Brief presentation

1. Fetal echocardiography
Kh. Batnasan
United Family Intermed Hospital
Ulaanbaatar, Mongolia

2. Contents
1. Introduction
2. Indications and imaging technique
3. Congenital heart diseases (CHD)

3. Contents
1. Introduction
2. Indications and imaging technique
3. Congenital heart diseases (CHD)

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

6. Contents
1. Introduction
2. Indications and imaging technique
3. Congenital heart diseases (CHD)

7. Indications
Maternal indications
• Autoimmune antibodies, anti-Ro (SSA)/anti-La (SSB)
• Familial inherited disorders (22q11.2 deletion
syndrome)
• In vitro fertilization
• Metabolic disease (diabetes mellitus and
phenylketonuria)
• Teratogen exposure (retinoids and lithium).
Fetal indications
• Abnormal cardiac screening examination
• First-degree relative of a fetus with congenital heart
disease
• Abnormal heart rate or rhythm
• Fetal chromosomal anomaly
• Extracardiac anomaly
• Hydrops
• Increased nuchal translucency
• Monochorionic twins

9. Imaging technique
1. Transverse view of the Upper
abdomen
2. Four chamber view
3. Left ventricular outflow tract
(LVOT)
4. Right ventricular outflow tract
(RVOT)
5. Three vessel view (3
vessel-trachea view)
http://www.tinytickers.org/content/5-view-details

10. Situs solitus
ISUOG practice guideline: sonographic screening examination of the fetal heart. Ultrasound Obstet Gynecol 2013; 41: 348-359

11. Four chamber view (FCV)
• Easy to obtain
• 2 types
• Subcostal
• Apical
• Detection rate – 40-60%

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”

19. Outflow tract
• Cephalad
movement starting
from FVC

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

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

23. 3-vessel view

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

25. 3-vessel view

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

28. Contents
1. Introduction
2. Indications and imaging technique
3. Congenital heart diseases (CHD)

29. Congenital heart diseases
Atrial septal defects

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.,

37. Congenital heart diseases
Ventricular septal defects

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

43. Ventricular septal defects – Sonographic criteria

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

45. Congenital heart diseases
Atrioventricular septal defects

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

54. Congenital heart diseases
Hypoplastic left heart syndrome

55. Hypoplastic left heart syndrome

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

58. Congenital heart diseases
Transposition of great arteries TGA

59. Transposition of great arteries

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 )

64. Transposition of great arteries

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 (+)

66. Familiar face

67. Thank you for your attention