Doppler Assessment of Fetal Arterial and Venous … Doppler Assessment of Fetal Arterial and Venous Systems in Congenital Heart Disease Dev Maulik, MD, PhD Fetal Cardiology Symposium
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Doppler Assessment of Fetal Arterial and Venous Systems in
Congenital Heart Disease
Dev Maulik, MD, PhD
Fetal Cardiology Symposium September 14, 2013
Children’s Mercy Hospital, KC, MO
Objectives • Appropriate use of Doppler for fetal
evaluation
• Demonstration of normal fetal Doppler patterns for umbilical artery, middle cerebral artery, ductus venosus and umbilical vein
• Abnormal fetal Doppler patterns – what do they look like and what does the information mean?
• Application in congenital heart disease
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Maulik
Doppler Effect and Blood Flow Velocity
Transmitted Beam
Scattered Beam
Frequency of the Transmitted Beam
Doppler Frequency Shift
Blood flow velocity information
Frequency of the Scattered Beam
Feasibility of Fetal Doppler Ultrasound: Time Line
Gill
FitzGerald ?Maida ?Pourcelot
Umbilical Vein
Umbilical Artery Umbilical Artery Fetal Aorta
1977 1979 1980 1983 1983 1986 1989 1991
Eik-Nes Maulik
Fetal Heart
Maulik
Fetal Cerebral Artery
Arbeille Wladimiroff
Fetal IVC
Chiba
Fetal Kidney
Vyas Veille
Ductus Venosus
Kiserud
Maulik
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Arterial Doppler Waveform Analysis Hemodynamic Basis
Maulik. Ultrasound Obstet Gynaecol, 1993. Downing, Maulik, Phillps, Kaddado. US Med Biol, 1993 Maulik, Arbeille, Kadado. Biol Neonate, 1992 Downing, Yarlagadda, Maulik. J Ultrasound Med, 1991 Downing, Yarlagadda, Maulik. J Ultrasound Med, 1991
Upstream Effect Downstream Effect
Maulik
Doppler Analysis – the Indices
Resistance Index (RI) Pulsatility Index (PI) Systolic/Diastolic Ratio (S/D) Diastolic Average Ratio (D/A)
Maulik et al, 1984
Maulik
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Umbilical Artery Doppler
End Diastolic Flow Maulik (2005) Doppler Ultrasound In Ob/Gyn; 2nd Edition; Springer.
16 wks
20 wks
24 wks
28 wks
32 wks
36 wks
Umbilical Artery Doppler Absent/Reverse End-Diastolic Flow
Compiled from 1126 reported cases
Maulik, D. Supplement 16, Williams Obstetrics, 19th Ed, 1997.
Perinatal Outcome Mean
Perinatal mortality 45%
Gestational age 31.6 wks
Cesarean for fetal distress
73%
Apgar score at 5min <7 26%
Admission to NICU 84%
Congenital anomalies 10%
Aneuploidy 6.4%
Maulik
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Umbilical Artery Doppler in CHD • Obstetric complications, e.g. fetal growth restriction • Increased abnormality in CHD with:
• Aneuploidy • Other malformations
• Isolated CHD • Most cases: no specific change • Higher UA pulsatility index in right heart
obstructive lesions, e.g. pulmonary stenosis, pulmonary atresia, TOF, severe Ebstein’s, tricuspid atresia
Copel et al, JUM, 1999; Ursem et al, UOG 2001; Donofrio et al, 2003; Kaltman et al, UOG,2005
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Middle Cerebral Artery Doppler
Arbeille et al, UMB, 1987
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• Increased MCA artery end-diastolic flow reflects lower flow impedance – response to in-utero hypoxia
• MCA Doppler / Umbilical artery Doppler ratio (CPR, U/C) reflects flow redistribution - “brain sparing effect”
• High MCA peak systolic velocity indicates fetal anemia Arbeille, UMB, 1987; Bahado-Singh et al, Amer J Ob Gyn, 1999; Ott. Amer J Ob Gyn, 1998. Mari, NEJM 1997.
Middle Cerebral Artery Doppler Maulik
Fetal Cerebral Artery Doppler in CHD
• MCA Doppler in hypoplastic left heart
• Decreased CV flow impedance
• Lower MCA Doppler indices
• MCA Doppler in right sided obstructions
• >> left sided obstructive lesions
• > normal
• Cerebral Doppler/umbilical Doppler (CPR, U/C)
• Controversial - ?“brain sparing effect” in CHD
• Higher (Donofrio 2003) vs. normal (Rychik 2005)
• ? Predictor of neurological outcome in CHD
Maulik
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Ductus Venosus Doppler
Kiserud: Dop US Ob Gyn, (Ed:Maulik), Springer. 2005
• S=ventricular peak systole • D=ventricular early diastole • A=atrial systole • Venous compliance and reservoir function • Reflects right heart function
S A
D
Maulik
Absent or reverse A wave • Right heart dysfunction • Late predictor fetal decompensation • Independent predictor of mortality in FGR • Independent predictor of intact survival (neonatal)
Mavrides et al, UOG, 2009; Baschat et al, UOG, 2007; Baschat et al, UOG, 2009;Borell et al, UOG, 2013.
Ductus Venosus Doppler
Kiserud: Dop US Ob Gyn, (Ed:Maulik), Springer. 2005
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Fetal Ductus Venosus Doppler in CHD • Absent or reverse “A” wave indicates fetal cardiac
failure and predicts the outcome including mortality
• Absent or reverse “A” in 1st Trimester predicts 30-40% of euploid CHDs
• Increased peak velocities in severe outflow tract obstructions (HLHS, PS, AS, TOF, Ebstein’s, TV atresia)
• Abnormal DV in CHD with other malformations, aneuploidy, fetal growth restriction
• No significant changes in most cases of CHD
Maulik
Ductus Venosus Doppler – Fetal Heart Failure
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• Advanced fetal decompensation
• Reflects right heart dysfunction with increased right atrial pressure
• Poor prognosis
Umbilical Vein Pulsation Maulik
Parameter Normal -1 point -2 point Hydrops None (2 points) Ascites, pleural or
pericardial effusion Skin edema
Umbilical vein Ductus venosus
No pulsation Normal
No pulsation A wave zero or reversed
Pulsation
Cardio-thoracic ratio
0.20> <0.35 0.35-0.50 >0.50 or <0.20
Cardiac function Normal TV and MV RV/LV S.F. >0.28 Biphasic diastolic filling
Holosystolic TR or RV/LV S.F. <0.28
Holosystolic MR or TR dP/dt 400 or monophasic filling
Umbilical artery Doppler
EDV present AEDV REDV
Cardiovascular Profile Score
TV=tricuspid valve; MV=,mitral valve; RV=right ventricle; LV=left ventricle: TR=tricuspid regurgitation; MR=mitral regurgitation: SF=shortening fraction; AEDV=absent end diastolic velocity; REDV=reverse end diastolic velocity.
Huhta et al, JMFNM, 2006
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Conclusions • Fetal Doppler findings in CHD depend on:
• Associated malformations
• Aneuploidy
• Obstetrical complications, e.g. fetal growth restriction, preeclampsia
• Fetal arterial Doppler has selective utility in CHD.
• Fetal venous Doppler has defined utility in CHD:
• Absent or reverse “A” wave in the ductus venosus indicates fetal heart failure and poor prognosis.
• Umbilical venous pulsations indicate poor prognosis.
Maulik
Thank You
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