Abnormal Fetal Heart - Part 2 (PDF)

ULTR‐3014 OBGYN Sonography 3 Module O.12: Abnormal Fetal Heart & Abdomen 2 Abnormal Fetal Heart – Part 2 1 2 Fetal Heart & Circulation textbook reference Module O.12 Abnormal Fetal Heart & Abdomen • • Curry 5th Edition Chapter 22 (p. 396‐400) Abnormal Heart – Part 2 • • 3 Rumack 5th Edition...

ULTR‐3014 OBGYN Sonography 3 Module O.12: Abnormal Fetal Heart & Abdomen 2 Abnormal Fetal Heart – Part 2 1 2 Fetal Heart & Circulation textbook reference Module O.12 Abnormal Fetal Heart & Abdomen • • Curry 5th Edition Chapter 22 (p. 396‐400) Abnormal Heart – Part 2 • • 3 Rumack 5th Edition Chapter 37 4 Abnormal Heart – Part 1 Abnormal Heart – Part 2 • Circulation • Basic cardiac anomalies • Arrhythmia • Fetal congestive heart failure • Echogenic intracardiac foci • Premature closure of ductus arteriosus • Congenital heart disease • Fetal heart ultrasound • Advanced fetal echocardiography 5 6 Basic Cardiac Anomalies Basic Cardiac Anomalies • The “Abnormal Fetal Heart” section will cover the basics of the most common cardiac anomalies • For further review check out the Fetal Echo Seminar in MEDL‐3048 and these YouTube playlists: AIUM – Fetal Heart https://youtube.com/playlist?list=PLHdaFPIA1zfYRRiGCV7TLHbRagvClpErv Philips – Views of the Fetal Heart https://youtube.com/playlist?list=PLHdaFPIA1zfa_B9bvkjDa‐YIeNmaKtbN3 1 ULTR‐3014 OBGYN Sonography 3 Module O.12: Abnormal Fetal Heart & Abdomen 2 Abnormal Fetal Heart – Part 2 7 8 Basic cardiac anomalies • Seen in the four chamber heart view • Seen in outflow tract views Cardiac Anomalies Four Chamber View 9 10 Four Chamber View Cardiac anomalies seen • Atrial septal defects • Ventricular septal defects • Atrioventricular septal defect • Small left ventricle • Enlarged right atrium • Intracardiac masses Atrial Septal Defects (ASD) goo.gl/RNaC5t (fig 1) 11 12 See Rumack 5th ed. Fig 27.25 Atrial Septa RA • • • Septum primum grows down from top of heart to reach the endocardial cushion Septum becomes perforated creating the foramen ovale Septum secondum grows down from the top of heart 3 LA Simplified development process septum primum Normal atrial septa (fetal) endocardial cushion 1: septum primum ventricles 2: septum secundum septum secundum RA 2 3: foramen ovale foraminal flap 1 septum primum endocardial cushion ventricles primum first secundum second 2 ULTR‐3014 OBGYN Sonography 3 Module O.12: Abnormal Fetal Heart & Abdomen 2 Abnormal Fetal Heart – Part 2 13 14 Atrial Septal Defects Definition Defect in atrial septum • Difficult to detect • Best seen with US beam perpendicular to septum • Not to be confused with normal foramen ovale 15 NORMAL 1 Abnormal atrial septa (neonatal) Uncommon 1: atrial septal defect 16 ATRIAL SEPTAL DEFECT Atrial Septal Defects Atrial septal defects – common forms Defect Ostium secundum Ostium primum Sinus venosus Location Near FO Inferior to FO Near SVC (or IVC) 80% of ASDs Least common FO: foramen ovale Ostium Small opening or orifice Atrial septal defect (arrow) – mixing of blood in neonate 17 18 NORMAL Atrial septal defects • ATRIAL SEPTAL DEFECT (ASD) SVC Three common forms septum primum ASD foraminal flap IVC Adapted from: Textbook of Diagnostic Sonography, 7th Edition (Hagen‐Ansert fig 34‐7) Ostium primum ASD Diagnostic Ultrasound, 5th Edition (Rumack fig 37.21 & 22) 3 ULTR‐3014 OBGYN Sonography 3 Module O.12: Abnormal Fetal Heart & Abdomen 2 Abnormal Fetal Heart – Part 2 19 20 26 weeks GA • Ostium primum ASD • Fetus also had ventriculomegaly and duodenal atresia • Fetal demise in utero at 35 weeks GA Ventricular Septal Defects (VSD) Ultrasonography in Obstetrics and Gynecology, 5th Edition (Callen fig 53‐17) 21 youtu.be/21b_VOzWHsw 3:23 22 Ventricular Septal Defects Normal heart More common Definition Defect (opening) in IVS 1: interventricular septum (IVS) AKA ventricular septum Left ventricle Right ventricle • Very small to very large • Isolated or part of a complex anomaly • Best seen with US beam perpendicular to septum • May be associated with chromosome anomalies and uncontrolled diabetes mellitus 1 23 24 Normal IVS • Angle of incidence perpendicular to IVS • Optimal view to assess septum Abnormal IVS (neonatal) 1: ventricular septal defect • IVS: interventricular septum DA: descending aorta Ultrasonography in Obstetrics and Gynecology LL/RL: left/right lungs 5th Edition (Callen fig 9‐73) Bidirectional flow across the shunt 1 4 ULTR‐3014 OBGYN Sonography 3 Module O.12: Abnormal Fetal Heart & Abdomen 2 Abnormal Fetal Heart – Part 2 25 NORMAL VENTRICULAR SEPTAL DEFECTS 26 Ventricular septal defects (arrows) • Ventricular septal defects (arrows) LARGE VSD PERIMEMBRANOUS MUSCULAR Note mixing of blood in neonate 27 28 Atrioventricular Septal Defect AKA Atrioventricular Septal Defect (AVSD) endocardial cushion defect, atrioventricular canal malformation Definition septum primum Defect in inferior atrial septum and superior ventricular septum • youtu.be/p2Kv5H407ws 1:10 29 Commonly associated with trisomy 21 (40%) Neonatal heart 30 Endocardial cushions • Cells in the developing heart that give rise to the valves and septa • Critical for the formation of the four‐chamber heart • Developmental problems result in AVSD • “Endocardial cushion defect” COMPLETE AVSD GA Diagnostic Ultrasound, 5th Edition (Rumack fig 37.19) 5 ULTR‐3014 OBGYN Sonography 3 Module O.12: Abnormal Fetal Heart & Abdomen 2 Abnormal Fetal Heart – Part 2 31 32 NORMAL ATRIOVENTRICULAR SEPTAL DEFECT (AVSD) AVSD crux foraminal flap Colour Doppler Diagnostic Ultrasound, 5th Edition (Rumack fig 37.21 & 27) 33 34 Small Left Ventricle Hypoplastic left heart Small Left Ventricle • Left ventricle much smaller than the right ventricle • Normal ventricles are approximately the same size • Associated with coarctation of the aorta youtu.be/zTVG_y5pQ8M 1:54 Coarctation of the aorta Stenosis in the aortic arch youtu.be/x58nNo4ca9E 2:23 35 36 Hypoplastic left heart • Small, thick‐walled LV (HLV) • Hypertrophied wall • Associated with aortic stenosis, aortic atresia, and mitral valve atresia • 80% have coarctation of the aorta LA RA Hypoplastic left heart LV RV Adapted from: Textbook of Diagnostic Sonography, 7th Edition (Hagen‐Ansert fig 34‐36) Hypertrophied wall 6 ULTR‐3014 OBGYN Sonography 3 Module O.12: Abnormal Fetal Heart & Abdomen 2 Abnormal Fetal Heart – Part 2 37 38 Hypoplastic Left Heart Coarctation of the aorta • Stenosis of aorta • Results in small LV • Muscle thickening • High association with intracardiac anomalies and Turner syndrome Textbook of Diagnostic Sonography, 7th Edition (Hagen‐Ansert fig 34‐43) 39 40 Normal Coarctation of the Aorta Coarctation of the aorta • Hypoplastic LV Aortic arch narrower than ductus arteriosus Hypertrophied Wall Ultrasonography in Obstetrics and Gynecology, 5th Edition (Callen fig 14‐26) 41 42 Coarctation of the aorta? • Long axis LVOT may a good view to see the ascending aorta Coarctation of aorta • 4CH • Ao out of the plane of section • RV is 65% wider than the LV Ultrasonography in Obstetrics and Gynecology, 5th Edition (Callen fig 14‐27) 7 ULTR‐3014 OBGYN Sonography 3 Module O.12: Abnormal Fetal Heart & Abdomen 2 Abnormal Fetal Heart – Part 2 43 44 Enlarged Right Atrium Ebstein anomaly Enlarged Right Atrium 45 • Right atrium larger than left atrium • Caused by downward displacement of the tricuspid valve leaflets • Can be near moderator band in RV • May have other heart defects • 50% have ASD • Trisomy association 46 moderator band Normal Ebstein Anomaly Septal leaflet RV LV 50% of Ebstein MV LV TV LA LA Ebstein anomaly – instagram.com/p/B8i7_28hp2j 47 RA TV RA Textbook of Diagnostic Sonography, 7th Edition (Hagen‐Ansert fig 34‐43) tricuspid valve (TV) septal leaflet inferiorly displaced; enlarged RA 48 NORMAL ENLARGED RIGHT ATRIUM TV TV RV foraminal flap RA Ebstein anomaly Diagnostic Ultrasound, 5th Edition (Rumack fig 37.21 & 28) Ebstein anomaly – note abnormal cardiac axis 8