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Fetal Cardiac Examination Presentation Transcript

  • 1. EXAMINATION OF THE FETALHEARTDr. Sameer DikshitMD,DGO,FCPS,FICOG
  • 2. FETAL MEDICINE CONSULTANT AT…… S L Raheja-Fortis  Sanket Sonography, Hospital, Mahim Borivali BSES MG Hospital,  Irla Nursing Home, Andheri Vile Parle Nowrosjee Wadia  Belle Vue, Andheri Hospital, Parelwww.birthdefects.in
  • 3.  Trained at King’s College, London Publications in national and international indexed journals Founder secretary Palghar Ob Gy Society FOGSI accredited sonography training centrewww.birthdefects.in
  • 4.  Basic Screening-4 chamber view Extended Basic Screening-4 chamber view + outflow tracts Fetal Echocardiographywww.birthdefects.in
  • 5. EXAMINATION OF FETAL HEARTAs a part of routine sonographic examination
  • 6. BASIC SCREENING- FOURCHAMBER VIEW
  • 7.  A part of routine mid trimester scan Any one who is doing it should be doing it should ATLEAST do a basic screening Preferably extended screeningwww.birthdefects.in
  • 8. FOUR CHAMBER VIEW-ADVANTAGES  Easy to obtain  Move up from AC view  Easy to identifywww.birthdefects.in
  • 9.  Easy to standardize Can be easily included in mid trimester scan protocol without incurring additional expense/ time/ personnelwww.birthdefects.in
  • 10. www.birthdefects.in
  • 11. WHAT DO YOU DOCUMENT???
  • 12. AXIS OF THE HEARTwww.birthdefects.in
  • 13. POSITION OF THE HEARTwww.birthdefects.in
  • 14.  Size Pericardial effusion 2 Atria roughly equal 2 Ventricles roughly equalwww.birthdefects.in
  • 15.  AV valves with offset IVS IAS with foraminal flap Heart ratewww.birthdefects.in
  • 16. www.birthdefects.in
  • 17. www.birthdefects.in
  • 18. www.birthdefects.in
  • 19. www.birthdefects.in
  • 20. “IS 4 CHAMBER VIEW A GOOD SCREENING TEST ?”www.birthdefects.in
  • 21.  Only 40% of CHD can be diagnosed with 4 Ch view Various studies quote a range from 15-60%www.birthdefects.in
  • 22. Screening Test DR Risk Factors approach 11% 4 Chamber View 40%www.birthdefects.in
  • 23. WHY 4 CH VIEW FAILS?www.birthdefects.in
  • 24. CHDS NOT ASSOCIATED WITHABNORMAL 4 CH VIEW 1. Abnormalities of great vessels not associated with any defect on cardiac chambers 2. CHDs with progressive evolution 3. CHDs not detectable in uterowww.birthdefects.in
  • 25. (1) ABNORMALITIES OF GREAT VESSELSNOT ASSOCIATED WITH EFFECT ONCHAMBERS  Mild Aortic stenosis, Tetralogy of Fallot Coarctation of aorta , Pulmonary stenosis Transposition of great vessels  Double outlet ventricle Truncus Arteriosus  Pulmonary atresia with VSDwww.birthdefects.in
  • 26. (2)CHDS WITH PROGRESSIVEEVOLUTION  Pulmonary stenosis  Aortic Coarctation  Ventricular hypoplasiawww.birthdefects.in
  • 27. (3)CHDS NOT DETECTABLE INUTERO Isolated ASD  (Postnatally) Patent ductus arteriosus Small VSD Partial anomalous pulmonary venous  (Postnatally) Patent connection foramen ovalewww.birthdefects.in
  • 28. EXTENDED BASIC SCREENING
  • 29.  4 chamber view Outflow tractwww.birthdefects.in
  • 30. www.birthdefects.in
  • 31. LVOT-LEFT VENTRICULAR OUTFLOWTRACTwww.birthdefects.in
  • 32. LVOT-LEFT VENTRICULAR OUTFLOWTRACT  Originates entirely from LV  Septo Aortic continuity  Free movement of the valves  No post valvular dilatation  No regurgitation on colour dopplerwww.birthdefects.in
  • 33. RVOT-RIGHT VENTRICULAR OUTFLOWTRACTwww.birthdefects.in
  • 34. RVOT-RIGHT VENTRICULAR OUTFLOWTRACT  Originates entirely from RV  It is anterior and to the left of aorta  Free movement of valves  Bifurcates in two after the origin  Aorta is seen as a ring  No regurgitation on Dopplerwww.birthdefects.in
  • 35. OUTFLOW TRACTS-CROSSING OVERwww.birthdefects.in
  • 36. www.birthdefects.in
  • 37. EXTENDED-EXTENDED BASICSCREENING
  • 38.  4 chamber view Outflow tract 3 vessel viewwww.birthdefects.in
  • 39. www.birthdefects.in
  • 40. www.birthdefects.in
  • 41. www.birthdefects.in
  • 42. www.birthdefects.in
  • 43. www.birthdefects.in
  • 44. www.birthdefects.in
  • 45.  Abnormal vessel size (PA>Ao) Abnormal vessel arrangement (LR – Pul-Ao-SVC) Abnormal vessel number (3)www.birthdefects.in
  • 46. ABNORMAL VESSEL SIZE Ao << Pulm  Ao & Pulm enlarged  Hypoplastic Left Heart ◦ Polyvalvular dysplasia  Aortic stenosis  Coarct of Ao Pulm << Ao  Enlarged SVC  Tetralogy of Fallot ◦ Interruption of IVC  Tricuspid Dysplasia ◦ Azygous continuationwww.birthdefects.in
  • 47. ABNORMAL VESSEL NUMBER2 vessels  Transposition of the great vessels  Truncus Arteriosus4 vessels  Persistent L SVCwww.birthdefects.in
  • 48. “YAGEL’S TRANSVERSE PLANETECHNIQUE”
  • 49. 1. AC view2. 4 Chamber view3. 5 Chamber view4. 3 vessel view5. 3 VT view www.birthdefects.in
  • 50. AC VIEWwww.birthdefects.in
  • 51. 4 CH VIEWwww.birthdefects.in
  • 52. 3 V VIEWwww.birthdefects.in
  • 53. “IS ALL THIS POSSIBLE FOR ANANTENATAL CLINIC”
  • 54. “4 CHAMBER VIEW + 3V VIEW + 3VT VIEW IN 2ND TRIMESTER SCAN” J of Perinatal Medicinewww.birthdefects.in
  • 55.  A busy ANC clinic Obstetrician did all mid trimester scans Additional cardiac screening was easily achievable No significantly extra time required Very effectivewww.birthdefects.in
  • 56. LIMITATIONS OF 4 CH + 3V + 3VT SCREENINGwww.birthdefects.in
  • 57. CHDs difficult toCHDs in evolution pick up on echo  Pulmonary stenosis ◦ Isolated ASD ◦ Small VSD  Aortic Coarctation ◦ Patent foramen ovale  Ventricular hypoplasia ◦ Patent ductus arteriosus ◦ Partial anomalous pulmonary venous connectionwww.birthdefects.in
  • 58. HOW EFFECTIVE IS THIS SCREENING??www.birthdefects.in
  • 59. “PRENATAL DIAGNOSIS OF CONGENITAL HEART DISEASE IN A NON-SELECTED POPULATION M. Juan et al Fundacio Hospital Son Llatzer, Spain “Ultrasound in Obstetrics and Gynaecology 2006;28;512-614www.birthdefects.in
  • 60.  6953 fetuses underwent midtrimester scan Yagel’s 5 transverse plane technique was usedwww.birthdefects.in
  • 61.  Neonatal Echocardiography or Autopsy was used to confirm the diagnosis The test had a sensitivity of 92.98% with positive predictive value of 100%www.birthdefects.in
  • 62. Screening Test DR Risk Factors approach 11% 4 Chamber View 40% 5 plane Technique 92%www.birthdefects.in
  • 63. WHAT EXACTLY WE WANT TO ACHIEVE?www.birthdefects.in
  • 64.  Not a comprehensive echocardiography Detailed echocardiography remains the best means to pick up CHDswww.birthdefects.in
  • 65.  But we improve our pick up rate from 4% (cursory look at heart ) to 60% (4 ch view) to 90% (4 ch + 3 VT view) (Li H et al, China Medical University, Shanghai) Integrate with malformation scanwww.birthdefects.in
  • 66. TIMING OF SCREENING FORHEART DEFECTS
  • 67.  ISUOG guidelines suggest that the fetal cardiac examination be performed between 18-22 weeks Under exceptional conditions, it can be performed earlier, especially if First Trimester Screening shows an abnormality or increased Nuchal Translucencywww.birthdefects.in
  • 68. TECHNICAL CONSIDERATIONS
  • 69.  High frequency probe to be used Harmonic imaging may aid in better image quality Gray scale is the basis for examination Narrow image field, high frame rate Image should be zoomed till it occupies 1/3 to 1/ 2 of the display screenwww.birthdefects.in
  • 70. DETAILED FETALECHOCARDIOGRAPHY
  • 71. INDICATIONS FOR FETAL ECHO When the risk for the fetus is more than background rate of 0.8% Maternal indications Fetal indications Increased NTwww.birthdefects.in
  • 72. www.birthdefects.in
  • 73. WHEN SHOULD A FETAL ECHO BE DONE Between 18-22 weeks In case NT is increased then should be done at 14 weeks and then repeated If First Trimester Screening shows some abnormality then repeat at 14 weekswww.birthdefects.in
  • 74. WHAT INFORMATION SHOULDECHOCARDIOGRAPHY PROVIDE? Anatomy of the heart  Size  Situs  Axis  Pericardial Effusionwww.birthdefects.in
  • 75. WHAT INFORMATION SHOULDECHOCARDIOGRAPHY PROVIDE? Morphology of the heart  Size of chambers  Comparison of right and left sides  Relationship of outflow tracts  IVS  AV & Semilunar valves  Arches of Aortawww.birthdefects.in
  • 76. WHAT INFORMATION SHOULDECHOCARDIOGRAPHY PROVIDE? Connections of the heart  Venous- Atrial  Atrio-Ventricular  Ventriculo-Arterialwww.birthdefects.in
  • 77. WHAT INFORMATION SHOULDECHOCARDIOGRAPHY PROVIDE? Function of heart  Myometrial contractility  Size  Endocardium  Flow across the connectionswww.birthdefects.in
  • 78. WHAT INFORMATION SHOULDECHOCARDIOGRAPHY PROVIDE? Rhythm of the heart  Atrial & Ventricularwww.birthdefects.in
  • 79.  If an abnormality is detected, then it should be mapped and as correct diagnosis as possible should be givenwww.birthdefects.in
  • 80.  Real time 2D scanning Colour Doppler Spectral Doppler M mode STICwww.birthdefects.in
  • 81. (1)RATE AND RHYTHM
  • 82. www.birthdefects.in
  • 83. www.birthdefects.in
  • 84. (2)VENO-ATRIAL CONNECTIONS
  • 85. VENO-ATRIAL CONNECTIONS- RIGHTATRIUMwww.birthdefects.in
  • 86. VENO-ATRIAL CONNECTIONS-LEFT ATRIUMwww.birthdefects.in
  • 87. www.birthdefects.in
  • 88. www.birthdefects.in
  • 89. INTER-ATRIAL SEPTUM
  • 90. INTER ATRIAL SEPTUMwww.birthdefects.in
  • 91. www.birthdefects.in
  • 92. www.birthdefects.in
  • 93. ATRIO-VENTRICULAR VALVES
  • 94. ATRIO-VENTRICULAR VALVESwww.birthdefects.in
  • 95. www.birthdefects.in
  • 96. www.birthdefects.in
  • 97. www.birthdefects.in
  • 98. www.birthdefects.in
  • 99. INTER VENTRICULAR SEPTUM
  • 100. INTER VENTRICULAR SEPTUMwww.birthdefects.in
  • 101. www.birthdefects.in
  • 102. www.birthdefects.in
  • 103. SHORT AXIS VIEW OF THE HEART
  • 104. SHORT AXIS VIEWwww.birthdefects.in
  • 105. AORTIC AND PULMONARYARCHES
  • 106. OUTFLOW TRACTSwww.birthdefects.in
  • 107. www.birthdefects.in
  • 108. DUCTUS VENOSUS
  • 109. FMF VIDEOS
  • 110. www.birthdefects.in
  • 111. VSD
  • 112. www.birthdefects.in
  • 113. NORMAL IN LATE PREGNANCY
  • 114. www.birthdefects.in
  • 115. TRICUSPID REGURGITATION
  • 116. www.birthdefects.in
  • 117. AVSD
  • 118. www.birthdefects.in
  • 119. EBSTEIN’S MALFORMATION
  • 120. www.birthdefects.in
  • 121. HEART BLOCK
  • 122. www.birthdefects.in
  • 123. TAPVR
  • 124. www.birthdefects.in
  • 125. SMALL CHEST-SKELETALDYSPLASIA
  • 126. www.birthdefects.in
  • 127. DEXTROCARDIA
  • 128. www.birthdefects.in
  • 129. ANEMIA
  • 130. www.birthdefects.in
  • 131. BILATERAL REGURGITATION
  • 132. www.birthdefects.in
  • 133. RHABDOMYOMAS
  • 134. www.birthdefects.in
  • 135. LUNG HYPOPLASIA
  • 136. www.birthdefects.in
  • 137. CONGENITAL DIAPHRAGMATICHERNIA
  • 138. THANK YOU
  • 139. WHAT INFORMATION SHOULDECHOCARDIOGRAPHY PROVIDE?www.birthdefects.in
  • 140. www.birthdefects.in
  • 141. www.birthdefects.in