Fetal echocardiography

Fetal echocardiography

Kh. Batnasan

United Family Intermed Hospital

Ulaanbaatar, Mongolia

Contents

1. Introduction

2. Indications and imaging technique

3. Congenital heart diseases (CHD)

Contents

1. Introduction



Introduction

Why do we need to check fetal heart?

1. High incidence• 4-13 in 1000 live births (in Mongolia: 8-10 in 1000 live births)

• All mild lesions – 75-80/1000 live births

2. Frequent association with other noncardiac and chromosomal anomalies • CHD 8-42% - extracardiac

• More than 50% with chromosomal anomalies – CHD (+)

Introduction – Cont’d

3. Increased neonatal and childhood morbidity and mortality• Almost one quarters of infant deaths – CHD• CHD – leading cause of perinatal morbidity and mortality

4. Positive impact of prenatal diagnosis on the postnatal

management • Appropriate timing of surgical repair • Shorter ICU stays • Decision of delivery route• Referral to tertiary center• Requirement of urgent postnatal intervention

Contents

1. Introduction



Indications

Maternal indications

• Autoimmune antibodies, anti-Ro (SSA)/anti-La (SSB)

• Familial inherited disorders (22q11.2 deletion syndrome)

• In vitro fertilization

• Metabolic disease (diabetes mellitus and phenylketonuria)

• Teratogen exposure (retinoids and lithium).

Fetal indications

• Abnormal cardiac screening examination

• First-degree relative of a fetus with congenital heart disease

• Abnormal heart rate or rhythm

• Fetal chromosomal anomaly

• Extracardiac anomaly

• Hydrops

• Increased nuchal translucency

• Monochorionic twins

Imaging technique

1. Transverse view of the Upper abdomen

2. Four chamber view

3. Left ventricular outflow tract (LVOT)

4. Right ventricular outflow tract (RVOT)

5. Three vessel view (3 vessel-trachea view)

http://www.tinytickers.org/content/5-view-details

Situs solitus

ISUOG practice guideline: sonographic screening examination of the fetal heart. Ultrasound Obstet Gynecol 2013; 41: 348-359

Four chamber view (FCV)

• Easy to obtain

• 2 types • Subcostal

• Apical

• Detection rate – 40-60%

What to document in FCV

• Axis

• Position

• Size pericardial effusion

• 2 atria roughly equal

• 2 ventricles roughly equal

• Pulmonary venous connections

• Morphology of the ventricles

• AV connections

What to document in FCV

• Axis

• Position

• Size pericardial effusion





• AV connections

• Levocardia

• Dextrocardia

• Mesocardia

What to document in FCV• Axis

• Position

• Size

• Pericardial effusion





• AV connections

What to document in FCV• Axis

• Position

• Size

• Pericardial effusion





• AV connections

ISUOG practice guideline: sonographic screening examination of the fetal heart. Ultrasound Obstet Gynecol 2013; 41: 348-359

Is FCV a good screening tool of the fetal heart?

FCV

• Only 40-60% of CHD can be diagnosed in FCV

• Various studies report – 15-60%

• Why?

Abnormalities of great vessels are not associated with chambers

• Tetralogy of Fallot (TOF)• Transposition of great arteries (TGA)• Truncus arteriosus • Mild aortic stenosis • Pulmonary atresia with VSD • Pulmonary stenosis

Beyond “ four chamber view”

Outflow tract

• Cephaladmovement starting from FVC

Left ventricular outflow tract (LVOT)

• Originates entirely from LV

• Septo-aortic continuity

• Free movement of the valves

• No postvalvular dilatation

• No regurgitation on Color Doppler

Right ventricular outflow tract (RVOT)

• Originates entirely from RV

• Anterior and left of the aorta

• Free movement of the valves

• Bifurcation in two after its origin

• Aorta is seen as a ring

• No regurgitation on Color Doppler

3-vessel view

3-vessel view

• Very useful to assess great vessels

• 3 vessels • Pulmonary artery• Aorta• Superior vena cava (SVC)

• Aligned in a straight line

(from left anterior to the

right posterior)

• Sized in a decreasing order

3-vessel view

Additional views of the fetal heart

Basal short-axis view

• Oblique view through the right lobe of the liver and left shoulder

• Discontinuity between tricuspid and pulmonary valves ( )

• Bifurcation of PA

http://en.academic.ru/dic.nsf/enwiki/3769815

Additional views of the fetal heart

• Aortic arch view

• From 3VV – 90° rotation

• “Candy cane”

• Aortic arch – from the center

of the heart

• Ductal arch – from the

anterior chest wall

Contents

1. Introduction



Congenital heart diseasesAtrial septal defects

Atrial septal defects

Types of ASD:

1. Ostium secundum (secundumASD or fossa ovalis defect)

• Most common (80% of all ASD)

• Located centrally in the atrial septum


2. Ostium primum

• Second most common type

• Usually associated with more complex congenital cardiac anomalies

• Located low in the atrial septum

• Immediately adjacent to the AV valves


3. Sinus venosus

• Very rare

• 5-10% of all ASDs

• 2 types

• Superior sinus venosus• Just inferior to the orifice of the SVC• Blood from SVC to both atria • Anomalous right pulmonary vein

drainage

• Inferior sinus venosus• Adjacent location to the orifice of

IVC

Atrial septal defects - Incidence

• 1 in 1000 live births

• 2:1 in female

• 3rd most common CHD

• Secundum ASD – cannot be diagnosed during fetal life

Atrial septal defects – Sonographic criteria • Larger-than-expected area of the foramen ovale

• “loose pocket”

• Thicker, relatively immobile septum secundum

• Visualized optimally in subcostal FCV

• Color Doppler – helpful (but obscure small defects)

Atrial septal defects – Sonographic criteria

• Primum ASD – the absence of the lower portion of the atrial septum

• Antenatal diagnosis of SV ASD –not reported yet

Atrial septal defects – Prognosis

• Depends on association with other cardiac or non-cardiac anomalies

• Isolated ASD – excellent prognosis

Associated anomalies:

• Holt –Oram syndrome (ASD+upper limb deformities) – 100%

• T13; T21; Triploidy; Turner syndrome and etc.,

Congenital heart diseasesVentricular septal defects

Ventricular septal defects

Interventricular septal regions:

A. View from LV

B. View from RV

1. The membranous septal region

2. The muscular septal region

3. Parietal band or distal conalseptum

Ventricular septal defects

• Most common CHD

• Isolated - 75-90% closure within the 1st year of life

• 2 types of VSD:

• Membranous defect (perimembranous)

• Muscular defect

Ventricular septal defects – Membranous

• Commonly associated with other structural abnormalities

• Up to 80% of VSDs

• Small membranous – greater chance of spontaneous closure

Ventricular septal defects – Muscular

• 10-15% of all VSDs

• Various in size

• Usually multiple defects (“Swiss cheese defects”)

• Spontaneous closure common

• Recurrence risk to the siblings – 3%

Ventricular septal defects – Sonographic criteria

• Color Doppler – useful to diagnose (low velocity scale)

• Best approach – subcostal FCV

• Apical FCV - “T” sign (not 100% reliable)

• LVOT view

• Membranous defect – highest probability of detection

• But high FFR and FNR

Ventricular septal defects – Sonographic criteria

Ventricular septal defects - Prognosis

• Depends on the anatomy and the degree of hemodynamic change

• Samanek et al., • 1-month survival rate – 92%

• 1-year survival rate 80%

• Kidd et al., 1993 - “higher than normal” incidence of serious arrhythmia and sudden death in small VSD

Congenital heart diseasesAtrioventricular septal defects

Atrioventricular septal defects

• Abnormalities included interatrial and interventricular septum and AV valves (mitral and tricuspid)

• Large septal defects in the center of the heart

• Characterized by common annulus with abnormal arrangement of the valve leaflets

• An unwedged position of the aortic valve

• Short dimension of the ventricular inlet


AV valve consists of 5 leaflets

1. Anterior bridging leaflet (ABL)

2. Posterior bridging leaflet (PBL)

3. Right lateral mural leaflet (RLM)

4. Left lateral mural leaflet (LLM)

5. Right anterior leaflet (RAL -between 1 and 3)


Types of AVSD:• Complete AVSD

• Partial AVSD

Levels of shunting:

• Interatrial and interventricular shunt

(not attached atrial or ventricular septal crest)

• Interatrial shunt

(attached to the ventricular septal crest)

Atrioventricular septal defects -

• Incidence - 17% of all CHDs

• Associated with a variety of syndromes and chromosomal anomalies

• 40-80% of AVSD – association with chromosomal anomalies

• T21 – 40% AVSD

• More often in females

Atrioventricular septal defects – Sonographic criteria

• Best approach – FCV (subcostal and apical)

• Complete AVSD – easy to recognize and appears as wide opening within the center of the heart

• Crux (-)

• Balanced; left-dominant; right dominant; (ABL attachment)


• Partial AVSD

• May be difficult to diagnose

• AV valves are present

• Apical FCV

• More apical insertion of tricuspid valve – lost


• Color Doppler – Communication with other chambers

• Elongation of LVOT – “ goose neck”

Atrioventricular septal defects -Prognosis

• If not corrected – death often occurs before 15 y.o

• If other anomalies are associated – death occurs in infancy

• Late death – rare

Congenital heart diseasesHypoplastic left heart syndrome

Hypoplastic left heart syndrome

Hypoplastic left heart syndrome

• Underdevelopment of the left ventricle, mitral valve, aorta and aortic valve

• Most severe from of CHDs

• Most common cause of death from CHDs in the early neonatal period

• 13% of all CHDs

• More often in males

• Always lethal

• Easily recognized in utero

• Keep in mind – it is progressive lesion!

• May not manifest until late 2nd trimester!

• Strong correlation with increased NT in the 1st trimester

• FCV – discrepancy of the ventricles, Extremely small LV

• Important! – recognition of LV (RV – moderator band, tricuspid valve)

• 3VV, short-axis view – atretic (more echoic) ascending aorta + enlarged PA

Hypoplastic left heart syndrome – Sonographic criteria

Congenital heart diseasesTransposition of great arteries TGA

Transposition of great arteries


• Reversed connection of the ventricles and great arteries

• Discordant ventriculoarterial connection

• Aorta from RV

• PA – from LV

Transposition of great arteries – Sonographic criteria

• Recognition of the chambers and great arteries

• Important – Morphologic characteristics

• Sonographic diagnosis – a challenge

•


Complete TGA

• FCV – completely normal chambers

• 3VV –• Triangular arrangement

• AAo: right and anterior malalignment


• LVOT, RVOT views – great vessels are parallel, not crossing • AAo: Arises from RV and

continues as the aortic arch and then descending aorta

• PA: from LV and branches into the left and right PA

• Short-axis view – two side-by-side circular structure

(instead of PA wrapping around

the circular aorta )


Transposition of great arteries –Congenitally corrected TGA

• L-loop ventricular relationship

(morphologically)

• Ao – is in left anterior

• RVOT – Narrowing

• In 60-70% of corrected TGA – VSD (+)

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Healthcare

Fetal echocardiography