Disclosure - 18th Annual High-Risk Fetal Imaging ...From Practical Guide To Fetal Echocardiography:...
Transcript of Disclosure - 18th Annual High-Risk Fetal Imaging ...From Practical Guide To Fetal Echocardiography:...
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Fetal Cardiac Imaging: Improving Detection of Congenital Heart Disease
Alfred Abuhamad, M.D. Eastern Virginia Medical School
Disclosure
•Ihavenorelevantfinancialrelationshiptodisclose•Iwillnotbediscussingoff-labeluseofmedicationsorproducts
The Top 4 Critical Anatomic Regions in Fetal Cardiac Imaging
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Top Critical Anatomic Regions
1. Normal Left Atrium
�4
Left Atrium
Ao
Left Atrium
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Pulmonary Veins
Pulmonary Veins
Left Atrium7
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Esophagus
Ao LA
Swallowing
Ao LA
Left Atrium
Left Atrium
Closed Esophagus Open Esophagus
TAPVR
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SupracardiacTAPVR
From Practical Guide To Fetal Echocardiography: Normal & Abnormal Hearts– Abuhamad, Chaoui – 3rd Edition -Oct 2015
Cardiac7 TAPVR
InfracardiacTAPVR
From Practical Guide To Fetal Echocardiography: Normal & Abnormal Hearts– Abuhamad, Chaoui – 3rd Edition -Oct 2015
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Left Atrium
TAPVRFrom Practical Guide To Fetal Echocardiography: Normal & Abnormal Hearts– Abuhamad, Chaoui – 3rd Edition -Oct 2015
Left Atrium
TAPVR
AO Azygos
AO
Left Atrium
Normal TAPVR
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TAPVR
�19 J Ultrasound Med 2014; 33:1193–1207
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�30
Do Not Miss The Diagnosis of a Normal Left Atrium
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1. Normal Left Atrium 2. Normal Left Ventricular Outflow
�31
Top Critical Anatomic Regions
LeCVentricularOuElow
LeCVentricularOuElow
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Normal TOFLeCVentricularOuElow
TOF
LeCVentricularOuElow
TOF
LeCVentricularOuElow
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LeCVentricularOuElow
LeCVentricularOuElow
From Practical Guide To Fetal Echocardiography: Normal & Abnormal Hearts– Abuhamad, Chaoui – 3rd Edition -Oct 2015
LeCVentricularOuElow
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LeCVentricularOuElow
10TGA:LeCVentricularOuElow
10TGA:LeCVentricularOuElow
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10TGA:LeCVentricularOuElow
10TGA:LeCVentricularOuElow
LVPA
Transposition of Great Arteries10
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Transposition of Great Arteries10
Transposition of Great Arteries10
�48Ultrasound Obstet Gynecol 2015; 45: 678
Overall rate of detection 23 %
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Normal Left Ventricular Outflow
•Mitral - aortic continuity •Aorta within left ventricle •Angle of ascending aorta with ventricular septum
•Aorta does not divide •Close observation of aortic valves
�50
Do Not Miss The Diagnosis of a Normal Left Ventricular Outflow
�51
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L
L
L
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L
L
• D-TGA–classic• VSD• Abnormal3VTView
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�59
L
LA
LV
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L
L
L
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L
L
L
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• TGA(atypical-posterior)• VSD• Normal-looking3VTView
1. Normal Left Atrium 2. Normal Ascending Aorta 3. Normal 3VT View
�69
Top Critical Anatomic Regions
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TransverseViews
Three-VesselView
DuctalArchView
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AorTcArchView
Three-VesselTracheaView
LeCBrachiocephalicVein
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LeCBrachiocephalicVein
3VTView
�77
PA
DA
Thymus AoA
Isthmus
SVC
E
AzV
PA
Thymus
AoA
Tr
SVC
R
L
Tr
R
L
BA
3VTView
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Azygos
PA AoA
Tr
SVC
„Thy-Box“
AoA
SPSP
Sternum
TrL L
BA
3VTView
PAAoA
L
R
SP
Tr
SVC
L
R
PAAoA
Tr
SVC
SPBA
3VTView
Blood Flow Towards the Spine
3VT
�81
Spine
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3VTView
3VTView
Follow the Aorta
13 wks
3VTView
Courtesy of Dr. Chaoui
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3VTView
• Course and size of PA, Ao and SVC• Aortic isthmus and ductus arteriosus• Aortic arch right or left-sided ?
(Trachea as landmark)
• Thymus visualized• Assessment with Color Doppler: “Blue V” or “Red V”
• Atypical vessels (left persistent SVC - Vertical Vein)
Checklist 3-VT-view
O
PAAo
Trachea
SVC
Thymus
3VT:3VesselsSeen
�87
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�88Coarctation of the Aorta Hypoplastic Left Heart Syndrome
3VTView:3VesselsSeenSmallAorta
!89
CoarctaTonofAorta
Hypoplastic Left Heart Syndrome
3VT View: 3 Vessels SeenSmall Aorta
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�91Pulmonary Stenosis - TOF Pulmonary Atresia
3VTView:3VesselsSeenSmallPA
TOF-PulmonaryStenosis
Pink
TOF-PulmonaryStenosis
Blue
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TOF-PulmonaryAtresia
PA
AO
AO
Dilated PA, turbulent Flow
L
L
Dilated PA
PA
BA
Tr Tr
SVCSVC
3VTView:3VesselsSeenLargePA
Absent Pulmonary Valve Syndrome
3VT:2VesselsSeen
�96
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AO
SVC
Tr
B
A
AO SVC
Tr
L
L
3VTView:2VesselsSeenNormalsizegreatvessel
TGA (Convex Course)
• TGA(atypical)• VSD• Normal-looking3VTView
3VT:AbnormalCourseofVessels
�99
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3VTView:3VesselsSeenAbnormalVesselCourse
Right Ao Arch - Right DA
Double Ao ArchRight Ao Arch - Left DA
Normal
BA
SVCSVC
Tr
PA
LLDA
RAoTr
PA
DA
RAo
LPAPA
Ao SVC
T
L
R
L
C
U-Sign, vascular ring (loose)
Right-Sided Aortic Arch - Left DA
3VTView:3VesselsSeenAbnormalVesselCourse
PA Ao
SVCTL R
3VTView:3VesselsSeenAbnormalVesselCourse
Right-Sided Aortic Arch - Left DAU-Sign, vascular ring (loose)
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PA
DA
Ao
RAoA
LAoA
SVC
L
R
T
A
LT
LAoA RAoA
DA
PA SVC
L
BA
3VTView:3VesselsSeenAbnormalVesselCourse
Double Aortic Arch
PA
DA
Ao
RAoA
LAoA
SVC
L
R
T
3VTView:3VesselsSeenAbnormalVesselCourse
Double Aortic Arch
3VT:4VesselsSeen
�105
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PA Ao SVC
B
LSVC
Trachea
PA
AoSVC
Trachea
LSVC
A
3VTView:4VesselsSeenPersistentLeCSuperiorVenaCava
!107
Ao
PA
SVC
LSVC
Trachea
L
3VTView:4VesselsSeenPersistentLeCSuperiorVenaCava
PAAo SVC
B
LSVC
Trachea
A
3VTView:4VesselsSeenSupracardiacTAPVR
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LSVC
Enlarged CS
Absent left BCV
PA
Ao
SVC
3VT View: 4 Vessels SeenLSVC vs. TAPVR ?
4thVessel
TAPVR
Normal CS
Large left BCV
PA
Ao
SVC
3VT View: 4 Vessels SeenLSVC vs. TAPVR ?
CS4thVessel
DAAneurysm
PA
aAo
SVC
Trachea
DAA
dAo
From“Echocardiographicanatomyinthefetus.”ChiappaE.Metal.
3VTView:4VesselsSeenDAAneurysm/Kinking
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3VTView:4VesselsSeenDAAneurysm/Kinking
• HLHS• HRHS• TGA• DORV• TOF• CAT• TAPVR• PA-VSD
3VT View
Trachea
SVC
• PS / PA• Critical Ao Stenosis• Coarctation of Ao• ARSA• LSVC• TA-VSD• RAA• Double Ao Arch• Ebstein• Interrupted Ao Arch
Abnormal in:
�114
Do Not Miss The Diagnosis of a Normal 3VT View
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1. Normal Left Atrium 2. Normal Ascending Aorta 3. Normal 3VT View 4. Normal Cardiac Axis in Early Gestation
�115
Top 5 Critical Anatomic Regions
CardiacAxis
Obstet.Gynecol.1987;70:1987
DataFromNormalFetuses(n=183)
• Axisataround45%• Rangeofnormal+/-20degrees• NochangewithgestaTon
AbnormalCardiacAxis
Obstet.Gynecol.1995;85:97
LeCAxisDeviaTon
• MostabnormalcardiacaxisareleCaxisdeviaTons• Mostarediagnosedinsecondtrimester
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CardiacAxis
DORV
TGA
TOF
CAT
CardiacAxis9weeks-52days
Cardiac Axis
2D 2D+color Doppler
2D+HD color Doppler
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Left Deviation
DORV, 12+6 weeks Mitral atresia with DORV 11+6 weeks
TOF, 11+4 weeks
Cardiac Axis in Early Gestation
�122
CRL, mm
CA
x, d
egre
es
Control Group Study Group
40 50 60 70 80 90
0
20
40
60
80
100
120197 cases of CHD and
Obstet Gynecol 2015;125:453–60
197 fetuses with CHD and 394 controls
�123Obstet Gynecol 2015;125:453–60)
197 fetuses with CHD and 394 controls
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PATIENT: 33 year old - G2P0
REASON FOR REFERRAL: Detailed 1st trimester ultrasound
with enlarged nuchal translucency noted on the outside
scan
GA AT PRESENTATION: 12+0 weeks
Case Presentation
12+0 weeks - TVUS
12+0 weeks - TVUS
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12+0 weeks - TVUS
12+0 weeks - TVUS
CHD: Tetralogy of Fallot with pulmonary stenosis -
ARSA
Small omphalocele
Two vessel umbilical cord
DIAGNOSIS
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Genetic Counseling: Work
up for chromosomal anomalies
Fetal Karyotype: 46XX,del(4)(p15.2) – Wolf-Hirschorn syndrome
Pregnancy outcome: termination at 15+1 weeks
�131
Do Not Miss The Diagnosis of a Normal Cardiac Axis in Early Gestation
5 Top Anatomic Regions
• Normal left atrium: rule out TAPVR, Isomerism, Interrupted IVC
• Normal ascending aorta: rule out TOF, TGA, DORV • Normal 3VT view: rule out conotruncal anomalies,
RAA, HLHS, coarctation of Ao • Normal cardiac axis in early gestation: rule out
major CHD in first trimester