4. 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 (+)
5. 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
12. 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
13. 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
• Levocardia
• Dextrocardia
• Mesocardia
14. 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
15. 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
16. ISUOG practice guideline: sonographic screening examination of the fetal heart. Ultrasound Obstet Gynecol 2013; 41: 348-359
17. Is FCV a good screening tool of the fetal heart?
18. 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”
20. 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
21.
22. 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
24. 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
26. 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
27. 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
30. Atrial septal defects
Types of ASD:
1. Ostium secundum (secundum
ASD or fossa ovalis defect)
• Most common (80% of all ASD)
• Located centrally in the atrial septum
31. Atrial septal defects
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
32. 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
33. 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
34. 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)
35. 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
36. 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.,
38. 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
39. 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
40. Ventricular septal defects – Membranous
• Commonly associated with other structural abnormalities
• Up to 80% of VSDs
• Small membranous – greater chance of spontaneous closure
41. 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%
42. 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
44. 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
46. 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
47. 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)
48. 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)
49. 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
50. 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)
51. 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
52. Atrioventricular septal defects – Sonographic criteria
• Color Doppler – Communication with other
chambers
• Elongation of LVOT – “ goose neck”
53. 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
56. 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
57. • 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
60. Transposition of great arteries
• Reversed connection of the ventricles and great arteries
• Discordant ventriculoarterial connection
• Aorta from RV
• PA – from LV
61. Transposition of great arteries – Sonographic criteria
• Recognition of the chambers and great arteries
• Important – Morphologic characteristics
• Sonographic diagnosis – a challenge
•
62. Transposition of great arteries – Sonographic criteria
Complete TGA
• FCV – completely normal
chambers
• 3VV –
• Triangular arrangement
• AAo: right and anterior
malalignment
63. 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
• Short-axis view – two side-by-
side circular structure
(instead of PA wrapping around
the circular aorta )
65. 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 (+)
Prenatal diagnosis of CHD has positive impact on postnatal management with reduced surgical delays, shorter ICU stays, decision of delivery routes, requirement of urgent postnatal management and etc.,