basic fetal echocardiography
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FETAL ECHOCARDIOGRAPHY:Basics You Need To Know
JONAS D. DEL ROSARIO, MD, FPPS, FPCC
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What is this?
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Congenital Heart Disease
8 per 1000 live birth (3 in 1000 is critical)
True incidence is higher in the fetus (abortuses and stillborns) --- as high as 5x
Intrauterine cardiac malformations are associated with a high incidence of infant mortality and fetal wastage
Most common congenital malformation
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Fetal Echocardiography
With the advent of ultrasound and the recent application of echocardiography to the human fetal heart, prenatal diagnosis and management of cardiac problems has become possible
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Importance of ID of Heart Disease in Utero
Delivery at an appropriate facility
In utero therapy (arrhythmia, hydrops)
Reassurance for both mom and physician in the setting of an increased risk factor
Termination in some countries
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Heart Defects Which Need INTERVENTION in the Perinatal Period
Arrrhythmia (SVT/Complete Heart Block)
Ductal-dependent lesions (HLHS, PA)
Myocardial dysfunction
EASILY DIAGNOSED WITH A DETAILED FETAL ECHO
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When is the ideal time?
Fetal heart is most easily examined transabdominally at 18-24 weeks of gestation
Non-fixed fetal position
Incompletely calcified bones
Abundant amniotic fluid
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20-week Fetal Heart
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Indications for FETAL ECHO
Fetal Risks Familial Risks Maternal Risks
CHD Suspect (4C) CHD, parent CHD
Chromosomal Abn CHD, prior child Metabolic D/O
Extracardiac Defcts Mendelian Syn Teratogen Exp
Arrhythmia
Hydrops (Non-imm)
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Technique
Transducer range 3-7 MHz
Segmental examination of the heart and great vessels
4 CHAMBER AND OUTFLOW TRACTS Views
Use of M-mode, 2 D, Pulsed and Color Flow Doppler
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The accuracy is also very much dependent on the SONOGRAPHER’sknowledge and experience.
Understanding of the cardiac anatomy and physiology is mandatory.
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Fetal Circulation
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The American College of Obstetrics and Gynecology (ACOG) , 19884 chamber view of the fetal
hearton a prenatal screening ultrasound
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Calculating Fetal Heart Size
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Normal Cardiac Axis
left
spine
sternum
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4-Chamber and ShortAxis of Ventricles
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Normal Doppler:Aorta
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Doppler Flow:Tricuspid Valve
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Color Doppler: Aortic Arch
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Color Doppler : Foramen Ovale
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4-Chamber View
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4 Chamber View
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Pseudo VSD
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Subcostal 4-Chamber View
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4 Chamber View Alone
Sensitivity 43%-92% (Median 68%)
Studying the outflow tracts in some
prospective studies increased
sensitivity to as much as 25%
About 70% of CHDs have an
abnormal 4-chamber view
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How accurate?
Various recent studies have reported sensitivity of 43-96% and a specificity approaching 100% with the variation depending on the sample population and technique employed, including interpretation.
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Reasons for NON-detection(FALSE NEGATIVES)
Unique fetal circulatory pathways
(PFO,PDA)
Poor image quality of the fetus Early (<20 wks) or later (>34 wks)
Obesity
Low-quality machines
Milder obstructive lesions can develop late
Small defects
Unusual defects
Inexperienced echocardiographer, erroneous interpretation
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CHDs with normal 4-Chamber View
TOF
DORV
Truncus Arteriosus
Outlet VSDs
D-TGA
Coarctation of the Aorta
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The accuracy of detecting CHDs on a screening ultrasound improves with the addition of OUTFLOW tract evaluation.
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Long-axis View of the Aorta
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Short-axis View of the Great Vessels
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Aortic Arch
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What CHDs are usually and easily diagnosed?
Enlargement or hypoplasia of atrium or
ventricle
Atresia of tricuspid or mitral valve
Atresia of pulmonary valve or aortic valve
Large septal defects
Functional abnormalities
Abnormal heart rhythm
Abnormal contractility
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Endocardial Fibroelastosis
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Complete AVSD
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Ebstein’s Anomaly
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HLHS with Hydrops Fetalis
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Truncus Arteriosus
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CHDs not always diagnose prenatally
Small VSD
Mild pulmonary or aortic stenosis
Branch pulmonary artery stenosis
Anomalous pulmonary venous connection (especially partial)
Cardiac tumors (small)
Coarctation of the aorta (mild)
PDA and ASD
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The cases of CHD detectable on FETAL ECHO constitute a more severecardiac anomaly with a less favorable long-term prognosis than the more minor defects infrequently detected.
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Serial fetal echo examinations improve accuracy and gives us a good picture of disease progression especially in high-risk conditions.
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Functional Abnormalities
Chamber sizes, wall thickness
Contractility (Ejection Fraction,Fractional Shortening)
AV Valve Regurgitation
RHYTHM
ESPECIALLY IN THE SETTING OFHYDROPS FETALIS
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HLHS with Hydrops Fetalis
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M-mode Measurements
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M-Mode Tracing
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Hypertrophic Cardiomyopathy
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Fetal Arrhythmias
Aside from detection of
structural heart disease, FETAL
ECHO has also enabled
pediatric cardiologists to assess and treat fetal
arrhythmias.
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Sinus Rhythym
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Normal Sinus Rhythm: Doppler Method
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Fetal Arrhythmias
1% of fetuses
Indications for evaluation
Sustained FHR of < 100 BPM
Sustained FHR of > 180 BPM
Repetitive Irregular Heartbeats
Unexplained Hydrops Fetalis
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Fetal Arrhythmias
ISOLATED ATRIAL EXTRASYSTOLES(PACs) is the most common
Self limited
Resolves spontaneously
Carries a benign prognosis though itmay persist for a variable period
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Premature Atrial Contractions
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Fetal Arrhythmias
Sustained tachyarrhythmias can lead to intrauterine cardiac failure, hydrops fetalis and fetal demise.
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Significant Fetal ArrhythmiasMost Common
SUPRAVENTRICULAR TACHYCARDIA (SVT)
ATRIAL FLUTTER
COMPLETE HEART BLOCK
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Fetal SVT
Most common
When sustained for 24 hours ---HYDROPS FETALIS
DIGOXIN is still drug of choice
Procainamide, Quinidine,Verapamil, Sotalol and Amiodarone
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Supraventricular Tachycardia
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Fetal Atrial Flutter
Difficult to treat
Digoxin remains drug of choice
Guarded prognosis in about 20%
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Atrial Flutter
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Fetal Complete Heart Block
Associated with structural heart disease in 50-60%
Outcome is poor if associated CHD, reported 80% perinatal mortality
In normal hearts, association with Maternal Connective Tissue D (SLE), screening of mom warranted (SS-A and SS-B antibodies)
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Complete Heart Block
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Complete Heart Block
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Summary
Fetal cardiology has made great strides in the detection of fetal heart disease thru FETAL ECHOCARDIOGRAPHY
Fetal ECHO is a relatively risk- free procedure and in the hands of an experienced fetal cardiologist has a high degree of sensitivity and specificity
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Summary
Fetal Echo enables us to diagnose
structural and functional heart disease
in-utero as early as 16 wks of AOG
4-chamber and outflow tract views are
important to diagnose more than 90% of
heart disease
Some CHDs are difficult to diagnose in-
utero (but are not critical)
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Summary
Most common indications for evaluation are suspected CHD on level 1 ultrasound, chromosomal abnormalities, extracardiac anomalies, family history of CHD, maternal diabetes and maternal teratogen exposure
Prenatal diagnosis of CHD may alter the natural course of CHD and improve on the perinatal morbidity and mortality
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THANK YOU
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