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FETAL ECHOCARDIOGRAPHY:

Basics You Need To Know

JONAS D. DEL ROSARIO, MD, FPPS, FPCC


What is this?

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Congenital Heart Disease
 8 per 1000 live birth (3 in 1000 is
critical)
 True incidence is higher in the fetus
(abortuses and stillborns) --- as high
as 5x
 Intrauterine cardiac malformations
are associated with a high incidence
of infant mortality and fetal wastage
 Most common congenital
malformation
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Fetal Echocardiography

 With the advent of ultrasound and the


recent application of
echocardiography to the human fetal
heart, prenatal diagnosis and
management of cardiac problems
has become possible

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Importance of ID of Heart
Disease in Utero

 Delivery at an appropriate facility


 In utero therapy (arrhythmia, hydrops)
 Reassurance for both mom and
physician in the setting of an
increased risk factor
 Termination in some countries

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Heart Defects Which Need
INTERVENTION
in the Perinatal Period

 Arrrhythmia (SVT/Complete Heart Block)


 Ductal-dependent lesions (HLHS, PA)
 Myocardial dysfunction

EASILY DIAGNOSED WITH A DETAILED FETAL


ECHO

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When is the ideal time?

 Fetal heart is most easily examined


transabdominally at 18-24 weeks of
gestation
 Non-fixed fetal position

 Incompletely calcified bones

 Abundant amniotic fluid

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20-week Fetal Heart

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Indications for FETAL ECHO

Fetal Risks Familial Risks Maternal Risks

CHD Suspect (4C) CHD, parent CHD


Chromosomal Abn CHD, prior child Metabolic D/O
Extracardiac Defcts Mendelian Syn Teratogen Exp
Arrhythmia
Hydrops (Non-imm)

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Technique

 Transducer range 3-7 MHz


 Segmental examination of the heart
and great vessels
 4 CHAMBER AND OUTFLOW TRACTS
Views
 Use of M-mode, 2 D, Pulsed and Color
Flow Doppler

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The accuracy is also very
much dependent on the
SONOGRAPHER’s
knowledge and
experience.

Understanding of the
cardiac anatomy and
physiology is mandatory.

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Fetal Circulation

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The American College of
Obstetrics and Gynecology
(ACOG) , 1988
4 chamber view of the fetal
heart
on a prenatal screening
ultrasound

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Calculating Fetal Heart Size

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Normal Cardiac Axis

sternum
left

spine

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4-Chamber and ShortAxis of
Ventricles

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Normal Doppler:Aorta

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Doppler Flow:Tricuspid Valve

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Color Doppler: Aortic Arch

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Color Doppler : Foramen Ovale

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4-Chamber View

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4 Chamber View

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Pseudo VSD

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Subcostal 4-Chamber View

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4 Chamber View Alone

 Sensitivity 43%-92% (Median 68%)


 Studying the outflow tracts in some
prospective studies increased
sensitivity to as much as 25%
 About 70% of CHDs have an
abnormal 4-chamber view

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How accurate?
Various recent studies have reported
sensitivity of 43-96% and a
specificity approaching 100% with
the variation depending on the
sample population and technique
employed, including interpretation.

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Reasons for NON-detection
(FALSE NEGATIVES)
 Unique fetal circulatory pathways
(PFO,PDA)
 Poor image quality of the fetus
 Early (<20 wks) or later (>34 wks)
 Obesity
 Low-quality machines
 Milder obstructive lesions can develop late
 Small defects
 Unusual defects
 Inexperienced echocardiographer, erroneous
interpretation

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CHDs with normal 4-
Chamber View
 TOF
 DORV
 Truncus Arteriosus
 Outlet VSDs
 D-TGA
 Coarctation of the Aorta

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The accuracy of detecting
CHDs on a screening
ultrasound improves with
the addition of OUTFLOW
tract evaluation.

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Long-axis View of the Aorta

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Short-axis View of
the Great Vessels

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Aortic Arch

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What CHDs are usually and
easily diagnosed?
 Enlargement or hypoplasia of atrium or
ventricle
 Atresia of tricuspid or mitral valve
 Atresia of pulmonary valve or aortic valve
 Large septal defects
 Functional abnormalities
 Abnormal heart rhythm
 Abnormal contractility

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Endocardial Fibroelastosis

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Complete AVSD

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Ebstein’s Anomaly

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HLHS with Hydrops Fetalis

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Truncus Arteriosus

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CHDs not always diagnose
prenatally
 Small VSD
 Mild pulmonary or aortic stenosis
 Branch pulmonary artery stenosis
 Anomalous pulmonary venous
connection (especially partial)
 Cardiac tumors (small)
 Coarctation of the aorta (mild)
 PDA and ASD

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The cases of CHD
detectable on FETAL ECHO
constitute a more severe
cardiac anomaly with a less
favorable long-term
prognosis than the more
minor defects infrequently
detected.

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Serial fetal echo
examinations improve
accuracy and gives us a
good picture of disease
progression especially in
high-risk conditions.

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Functional Abnormalities
 Chamber sizes, wall thickness
 Contractility (Ejection Fraction,Fractional
Shortening)
 AV Valve Regurgitation
 RHYTHM

ESPECIALLY IN THE SETTING OF


HYDROPS FETALIS

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HLHS with Hydrops Fetalis

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M-mode Measurements

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M-Mode Tracing

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Hypertrophic
Cardiomyopathy

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Fetal Arrhythmias

Aside from detection of


structural heart disease, FETAL
ECHO has also enabled
pediatric cardiologists to
assess and treat fetal
arrhythmias.

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Sinus Rhythym

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Normal Sinus Rhythm:
Doppler Method

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Fetal Arrhythmias
 1% of fetuses

 Indications for evaluation


 Sustained FHR of < 100 BPM

 Sustained FHR of > 180 BPM

 Repetitive Irregular
Heartbeats
 Unexplained Hydrops Fetalis

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Fetal Arrhythmias

ISOLATED ATRIAL EXTRASYSTOLES


(PACs) is the most common

Self limited
Resolves spontaneously
Carries a benign prognosis though it
may persist for a variable period

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Premature Atrial Contractions

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Fetal Arrhythmias

 Sustained tachyarrhythmias can


lead to intrauterine cardiac
failure, hydrops fetalis and fetal
demise.

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Significant Fetal Arrhythmias
Most Common

 SUPRAVENTRICULAR
TACHYCARDIA (SVT)

 ATRIAL FLUTTER

 COMPLETE HEART BLOCK


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Fetal SVT

 Most common
 When sustained for 24 hours ---
HYDROPS FETALIS
 DIGOXIN is still drug of choice
 Procainamide,
Quinidine,Verapamil, Sotalol
and Amiodarone

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Supraventricular Tachycardia

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Fetal Atrial Flutter

Difficult to treat
Digoxin remains drug of
choice
Guarded prognosis in
about 20%

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Atrial Flutter

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Fetal Complete Heart Block

 Associated with structural heart


disease in 50-60%
 Outcome is poor if associated CHD,
reported 80% perinatal mortality
 In normal hearts, association with
Maternal Connective Tissue D (SLE),
screening of mom warranted (SS-A
and SS-B antibodies)

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Complete Heart Block

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Complete Heart Block

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Summary
 Fetal cardiology has made great strides in
the detection of fetal heart disease thru
FETAL ECHOCARDIOGRAPHY

 Fetal ECHO is a relatively risk- free


procedure and in the hands of an
experienced fetal cardiologist has a high
degree of sensitivity and specificity

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Summary
 Fetal Echo enables us to diagnose
structural and functional heart disease
in-utero as early as 16 wks of AOG
 4-chamber and outflow tract views are
important to diagnose more than 90% of
heart disease
 Some CHDs are difficult to diagnose in-
utero (but are not critical)

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Summary
 Most common indications for evaluation
are suspected CHD on level 1 ultrasound,
chromosomal abnormalities,
extracardiac anomalies, family history of
CHD, maternal diabetes and maternal
teratogen exposure
 Prenatal diagnosis of CHD may alter the
natural course of CHD and improve on
the perinatal morbidity and mortality

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THANK YOU

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