia with severe tricuspid valve regurgitation fetal demise 3rd trimester

Partially fused E/A inflow signal

Decreased inflow velocity with increased E wave as compared to A wave

Severe tricuspid valve regurgitation

20 weeks gestation

LR

#6 Aortic and Pulmonary Outflow Doppler Angle- dependent; accurate angle

of insonation ~0 to 20 degrees of the direction of blood flow

Doppler waveforms across the semilunar valves are uniphasic

Sample gate ~2 mm

Nyquist limit/scale > 30 cm/sec

Peak systolic velocity (PSV) increases with advancing gestation and is higher across the aorta than it is across the pulmonary artery due to a decreased afterload

Aortic valve Pulmonary valve

Aortic valve peak velocity 0.5-1.2 m/sec(average, mid-gestation)

Pulmonary valve peak velocity 0.4-1 m/sec(average, mid-gestation)

Case #6

Critical aortic valve stenosis with post-stenotic dilation of the ascending aorta successful neonatal transcatheter balloon valvuloplasty

22 5/7 weeks gestation

Main pulmonary artery: 4.5 mm (z-score +0.9)

Ascending aorta: 5.2 mm (z-score +2.3)

Krishnan, et al.

Color Doppler indicates aliasing at Nyquist ~60 cm/sec

Abnormal aortic valve peak velocity > 2 m/sec (suboptimal angle of interrogation)

L

R

#7 Ductus Arteriosus Doppler

Normal fetal ductal flow in utero is from right to left throughout the cardiac cycle

Biphasic, with a peak systolic velocity of 50–140 cm/s, end-diastolic velocities of 6–30 cm/s (these parameters increase with gestational age)

Normal pulsatility index of 1.9–3

A

P

Case #7 Small 2D diameter of ductus arteriosus

Aliasing of flow on color Doppler, and high systolic and diastolic Doppler velocities (>95th percentiles for gestational age, PSV )

Decreased pulsatility index = 1.6

Secondary fetal echo findings may include: cardiomegaly, dilation of the RA, RV and pulmonary artery, RV hypertrophy and dysfunction, and high-velocity tricuspid and pulmonary valve regurgitation

Premature constriction of the ductus arteriosus secondary to maternal NSAID exposure s/p

normalization with discontinuation of medication

#8 Pulmonary Vein Doppler Angle- dependent; accurate angle

of insonation ~0 to 20 degrees of the direction of blood flow

Nyquist limit/doppler velocity range ~15-25 cm/sec

Low filter and high persistence given low velocity flow

S wave: from left atrial pressure reduction during MV opening

D wave: rapid left atrial emptying during LV relaxation

A wave: rise in left atrial pressure

A

P

L

R

S DA

Case #8

In the fetus with HLHS, a PVD forward/reverse VTI ratio of <5 is the strongest predictor of the need for emergent atrial septostomy in the newborn period

Hypoplastic Left Heart Syndrome with Mitral Stenosis and Aortic stenosis

(forward : reverse VTI ratio = 3)

#9 Ductus Venosus Doppler

Allows for accurate interpretation of fetal cardiac function and myocardial hemodynamics

Narrow gate 0.5-1 mm and high sweep speed 2 cm/sec

Nyquist limit/doppler velocity range ~15-25 cm/sec

Low filter and high persistence given low velocity flow

S wave: fetal ventricular contraction

D wave: fetal early ventricular diastole

A wave: fetal atrial contraction

S DA

A

P

Case #9

Double outlet right ventricle, unbalanced atrioventricular canal, D-malposed great

arteries with complete heart block and evolving hydrops postnatal comfort care

R

L

Thank You

CHOC Fetal Cardiology Team

Pierangelo Renella, MD Wyman Lai, MD, MBA, MPH

Sherisse Mora RDCS, RCS Vanessa Patino RDCS, RCS Komal Suryawalla RDMS

Rebecca Kruse, LVN Amy Cuevas, RN Kira Sandifer, RN

References C. Franklin, CNP, et al. Predictive Value of Fetal Pulmonary Venous Flow Patterns in Identifying the Need for Atrial Septoplasty in the Newborn With Hypoplastic Left

Ventricle. Circulation. 2005;112:2974-2979.

AIUM Practice Parameter for the Performance of Fetal Echocardiography. J Ultrasound Med 2020; 39:E5–E16.

M. Donofrio, et al. Diagnosis and Treatment of Fetal Cardiac Disease: A Scientific Statement From the American Heart Association. Circulation. 2014;129:2183–2242.

L. Hornberger. Role of quantitative assessment in fetal echocardiography. Ultrasound in Obstetrics and Gynecology. January 2010; Volume 35 (1): 4-6.

V. Seravalli, et al. Ductus venosus Doppler in the assessment of fetal cardiovascular health: an updated practical approach. Fetal Cardiovascular Physiology. June 2016; Volume 95(6): 615-709.

A. Familiari, et al. Risk Factors for Coarctation of the Aorta on Prenatal Ultrasound. A Systematic Review and Meta-Analysis. Circulation. 2017; 135: 772–785.

C. Schneider, et al. Development of Z-scores for fetal cardiac dimensions from echocardiography. Ultrasound in Obstetrics and Gynecology. 2005; 26(6): 599-605

ME Godfrey, et al. Functional assessment of the fetal heart: a review. Ultrasound in Obstetrics and Gynecology. 2012; 39(2): 131-144.

E. Hernandez Andrade, et al. Evaluation of Conventional Doppler Fetal Cardiac Function Parameters: E/A Ratios, Outflow Tracts, and Myocardial Performance Index. Fetal Diagnosis and Therapy 2012;32:22–29.

M. Beattie, et al. Toward Improving the Fetal Diagnosis of Coarctation of the Aorta. Pediatric Cardiology. 2017 Feb;38(2):344-352.

LR Freud, et al. Outcomes and Predictors of Perinatal Mortality in Fetuses With Ebstein Anomaly or Tricuspid Valve Dysplasia in the Current Era: A Multicenter Study. Circulation. 2015; Aug 11;132(6):481-9.