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:...
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
Top Critical Anatomic Regions
1. Normal Left Atrium
�4
Left Atrium
Ao
Left Atrium
Pulmonary Veins
Pulmonary Veins
Left Atrium7
Esophagus
Ao LA
Swallowing
Ao LA
Left Atrium
Left Atrium
Closed Esophagus Open Esophagus
TAPVR
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
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
TAPVR
�19 J Ultrasound Med 2014; 33:1193–1207
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Do Not Miss The Diagnosis of a Normal Left Atrium
1. Normal Left Atrium 2. Normal Left Ventricular Outflow
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Top Critical Anatomic Regions
LeCVentricularOuElow
LeCVentricularOuElow
Normal TOFLeCVentricularOuElow
TOF
LeCVentricularOuElow
TOF
LeCVentricularOuElow
LeCVentricularOuElow
LeCVentricularOuElow
From Practical Guide To Fetal Echocardiography: Normal & Abnormal Hearts– Abuhamad, Chaoui – 3rd Edition -Oct 2015
LeCVentricularOuElow
LeCVentricularOuElow
10TGA:LeCVentricularOuElow
10TGA:LeCVentricularOuElow
10TGA:LeCVentricularOuElow
10TGA:LeCVentricularOuElow
LVPA
Transposition of Great Arteries10
Transposition of Great Arteries10
Transposition of Great Arteries10
�48Ultrasound Obstet Gynecol 2015; 45: 678
Overall rate of detection 23 %
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
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Do Not Miss The Diagnosis of a Normal Left Ventricular Outflow
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L
L
L
L
L
• D-TGA–classic• VSD• Abnormal3VTView
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L
LA
LV
L
L
L
L
L
L
• TGA(atypical-posterior)• VSD• Normal-looking3VTView
1. Normal Left Atrium 2. Normal Ascending Aorta 3. Normal 3VT View
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Top Critical Anatomic Regions
TransverseViews
Three-VesselView
DuctalArchView
AorTcArchView
Three-VesselTracheaView
LeCBrachiocephalicVein
LeCBrachiocephalicVein
3VTView
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PA
DA
Thymus AoA
Isthmus
SVC
E
AzV
PA
Thymus
AoA
Tr
SVC
R
L
Tr
R
L
BA
3VTView
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
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Spine
3VTView
3VTView
Follow the Aorta
13 wks
3VTView
Courtesy of Dr. Chaoui
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
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�88Coarctation of the Aorta Hypoplastic Left Heart Syndrome
3VTView:3VesselsSeenSmallAorta
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CoarctaTonofAorta
Hypoplastic Left Heart Syndrome
3VT View: 3 Vessels SeenSmall Aorta
�91Pulmonary Stenosis - TOF Pulmonary Atresia
3VTView:3VesselsSeenSmallPA
TOF-PulmonaryStenosis
Pink
TOF-PulmonaryStenosis
Blue
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
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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
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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)
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
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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
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
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:
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Do Not Miss The Diagnosis of a Normal 3VT View
1. Normal Left Atrium 2. Normal Ascending Aorta 3. Normal 3VT View 4. Normal Cardiac Axis in Early Gestation
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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
CardiacAxis
DORV
TGA
TOF
CAT
CardiacAxis9weeks-52days
Cardiac Axis
2D 2D+color Doppler
2D+HD color Doppler
Left Deviation
DORV, 12+6 weeks Mitral atresia with DORV 11+6 weeks
TOF, 11+4 weeks
Cardiac Axis in Early Gestation
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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
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
12+0 weeks - TVUS
12+0 weeks - TVUS
CHD: Tetralogy of Fallot with pulmonary stenosis -
ARSA
Small omphalocele
Two vessel umbilical cord
DIAGNOSIS
Genetic Counseling: Work
up for chromosomal anomalies
Fetal Karyotype: 46XX,del(4)(p15.2) – Wolf-Hirschorn syndrome
Pregnancy outcome: termination at 15+1 weeks
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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