isuog basic training...4. which abnormalities should be excluded after correct assessment of planes...
TRANSCRIPT
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Basic Training
ISUOG Basic TrainingObtaining & Interpreting Heart Views Correctly
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Basic Training
Learning objectivesAt the end of the lecture you will be able to:
• Describe how to assess cardiac situs
• Describe the key features of the 4 planes required to assess the fetal heart correctly
• Recognise the differences between the normal & most common abnormal cardiac ultrasound appearances of the 4 planes
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Basic Training
Key questions1. What are the key ultrasound features of plane 7 (chest)?
2. What probe movements are required to move through the
4 cardiac planes correctly?
3. What are the key ultrasound features of plane 10 (3VT)?
4. Which abnormalities should be excluded after correct
assessment of planes 7 (chest), 8 (LVOT), 9 (RVOT) &10
(3VT)?
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Basic Training
Plane Description
1
2
3
Sagittal complete spine with skin covering
Coronal complete spine
Coronal section of body
4
5
6
Transventricular plane*
Transthalamic plane*
Transcerebellar plane*
7
8
9
10
Lungs, 4 chamber view of heart
Left ventricular outflow tract (LVOT)
Right ventricular outflow tract (RVOT)
& crossover of LVOT
3 vessel trachea (3VT) view of heart
The 20 + 2 planes
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Basic Training
Plane 7 (chest) - Four-chamber view
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Basic Training
Plane 8 (LVOT) - Left ventricular outflow
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Basic Training
Plane 9 (RVOT) - Right ventricular outflow
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Basic Training
Plane 10(3VT) – Three vessel trachea
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Basic Training
Four chamber view
• Fetal laterality (identify right & left sides of fetus)
• Stomach & heart on left
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Basic Training
Normal situs – abdominal circumference
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Basic Training
Normal situs - Chest
Ao
Abuhamad, Chaoui: A Practical Guide To Fetal Echocardiography (2) 2012: 315
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Basic Training
Four chamber view
• Fetal laterality (identify right & left sides of fetus)
• Stomach & heart on left
• Heart occupies one third of chest
• Majority of heart in left chest
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Basic Training
1/32/3
L
Cardiac position
R
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Basic Training
Four chamber view
• Fetal laterality (identify right & left sides of fetus)
• Stomach & heart on left
• Heart occupies one third of chest
• Majority of heart in left chest
• Cardiac axis (apex) points to left by 450 ± 200 relative to the
vertical
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Basic Training
Four chamber view
• Fetal laterality (identify right & left sides of fetus)
• Stomach & heart on left
• Heart occupies one third of chest
• Majority of heart in left chest
• Cardiac axis (apex) points to left by 450 ± 200 relative to the
vertical
• Four chambers present
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Basic Training
Four chamber viewApical
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Basic Training
Four chamber viewAxial
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Basic Training
Atrial Chambers
• Two atria, approximately equal in size
• Foramen ovale seen flapping in left atrium
• Atrial septum primum present (adjacent to crux)
• Pulmonary veins entering left atrium
Ultrasound Obstet Gynecol 2013; 41: 348–359
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Basic Training
Left atrium
Ao
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Basic Training
Right atrium
Abuhamad, Chaoui: A Practical Guide To Fetal Echocardiography (3), 2012
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Basic Training
RVLV
RA
LA
L
Interatrial septum
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Basic Training
Ventricular chambers
• Two ventricles, approximately equal in size
• No ventricular wall hypertrophy
• Moderator band at right ventricular apex
• Ventricular septum intact (apex to crux)
Ultrasound Obstet Gynecol 2013; 41: 348–359
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Basic Training
Right ventricle
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Basic Training
Right ventricle
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Basic Training
Left ventricle
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Basic Training
Atrioventricular junction & valves
• Intact cardiac crux
• Two atrioventricular valves open, close & move freely
• Differential offsetting: tricuspid valve leaflet inserts on
ventricular septum closer to cardiac apex than the mitral
valve
Ultrasound Obstet Gynecol 2013; 41: 348–359
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Basic Training
Atrioventricular valves
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Basic Training
Four chamber view
• Fetal laterality (identify right & left sides of fetus)
• Stomach & heart on left
• Heart occupies one third of chest
• Majority of heart in left chest
• Cardiac axis (apex) points to left by 450 ± 200 relative to the vertical
• Four chambers present
• Regular cardiac rhythm
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Basic Training
Regular cardiac rhythm
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Basic Training
Four chamber view
• Fetal laterality (identify right & left sides of fetus)
• Stomach & heart on left
• Heart occupies one third of chest
• Majority of heart in left chest
• Cardiac axis (apex) points to left by 450 ± 200 relative to the vertical
• Four chambers present
• Regular cardiac rhythm
• No pericardial effusion
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Basic Training
Four chamber view - detectable anomalies
Muscular - ventricular septal defect (VSD)
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Basic Training
Four chamber view - detectable anomalies
Perimembranous VSD
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Basic Training
Four chamber view - detectable anomalies
AVSD
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Basic Training
Hypoplastic left ventricle –
univentricular heart
Four-chamber view – detectable anomalies
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Basic Training
Plane 7- Four chamber view
Abuhamad, Chaoui: A Practical Guide To Fetal Echocardiography (3), 2012
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Basic Training
Plane 7 anomalies excluded
4 chamber view
• Situs abnormality
• Ectopia cordis
• Univentricular heart
• Atrioventricular defect (AVSD)
• Pericardial effusion > 4mm
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Basic Training
Plane 8 - Left ventricular outflow
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Basic Training
Left ventricular outflow
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Basic Training
TOF
Left ventricular outflow
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Basic Training
Left ventricular outflowTransposition of
the great arteries(TGA)
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Basic Training
Left ventricular outflow
• Mitral - aortic continuity
• Aorta completely within left ventricle
• Angle of ascending aorta with ventricular septum, & towards
right shoulder
• Aorta does not divide
• Close observation of aortic valve
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Basic Training
Plane 8 (LVOT) anomalies excluded
Left Ventricular Outflow Tract
• Overriding aorta
• TGA
Overriding Aorta
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Basic Training
Plane 9 (RVOT) - Right ventricular outflow
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Basic Training
Plane 10 (3VT) – Three vessel trachea
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Basic Training
Three vessel trachea
45
Blood flows towards the spine
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Basic Training
Three vessel trachea
46
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Basic Training
3 vessel trachea view
• Severe aortic stenosis (AS)
• Severe pulmonary stenosis (PS)
• Transposition of the great arteries (TGA)
• Truncus
• Hypoplastic left heart syndrome (HLHS)
• Right aortic arch (RAA)
• Interrupted aortic arch (IAA)
• Tetralogy of Fallot (TOF)
Three vessel trachea – detectable anomalies
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Basic Training
TGA HLHS
RAA
IAA TOF
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Basic Training
Key points
• Normal situs
• Normal axis
• Ventricles equal in
size & contractility
• LVOT to right shoulder
• LVOT does not divide
• Aortic valve normal
action
• PA anterior to aorta
• PA & Ao similar size
• pulmonary valve normal
action
• 3 vessels seen
• PA & Ao similar size
• DA & Ao Arch to left of
trachea
7 8 9 10
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Editable text hereBASIC TRAININGBasic Training
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