fetal echocardiography
TRANSCRIPT
Fetal echocardiography
Kh. Batnasan
United Family Intermed Hospital
Ulaanbaatar, Mongolia
Contents
1. Introduction
2. Indications and imaging technique
3. Congenital heart diseases (CHD)
Contents
1. Introduction
2. Indications and imaging technique
3. Congenital heart diseases (CHD)
Introduction
Why do we need to check fetal heart?
1. High incidence• 4-13 in 1000 live births (in Mongolia: 8-10 in 1000 live births)
• All mild lesions – 75-80/1000 live births
2. Frequent association with other noncardiac and chromosomal anomalies • CHD 8-42% - extracardiac
• More than 50% with chromosomal anomalies – CHD (+)
Introduction – Cont’d
3. Increased neonatal and childhood morbidity and mortality• Almost one quarters of infant deaths – CHD• CHD – 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 route• Referral to tertiary center• Requirement of urgent postnatal intervention
Contents
1. Introduction
2. Indications and imaging technique
3. Congenital heart diseases (CHD)
Indications
Maternal 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 anomaly
• Hydrops
• Increased nuchal translucency
• Monochorionic twins
Imaging technique
1. Transverse view of the Upper abdomen
2. Four chamber view
3. Left ventricular outflow tract (LVOT)
4. Right ventricular outflow tract (RVOT)
5. 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 FCV
• Axis
• Position
• Size pericardial effusion
• 2 atria roughly equal
• 2 ventricles roughly equal
• Pulmonary venous connections
• Morphology of the ventricles
• AV connections
What to document in FCV
• Axis
• Position
• Size pericardial effusion
• 2 atria roughly equal
• 2 ventricles roughly equal
• Pulmonary venous connections
• Morphology of the ventricles
• AV connections
• Levocardia
• Dextrocardia
• Mesocardia
What to document in FCV• Axis
• Position
• Size
• Pericardial effusion
• 2 atria roughly equal
• 2 ventricles roughly equal
• Pulmonary venous connections
• Morphology of the ventricles
• AV connections
What to document in FCV• Axis
• Position
• Size
• Pericardial effusion
• 2 atria roughly equal
• 2 ventricles roughly equal
• Pulmonary venous connections
• Morphology of the ventricles
• 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?
FCV
• Only 40-60% of CHD can be diagnosed in FCV
• Various 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
• Cephaladmovement 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 artery• Aorta• Superior 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 shoulder
• Discontinuity 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
Contents
1. Introduction
2. Indications and imaging technique
3. Congenital heart diseases (CHD)
Congenital heart diseasesAtrial septal defects
Atrial septal defects
Types of ASD:
1. Ostium secundum (secundumASD 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 septum
• Immediately adjacent to the AV valves
Atrial septal defects
3. Sinus venosus
• Very rare
• 5-10% of all ASDs
• 2 types
• Superior sinus venosus• Just inferior to the orifice of the SVC• Blood from SVC to both atria • Anomalous right pulmonary vein
drainage
• Inferior sinus venosus• Adjacent location to the orifice of
IVC
Atrial septal defects - Incidence
• 1 in 1000 live births
• 2:1 in female
• 3rd most common CHD
• Secundum 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 anomalies
• Isolated 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 defects
Interventricular septal regions:
A. View from LV
B. View from RV
1. The membranous septal region
2. The muscular septal region
3. Parietal band or distal conalseptum
Ventricular septal defects
• Most common CHD
• Isolated - 75-90% closure within the 1st year of life
• 2 types of VSD:
• Membranous defect (perimembranous)
• Muscular defect
Ventricular septal defects – Membranous
• Commonly associated with other structural abnormalities
• Up to 80% of VSDs
• Small membranous – greater chance of spontaneous closure
Ventricular septal defects – Muscular
• 10-15% of all VSDs
• Various in size
• Usually multiple defects (“Swiss cheese defects”)
• Spontaneous closure common
• Recurrence 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 - Prognosis
• Depends on the anatomy and the degree of hemodynamic change
• Samanek 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 defects
• Abnormalities 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 defects
AV valve consists of 5 leaflets
1. Anterior bridging leaflet (ABL)
2. Posterior bridging leaflet (PBL)
3. Right lateral mural leaflet (RLM)
4. Left lateral mural leaflet (LLM)
5. Right anterior leaflet (RAL -between 1 and 3)
Atrioventricular septal defects
Types of AVSD:• Complete AVSD
• Partial 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 CHDs
• Associated with a variety of syndromes and chromosomal anomalies
• 40-80% of AVSD – association with chromosomal anomalies
• T21 – 40% AVSD
• More 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 AVSD
• May be difficult to diagnose
• AV valves are present
• Apical FCV
• More apical insertion of tricuspid valve – lost
Atrioventricular septal defects – Sonographic criteria
• Color Doppler – Communication with other chambers
• Elongation of LVOT – “ goose neck”
Atrioventricular septal defects -Prognosis
• If not corrected – death often occurs before 15 y.o
• If other anomalies are associated – death occurs in infancy
• Late 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 valve
• Most severe from of CHDs
• Most common cause of death from CHDs in the early neonatal period
• 13% of all CHDs
• More often in males
• Always 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 PA
Hypoplastic left heart syndrome – Sonographic criteria
Congenital heart diseasesTransposition of great arteries TGA
Transposition of great arteries
Transposition of great arteries
• Reversed connection of the ventricles and great arteries
• Discordant ventriculoarterial connection
• Aorta from RV
• PA – from LV
Transposition of great arteries – Sonographic criteria
• Recognition of the chambers and great arteries
• Important – Morphologic characteristics
• Sonographic diagnosis – a challenge
•
Transposition of great arteries – Sonographic criteria
Complete TGA
• FCV – completely normal chambers
• 3VV –• Triangular arrangement
• AAo: right and anterior malalignment
Transposition of great arteries – Sonographic criteria
• LVOT, RVOT views – great vessels are parallel, not crossing • AAo: Arises from RV and
continues as the aortic arch and then descending aorta
• PA: 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