FETAL ECHOCARDIOGRAPHY-006.pptx

Fetal echocardiography is a specialized ultrasound test performed during pregnancy to evaluate the posotion, size, structure, function and rhythm of the unborn baby’s heart.

1. FETAL ECHOCARDIOGRAPHY Name : YUKTA WANKHEDE PRN: 21040143006 Programme : M.Sc Medical Technology ( Cardiac Care Technology) Subject: Echocardiography & Perpherial Echoardiography

2. Introduction Fetal echocardiography is a specialized ultrasound test performed during pregnancy to evaluate the posotion, size, structure, function and rhythm of the unborn baby’s heart.

3. Indications The indications for performing such examination can be divided into two main categories: F etal and M aternal. Fetal Indications Morphostructural exam in another gestation age which suggests the presence of factors possibly indicating CC. The presence of other alterations which refer to other fetal organs and/or structures. Cromosomal abnormalities. Cardiac arrhythmia (persistent tachycardia, persistent bradycardia, persistent irregular fetal heart rate). Fetal hydrops. Monocorial twin pregnancy and suspected TTTS (Twin to Twin Transfusion Syndrome). Increased values of nuchal translucency during the first trimester of gestation (>3.5 mm). Early fetal growth restriction (that appears in the II trimester); in these cases, CC are most frequently associated with aneuploidy or with complex syndromes

4. Indications Maternal indications Familiar anamnesis positive for CHD. Metabolic disorders such as Insulin-Dependet Diabetes Mellitus (IDDM), especially if not compensated during pregnancy, and phenylchetonuria, due to fetal exposition during organogenesis to values of maternal phenylalanine > 15mg/dL. Exposition to teratogenic agents such as: steroids, anticonvulsivants, alcohol, lithium, but most of all derivatives of vitamine A (retinoic acid and derivatives). Exposition to inhibitors of prostaglandin synthesis (ibuprofen, salicylic acid, indometacine). Infections from rubella, CMV, Coxackie e Parvovirus B19. Autoimmune diseases such as LES and Sjogren’s syndrome. Hereditary familiar disorders such as, for example,Marfan’s syndrome. Medically Assisted Reproduction (PMA).

5.   Equipment The spatial and temporal resolution needs to be good. The system should have color Doppler, pulsed Doppler, and continuous wave Doppler. Curvilinear probe is used.

6. Cardiac E mbryology Weeks Length ( mm ) Event 1-2 1.5 No heart or great vessel 4 2 Single median cardiac tube, ineffective contraction 5 4 Bilobed atrium 5 4 Begining of circulation 5 7.5 AV orifices, 3 chamber heart 6 8.5-13 Septum secundum , complete inferior septum, divided truncus arteriosus , 7 20 4 chamber heart .

7. Timing of Fetal Echocardiography The echocardiographic study of the fetal heart is optimally performed between 18 and 22 weeks of gestational age , a time window that enables the evaluation of most details of fetal cardiac anatomy. The use of the Color Doppler is of utmost importance in the early echocardiography as it helps in the recognition of the large vessels. The undertaking of fetal heart screening towards mid second trimester can be very useful in addition to a previous fetal echocardiography performed a few weeks earlier, since several cardiac pathologies tend to show a later onset (for example, ventricular hypoplasia due to obstructive process). If fetal echocardiography examination conducted in the first trimester or during pre-morphologic age (16-18 weeks of gestation) cannot exclude the development of late onset pathologies, the undertaking of such exam around the 28th-30th week of gestation can face some obstacles provided by the fetal position and the rib bones.

8. Cardiac Imaging Guidelines: Basic Approach The fetal echocardiogram is a detailed evaluation of cardiac structure and function. This assessment involves a sequential segmental analysis of 4 basic areas that include the situs, atria, ventricles, and great arteries and their connections. This analysis includes an initial assessment of the fetal right/left orientation, followed by an assessment of the following segments and their relationships: Visceral/abdominal situs Atria Ventricles Great Arteries Atrioventricular junction Ventriculoarterial junction

9. 1. Visceral/abdominal situs Position of the stomach, portal vein, descending aorta, and inferior vena cava in the axial view of the abdomen. Cardiac apex position and cardiac axis in the axial view of the chest. 2. Atria Situs Systemic and pulmonary venous connections Systemic venous anatomy, including normal/ abnormal variations (eg, ductus venosus) Pulmonary venous anatomy, noting normal connection of at least one right and one left pulmonary vein Atrial anatomy (including the septum, foramen ovale, and septum primum) 3. Ventricles: Position Atrioventricular connections (including offsetting of the mitral and tricuspid valves) Right and left ventricular anatomy (including the septum) Relative and absolute sizes Systolic function Pericardium

10. 4. Great arteries (aorta, main and branch pulmonary arteries, and ductus arteriosus): Ventricular connections Vessel size, patency, and flow (both velocity and direction) Relative and absolute sizes of the aortic isthmus and ductus arteriosus. Pulmonary artery bifurcation. Position of the transverse aortic arch and ductus arteriosus relative to the trachea The following connections should be also evaluated as part of a segmental analysis: 5. Atrioventricular junction: Anatomy, size, and function (stenosis or regurgitation) of atrioventricular (eg, mitral and tricuspid or common atrioventricular) valves. 6. Ventriculoarterial junction: Anatomy, size, and function (stenosis or regurgitation) of semilunar (eg, aortic and pulmonary or truncal) valves, including assessments of both the subpulmonary and subaortic regions.

11. Grayscale Imaging Scanning planes can provide useful diagnostic information about the fetal heart. The evaluation should include the following anatomic regions, including the upper abdomen for situs, cardiac chambers, valves, vessels, and pericardium: Four-chamber view, including pulmonary veins Left ventricular outflow tract Right ventricular outflow tract Branch pulmonary artery bifurcation Three-vessel view (including a view with pulmonary artery bifurcation and a more superior view with the ductal arch) Short-axis views (“low” for ventricles and “high” for outflow tracts) Long-axis view (if clinically relevant) Aortic arch Ductal arch Superior and inferior venae cavae (Bicaval View)

12. Four-chamber view, including pulmonary veins 2. Left ventricular outflow tract 3. Right ventricular outflow tract 4. Branch pulmonary artery bifurcation 5. Three-vessel view (including a view with pulmonary artery bifurcation and a more superior view with the ductal arch) 6.Short-axis views (“low” for ventricles and “high” for outflow tracts)

13. Color Doppler Ultrasound (Required) Color Doppler ultrasound should be used to evaluate the following structures for potential flow disturbances : Systemic veins (including superior and inferior venae cavae and ductus venosus) Pulmonary veins (at least two: one right vein and one left vein) Atrial septum and foramen ovale Atrioventricular valves Ventricular septum Semilunar valves Ductal arch Aortic arch

14. Cardiac Biometry Normal ranges for fetal cardiac measurements have been published as percentiles and z scores that are based on gestational age or fetal biometry. Individual measurements should be determined from 2-dimensional (2D) images and include the following parameters: Aortic and pulmonary valve annulus in systole (absolute size with comparison of left- to right-sided valves) Tricuspid and mitral valve annulus in diastole (absolute size with comparison of left- to right-sided valves)

15. Cardiac Biometry Additional fetal cardiac biometry can also be performed for suspected structural and functional cardiac anomalies, including but not limited to: Right and left ventricular lengths Aortic arch and isthmus diameter measurements from the sagittal arch view or 3-vessel and trachea view with comparison of the aortic isthmus to ductus arteriosus Main pulmonary artery and ductus arteriosus measurements End-diastolic ventricular diameter just inferior to the atrioventricular valve leaflets in the short- or long-axis view Thickness of the ventricular free walls and interventricular septum in diastole just inferior to the atrioventricular valves Cardiothoracic ratio

16. Specific Documentation of Heart Views In addition to still-frame acquisition and storage documenting the grayscale, color, and pulsed Doppler views, the following motion video clips should be obtained for routine documentation. If there are suspected structural or functional cardiac anomalies, additional motion video clips should be considered. Required clips include: Axial sweep from the stomach to the upper mediastinum, to include the 4-chamber view, arterial outflow tracts, as well as the 3-vessel and trachea view Four-chamber view: 2D and color Doppler ultrasound Left ventricular outflow tract view: 2D and color Doppler ultrasound Right ventricular outflow tract view: 2D and color Doppler ultrasound Three-vessel and trachea view: 2D and color Doppler ultrasound Sagittal view of the aortic and ductal arches: 2D and color Doppler ultrasound

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