胎儿的循环系统(英文版).ppt

Fetal CardiologyKottler NE,Leopold GR,OBoyle M,Pretorius D,Sirlin CB第一页，共七十四页。Fetal CardiologyCardiac anomalies are the most frequently overlooked group of abnormalitiesCongenital heart disease=0.8%of all pregnancies4%one sibling affected;10%two siblings affected9%father affected12%mother affectedCauses 50%deaths from congenital disease第二页，共七十四页。Fetal CardiologyRisk Factors for congenital heart disease:Family history Recurrence risk(hypoplastic left heart as high as 13.5%)Nongestational DM Maternal infection(rubella)Lupus Drugs(anticonvulsants,etoh,amphetamines,ocp,vit A,steroids,etc.)第三页，共七十四页。Fetal CardiologyAIUM/ACR standards in the 2nd and 3rd trimesters include:Four chamber view Position of fetal heart in the thorax LVOT and RVOT not yet part of standards4 chamber view alone:33-63%sensitiveWith outflow tracts:83-85%sensitive 2第四页，共七十四页。GOALSReview normal cardiac anatomy and its sonographic appearance(four chamber,LVOT,RVOT)Explore diagnostic pitfallsReview the appearance of more common structural cardiac defects第五页，共七十四页。The Four Chamber View1.Heart fills one third of the chest第六页，共七十四页。The Four Chamber View2.Apex points to the left(45 degree angle)第七页，共七十四页。The Four Chamber View3.Size of right chambers approximates left chambers第八页，共七十四页。The Four Chamber View1.MV and TV move on real time imaging4.Ventricular septum symmetric第九页，共七十四页。The Four Chamber View6.Portion of the atrial septum present(crus)第十页，共七十四页。Left Ventricular Outflow TractIdentify:LV,RV,IV septum,aorta(normal caliber),+/-LA,+/-RAMedial wall of the ascending aorta merges with the top of the IV septum(most frequent location for VSD)Pathology:VSD,tetralogy of Fallot,transposition,truncus arteriosus第十一页，共七十四页。Right Ventricular Outflow TractIdentify:branching of the main PA into right PA and ductus arteriosus(to desc Aorta),asc aorta in cross section,desc aorta to left of spine;verify PA crosses anterior to asc aortaPathology:transposition,truncus arteriosus第十二页，共七十四页。SpineSpLeft AtriumRight AtriumLeft VentricleRight VentricleModerator BandForamen OvaleFour ChamberInterventricular Septum第十三页，共七十四页。Left AtriumLeft VentricleRight VentricleAortaMitral Valve(closed)Aortic Valve(open)Interventricular SeptumLeft Ventricular Outflow Tract第十四页，共七十四页。Right Ventricular Outflow TractRight AtriumRight VentricleMain Pulmonary ArteryRight Pulmonary ArteryDuctus ArteriosusAscending AortaAoTricuspid ValvePulmonic Valve(open)Descending AortadAoSp第十五页，共七十四页。Pitfalls:PseudoVSDWhen the IV septum parallels the US beam,resultant echo drop out looks like VSDIV septum normally tapers near the AV valvesCorrected by changing the angle of viewIV septum parallels US beam (echo dropout)Changing Angle第十六页，共七十四页。Pericardial effusion?NO!Normal amount fluid(PA第三十页，共七十四页。Tetralogy of FallotvideoCourtesy of Dr Alfred Albahamedclick image to play video第三十一页，共七十四页。Endocardial Cushion Defect5%of CHD Recur risk=3%(1 sib),10%(2 sibs),1%(dad),14%(mom)Freq assoc with other anomalies;strong assoc with Trisomy 21Large defect at the crus of heart on four chamber view第三十二页，共七十四页。Endocardial Cushion DefectSeveral types depend on how AV valves attach.Most common is type III,complete AV canal and common AV valveEndocardial cushions fail to fuse;cause defect in both the atrial and ventricular septae(AV canal)第三十三页，共七十四页。Endocardial Cushion Defectatriavents第三十四页，共七十四页。Endocardial Cushion Defect 4 Chamber View第三十五页，共七十四页。Endocardial Cushion Defect 4 Chamber ViewCourtesy of Dr Mark Skalansky第三十六页，共七十四页。Endocardial Cushion Defectatriavents第三十七页，共七十四页。Endocardial Cushion Defectventsatria第三十八页，共七十四页。Endocardial Cushion Defectvideoclick image to play video第三十九页，共七十四页。Transposition of Great VesselsD-type(“complete”)=heart tube loops to the right normal orientation of ventricles;but vessels malform(cyanosis)L-type(“congenitally corrected”)=heart tube loops to the left ventricular inversion,but normal vessel orientation(no cyanosis)Childrens Virtual Hospital第四十页，共七十四页。Transposition of the Great Vessels4-6%of CHDRecurrence risk=1.5%(1 sib),5%(2 sibs)Association with excessive vitamin ARarely associated with chromosome abnormalities 4第四十一页，共七十四页。Transposition Great VesselsVSD(30-50%)Aorta arises anterior and to the right of PA;great vessels parallel each other5 year survival(surgery)90%第四十二页，共七十四页。Transposition Great VesselsCourtesy of Dr Mark Skalansky第四十三页，共七十四页。Transposition Great VesselsvideoCourtesy of Dr Alred Albafamedclick image to play video(video starts slowly)第四十四页，共七十四页。Hypoplastic Left Heart2-4%of CHD 3Hypoplasia of the LV;MV/AV stenosis or atresiaAssoc with coarctation of aorta(80%)when AV atreticHypothesis:low blood flow to LV causes hypoplasia第四十五页，共七十四页。Hypoplastic Left HeartCauses hypoperfusion of coronary arts;CHF from ischemiaCyanosis at birth if LA to RA shunt not adequateAssociated with chromosomal anomalies=16%(one half from Trisomy 18 alone)4第四十六页，共七十四页。Hypoplastic Left Heart4 Chamber View第四十七页，共七十四页。Hypoplastic Right HeartUnderdevelopment of right sided heart structuresHypoplasia of the RV and PA;RV wall thick;hypoplastic or incompetent TV;PV atresiaRelies on patent ductus arteriosus for blood supply to lungs(PGE1)Tx=surgical sytemic to pulmonary shunt(Blalock Taussig Shunt)第四十八页，共七十四页。Hypoplastic Right HeartSmall RV,thick wall第四十九页，共七十四页。Hypoplastic Right HeartSmall RVNotice themoderator band第五十页，共七十四页。Hypoplastic Right Heart RVOT LVOTCaliber of PA aorta第五十一页，共七十四页。Double Outlet Right Ventricle1%of CHDRecurrence risks not definedBoth PA and at least half of the aorta originate from RVKaryotype abnormalities=5%;including Trisomy 13,18 4第五十二页，共七十四页。Double Outlet Right VentricleAssociated with VSD,ascending aortic stenosis,pulmonic stenosis,AV abnormalitiesComplex embryologic changes involving bulbus cordis(RV),conus cordis(septum),and truncus arteriosus(great vessels)第五十三页，共七十四页。Double Outlet Right VentricleBoth the PA and aorta(more than 50%)arise from the RV第五十四页，共七十四页。Double Outlet Right Ventriclevideoclick image to play video第五十五页，共七十四页。Truncus Arteriosus1%CHDSingle arterial vessel“truncus”arises from the heart and supplies the coronary arteries,pulmonary and systemic circulations Recurrence risk=1%(1 sib),3%(2 sibs)4第五十六页，共七十四页。Truncus ArteriosusOther associated pathology:VSD,abnormal trucal valve,ASD20%overall mortality(surg 6mo to avoid pulmonary HTN)Differentiate from tetralogy of Fallot=no RVOT;look for origin of PAs from truncus第五十七页，共七十四页。Truncus Arteriosus第五十八页，共七十四页。Truncus Arteriosus第五十九页，共七十四页。Truncus ArteriosusFour Types(Van Praagh Classification)1.Main PA arises from truncal root and divides2.Both PAs arise from the truncal root separately3.Left PA supplied by collaterals from aortic arch4.Aortic arch interrupted;desc aorta supplied by ductus(10-15%)第六十页，共七十四页。Ebstein Anomaly1%CHDRecurrence risk=1%(1 sib),3%(2 sibs)Apical displacement of TV;small RV;RA grossly dilated because TV incompetent第六十一页，共七十四页。Ebstein AnomalyAssoc with ASD,WPW syndrome(30%),RV outflow obstruction(PS);CHF in utero from TR 1Surgery to replace TV 1;arrhythmia is frequent after correction(dilated RA)第六十二页，共七十四页。Ebstein Anomaly4 Chamber ViewTV第六十三页，共七十四页。Ebstein AnomalyCourtesy of Dr Mark Skalansky第六十四页，共七十四页。Ebstein AnomalyCourtesy of Dr Alfred Albafamedclick image to play video第六十五页，共七十四页。Coarctation of Aorta 2/1 (normal 1.8/1)Assoc w/other cardiac defects=bicuspid aortic valve,VSD,ASD10%association with chromosomal anomalies(especially Turners)第六十八页，共七十四页。Coarctation of Aorta第六十九页，共七十四页。Coarctation of Aortavideoclick image to play video第七十页，共七十四页。References1.Diagnostic Ultrasound of Fetal Anomalies:Text and Atlas,Nyberg DA,Mahony BS,Pretorius DH,1990,Year Bood Medical Publisher,Inc.2.Sonography of the Normal Fetal Heart:A Practical Approach,Frates MC,AJR 1999;173:1363-70.3.Prenatal Diagnosis of Congenital Cardiac Anomalies:A Practical Approach Using Two Basic Views,Barboza JM,Dajani NK,Glenn LG,Angtuaco Tl,Radiographics 2002;22:1125-1138.4.Structural Fetal Abnormalities:The Total Picture,Rodger C Sanders et al,2nd edition,2002 Mosby,Inc.第七十一页，共七十四页。References5.Fetal Echocardiography:An Atlas,Kathryn L Reed,Caroline F anderson,Lewis Shender,1988 Alan R Liss,Inc,NY,NY.6.Color Atlas of Fetal Cardiology,Lindsey Allan,Gurleen Sharland,Andrew Cook,1994 Mosby Wolfe Publishing.7.Significance of Fetal Intracardiac Echogenic Foci in Relation to Trisomy 21:A prospective Sonographic Study of High Risk Pregnant Women,Manning JE,Ragavendra N,Sayre J,Laifer-Narin SL,Melany ML,Grant EG,Crandall BF,AJR 1998;170:1083-4.第七十二页，共七十四页。THANK YOU!第七十三页，共七十四页。内容(nirng)总结Fetal Cardiology。Maternal infection(rubella)。Pulmonic Valve(open)。Tetralogy of Fallotvideo。Coarctation of Aortavideo。THANK YOU第七十四页，共七十四页。