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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 8