1. "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

2. I have no financial relationships to disclose.

5. 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

6. 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, M-mode scanning, pulsed- and continuous-wave Doppler measurements, and color-flow mapping

7. 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

8. Fetal Cardiology
The immature fetal myocardium has decreased contractility and compliance as well as slower contractility and relaxation rates than Neonatal and Adult myocardium.

9. 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

10. Indications 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

11. 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

12. Fetal Cardiology 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

13. 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.

14. Fetal Cardiology Counseling Follow-up scans Planning Delivery
Handling the Newborn
Intervention after birth
Quality of life
Parent support group

15. 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 long-term neurologic and functional result than mortality risk

16. Fetal Echocardiography

18. Fetal Cardiology

19. Fetal Aortic Arch
Aortic arch is a candy cane structures/ head and neck vessels, runs parallel to the spine

20. Fetal Aortic Arch
The ductal arch: Hockey stick-shaped structure that is continuation of the main pulmonary artery

24. 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).

25. Fetal Aortic Arch

26. Fetal Aortic Arch CS Index N- 1.1/ Abnormal 0.7

29. Fetal Cardiology Cardiomyopathy/coarctation

32. Fetal Cardiology

33. Fetal Cardiology

34. Fetal Aortic Arch

36. Fetal Hydrops Ascites

38. Fetal Cardiology

39. Fetal Cardiology

40. Fetal Cardiology Fetal Cardiac Intervention : Is feasible
1. Aortic stenosis evolving to HLHS
2. Pulmonary atresia evolving to Hypoplastic right heart
3. Creation of atrial communication

41. 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.

42. Fetal Cardiology
Suggested preoperative Echocardiographic Criteria with Threshold Z scores for Balloon Valvuloplasty
Aortic valve
Mitral Valve
Left ventricular function
Left ventricular measurements/ long axis/short axis

43. Fetal Cardiology
ASD
Pulmonary stenosis/Pulmonary atresia

44. THANK YOU
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