Download The Fetal Heart: Beyond the 4

The Fetal Heart:
Beyond the 4-Chamber View
What do these patients have in common?
MICHAEL WALSH, MD
PEDIATRIC
AND FETAL
CARDIOLOGY
26 SEPTEMBER 2012
y Normal 4-chamber views
When a 4-chamber isn’t good enough
Goals
y Why fetal echo makes a difference
y Normal fetal circulation
y The
Th ffetall echocardiogram
h
di
–
(beyond the 4-chamber)
Normal
Transposition of
the Great Arteries
Tetralogy of Fallot
Definition
Fetal echocardiography
A detailed sonographic evaluation that is used to
identify and characterize fetal heart anomalies and
malfunctions before delivery
“Basic” fetal cardiac screening
“Extended basic” cardiac screening
1
Know the Adversary
Making a Difference
Congenital Heart Disease
y Improved pre-operative stability
{ Ductal-dependent
lesions
y Neurodevelopmental
N
d l
t l outcomes
t
y Parental understanding
y Societal cost benefits
y Overall mortality???
y Most
M t common congenital
it l anomaly
l
y A leading cause of infant mortality and morbidity
y Often occurs in low-risk pregnancy
1 Landis et al.,New York, 2011
2 Caldeon et al., Paris 2012
3 Williams et al., Columbia (NY) 2008
4 Jegatheeswaran et al., Toronto, 2011
Indications for Fetal Echo
Indications for Fetal Echo
Fetal Indications
Fetal Indications
Maternal Indications
y Abnormal screening U/S
y Abnormal screening U/S
y Family history of CHD
y Chromosomal
y Chromosomal
y Teratogen exposure
y
y
y
y
y
abnormality
b
lit
Arrhythmia
Extra-cardiac anomaly
Hydrops
Increased 1st trimester NT
Concern for twin-twin
The Fetal Echocardiogram
y Timing of Study
{ “optimally”
between 18-22 weeks
{ Earliest 4 chamber view:14-15 weeks (EFCI)
{ Transvaginal: 10-14 weeks
{ Beyond 32-34 weeks: ratio of amniotic fluid to
fetal size decreases Æ decr. image quality
y
y
y
y
y
abnormality
b
lit
Arrhythmia
Extra-cardiac anomaly
Hydrops
Increased 1st trimester NT
Concern for twin-twin
{
Al h l AED
Alcohol,
y Metabolic disorders
{
Diabetes, PKU
y In vitro fertilization
y Autoimmune dz
y Inheritable disorders
{
Marfan’s, Noonan’s
What Types of Defects Can We See?
y Septal
y Endocardial cushion
y Right-sided obstruction
y Left-sided
f id d obstruction
b
i
y Conotruncal
y Single ventricle
y Complex
2
Goals of fetal circulation
1.
Preferential streaming of oxygenated blood to
the myocardium and brain
¾
O2 rich blood received in the RA via the DV,
not the LA from the pulm veins
Eustachian value
Ductus venosus
2.
Recycling of blood through the placenta (via
the DAO) for re-oxygenation
¾
low resistance
Umbilical vein
carrying fully
saturated blood
i.e. blue blood to the placenta
lower body
placenta
The Fetal Echocardiogram
Distribution of
combined CO
7%
y Fetal position
{Left
66%
34%
vs. Right
y Abdominal situs
y Cardiac position
y Fetal biometry
placenta
It’s not always normal
Right-sided stomach, left-sided heart
Fetal Echo Protocol
y Obtain a 2D AND color flow in 4 major imaging views
y Transverse views (short axis of the BABY):
{ 4-chamber
{ 5-chamber
{ 3-vessel view
y Arches (long axis of the BABY)
{ Ductal arch
{ Aortic arch
{ Bi-caval view
y Short-axis of the HEART
{ Great Arteries
{ Ventricles
y Long-axis of the HEART
{ LVOT
{ RVOT
3
Transverse Imaging Planes
Transverse Imaging Planes
Three
vessel
view
LVOT
RVOT
4chamber
Espinoza J, Gotsch F, Kusanovic JP, et al. J Ultrasound Med 2007;26:437–443
Espinoza J, Gotsch F, Kusanovic JP, et al. J Ultrasound Med 2007;26:437–443
4-chamber
Espinoza J, Gotsch F, Kusanovic JP, et al. J Ultrasound Med 2007;26:437–443
4-chamber color
Espinoza J, Gotsch F, Kusanovic JP, et al. J Ultrasound Med 2007;26:437–443
Outflow tracts
Normal Outflow Tracts?
LVOT
LVOT
RVOT
Espinoza J, Gotsch F, Kusanovic JP, et al. J Ultrasound Med 2007;26:437–443
RVOT
Espinoza J, Gotsch F, Kusanovic JP, et al. J Ultrasound Med 2007;26:437–443
4
Three vessel view
Three vessel view
Three
vessel
view
RVOT
Espinoza J, Gotsch F, Kusanovic JP, et al. J Ultrasound Med 2007;26:437–443
Three vessel view
Espinoza J, Gotsch F, Kusanovic JP, et al. J Ultrasound Med 2007;26:437–443
Long-axis of the BABY
Bi-caval view
Espinoza J, Gotsch F, Kusanovic JP, et al. J Ultrasound Med 2007;26:437–443
The Arches
Espinoza J, Gotsch F, Kusanovic JP, et al. J Ultrasound Med 2007;26:437–443
Bicaval View
Espinoza J, Gotsch F, Kusanovic JP, et al. J Ultrasound Med 2007;26:437–443
5
Aortic Arch
Aortic Arch Color
Ductal Arch
Aortic Arch Hypoplasia
Aortic Arch Hypoplasia
The Short Axis Views
Basal
Apical
Espinoza J, Gotsch F, Kusanovic JP, et al. J Ultrasound Med 2007;26:437–443
6
The Short-Axis
Short-Axis Color
Long axis of the HEART
Long Axis View
Long Axis Color
Long Axis Pathology
7
Measurements
Doppler Investigation
y Atrioventricular valve diameters
y AV valve inflow
y Ductus arteriosus
y Semilunar valve diameters
y Aortic outflow
y Aortic arch
y Ascending aorta
y Pulmonary outflow
y Umbilical artery
y Transverse aortic arch
y Pulmonary veins
y Umbilical vein
y MPA and branches
y Patent foramen
y MCA
ovale
y Ductus venosus
Parameter(z): www.parameterz.com
Ultrasound Safety During Pregnancy
WFU Fetal Heart Program
y Ultrasound energy expenditure can be high
y Mike Quartermain, MD – Director
y No confirmed harmful effects from ultrasound
y Cheryl Cammock, MD
y Theoretical risks:
{ Mechanical energy – cavitation (MI)
{ Thermal energy (TIS/TIB)
y Mike Walsh, MD
y Jackie Sledge,
g , RCDS – Senior fetal sonographer
g p
y Sherry McNeil, RN, RCDS – Fetal Heart Program
Nurse Coordinator
y ALARA – As low as reasonably achievable
Summary
y Congenital heart disease is most common congenital
anomaly
y Prenatal diagnosis improves outcomes
y Enhanced imaging from a greater number of views
will lead to more pick-ups
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