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Ppt fetal echo
Ppt fetal echo
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  1. 1. •Structural cardiac anomalies are estimated to occur in 8 of 1,000 live births •Cardiovascular anomalies are frequently associated with other congenital anomalies because the heart begins to develop the 3rd week after conception and continues to develop until the end of the 8th week.
  2. 2. •Since most cardiac abnormalities are found in patients without associated risk factors, evaluation of the fetal heart is an important component of a routine obstetric ultrasonographic examination.
  3. 3. •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 Translucency
  4. 4. • Firstly, a ‘basic’ scan should be performed by analyzing a four-chamber view of the fetal heart. • Secondly, an ‘extended-basic’ scan further examines the size and relationships of both arterial outflow tracts. • The term ‘fetal echocardiogram’ was also mentioned as a more detailed sonographic evaluation to be performed by specialists in the prenatal diagnosis of CHD.
  5. 5. •Maternal indication •Fetal indication
  6. 6. •A fetal echocardiogram should be performed if recognized risk factors raise the likelihood of congenital heart disease beyond what would be expected for a low-risk screening population.
  7. 7. •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 screen
  8. 8. Before any abnormalities can be described, the proper technique of fetal heart ultrasound examination should be discuses
  9. 9. •First know the orientation of the fetus: •Presentation and lie of the fetus •Supine or prone position •The spine becomes the point of reference in determining fetal orientation.
  10. 10. R R
  11. 11. WHAT CONSTITUTES A FATAL CARDIAC EXAMINATION •Basic Screening-4 chamber view •Extended Basic Screening-4 chamber view + outflow tracts •Fetal Echocardiography
  13. 13. BASIC SCREENING FOUR CHAMBER VIEW •A part of routine mid trimester scan • Any one who is doing it should be doing it should At LEAST do a basic screening • Preferably extended screening
  14. 14. BASIC SCREENING FOUR CHAMBER VIEW •Easy to obtain •Move up from AC view •Easy to identify •Easy to standardize •Can be easily included in mid trimester scan protocol without incurring additional expense/ time.
  16. 16. AXIS OF THE HEART •Situs abnormalities should be suspected when the fetal heart and/or stomach is/are not found on the left side as well. •Abnormal axis increases the risk of a cardiac malformation, especially involving the outflow tracts.
  18. 18. POSITION OF THE HEART •Abnormal cardiac position can be caused by a diaphragmatic hernia or space-occupying lesion, such as cystic adenomatoid malformation. •Position abnormalities can also be secondary to fetal lung hypoplasia or agenesis.
  19. 19. •Size •Pericardial effusion •2 Atria roughly equal •2 Ventricles roughly equal
  20. 20. • Two distinct atrioventricular valves (right-sided, tricuspid and left-sided, mitral) should be seen to open separately and freely. • The septal leaflet of the tricuspid valve is inserted to the septum closer to the apex when compared to the mitral valve (i.e. normal offset). • Abnormal alignment of the atrioventricular valves can be a key sonographic finding for cardiac anomalies such as atrioventricular septal defect
  21. 21. HEART RATE • Cardiac rate and regular rhythm should be confirmed. • The normal rate ranges from 120 to 160 beats per minute. • Mild bradycardia is transiently observed in normal second- trimester fetuses. • Fixed bradycardia, especially heart rates that remain below 110 beats per minute, requires timely evaluation for possible heart block. • Repetitive heart rate decelerations during the third trimester can be caused by fetal distress. • Persistent tachycardia, however, should be further evaluated for possible fetal distress or more serious tachydysrhythmias.
  22. 22. SUMMARY
  23. 23. • Two-thirds of the heart in left hemithorax.
  24. 24. • Apex on the left, with 45° ± 20° cardiac axis (levocardia).
  25. 25. • At least two pulmonary veins draining in the left atrium.
  26. 26. • Two atria of similar size.
  27. 27. • Foramen ovale flap opening into the left atrium, with evidence of the septum premium.
  28. 28. • Presence of the crux of the heart, with offset aspect of the two atrioventricular valves, which show normal systo-diastolic excursion.
  29. 29. • Two ventricles of similar diameter, with mild prevalence of the right one, which also shows a rounder appearance because of the presence of the moderator band. The left ventricle forms the cardiac apex.
  30. 30. • Equal thickness of the free ventricular walls, with normal contractility.
  31. 31. • Intact interventricular septum. In addition, the rhythm and rate should be checked.
  32. 32. SUMMARY
  33. 33. • Normal heart.
  34. 34. • Right atriomegaly from tricuspid dysplasia and insufficiency.
  35. 35. • Ebstein’s anomaly, with apical displacement of the insertion of the tricuspid valve.
  36. 36. • Ventricular septal defect.
  37. 37. • Atrioventricular septal defect (with common atrioventricular valve).
  38. 38. • Left ventricular hypoplasia and mitral atresia (hypoplastic left heart syndrome).
  39. 39. • Right ventricular hypoplasia (plus ventricular septal defect) due to tricuspid atresia
  40. 40. • Double-inlet single ventricle.
  41. 41. • Ventricular disproportion and moderate prevalence of the right ventricle (an indirect sign of aortic coarctation).
  42. 42. • Biventricular hypertrophy (cardiomyopathy).
  43. 43. • Tumors (rhabdomyomatosis).
  45. 45. LIMITATIONS OF 4 CHAMBERS VIEW •Only 40% of CHD can be diagnosed with 4 Chamber view • Various studies quote a range from 15-60%
  46. 46. LIMITATIONS OF 4 CHAMBERS VIEW • WHY 4 CH VIEW FAILS? • CHD NOT ASSOCIATED WITH ABNORMAL 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 utero
  47. 47. LIMITATIONS OF 4 CHAMBERS VIEW (1) ABNORMALITIES OF GREAT VESSELSNOT ASSOCIATED WITH EFFECT ON CHAMBERS: • Mild Aortic stenosis, • Tetralogy of Fallot • Coarctation of aorta • Pulmonary stenosis • Transposition of great vessels • Double outlet ventricle • Truncus Arteriosus • Pulmonary atresia with VSD
  48. 48. LIMITATIONS OF 4 CHAMBERS VIEW (2) CHDS WITH PROGRESSIVE EVOLUTION •Pulmonary stenosis •Aortic Coarctation •Ventricular hypoplasia
  49. 49. LIMITATIONS OF 4 CHAMBERS VIEW (3) CHDS NOT DETECTABLE INUTERO •Isolated ASD •(Postnatally) Patent ductus arteriosus •Small VSD •Partial anomalous pulmonary venous •(Postnatally) Patent connection foramen ovale
  50. 50. EXTENDED BASIC SCREENING 4 chamber view + Outflow tract
  52. 52. •Originates entirely from LV •Septo Aortic continuity •Free movement of the valves •No post valvular dilatation •No regurgitation on color Doppler
  53. 53. •LVOT is truly the aorta, it should even be possible to trace the vessel into its arch •The LVOT view may help to identify ventricular septal defects and conotruncal abnormalities that are not seen during the basic cardiac examination alone.
  54. 54. •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 Doppler
  55. 55. Differentialdiagnosisofleftoutflow tractanomalies Out flow obstruction Cross over anomalies transposition of the great arteries double-outlet right ventricle Anomalies of septo-aoratic continuity Right out flow tract assessment
  56. 56. • transposition of the great arteries, if each vessel is connected with the contralateral ventricle ( left ventricle-pulmonary artery and right ventricle -aorta;
  57. 57. • double-outlet right ventricle, if both great vessels are connected with the right (anterior) ventricle.
  58. 58. • Hypoplastic Left Heart Syndrome • Endocardial Cushion Defect • Ventricular Septal Defect • Persistent Truncus Arteriosus • Complete Transposition of the Great Arteries • Double-Outlet Right Ventricle • Tetralogy of Fallot
  59. 59. • Hypoplastic left heart syndrome is a spectrum of heart malformations that consists of a small left ventricle, which is associated with aortic atresia and an atretic or hypoplastic mitral valve. • Represents 2%–4% of congenital heart defects
  60. 60. • In making the diagnosis, the four-chamber view is usually sufficient to, demonstrate the abnormalities • Base view may be helpful in documenting the disproportionately smaller aorta in comparison to the pulmonary artery
  61. 61. • When the endocardial cushions fail to fuse, a wide range of atrioventricular septal defects occur. • The complete form of endocardial cushion defect consists of a large defect involving the inferior portion of the atrial septum and the posterior portion of the ventricular septum
  62. 62. •An endocardial cushion defect can be accurately diagnosed by using only the four-chamber view
  63. 63. • one of the most common cardiac anomalies, accounting for 20%–40% of congenital heart defects • A normal interventricular septum extends from the cardiac apex to the atrial septum • Formation of the interventricular septum begins at approximately 28 days gestation when the median muscular ridge begins to invaginate.
  64. 64. • The muscular septum fuses with the membranous septum formed by the endocardial cushions at approximately 49 days gestation • A ventricular septal defect (VSD) results from maldevelopment of the embryonic muscular septum, maldevelopment of the endocardial cushions, or excess resorption of myocardial tissue in the muscular septum
  65. 65. • A large VSD is easily diagnosed on the four-chamber view alone. • However, color Doppler US may be needed to demonstrate smaller defect • Some may not be detected until after birth.
  66. 66. • Persistent truncus arteriosus accounts for approximately 1%–2% of congenital heart defects • It is characterized by a single overriding arterial trunk that feeds both the aorta and the pulmonary artery. • The undivided truncus receives blood from both ventricles. • A VSD is almost always present
  67. 67. • This diagnosis may not be apparent on the four- chamber view alone. • However, several attempts at obtaining a base view will fail to reveal normal crossing of the great vessels. • Instead, a single vessel is seen with several branches connecting with the pulmonary vessels and aorta
  68. 68. •Represents 2.5%–5% of congenital heart defects •This occurs by the caudal and spiral growth of the conal truncal ridge, which is usually complete by the end of the 4th week after conception
  69. 69. • Only when the aorta is seen to arise definitely from the right ventricle and the pulmonary artery is seen to arise definitely from the left ventricle can one be confident of the diagnosis. • The base view of the fetal heart is needed to confirm the diagnosis by demonstrating that the great vessels do not cross
  70. 70. • Tetralogy of Fallot is caused by unequal division of the conus resulting from anterior displacement of the truncoconal system. • Tetralogy of Fallot has four classic features: a VSD, an overriding aorta, pulmonary artery stenosis, and right ventricular hypertrophy. Owing to the shunts that exist in the fetal circulation, the right ventricular hypertrophy may not be seen in utero. • Represents approximately 3%–7% of congenital heart defects
  71. 71. • The diagnosis of tetralogy of Fallot is suspected when a large VSD leads into a great vessel that straddles the interventricular septum. • The pulmonary artery may not be easily demonstrated, since the predominant feature of the anomaly is usually the overriding aorta. Again, the main reason for suspecting this anomaly is failure to demonstrate the normal crossing of the great vessels at the base of the heart
  73. 73. • Gray scale and Doppler image Four chamber view of fetal heart show a defect in proximal part of VSD with right to left flow seen in Doppler images. Normal axis, position…….. • Dx: VSD •IS THIS ENOUGH??!! •NO.. • VSD ASSOCIATED WITH . • Transposition of the great arteries Tetralogy of Fallot Truncus arteriosus • OTHER VIEW IS ESSENTIAL
  74. 74. • Gray scale of left out flow view show fetal heart show a defect in proximal part of VSD, the malalignment ventricular septal defect leads into a great vessel that straddles the interventricular septum •Dx: Tetralogy of Fallot

Notas do Editor

  • Four-chamber view of the fetal heart. Key components of a normal four-chamber view include an intact interventricular septum and atrial septum primum. There is no disproportion between the left (LV) and right (RV) ventricles. A moderator band helps to identify the morphologic right ventricle. Note how the ‘offset’ atrioventricular septal valve leaflets insert into the crux
  • Both atrial chambers normally appear similar in size and the foramen ovale flap should open into the left atrium
    mandatory part of a basic cardiac screening examination.
    The lower rim of atrial septal tissue, called the septum primum, should be present.
    A moderator band helps to identify the morphologic right ventricle.
    Both ventricles should also appear similar in size without evidence for thickened walls. Although mild ventricular disproportion can occur as a normal variant, hypoplastic left heart syndrome and aortic coarctation are important causes of this disparity
    The ventricular septum should be carefully examined for cardiac wall defects from the apex to the crux
    AV valves with offset

    Heart rate

  • etal heart scanning technique. The four-chamber view of the heart is obtained from an axial scanning plane across the fetal thorax. Corresponding views of the left (LVOT) and right (RVOT) ventricular outflow tracts are found by angling the transducer toward the fetal head.
  • Hypoplastic left heart syndrome in a fetus with a cephalic presentation. Transabdominal US image (four-chamber view) shows that the left ventricle is small relative to the right ventricle and the left atrium is small relative to the right atrium. Arrow spine.
  • Endocardial cushion defect in a fetus with a cephalic presentation. Transabdominal US image (four-chamber view) shows absence of the interventricular and interatrial septa, thus producing connections between the ventricles and between the atria.