comprehensive first trimester cardiac assessment...

COMPREHENSIVE FIRST TRIMESTERCARDIAC ASSESSMENT

Reem S. Abu-Rustum, MD, FACOG, FACS, FAIUMCenter For Advanced Fetal Care

Tripoli - Lebanon

AIUM Annual Convention NYC 18 March 2016

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OBJECTIVES

Background

Why Early?

What Can We See?

Learning Curve

Guidelines & Data

Conclusions

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Background

Why Early?

What Can We See?

Learning Curve

Guidelines & Data

Conclusions

IT ALL STARTS WITH…

IT ALL STARTS WITH…… A HEARTBEAT

8w3d

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

• Majority: no risk factors

• MUST screen the entire population

HOW GOOD ARE WE?

Tegnander et al. UOG 2006; 27:252

• Non-selected population in Norway

• 30149 fetuses

Detection Rate at

57%

HOW GOOD ARE WE?

Friedberg et al. J. Pediatr. 2009; 155:26

• Prospective 1 year study

• Northern California

• Fetuses and infants with CHD < 6 months

HOW GOOD ARE WE?

Friedberg et al. J. Pediatr. 2009; 155:26

HOW GOOD ARE WE?

CAN WE IMPROVEOUR DETECTION?

Hunter et al. Heart 2000; 84:294

Prenatal recognition of CHD rose from 17% in 1994 to 30% in 1995 and36% in 1996.

Conclusions—A simple training program for obstetric ultrasonographersincreased their ability to detect serious congenital heart disease at aroutine 18–20 week anomaly scan.

Background

Why Early?

What Can We See?

Learning Curve

Guidelines & Data

Conclusions

WHY DETECT EARLY?MAIN CONSIDERATIONS

• Workup• Options• TOP Limitations• Safety• Explain sudden IUFD• Natural progression• Psychological• Obstetrical care

• Early Reassurance

Courtesy of Prof. Nicolaides

De

ath

s /

10

0,0

00

ab

ort

ion

s

Abortions in the USA 1988-1997

Bartlett et al 2004

10 12 14 16 18 20

0

2

4

6

Gestation (wks)

0.5

4

Barlett et al. Obstet Gynecol 2004; 103:729

WHY DETECT EARLY?MAIN CONSIDERATIONS

Maiz et al. Prenatal Diagnosis 2016; ePub ahead of print.

GLOBAL IMPLEMENTATIONAS A RESULT OF

NT

Technical Advances

NIPT

CAx

GLOBAL IMPLEMENTATIONAS A RESULT OF

NT

Technical Advances

NIPT

CAx

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. 2009Hyett 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; 10:242Abuhamad & Chaoui. Practical Guide to Fetal Echocardiography: Normal and Abnormal Hearts. 2nd Edition

NUCHAL TRANSLUCENCY

Sotiriadis et al. UOG 2013; 42:383

Sotiriadis et al. UOG 2013; 42:383

GLOBAL IMPLEMENTATIONAS A RESULT OF

NT

Technical Advances

NIPT

CAx

WITH THETECHNOLOGICAL ADVANCES

Sinkovskaya et al. UOG 2012; 40:90

HD FLOW 13W1D

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SAo

RV

RALV

LA

3VVAo

PA

FO

3D VOLUME AT 13W2D

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

Votino et al. UOG 2013; 42:669

AIUM 2011

SAFETYIN THE FIRST TRIMESTER

ISUOG 2011

SAFETYIN THE FIRST TRIMESTER

GLOBAL IMPLEMENTATIONAS A RESULT OF

NT

Technical Advances

NIPT

CAx

WITH NIPT…

…A SHIFT IN THE ROLE OF NT

BEYOND SCREENING FOR ANEUPLOIDY

FULL ANATOMIC SURVEY

FULL ANATOMIC SURVEY

Genitalia

Bladder + 3VC

FULL ANATOMIC SURVEY

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INCLUDING THE FETAL HEART…

IVC

SVC

RA

DAo

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Larion et al. AJOG 2014: 65121

KEEPIN MIND…

Dolk et al. Adv Exp Med Biol. 2010; 686:349

PRIOR TO NIPT, CRITICAL TO RULE OUT

AND MAJOR CONGENITAL HEART DEFECTS

HLH 13w3d

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GLOBAL IMPLEMENTATIONAS A RESULT OF

NT

Technical Advances

NIPT

CAx

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THE FIRST TRIMESTER HEART

OFT

3VV

4CV

KEEPING IN MIND……THE DIFFICULTY

OFT4CV

AoA & DAoBicaval View

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. 2009Hyett et al. UOG 1997; 10:242

NUCHAL TRANSLUCENCY

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

CARDIAC AXIS 30-60 FTS

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Sinkovskaya et al Obstet Gynecol 2015; 125: 453

Sinkovskaya et al Obstet Gynecol 2015; 125: 453

Sinkovskaya et al Obstet Gynecol 2015; 125: 453

Sinkovskaya et al Obstet Gynecol 2015; 125: 453

Background

Why Early?

What Can We See?

Learning Curve

Guidelines & Data

Conclusions

EARLIEST REPORTS

Gemburch et al. Obstet Gynecol 1990; 75:496

Achiron et al. J Ultrasound Med 1994; 13:783

12

14

20

MORE RECENTLY…

• Haak et al

UOG 2002; 20:9

Transvaginal 92%

• Huggon et al

UOG 2002; 20:22

Transabdominally 84%

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Haak et al. UOG 2002; 20:9

Transvaginal

Huggon et al. UOG 2002; 20:22

Transabdominal

DeVore. UOG 2002; 20:6

NEWEST TREND: CARDIAC IMAGING AT 11-14 WEEKS

KEEPING IN MIND…

12

14

20

Grain Rice Coin: 1 Euro

Allan, Cook & Huggon. Fetal Echocardiography: A Practical Guide. 2009

Key Points• Heart Develops GA 5-8 Weeks• Chest AP diameter is about 2.5 cm at 12-13 weeks

Can Assess• Position• Connections• Symmetry of 4 Chambers• 2 AV valves/Septum (Doppler)• Septoaortic Continuity• 2 Semilunar Valves (Doppler)• Normal Cross Over of Arteries

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CARDIAC IMAGING AT 11-14 WEEKS

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ANATOMIC LANDMARKS

• Right ventricle is the most anterior, below thesternum

• Left atrium is closest to the spine most centralstructure in the chest

• Aorta is just anterior to the left of the spine

• Tricuspid valve is more apical than mitral valve

• Flap of the foramen ovale in the left atrium

• Moderator band is in the right ventricle

• Apex formed by the left ventricle

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• Left atrium and aorta occupy the center of the chest

• Aorta points to the right shoulder as it exits then heads posteriorlytowards the spine

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

• Outflow tracts cross over, with the PA being more anterior than the left ventricular outflow tract

• Post bifurcation of the PA, the aorta and PA are almost parallel

ANATOMIC LANDMARKS

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SYSTEMIC EVALUATION TRANSVERSE VIEWS

ISUOG FE Guidelines 2013

SYSTEMIC EVALUATION SAGITTAL VIEWS

SYSTEMIC EVALUATION TRANSVERSE VIEWS

ISUOG FE Guidelines 2013

Abd Circ

Apex4CV

LVOT-Ao

RVOT-PA

3VV

Diagram Courtesy of Linda Daou, MD

SYSTEMIC EVALUATION TRANSVERSE VIEWS

Abd Circ

Apex4CV

LVOT-Ao

RVOT-PA

3VV

Diagram Courtesy of Linda Daou, MD

SYSTEMIC EVALUATION TRANSVERSE VIEWS

TV at 11w3d Using RIC 6-12

ESTABLISHING SITUS

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ESTABLISHING SITUS

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ESTABLISHINGSITUS

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4 CHAMBER VIEW

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TV at 11w2d Using RIC 6-12

4 CHAMBER VIEW

RALV

LA

RV

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Sinkovskaya et al. UOG 2010; 36:676

CARDIAC AXIS 30-60 FTS

TRICUSPID REGURGITATION

PULMONARY VEINS

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PULMONARY VEINS

TA at 13w1d Using Linear 9MHz Probe

RL

Abd Circ

Apex4CV

LVOT-Ao

RVOT-PA

3VV

Diagram Courtesy of Linda Daou, MD

SYSTEMIC EVALUATION TRANSVERSE VIEWS

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OUTFLOW TRACTS

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OUTFLOW TRACTS

OUTFLOW TRACTS

TA at 13w5d Using RMC/OB

RVOT LVOT

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CROSS OVER

Abd Circ

Apex4CV

LVOT-Ao

RVOT-PA

3VV

Diagram Courtesy of Linda Daou, MD

SYSTEMIC EVALUATION TRANSVERSE VIEWS

3 VESSEL VIEW

PA

AoSVC

DAo

DA

TV at 13w1d Using RIC 6-12

3 VESSEL VIEW

PAAo

SVC

DAoDA

TV at 9w5d Using RIC6-12

PA AoSVC

DAoDA

3 VESSEL VIEW

TA at 13w0d Using RM6C/OB

SYSTEMIC EVALUATION TRANSVERSE VIEWS

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TA at 13w2d Using RM6C/OB

SYSTEMIC EVALUATION TRANSVERSE VIEWS

SAo

RV

RALV

LA

3VVAo

PA

FO

3D VOLUME AT 13W2D

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

SYSTEMIC EVALUATION SAGITTAL VIEWS

IVC

SVC

RA

DAo

RIGHT ATRIAL INFLOW

TA at 12w6d Using RM6C/OB

RIGHT ATRIAL INFLOW

RIGHT ATRIAL INFLOW

TV at 13w1d Using RIC 6-12

RASVC

IVC

AORTIC ARCH & DESCENDING AORTA

TA at 13w2d Using RM6C/OB

AORTIC ARCH & DESCENDING AORTA

TV at 13w1d Using RIC 6-12

AORTIC ARCH & DESCENDING AORTA

DUCTAL ARCH

DUCTAL ARCH

AoA

DA

DUCTUS VENOSUS

ONCE WE RECOGNIZE NORMAL ANATOMY WE CAN IDENTIFY THE ABNORMALS

ONCE WE RECOGNIZE NORMAL ANATOMY WE CAN IDENTIFY THE ABNORMALS

Univentricle 12w2d

ONCE WE RECOGNIZE NORMAL ANATOMY WE CAN IDENTIFY THE ABNORMALS

AV Canal 13w5d

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Abu-Rustum, Ayoubi and Jani. UOG 2011; 38:190

Left CDH at 12w5d

ONCE WE RECOGNIZE NORMAL ANATOMY WE CAN IDENTIFY THE ABNORMALS

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THE LEBANESE CAx

CoA

TOF HLH AV Canal

VSDHLHCAx 82.02

CAx 78.05

CAx 84.98 CAx 65.90

CAx 85.60 CAx 13.15

Background

Why Early?

What Can We See?

Learning Curve

Guidelines & Data

Conclusions

MUST ACQUIRE SKILLIN THE SECOND TRIMESTER

24W5D21W5D

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

SYSTEMIC APPROACH18-22 WEEKS

RL

BEFORE MOVINGTO THE FIRST TRIMESTER

OFT4CV

AoA & DAoBicaval View

NOW WE GO TONORTH LEBANON

Abu-Rustum et al. JUM 2011; 30:695

4CV PV CODoppler of 4CV 3VV LVOT 3VVBPA RV Inflow

To assess the learning curve and factors influencingthe feasibility of carrying out a complete fetalcardiac evaluation at the time of the first trimesterscan.

OBJECTIVE

4CV PV CODoppler of 4CV 3VV LVOT 3VVBPA RV Inflow

•Prospective study•104 gravidas at 11w6d-13w6d•Maternal body mass index BMI•Fetal crown-rump length CRL•Transabdominal scans•Single sonologist•8 cardiac parameters•Average time: first to last cardiac image

METHODS

4CV PV CODoppler of 4CV 3VV LVOT 3VVBPA RV Inflow

CARDIAC PARAMETERS1. 4 Chamber view (4CV)2. Tricuspid regurgitation (TR)3. Outflow tracts cross over (CO)4. Bifurcating pulmonary artery (BPA)5. 3 Vessel view (3VV)6. Aortic arch sagitally (AoA)7. Bicaval view (RA Inflow)8. Doppler of the ductus venosus (DV)

METHODS

4CV PV CODoppler of 4CV 3VV LVOT 3VVBPA RV Inflow

Data Analysis•Chi square•ANOVA•Scatter plot•Polynomial curve fitting•P < 0.05

METHODS

4CV PV CODoppler of 4CV 3VV LVOT 3VVBPA RV Inflow

•103/104 Fetuses evaluated•Median CRL 72.1 mm (range 53.9-85.8 mm)•Median BMI was 23 kg/m2 (range 17.7-32.3 kg/m2)•A complete exam was feasible in 55% of cases•A complete exam was feasible in 15% of the first 52 cases•A complete exam was feasible in 94% of the last 51 cases

RESULTS

4CV PV CODoppler of 4CV 3VV LVOT 3VVBPA RV Inflow

Cardiac View Successful Visualization

4 Chamber View 100 %

Tricuspid Regurgitation 100 %

Outflow Tract Cross Over 90 %

Bifurcation Pulmonary Artery 81 %

3 Vessel View 55 %

Venae Cavae 65 %

Aortic Arch 76 %

Ductus Venosus 99 %

RESULTS

1st period[Case 1-21]

2nd period[Case 22-52]

3rd period[Case 53-103] p-value

#Views out of 8 4.76 (59.5%) 6.0 (75%) 7.89 (98.6%) 0.0001

Average Time (sec) 262.4 (4.37 m) 429.3 (7.13m) 560.1 (9.3m) 0.032

BMI 24.08 24.0 23.5 0.752

CRL 72.2 72.7 72.1 0.899

4CV PV CODoppler of 4CV 3VV LVOT 3VVBPA RV Inflow

RESULTS

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30

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50

60

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90

100

0 20 40 60 80 100 120

Number of cases

Perc

en

tag

e o

f fi

nd

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s

.

Case Number

% C

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xam

4CV PV CODoppler of 4CV 3VV LVOT 3VVBPA RV Inflow

RESULTS

AV Canal

HRH

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CONCLUSION

• Fetal cardiac evaluation is feasible in the first trimester

• At least 52 exams and an average time of 10 minutesneeded

• Time allocation and gained sonographer experienceare the most significant factors

TECHNICAL/PERSONALLIMITATIONS

Training

Machinery

Maternal Body Habitus

Developmental Stage

Time Consuming

Undue

Anxiety

Greatest challenge is the LOW RISK PATIENT!

Background

Why Early?

What Can We See?

Learning Curve

Guidelines & Data

Conclusions

AIUM 2013 GUIDELINESACOG, ASE & SMFM

ENDORSED BY ACR

ISUOG 2013 GUIDELINES

Carvalho. PD 2004; 24:1060

Rossi et al. AJOG 2013; 122:1160

Rossi et al. AJOG 2013; 122:1160

Background

Why Early?

What Can We See?

Learning Curve

Guidelines & Data

Conclusions

CONCLUSIVE PEARLS

Comfort in the Second Trimester

Commence with Low BMI Patients

Employ Magnification

Use Doppler (HDF) but Adhere to Safety

Concerns

Utilize Various Probes/Routes

Practice & Patience

CONCLUSION

• First trimester fetal cardiac imaging is feasible

• Powerful tool for early reassurance

• Does not replace second trimester echocardiography

• Consultation with Pediatric Cardiology is a MUST

• Though there are no current guidelines, its

incorporation into clinical practice is inevitable

• The future has unlimited potential

• The time to start is NOW

• Practice, PATIENCE and a ready mind make perfect

IS IT TIME FOR FIRST TRIMESTER GUIDELINES?

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IT ALL ENDS WITH……A HEARTBEAT

12w4d

…The Future is so Incredibly Bright

THANK YOU!

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