Transcript

Hi, this is Dr. Jason Cox, practicing radiologist and program

director of the Institute for Advanced Medical

Education. I'd like to welcome you to our webinar

series,

uh, but first we're gonna go through some, some housekeeping

and talk about what we do here at

IAME.

Uh, what do you need to know about our webinars?

First, webinars are always free to

members, and you may have access as a non-member and be able to watch

tonight's event. Um, members, however, get year-round

access to the recording of the, uh, webinar.

They can also have CME credit that is awarded, uh,

for attendance, and then you also have your

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credits. Non-members may have access to this webinar, but they're not

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are not a member tonight, and we'd love you to become a member,

uh, we'll have some exclusive discount for you for completing, uh, watching the

course.

About Institute for Advanced Medical Education.

We've been around for about 30 years.

Um, we're the largest educator of sonographers

and physicians that, uh, practice sonography and interpret

sonography in the United States and, by extension, the

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have trusted us for over 30 years.

Just a little bit about our training philosophy.

Our courses are built for both

sonographers and for physicians and others who practice in

sonography. Whether you're a,

uh,

echo tech or a sonographer or a radiologist

or a vascular surgeon or OBGYN

doctor, um, we design our courses to

work as a team because sonography is the only,

uh, category of medicine where we work so closely as a team.

We believe that learning together is how you perform better for your patient and

have better outcomes, and research shows this.

Um, just a little bit of, um,

housekeeping here. Um, as an ACCME accredited provider, we're required to read this

statement to you every time so that you understand,

um,

any, um- that this is an evidence-based educational program and that

there's no kind of funny business going on.

Uh, this activity has been planned and implemented in accordance with the

accreditation requirements and policies of the Accreditation Council for Continuing

Medical Education, the ACCME. IAME is

accredited by the ACCME to provide continuing medical education for

physicians, IAME designates. This

live online webinar for a maximum of one AMA PRA category one

credit. Physicians and attendees should claim only the

credit commensurate with the extent of their participation in the

activity. In compliance with the essentials and standards

of the ACCME, the authors of this CME activity is required

to disclose any significant financial or other relationships that they may have

with commercial interests. Myself, Jason Cox, MD, and

the author of tonight's presentation, LaChelle Jones, disclose

no such relationships exist. IAME has assessed any conflicts of interest

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a position to control the content of this CME activity and any

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Tonight, we'll talk about fetal echo

applications. I'm really excited for this topic

because I feel like all year

we have been learning all about fetal heart

assessment. Now it's time to apply what we've gone

over throughout the year. Okay? Now, after completing this

activity, you will be able to apply a

systematic approach to fetal cardiac assessment

across common and complex clinical scenarios.

We're gonna do a quick review on some sonographic features and

views. We're gonna go over some cardiac

measurements. We're gonna go over, uh, quite a few

abnormal patterns. It's gonna be really helpful, um,

in recognizing, uh, some typical, like, uh, heart

defects, uh, or disease. We'll go over a few

ultrasound findings with clinical decision-making tips,

and then we're gonna incorporate everything we went over tonight

into, uh, registry-relevant concepts as well

as kind of parallel it with your fetal heart

assessment.... okay, in the real world.

So let's get started. Now at first, kind of, I wanna go

over or show the outline, um, from

ARDMS on all that's on your fetal

echo exam. Now you see the three,

two, three, and four are the three most percentage

of what you'll see on your exam. And then as well as you have some of

the medical history, which is about 7%.

Each part of this outline is very

important. I want to, uh, highlight here

in 1A.4 where it stands out, an

example of CHARGE or VACRO syndrome.

Um, we're gonna actually go over a few of these syndromes and

some common heart defects and, uh, anomalies that

you will see with these syndromes to kinda help you answer these questions when you

see them on your board exam. Um, you can find this on the

ARDMS website where you can go over, uh, all

of this outline so you can be prepared for your test.

Now the next test, uh, date as you see

here, it's in March, but guess what?

You can apply now to take the board.

So in between December 9th and February 17th,

it's, uh, open as of yesterday. Um, you won't be able to sit

for this particular exam until March 3rd through March

26th of next year, okay?

All right, so let's move on. So just,

uh, just to kinda go over our outline before we get started,

uh, typically before a defect of the

heart is, uh, diagnosed, there is a proposed

clinical pathway, um, starting with the routine prenatal

care, and then it's fo- usually followed by a 20-week

standard, uh, scan that everyone will have to

have during their pregnancy. Now, um, if there's no

history of a heart defect or family history of any

kind, usually that may be the last one far as heart

assessment. But if there is a history or indication for a fetal

echo, you will have, uh, the patient will have a fetal echo

after their 20-week scan. If there was an

anomaly, especially a complex one that was detected,

they will either see a, a cardiologist or have a MRI,

and it just, it really helps with the family and the doctors to have

this pathway in this order to improve the neonatal outcome in

the long run, okay? Now let's go over or let's take

a look at, uh, some indications to why a fetal echo would

need to be ordered. I do wanna point out that it

is usually due to these five reasons, whether it's maternal

reason, a fetal risk factor,

chromosomal issue, a teratogen, uh,

effect, or extra cardiac anomaly.

These are usually the indications to why a fetal echo

would be ordered. Now a step further from

there, what are those risk factors?

Now here are a list, and it's just a few, of maternal

risk factors, start with diabetes, uh, we have

PKU, uh, the antibody assessments,

teratogen exposure to retinoids, and then a confirmed

rubella infection in the first trimester.

So that's just a brief, just a brief overview of some

maternal risk factors. There is a longer

list here as far as the fetus. Now, um, just a

list, just a couple, uh, we have an increase NT

greater than 3.5, if there is a cardiac

structural anomaly that may be shown at the 20-week

scan, hydrops or arrhythmia, or even with

monochorionic twins this is usually a indicator as

far as the fetal risk factors or a fetal echo.

All right. Now when you see, uh, the doctor may consider a

referral if there's greater than two of these

listed on the orange side, so that's IVF, uh,

followed by maternal obesity could be a risk.

Um, we've mentioned NT greater than three already, uh,

but in cases where there's a two-vessel cord, that's usually a

consideration for a fetal echo to be ordered, okay?

Now some of the teratogens that are, uh, listed have

some association to cardiac defects.

You wanna be mindful of these particular ones 'cause I did have a

few test questions that mention, uh, what are the

associate cardiac defects with the teratogen.

Uh, lithium was one, as well as

indomethacin, okay? So it's really, you wanna be,

uh, uh, very familiar with these associated

cardiac defects so you can be prepared for your exam.

Another thing here is the risk of the congenital

heart defect in a fetus as for the affected

relative. I had two test questions that mentioned,

uh, about the mom, if mother was affected, what

was the risk to the fetus, which is a 10- to 12%

risk, as well as if father is

affected, there is a 1 to 3% risk of

congenital heart disease to the fetus.

And so you wanna be mindful of all four just in case, um,

and it's just helpful to know in your real world, uh, fetal heart assessment

as well. Okay, now as for your

syndromes, your syndromes have common defects that are

associated with each. Now I want you to be mindful

of the higher percentage of the percentage you see

here, and we have trisomy 13, 18,

Williams syndrome, and DiGeorge syndrome.

Notice, these syndromes carry a higher risk of

congenital heart disease, which is greater than

90%.Okay. Now followed by trisomy

21, we had a 50% risk, and then

we had Noonan syndrome at 65% for having

pulmonary stenosis, and then Turner syndrome with its

association with coarctation. That carries about a 25 risk

factor. Okay? All

right. So, we're gonna go over the

standard fetal heart views. We're gonna talk about

angulation, um, and what are their importance,

um, for the heart assessment, okay?

So, we'll start off with the four-chamber view.

Now the four-chamber view, this...

And a lot of this should be a quick review.

If not, I'm glad to go over it. Uh, four-chamber

view, it's at 45 degrees plus or minus

20, okay? That's normal. And it should take about

one-third of the fetal thorax. Now the normal

position of the four-chamber heart is levocardia,

which is pointing towards the left side, the apex, and

majority of that heart is positioned on the left side

and that is known as levo position.

Okay? Now we're gonna go over some landmarks and some,

uh, morphological markers. I do want to point out the location

here of the descending aorta and how it is adjacent

to that left atrium,

okay? That's all normal. And then what's connected

with the left atrium is the pulmonary veins,

okay? Followed by, we see a moderator

band seen in that right

ventricle

and also what's noted here is the offset of these

valves. The tricuspid valve on that right side

followed by the mitral valve on the left

side, and that's associated with that left

ventricle. We have the right ventricle where that moderator

band is, followed by the right atrium,

okay? So, we're gonna break down each one of these chambers and these

markers, okay? I do want to point out

too that that foramen oval flap is

seen on that left side within that left

atrium. So, these are all normal landmarks within

that four-chamber view.

All right. Now we went over some key landmarks, now we're gonna

talk about, uh, the planes that are associated with the

four-chamber view. Those are the apical

plane, the axial plane, and the basal plane,

okay? Each three of these all have a

special purpose, and so we're gonna go over what structures are

seen in each plane, okay?

So let's start with the apical plane, which we saw here.

The pro marker direction I listed here for each

one, and the primary movement of your

transducer. Now as far as the key structures

that's visualized in your apical, those key

structurals- structures are the AV valves, and we

can also show the chamber symmetry, okay?

It's really helpful to see that in the apical view.

As for your basal view, the key structures that are visualized

are the atrias, the pulmonary veins, that's usually where you can

sample and get nice waveforms there, as well as the crooks of the

heart. I must add that I- I feel like the

crooks of the heart is also seen in the

apical plane as well, okay, so I did want to point

that out. And then as for your axial plane,

this one is especially helpful for those key structures such as the

situs, the chamber proportion, as well as the cardiac

axis. Now why is accurate transducer

angulation critical when obtaining the four-chamber

view? If you just had to take a guess.

Uh, I came up with a few reasons to why it's especially

important that you have correct transducer

angulation, okay? With that ultrasound beam, it

intersects that heart in a correct anatomical

plane. But any small deviations in

tilt or rotation or you're off-axis, it can

distort the apparent chamber size or symmetry.

It can obscure the septum. You- you can't really see

the whole septum, uh, if you're off-axis

somehow. It misrepresent outflow tract

crossover, and it can lead to false diagnosis of,

uh, congenital heart defects, and we really want to avoid that.

So that's why it's helpful to really make sure that we're aligned in the

correct plane where- when we're assessing these key

structures. All right. Now, let's go...

Let's take a step further and go into those morphological markers

that we were discussing. Now as how to recognize the

right ventricle. Um, the morphological markers are especially

important in those cases like, say, transposition where you

want to make sure that you are, uh, looking at the proper

cham- chamber. Uh, sometimes it's out of place in those, uh, different

anomalies, and so you want to be mindful of the

morphological markers in each chamber.

Now as for the right ventricle, notice, and here

it's- it's outlined in A, where it's- it takes on a more

triangular shape, okay? And it's followed by that

moderator band which we did see earlier.

You have that apical muscle band

connected to that papillary muscle, and then remember the

offset of the tricuspid valve, okay?

I label it as T-map, okay, for right ventricle.

Triangular moderator band equals the right

ventricle.Okay.

Now, uh, just a tip here, um, you wanna trace the

valve insertion point, not just the chamber

shape. Okay? So, you really wanna see, uh, other

structures, not just the shape of that ventricle to help identify

it.

All right? Now, if the muscle looks like a wall, follow

it. The papillary muscles move, but the ventricle walls

do not. So, just keep that in mind.

All right. Now, how to recognize the left ventricle.

The left ventricle is, it's- it's different. It's, uh, more smoother.

So, I called it B smooth (laughs) as for the left side.

And so, B, beyond the septal angle.

S, it has smooth ventricle walls, which you can see

here, okay? The shape of this chamber, it's

more oval or bullet-shaped

and one cavity with a smooth contour.

It traces cleanly. Okay? So, the papillary muscles and the, with the

vessel and the ventricle wall. And it's a high-pressure

ventricle. All right? So, keep in mind, smooth

walls, bullet-shaped mitral valve, insertion beyond

that septal angle, equals the left

ventricle.

And a quick tip. When in doubt, ask yourself, do I

see a moderator band? If no, and the walls are smooth,

you're most likely looking at the left ventricle on that left

side.

Or hopefully on the left side

(laughs) . All right. Now, here are different, uh ...

I like the maturation of the four-chamber view, starting at the

16 weeks, all the way into the 36 weeks

mark. Now, you may wanna look there at that 16 week.

It- it's- it's hard to see, uh, that moderator band,

if you notice. Uh, I feel like the moderator band really,

uh, enhance the self as the heart, uh, grow-

grows and get bigger. Um, but you can still see the triangular

shape as well as the papillary muscle, uh, there to know that that is the

right ventricle. But here is just a different variations of

four-chamber view throughout the whole gestation.

All right. Now, um, as I tell my students,

uh, don't be afraid to move your transducer

around, uh, especially when we're applying those views

for the different planes. Move it around the mom's

belly and to really, uh, see the different, uh,

chambers of the heart and the four, four-chamber planes.

And so, that's what this here is demonstrating, okay?

So, don't just stay in one place. Move from your left to your right

side or top or bottom, just to see all the chambers

correctly.

All right. Now, it's a standard heart sweep.

I- I really take this into mind, um,

it should flow just as is shown in this

picture. And so, whenever there is a deviation off or

there's not a- a quick up to your sweep and to the next, uh,

segment of that heart, then usually there's anomaly present.

It should be a nice, even flow up towards the fetus

head. Uh, one to two is starting at the situs in

four-chamber view. Two to three is your outflows

and so forth. And so, we're gonna go through each step in this heart

sweep, okay?

All right. And so, here it is again.

I took some pictures starting at the s- ...

situs here, head down. Okay?

So, we started there

and then from there we have our four-chamber view,

followed by the left ventricle outflow check.

We can see the ascending aorta,

followed by the RVOT, okay? Which leads into

the three-vessel view and the three-vessel tri-quer

view.

All right. So, we're gonna start with the outflow tracts, okay?

And so, starting with the right, your right outflow tract

projects superior, and anterior, and

leftward, okay? And so, the

LVOT is angled towards the fetus' right

shoulder. So, it's, that's that crossover that we're seeing as we

are looking at the outflow tracts, okay?

So, it's just a perfect

crossover. Now, looking here

at the LVOT, first and foremost, the purpose, we

wanna show the continuation of that ascending aorta leading from that

left ventricle. Okay? So, this is the second step

of that heart sweep plane from the four-chamber view. Okay?

So, you would, just wanna tilt that towards the fetus' right shoulder and

show that continuation. You have a beautiful shot there, as well

as showing that forward flow once you apply the color

doppler, which you can see demonstrated here at the

bottom. Okay?

All right. Your RVOT view. As you see here, we

mentioned this is where that crossover starts.

Notice where it's from the top of the chest, crossing

over the aorta. Okay? Now, from the

LVOT, you wanna tilt anteriorly and rotate towards the

fetus' left shoulder. It's almost like a 90-degree sweep.

Okay? Again, you do want to confirm antegrade

flow once you apply the color doppler, which you can see

demonstrated here.

All right. And so, here's a closer look at that, once

again, um, where you can see the criss-cross of the

outflow, as well as the color doppler

apply.

And then once we do the crossover, especially with that

RVOT view, you want to demonstrate the

bifurcation, which is shown at the bottom in B and

C, where you can see ...... the right pulmonary

artery, which is below the aorta, followed by the left

pulmonary artery, okay? This is also,

uh, a key landmark to know that we are indeed looking at the

pulmonary artery, because we see the bifurcation

demonstration. All

right. Now, from the four-chamber view, I just wanted to show

where you can see that rotation, that 90-degree

rotation, um, from these views here.

And so, that's what this demonstration is showing you from A to D.

Starting at the four-chamber view, look, look at the

probe as we are applying to that LVOT

view. So, look at the probe and its handle.

Now, we are almost going into that aortic

arch. You see the ascending aorta followed with the

descending aorta, and just look at that probe angulation.

And then we carry over into that RVOT

and that pulmonary valve, that pulmonary artery, the

crossover from the top of the chest. All right?

So, it's just the

angulation there of your probe.

All right. So now, we're going into the three-vessel view, which is the step up

from the RVOT. Uh, it's pretty much a, where you

wanna see or demonstrate these three vessels, starting with

the pulmonary artery, which is the largest and most anterior.

Then you have your aorta, slightly, slightly smaller than that, uh,

pulmonary artery, followed by the SVC. Okay?

So, we definitely want to compare, uh, the arrangement,

make sure it's just three vessels and not four or

two or one. And then you want to also, uh,

demonstrate the flow, which we'll see in the next page.

But that's gonna be a forward flow, okay?

So, let's get to that. All right. So, this is where

the demonstration of the forward flow.

This is slightly higher from that three-vessel view, so it's just a

slight, uh, a hairline click or sweep

up. You'll get into the three-vessel tracheal view, which is

gonna demonstrate the V, which is seen

here. When you apply the color doppler, depending

on the alignment of the spine, it should flow

towards that spine and have that forward flow.

So, in this case, the spine is down, which is why it's demonstrated

in blue.

All right. Now, uh, this is just a step-by-step guide

where you sweep in again. Uh, I can't express that enough 'cause it should be

a natural, normal sweep into these views.

Start with your four-chamber view, sweep up, and then

you'll get to that three-vessel view and three-vessel tracheal view, and

even up into the mediastinal structures where you can see the

thymus gland. Okay? So, it should just be all sweep up

towards the fetus' head. Now, I just

was mentioning earlier about the spine and depending on the

position, the flow of the blood, which you can see

here, the spine is up and there's that forward flow, which

is indeed shown in red. In this particular example, spine

is down, that's why it's blue. So, there's the difference

there.

All right. There we go again. Nice forward flow.

Beautiful images. I love beautiful, uh, images of the heart,

especially for the three-vessel tracheal view.

It's like one of my favorites. Okay?

And then here we are again. Uh, these are just showing the different variations

from the RVOT, followed by the

bifurcation, which is demonstrated in B and

C. Here, you're just showing pulmonary artery and aorta

SVC. We're getting into the thymus gland, which you can kind of see.

Yeah, you can kind of see it up there.

Here's a better demonstration of the thymus gland, which

just sits adjacent to those vessels.

Okay?

All right. My favorite shot is this thigh box.

I love this. Now, to demonstrate these, uh, mammary arteries

here, you want to, uh, adjust your PRF setting

to a lower scale in order to visualize these

vessels. Um, but here, it outlines the thigh box

or the thymus. And then if you go a little further

up, you can see, uh, the sternum, which is

demonstrated as well. All right. I do wanna

point out the azygos. That's normal.

This azygos drain into the SVC, which is shown here in

this image. Okay?

All right. So, let's take a look at a sweep.

This is, uh, I'm just sweeping through the heart

entirely. I started out demonstrating

the thymus gland and the thigh box.

We can play that again, actually. Um, so here you can see the

mammary arteries, the thigh boxes

within. Here's the three-vessel trachea view.

There's that four-chamber view.

Beautiful image of that.

Okay. So now, we're getting into the aortic arch.

Now, with the aor- aortic arch view, uh, you wanna evaluate the

curvature and branching. Uh, with the aortic arch, you

should see those three branches, um, that lets you know

as- as well that you're looking at the aorta and not the

ductile, as well as its curvature.

It's more take on a candy cane appearance, whereas the ductile arch

is more hockey stick. Okay? You do wanna demonstrate with

doppler that continues laminar antegrade flow.

This is all normal. Okay? This right here is

all normal.

All right. Now, here's a demonstration of that.

Now, as you're angling this transducer, if you wanna,

uh, rotate from the LVOT view, which we saw

earlier, with the rotation and the angulation, you can

rotate from your LVOT view into the aortic

arch.... which is seen here, okay?

And it's that classic candy cane shape appearance of

that.

Also note the IVC- IVC, which is

seen here, as well as the SVC. Um, but this here we're

highlighting is the aortic arch, and you can see the head and neck vessels,

those three branches there of the aortic

arch.

All right. Now, if you're in a three-vessel view, and

if you rotate that transducer about 90 degrees to either

side, the plane will line up for the aortic arch to come

into play. Uh, you'll reveal it as a candy cane or inverted

shape. Uh, key clue, um, with this particular one is

to check for the, the head and neck vessels.

Um, also, uh, where coarctation usually occur, you want to

assess the isthmus of the, uh, aorta

for narrowing. So you want to check on that and just rule that out.

Uh, make sure that it all has that continuous flow

pattern. All

right. Now, um, some key things. You know, I always was

nervous about missing a coarctation, uh, 'cause

sometimes it could be subtle, and I ran across this recent

study that demonstrated, uh, a, a, a...

Like, a key finding into how to, um,

pin or point out coarctation. And so here, if you

look here in one, uh, the left carotid artery and left subclavian

artery, just notice the distance, okay?

Which you can see here. It seems like a normal distance in

relation to when there is a obstruction

or a coarctation present, the distance between the left

carotid and left subclavian is wider, okay?

So that's just something to remember, um, when ruling out these

cases of coarctation.

All right. Also, if you suspect that there

is a, uh, coarctation, the waveform of

the isthmus will be affected as well.

So, in the normal case, you see normal aortic isthmus Doppler has that

fast systolic upstroke, which is demonstrated here,

with the small end diastolic notch which is

present. Um, in cases for

coarctation, there is a delay in that upstroke.

Notice it is different. Uh, it's not as, uh,

fast-forward as the normal case. And then there is

persistent forward diastolic flow.

It almost remind me of speed bumps.

Uh, they, they call this appearance of this waveform as a

sawtooth waveform in cases of, uh,

coarctation. Okay? So this is a classic

finding, um, in a case of obstruction.

All right, so now we're getting into the ductal arch.

Ductal arch view is simply the main p- pulmonary artery

leading into that ductus arteriosus, followed by

the descending aorta, okay? This takes on a

hockey stick appearance,

okay?

All right. So here, A and B, one is the

aorta or aortic arch, one is the ductal

arch. Now, although in A, which is the aortic

arch, uh, the head and neck vessels aren't as clear, but you

can see the curvature of this vessel is taking a more

of a candy cane or has a arch, uh, with

it. Whereas B, you can clearly

see the hockey stick or the flatness of

the- this particular arch. Another key thing to

recognize in the ductal arch is I can see, uh, the

ductus arteriosus, which is here.

Um, it, it usually shows off with, uh, uh, the

elison seen, um, before it reaches the

descending aorta. So that's a key landmark usually

for a ductal arch. You'll see that, uh, ductus

arteriosus elison in the

Doppler.

All right, so there's that candy cane for the aortic arch, and

then the hockey stick

for ductal arch.

All right, now we're getting into our systemic and pulmonary venous return

views. Uh, IVC, SVC enters the right

atrium, as we saw earlier. The pulmonary

veins enters the left atrium, okay?

So we want to confirm normal venous drainage

into its respective atria.

All right, now here we're looking at those pulmonary veins.

Now, we're... On the left side you have the apical view.

You see where I'm sampling the right pulmonary artery

and pulmonary vein. This is the waveform from

that. Now, m- mind you, we could also sample

the right from this view as well, um, but I

find that this view is more helpful when you're, want to

sample the left side. It's difficult to, uh, assess the

left pulmonary artery and vein from the apical view, okay?

So from this view here, we are assessing the left

pulmonary vein and left pulmonary

artery.

All right. And lastly, we have the short axis view.

With the short axis view, there's three different planes

or views, um, with this particular one,

um, but overall we're assessing for ventricle

symmetry. Okay? So let's break down each one,

okay? So starting with that high short axis,

and then you have the low short axis, okay?And so,

from the high short axis, that's usually, uh, useful for your

outflow tracts, your septum, your function, your AV valve

anatomy. It shows both the aortic valve and the

pulmonary artery wrapping around, which you can clearly see that

there. It display the branching of the pulmonary

arteries

and is best for identifying any obstruction in- with the

RVOT, as well as outlet VSDs and

tricuspid regurgitation. Okay. Now, as for the

low short axis views, there are two that you can usually see

with this particular one. That's the demonstration of the papillary

muscles, as well as the mitral valve and tricuspid

valve. And so, this particular one evaluates

ventricle function. It will show off those muscular

VSDs. Uh, color doppler is especially

helpful. Okay. You also want to assess AV valve

morphology, uh, common AV valve mitral cleft in this

particular view. All right. Now, we're

gonna just go over, uh, some quick, uh, I guess, tips

on how to fit your image, your frame rate, and so forth.

Uh, we talked about the fetal thorax, it occupies one-third of the

screen. You want to have a narrow sector width,

high frame rate, low dynamic range. Okay?

And use the highest resolution transducer

possible. As for your color doppler, you have to

optimize that grayscale image first, then apply the

color doppler, followed by a narrow color box

that filter mid-wall, mid-velocity color doppler

range. You want high color persistence, not too much

doppler gain, and we're gonna look at that and see what happens when you apply too

much color doppler gain. You want to have a low-power

output and use a bidirectional doppler.

All right. So, here, here's the image at a wide color

box. Okay. Let's see what's happening there.

Now, if the widen of the sector slows everything down,

what is the quick fix to get our frame back...

uh, frame rate back? What's a quick fix, if you could think right off?

You can just talk amongst yourselves (laughs) since I can't hear you.

Um, but the quick fix is to narrow that color

box. Okay. You narrow in that color box, right

away that narrow color box... and it will reduce the

depth, higher frame rate, and the zoom is also

responsible for that as well. Okay.

So, that's the quick fix in, uh, fixing that frame

rate. All right. Now, here are the sentence

I was talking about earlier about applying too much color gain.

Now, take a look at A and B, where it's, uh, high color

gain followed by appropriate color gain, and then look

at low PRF versus high PRF. I do

want to point out, with your PRF settings,

even with it being low and high, we

can still see the septum

in both settings. Okay. And but, but notice that

there is some alusin, uh, where the valves are.

You see that? In this low setting. And so, when you adjust it

by turning up your PRF, it kind of just, kind of cleans that up, make

it all uniform. Okay. But, just, I do want to point out that you could

still see the septum in both settings.

But in a case where there's high color gain and, um, when it is

appropriate, notice in the high-color gain, the septum is, is

somewhat obscured. Okay. And so, this leads

to, uh, a false diagnosis of VSDs in this case.

And so, you want to have appropriate color gain and just kind of, just kind

of turn that down. It's too high.

Okay.

All right. So, now we're gonna get into

some applying, uh, some of these

strategies and go over a few scenarios, um,

before we end tonight. So, I'm excited about this next

half of the lesson. Okay. So, uh, it's

gonna be like a case scenario. We kind of just go over it and talk it out.

Um, so this particular one, we have a clinical scenario.

As a sonographer, we're performing a 22-week scan.

Okay. Gravity II patient one, she's referred to us.

Doing the routine 20-week scan, they noted some, uh, the baby or

fetus had malgrowth restriction, some outflow tract,

um, issues were happening, and they had a hard time seeing the

nasal bone. Okay. But everything else was considered

normal. Okay. Four-chamber view, as we're

assessing, we noticed that there is a...

uh, right ventricle slightly larger than the left, outflow tracts were, were

abnormal. Okay. And then the conotruncal view,

there was a VSD defect

detected. And then far as the three-vessel view, abnormal

alignment of those great vessels. Okay.

Oh, but there were some other things happening.

We had a cleft lip involved, nasal passage,

that's why they couldn't find the nasal bone, was obstructed.

There was a ear anomaly, a renal,

uh, assessment, some unilateral hydronephrosis, and

the growth lagged by two weeks. So, looking at this

whole clinical picture, uh, there is a syndrome

associated with these findings and that is

indeed the CHARGE syndrome. Okay.

Where CHARGE syndrome should be suspected prenatally when there are

heart defects, co-occur with craniofacial

defects, nasal, ear, and renal anomalies.

So, it's helpful to apply the entire picture, not just heart signs,

but the entire picture in order to, uh, come up with a

diagnosis of this particular

syndrome.All right.

Here's another one. We have a 24-week gestation fetus was

referred. This one showed poly, which is increased

amniotic fluid, a possible cardiac defect, and

abnormal curvature of the spine. Everything else was low

risk. We performed the echo. There is slight enlargement of the right

ventricle, abnormal color flow of the outflow tracts.

You can see a conotruncal view that showed a paramarenous

VSD, as well as the, uh, slightly narrowed distal

arch of the aor- aorta. There were some renal

anomalies present. You had a right kidney was absent,

left kidney was malenlarged. We did see

two-vessel cord

and this particular one had aulical,

okay? And then there was, uh, vertebral

defects. We saw, uh, limb anomalies as

well as gastrointestinal anomalies.

So, all of these, uh, correlate with a particular

syndrome. Uh, you, I, I may have gave it away,

um, with the acronyms (laughs) , um, but yes, it is

indeed VACTERL, VACTERL

syndrome. Um, this association is usually identified

with at least three anomalies among the

vertebral, anal, cardiac, uh,

renal, and limb defects, okay? So, that- the entire picture.

So, so sometimes we, uh, we get, like, caught up with just- just

the heart, but we have to just also apply the

other, uh, defects that we may see with the fetus 'cause it

is helpful in, um, diagnosing, um, or help in diagnose

with a syndrome that's associated with the doctor,

okay? All right, so this particular one, we're just going through

the syndromes and its association with, uh, these

findings, okay? This is gonna be helpful for your echo

exam. So, we have a 23-week fetus, uh, revealed an

increase in TE. We also saw AV canal

defect, uh, balanced four-chamber view, common AV

valve. There was some pericardial effusion.

The humerus and the femur were shortened, followed by, uh, duodenal

atresia. So, right away, with these findings, it's

associated with one of these syndromes, which I feel like could

be easy, um, but yes, it is

trisomy 21, okay? So, these are all common

findings related to that particular

syndrome. All right, so trisomy

21 carries a 40 to 50% chance of having, uh, this

heart disease, which is with the AV canal defect.

All right, so speaking of, we're gonna talk about the ductus

venosus. Um, so here we have an example of ductus

venosus in both A and B. Which one's normal,

which one's abnormal? Okay, so just going

through A, A is the normal ductus venosus

waveform. It has that triphasic pattern, as you

see, okay? So, that is with the S and

D and the A wave, that is a triphasic

normal pattern of the ductus venosus.

Now, on the B side, you can see it looks

different from A, of course. Um, this is indeed

abnormal, and right away you may say, "Well, what- what

is going on here?" Um, the S and the D

is here seen together, but the A is below

that baseline, um, or under the baseline here.

So, this is a example of

reversal of that A wave, which is an abnormal

pattern of the ductus venosus,

okay? All right,

so now we have a 26-week fetus has severe

growth restriction, VSD, RVOT, a small

RVOT, followed by a overrided aorta.

There is clenched fists, rocker bottom feet, and CP

cyst noted. And so, we may remember this from our OB

board- boards, but this particular one is most

commonly seen in trisomy 18, okay?

So, those are all classic features for the trisomy 18

syndrome.

All right, 90% of these heart defects will usually, there'll be a

VSD, double outlet, right, or arch anomaly.

Okay, and the last one, which may give away, 'cause process of

elimination, right? We have a 22-week anatomy scan,

hypoplastic left heart, truncus type, single outflow

tract, a cleft lip palate, holenchoencephaly,

polydactyly, and yes indeed, this is all classic

features of trisomy 13,

okay? All right, so 80% of these, uh, heart defects present with

trisomy 13 will either be a conotruncal, single ventricle

lesion, uh, usually a midline facial and brain

defect. All right, so now we're just going

over some of these common, uh, waveforms that are

seen. We'll start with A at the

top, um, and I'm just gonna just go through each

one. And so A is demonstrating the

mitral

valve velocity or waveform, which is the E and the A

biphasic waveform, followed by the tricuspid

there on the right side, which also demonstrate biphasic waveform,

E and A waveform. Notice the A is the dominant,

dominus wave. And then here down in C,

C is demonstrating the aortic outflow, that's a monophasic

waveform, followed by the pulmonary, which is

also monophasic waveform. Okay, so these are all normal

waveforms of those

valves.Okay. Now, speaking

of, so we have a scenario where there is a- a 32-week

fetus, um, had a very high heart rate,

okay, it was extremely high. Now, notice in the

example, it is sampling the tricuspid valve.

Now, we just went over that it should show a

biphasic, uh, wave pattern but

here, I don't see my E at all. I- is it high

A? Uh, so we see right away, uh, we anticipate that

there is a problem here, okay? So the spectral doppler trace is

obtained, there's inflow shown by the gate of the

tricuspid valve. And so, it's showing monophasic,

however, we're sampling the tricuspid valve where it should be

biphasic. Why is that? Okay, so what's happening in

this particular case, with that inflow wave, it appears

monophasic, it is due to that rapid or that

elevated heart rate. So they're just merging together.

The heart's moving so fast that we're- we can't see the E and

the A waveform, they're just merged together.

And so that's why it appears as monophasic in this

particular scenario, okay? So they're just

overlapping one another, okay? So when- cases where there is a

high heart rate, anticipate that you may have a

monophasic wave pattern when you sample, uh, those inflow

valves.

All right. Perfect, okay. All right.

So we talk about that normal pattern, okay?

And, um, this is just demonstrating the case of the high heart rate

where the E and the A will join together, so that's just

reiterating, um, that previous slide. Okay?

Now, um, I do want to mention, um, in this particular

case, that monophasic waveform is rate

related and it's not a sign of pathology, so I do want to point

that out, okay?

It's just 'cause of that high heart rate.

All right, so there's the cases where, uh, we're gonna just go over some different

patterns to why, uh, the E and A

will be switched around. In a normal case, the E should be smaller, the A

should be dominant, but in cases where there is diastolic

dysfunction, it would ha- show or reveal some

abnormal patterns. And so, we're just gonna go over why we would

see these different, uh, pieces of that. Okay?

So followed by, number one, if there's a abnormal filling

pattern but at a normal heart rate, this will cause that

E:A ratio to decrease, okay? So if there's a

stiff ventricle beating, okay, that's gon'

be- impair that ventricle relaxation.

You'll have passive filling of that ventricle, um,

that's gonna cause that E wave velocity to decrease, that

atrial contraction will increase.

Okay, so that's where you'll see that mix-match there.

Um, A wave dominant and the E

would be below gestational age, okay?

Now, this s- scenario is usually seen in cases with a fetus with

hypertrophic cardiomyopathy. All right?

Some other reasons to see this particular case is with maternal

diabetes, Noonan syndrome, as well as twin-to-twin

transfusion syndrome, um, on the recipient

twin. Okay? Uh, in a case where there is a

reversed or diminished A wave, uh, you will see this in

cases with a fetus with restrictive, uh,

cardiomyopathy, uh, endocardial

fibroelastosis, or if there is severe tricuspid

regurgitation. Um, so that will cause that A wave

flow to reverse in this

scenario. All right. And then

lastly, uh, as you see here, there's

extreme, uh, tricuspid regurgitation where it's

gonna have a prolonged deceleration time of that E

wave, okay, causing the A wave to not be

dominant, where it's diminished in this case.

Um, also note that there is reversal flow,

uh, seen in the hepatic veins. I do believe,

too, um, I wanna mention with the A wave

reversal, I do wanna mention that, that just reminded me, you will see

reversal also seen in the ductus

venosus. Um, and so if you suspect that there is

something going on, try checking that ductus venosus

waveform and demonstrate that, uh, A wave, uh, reversing as

well. Okay? So I did wanna point that out. Okay?

Now, for this particular case, uh, you will see this in case of the Ebstein

anomaly

or pulmonary atresia with intact

septum. Okay? All right, so

we're getting to the end here. Uh, I do want to, uh,

talk about the tricuspid regurgitation.

There are three, uh, different kinds.

Uh, this particular, uh, uh, progression into this

regurgitation, or it could just be trivial.

Uh, trivial, when isolated, usually resolves, there's no

problems. Uh, mild tricuspid regurgitation, the jet

will extend about one-third distance to the atrial wall,

whereas severe (laughs) tricuspid regurgitation really speaks for

itself, um, but it'll take on that holosystolic, uh,

position here, uh, which you can really see that filling of that

atria.

All right. So on the waveform here, each one of these

demonstrate a difference of the regurgitations, and so we're

gonna go through each one. The first one here showed a

mild case of TR, followed by the

severe case of TR where you can really see that holosystolic

presence there, of flow. And then

lastly, trivial. Okay? So you can see the

difference of all three.All

right. Now, uh, trivial versus mal 'cause some may say, "Well, they, they

appear the same." Uh, "How would you know the difference?" Uh, trivial,

like I mentioned earlier, uh, it...

Typically, it will go away, especially when it's isolated.

By the time the patient come back for their follow-up, it's no longer,

longer seen. Uh, in cases with, uh, mal

regurgitation, it's also typically benign.

Um, and so, it, it may... Just pay attention to, uh, the

spectral doppler waveform, uh, to know the difference between the two.

But it seem, between the two, uh, no treatment is

usually needed. Um, and s- and then when it's isolated, it

usually, uh, causes no, uh, issues with the fetus for

both. Okay?

All right, so let's just go over hydrops and some expected heart

changes that, uh, we could anticipate.

In the case of heart hydrops, the heart size would

appear big, okay? It will appear big.

The contractility of the heart would be weakened,

okay? So we'll have, the fetus will have a weakened heart rate

as well as low cardiac output, and that heart

rhythm, we can expect, would be abnormal,

okay? So those are the changes of hydrops.

Okay. Now, when hydrops are seen, there is a doppler study

that should be performed and that is with the TAI

index. Okay? Now with the TAI index, it really

helps, uh, to perform this and to get the value, normal

value less than that 0.36. Uh, and it will really

demonstrate if there is, uh, some really

severe cardiac dysfunction happening.

The TAI index is the same setup as the PR interval, which

we are about to go over, to where you would sample that, uh,

sample gate there at that left ventricle, demonstrating both

the inflow of the mitral valve and the aortic valve,

okay? With this particular doppler study, you do want it, the normal

value to be, uh, less than that 0.36,

okay?

All right. Uh, we just got a couple more case in points.

Uh, this particular one is there's no visible spleen, spleen

shown. Uh, there was bilateral trilobe

lungs. The IVC and aorta both were seen side

by side, which we know that's not normal, on the same side

of the spine, and there was a common AV canal defect.

Now, there is... This is, uh, related to a syndrome.

This is gonna be especially helpful for those taking their boards.

So, all of these features are classic for

right isomerism, okay? And just, what's key is the

fact that there was no visible spleen.

So, it was all right-sided structures.

And so, that's the case of the right iso.

Whereas on hindsight, the opposite where there's multiple small

spleens visualized, long left upper abdomen.

You have bilateral bilobe lungs, interrupted

IVC with azygos, continuation to the SVC,

and partial anomalous pulmonary venous return was

seen. All these together are

classically seen with the le- left isomerism,

okay? And, um, the key classic feature would be the

multiple s- small spleens that's visualized, which is a

polysplenia syndrome. All

right, so we're getting to the end.

Uh, here it is just showing the demonstration of the heart

rates. And by, uh, different stages of the

gestation, uh, there is normal versus, uh,

abnormal. So, you see starting out normal, 90 to

110 beats per minute is appropriate.

Whereas at the, uh, towards the end or mid region, less than

110 would not be appropriate at that stage, okay?

So, just be mindful of the times where you're seeing

those, uh, heart rates and what's appropriate.

Once we get to weeks 13 leading to the end at

week 40, normal range is between 110 to

160. All right? All right,

so here's a particular, uh, spectral doppler waveform.

Notice with it being spaced out and the

elongation of the diastolic region, we

can assume or anticipate that this is a example

of bradycardia. This one, in particular, was at

60 beats per minute.

All right? So, this would lead you, or you would suspect

that what kind of heart arrhythmia is present, and that

would be the complete heart block, which we will be discussing here

shortly, okay? Now, in cases

where, uh, antibodies are transported across the

placenta, so those are, that's just a risk factor from a

mom, maternal risk factor for having SSA

antibodies. When they cross over the placenta, how

will they affect the heart? Um, so I took a, a deep dive

and researched this. And so, between the two, there

are AV nodes that are affected, um, with this particular

case, um, because it crosses over, it affects the AV

node. And if it affects the AV node, which deals with the

cardiac function, you can assume that the heart

rhythm would be abnormal. Okay? And then

this will lead us to suspect complete heart block in

this case, okay? Now, there is a doppler

study

to perform in cases of a suspect or to rule

out complete heart block, and that is indeed the PR

interval, okay, that we had discussed.

Normal PR interval, it should be, uh, less than

150 meters per second.All right. Now, let's

take a look at how to, uh, line up,

uh, for a PR interval. As we saw in the tie index, it's the

same lineup with the sample gate, which you can see

here. We've kind of placed it adjacent to the mitral valve, and the

onset of the aortic valve and ascending aorta.

And what we're showing is the inflow of the mitral

valve and then the... which is demonstrated there with

that EA wave. And then we demonstrate the

outflow of the aortic, uh, valve. And

that is demonstrated through the monophasic, uh, outflow

waveform below that baseline. Now, how to,

uh, line up your calipers to... in order to measure for your PR

interval. A lot of your, uh, ultrasound machines have this

calc on your, uh, package, under your heart package.

You want to go under PR interval. You want to place your first

caliper in between the E and the A

wave, just there in the middle, and then the other one at the

onset of that aortic outflow. Okay?

And then it's gonna calculate it for you, and you should get a value,

a normal value less than 150 meters per

second.

All right, so here we're just matching up the heart arrhythmia.

Again, a sustained tic- tachycardia heart rate is

at greater than 180 beats per minute.

Normal is between the 110 and 180, um,

at sustained, but, you know, in a clinical setting, it's really at 160

at the maximum. And then sustained bradycardia is less

than 110 beats per minute.

Okay. We're getting to the end. Um, just a, uh, final

recap on the normal situs solitus. Uh, your heart...

the fetus heart apex should be pointed where or how?

That is to the left, okay, liver cardia.

The stomach as well should be on the left side, as well as

the aorta, okay? Inferior vena cava

is on the right. Now, in cases with situs

inversus, it's a mirror image of normal.

And so, just switch everything around.

The heart apex in the case of situs inversus will be on the right

side. Stomach is on the right, aorta is on the

right, inferior vena cava on the left

side. All right. Uh, just quickly,

here we have a heart, we want to fix this image.

How do we fix it? We're going to place that focal zone at

the death region of interest. We want to lower the dynamic

range,

high frame rates. We're going to zoom in that picture and magnify

it to one-third or one-fourth of display.

All right. Here we have a PRF

setting. Right away, we already know this answer (laughs)

We are going to increase the PRF to make it

more uniform, which you can see here.

All right. Uh, quickly, uh, VSD present or is this an

artifact?

Right away, remember with our color gain earlier?

It's just the color gain is set too high. This is an artifact.

This is not a VSD present. If VSD is

present, you'll see the crossing over of the blood.

And so, it's going to demonstrate in both red and blue.

And so, that's gonna let you know whether truly there is a VSD

present. Okay. Uh, here

we have a 20-week scan. Uh, 40 years old,

previous child born with VSD, positive NIPT for

trisomy 21, and we have a absent nasal

bone. And what do we have here? Right away,

you can see the crux of that heart is obsolete.

And so, that is indeed a AV canal defect, okay,

which is the strong association with the T21

cases. Okay. Here I'm pointing

out there's two different cases of heart anomalies.

One, on this side, is showing more of the Y

appearance there in the middle, where this one is...

In the grayscale it looks like a Y, but with color you can see that there...

this flow is flowing and then there's some bifurcation.

Um, so there's a demonstration of w- the common

arterial trunk, which is on the right side.

Uh, with this particular one, you want to think if there's only one great artery

present, the aorta and pulmonary artery never

separated. Now, in a case on the left side where

we saw the Y, uh, this particular one was example of

tetralogy.

And now with tetralogy, there are four defects

present. And so, y- you're going to demonstrate either a hole

between the two ventricles, uh, pulmonary stenosis,

overriding aorta, okay? So, if you can identify, uh,

usually two separate outflow tracts, but there is

narrowing and there's other, uh, anomalies

seen, uh, that's most likely your tetralogy and not

the common arterial trunk defect.

All right. Uh, just going through far as VSDs, I've seen

where, uh, VSDs are mislabeled. And so,

I do want to just point out, uh, the difference between the three

here. Um, so starting with A, A is a

demonstration of an inlet VSD. And

how I remember this particular one, I think of my inlet

valves, uh, and so that's usually demonstrated

with the inlet valves present there in view.

Your muscular, I feel like is easier because it's...

it is within the muscular region of that septum, where the

paramembranous-... is usually seen from the

five-chamber view. So, right where you see where our s- that LVOT is coming

into view, that is your paramembranous, uh,

VSDF is present, it will be within that five-chamber view.

Okay? All

right. Now, just going over those waveforms again, uh,

as we see in our picture, we're, uh, sampling an

inflow valve, okay? And so starting with

A, we're just gonna, uh, label each one

first. A is a demonstration of a E and A

waveform, so that is indeed a biphasic

waveform. Now, in B, we see a S, we see a

D, a S, a D, a A, so this is

a demonstration of a triphasic waveform, which is a ductus

venosus. And then here at the bottom with

C, it's just the one peak here,

monophasic, looks like a aortic valve, uh, but this is a monophasic

waveform. But what is this sampling or the demonstration

here? Look at your landmarks of your heart.

You see your descending aorta, your left atrium.

So, this is indeed a mitral valve, which will be

demonstrated with the biphasic waveform. Okay?

It's all about anticipating what to see.

All right? Same for here. We have...

Let's start with the ductus venosus. I kind of gave you that answer already.

The ductus venosus waveform, we anticipate it to be triphasic,

which is seen here. That's normal, with the SD and A

above the baseline. And then this other one here, we're at,

like, a five-chamber angle, so we're assessing that aortic

valve. And so we're assessing the aortic

outflow, okay? That's demonstrated

here.

All right. Here, uh, I noticed with the progression of

abnormal, especially with the ductus venosus, where it's starting off

normal and then it, that A wave will become diminished and

then, by the next time, it may even be reversed.

And so it's helpful to know those differences.

And so starting with the reversal, we know that the A wave will be there

below that baseline. Diminished, the A wave

is almost to the baseline. Not quite gone, but it's

diminished. And of course, the top one is normal

ductus venosus waveform. All

right. Here is an example of, uh, three variations of

the coarctation. Uh, now, sometimes it's, it's

subtle. You may not even see the narrowing from the sagittal view.

And so here we can see where the left ventricle is

affected, where it's much smaller, as well as

the ascending aorta. So, definitely look at all of your

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The Fetal Heart Playbook: What to Do, What to Measure, What to Expect

Chapter 1