Course Director

September 28-30, 2018

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Fetal Cardiac Imaging in Early Gestation

Alfred Abuhamad M.D.

Chronology of Cardiac Development

End of 9th menstrual week

Chronology of Cardiac Development

From Practical Guide To Fetal Echocardiography – Abuhamad, Chaoui – 2nd Edition

End of 9th menstrual week

• Caution in detailed anatomic cardiac evaluation at less than 10 weeks gestation

Cardiac Imaging in Early Gestation

9 Weeks

9 Weeks Gestation

Color Doppler helps but still

0!

100!

200!

300!

400!

500!

600!

700!

2.5-3.4! 3.5-4.4! 4.5-5.4! 5.5-6.4! 6.5-8.4! >8.5!15.5 33.5

74.8

150.0 190.5

643.0

Prevalence CHD/1000 against NT measurement !

NT measurements in mm

Prev

alenc

e CH

D/10

00

Bahado-Singh, AJOG 2005 Clur, Prenatal Diagnosis 2009

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• Transvaginal • Transabdominal

Approach to Examination

Cardiac Imaging in Early Gestation

• Better resolution of probe • Closer to fetal heart •  Inconvenience to patients • Limited probe range of motion • Requires expertise

Transvaginal

Cardiac Imaging in Early Gestation

• Most optimal < 13 weeks • Fetus in transverse lie

Transvaginal

Cardiac Imaging in Early Gestation Transvaginal Cardiac Imaging in Early Gestation

Cardiac Imaging in Early Gestation 13 Weeks

TransabdominalApproach

12

13 Weeks

•  4CV •  PV

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TransabdominalApproach

13

13 Weeks

•  4CV •  Cardiac axis •  Left PV

TransabdominalApproach

14

13 Weeks

•  3VT

TransabdominalApproach

15

13 Weeks

•  IVC •  SVC •  Short axis

CardiacStructures

16J Am Soc Echocardiogr 2017;30:763-72

CardiacStructures

17J Am Soc Echocardiogr 2017;30:763-72

Early Fetal Echocardiography

•  Increased NT •  Reverse flow in Ductus Venosus •  Tricuspid / mitral regurgitation •  Abnormal cardiac axis* •  Other (suspected abnormality)

Indications (10 - 14 weeks)

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Cardiac Imaging in Early Gestation

•  Is all about image optimization 19 20

Early Fetal Cardiac Imaging

From Practical Guide To Fetal Echocardiography – Abuhamad, Chaoui – 3rd Edition - Oct 2015

21

Early Fetal Cardiac Imaging

From Practical Guide To Fetal Echocardiography – Abuhamad, Chaoui – 3rd Edition - Oct 2015

Color Doppler in Early Echo

Color Doppler High Definition/Power Doppler

13 Weeks

Abdominal Situs 12 Weeks

Four Chamber View

From Practical Guide To Fetal Echocardiography – Abuhamad, Chaoui – 2nd Edition

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Four Chamber View

From Practical Guide To Fetal Echocardiography – Abuhamad, Chaoui – 2nd Edition

Four Chamber View 11 Weeks

Four Chamber View 13 Weeks

Four Chamber View 13 Weeks

Four Chamber View 12 Weeks

Pulmonary Veins 11 Weeks

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Pulmonary Veins 12 Weeks

Outflow Tracts

Left Ventricular Outflow 13 Weeks

Outflow Tracts – LVOT-RVOT-3VT

Transverse Ductal Arch Three Vessel Trachea

13 Weeks

Outflow Tracts – 3V / 3VT

Transverse Ductal Arch Three Vessel Trachea

13 Weeks

Outflow Tracts – 3V / 3VT 12 Weeks

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Outflow Tracts-3VT 13 Weeks

Outflow Tracts-3VT 13 Weeks

Aortic & Ductal Arches 13 Weeks

RL *!A! B!

C! D!

RV LV

RV LV

Ao PA

L

L

L

R

R R

4 Views in Early Cardiac Screening

My Recommendations

Abnormal Anatomy RV

AoA

A

RV

RA LA

B C

RA

PA

Hypoplastic Left Heart Syndrome

13 Weeks

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LV

RA

RV

LA

RV

LV

A B

Hypoplastic Left Heart Syndrome

14 Weeks

Hypoplastic Left Heart Syndrome

12 Weeks

14 Weeks

Coarctation of Aorta Coarctation Aorta-4D

12 Weeks

Aortic Stenosis

13 Weeks

RV LV

RV LV

RA LA

B A

RA LA

13 Weeks

Atrioventricular Septal Defect

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Atrioventricular Septal Defect

12 Weeks

50

A B C

LV

LV

LV RV

RV

RV

Atrioventricular Septal Defect

A B

Ao PA

LV

LA RA

RV

13 Weeks

Tricuspid Atresia - VSD 52

PA AO

AO

RV LV

RV

LV

RV LV

A B

C D

Tetralogy of Fallot

14 Weeks

AO

RV LV AO

DA

A B

Tetralogy of Fallot - PA

RA

RV

LV

LA

A B C

RA

RV

LV

LA

PA Ao

DA

13 Weeks

Pulmonary Atresia

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LV

AO PA

RV

B A

Ao

Trachea

Transposition of Great Arteries

13 Weeks Transposition of Great Arteries

3VT – 2 vessels seen

Transposition of Great Arteries

3VT – 2 vessels seen

13 Weeks

58Journal of Maternal-Fetal & Neonatal Medicine 2017

Common Arterial Trunk

13 Weeks

RV

RA

*

* * *

RV RA

L

A B C

L

LV

Ebstein Anomaly

13 Weeks

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LA RA

SV

SV

LA

RA

L

A B

Single Ventricle

15 Weeks

L

R

B A

St

L

R

Heterotaxy

15 Weeks

Heterotaxy

12 Weeks

Ventricular Septal Defect

13 Weeks

Ventricular Septal Defect

12 Weeks

3VT in Early Gestation

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3VT in Early Gestation 12 Weeks

Cardiac Axis in the First Trimester

Cardiac Axis 11 0/7 to 14 6/7 Weeks

Cardiac Axis

2D 2D+color Doppler

2D+HD-color Doppler

4 Chamber View

Cardiac Axis 12 Weeks

CardiacAxis9 Weeks - 52 days

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74

197 cases of CHD and

Obstet Gynecol 2015;125:453–60

197 fetuses with CHD and 394 controls

75Obstet Gynecol 2015;125:453–60)

197 fetuses with CHD and 394 controls

4D Ultrasound and Early Fetal Echocardiography

4D Ultrasound 11 Weeks

Mitral Atresia – 4D 13 Weeks

AV- Canal – 4D 14 Weeks

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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 #1 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

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SpectrumofCHD

86Circulation. 2017;135:1045–1055.

Early Fetal Imaging National Guidelines - AIUM

http://www.aium.org/resources/guidelines/obstetric.pdf - 2013

ISUOG Guidelines Early Fetal Imaging

http://www.isuog.org - 2013

Early Fetal Imaging National Guidelines

NICHD Consensus on fetal imaging - 2013

•  First trimester ultrasound remains indication driven •  If a late first trimester US is performed – evaluation for early detection of severe anomalies is reasonable •  In some experienced centers, detection of major fetal anomalies in first trimester is possible

Early Fetal Imaging

Do we need a new CPT code for “detailed first trimester ultrasound”

Early Fetal Imaging Spectral Doppler Safety - AIUM

The use of Doppler ultrasound during the first trimester is currently being promoted as a valuable diagnostic aid for screening for and diagnosis of some congenital abnormalities. The procedure requires considerable skill, and subjects the fetus to extended periods of relatively high ultrasound exposure levels. Due to the increased risk of harm, the use of spectral Doppler ultrasound with high TI in the first trimester should be viewed with great caution. Spectral Doppler should only be employed when there is a clear benefit/risk advantage and both TI and examination duration are kept low

http://www.aium.org/officialStatements/42 - 2011

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Early Fetal Imaging National Guidelines - AIUM

http://www.aium.org/officialStatements/42 - 2011

Spectral Doppler Safety - AIUM Early Fetal Imaging

National Guidelines - AIUM Spectral Doppler Safety - ISUOG

• More complex abnormalities • Higher association with

aneuploidy • Higher association with hydrops

Spectrum of CHD Cardiac Imaging in Early Gestation

•  It is easier than you think! • Adjust your US presets (NT+Fetal

Echo) • Attempt to look on every scan •  Look at cardiac axis (measure?) • High definition color optimal •  Look at 3-Vessel-Trachea View

My Recommendations Cardiac Imaging in Early Gestation