disclosure - 18th annual high-risk fetal imaging ...from practical guide to fetal echocardiography:...

Fetal Cardiac Imaging: Improving Detection of Congenital Heart Disease

Alfred Abuhamad, M.D. Eastern Virginia Medical School

Disclosure

•Ihavenorelevantfinancialrelationshiptodisclose•Iwillnotbediscussingoff-labeluseofmedicationsorproducts

The Top 4 Critical Anatomic Regions in Fetal Cardiac Imaging

Top Critical Anatomic Regions

1. Normal Left Atrium

�4

Left Atrium

Ao

Left Atrium

Pulmonary Veins

Pulmonary Veins

Left Atrium7

Esophagus

Ao LA

Swallowing

Ao LA

Left Atrium

Left Atrium

Closed Esophagus Open Esophagus

TAPVR

SupracardiacTAPVR

From Practical Guide To Fetal Echocardiography: Normal & Abnormal Hearts– Abuhamad, Chaoui – 3rd Edition -Oct 2015

Cardiac7 TAPVR

InfracardiacTAPVR

From Practical Guide To Fetal Echocardiography: Normal & Abnormal Hearts– Abuhamad, Chaoui – 3rd Edition -Oct 2015

Left Atrium

TAPVRFrom Practical Guide To Fetal Echocardiography: Normal & Abnormal Hearts– Abuhamad, Chaoui – 3rd Edition -Oct 2015

Left Atrium

TAPVR

AO Azygos

AO

Left Atrium

Normal TAPVR

TAPVR

�19 J Ultrasound Med 2014; 33:1193–1207

�30

Do Not Miss The Diagnosis of a Normal Left Atrium

1. Normal Left Atrium 2. Normal Left Ventricular Outflow

�31

Top Critical Anatomic Regions

LeCVentricularOuElow

LeCVentricularOuElow

Normal TOFLeCVentricularOuElow

TOF

LeCVentricularOuElow

TOF

LeCVentricularOuElow

LeCVentricularOuElow

LeCVentricularOuElow

From Practical Guide To Fetal Echocardiography: Normal & Abnormal Hearts– Abuhamad, Chaoui – 3rd Edition -Oct 2015

LeCVentricularOuElow

LeCVentricularOuElow

10TGA:LeCVentricularOuElow

10TGA:LeCVentricularOuElow

10TGA:LeCVentricularOuElow

10TGA:LeCVentricularOuElow

LVPA

Transposition of Great Arteries10

Transposition of Great Arteries10

Transposition of Great Arteries10

�48Ultrasound Obstet Gynecol 2015; 45: 678

Overall rate of detection 23 %

Normal Left Ventricular Outflow

•Mitral - aortic continuity •Aorta within left ventricle •Angle of ascending aorta with ventricular septum

•Aorta does not divide •Close observation of aortic valves

�50

Do Not Miss The Diagnosis of a Normal Left Ventricular Outflow

�51

L

L

L

L

L

• D-TGA–classic• VSD• Abnormal3VTView

�59

L

LA

LV

L

L

L

L

L

L

• TGA(atypical-posterior)• VSD• Normal-looking3VTView

1. Normal Left Atrium 2. Normal Ascending Aorta 3. Normal 3VT View

�69

Top Critical Anatomic Regions

TransverseViews

Three-VesselView

DuctalArchView

AorTcArchView

Three-VesselTracheaView

LeCBrachiocephalicVein

LeCBrachiocephalicVein

3VTView

�77

PA

DA

Thymus AoA

Isthmus

SVC

E

AzV

PA

Thymus

AoA

Tr

SVC

R

L

Tr

R

L

BA

3VTView

Azygos

PA AoA

Tr

SVC

„Thy-Box“

AoA

SPSP

Sternum

TrL L

BA

3VTView

PAAoA

L

R

SP

Tr

SVC

L

R

PAAoA

Tr

SVC

SPBA

3VTView

Blood Flow Towards the Spine

3VT

�81

Spine

3VTView

3VTView

Follow the Aorta

13 wks

3VTView

Courtesy of Dr. Chaoui

3VTView

• Course and size of PA, Ao and SVC• Aortic isthmus and ductus arteriosus• Aortic arch right or left-sided ?

(Trachea as landmark)

• Thymus visualized• Assessment with Color Doppler: “Blue V” or “Red V”

• Atypical vessels (left persistent SVC - Vertical Vein)

Checklist 3-VT-view

O

PAAo

Trachea

SVC

Thymus

3VT:3VesselsSeen

�87

�88Coarctation of the Aorta Hypoplastic Left Heart Syndrome

3VTView:3VesselsSeenSmallAorta

!89

CoarctaTonofAorta

Hypoplastic Left Heart Syndrome

3VT View: 3 Vessels SeenSmall Aorta

�91Pulmonary Stenosis - TOF Pulmonary Atresia

3VTView:3VesselsSeenSmallPA

TOF-PulmonaryStenosis

Pink

TOF-PulmonaryStenosis

Blue

TOF-PulmonaryAtresia

PA

AO

AO

Dilated PA, turbulent Flow

L

L

Dilated PA

PA

BA

Tr Tr

SVCSVC

3VTView:3VesselsSeenLargePA

Absent Pulmonary Valve Syndrome

3VT:2VesselsSeen

�96

AO

SVC

Tr

B

A

AO SVC

Tr

L

L

3VTView:2VesselsSeenNormalsizegreatvessel

TGA (Convex Course)

• TGA(atypical)• VSD• Normal-looking3VTView

3VT:AbnormalCourseofVessels

�99

3VTView:3VesselsSeenAbnormalVesselCourse

Right Ao Arch - Right DA

Double Ao ArchRight Ao Arch - Left DA

Normal

BA

SVCSVC

Tr

PA

LLDA

RAoTr

PA

DA

RAo

LPAPA

Ao SVC

T

L

R

L

C

U-Sign, vascular ring (loose)

Right-Sided Aortic Arch - Left DA

3VTView:3VesselsSeenAbnormalVesselCourse

PA Ao

SVCTL R

3VTView:3VesselsSeenAbnormalVesselCourse

Right-Sided Aortic Arch - Left DAU-Sign, vascular ring (loose)

PA

DA

Ao

RAoA

LAoA

SVC

L

R

T

A

LT

LAoA RAoA

DA

PA SVC

L

BA

3VTView:3VesselsSeenAbnormalVesselCourse

Double Aortic Arch

PA

DA

Ao

RAoA

LAoA

SVC

L

R

T

3VTView:3VesselsSeenAbnormalVesselCourse

Double Aortic Arch

3VT:4VesselsSeen

�105

PA Ao SVC

B

LSVC

Trachea

PA

AoSVC

Trachea

LSVC

A

3VTView:4VesselsSeenPersistentLeCSuperiorVenaCava

!107

Ao

PA

SVC

LSVC

Trachea

L

3VTView:4VesselsSeenPersistentLeCSuperiorVenaCava

PAAo SVC

B

LSVC

Trachea

A

3VTView:4VesselsSeenSupracardiacTAPVR

LSVC

Enlarged CS

Absent left BCV

PA

Ao

SVC

3VT View: 4 Vessels SeenLSVC vs. TAPVR ?

4thVessel

TAPVR

Normal CS

Large left BCV

PA

Ao

SVC

3VT View: 4 Vessels SeenLSVC vs. TAPVR ?

CS4thVessel

DAAneurysm

PA

aAo

SVC

Trachea

DAA

dAo

From“Echocardiographicanatomyinthefetus.”ChiappaE.Metal.

3VTView:4VesselsSeenDAAneurysm/Kinking

3VTView:4VesselsSeenDAAneurysm/Kinking

• HLHS• HRHS• TGA• DORV• TOF• CAT• TAPVR• PA-VSD

3VT View

Trachea

SVC

• PS / PA• Critical Ao Stenosis• Coarctation of Ao• ARSA• LSVC• TA-VSD• RAA• Double Ao Arch• Ebstein• Interrupted Ao Arch

Abnormal in:

�114

Do Not Miss The Diagnosis of a Normal 3VT View

1. Normal Left Atrium 2. Normal Ascending Aorta 3. Normal 3VT View 4. Normal Cardiac Axis in Early Gestation

�115

Top 5 Critical Anatomic Regions

CardiacAxis

Obstet.Gynecol.1987;70:1987

DataFromNormalFetuses(n=183)

• Axisataround45%• Rangeofnormal+/-20degrees• NochangewithgestaTon

AbnormalCardiacAxis

Obstet.Gynecol.1995;85:97

LeCAxisDeviaTon

• MostabnormalcardiacaxisareleCaxisdeviaTons• Mostarediagnosedinsecondtrimester

CardiacAxis

DORV

TGA

TOF

CAT

CardiacAxis9weeks-52days

Cardiac Axis

2D 2D+color Doppler

2D+HD color Doppler

Left Deviation

DORV, 12+6 weeks Mitral atresia with DORV 11+6 weeks

TOF, 11+4 weeks

Cardiac Axis in Early Gestation

�122

CRL, mm

CA

x, d

egre

es

Control Group Study Group

40 50 60 70 80 90

0

20

40

60

80

100

120197 cases of CHD and

Obstet Gynecol 2015;125:453–60

197 fetuses with CHD and 394 controls

�123Obstet Gynecol 2015;125:453–60)

197 fetuses with CHD and 394 controls

PATIENT: 33 year old - G2P0

REASON FOR REFERRAL: Detailed 1st trimester ultrasound

with enlarged nuchal translucency noted on the outside

scan

GA AT PRESENTATION: 12+0 weeks

Case Presentation

12+0 weeks - TVUS

12+0 weeks - TVUS

12+0 weeks - TVUS

12+0 weeks - TVUS

CHD: Tetralogy of Fallot with pulmonary stenosis -

ARSA

Small omphalocele

Two vessel umbilical cord

DIAGNOSIS

Genetic Counseling: Work

up for chromosomal anomalies

Fetal Karyotype: 46XX,del(4)(p15.2) – Wolf-Hirschorn syndrome

Pregnancy outcome: termination at 15+1 weeks

�131

Do Not Miss The Diagnosis of a Normal Cardiac Axis in Early Gestation

5 Top Anatomic Regions

• Normal left atrium: rule out TAPVR, Isomerism, Interrupted IVC

• Normal ascending aorta: rule out TOF, TGA, DORV • Normal 3VT view: rule out conotruncal anomalies,

RAA, HLHS, coarctation of Ao • Normal cardiac axis in early gestation: rule out

major CHD in first trimester