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Fetal Heart Scanning=Lindsay Allan

Fetal Heart Scanning=Lindsay Allan

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A Practical Approach to Fetal Heart Scanning
Lindsey D. Allan
Evaluation of the fetal heart can be readily incorporated into the obstetric ultrasound examinationand need not add more than a few minutes to the examination. Correct analysis of the four-chamberview and both outflow tracts will exchule the majority of serious congenital heart disease. Wherecardiac malformations are identified during pregnancy, parents should be referred to a pediatriccardiologist with expertise and experience of fetal heart scanning for further counseling. This allowsfor management of the pregnancy to be tailored to the parents wishes and the type of malformationfound.
Copyright 9 2000 by W.B. Saunders Company
C
ardiac malformations are common, affect-ing about 8 of 1,000 pregnancies. However,only about 3 of 1,000 are serious and readilydetectable prenatally. It is important to detectserious forms of congenital heart disease in thefetus as they are associated with a significantmorbidity and mortality in affected children.All forms of congenital heart disease nowadayscan be treated, although at varying levels ofrisk and quality of outcome. A clear understand-ing in early pregnancy of the prognosis for thechild allows parents to make informed decisionsconcerning the management. In continuingpregnancies, the outcome for the affected childcan be improved by optimizing perinatal man-agement. There are some categories of preg-nancy in which there is an increased risk ofcongenital heart disease and these mothersshould be referred to a fetal echocardiographerfor detailed study. These include mothers with afamily history of congenital heart disease, mater-nal diabetes, exposure to cardiac teratogens inearly pregnancy, and the detection of fetal ar-rhythmias or extracardiac abnormalities. Thislast group include those with extracardiac mal-formations, especially those with nuchal edema,or fetal hydrops. However, 90% of mothers whogive birth to infants with congenital heart dis-ease have no high risk features noted in theirpregnancy. The only hope these patients have of
From the Department of Pediatric Cardiology, New York PresbyterianHospital, New Yark, NY.Address reprint requests to Lindsey D. Allan, MD, FRCP, FACC,Babies Hospital 2N, 3959 Broadway, New York, NY 10032; e-mail:la48@columbia.eduCopyright 9 2000 by W.B. Saunders CompanyO146-0005/00/2405-0002510. 00/0doi: 10. 1053/sper. 2000.16551
congenital heart disease being detected is forsomething abnormal being recognised duringthe obstetric scan. For this reason, the conceptof "screening" the fetal heart in a simplifiedfashion during routine obstetric scanning wasintroduced. 1Cardiac assessment during an anatomical ob-stetric survey is recommended to include at leasta four-chamber view of the heart, 2 and this sin-gle view will detect about 60% of serious malfor-mations or abnormalities in about 2 of 1,000pregnancies scanned. Despite the fact that al-most all pregnancies are scanned at some timeduring gestation and that the four-chamber viewshould be part of every ultrasound assessment,many forms of congenital heart disease recogni-sable in this view continue to be overlookedduring obstetric evaluation/Many authors havesuggested a more detailed study be performedduring obstetric evaluation to increase the de-tection of congenital heart disease by includingidentification of the great artery connections. 4Accurate evaluation of the great arteries connec-tions will detect up to 90% of serious cardiacmalformations.
Practical Scanning
For the perinatologist the following aspects ofcardiac structure or function should be estab-lished: (1) The heart lies on the left side of thefetus, on the same side as the stomach; (2) Thefour-chamber view is normal; (3) The ventriculo-arterial connections are normal; and (4) Thearch and duct are normal.324
Seminars in Perinatology,
Vol 24, No 5 (October), 2000: pp 324-330
 
A Practical Approach to Fetal Heart Scanning 325
The Heart Lies on the Left Side of theFetus (on the Same Side as the Stomach)
Normally, when the ultrasound beam is sweptcranially from a transverse section of the ab-domen to the apex of the heart, it can be seenthat both the stomach and the heart lie on thesame side of the fetus (Fig 1). This will almostalways mean that they are both on the left sidebut if they are discrepant, the side of eachmust be determined. Also, although rarely,they can both be normal but both lie on theright (situs inversus). The technique of Cordeset al 5 for determining "sidedness" appears tobe reliable. The first step is to orientate thetransducer in the long-axis of the fetus withthe head to the right of the screen. The trans-ducer is then turned through 90 ~ in a clock-wise direction. If the spine is posterior, the leftside of the fetus will be on the right of thescreen. Conversely, if the spine is anterior, theleft side of the fetus wilt be on the left of thescreen.
The Four-Chamber View is Normal
A four-chamber view of the fetal heart is ob-tained in a horizontal cross-section of the tho-rax just above the diaphragm. A normal four-chamber view excludes many forms ofcongenital heart disease. It must be evaluatedin a systematic fashion, which includes an as-sessment of heart size, position, structure, andfunction.
Size.
Normally, the heart occupies about onethird of the thorax. If there is doubt about theheart size on a visual assessment, the area or thecircumference of the heart can be measured andcompared to normal values. 7
Position.
Normally, the midline of the tho-rax passes through the left atrium, foramenovale, the right atrium, and the anterior cor-ner of the right ventricle, such that most of theheart lies in the left chest (Fig 2). The inter-ventricular septum forms an angle of about40 ~ with the midline, s An abnormal angle ofthe septum can indicate a cardiac malforma-tion or a space-occupying lesion within thechest. 9
Structure.
To orient in the four-chamberview, it is useful to relate the heart to thespine. Opposite the spine is the anteriorchest wall or sternum and below this is theright ventricle. Immediately anterior and tothe left of the spine is the descending aortaand anterior to that is the left atrium. Theright atrium and left ventricle can then bededuced.In the four-chamber view, the following as-pects of structure should be seen:Figure 1. (A) The stomach in the abdomen in the usual position. (B) Sweeping cranially, the four-chamberview in seen in the thorax just above the diaphragm, with the apex on the same side of the fetus as thestomach.
 
326
Lindsey D. Allan
Figure 2. The interventricular septum forms an an-gle of about 40 ~ to the midline of the thorax. Theright ventricle lies below the sternum. The left atriumis anterior to the descending aorta, which is, in turn,anterior to the spine.1. Two equally sized atria2. Two equally sized ventricles3. Two equally opening atrioventricular valves,no valvar regurgitation4. An intact "crux" of the heart, with differentialinsertion, or "off-setting" of the atrioventric-ular valves.5. The pulmonary veins enter the back of theleft atrium6. The foramen ovale defect occupies the mid-dle third of the atrial septum7. The ventricular septum is intactIn the last 10 weeks of pregnancy, there can bemild, or close to term even fairly marked, dis-crepancy in the sizes of the ventricles with rightheart dilatation, even when the heart is normal.However, pathological causes of right heart di-latation should be excluded, such as coarctationof the aorta a~ or totally anomalous pulmonaryvenous drainage, before attributing any discrep-ancy to gestational age.The atrioventricular valves should be exam-ined by color flow mapping to ensure that theorifices are of equal size and that both ventri-cles fill equally in diastole. In addition, thereshould be no regurgitation from either valve.However, with some of the most recent ultra-sound equipment, trivial tricuspid regurgita-tion can be seen in a normal heart. However acause for tricuspid regurgitation should beexcluded before denoting this "physiological,"as it is not as common in the fetus as it is inpostnatal life. nIn the normal heart, the atrial septum meetsthe ventricular septum at the site of insertion ofthe 2 atrioventricular valves, forming a "cross" atthe crux or center of the heart (Figs 1 and 2).Because the septal leaflet of the tricuspid valve isinserted slightly lower in the ventricular septumthan the septal leaflet of the mitral valve, thisgives the appearance of "off-setting" or a crossthat is not quite straight. This is an importantnormal finding that is lost in some cardiac mal-formations.On examination of the atrial septum, the fo-ramen ovale can be seen to occupy the middlethird of the septum, although the size of theforamen appears larger if it is imaged in apicalprojections. The flap valve is pushed open by ajet of blood from the ductus venosus via theinferior vena cava and lies in the cavity of the leftatrium during most of the cardiac cycle. It has,however, a biphasic motion drifting toward theatrial septum towards the end of systole andclosing for about 20% of the cardiac cycle dur-ing atrial contraction. 12 A right to left shuntthrough the foramen can be documentedthroughout most of the cardiac cycle, although abrief jet of left to right flow can occur duringatrial systole. The flap valve can sometimes beredundant and impinge on the left atrial wall inthe normal fetus.Finally, it is important to focus on the ven-tricular septum in order to exclude a ventric-ular septal defect. The septum should beimaged from the apex to the crux in the four-chamber view, thus imaging part of the mus-cular and inlet septum and then the beamswept up to the aortic outflow, which imagesmost of the rest of the muscular septum andthe perimembranous and outlet parts of theseptum. It should be imaged in both apicalprojection and lateral projections (Fig 3). Ifthere is a real ventricular septal defect, colorflow will be seen to breach the septum in alateral view when the septum is perpendicularto the beam. However, small defects, especiallyin the perimembranous region or multiple de-

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