powerpoint presentationjeffline.jefferson.edu/jurei/conference/pdfs/obgyn... · a practical guide...

4/5/2019

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A SYSTEMATIC APPROACH TO EVALUATING THE FETAL HEART

Reem S. Abu-Rustum, MD, FACOG, FACS, FAIUMDept. of Ob/Gyn, Division of MFM, University of Florida

• I have no disclosures

DISCLOSURES

By the end of this lecture the viewer should be able to describe:

• The scope of the problem of CHD

• A systematic approach to evaluating the fetal heart

• The role of the 4CV and the 3VV

• Future direction of screening for CHD

LEARNING OBJECTIVES

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L

AROUND THE FETAL HEARTIN 4O MINUTES…

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Introduction

Anatomy of the Scene

4-Chamber View

3-Vessel View

Future Direction

Conclusion

OBJECTIVES

Introduction


4-Chamber View

3-Vessel View

Future Direction

Conclusion

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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

90% of infants with cardiac defects are born to moms without risk factors

, MUST screen the general population

In a systematic mannerAdhering to GUIDELINES

HOWEVER

HOW GOOD ARE WE?

• Non-selected population in Norway

• 30149 fetuses

Detection Rate at57%

HOW GOOD ARE WE?

Abu-Rustums, Daou

MORE RECENTLY…

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PROPER TRAINING

Hunter 2000 Heart 84: 294-298

Prenatal recognition of CHD rose from 17% in 1994 to 30% in1995 and 36% in 1996.

Conclusions - A simple training program for obstetricultrasonographers increased their ability to detect seriouscongenital heart disease at a routine 18 - 20 week anomaly scan.

Hunter 2000 Heart 84: 294-298

• We see the patients

• We all have US machines• We have the ability to screen• The revolution of the NT

• CAx at 11-14 weeks• We have pediatric cardiology expertise

Screen: Recognize the High Risk & AbnormalREFER

THE ROLE OF THE OBSTETRICIAN

AIUM 2013 GUIDELINES ACOG,ASE & SMFM ENDORSED BY ACR

ISUOG 2013 GUIDELINES ISUOG 2013 GUIDELINES

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AHA 2014 GUIDELINES WHAT ARE WE DOING WRONG?

Sklansky & DeVore. JUM 2016; 35:679-681.

WHAT ARE WE DOING WRONG?

Introduction


4-Chamber View

3-Vessel View

Future Direction

Conclusion

ISUOG 2013 GUIDELINES

Abd Circ

Apex4CV

LVOT-Ao

RVOT-PA

3VTV

Diagram Courtesy of Linda Daou, MD

SYSTEMIC EVALUATION TRANSVERSE VIEWS

ISUOG 2013

FE Guidelines

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Ao

MBTV

MV

4CV

Adapted from "A Practical Guide to 3D Ultrasound". RS Abu-Rustum. CRC Press 2015

• Easy view to obtain

• No specialized skill needed

• Obtainable in all fetal positions

• Rules out 60% CHD

• Easy slide up from AC with full rib

• Starting point for the sweep

L

R

Pathological image adapted from Abuhamad & Chaoui. A Practical Guide to Fetal Echocardiography: Normal and Abnormal Hearts. 3rd Edition

WHY THE 4CV?

4CV

R

L• Sits to the left of the chest

• Area 1/3 chest

• Circumference ½ chest

Pathological image adapted from Abuhamad & Chaoui.A Practical Guide to Fetal Echocardiography: Normal and Abnormal Hearts. 3rd Edition

LR

• Right ventricle is the most

anterior, below the sternum

• Left atrium is closest to the

spine and the most central

structure in the chest

• Tricuspid valve is more apical

than the mitral valve

• Flap of the foramen ovale is in

the left atrium

• Moderator band is in the right

ventricle

ANATOMIC LANDMARKS

• Aorta is just anterior

to the spine and to the left

• Pulmonary veins enter the LA

• Azygous vein

AREA BEHIND THE HEART 2D CINE

S

L

R

Ao

Sp

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HOW CAN WE CARRY OUT A GOOD CARDIAC EXAM?

SYSTEMATICALLY…

Check it systematically

• Size

• Position

• Structure

• Function

Analyze it while seeing the crux

of the heart

• If too posterior coronary sinus

• If too anterior outflow tracts

RS Abu-Rustum. A Practical Guide to 3D Ultrasound. CRC Press 2015

L R

CS

L

R

4 CHAMBER VIEWUSING 4D INVERSION MODE

LVRV

PA

Ao

ANTERIOR TO THE 4 CHAMBER VIEWUSING 4D INVERSION MODE WITH HDlive

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RVLV

PA

LVOT

Practical Guide to 3D Ultrasound. CRC Press 2015

VENTRICLES RIGHT VENTRICLE

Right Ventricle• Anterior • Heavily trabeculated• Moderator Band• Inlet and outlet at different levels

R L

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Left Ventricle• Posterior • Smooth walled • Conical shaped• Forms the apex• Single leveled

LEFT VENTRICLE

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INTERVENTRICULAR SEPTUM

• 2/3 Muscular

• 1/3 Membranous

• True positives versus false positives

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L

BEWARE……FALSE POSITIVE SHADOW DROPOUT

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L


R L


R

L

ATRIA

Schematic adapted from Rychik & Tian. Fetal Cardiovascular Imaging. Elsevier 2012

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CS

RRL

RIGHT ATRIUM

Right Atrium• Anterior • Vena cavae• Coronary sinus• Eustachian valve• Pyramidal appendage

RLL

R

L

LEFT ATRIUM

Left Atrium• Posterior• Center of chest• Pulmonary veins (inferior)• Foramen Ovale leaflet• Coumadin Ridge• Finger-like appendage

RL

LEFT ATRIUMPULMONARY VEINS

PV

PV

LA

R

L

LEFT ATRIUMCLUES

L

R

pvAo

FORAMEN OVALE FORAMEN OVALE

R

L

L

R

L

R

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INTERATRIAL SEPTUM ATRIOVENTRICULAR VALVES

Tricuspid Valve• 3 Leaflets • 3 Papillary muscles • Attaches to septum & wall• Septal leaflet more apical• Always attaches to RV

R

L

ATRIOVENTRICULAR VALVES

Mitral Valve

• 2 Leaflets • 2 Papillary muscles• Attaches to the wall only• Always connects to LV

R

L



Systole

Diastole


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AREA BEHINDTHE HEART

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L

AREA BEHINDTHE HEART

ASSESSING HEART FUNCTION

• Ventricles contract equally andbriskly

• AV valves open equally and freely

• Equal filling

• No significant AV regurgitation

• Synchronous contraction

• FHR 120-160

• Minimal pericardial effusion isnormal

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L

DON’T FORGET TOUSE COLOR DOPPLER

R

L

Abd Circ

Apex4CV

LVOT-Ao

RVOT-PA

3VTV


ISUOG 2013

FE Guidelines


BEYOND THE 4CV27 SEC SWEEP

LVOT

3VV

RV LV

RVOT

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L

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• Left atrium and aorta occupythe center of the chest

• Aorta points to the rightshoulder as it exits then headsposteriorly towards the spine

• Pulmonary artery (PA) pointsto the left shoulder as it exits

OUTFLOW TRACTS

RL

R

L

Practical Guide to Fetal Echocardiography: Normal and Abnormal Hearts: Abuhamad and Chaoui 2009

• Outflow tracts cross over

• PA more anterior than theLVOT

• Post bifurcation of the PA,they are almost parallel

ANATOMIC LANDMARKS

LVRV

PAAo

L

R

RV

Ao

LV

Ao

LVOT LVOT

R

LRV

LV

Ao

L

R

RVOT

RVOT

Ao

RBPA

AoLBPA SVC

R

L

66

RV

RALV

LA

Ao

TV

MV

HOW GOOD IS THEFOUR CHAMBER VIEW?


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FOUR CHAMBER VIEW: SENSITIVITY

Abu-Rustums, Daou

*

*

Adapted from Abuhamad & Chaoui. Practical Guide to Fetal Echocardiography: Normal and Abnormal Hearts. 2ndnd Edition

FOUR CHAMBER VIEW: SENSITIVITY

Abu-Rustums, Daou

Schematic adapted from Paladini & Volpe. Ultrasound of Congenital Fetal Anomalies. 2nd Edition

• Mitral/aortic atresia• Tricuspid/pulmonary atresia• Epsteins/dysplastic tricuspid valve• AV Canal• Large VSD• Single Ventricle• Severe PS/AS• Severe CoA• TAPVR• Cardiomyopathy/tumor• Clue to other structural abnormalities

FOUR CHAMBER VIEW: TRUE POSITIVES

Abu-Rustums, Daou

MV

Sp

L

MITRAL ATRESIA

R

Abu-Rustums, Daou



Abu-Rustums, Daou

LR


TRICUSPID ATRESIA

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Abu-Rustums, Daou TVL RTV

L R

DYSPLASTIC TRICUSPID VALVE

Abu-Rustums, Daou



Abu-Rustums, Daou

R

L

Loss of Off-Set

Abu-Rustums, Daou

ATRIOVENTRICULAR SEPTAL DEFECT

Schematic adapted from Rychik & Tian. Fetal Cardiovascular Imaging. Elsevier 2012



Abu-Rustums, Daou

VSD

R

L


VENTRICULAR SEPTAL DEFECT


VSD

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Abu-Rustums, Daou Abu-Rustums, Daou

UNIVENTRICLE



Abu-Rustums, Daou

RL

AORTIC STENOSIS



Abu-Rustums, Daou

LV

COARCTATION OF THE AORTA

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L

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Abu-Rustums, Daou

Images adapted from Mahmoud et al. ePoster AIUM Annual Convention 2016.Schematics adapted from Abuhamad & Chaoui. A Practical Guide to Fetal Echocardiography: Normal and Abnormal Hearts. 3rd Edition

CV

pv

pv

pvpv

L

R

L

R

TAPVR

POST LA SPACE

L

R



Abu-Rustums, Daou


RHABDOMYOMAS

L

R



Abu-Rustums, Daou


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AoAz

LEFT ATRIAL ISOMERISM

R

L

H

S

Loss Off-SetR

L

H S

LEFT CONGENITAL DIAPHRAGMATIC HERNIA

Abu-Rustums, Daou

RESTRICTIVE FORAMEN OVALE

L

R

pvAo

L

R

LSVC

LEFT PERSISTENT SUPERIOR VENA CAVA

False Negatives• Tetralogy of Fallot• Transposition of great vessels• Double outlet RV• Small VSD• Common Arterial Trunk• Mild semilunar valve stenosis• Aortic arch abnormalities

FOUR CHAMBER VIEW: FALSE NEGATIVES

R L

Abu-Rustums, Daou

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EXTENDED BASIC CARDIAC EXAM: SENSITIVITY

Basic Exam Extended Exam

Bromley 1992 63% 83%

Kirk 1994 47% 78%

98

THERE’S A LOT MOREBEYOND THE 4CV…

S


Introduction


4-Chamber View

3-Vessel Trachea View

Future Direction

Conclusion

Abd Circ

Apex4CV

LVOT-Ao

RVOT-PA

3VTV


ISUOG 2013

FE Guidelines


3VT

Schematic Adapted from Abuhamad & Chaoui. Practical Guide to Fetal Echocardiography: Normal and Abnormal Hearts. 3rdnd Edition

SVC

T

PA

Ao

R

L

3VT

SVCT

PA

Ao

L

R


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PAAo

SVC

DAoDA

3VT


RL

3VT


SVC

R

PAAo L

L

3-VESSEL VIEW

WHY 3VV/3VT VIEW?

R

L

R

L

R

L

R

L

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WHY 3VV/3VT VIEW?

• Easy view to obtain

• No specialized skill needed

• Obtainable at all gestations

• Rules out majority of OFT

• Visualization of both arches

• Helpful in early gestation/high BMI

R

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ANATOMIC LANDMARKS


R

L

ANATOMIC LANDMARKS

R

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CLUES OF 3VT VIEW

• Size

• Alignment (Flow)

• Arrangement (Trachea)

• Number

R

L

• Size



• Number

R

L

CLUES OF 3VT VIEW

• Size



• Number

Sp

Sp

CLUES OF 3VT VIEW

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• Size



• Number

R

L

CLUES OF 3VT VIEW

• Size



• Number

R

L

12 3

CLUES OF 3VT VIEW

L

NORMAL 3-VESSEL VIEWABNORMAL SIZE

CASE 1

R

L

CASE 123W5D

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L

CASE 123W5D

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L

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CASE 123W5D

TETRALOGY OF

FALLOT

CASE 228W3D

R

L

R

L

CASE 228W3D

CASE 232W5D

AORTIC

COARCTATION

3-VESSEL VIEWABNORMAL ARRANGEMENT

R

L

CASE 323W2D

R

L

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CASE 323W2D

R L

PAAo

PA

Ao

CASE 323W2D

T

T

R

L

CASE 323W2D

CASE 323W2D

RIGHT SIDED AoA

CASE 422W5D

1 2

R

L

CASE 422W5D

R

L

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CASE 422W5D

A B

Loss of normal off-setASD and VSD and HRV

CAT

Right

Left

S

HRV


CASE 422W5D

COMMONT

ARTERIAL TRUNK

CASE 530W1D

1

2

3

4

R

L

CASE 530W1D

CASE 530W1D

PERSISTENT LSVC

R

L

1

2

3

4

CASE 530W1D

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Introduction


4-Chamber View

3-Vessel View

Future Direction

Conclusion

THE FUTURE TODAY?

NEWEST TREND: CARDIAC IMAGING AT 11-14 WEEKS

DeVore 2002, Haak 2002, Huggon 2002, Carvalho 2004, Lombardi 2007

142


CARDIAC IMAGING AT 11-14 WEEKS

KEEPING IN MIND…

12

14

20

Grain Rice Coin: 1 Euro

EVALUATINGTHE FIRST TRIMESTER HEART…

IVCSVC

RA

DAo

RL

RL

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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. 2009

Hyett 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; 10:242

Abuhamad & Chaoui. Practical Guide to Fetal Echocardiography: Normal and Abnormal Hearts. 2nd Edition

NUCHAL TRANSLUCENCY CARDIAC AXIS 30-60 FTS

R

L

Sinkovskaya et al. UOG 2010; 36:676 Sinkovskaya et al. UOG 2014; 44:10

Sinkovskaya et al Obstet Gynecol 2015; 125: 453 Sinkovskaya et al Obstet Gynecol 2015; 125: 453

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Sinkovskaya et al Obstet Gynecol 2015; 125: 453 Sinkovskaya et al Obstet Gynecol 2015; 125: 453

153

AoA

IVC

DAo

SVC

RA

STIC/TUI


SAo

RV

RALV

LA

3VVAo

PA

FO


3D VOLUME AT 13W2D

ABUHAMAD’S AUTOMATION

• Acquired volume of a structure contains all the anatomical 2D planes for a complete evaluation of this structure

• For every organ, 2D anatomical planes that are needed for a complete evaluation are organized in a constant anatomic relationship to each other.

J Ultrasound Med 2005 24: 397 J Ultrasound Med 2007 26: 501UOG 2008 31: 30

155

Courtesy of Prof. AZ Abuhamad, MD

MAIN CONCEPT

Computerized program to automatically display all2D planes that are required for a complete evaluation

of this particular organ.

Obtain a volume of an organ

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Introduction


4-Chamber View

3-Vessel View

Future Direction

Conclusion

CONCLUSION

• Screen the entire population

• Go beyond the 4CV

• 3VT critical

• Learn to identify the normal heart

• RECOGNIZE the abnormal heart

• Referral and preparation improves outcome

• The future has unlimited potential

THANK YOU…

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