This presentation is for those radiologists and residents who have an interest to perform advanced fetal echocardiography. Simply started and gradually covers the advanced part of it. It includes normal findings only.
2. Learning objects…
INTRODUCTION
TIMING OF FETAL ECHOCARDIOGRAPHY
EQUIPMENT
LATERALITY OF FETAL BODY AND IMAGE ORIENTATION
CARDIAC POSITION AND AXIS ORIENTATION
SEGMENTAL ANALYSIS
ECHOCARDIOGRAPHIC PROJECTIONS
ROLE OF PULSED WAVE DOPPLER
3D TECHNIQUES
M MODE AND ADVANCED TECHNIQUES
3. Introduction…
Congenital malformations of the heart and arterial trunks are the most
common form of congenital anomalies found in humans.
It accounts for more than half of the deaths from congenital abnormalities
in childhood
4. Prevalence
Prevalence of CHD in live
born Indian child
Total CHD at birth 130-270,000/year
Critical CHD (requiring intervention in
infancy): 80,000
Critical CHD receiving treatment is
only 3.04%
CHD mortality as a fraction of infant
mortality: 3-17%
fetalechocardiography
*Based on available data of CHD prevalence at birth
In developed countries and present birth rates in India
5. Antenatal Cardiac Diagnosis
Importance in developing world
Limited resources to treat complex heart
problems.
Relatively few centres in public sector
offering treatment for complex CHD.
Very limited infrastructure for transporting
sick neonates with critical CHDs which are
correctable.
Early diagnosis is a solution for this
6. Prevalence….only tip of iceberg!
The incidence of CHD is much higher in the fetal population. Because…
Number of unidentifiable cause for CHD is more than identifiable cause, so
only high risk pregnancy are screened
A good number of fetuses with complex cardiac anomalies succumb in the
first trimester itself, even before the cardiac anomaly is suspected;
Some parents opt for termination of pregnancy after the diagnosis is made
in the mid-trimester
Some cardiac anomalies are progressive and end in intrauterine death.
Thus, the incidence quoted above may be only the tip of the iceberg.
7. Need for Fetal Echo!
Fetal echocardiography, or the use of ultrasonic technologies to evaluate
the fetal cardiovascular system, enables diagnosis of structural heart
defects, and offers a way to observe complex physiological processes prior
to birth
Apart from training of sonographers / radiologists, high level of suspicion
and detailed anatomic knowledge are mandatory
Some automated 3D US also increase the sensitivity of detection
9. Indications for fetal echocardiography
C. Familial indications :
History of CHD
Previous sibling , paternal
Mendalian syndromes
Williams syndrome , Digeorge
syndrome
Consanguinity
D. Indications for converting a routine
scan into fetal echocardiography
Chamber asymmetry
Altered cardiac axis
Altered position of the fetal heart
Enlarged fetal heart
Arrhythmia
10. TIMING OF FETAL
ECHOCARDIOGRAPHY
Fetal echocardiography is best performed between 18 and 22 weeks of
gestation.
After 30 weeks gestation,
the shadowing effects of the fetal ribs,
ratio of fetal body mass-to-amniotic fluid increases
so acquisition of images more difficult.
Early maternal transabdominal or trans-vaginal scan at 11 to 14 weeks of
gestation, in pt with Increased nuchal translucency.
In the first trimester (11–14 weeks), cardiac details may not be elicited well, but
the presence of a pulsatile ductus venosus or tricuspid regurgitation can be
a very strong marker for cardiac and chromosomal anomalies.
11. Equipment &Technical aspects
High frequency transducers probes
for resolution and details
Phased array transducers with
fundamental frequencies between 4
and 12 MHz are generally used.
Curvilinear probe with wider near-
field of view.
High frequency transducers with a
narrower footprint
Low frequency transducers and
harmonic imaging ---3rd trimester and
axial resolution of 1 mm or less
this is particularly important given
the small size of critical fetal cardiac
structures.
Frames rates of 80 to 100 Hz are
frequently needed to view important
events occurring at heart rates in
excess of 140 beats per minute
12. Equipment &Technical aspects
The system should have the ability to zoom the image without causing
deterioration of image quality.
A higher pulse repetition frequency (PRF) is required for colour Doppler in
the fetus as compared to the settings used for routine obstetric colour
Doppler.
Role of Color Doppler:
Increase accuracy
Speed up examination
13. Role of Color Doppler: Image optimization
Smallest color box possible to
maintain the frame rate as high as
possible (20-25 fps is real time to eye)
14. Role of Color Doppler: Image optimization
Velocity Scale / PRF:
High-velocity range (> ± 30 cm/sec):
atrioventricular valves, the semilunar
valves, and the great vessels
Low- to mid-velocity scales (10 - 20
cm/sec): pulmonary and caval veins
15. Role of Color Doppler: Image optimization
Color Filter / Wall Filter:
high filter: for aorta
Low filter: for pulmonary artery
Low Color Persistence
Optimum color gain: The color gain in
cardiac imaging should
therefore be initially set on low and
gradually increased until the color
information is optimized.
Color Doppler Image Resolution and
Color Line Density: compromise
between high resolution and frame
rate.
16. Image orientation
First step in the ultrasonographic
evaluation of the fetal heart is the
assessment of the fetal visceral situs
Allows for an accurate determination
of ventricular and atrial situs
Abnormal situs associated higher CHD
Fetal situs determination can be done by:
Position of the stomach and heart in
the abdomen and chest respectively
Position of the aorta and inferior
vena cava below the diaphragm
Presence of bowel dilatation
The presence of a gallbladder
The presence and location of the
spleen
17. Image orientation
Techniques:
Determine the presenting part
Determine the fetal lie within the uterus by
obtaining a sagittal view of the fetal spine.
determine the location
of the fetal left side with regard to the maternal
abdomen
Fetal left side is anterior [closer to the transducer]
Posterior [closer to the posterior uterine wall]
Right lateral [closer to maternal right uterine wall]
Left lateral [closer to maternal left uterine wall]
Obtain a transverse view of the fetal abdomen by
rotating the transducer 90 degrees from the
sagittal view of the lower thoracic spine
18. Image orientation
The fetal stomach is imaged in the left
side of the abdomen, the descending
aorta is posterior to the left, and the
inferior vena cava is anterior to the
right
sliding the transducer toward the fetal
chest, a four-chamber view of the
heart is imaged
the apex of the heart is pointing
toward the left side of the fetal chest
19. Image orientation
Most common used method for assesing
laterality is proposed by Cordes et al.
It is easy when fetus is in transverse position
Procedure:
1. Obtaining sagittal view of fetal body. Align
transducer in long axis of fetus (spine)
1. Orient the transducer so that fetal head is on
the right side of observer on the screen
2. Rotate the transducer 90* clockwise to obtain a
transverse view of fetal body
3. Tranverse section thus aquired is caudocranial
axis
21. Image orientation
Another method reported by
Bronshtein et al
right-hand rule for abdominal
scanning and the left-hand rule for
transvaginal scanning
hand corresponds to the face of the
fetus, and the examiner holds
the hand according to the side of the
fetal face
the fetal heart and stomach are shown
by the examiner’s thumb
23. Cardiac position and Axis orientation
Cardiac position and axis can be assessed in four chamber view
In this view by tracing sagittal and coronal planes through centre of thorax
four quadrants are identified
Lv and most of RV and anterior part of LA lie in left anterior quadrant
25. Cardiac Axis
Left Axis Deviation: tetralogy of Fallot,
coarctation of the aorta and Ebstein
anomaly
Right Axis Deviation: double outlet
right ventricle, atrioventricular septal
defect, and common atrium
Abnormal cardiac axes are also noted in fetuses with
abdominal wall defects such as omphaloceles and
gastroschisis
In rare occasions involving complex congenital heart
disease, the apex of the heart may not be identifiable
26. Cardiac Position
Position of the heart within the chest and
is independent of the fetal cardiac axis,
fetal situs, cardiac anatomy, or chamber
organization.
Dextrocardia
Mesocardia
Levocardia
27. Cardiac Position
Dextroposition and Dextroversion
Dextroposition of the heart, a form of
dextrocardia, refers to a condition in
which the heart is located in the right
chest and the cardiac apex points
medially or to the left occurs in results
from extrinsic factors like diaphragmatic
hernia, left lung mass, left pleural
effusion, agenesis of the right lung
When the heart is located in the right
chest with the cardiac axis pointing to
the right side, the term dextroversion
has been used and is found in situs
inversus and situs ambiguous
28. Cardiac Position
Levocardia can be associated with
normal situs (normal anatomy), situs
inversus, or situs ambiguous
Levoposition is usually in association
with a space-occupying lesion on the
right side
Mesocardia associated with abnormal
ventriculoarterial connections such as
transposition of great vessels and
double outlet right ventricle
29. Cardiac dimensions
Cardiothoracic (C/T) ratio: fairly constant
throughout gestation, with a mean value of
0.45 at 17 weeks and 0.50 at term (range:
0.25 - 0.35)
Cardiomegaly: C/T area greater than 2
standard deviations
An increased C/T circumference can also be observed in the
presence of reduced chest volume rather than an enlarged
heart, and thus, it is important to compare the measured
chest circumference to gestational age nomograms as part
of this evaluation
May be seen in skeletal dysplasia, pulmonary hypoplasia.
32. Internal Cardiac anatomy: Tricuspid
valve
three leaflets—anterior, septal, and
posterior
chordae tendineae
papillary muscles: Ant, post and septal
Chordae tendineae from the valve
leaflets insert directly into the septal
wall, a feature found only in the right
ventricle
Unlike the mitral valve, a subpulmonic
conus separates the tricuspid valve from
the pulmonary valve, resulting in no
fibrous continuity between the two
35. Internal Cardiac anatomy: Mitral valve
Two leaflets – anteromedial &
posterolateral
anterolateral and posteromedial
papillary muscles
anteromedial leaflet, attaches
primarily to the anterolateral
papillary muscle and is in fibrous
continuity with the aortic valve
36. Internal Cardiac anatomy: LV
The ventricles are separated by the ventricular septum. The apical
portion (near the cardiac apex) is muscular in origin, and the basal
portion (near the atrioventricular valves) is membranous.
37. Echocardiographic projections:
Abdominal circumference
Four-chamber view
Five-chamber view
Three-vessel view
Transverse view of the arterial duct
(ductus arteriosus)
Transverse view of the aortic arch
Three-vessel-trachea view (transverse
view of aortic and ductal arches)
38. Echocardiographic projections:
Technique
Determine the fetal situs
Obtain a four-chamber view
left ventricular outflow tract (the aorta), referred to as the
five-chamber view, can be imaged by a slight tilt or
rotation of the medial aspect of the transducer in the
direction of the fetal head
From the four-chamber view, the three-vessel view can
be imaged by sliding the transducer cranially while
maintaining the transverse orientation in the chest
From the three-vessel view, the transverse view of the
arterial duct can be obtained by a slight cranial tilt of the
transducer
From the transverse view of the arterial duct, the
transverse view of the aortic arch can be obtained by a
slight cranial slide of the transduce
From the transverse view of the aortic arch, the three-
vessel-trachea view can be obtained by slightly
angulating the transducer caudally and to the left
39. Abdominal plane
Upper Abdomen: to see hepatic veins,
umbilical veins and ductus venosus.
This plane is also useful to describe
vein anomalies in suspected
heterotaxy and R/O ductus agenesis
40. 4 Chamber View
Scanning Technique
1. Determine the fetal situs
2. Obtain a transverse plane of the fetal
abdomen: full length rib is visible
3. slide the transducer toward the fetal
chest till proper 4 chamber view is
obtained
Criteria of good view:
Complete rib on both side
Apex
Inferior pulmonary vein draining
posteriorly in LA
41. 4 Chamber View
Types of Four-chamber View:
apical four-chamber view
basal four-chamber view
apex of the heart, the ventricles, the atrioventricular valves, and longitudinal atrial and ventricular
dimensions
long-axis or axial four-chamber view
atrial and ventricular septae
42. Role of Color Doppler: Image planes
The four-chamber plane in color
Doppler is best visualized from an
apical (A) or a basal (B) view in order
to demonstrate ventricular filling
either in red (A) or in blue (B) in
diastole.
In these orientations, the course of
blood flow is nearly parallel to the
angle of insonation.
No flow is present during ventricular
systole unless TR is present.
44. The Five-chamber View
Five-chamber view of the fetal heart demonstrating the
continuity of the posterior wall of the aorta with the mitral valve (small
arrows) and the continuity of the anterior wall of the ascending aorta
(AAo) with the ventricular septum (asterisks). The inflow and outflow
components of the left ventricle (LV) are seen in one view (open arrow).
The right and left superior pulmonary veins (RSPV, LSPV) enter the
posterior wall of the left atrium at this level. RV, right ventricle; LA, left
atrium; DAo, descending aorta; L, left.
Five-chamber view of the fetal heart demonstrating the wide
angle between the direction of the ventricular septum and the anterior
wall of the ascending aorta (AAo). This important anatomic observation
is commonly absent in conotruncal malformations. LV, left ventricle; RV,
right ventricle; LA, left atrium; DAo, descending aorta; L, left.
45. Role of Color Doppler: Image planes
Five-chamber View:
Demonstrating aortic blood flow in
blue color within the ascending aorta
or from a basal view (right side of
fetus) demonstrating aortic blood
flow in red color within the ascending
aorta
Color Doppler of the five-chamber
view in the normal fetus shows the
septo-aortic continuity, the absence
of turbulences in systole, and
insufficiency in diastole across the
aortic valve
47. The Three-vessel View
pulmonary trunk in an oblique section
and the ascending aorta and the
superior vena cava in transverse
sections
48. Role of Color Doppler: Image planes
Short-axis or Three-vessel View: show
pulmonary blood flow in
blue color demonstrating the
nonturbulent flow across the
pulmonary valve and the bifurcation
into the right and left pulmonary
arteries
53. Role of Color Doppler: Image planes
Three-vessel-trachea View:
Most important plane
aortic and ductal arches forming a ‘‘V-
configuration
Turbulent flow, reversal flow, size
discrepancy, or even absence or
interruption of a vessel can be easily
assessed
55. Sagittal Views
Techniques:
1. Determine the fetal situs
2. Obtain a sagittal view of the thoracic
fetal spine.
3. sliding the transducer from the right
parasagittal to the left parasagittal chest
while maintaining a sagittal orientation,
three ultrasound planes can be imaged:
i. the superior and inferior venae cavae
ii. the aortic arch
iii. the ductal arch
58. Role of Color Doppler: Image planes
Longitudinal Views of Aortic and
Ductal Arches: often power doppler
and bidirectional HD color may be
needed.
59. Sagittal Views : The Ductal Arch View
sagittal or parasagittal approach
62. Oblique Views
Right ventricular outflow view (short
axis)
Left ventricular long-axis view
Ventricular short-axis views
63. Oblique Views
Scanning techniques:
Determine the fetal situs
Obtain a midsagittal plane of the fetal
chest
The right ventricular outflow view:
angling the transducer to an oblique
plane that is oriented from the right iliac
bone to the left shoulder of the fetus
The left ventricular outflow view: angling
the transducer to an oblique plane that
is oriented from the left iliac bone to the
right shoulder of the fetus
66. Short Axis view
Scanning Technique
1. Determine the fetal situs
2. Obtain a four-chamber-view
3. rotate the transducer 90 degrees to
obtain short-axis views of the heart
4. Serial short-axis views of the heart,
from the apex of the left ventricle to
the pulmonary artery bifurcation, can
be obtained by slight anterior-to-
posterior (apical-to-basal) angulation
of the transducer
67. Short Axis view
Utility:
spatial relationship of cardiac
chambers
ventricular size, ventricular wall,
and septal thickness
orientation of the great vessels and
their divisions
68. Short Axis view: At the ventricular level
Compare both ventricular wall
thickness
Right ventricle identified by irregular
wall
Compare the papillary muscles of left
ventricle (anteromedial vs
posterolateral)
IVS
69. Short Axis view: At the AV valve
mitral valve, with its anterior and
posterior leaflets, is crescent shaped
and has the appearance of a fish
mouth
tricuspid valve is more apically placed
in the heart than the mitral valve
70. Power doppler and bidirectional HD
color
Enhanced sensitivity: amplitude of Doppler
signals instead of their frequency shift is
detected
Improved noise differentiation: In power
Doppler, noise signals are encoded in a
uniform color
Enhanced edge definition: This is because
color signals, which extend partially beyond
the edges, have lower signal amplitude due
to the lack of moving erythrocytes and are
thus not displayed
Flow detection irrespective of angle
insonation: The amplitudes of the positive
and negative components of the flow tend to
add up, resulting in a powerful signal
Disadvantages of power Doppler in
fetal cardiology include the lack of
information on direction of blood flow
and on the presence or absence of
turbulence
combining the Doppler frequency
shifts with signal amplitude, digital
broadband assessment of Doppler
signals is applied providing a very
sensitive tool known as advanced
dynamic flow or ‘‘high-definition (HD)
flow’’
higher resolution, good lateral
discrimination, and higher sensitivity
72. Role of Pulsed wave Color Doppler
Δf = (2f0Vcosθ)/c
Doppler frequency shift therefore
reflects but does not actually measure
the velocity of blood flow
To obtain absolute value, we need to
insonate within 10-15˚
Sample volume is kept distal to the
valve
Multiple measures taken and also
during fetal apnea
Color Doppler is used to direct
placement of the sample volume
73. Doppler Indices
Peak velocity: The maximum velocity on
the Doppler spectrum (cm/sec)
Time-to-peak velocity (TPV): The time
from onset to peak velocity (msec), also
referred to as acceleration time
Deceleration time: The time from the
peak of the waveform to the
intersection of the descending slope
with the baseline (msec)
Time-velocity integral (TVI): The
measurement of the area under the
Doppler waveform over one cardiac
cycle (cm)
Time-averaged velocity (TAV): TVI
divided by the period time (cm/sec)
74. Doppler Indices
E/A ratio: A measurement used to
quantify Doppler waveforms across
the atrioventricular valves. E
represents peak velocity during early
ventricular filling, and A represents
peak velocity during the atrial
contraction
Filling time: The diastolic time of the
cardiac cycle (msec)
Ejection time: The systolic time of the
cardiac cycle (msec)
75. Doppler Indices
Percent reverse flow: A measurement
used to quantify Doppler waveforms
in the inferior
vena cava. It represents TVI of the
reverse flow segment (atrial
contraction) divided by the TVI of the
total forward flow and multiplied by
100
76. Doppler Indices
S/A: A measurement used to quantify
Doppler waveforms in the ductus
venosus. S represents maximum
systolic velocity and A represents the
atrial nadir
79. PW Doppler at AV valve
Doppler waveform across
the mitral valve shows aortic flow during the
systolic component due to leaflet continuity
between the mitral and aortic valve annuli
The E/A ratio is an index of ventricular
diastolic function
in the fetus the velocity of the A wave is
higher than that of the E wave
As ventricular stiffness decreases with
advancing gestation, E/A ratio increases from
0.53 ± 0.05 in the first trimester to about 0.70
± 0.02 in the second half of pregnancy
The rise in E/A ratio with advancing gestation
suggests a shift of blood flow from late to
early diastole
81. PW Doppler at IVC
These waveforms are triphasic with
the first phase corresponding to
ventricular systole (S); the second
phase corresponding to early diastole
(D); and the third phase (reverse flow)
corresponding to the atrial
contraction (A)
The percentage of reverse flow, which
is a ratio of the time velocity integral
during the atrial contraction divided
by the time velocity integral during
total forward flow, is used for Doppler
waveform quantification in the inferior
vena cava
82. PW Doppler at Ductus Venosus
Approach to imaging of the ductus venosus (DV) on color Doppler. In A, a coronal plane of
the chest shows the DV as it joins the inferior vena cava (IVC) toward the right atrium (RA).
The hepatic vein (HV) is also seen in this plane. In B, a parasagittal plane shows the DV
originating from the umbilical vein (UV), and in C, a transverse plane of the abdomen shows
the DV as it originated from the UV. Note the presence of color aliasing in the DV in the
three planes.
83. PW Doppler at Ductus Venosus
Doppler waveforms are biphasic in
morphology with a first peak
concomitant with systole (S); a second
peak concomitant with early diastole
(D); and a nadir concomitant with the
atrial contraction (A)
forward flow is present throughout
the entire cardiac cycle in the ductus
venosus in the normal human fetus
Two such indices were developed based
on peak velocities during systole and
during the atrial contraction (S/A,
S-A/S)
85. 3D Ultrasound
3-D ultrasound provides a volume of a
target anatomic region, which contains
an infinite number of 2-D planes
Optimization of 3D image needs
optimization of reference image which is
2D image
Infinite number of planes are acquired
parallel to reference plane
Images are reconstructed in orthogonal
and oblique planes or volume / surface
rendered
Resolution is best in reference & its
parallel planes
reference plane should therefore be
chosen based on the anatomic region
of interest within the heart
4 chamber plane: cardiac
chambers, origin of great vessels, and
the three-vessel and three-vessel-
trachea views
Sagittal plane: aortic, ductal arches
and venous connections
86. 3D Ultrasound: few terms
ROI box: height and width,
corresponding to the x and y axes. It
should be smallest for fastest acquisition
and better resolution
Angle of acquisition: sweep angle of the
elements within the probe and is
adjusted by the operator. It refers to the
depth of a volume, corresponding to the
z axis
For static 3D: 40 – 45˚
For STIC: 20 - 35˚
Smaller angle: fastest acquisition
Quality of acquisition: number of planes
acquired within a volume.
For static 3D: low, medium or high
For STIC: 7.5, 10, 12.5, or 15 seconds
87. Static Three-dimensional (Direct
Volume Scan: Nongated)
contains an infinite number of 2-D still
ultrasound planes with no regard to
temporal or spatial motion
Rapid acquisition & easy volume
manipulation and also large volumes
Acquisition can be compiled with
power doppler or B flow image
inability to assess events related to
the cardiac cycle, valve motion in the
heart, and myocardial contractility
88. Spatio-temporal Image Correlation
(STIC) (Indirect Volume Scan, Motion Gated: Offline Four-
dimensional)
It is an indirect, motion-gated, offline mode
based on the concept of using tissue
excursion concurrent with cardiac motion to
extract the temporal information regarding
the cardiac cycle
The acquired volume is processed internally,
where the systolic peaks are used to calculate
the fetal heart rate and the volume images
are then rearranged according to their
temporal events within the heart cycle, thus
creating a cine-like loop of a single cardiac
cycle
assess atrial and ventricular wall
motion and valve excursion and combined
with Doppler
delayed acquisition time
89. Real-time Three-dimensional (Direct
Volume Scan, Real Time, Online Four-dimensional)
Done by mechanical transducer
rotation or by matrix transducer
gating of the heart rate is not required
and volumes of the beating heart are
displayed instantaneously without any
transfer or postprocessing of the data
Color Doppler can also be added
acquired volume, often too small
90. Volume manipulation
Volume Display in Two-dimensional
Planes:
Single Two-dimensional Planes or
Multiplanar Orthogonal Display
Both for static 3D or STIC
Multiplanar Tomographic Ultrasound
Imaging
Volume Display in Rendering: display
of external or internal surfaces of
acquired volumes
91. Volume manipulation
Manipulation of a spatio-temporal image
correlation (STIC) volume.
A: The original
STIC data set is shown in an orthogonal plane
display.
The four-chamber plane as a ‘‘single
plane’’ is demonstrated in systole (B) with closed
atrioventricular valves and in diastole (C) with
opened valves.
Scrolling through the volume demonstrates the
upper abdomen with the stomach
(ST) (D),
the slightly oblique five-chamber view (E),
the three-vessel-trachea view in the upper
thorax (F)
a reconstructed longitudinal plane (G) of the
aortic arch.
92. Volume manipulation
Spatio-temporal image correlation (STIC) volume
in a fetus with an atrioventricular septal defect. In
plane A, the defect is not clearly demonstrated as
the valve leaflets are closed. By scrolling through
the cursor (open arrow), the interventricular septal
defect is clearly demonstrated (asterisk) in plane B
when the valve leaflets are open.
Tomographic ultrasound imaging of spatio-temporal
image correlation (STIC) volume of the fetal heart in
gray scale. In the upper left image, the orientation
plane A is seen (highlighted in yellow) with the parallel
vertical lines referring to the planes shown in the
display (-4 to +4). Interplane distance and total
number of planes are chosen by the examiner
94. Volume Display in Rendering
Transparent Minimum Mode:
anatomic details of structures are
limited, but the projection of
anechoic structures such as the
cardiac chambers and great vessels
allows for a useful display
of cardiac anatomy.
98. M-mode Echocardiography
The M-mode display is a linear
representation of adjacent cardiac
structures as a function of time
accurate and reproducible
measurements of various cardiac
chambers and great vessel diameters
The M-mode cursor is often placed to
intersect an atrium and a ventricle so
that the relationship of atrial to
ventricular contractions is recorded
99. Color Doppler M Mode
Colors are added to accurate the
systole and diastolic component.
100. Tissue Doppler Imaging
By sampling atrial and ventricular wall
motion, however, tissue Doppler can
provide accurate
measurements of cardiac intervals and
cardiac wall velocities
Color persistence allows information from prior images to be overlapped on the current image, superimposing color signals from different phases of the cardiac cycle and thus reducing the impression of pulsation
Image orientation and determining the laterality of fetal body is important.
This continuity is disrupted in the presence of aortic override
absent in conotruncal anomalies (more parallel orientation with the ventricular septum)
This view is useful in assessment of conotruncal abnormalities. Abnormalities may involve vessel size, vessel alignment, vessel arrangement, vessel number, and location of descending aorta
Both arches are located to the left of the spine and trachea, an important anatomic landmark because no vessel is seen to the right of the trachea in normalcardiovascular anatomy
ductal arch is seen to arise from the anterior aspect of the chest, with a wide, angular curvature, almost perpendicular to the descending aorta
secondary to an increase in ventricular compliance, a rise in ventricular relaxation rate, or a reduction in afterload with decreased placental resistance
Abnormal findings: decrease mitral flow in HLHS, aortic stenosis, reversed flow in endocardial fibroplasia. Decrease tricuspid flow in HRHS or tricuspid atresia, reversed flow in TR
Peak systolic velocity and time-to-peak velocity are the most commonly used indices for Doppler waveform quantification
Peak systolic velocity is a function of myocardial contractility, valve annulus size, preload, and afterload
time-to-peak velocity is a function of mean arterial pressure
peak systolic velocity and time-to-peak velocity increase with advancing gestation Peak systolic velocity is greater in the aorta than in the pulmonary artery due to larger annulus in the pulmonary artery or a decreased afterload inthe aorta secondary to the cerebral circulation
Time-to-peak velocity is shorter in the pulmonary artery than in the aorta, which suggests a higher mean arterial pressure in the pulmonary artery in the fetus Abnormal finding in AS, Coarctation, PS, PR
This index of flow is a reflection of the pressure gradient between the right atrium and the right ventricle at end diastole, which is dependent on ventricular compliance and end diastolic pressure within the right ventricle The percentage of reverse flow in the inferior vena cava decreases linearly with advancing gestation
In IUGR reverse % flow is increased
reduced, absent, or reversed flow in the atrial contraction portion of the waveform (A) (Fig. 8-24). Abnormal DV waveforms may also be seen in obstructive lesions of the right heart.
Abnormal pulmonary vein Doppler waveforms are seen in fetuses with hypoplastic left heartsyndrome with narrow interatrial communication showing flow reversal during late diastole(see Fig. 11-25). In fetuses with anomalous venous connections, Doppler of the pulmonaryveins shows absence of the typical triphasic shape.
records ultrasound beam reflections in relation to depth from the transducer and time.