fetal echocardiography

Fetal echocardiography

Fetal echocardiographyKh. Batnasan United Family Intermed HospitalUlaanbaatar, Mongolia

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ContentsIntroduction Indications and imaging technique Congenital heart diseases (CHD)


IntroductionWhy do we need to check fetal heart?High incidence4-13 in 1000 live births (in Mongolia: 8-10 in 1000 live births)All mild lesions 75-80/1000 live births

Frequent association with other noncardiac and chromosomal anomalies CHD 8-42% - extracardiacMore than 50% with chromosomal anomalies CHD (+)

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Introduction Contd3. Increased neonatal and childhood morbidity and mortalityAlmost one quarters of infant deaths CHDCHD leading cause of perinatal morbidity and mortality

4. Positive impact of prenatal diagnosis on the postnatal management Appropriate timing of surgical repair Shorter ICU stays Decision of delivery routeReferral to tertiary centerRequirement of urgent postnatal intervention

Prenatal diagnosis of CHD has positive impact on postnatal management with reduced surgical delays, shorter ICU stays, decision of delivery routes, requirement of urgent postnatal management and etc., 5


IndicationsMaternal indications

Autoimmune antibodies, anti-Ro (SSA)/anti-La (SSB)

Familial inherited disorders (22q11.2 deletion syndrome)

In vitro fertilization

Metabolic disease (diabetes mellitus and phenylketonuria)

Teratogen exposure (retinoids and lithium). Fetal indications

Abnormal cardiac screening examination

First-degree relative of a fetus with congenital heart disease

Abnormal heart rate or rhythm

Fetal chromosomal anomaly

Extracardiac anomalyHydropsIncreased nuchal translucencyMonochorionic twins

Imaging technique Transverse view of the Upper abdomen

Four chamber view

Left ventricular outflow tract (LVOT)

Right ventricular outflow tract (RVOT)

Three vessel view (3 vessel-trachea view)http://www.tinytickers.org/content/5-view-details

Situs solitus

ISUOG practice guideline: sonographic screening examination of the fetal heart. Ultrasound Obstet Gynecol 2013; 41: 348-359

Four chamber view (FCV) Easy to obtain 2 types Subcostal Apical Detection rate 40-60%

What to document in FCVAxis

Position

Size pericardial effusion

2 atria roughly equal

2 ventricles roughly equal

Pulmonary venous connections

Morphology of the ventricles

AV connections

Axis - 12


Position

Size pericardial effusion





AV connections

LevocardiaDextrocardia Mesocardia


Position

Size

Pericardial effusion





AV connections


Position

Size

Pericardial effusion





AV connections

ISUOG practice guideline: sonographic screening examination of the fetal heart. Ultrasound Obstet Gynecol 2013; 41: 348-359

Is FCV a good screening tool of the fetal heart?

FCVOnly 40-60% of CHD can be diagnosed in FCVVarious studies report 15-60%

Why?Abnormalities of great vessels are not associated with chambers Tetralogy of Fallot (TOF)Transposition of great arteries (TGA)Truncus arteriosus Mild aortic stenosis Pulmonary atresia with VSD Pulmonary stenosis

Beyond four chamber view

Outflow tract Cephalad movement starting from FVC

Left ventricular outflow tract (LVOT)

Originates entirely from LV

Septo-aortic continuity

Free movement of the valves

No postvalvular dilatation

No regurgitation on Color Doppler

Right ventricular outflow tract (RVOT)Originates entirely from RV

Anterior and left of the aorta

Free movement of the valves

Bifurcation in two after its origin

Aorta is seen as a ring

No regurgitation on Color Doppler

3-vessel view

3-vessel view Very useful to assess great vessels

3 vessels Pulmonary arteryAortaSuperior vena cava (SVC)

Aligned in a straight line (from left anterior to the right posterior)

Sized in a decreasing order

3-vessel view

Additional views of the fetal heart Basal short-axis view

Oblique view through the right lobe of the liver and left shoulderDiscontinuity between tricuspid and pulmonary valves ( ) Bifurcation of PA

http://en.academic.ru/dic.nsf/enwiki/3769815

Additional views of the fetal heart Aortic arch view

From 3VV 90 rotation Candy cane

Aortic arch from the center of the heart

Ductal arch from the anterior chest wall


Congenital heart diseasesAtrial septal defects

Atrial septal defects Types of ASD:Ostium secundum (secundum ASD or fossa ovalis defect)

Most common (80% of all ASD)Located centrally in the atrial septum

Atrial septal defects 2. Ostium primum

Second most common type Usually associated with more complex congenital cardiac anomalies Located low in the atrial septumImmediately adjacent to the AV valves

Atrial septal defects 3. Sinus venosus Very rare5-10% of all ASDs 2 types Superior sinus venosus Just inferior to the orifice of the SVCBlood from SVC to both atria Anomalous right pulmonary vein drainage Inferior sinus venosus Adjacent location to the orifice of IVC

Atrial septal defects - Incidence1 in 1000 live births2:1 in female3rd most common CHDSecundum ASD cannot be diagnosed during fetal life

Atrial septal defects Sonographic criteria Larger-than-expected area of the foramen ovale

loose pocket

Thicker, relatively immobile septum secundum

Visualized optimally in subcostal FCV

Color Doppler helpful (but obscure small defects)

Atrial septal defects Sonographic criteria Primum ASD the absence of the lower portion of the atrial septum

Antenatal diagnosis of SV ASD not reported yet

Atrial septal defects Prognosis Depends on association with other cardiac or non-cardiac anomaliesIsolated ASD excellent prognosis

Associated anomalies:Holt Oram syndrome (ASD+upper limb deformities) 100%T13; T21; Triploidy; Turner syndrome and etc.,

Congenital heart diseasesVentricular septal defects

Ventricular septal defectsInterventricular septal regions: View from LVView from RV

The membranous septal region The muscular septal region Parietal band or distal conal septum

Ventricular septal defectsMost common CHDIsolated - 75-90% closure within the 1st year of life2 types of VSD:

Membranous defect (perimembranous)Muscular defect

Ventricular septal defects Membranous Commonly associated with other structural abnormalitiesUp to 80% of VSDsSmall membranous greater chance of spontaneous closure

Ventricular septal defects Muscular 10-15% of all VSDsVarious in sizeUsually multiple defects (Swiss cheese defects)Spontaneous closure commonRecurrence risk to the siblings 3%

Ventricular septal defects Sonographic criteria Color Doppler useful to diagnose (low velocity scale)

Best approach subcostal FCV

Apical FCV - T sign (not 100% reliable)

LVOT view

Membranous defect highest probability of detection

But high FFR and FNR

Ventricular septal defects Sonographic criteria

Ventricular septal defects - PrognosisDepends on the anatomy and the degree of hemodynamic changeSamanek et al., 1-month survival rate 92% 1-year survival rate 80% Kidd et al., 1993 - higher than normal incidence of serious arrhythmia and sudden death in small VSD

Congenital heart diseasesAtrioventricular septal defects

Atrioventricular septal defectsAbnormalities included interatrial and interventricular septum and AV valves (mitral and tricuspid)

Large septal defects in the center of the heart

Characterized by common annulus with abnormal arrangement of the valve leaflets

An unwedged position of the aortic valve

Short dimension of the ventricular inlet

Atrioventricular septal defectsAV valve consists of 5 leaflets Anterior bridging leaflet (ABL)Posterior bridging leaflet (PBL)Right lateral mural leaflet (RLM)Left lateral mural leaflet (LLM)Right anterior leaflet (RAL - between 1 and 3)

Atrioventricular septal defectsTypes of AVSD:Complete AVSDPartial AVSD

Levels of shunting:Interatrial and interventricular shunt (not attached atrial or ventricular septal crest)

Interatrial shunt (attached to the ventricular septal crest)

Atrioventricular septal defects - Incidence - 17% of all CHDsAssociated with a variety of syndromes and chromosomal anomalies40-80% of AVSD association with chromosomal anomaliesT21 40% AVSDMore often in females

Atrioventricular septal defects Sonographic criteria Best approach FCV (subcostal and apical)Complete AVSD easy to recognize and appears as wide opening within the center of the heart Crux (-)

Balanced; left-dominant; right dominant; (ABL attachment)

Atrioventricular septal defects Sonographic criteria Partial AVSDMay be difficult to diagnoseAV valves are presentApical FCVMore apical insertion of tricuspid valve lost

Atrioventricular septal defects Sonographic criteria Color Doppler Communication with other chambersElongation of LVOT goose neck

Atrioventricular septal defects -PrognosisIf not corrected death often occurs before 15 y.oIf other anomalies are associated death occurs in infancyLate death rare

Congenital heart diseasesHypoplastic left heart syndrome

Hypoplastic left heart syndrome

Hypoplastic left heart syndrome Underdevelopment of the left ventricle, mitral valve, aorta and aortic valveMost severe from of CHDsMost common cause of death from CHDs in the early neonatal period13% of all CHDsMore often in malesAlways lethal

Easily recognized in utero

Keep in mind it is progressive lesion!

May not manifest until late 2nd trimester!

Strong correlation with increased NT in the 1st trimester

FCV discrepancy of the ventricles, Extremely small LV

Important! recognition of LV (RV moderator band, tricuspid valve)

3VV, short-axis view atretic (more echoic) ascending aorta + enlarged PAHypoplastic left heart syndrome Sonographic criteria

Congenital heart diseasesTransposition of great arteries TGA

Transposition of great arteries

Transposition of great arteriesReversed connection of the ventricles and great arteriesDiscordant ventriculoarterial connection Aorta from RVPA from LV

Transposition of great arteries Sonographic criteriaRecognition of the chambers and great arteries Important Morphologic characteristics Sonographic diagnosis a challenge

Transposition of great arteries Sonographic criteriaComplete TGA

FCV completely normal chambers

3VV Triangular arrangementAAo: right and anterior malalignment

Transposition of great arteries Sonographic criteriaLVOT, RVOT views great vessels are parallel, not crossing AAo: Arises from RV and continues as the aortic arch and then descending aortaPA: from LV and branches into the left and right PA

Short-axis view two side-by-side circular structure (instead of PA wrapping around the circular aorta )

Transposition of great arteries

Transposition of great arteries Congenitally corrected TGA

L-loop ventricular relationship (morphologically)

Ao is in left anterior

RVOT Narrowing

In 60-70% of corrected TGA VSD (+)

Familiar face

Thank you for your attention

fetal echocardiography

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