Antenatal Diagnosis of Fetal Heart Disease
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Detail of all major congenital heart diseases
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Semelhante a Antenatal Diagnosis of Fetal Heart Disease
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Antenatal Diagnosis of Fetal Heart Disease
- 1. Dr. Tarique Ajij Resident, Radio-Diagnosis, Medical College, Kolkata
- 3. Atrial septal defects 5th most common form of congenital heart disease and is the most common form in adult patients 1 per 1500 live births 6.7% of CHD in live-born infants
- 4. Atrial septal defects: Atrial Septum Developement Septum Primum Osteum primum: disappears Osteum secondum Septum Secondum, right to above Foramen ovale
- 5. Atrial septal defects Types of ASD: 1. Ostium secundum (secundum ASD or fossa ovalis defect) Most common (80% of all ASD) excessive resorption of the septum primum (foraminal flap) or by inadequate growth of the septum secundum Located centrally in the atrial septum
- 6. Atrial septal defects 2. Ostium primum Second most common type Usually associated with more complex congenital cardiac anomalies like ASVD Located low in the atrial septum Immediately adjacent to the AV valves
- 7. Atrial septal defects 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
- 8. Atrial septal defects – Sonographic criteria Secundum ASD – cannot be diagnosed during fetal life Larger-than-expected area of the foramen ovale (normal foramen ovale differs by 1 mm or less from the aortic root diameter at all gestational ages) Visualized optimally in subcostal FCV Color Doppler – helpful (but obscure small defects)
- 9. 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
- 10. 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.,
- 12. 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 conal septum
- 13. Ventricular septal defects Most common CHD, 30% of heart defects diagnosed in live-born infants Isolated - 75-90% closure within the 1st year of life 2 types of VSD: Membranous defect (perimembranous) Muscular defect
- 14. Ventricular septal defects – Membranous Commonly associated with other structural abnormalities Up to 80% of VSDs Small membranous – greater chance of spontaneous closure
- 15. 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%
- 16. Ventricular septal defects – Sonographic criteria Apical FCV - “T” sign (not 100% reliable) Best approach – subcostal FCV Color Doppler – useful to diagnose (low velocity scale) Bidirectional VSD can be diagnosed LVOT view Membranous defect – highest probability of detection
- 17. Ventricular septal defects – Sonographic criteria
- 18. Ventricular septal defects – Sonographic criteria
- 19. 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
- 21. Atrioventricular septal defects AKA Endocardial cushion defect / AV canal defect 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 Associated with Left atrial isomerism, CHB, septum secundum ASD, hypoplastic left heart syndrome, valvular pulmonary stenosis, coarctation of the aorta, and tetralogy of Fallot Associated extracardiac anomalies are common, including omphalocele, duodenal atresia, tracheoesophageal atresia, facial clefts, cystic hygroma, neural tube defects, and multicystic kidneys
- 22. Atrioventricular septal defects Suspicion of AVSD: 1. Abnormalities included interatrial and interventricular septum and AV valves (mitral and tricuspid) 2. Large septal defects in the center of the heart 3. Characterized by common annulus with abnormal arrangement of the valve leaflets 4. An unwedged position of the aortic valve 5. Short dimension of the ventricular inlet
- 24. Atrioventricular septal defects 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)
- 25. Atrioventricular septal defects 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)
- 26. 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 / single AV valve The defect is better visualized in diastole than in systole Crux (-) Balanced; left-dominant; right dominant; (ABL attachment)
- 27. Atrioventricular septal defects – Sonographic criteria Elongation of LVOT – “ goose neck”
- 28. Atrioventricular septal defects – Sonographic criteria Color Doppler: open area of flow across the atrioventricular septal defect and the abnormal A-V valve Holosystolic valvular insufficiency a left ventricular–to–right atrial jet can be identified across the ostium primum defect before the onset of holosystolic valvular insufficiency Balanced AVSD
- 29. Atrioventricular septal defects – Sonographic criteria Unalanced AVSD
- 30. Atrioventricular septal defects – Sonographic criteria Partial AVSD May be difficult to diagnose AV valves are present Apical FCV More apical insertion of tricuspid valve – lost
- 31. Atrioventricular septal defects – Sonographic criteria
- 32. Atrioventricular septal defects -Prognosis If not corrected – death often occurs before 15 yrs If other anomalies are associated – death occurs in infancy Late death – rare
- 33. Ebstein Anomaly
- 34. Ebstein Anomaly 7% of cardiac anomalies in the fetal population approximately 1 per 20,000 live births Associated with use of Lithium Associated with pulmonary atresia or stenosis, arrhythmias, and chromosomal anomalies. Ebstein anomaly is characterized by apical displacement of the tricuspid valve Enlarged right atrium containing a portion of the “atrialized” right ventricle Reduction in size of the functional right ventricle Cardiac dysfunction in utero, frequently with cardiomegaly, hydrops, and tachyarrhythmias
- 35. Ebstein Anomaly: B mode USG
- 36. Ebstein Anomaly: color Doppler color Doppler: TR causing further RA enlargement Tethered distal attachments of the tricuspid valve, marked right atrial enlargement compression with narrowing of the pulmonary outflow tract are all associated with a poor prognosis supraventricular tachycardias, are common with Ebstein anomaly and can further compromise the fetus
- 37. Ebstein Anomaly: Prognosis the 3-month mortality rate of patients diagnosed in utero is 80% Surgical correction of Ebstein anomaly in young children is associated with a low mortality and an excellent quality of life
- 38. Hypoplastic left heart syndrome
- 39. 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 The primary abnormalities include aortic atresia, aortic stenosis, and mitral valve atresia. It is associated with coarctation of the aorta in 80% of cases
- 40. Hypoplastic left heart syndrome – Sonographic criteria 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
- 41. Hypoplastic left heart syndrome Color Doppler: demonstrating the absence of flow through the mitral and aortic valves
- 42. Hypoplastic left heart syndrome
- 43. Hypoplastic left heart syndrome
- 45. Tetralogy of Fallot 5% to 10% of CHD in live births associated with a variety of cardiac and extracardiac abnormalities and chromosomal anomalies Tetralogy of Fallot consists of (1) VSD, (2) overriding aorta, (3) hypertrophy of the right ventricle, and (4) stenosis of the right ventricular outflow tract
- 46. Tetralogy of Fallot: Imaging
- 47. Tetralogy of Fallot: Imaging
- 48. Tetralogy of Fallot: Color Doppler
- 49. Tetralogy of Fallot: Color Doppler PSV in A: 85 cm/sec PSV in B: 130 cm/sec
- 50. Tetralogy of Fallot: Advanced Imaging
- 51. Tetralogy of Fallot: Prognosis Typical cases of tetralogy of Fallot are repaired at 4 to 6 months of age, with close to 90% survival at 1 year Patients surviving early surgery (before 5 years old) have a 32-year survival of 90% The presence of congestive heart failure in the fetus or newborn is associated with 17% to 41% mortality
- 53. Double-Outlet Right Ventricle Less than 1% of all CHD Double-outlet RV is associated with other cardiac defects (particularly VSD), various extracardiac defects, fetal chromosomal anomalies, maternal diabetes, and maternal alcohol consumption.
- 56. Double-Outlet Right Ventricle: Prognosis With surgical intervention, 10-year survival is up to 97% When extracardiac or chromosomal anomalies are present, prognosis is poor, with 69% mortality when the diagnosis of DORV is made in utero
- 57. Transposition of great arteries / TGA
- 58. Transposition of great arteries Two types: complete or dextrotransposition (D-TGA) in 80% corrected or levotransposition (L-TGA) in 20%
- 59. Transposition of great arteries – Sonographic criteria Recognition of the chambers and great arteries Important – Morphologic characteristics Sonographic diagnosis – a challenge
- 60. Transposition of great arteries – Sonographic criteria Complete TGA FCV – completely normal chambers 3VV – Triangular arrangement AAo: right and anterior malalignment 3VT – single Aorta left to SVC
- 61. Transposition of great arteries – Sonographic criteria 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
- 62. Transposition of great arteries – Sonographic criteria Long-axis view – two side-by-side circular structure (instead of PA wrapping around the circular aorta )
- 63. Transposition of great arteries – Sonographic criteria Long-axis view – two side-by-side circular structure (instead of PA wrapping around the circular aorta )
- 64. Transposition of great arteries – Sonographic criteria
- 65. Transposition of great arteries – Sonographic criteria
- 66. Transposition of great arteries
- 67. Transposition of great arteries – Prognosis After birth, d-TGA is incompatible with life unless some shunts are presents. Temporizing shunt is created before definitive treatment. With surgical intervention, 12-month survival can be expected in 80% In the absence of associated cardiac anomalies, patients with corrected TGA may remain asymptomatic throughout their lives.
- 69. Coarctation of Aorta incidence of 6% prenatally 90% of the cases are associated with other cardiac anomalies, including abnormal aortic valve (bicuspid or stenotic), VSD, DORV, and AVSD Ventricular size discrepancy with a prominent right ventricle and relatively small left ventricle Color Doppler ultrasound is useful in identifying the area of narrowing. Spectral Doppler ultrasound may detect increased flow distal to the narrowed segment Many coarctations do not become evident until closure of the ductus arteriosus at birth
- 73. Coarctation of Aorta: Prognosis Although isolated coarctation has a good prognosis, 39% mortality is reported when associated anomalies are present
- 74. Cardiac Rhabdomyoma solid, echogenic masses singular or multiple, typically arising from the inter-ventricular septum 30% to 78% have tuberous sclerosis hemodynamically signifcant by causing obstruction to the outflow tracts or A-V valves, resulting in congestive heart failure, hydrops, pericardial effusion, and arrhythmias Prognosis depends on the size, number, and exact location of the tumor as well as associated arrhythmias and anomalies
- 75. Fetal Arrhythmia
- 76. APC M-mode recording of a fetus with conducted premature atrial contractions. The M-mode cursor line intersects the right atrium (RA) and left ventricle (LV). Normal atrial contractions (A) are seen followed by normal ventricular contractions (V). Two premature atrial contractions are shown (arrows) followed by two premature ventricular contractions (asterisk)
- 78. 1˚ HB and 2˚ HB
- 79. SVT and Atrial Flutter
Notas do Editor
- “loose pocket” Thicker, relatively immobile septum secundum
- VSDs have the highest recurrence rate and the highest association with teratogen exposure
- R to L on systole and reverse on diastole
- Atrioventricular septal defects are considered balanced when the A-V junction is connected to both the right and the left ventricle, such that blood flow is relatively evenly distributed. If this connection exists with primarily one ventricle, such as in the setting of a hypoplastic left ventricle, it is termed an unbalanced AVSD
- Color Doppler during systole at the four-chamber view in two fetuses with Ebstein anomaly demonstrating severe tricuspid regurgitation into the dilated right atrium (RA). Open arrows point to the site of closure of the dysplastic tricuspid valves. Solid arrows point to the attachment of the mitral valves. Note the anatomic origin of the regurgitant jet, deep in the right ventricle (RV), a differentiating point from tricuspid dysplasia
- Three-dimensional tomographic display of the chest and abdomen at 30 (A) and 33 (B) weeks’ gestation in a fetus with Ebstein anomaly showing the development of ascites at 33 weeks (B). This fetus died in utero at 36 weeks’ gestation. RA, right atrium; RV, right ventricle.
- Three-vessel-trachea view in a fetus with hypoplastic left heart syndrome in twodimensional (A) and color Doppler (B) imaging. In A, the ascending aorta is not visible on twodimensional ultrasound (open arrow). Color Doppler as seen in B aids in the visualization of the aortic arch (AOA) (open arrow) with reverse blood flow to that of the ductal arch (DA)
- Four-chamber view in two-dimensional (A) and color Doppler (B) imaging in a fetus with hypoplastic left heart syndrome at 21 weeks’ gestation. The atrial septum bulges into he right atrium (RA) (black open arrow) due to left-to-right shunting at the foramen ovale. B demonstrates left-to-right blood shunting at the foramen ovale on color Doppler A: Reverse flow in the transverse aortic arch (AOA) on color Doppler at the three-vessel-trachea view. B: A three-dimensional-rendered image in glass body mode showing a sagittal view of the ductal arch (DA) with retrograde flow across the aortic isthmus (arrow) into the aortic arch. LPA, left pulmonary artery; PA, pulmonary artery
- 2nd image: A normal, B TOF
- concordance discordance
- This is nutshell about diagnosis CHD. There are so many heart diseases that can affect fetus. I mentioned only those are important and common.