Transcript Fetal Diagnosis and Treatment of

"Fetal Diagnosis and Treatment of
Cardiovascular Conditions"
Shanthi Sivanandam, MD,FASE
Medical Director, Fetal Cardiology
Co- Director, Echocardiography
Co-Director Fetal Diagnostic and Treatment Center
University of Minnesota Medical School
I have no financial relationships to
disclose.
Fetal Cardiology
• Incidence of Congenital heart defects in
general population 8-10 per 1000 live births
• Fetal echocardiography has given us an
opportunity to diagnose CHD in utero,as
well as to observe the natural history of
many cardiac defects
Fetal Cardiology
• Fetal echocardiography is now paramount in
making an early and accurate assessment of
cardiovascular structure as well as diagnosing and
treating fetal arrhythmias.
• Complete fetal echocardiographic study includes
the structural and rhythm analysis using a
combination of two-dimensional imaging, Mmode scanning, pulsed- and continuous-wave
Doppler measurements, and color-flow mapping
Fetal Cardiology
• Fetal cardiovascular system differs from adult in
many ways
• Intrauterine ventricles work in parallel rather than
in series
• Three communications-ductus venosus, foramen
ovale, ductus arteriosus
• RV is the dominant ventricle-60-65% combined
cardiac output
Fetal Cardiology
• The immature fetal myocardium has
decreased contractility and compliance as
well as slower contractility and relaxation
rates than Neonatal and Adult myocardium.
Fetal Cardiology
• Ultrasonic imaging -fetal heart began to appear in
the literature as early as 1970’s
• Ability to diagnose CHD and arrhythmias in the
fetus utilizing M-mode and real time 2D-1980’s
• Transabdominal fetal echocardiography is
performed at 18 to 24 weeks gestation
Indications
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Abnormal cardiac examination on routine ultrasound
Parents with congenital heart disease
Previous child with congenital heart disease
Family Hx of left sided cardiac lesions (HLHS)
Identification of other congenital malformation
Identification of chromosomal abnormalities
Abnormal fetal growth or evidence of fetal distress
Exposure to a known Teratogen (Lithium, Alcohol,
Anticovulsants,Paxil, Isotretinoin)
Maternal Hx of Autoimmune disorder (Lupus, Sjogrens)
Abnormal heart rate or rhythm
Maternal Hx of Diabetes
2 vessel cord
Heterotaxy
TTTS
Fetal Cardiology
• Fetus dictate the ease in which the images can be
obtained
• Determine position of the fetus, left and right side,
position of the liver,stomach,and descending aorta
• Heart occupy one third the volume of the thorax
Fetal Cardiology
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Right atrium- Eustachian valve, SVC,IVC
Left atrium- pulmonary veins
Four chamber
Atrioventricular concordance
Venticuloarterial concordance
Aortic arch, Ductal arch, branch PA
HR, IVS thickness, Cardiac function
Fetal Cardiology
• When a prenatal diagnosis of structural or
rhythm abnormalities is obtained, the health
care team can outline a management
strategy to optimize the care and support
given to the fetus, mother, and family.
Fetal Cardiology
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Counseling
Follow-up scans
Planning Delivery
Handling the Newborn
Intervention after birth
Quality of life
Parent support group
Fetal Cardiology
• 23% of infants with ductal-dependent circulation
are d/c from hospital, only to return days later in
shock from ductal closure.
• True benefits prenatal diagnosis-improved longterm neurologic and functional result than
mortality risk
Fetal Echocardiography
Fetal Cardiology
Fetal Aortic Arch
• Aortic arch is a candy cane structures/ head
and neck vessels, runs parallel to the spine
Fetal Aortic Arch
• The ductal arch: Hockey stick-shaped
structure that is continuation of the main
pulmonary artery
Fetal Aortic Arch
• Carotid-subclavian artery index (d1/d2) is
measured at the origin of the left subclavian
artery (d1) and the distance between the
origin of the left carotid artery and the origin
of the left subclavian artery (d2).
Fetal Aortic Arch
Fetal Aortic Arch
CS Index N- 1.1/ Abnormal 0.7
Fetal Cardiology
Cardiomyopathy/coarctation
Fetal Cardiology
Fetal Cardiology
Fetal Aortic Arch
Fetal Hydrops
Ascites
Fetal Cardiology
Fetal Cardiology
Fetal Cardiology
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Fetal Cardiac Intervention : Is feasible
1. Aortic stenosis evolving to HLHS
2. Pulmonary atresia evolving to Hypoplastic right heart
3. Creation of atrial communication
Fetal Cardiology
• Fetal Diagnosis of Aortic Stenosis
Patient selection for fetal intervention
In midgestation fetuses with AS and normal LV length, reversed
flow in the TAA and foramen ovale, monophasic mitral inflow,
and LV dysfunction are predictive of progression to HLHS.
These physiological features may help refine patient selection
for fetal intervention to prevent the progression of AS to HLHS.
Fetal Cardiology
• Suggested preoperative Echocardiographic Criteria with
Threshold Z scores for Balloon Valvuloplasty
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Aortic valve
Mitral Valve
Left ventricular function
Left ventricular measurements/ long axis/short axis
Fetal Cardiology
• ASD
• Pulmonary stenosis/Pulmonary atresia
THANK YOU
QUESTIONS