comprehensive first trimester cardiac assessment...
TRANSCRIPT
COMPREHENSIVE FIRST TRIMESTERCARDIAC ASSESSMENT
Reem S. Abu-Rustum, MD, FACOG, FACS, FAIUMCenter For Advanced Fetal Care
Tripoli - Lebanon
AIUM Annual Convention NYC 18 March 2016
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OBJECTIVES
Background
Why Early?
What Can We See?
Learning Curve
Guidelines & Data
Conclusions
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Background
Why Early?
What Can We See?
Learning Curve
Guidelines & Data
Conclusions
IT ALL STARTS WITH…
IT ALL STARTS WITH…… A HEARTBEAT
8w3d
CONGENITAL HEART DISEASE
Pentalogy of Cantrell
Hoffman et al. Am J Cardio 1978; 42:641Abuhamad & Chaoui. Practical Guide to Fetal Echocardiography: Normal and Abnormal Hearts. 2nd Edition
• Most common major abnormality
• Incidence: 8.8/1000 live births
• 30% with associated defects
• Contributes to >50% of congenital anomaly-related deaths in childhood
• Majority: no risk factors
• MUST screen the entire population
HOW GOOD ARE WE?
Tegnander et al. UOG 2006; 27:252
• Non-selected population in Norway
• 30149 fetuses
Detection Rate at
57%
HOW GOOD ARE WE?
Friedberg et al. J. Pediatr. 2009; 155:26
• Prospective 1 year study
• Northern California
• Fetuses and infants with CHD < 6 months
HOW GOOD ARE WE?
Friedberg et al. J. Pediatr. 2009; 155:26
HOW GOOD ARE WE?
CAN WE IMPROVEOUR DETECTION?
Hunter et al. Heart 2000; 84:294
Prenatal recognition of CHD rose from 17% in 1994 to 30% in 1995 and36% in 1996.
Conclusions—A simple training program for obstetric ultrasonographersincreased their ability to detect serious congenital heart disease at aroutine 18–20 week anomaly scan.
Background
Why Early?
What Can We See?
Learning Curve
Guidelines & Data
Conclusions
WHY DETECT EARLY?MAIN CONSIDERATIONS
• Workup• Options• TOP Limitations• Safety• Explain sudden IUFD• Natural progression• Psychological• Obstetrical care
• Early Reassurance
Courtesy of Prof. Nicolaides
De
ath
s /
10
0,0
00
ab
ort
ion
s
Abortions in the USA 1988-1997
Bartlett et al 2004
10 12 14 16 18 20
0
2
4
6
Gestation (wks)
0.5
4
Barlett et al. Obstet Gynecol 2004; 103:729
WHY DETECT EARLY?MAIN CONSIDERATIONS
Maiz et al. Prenatal Diagnosis 2016; ePub ahead of print.
GLOBAL IMPLEMENTATIONAS A RESULT OF
NT
Technical Advances
NIPT
CAx
GLOBAL IMPLEMENTATIONAS A RESULT OF
NT
Technical Advances
NIPT
CAx
Salveson et al. UOG 2011; 37:625
NT RISK OF CHD
2.5-3.4 x2
3.5-4.4 x4 (3% )
4.5-6.4 x6.5 (10%)
5.5-6.5 x14
> 6.5 x26 (20%)
Allan, Cook & Huggon. Fetal Echocardiography: A Practical Guide. 2009Hyett et al. UOG 1997; 10:242
NUCHAL TRANSLUCENCY
• Cardiac Abnormalities 5/1000 (0.5%)
• Diabetic Mom 10-15/1000 (1-1.5%)
• Previous Affected Child 20/1000 (2%)
• NT > 3.5 mm 50-70/1000 (5-7%)
Hyett et al.UOG 1997; 10:242Abuhamad & Chaoui. Practical Guide to Fetal Echocardiography: Normal and Abnormal Hearts. 2nd Edition
NUCHAL TRANSLUCENCY
Sotiriadis et al. UOG 2013; 42:383
Sotiriadis et al. UOG 2013; 42:383
GLOBAL IMPLEMENTATIONAS A RESULT OF
NT
Technical Advances
NIPT
CAx
WITH THETECHNOLOGICAL ADVANCES
Sinkovskaya et al. UOG 2012; 40:90
HD FLOW 13W1D
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SAo
RV
RALV
LA
3VVAo
PA
FO
3D VOLUME AT 13W2D
RS Abu-Rustum. A Practical Guide to 3D Ultrasound. CRC Press 2015
Votino et al. UOG 2013; 42:669
AIUM 2011
SAFETYIN THE FIRST TRIMESTER
ISUOG 2011
SAFETYIN THE FIRST TRIMESTER
GLOBAL IMPLEMENTATIONAS A RESULT OF
NT
Technical Advances
NIPT
CAx
WITH NIPT…
…A SHIFT IN THE ROLE OF NT
BEYOND SCREENING FOR ANEUPLOIDY
FULL ANATOMIC SURVEY
FULL ANATOMIC SURVEY
Genitalia
Bladder + 3VC
FULL ANATOMIC SURVEY
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INCLUDING THE FETAL HEART…
IVC
SVC
RA
DAo
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Larion et al. AJOG 2014: 65121
KEEPIN MIND…
Dolk et al. Adv Exp Med Biol. 2010; 686:349
PRIOR TO NIPT, CRITICAL TO RULE OUT
AND MAJOR CONGENITAL HEART DEFECTS
HLH 13w3d
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GLOBAL IMPLEMENTATIONAS A RESULT OF
NT
Technical Advances
NIPT
CAx
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THE FIRST TRIMESTER HEART
OFT
3VV
4CV
KEEPING IN MIND……THE DIFFICULTY
OFT4CV
AoA & DAoBicaval View
NT RISK OF CHD
2.5-3.4 x2
3.5-4.4 x4 (3% )
4.5-6.4 x6.5 (10%)
5.5-6.5 x14
> 6.5 x26 (20%)
Allan, Cook & Huggon. Fetal Echocardiography: A Practical Guide. 2009Hyett et al. UOG 1997; 10:242
NUCHAL TRANSLUCENCY
Sinkovskaya et al. UOG 2010; 36:676 Sinkovskaya et al. UOG 2014; 44:10
CARDIAC AXIS 30-60 FTS
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Sinkovskaya et al Obstet Gynecol 2015; 125: 453
Sinkovskaya et al Obstet Gynecol 2015; 125: 453
Sinkovskaya et al Obstet Gynecol 2015; 125: 453
Sinkovskaya et al Obstet Gynecol 2015; 125: 453
Background
Why Early?
What Can We See?
Learning Curve
Guidelines & Data
Conclusions
EARLIEST REPORTS
Gemburch et al. Obstet Gynecol 1990; 75:496
Achiron et al. J Ultrasound Med 1994; 13:783
12
14
20
MORE RECENTLY…
• Haak et al
UOG 2002; 20:9
Transvaginal 92%
• Huggon et al
UOG 2002; 20:22
Transabdominally 84%
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Haak et al. UOG 2002; 20:9
Transvaginal
Huggon et al. UOG 2002; 20:22
Transabdominal
DeVore. UOG 2002; 20:6
NEWEST TREND: CARDIAC IMAGING AT 11-14 WEEKS
KEEPING IN MIND…
12
14
20
Grain Rice Coin: 1 Euro
Allan, Cook & Huggon. Fetal Echocardiography: A Practical Guide. 2009
Key Points• Heart Develops GA 5-8 Weeks• Chest AP diameter is about 2.5 cm at 12-13 weeks
Can Assess• Position• Connections• Symmetry of 4 Chambers• 2 AV valves/Septum (Doppler)• Septoaortic Continuity• 2 Semilunar Valves (Doppler)• Normal Cross Over of Arteries
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CARDIAC IMAGING AT 11-14 WEEKS
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ANATOMIC LANDMARKS
• Right ventricle is the most anterior, below thesternum
• Left atrium is closest to the spine most centralstructure in the chest
• Aorta is just anterior to the left of the spine
• Tricuspid valve is more apical than mitral valve
• Flap of the foramen ovale in the left atrium
• Moderator band is in the right ventricle
• Apex formed by the left ventricle
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• Left atrium and aorta occupy the center of the chest
• Aorta points to the right shoulder as it exits then heads posteriorlytowards the spine
• Pulmonary artery (PA) points to the left shoulder as it exits
• Outflow tracts cross over, with the PA being more anterior than the left ventricular outflow tract
• Post bifurcation of the PA, the aorta and PA are almost parallel
ANATOMIC LANDMARKS
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SYSTEMIC EVALUATION TRANSVERSE VIEWS
ISUOG FE Guidelines 2013
SYSTEMIC EVALUATION SAGITTAL VIEWS
SYSTEMIC EVALUATION TRANSVERSE VIEWS
ISUOG FE Guidelines 2013
Abd Circ
Apex4CV
LVOT-Ao
RVOT-PA
3VV
Diagram Courtesy of Linda Daou, MD
SYSTEMIC EVALUATION TRANSVERSE VIEWS
Abd Circ
Apex4CV
LVOT-Ao
RVOT-PA
3VV
Diagram Courtesy of Linda Daou, MD
SYSTEMIC EVALUATION TRANSVERSE VIEWS
TV at 11w3d Using RIC 6-12
ESTABLISHING SITUS
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ESTABLISHING SITUS
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ESTABLISHINGSITUS
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4 CHAMBER VIEW
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TV at 11w2d Using RIC 6-12
4 CHAMBER VIEW
RALV
LA
RV
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Sinkovskaya et al. UOG 2010; 36:676
CARDIAC AXIS 30-60 FTS
TRICUSPID REGURGITATION
PULMONARY VEINS
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PULMONARY VEINS
TA at 13w1d Using Linear 9MHz Probe
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Abd Circ
Apex4CV
LVOT-Ao
RVOT-PA
3VV
Diagram Courtesy of Linda Daou, MD
SYSTEMIC EVALUATION TRANSVERSE VIEWS
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OUTFLOW TRACTS
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OUTFLOW TRACTS
OUTFLOW TRACTS
TA at 13w5d Using RMC/OB
RVOT LVOT
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CROSS OVER
Abd Circ
Apex4CV
LVOT-Ao
RVOT-PA
3VV
Diagram Courtesy of Linda Daou, MD
SYSTEMIC EVALUATION TRANSVERSE VIEWS
3 VESSEL VIEW
PA
AoSVC
DAo
DA
TV at 13w1d Using RIC 6-12
3 VESSEL VIEW
PAAo
SVC
DAoDA
TV at 9w5d Using RIC6-12
PA AoSVC
DAoDA
3 VESSEL VIEW
TA at 13w0d Using RM6C/OB
SYSTEMIC EVALUATION TRANSVERSE VIEWS
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TA at 13w2d Using RM6C/OB
SYSTEMIC EVALUATION TRANSVERSE VIEWS
SAo
RV
RALV
LA
3VVAo
PA
FO
3D VOLUME AT 13W2D
RS Abu-Rustum. A Practical Guide to 3D Ultrasound. CRC Press 2015
SYSTEMIC EVALUATION SAGITTAL VIEWS
IVC
SVC
RA
DAo
RIGHT ATRIAL INFLOW
TA at 12w6d Using RM6C/OB
RIGHT ATRIAL INFLOW
RIGHT ATRIAL INFLOW
TV at 13w1d Using RIC 6-12
RASVC
IVC
AORTIC ARCH & DESCENDING AORTA
TA at 13w2d Using RM6C/OB
AORTIC ARCH & DESCENDING AORTA
TV at 13w1d Using RIC 6-12
AORTIC ARCH & DESCENDING AORTA
DUCTAL ARCH
DUCTAL ARCH
AoA
DA
DUCTUS VENOSUS
ONCE WE RECOGNIZE NORMAL ANATOMY WE CAN IDENTIFY THE ABNORMALS
ONCE WE RECOGNIZE NORMAL ANATOMY WE CAN IDENTIFY THE ABNORMALS
Univentricle 12w2d
ONCE WE RECOGNIZE NORMAL ANATOMY WE CAN IDENTIFY THE ABNORMALS
AV Canal 13w5d
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Abu-Rustum, Ayoubi and Jani. UOG 2011; 38:190
Left CDH at 12w5d
ONCE WE RECOGNIZE NORMAL ANATOMY WE CAN IDENTIFY THE ABNORMALS
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THE LEBANESE CAx
CoA
TOF HLH AV Canal
VSDHLHCAx 82.02
CAx 78.05
CAx 84.98 CAx 65.90
CAx 85.60 CAx 13.15
Background
Why Early?
What Can We See?
Learning Curve
Guidelines & Data
Conclusions
MUST ACQUIRE SKILLIN THE SECOND TRIMESTER
24W5D21W5D
RS Abu-Rustum. A Practical Guide to 3D Ultrasound. CRC Press 2015
SYSTEMIC APPROACH18-22 WEEKS
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BEFORE MOVINGTO THE FIRST TRIMESTER
OFT4CV
AoA & DAoBicaval View
NOW WE GO TONORTH LEBANON
Abu-Rustum et al. JUM 2011; 30:695
4CV PV CODoppler of 4CV 3VV LVOT 3VVBPA RV Inflow
To assess the learning curve and factors influencingthe feasibility of carrying out a complete fetalcardiac evaluation at the time of the first trimesterscan.
OBJECTIVE
4CV PV CODoppler of 4CV 3VV LVOT 3VVBPA RV Inflow
•Prospective study•104 gravidas at 11w6d-13w6d•Maternal body mass index BMI•Fetal crown-rump length CRL•Transabdominal scans•Single sonologist•8 cardiac parameters•Average time: first to last cardiac image
METHODS
4CV PV CODoppler of 4CV 3VV LVOT 3VVBPA RV Inflow
CARDIAC PARAMETERS1. 4 Chamber view (4CV)2. Tricuspid regurgitation (TR)3. Outflow tracts cross over (CO)4. Bifurcating pulmonary artery (BPA)5. 3 Vessel view (3VV)6. Aortic arch sagitally (AoA)7. Bicaval view (RA Inflow)8. Doppler of the ductus venosus (DV)
METHODS
4CV PV CODoppler of 4CV 3VV LVOT 3VVBPA RV Inflow
Data Analysis•Chi square•ANOVA•Scatter plot•Polynomial curve fitting•P < 0.05
METHODS
4CV PV CODoppler of 4CV 3VV LVOT 3VVBPA RV Inflow
•103/104 Fetuses evaluated•Median CRL 72.1 mm (range 53.9-85.8 mm)•Median BMI was 23 kg/m2 (range 17.7-32.3 kg/m2)•A complete exam was feasible in 55% of cases•A complete exam was feasible in 15% of the first 52 cases•A complete exam was feasible in 94% of the last 51 cases
RESULTS
4CV PV CODoppler of 4CV 3VV LVOT 3VVBPA RV Inflow
Cardiac View Successful Visualization
4 Chamber View 100 %
Tricuspid Regurgitation 100 %
Outflow Tract Cross Over 90 %
Bifurcation Pulmonary Artery 81 %
3 Vessel View 55 %
Venae Cavae 65 %
Aortic Arch 76 %
Ductus Venosus 99 %
RESULTS
1st period[Case 1-21]
2nd period[Case 22-52]
3rd period[Case 53-103] p-value
#Views out of 8 4.76 (59.5%) 6.0 (75%) 7.89 (98.6%) 0.0001
Average Time (sec) 262.4 (4.37 m) 429.3 (7.13m) 560.1 (9.3m) 0.032
BMI 24.08 24.0 23.5 0.752
CRL 72.2 72.7 72.1 0.899
4CV PV CODoppler of 4CV 3VV LVOT 3VVBPA RV Inflow
RESULTS
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10
20
30
40
50
60
70
80
90
100
0 20 40 60 80 100 120
Number of cases
Perc
en
tag
e o
f fi
nd
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s
.
Case Number
% C
om
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te E
xam
4CV PV CODoppler of 4CV 3VV LVOT 3VVBPA RV Inflow
RESULTS
AV Canal
HRH
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CONCLUSION
• Fetal cardiac evaluation is feasible in the first trimester
• At least 52 exams and an average time of 10 minutesneeded
• Time allocation and gained sonographer experienceare the most significant factors
TECHNICAL/PERSONALLIMITATIONS
Training
Machinery
Maternal Body Habitus
Developmental Stage
Time Consuming
Undue
Anxiety
Greatest challenge is the LOW RISK PATIENT!
Background
Why Early?
What Can We See?
Learning Curve
Guidelines & Data
Conclusions
AIUM 2013 GUIDELINESACOG, ASE & SMFM
ENDORSED BY ACR
ISUOG 2013 GUIDELINES
Carvalho. PD 2004; 24:1060
Rossi et al. AJOG 2013; 122:1160
Rossi et al. AJOG 2013; 122:1160
Background
Why Early?
What Can We See?
Learning Curve
Guidelines & Data
Conclusions
CONCLUSIVE PEARLS
Comfort in the Second Trimester
Commence with Low BMI Patients
Employ Magnification
Use Doppler (HDF) but Adhere to Safety
Concerns
Utilize Various Probes/Routes
Practice & Patience
CONCLUSION
• First trimester fetal cardiac imaging is feasible
• Powerful tool for early reassurance
• Does not replace second trimester echocardiography
• Consultation with Pediatric Cardiology is a MUST
• Though there are no current guidelines, its
incorporation into clinical practice is inevitable
• The future has unlimited potential
• The time to start is NOW
• Practice, PATIENCE and a ready mind make perfect
IS IT TIME FOR FIRST TRIMESTER GUIDELINES?
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IT ALL ENDS WITH……A HEARTBEAT
12w4d
…The Future is so Incredibly Bright
THANK YOU!
Adapted from ‘A Practical Guide to 3D Ultrasound’. RS Abu-Rustum. CRC Press 2015