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EXAMINATION OF THE FETALHEARTDr. Sameer DikshitMD,DGO,FCPS,FICOG
FETAL MEDICINE CONSULTANT AT……   S L Raheja-Fortis      Sanket Sonography,    Hospital, Mahim         Borivali   BSES M...
   Trained at King’s College, London   Publications in national and international    indexed journals   Founder secreta...
   Basic Screening-4 chamber view   Extended Basic Screening-4 chamber view +    outflow tracts   Fetal Echocardiograph...
EXAMINATION OF FETAL HEARTAs a part of routine sonographic examination
BASIC SCREENING- FOURCHAMBER VIEW
   A part of routine mid trimester scan   Any one who is doing it should be doing it should    ATLEAST do a basic screen...
FOUR CHAMBER VIEW-ADVANTAGES             Easy to obtain             Move up from AC view             Easy to identifyww...
   Easy to standardize   Can be easily included in mid trimester scan protocol    without incurring additional expense/ ...
www.birthdefects.in
WHAT DO YOU DOCUMENT???
AXIS OF THE HEARTwww.birthdefects.in
POSITION OF THE HEARTwww.birthdefects.in
   Size   Pericardial effusion   2 Atria roughly equal   2 Ventricles roughly equalwww.birthdefects.in
   AV valves with offset   IVS   IAS with foraminal flap   Heart ratewww.birthdefects.in
www.birthdefects.in
www.birthdefects.in
www.birthdefects.in
www.birthdefects.in
“IS 4 CHAMBER VIEW A GOOD SCREENING       TEST ?”www.birthdefects.in
   Only 40% of CHD can be diagnosed with 4 Ch view   Various studies quote a range from 15-60%www.birthdefects.in
Screening Test          DR               Risk Factors approach   11%               4 Chamber View          40%www.birthdef...
WHY 4 CH VIEW FAILS?www.birthdefects.in
CHDS NOT ASSOCIATED WITHABNORMAL 4 CH VIEW          1.   Abnormalities of great vessels not associated with               ...
(1) ABNORMALITIES OF GREAT VESSELSNOT ASSOCIATED WITH EFFECT ONCHAMBERS                             Mild Aortic stenosis,...
(2)CHDS WITH PROGRESSIVEEVOLUTION             Pulmonary stenosis             Aortic Coarctation             Ventricular...
(3)CHDS NOT DETECTABLE INUTERO Isolated ASD           (Postnatally) Patent                          ductus arteriosus S...
EXTENDED BASIC SCREENING
   4 chamber view   Outflow tractwww.birthdefects.in
www.birthdefects.in
LVOT-LEFT VENTRICULAR OUTFLOWTRACTwww.birthdefects.in
LVOT-LEFT VENTRICULAR OUTFLOWTRACT                       Originates entirely                        from LV              ...
RVOT-RIGHT VENTRICULAR OUTFLOWTRACTwww.birthdefects.in
RVOT-RIGHT VENTRICULAR OUTFLOWTRACT                       Originates entirely                        from RV             ...
OUTFLOW TRACTS-CROSSING OVERwww.birthdefects.in
www.birthdefects.in
EXTENDED-EXTENDED BASICSCREENING
   4 chamber view   Outflow tract   3 vessel viewwww.birthdefects.in
www.birthdefects.in
www.birthdefects.in
www.birthdefects.in
www.birthdefects.in
www.birthdefects.in
www.birthdefects.in
 Abnormal      vessel size  (PA>Ao) Abnormal vessel  arrangement (LR –  Pul-Ao-SVC) Abnormal vessel  number (3)www.bir...
ABNORMAL VESSEL SIZE Ao   << Pulm                    Ao & Pulm enlarged     Hypoplastic Left Heart       ◦   Polyvalvul...
ABNORMAL VESSEL NUMBER2    vessels   Transposition of the great vessels   Truncus Arteriosus4    vessels     Persiste...
“YAGEL’S TRANSVERSE PLANETECHNIQUE”
1.   AC view2.   4 Chamber view3.   5 Chamber view4.   3 vessel view5.   3 VT view     www.birthdefects.in
AC VIEWwww.birthdefects.in
4 CH VIEWwww.birthdefects.in
3 V VIEWwww.birthdefects.in
“IS ALL THIS POSSIBLE FOR ANANTENATAL CLINIC”
“4 CHAMBER VIEW + 3V VIEW +       3VT VIEW IN 2ND TRIMESTER       SCAN”          J of Perinatal Medicinewww.birthdefects.in
   A busy ANC clinic   Obstetrician did all mid trimester scans   Additional cardiac screening was easily achievable  ...
LIMITATIONS OF 4 CH + 3V + 3VT       SCREENINGwww.birthdefects.in
CHDs difficult toCHDs in evolution                               pick up on echo     Pulmonary stenosis         ◦   Isola...
HOW EFFECTIVE IS THIS SCREENING??www.birthdefects.in
“PRENATAL DIAGNOSIS OF CONGENITAL       HEART DISEASE IN A NON-SELECTED       POPULATION          M. Juan et al          F...
   6953 fetuses underwent midtrimester scan   Yagel’s 5 transverse plane technique was usedwww.birthdefects.in
   Neonatal Echocardiography or Autopsy was used to    confirm the diagnosis   The test had a sensitivity of 92.98% with...
Screening Test          DR               Risk Factors approach   11%               4 Chamber View          40%            ...
WHAT EXACTLY WE WANT TO ACHIEVE?www.birthdefects.in
   Not a comprehensive echocardiography   Detailed echocardiography remains the best means to    pick up CHDswww.birthde...
   But we improve our pick up rate from 4% (cursory look    at heart ) to 60% (4 ch view) to 90% (4 ch + 3 VT view)    (L...
TIMING OF SCREENING FORHEART DEFECTS
   ISUOG guidelines suggest that the fetal cardiac    examination be performed between 18-22 weeks   Under exceptional c...
TECHNICAL CONSIDERATIONS
   High frequency probe to be used   Harmonic imaging may aid in better image    quality   Gray scale is the basis for ...
DETAILED FETALECHOCARDIOGRAPHY
INDICATIONS FOR FETAL ECHO   When the risk for the fetus is more than    background rate of 0.8%   Maternal indications...
www.birthdefects.in
WHEN SHOULD A FETAL ECHO BE DONE   Between 18-22 weeks   In case NT is increased then should be done at 14    weeks and ...
WHAT INFORMATION SHOULDECHOCARDIOGRAPHY PROVIDE?   Anatomy of the heart       Size       Situs       Axis       Peric...
WHAT INFORMATION SHOULDECHOCARDIOGRAPHY PROVIDE?   Morphology of the heart       Size of chambers       Comparison of r...
WHAT INFORMATION SHOULDECHOCARDIOGRAPHY PROVIDE?   Connections of the heart       Venous- Atrial       Atrio-Ventricula...
WHAT INFORMATION SHOULDECHOCARDIOGRAPHY PROVIDE?   Function of heart       Myometrial contractility       Size       E...
WHAT INFORMATION SHOULDECHOCARDIOGRAPHY PROVIDE?   Rhythm of the heart       Atrial & Ventricularwww.birthdefects.in
   If an abnormality is detected, then it should be    mapped and as correct diagnosis as possible    should be givenwww....
   Real time 2D scanning   Colour Doppler   Spectral Doppler   M mode   STICwww.birthdefects.in
(1)RATE AND RHYTHM
www.birthdefects.in
www.birthdefects.in
(2)VENO-ATRIAL CONNECTIONS
VENO-ATRIAL CONNECTIONS- RIGHTATRIUMwww.birthdefects.in
VENO-ATRIAL CONNECTIONS-LEFT ATRIUMwww.birthdefects.in
www.birthdefects.in
www.birthdefects.in
INTER-ATRIAL SEPTUM
INTER ATRIAL SEPTUMwww.birthdefects.in
www.birthdefects.in
www.birthdefects.in
ATRIO-VENTRICULAR VALVES
ATRIO-VENTRICULAR VALVESwww.birthdefects.in
www.birthdefects.in
www.birthdefects.in
www.birthdefects.in
www.birthdefects.in
INTER VENTRICULAR SEPTUM
INTER VENTRICULAR SEPTUMwww.birthdefects.in
www.birthdefects.in
www.birthdefects.in
SHORT AXIS VIEW OF THE HEART
SHORT AXIS VIEWwww.birthdefects.in
AORTIC AND PULMONARYARCHES
OUTFLOW TRACTSwww.birthdefects.in
www.birthdefects.in
DUCTUS VENOSUS
FMF VIDEOS
www.birthdefects.in
VSD
www.birthdefects.in
NORMAL IN LATE PREGNANCY
www.birthdefects.in
TRICUSPID REGURGITATION
www.birthdefects.in
AVSD
www.birthdefects.in
EBSTEIN’S MALFORMATION
www.birthdefects.in
HEART BLOCK
www.birthdefects.in
TAPVR
www.birthdefects.in
SMALL CHEST-SKELETALDYSPLASIA
www.birthdefects.in
DEXTROCARDIA
www.birthdefects.in
ANEMIA
www.birthdefects.in
BILATERAL REGURGITATION
www.birthdefects.in
RHABDOMYOMAS
www.birthdefects.in
LUNG HYPOPLASIA
www.birthdefects.in
CONGENITAL DIAPHRAGMATICHERNIA
THANK YOU
WHAT INFORMATION SHOULDECHOCARDIOGRAPHY PROVIDE?www.birthdefects.in
www.birthdefects.in
www.birthdefects.in
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Fetal Cardiac Examination

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Fetal Cardiac Examination

  1. 1. EXAMINATION OF THE FETALHEARTDr. Sameer DikshitMD,DGO,FCPS,FICOG
  2. 2. FETAL MEDICINE CONSULTANT AT…… S L Raheja-Fortis  Sanket Sonography, Hospital, Mahim Borivali BSES MG Hospital,  Irla Nursing Home, Andheri Vile Parle Nowrosjee Wadia  Belle Vue, Andheri Hospital, Parelwww.birthdefects.in
  3. 3.  Trained at King’s College, London Publications in national and international indexed journals Founder secretary Palghar Ob Gy Society FOGSI accredited sonography training centrewww.birthdefects.in
  4. 4.  Basic Screening-4 chamber view Extended Basic Screening-4 chamber view + outflow tracts Fetal Echocardiographywww.birthdefects.in
  5. 5. EXAMINATION OF FETAL HEARTAs a part of routine sonographic examination
  6. 6. BASIC SCREENING- FOURCHAMBER VIEW
  7. 7.  A part of routine mid trimester scan Any one who is doing it should be doing it should ATLEAST do a basic screening Preferably extended screeningwww.birthdefects.in
  8. 8. FOUR CHAMBER VIEW-ADVANTAGES  Easy to obtain  Move up from AC view  Easy to identifywww.birthdefects.in
  9. 9.  Easy to standardize Can be easily included in mid trimester scan protocol without incurring additional expense/ time/ personnelwww.birthdefects.in
  10. 10. www.birthdefects.in
  11. 11. WHAT DO YOU DOCUMENT???
  12. 12. AXIS OF THE HEARTwww.birthdefects.in
  13. 13. POSITION OF THE HEARTwww.birthdefects.in
  14. 14.  Size Pericardial effusion 2 Atria roughly equal 2 Ventricles roughly equalwww.birthdefects.in
  15. 15.  AV valves with offset IVS IAS with foraminal flap Heart ratewww.birthdefects.in
  16. 16. www.birthdefects.in
  17. 17. www.birthdefects.in
  18. 18. www.birthdefects.in
  19. 19. www.birthdefects.in
  20. 20. “IS 4 CHAMBER VIEW A GOOD SCREENING TEST ?”www.birthdefects.in
  21. 21.  Only 40% of CHD can be diagnosed with 4 Ch view Various studies quote a range from 15-60%www.birthdefects.in
  22. 22. Screening Test DR Risk Factors approach 11% 4 Chamber View 40%www.birthdefects.in
  23. 23. WHY 4 CH VIEW FAILS?www.birthdefects.in
  24. 24. CHDS NOT ASSOCIATED WITHABNORMAL 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 uterowww.birthdefects.in
  25. 25. (1) ABNORMALITIES OF GREAT VESSELSNOT ASSOCIATED WITH EFFECT ONCHAMBERS  Mild Aortic stenosis, Tetralogy of Fallot Coarctation of aorta , Pulmonary stenosis Transposition of great vessels  Double outlet ventricle Truncus Arteriosus  Pulmonary atresia with VSDwww.birthdefects.in
  26. 26. (2)CHDS WITH PROGRESSIVEEVOLUTION  Pulmonary stenosis  Aortic Coarctation  Ventricular hypoplasiawww.birthdefects.in
  27. 27. (3)CHDS NOT DETECTABLE INUTERO Isolated ASD  (Postnatally) Patent ductus arteriosus Small VSD Partial anomalous pulmonary venous  (Postnatally) Patent connection foramen ovalewww.birthdefects.in
  28. 28. EXTENDED BASIC SCREENING
  29. 29.  4 chamber view Outflow tractwww.birthdefects.in
  30. 30. www.birthdefects.in
  31. 31. LVOT-LEFT VENTRICULAR OUTFLOWTRACTwww.birthdefects.in
  32. 32. LVOT-LEFT VENTRICULAR OUTFLOWTRACT  Originates entirely from LV  Septo Aortic continuity  Free movement of the valves  No post valvular dilatation  No regurgitation on colour dopplerwww.birthdefects.in
  33. 33. RVOT-RIGHT VENTRICULAR OUTFLOWTRACTwww.birthdefects.in
  34. 34. RVOT-RIGHT VENTRICULAR OUTFLOWTRACT  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 Dopplerwww.birthdefects.in
  35. 35. OUTFLOW TRACTS-CROSSING OVERwww.birthdefects.in
  36. 36. www.birthdefects.in
  37. 37. EXTENDED-EXTENDED BASICSCREENING
  38. 38.  4 chamber view Outflow tract 3 vessel viewwww.birthdefects.in
  39. 39. www.birthdefects.in
  40. 40. www.birthdefects.in
  41. 41. www.birthdefects.in
  42. 42. www.birthdefects.in
  43. 43. www.birthdefects.in
  44. 44. www.birthdefects.in
  45. 45.  Abnormal vessel size (PA>Ao) Abnormal vessel arrangement (LR – Pul-Ao-SVC) Abnormal vessel number (3)www.birthdefects.in
  46. 46. ABNORMAL VESSEL SIZE Ao << Pulm  Ao & Pulm enlarged  Hypoplastic Left Heart ◦ Polyvalvular dysplasia  Aortic stenosis  Coarct of Ao Pulm << Ao  Enlarged SVC  Tetralogy of Fallot ◦ Interruption of IVC  Tricuspid Dysplasia ◦ Azygous continuationwww.birthdefects.in
  47. 47. ABNORMAL VESSEL NUMBER2 vessels  Transposition of the great vessels  Truncus Arteriosus4 vessels  Persistent L SVCwww.birthdefects.in
  48. 48. “YAGEL’S TRANSVERSE PLANETECHNIQUE”
  49. 49. 1. AC view2. 4 Chamber view3. 5 Chamber view4. 3 vessel view5. 3 VT view www.birthdefects.in
  50. 50. AC VIEWwww.birthdefects.in
  51. 51. 4 CH VIEWwww.birthdefects.in
  52. 52. 3 V VIEWwww.birthdefects.in
  53. 53. “IS ALL THIS POSSIBLE FOR ANANTENATAL CLINIC”
  54. 54. “4 CHAMBER VIEW + 3V VIEW + 3VT VIEW IN 2ND TRIMESTER SCAN” J of Perinatal Medicinewww.birthdefects.in
  55. 55.  A busy ANC clinic Obstetrician did all mid trimester scans Additional cardiac screening was easily achievable No significantly extra time required Very effectivewww.birthdefects.in
  56. 56. LIMITATIONS OF 4 CH + 3V + 3VT SCREENINGwww.birthdefects.in
  57. 57. CHDs difficult toCHDs in evolution pick up on echo  Pulmonary stenosis ◦ Isolated ASD ◦ Small VSD  Aortic Coarctation ◦ Patent foramen ovale  Ventricular hypoplasia ◦ Patent ductus arteriosus ◦ Partial anomalous pulmonary venous connectionwww.birthdefects.in
  58. 58. HOW EFFECTIVE IS THIS SCREENING??www.birthdefects.in
  59. 59. “PRENATAL DIAGNOSIS OF CONGENITAL HEART DISEASE IN A NON-SELECTED POPULATION M. Juan et al Fundacio Hospital Son Llatzer, Spain “Ultrasound in Obstetrics and Gynaecology 2006;28;512-614www.birthdefects.in
  60. 60.  6953 fetuses underwent midtrimester scan Yagel’s 5 transverse plane technique was usedwww.birthdefects.in
  61. 61.  Neonatal Echocardiography or Autopsy was used to confirm the diagnosis The test had a sensitivity of 92.98% with positive predictive value of 100%www.birthdefects.in
  62. 62. Screening Test DR Risk Factors approach 11% 4 Chamber View 40% 5 plane Technique 92%www.birthdefects.in
  63. 63. WHAT EXACTLY WE WANT TO ACHIEVE?www.birthdefects.in
  64. 64.  Not a comprehensive echocardiography Detailed echocardiography remains the best means to pick up CHDswww.birthdefects.in
  65. 65.  But we improve our pick up rate from 4% (cursory look at heart ) to 60% (4 ch view) to 90% (4 ch + 3 VT view) (Li H et al, China Medical University, Shanghai) Integrate with malformation scanwww.birthdefects.in
  66. 66. TIMING OF SCREENING FORHEART DEFECTS
  67. 67.  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 Translucencywww.birthdefects.in
  68. 68. TECHNICAL CONSIDERATIONS
  69. 69.  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 screenwww.birthdefects.in
  70. 70. DETAILED FETALECHOCARDIOGRAPHY
  71. 71. INDICATIONS FOR FETAL ECHO When the risk for the fetus is more than background rate of 0.8% Maternal indications Fetal indications Increased NTwww.birthdefects.in
  72. 72. www.birthdefects.in
  73. 73. WHEN SHOULD A FETAL ECHO BE DONE Between 18-22 weeks In case NT is increased then should be done at 14 weeks and then repeated If First Trimester Screening shows some abnormality then repeat at 14 weekswww.birthdefects.in
  74. 74. WHAT INFORMATION SHOULDECHOCARDIOGRAPHY PROVIDE? Anatomy of the heart  Size  Situs  Axis  Pericardial Effusionwww.birthdefects.in
  75. 75. WHAT INFORMATION SHOULDECHOCARDIOGRAPHY PROVIDE? Morphology of the heart  Size of chambers  Comparison of right and left sides  Relationship of outflow tracts  IVS  AV & Semilunar valves  Arches of Aortawww.birthdefects.in
  76. 76. WHAT INFORMATION SHOULDECHOCARDIOGRAPHY PROVIDE? Connections of the heart  Venous- Atrial  Atrio-Ventricular  Ventriculo-Arterialwww.birthdefects.in
  77. 77. WHAT INFORMATION SHOULDECHOCARDIOGRAPHY PROVIDE? Function of heart  Myometrial contractility  Size  Endocardium  Flow across the connectionswww.birthdefects.in
  78. 78. WHAT INFORMATION SHOULDECHOCARDIOGRAPHY PROVIDE? Rhythm of the heart  Atrial & Ventricularwww.birthdefects.in
  79. 79.  If an abnormality is detected, then it should be mapped and as correct diagnosis as possible should be givenwww.birthdefects.in
  80. 80.  Real time 2D scanning Colour Doppler Spectral Doppler M mode STICwww.birthdefects.in
  81. 81. (1)RATE AND RHYTHM
  82. 82. www.birthdefects.in
  83. 83. www.birthdefects.in
  84. 84. (2)VENO-ATRIAL CONNECTIONS
  85. 85. VENO-ATRIAL CONNECTIONS- RIGHTATRIUMwww.birthdefects.in
  86. 86. VENO-ATRIAL CONNECTIONS-LEFT ATRIUMwww.birthdefects.in
  87. 87. www.birthdefects.in
  88. 88. www.birthdefects.in
  89. 89. INTER-ATRIAL SEPTUM
  90. 90. INTER ATRIAL SEPTUMwww.birthdefects.in
  91. 91. www.birthdefects.in
  92. 92. www.birthdefects.in
  93. 93. ATRIO-VENTRICULAR VALVES
  94. 94. ATRIO-VENTRICULAR VALVESwww.birthdefects.in
  95. 95. www.birthdefects.in
  96. 96. www.birthdefects.in
  97. 97. www.birthdefects.in
  98. 98. www.birthdefects.in
  99. 99. INTER VENTRICULAR SEPTUM
  100. 100. INTER VENTRICULAR SEPTUMwww.birthdefects.in
  101. 101. www.birthdefects.in
  102. 102. www.birthdefects.in
  103. 103. SHORT AXIS VIEW OF THE HEART
  104. 104. SHORT AXIS VIEWwww.birthdefects.in
  105. 105. AORTIC AND PULMONARYARCHES
  106. 106. OUTFLOW TRACTSwww.birthdefects.in
  107. 107. www.birthdefects.in
  108. 108. DUCTUS VENOSUS
  109. 109. FMF VIDEOS
  110. 110. www.birthdefects.in
  111. 111. VSD
  112. 112. www.birthdefects.in
  113. 113. NORMAL IN LATE PREGNANCY
  114. 114. www.birthdefects.in
  115. 115. TRICUSPID REGURGITATION
  116. 116. www.birthdefects.in
  117. 117. AVSD
  118. 118. www.birthdefects.in
  119. 119. EBSTEIN’S MALFORMATION
  120. 120. www.birthdefects.in
  121. 121. HEART BLOCK
  122. 122. www.birthdefects.in
  123. 123. TAPVR
  124. 124. www.birthdefects.in
  125. 125. SMALL CHEST-SKELETALDYSPLASIA
  126. 126. www.birthdefects.in
  127. 127. DEXTROCARDIA
  128. 128. www.birthdefects.in
  129. 129. ANEMIA
  130. 130. www.birthdefects.in
  131. 131. BILATERAL REGURGITATION
  132. 132. www.birthdefects.in
  133. 133. RHABDOMYOMAS
  134. 134. www.birthdefects.in
  135. 135. LUNG HYPOPLASIA
  136. 136. www.birthdefects.in
  137. 137. CONGENITAL DIAPHRAGMATICHERNIA
  138. 138. THANK YOU
  139. 139. WHAT INFORMATION SHOULDECHOCARDIOGRAPHY PROVIDE?www.birthdefects.in
  140. 140. www.birthdefects.in
  141. 141. www.birthdefects.in

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