Transcript

Hi, this is Dr. Jason Cox, practicing radiologist

and program director of the Institute

for Advanced Medical Education.

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I wanna thank IAME again for allowing

me to share.

I'm so excited to get started

and share with you all on a very scary topic

for some, uh, doppler.

And so, um, let's get started.

Today we're gonna learn some tips on how to master

doppler and fetal heart imaging from flow patterns.

So we're talking about normal flow patterns to, uh,

pathological clinical correlation.

Okay. If we see, um, some pathologies.

And so before we get started,

we'll talk about a few of the objectives.

Now, the first objective, we're gonna understand indications

to why we would need

to use Doppler in a fetal heart assessment.

From there, we'll go over, um, optimal timing

for Doppler evaluation.

We're gonna master some techniques

and go over some settings that you would like to apply

to really enhance your pictures.

We're gonna apply these best practices that we learn

to evaluate key cardiac structures and flow.

And then at the end, we're going to just recognize

abnormal doppler patterns

and then their clinical implications when we see them.

Okay. Now, before we get into the nitty gritty,

we're gonna just go over a quick overview of fetal doppler.

So when we're assessing fetal doppler, what,

what are we visualizing?

We're watching blood flow real time. Okay.

So it's a real time flow visualization of the blood flowing.

We're gonna, we see direction, we see speed from there,

we're able to sample, let's play that again.

We're able to sample this, uh, wave forms,

and so we're able to assess if there is regurgitation

or turbulent flow.

We're able to see those velocities

with a spectral doppler wave form.

We're able to look at our valves in the outflow, tracts, any

abnormal flow detection.

And overall, in the early first trimester, we're able

to get a hemodynamic assessment early on.

And so doppler is really useful, um,

when we're assessing the fetal heart.

And this particular example that we're seeing here,

this is an example of a ductus arter, um, aneurysm.

And so you see your ductus arteriosis,

and it's, uh, extremely dilated,

and we're watching the turbulent flow

there within that vessel.

Okay, so let's go on.

All right, before we get into, uh, doppler settings,

we wanna do a quick doppler quick guide,

and some do's and don'ts.

Okay? So starting with the do's, do use

doppler when clinically necessary.

Okay? If there's an indication, then yes, it's okay

to use doppler within reason.

You wanna keep your thermal index less than 1.0.

You do wanna minimize your exposure time.

And before you apply your doppler, you want to

optimize your 2D imaging, okay?

Always, uh, expect your valve with color doppler first

before applying your pulse doppler wave

to get the spectral doppler waveform.

And then lastly, practice your lower principle,

which we all know is as low as reasonably achievable.

Okay? Now, some don'ts.

You don't wanna routinely use spectral doppler in the first

trimester, okay?

Only if there's an indication.

Now, don't raise output power unless necessary,

and don't leave Doppler on while you're searching.

If fetus is moving, don't have your doppler just there.

And just trying to get the quick, uh, a good picture.

You want to first optimize your 2D image,

then apply your doppler,

then assess the waveform from there.

And, um, lastly, don't use doppler

for entertainment imaging.

Um, it should, should be avoided,

and don't ignore the safety limits that we just went over.

Okay? All right, so let's go over some settings.

Now. First and foremost, we want to adjust that scale

and our PRF, this is really going

to help us prevent the ali, okay?

From there, we want to, uh, adjust our wall filter.

You know, for our smaller vessels, we may need

to bump it down.

And then for in cases with your outflow tracks,

or your mitral or trius valves, you may need to bump it up.

And so you really wanna adjust your pr scale,

your sample gate size, you wanna keep it narrow for

that precise measurement.

And so you wanna avoid the over gain

as well with your color.

Okay? And then from there, you want to,

with your sweep speed, whether you want to increase

for arrhythmia assessment or for valve timing,

and I save the best for last your angle of intonation.

You wanna keep this closer to zero degrees, okay?

The smaller angle will give you a more accurate

velocity, right?

So just this is right here will be just a quick review

because we've, we've all done physics, we we're probably,

um, all scanning and we know the different types of doppler.

But just in case, I just wanna do a quick review. Okay?

So starting with color doppler.

Color doppler is gonna help map direction

and speed of blood flow, okay?

Using the color signals.

From there, we have a power doppler,

which is my absolute favorite,

especially in the first trimester.

So with power doppler, we are able to detect

and presence, uh, the intensity of the smaller vessels.

Um, it's especially helpful in picking up the aberrant right

subclavian artery.

We have a few examples of that coming up.

And then from there we have your pulse wave, Doppler

pulse wave doppler will help sample the flow at a

particular location.

And then from there, we're able to measure

that velocity in timing.

And then spectral doppler is a waveform

that's gonna display the velocity over time.

This is where we're gonna see the abnormal

patterns, if there are any.

Okay? Alright. So now let's break it down.

Now, the uses with color doppler, especially helpful,

where you want to screen for any abnormal flow patterns such

as, uh, ventricle septal defect.

I have an example where you'll demonstrate the shunt across

the septal wall.

So it's really helpful to pick up the VSD.

Also, with color doppler, we're able to

identify any turbulence or regurgitation.

Now, just to, uh, recap, remember

above the baseline,

that's demonstrate flow towards the transducer, so

that's the flow in red.

And then anything below the baseline here,

demonstrated in blue

or green, that's flow, moving away from the transducer.

All right. So with power doppler, the uses is just

to visualize, uh, blood flow.

It, I feel like it gives it a pop

and the such, like we can achieve the same picture here,

color doppler, but power doppler really just

enhance it for me.

I'm able to see the branches off the aortic arch.

I'm able to see the ductus osis clearly, so it just kind

of enhance a color picture.

Okay? Um,

and so another key thing with power doppler, it says here,

map and vascular anatomy in

that arterial branching patterns.

And so later on in the slides, we'll be able to, uh,

really see this in action.

All right. So with pulse doppler, the uses usually are seen

with measuring inflow or outflow velocities.

With this particular one, we're able to assess rhythm, um,

diastolic function and cardiac output.

Here are some examples of the sampling of the mitral valve

as well as the trius valve.

We'll talk about this a little more, um, just the detail

of what's normal with these particular

assessments coming up.

Okay? Alright.

Spectral doppler, this is where once we apply

that sample gate, a spectral doppler waveform will give us

that, uh, that wave pattern for that particular valve.

And so we're able to evaluate diastolic filling.

Um, that's seen with the e and the A waves.

We're able to measure the function of those, uh, waves,

as well as analyze the arrhythmias, detect

that there's a obstruction in place.

Um, and in this particular example is a

demonstration of regurgitation.

So we're able to see that with a spectral doppler wave form,

and then we're able to monitor fetal wellbeing.

Okay? So as you see, all four have a unique use usage,

and it's really helpful when we're

assessing the fetal heart.

All right. Now, here are some very important tips

depending on what your sampling

or what you're trying to assess.

You want to set your pulse doppler gate

in a particular section on the heart,

depending on what you're evaluating.

So in case where you're assessing

or you suspect that there is regurgitation,

you wanna place the gate proximal to those valves

as you see in the demonstration.

So that's gonna be more within like the atrial region.

And this is gonna give you that assessment if there is

regurgitation present.

Okay? Now, in cases where you just want to, uh,

show the velocity of the valve and achieve a e

or a wave form.

So in this case, you wanna place the gate distal,

which is seen here within the ventricle.

And I, I usually place the gate right at the leaflet tips.

And so that will, uh,

really help you assess the EEA wave form.

All right? Now, first

and foremost, always optimize your 2D gray scale

image, okay?

From there, then you apply your color doppler.

In this case here, you can see there is a NAL cord present.

I'm doing a first trimester screening.

I applied my color doppler.

I was able to see that I wanted to go a step further

and assess the smaller slow flow vessels.

So then I applied power doppler in that case,

which you can see here.

And then from there, I noticed a bulging

of the abdominal region appeared like ail.

So this gave me an indication to

apply spectral doppler

to assess the ductus venosus waveform.

And so from there, I was able to pick up reversal

of the ductus phe nosis.

Okay? So once again, I did not attempt

to do the spectral doppler until there was an indication,

which in this case, um, we suspected

or we saw a, um, foil.

All right, so we're gonna talk about

the Doppler evaluation steps in the first trimester,

we wanna practice as safety tips.

And so I am highlighting here

where the thermal index is usually seen on your, uh, image,

on your ultrasound image, you wanna make sure that it's

below 0.7.

A lot of times when you're using your first trimester

package, your machine set these settings in place.

So it's not, we don't necessarily have to change

with adjust anything.

Usually if you go under your first trimester cardiac

package, it should be automatically set by your, uh,

ultrasound machine.

Okay? And then from there, when you're assessing,

you wanna check for any anomalies or so forth.

That's going to tell you if you need to persist in, uh,

apply a spectral doppler waveform.

If everything's pretty normal,

we'll just do a standard color doppler with the gray scale,

not the spectral doppler in this case.

Okay? All right.

So if you follow a protocol with your first trimester scans,

we have to still apply

and still assess the heart, um, as we would

for like a level two or a detailed anatomy scan.

Not as much detail,

but you definitely still have

to hit on the foundational points.

And so that's the four chamber view.

The LVOT view, which you can see is demonstrated here

as well as the RVOT.

Now, a lot of times the LVOT

and RVOT views may not be obtained on everyone,

but standardly you should be applying a four chamber view

with and without color doppler, as well

as a three vessel trache view that should be demonstrated

on all of your first trimester screenings.

Okay? And a lot of times with color doppler

or power doppler, for some patients, it's,

it's easily picked up.

Okay? All right.

Now these particular cases here demonstrated some

pathologies that were found in the first trimester.

And I must admit, I wanna say almost 90%

of these weren't, were not gonna be found

unless I applied color doppler.

Um, the gray scale, you know, is limited,

especially when you're looking at a heart at 11

weeks or 12 weeks.

And so it's when once I applied the color doppler,

I was able to pinpoint a lot of these anomalies.

Um, remember earlier where I mentioned about the AB

and right subclavian artery.

This vessel here is below the trachea

and it's heading towards that right shoulder.

Now, this one is tricky, I must admit.

And a lot of times the arsa vessel is not picked up

unless that PRF scale is below 20 centimeters per second.

So keep that in mind.

In cases where you want to rule out

ab right subclavian artery, you wanna bump

down your PRF scale to pick up that vessel, okay?

Uh, another example I have here is a right aortic arch,

which you can see a clear u shape of this aorta.

And then we have a confirmed case of a aortic coarctation.

Now, it was not in the first trimester,

but we were able

to follow this particular case into the third trimester

where you can see that indeed it was, uh,

aortic cooptation, okay?

In the case we had, uh, overriding aorta as well

demonstrated in this particular case.

Alright? Now, did you know between 11

and 13 weeks, if there is tricuspid regurgitation,

it's usually due to either a chromosomal anomaly

or a heart defect is present.

Okay? Now about 80% of T 21 cases

will have a abnormal ductus osis flow.

And then for as your T 18 cases,

these will usually demonstrate tricuspid regurgitation due

to tricuspid valve anomalies.

Okay? So that's why it's important.

Once we have an indication,

then we apply the spectral doppler, we'll kind

of assess the findings from there.

If you're interested.

Um, fetal medicine foundation has a certification process

where you can, uh, submit

for a tricent regurgitation certification as well as,

um, the other one is ducts nosis.

And so if you're interested, here are the cases here

or the steps to do that.

But in a normal assessment, even without uh,

achieving certification,

you still wanna have a normal process of how

to assess, okay?

So if I try cus regurgitation, just

remember your standard zoom in your picture to

where you can, uh, have the four chamber heart I view,

which you can see in a demonstration.

And from there, since we're assessing for regurgitation,

we know that we want to put a gate more and with that atria,

and that's where we're gonna assess the regurgitation

if it is present.

Okay? Now, one thing to keep in mind, um, for true

cusa regurgitation, it has to last at least half

of asystole okay?

Process. And the velocity has

to be greater than 60 centimeter.

Okay? So that's, there is a true trius of

regurgitation present.

All right? Now, when you're assessing for ductus osis, um,

instead of zooming in on the transverse heart, you want

to zoom in on the midsagittal view, uh,

where you can assess the umbilical vein

and the ductus osis connection.

And from there, that's where you wanna place

that postop sample gate, right?

Where you see the alist, place it there

and you'll achieve this phasic waveform.

Okay? It's pretty classic, uh, waveform

with the ductus osis, where you'll demonstrate the s, the d,

and the a wave above that baseline.

And this is a normal ductus osis wave pattern, okay?

Now, in cases where there is abnormal ductus osis,

a abnormal ductus osis wave pattern will persist either

as a reversal of that, a wave, which we saw earlier with

Emil or absent a wave.

Now, I did, uh, like a, um, reverse, uh, imaging here

where you can see the reversal demonstrated

of the A wave in this particular case.

And then here, there's none, no a wave at all.

Both are abnormal.

And remember, this is a strong marker for down syndrome.

I, all right,

so now we're talk about first, uh,

second trimester doppler evaluation

of the fetal heart assessment into y.

Now, our window

to assess in the second trimester is usually a 20 week scan

and our fetal echo, okay?

So that window is in between 18 to 22 weeks.

Now, the key doppler checks are the inflow valves,

the outflow valves, great arteries, we're assessing, uh,

ductus, venosus and fetal heart rhythm.

Okay? Now, the goal during this time is

to assess a full hemodynamic picture of the fetal heart

and structural assessment.

Okay? Now, in cases where we have

to do a doppler evaluation in the third trimester,

that's usually done in cases where we suspected

that there was a heart defect from the second trimester,

or if there's arrhythmia.

A lot of times for, um, some of our patients

who are coffee drinkers, they may have, uh,

what's called a premature atrial contraction.

And so in those cases, we have to assess the heart

and apply doppler, uh, evaluation tools to check

to make sure everything's good there.

Um, in cases where there's hydro drops

or any concern of fetal anemia, we'll have

to do a doppler eval as well.

In those cases of growth restriction, it's really helpful.

I have a case coming up that talk about, um, a case

where we did see abnormal wave pattern in a growth

restriction, um, scenario.

Okay? Now, the key goal

for a third trimester evaluation is

to monitor the fetal cardiac performance as well

as hemodynamic.

All right? So we pretty much touched on, uh,

color doppler, power doppler, uh, why we need to assess

or how it would help us assess the fetal heart.

Now we're going to get to the fun part, the nitty gritty,

where we'll discuss artifacts and how to fix and so forth,

and go over some case scenarios.

And so, let's take a look, um, at the key cardiac valves.

Now, each one of the valves in the heart

gives us a doppler assessment, okay?

So when we're looking at the cusa

and mitral valves, we're,

we're assessing inflow patterns, okay?

Blood flowing in.

When we're looking at the aortic

and pulmonary valves, we're assessing outflow velocities.

The ductus osis gives us the cardiac dysfunction assessment.

The foramen shows us flow, direction, and presence of flow.

Pulmonary veins is going to show us

or confirm if there is true connection into the left atrium.

And then with the aortic isus

and ductus arteriosis,

that's gonna give us our postductal velocities.

Okay? So we're gonna kind of touch on each one

and look at some patterns.

Okay? Now,

before we go there, I do wanna point out that

with each doppler type, a heart defect, um,

is best demonstrated with, so with color doppler,

as I mentioned earlier, best demonstrates the

VSDs, okay?

It's, it's like the go-to now with your power doppler.

So in cases of, uh, rule out arsa

or your vascular rings, that's the doppler type

that you usually wanna utilize.

Your pulse doppler is gonna show the,

or it's gonna pinpoint if you see a turbulence

around the valve

or, uh, a flow jet,

then you wanna assess for regurgitation.

That's where you wanna sample with a pulse doppler.

And then your spectral doppler will

demonstrate that waveform.

If it's a stenotic regurgitation, it will demonstrate it.

Okay? All right, so pd

PD here is, you're gonna see, he's gonna come around

and show us or let us know, Hey, it's red flags,

something's abnormal, there's some kind

of pathology going on here.

And so you're gonna see PD from here on out. Okay?

Now, some abnormal doppler patterns

or red flags, um, will present itself either with a reverse,

a wave of the ductus osis.

Um, you, you'll either see a pulsitile flow

with your umbilical vein.

You'll either see regurgitation, which is demonstrated

mix match, so where it should be forward flow,

you see reverse flow.

So there's a mix match there.

And then in cases where there's no flow

that will be demonstrated.

So we're gonna take a look at all of these cases

and see why what co congenital heart defect is

behind this abnormal pattern.

All right, so starting off with your valve function,

we're gonna just focus on the artifact and the fixed tips.

'cause we already know about the benefit

and why we would need to apply it.

And so when you're assessing for your valve function,

the artifact that's usually seen in this particular case

is lysin.

Okay? And how do we fix lysin?

We fix in, uh, increasing our PRF scale

or lowering the baseline to reduce it.

Remember in this case, to always keep that angle closer

to zero, less than 20.

And in, in cases you may need

to use a smaller sample gate, okay?

Just to fix that. All right?

Now with we're back at a mitral valve

and a cusa valve assessment, we have to know what's normal.

So when we're normally assessing the a wave, when we measure

the velocity matters.

And so with your cusa valve versus your mitral valve,

let's look at some of the normal values.

And so with the mitral valve, the mean velocity

is about 45, okay?

And cusa valve mean velocity is around 46,

but it can go from a mean of 46 maximum to 76,

or from the mitral valves.

That's 75 always.

Keep in mind though,

your trius valve value is usually greater than the mitral

valve, okay?

So in your normal, uh, cases,

the T is greater than the mitral.

Alright? Alright.

Now when there's a abnormal mitral valve, okay,

so there's either a altered EA ratio

or a abnormal peak velocity, you wanna think there is a

decrease in the left ventricle compliance

or increase in the left ventricle pressure.

And so that's usually seen in cases

of hypoplastic left heart or critical aortic stenosis.

Now, in a case where your cus valve has a reverse

or a blunted EA

or a ho cystic regurgitation pattern seen, you wanna think

that there is a volume overload

or increased, uh, right ventricle pressure.

And so that's usually seen in neo pulmonary atresia

with an intact septum, um, hypoplastic right ventricle.

Now what if both valves are abnormal so

that we got problems there?

Big problems. And

so there's a usually a global ventricle dysfunction

that's seen in a cardiomyopathy, whether it's dilated

or hypertrophic.

Um, you can even see it in a fetal growth restricted fetus

or a poorly controlled diabetic,

and usually show abnormal flow patterns across both valves.

All right, so now we're gonna assess the outflows.

And so we have the LVOT outflow track

and the RVOT outflow.

Okay? Now with these particular ones in your grade scale,

you wanna demonstrate the valves open and closing.

I usually do a side by side picture where I show the valve

close and then open right side by side so the doctor can see

that that is indeed normal.

Then we'll assess with our color doppler.

We wanna measure our velocities, okay?

And so there is a particular velocity for each valve.

Your PA valve is less than the aortic valve in normal cases.

Now, if you notice that there is abnormal waveform,

whether it's cross aortic valve

or the pulmonary valve, that's usually in cases

of critical aortic stenosis

or coarctation for the right side, pulmonary stenosis

or pulmonary regurgitation.

Okay? The normal velocities are between 60

to 80, okay?

But the, uh,

pulmonary valve is gonna be less than the aorta.

Aorta is always higher than the right side. Okay?

All right, so here's pd, the penguin.

We have quite a few red flags happening here.

Quite a few. So we're gonna start actually on the left side.

Um, start here at the top

where you have a four chamber view.

The chambers looks enlarged.

We don't have the actual motion,

so we don't know are the vows stiffed or whatnot.

We just have this picture, this gray scale.

So then we apply the color doppler.

So from there we applied color doppler.

And look at here,

there's no flow happening within the left ventricle.

We can see that. So from there, right away, when we see

that there's no flow going, um, inside the left ventricle,

then my thought is to now assess the my valve.

We wanna look at the aortic flow.

In this case where we're seeing those jets,

there's some regurgitation happening, which we can see here.

Once we apply the pulse doppler in this gate here,

you can see the spectral doppler wave form.

And so we have the regurgitation that is present.

From there, we assess with the three vessel trachea view,

which we did see the mix match,

and notice that there is reverse flow in the aorta.

Now, from this view where the spine being below, we know

that both pulmonary

and aorta should demonstrate forward flow towards the spine.

But in this particular case, there was reverse flow. Okay?

So then this gives us the suspicion of, uh,

critical aortic stenosis.

And our clues for that is the 2D appearance showed a thicken

dysplastic aortic valve.

We do see hypertrophy there in the of the left ventricle.

And then upon our spectral doppler assessment,

we notice the high peak velocity, which we check for

that retrograde aortic arch flow.

Okay? So we were able to see that,

and indeed it was confirmed this was a case of, uh,

Turner syndrome, um, Turner syndrome.

Uh, it did demonstrate all of these findings here,

and it did persist in, progressed to

hypoplastic left, which is commonly seen, um,

with these particular findings.

Oh, okay, we're back. We have another case here.

Um, this time it's the right side. Okay?

Now, this particular assessment, we have some clues.

And so with a 2D appearance right away,

and it's pretty obvious that you can see

this enlarged right atrium, okay?

And then from there, we're noticing the domen

of the pulmonary valve.

And so right away when you see, see this,

you want the oh color, let's apply a color doppler.

Let's look at this in different views.

And so upon further investigation,

we notice here the turbulent flow across

that pulmonary valve leading into that dilated

main pulmonary artery.

And from there, once we notice that abnormal color doppler,

we apply a pulse sample gate,

and then we have a spectral doppler waveform here,

very high velocity.

So this deed and it, it did, uh, confirm

that there was a pulmonary stenosis in this,

this particular case, and it was all seen

without clues here present.

All right? So once again, we have some may say, well,

how well I know the difference between pulmonary stenosis

and pulmonary regurgitation.

And so I have a demonstration where, once again,

a pulmonary stenosis, pulmonary stenosis

really shows a dilated vessel, which you can see here.

And then turbulence, um,

notice the turbulence flow across the valve,

whereas regurgitation, you know,

it's just like a color jet there backflow.

And so that really gives us a clue with a, a color doppler.

Okay? And then from there, we assess with a spectral doppler

and assess the waveform that we will see from each one.

Okay? Now, keep in mind, um, when you think

of a stenotic valve,

what's happening in this particular valve,

it's doesn't open all the way.

So not enough blood is passing through,

which shows in the turbulent flow that we're seeing.

Whereas with regurgitation,

the valve doesn't close all the way,

so blood is leaking backwards.

Okay? Another tip that you wanna keep in mind is that

with a stenotic vessel

or a stenotic valve, high velocity usually is demonstrated

with the turbulent jet during that opening phase.

And then with regurgitation, you'll have that reverse flow,

and that's during the closed phase.

Okay? Now we're gonna get into, uh,

like arrhythmia assessments.

Um, in cases of, uh, your assessing for arrhythmia,

the artifact usually is motion.

Okay? Whether it's fetus moving, fetus breathing,

mom breathing, and so forth.

And so tips in that case just wait until fetus is still, um,

we may have to ask mom hold her breath or so forth.

And so those just some quick tips on how

to fix that artifact.

Now, um, one particular assessment, especially

for our lupus patients, we, uh, apply

or we assess PR intervals routinely

to determine if there's a heart block present.

And so in cases where you want to, uh, do a PR interval,

you want to achieve it by the five chamber view.

Um, and it's, it's hard

because it's a still shot, so it's hard

to demonstrate the LVOT that I was seeing

before I froze the picture.

But upon assessing for the PR interval,

you wanna place your pulse doppler gate right here,

right where that aortic flow

or LVLT flow is starting to open,

and that's where you're gonna sample

to achieve the spectral doppler wave form.

Okay? And so we're showing the inflow, the ea

above the baseline, the aortic outflow demonstrated below.

And so upon there,

you wanna place your first caliper there.

In between the e and the a.

A lot of your ultrasound machines have a

PR interval on the package.

And so upon placing your first caliper there between the e

and a, your second caliper, right after the a

before this aortic flow,

and you should have assessment of the PR interval, okay?

Now, normal PR interval should be less than one 50

in cases of heart block.

Um, it will be really high in those cases. Okay?

So normal measurement is less than one 50.

All right? Now let's talk about, uh, assessing for, uh,

heart disease and so forth.

And so with this particular example, uh, the main artifact

with this one is the over gain.

And it's a simple fix.

Simple fix, lower your color gain, get rid of the noise,

narrow in your color box, that's going

to improve your frame rate,

and then stabilize the probe to reduce movement.

Now, this is where we're assessing my favorite, uh, the VSD,

um, with the color doppler.

Now, in this particular demonstration, and,

and when I suspect that there is a VSD present, I do, uh,

demonstrate it in two planes.

And then from there I apply my color doppler

and I demonstrate it side by side.

So I'm going to show flow moving across the septum.

And so here it is my assessment of A VSD,

I'm letting the doctor know

that flow is moving across the septum.

Okay? And so that's demonstrated in the blue

and the red show here.

So that's showing the shunting of the blood flow.

All right? Now for Raymond, um,

eval assessment will show shunting

where foraminal valve flow should be from right to left.

And you could demonstrate that with your color doppler.

Okay? 'cause it's known for showing the shunting.

Another tip too, if you wanna assess the waveform

of the forin, a vow, it demonstrates a e

or a ea waveform

or a biphasic waveform that's demonstrated in a mitral

and trius valves.

But you can see this is normal, uh,

biphasic waveform pattern of the foramen.

Okay? Now, in cases where this shunt is from left to right,

instead, uh, usually that's due

to some abnormally high pressures on that left side.

Um, whether that's hypoplastic left heart syndrome,

aortic stenosis, or tresa mitral stenosis or tressa

or severe aortic car ation.

Okay? So that's why it's helpful to always assess, uh,

these normal patterns.

All right, so now we're getting into umbilical vein.

Umbilical vein brings in the oxygen.

This is the main, uh, first stop as far

as oxygen coming into the fetus.

And so quickly,

a artifact seen when assessing the umbilical vein, um,

is cord compression may mimic high resistance alist.

If the PRF is too low.

Quick tip, adjust, move, uh, mom

or baby by moving mom,

you wanna sample in a free floating loop of cord, okay?

And then raise your PRF if you notice e listen, right?

So let's take a look at a normal umbilical rating.

Normal umbilical vein should be moving forward, okay?

'cause it's coming in, it's bringing in oxygen.

And so this is a normal wave pattern.

We assess the umbilical vein in both intrabdominal

as well as free floating.

They both should demonstrate the same normal,

continuous forward flow.

Okay? Now, um, I went,

I would say almost, almost 20 years.

And it wasn't until this year actually that I found

a abnormal umbilical vein.

Okay? And so here, here's the case.

Here was a set of mono die twins.

And, uh, this was the recipient twin where

I was assessing 'cause it was a fetal echo.

And so I had to assess for intraabdominal umbilical vein

as well as free floating.

And as you can see, it doesn't look like the, this picture

as you can see there clearly.

Um, there it was pulit tau

and you can even hear it when you're sampling.

And so I was like, oh, that's, that's weird.

Um, is this what they mean when they say pulit tau

umbilical vein flow?

And sure enough, it was.

And so, um, when you find a abnormal, uh,

umbilical vein, especially if it has pulses, you want to

listen to or assess your ductus

or assess the fetus ductus osis.

And, um, it, it, if there is a problem

or fetal compromise, you're gonna see it there as well.

And so I did,

and sure enough, the ductus osis wave form,

as you see the reversal of the A wave, okay?

So it, it correlated that there is, uh,

severely fetal compromise, which it was, uh,

compromise with the twins.

And so they were sent to Johnna Hopkins

and she received, uh, the laser treatment, okay?

The laser treatment she received

that she came back a few weeks later, and lo

and behold, voila, here we go.

We have a normal umbilical vein now status post.

And so, um, the doctor, we, we really did, um,

a number on this one because we in, in hindsight,

saved the baby's lives.

Uh, she did go to deliver, um,

I believe it was at 36 weeks,

I believe 36, 37 weeks healthy babies.

And so, um, this was a happy ending to this particular case.

Alright, so, um, just once again,

why there was pulsitile happening in the umbilical vein.

Um, it's usually due

to baby's heart being under severe stress.

Um, and so that's what was causing this

particular weight pattern.

Okay? Getting down to the end.

So now we're assessing, uh, pulmonary veins.

Now the artifact seen with assessment

of the pulmonary veins is misidentifying the left atrium.

Instead of the pulmonary vein motion blur, you want

to confirm that the vessels is entering into the left atrium

with color first before applying your, uh, spectral doppler

or your pulse doppler

to achieve your spectral Doppler weight form.

Okay? All right.

Now some tips on how to assess for, uh, the pulmonary vein

and pulmonary artery assessment.

It depends on which one.

So in cases where you're sampling, uh,

the right pulmonary vein or right atrium, I usually get that

or achieve that from the apical uh,

view, which you can see here.

And you place that gate right there

and you achieve that wave form.

You see in this particular case,

the right pulmonary arteries above the baseline,

the right pulmonary vein is below.

In a case where you're assessing for the left pulmonary vein

or artery, that's usually achieved

through the subcostal view.

I do find though, from the subcostal view,

you could achieve the right as well.

Um, but for sure for the left

it's easier from the subcostal view.

All right? Now, um, I don't know if you picked that up,

but the wave pattern

for the pulmonary vein in ductus osis are, are similar.

They both have the phasic wave pattern seed, okay?

Which the S-D-D-N-A of course is different functions

for these particular vessels.

So for your ductus venos, the SDA is

for ventricular systolic contraction,

early ventricular diastole, then atrial contraction.

Whereas for the pulmonary vein,

you have the left atrium pressure reduction per S wave D is

for rapid filling during the left ventricle relaxation.

And a left atrium pressure increases

during than atrial contraction, but it should have

or demonstrate that tri phasic wave pattern.

Okay? Now, in fetuses, both the pulmonary vein

and ductus will show that PHA exit pattern,

but the ductus foot nosis velocities are two

to three times higher, um, due to its major role, you know,

that's the next connection to the umbilical vein.

So that's why it has that high velocity.

All right, so here's a particular case

where there was partial anomalous pulmonary venous return.

I do not have the waveform for this particular case,

but I'm, I wanted to demonstrate where color

really showed, uh, the vessels

of the pulmonary veins not entering into the left atrium,

but instead of that common vessel, which you can see here,

three were demonstrated entering that common vessel

where they one was into the left atrium.

That's why it's partial. Okay?

All right, so here are some abnormal wave patterns seen in

your pulmonary veins, okay?

Right away you can see

where the a wave is baseline showing the reversal.

So it's pretty, pretty noticeable in these particular cases.

Okay? These three fetuses all had hypoplastic

left heart syndrome.

Mm-hmm. All right, I'm getting down to an end.

So aortic isus, when we're assessing for aortic isus,

the one key artifact

with this particular assessment is in the wrong place.

And so you want to achieve it, um, just

to get your landmark correlation.

You want to achieve it from the sagittal view, such

as demonstrated here.

And then you want to place your gate right at

that isus there connection to the aorta, okay?

Which you can see here. Alright?

Now, um, in cases

where fetus is just not in a good position in this

particular case, you want

to assess it from the three vessel trache of view.

I actually find this way easier,

especially if fetus is in a good position.

Now, um, the aorta isus is the arterial connection

between the right and left ventricles.

This is where we're gonna see some compromise happening if

there is, uh, abnormal, uh, patterns in this particular one,

um, most of the time either reversal or so forth.

And so, um, this is a normal assessment of the isus.

So you place the gate there, you wanna demonstrate

that normal forward flow, which it shows here,

and it should be stable throughout gestation.

All right? Now in cases of aortic coaptation,

you place the sample volume distal.

So the narrow one, okay?

So usually somewhere within that descendant your order, um,

in normal cases you'll have that continuous forward flow.

But in case of aortic tation,

you'll have a saw tooth waveform, okay?

And that will confirm

that there is some obstruction happening.

All right? Now, um, this is earlier we talked about, uh,

the reversal that we saw there in the aortic, um, vessel.

And so with antegrade flow flow, remember blue

away from the transducer,

and so forward flow is demonstrated, it's antegrade flow.

In a case of reversal, there's flow flowing backwards, okay?

And so in this case where it should be flowing down

away from the transducer instead is flowing back up

towards the transducer.

And that's why it is demonstrated in red. Okay?

So it's considered retrograde flow. All right?

Now in a case where, uh, here's that case from earlier, uh,

there was severely IUGR.

And so that's where we did notice, um, the reversal

of flow there, just demonstrating

that compromise of the fetus.

Now, as far as the abnormal wave pattern,

you can see the reverse flow is demonstrated

where you're seeing that flow below the baseline there.

We also notice there's some narrowing of

that aorta on that side.

Okay? So when you see the reversal flow in this particular,

uh, case, uh, think of it like, uh,

I think like a check engine light.

Okay? Like, okay, something's going down, we need to get

to the station, um, fast.

And so reversal means that's the warning, light is flashing,

urgent action is needed.

Typically, um, doctors may have patient get delivered

and, um, these particular cases,

but it's usually a, a late marker of compromise.

And um, unfortunately it may appear sometime just

before there is fetal demise, okay?

So it's usually, um, uh, a bad sign.

And so you want to, uh, try

to either have patient get delivered if

that's the doctor's wish or so forth, okay?

So it's really critical, um,

when you notice a retrograde flu.

All right? And lastly, I want to end with, uh,

the difference between Aus vein versus your arsa.

I've many times seen where, uh, Aus been called

as a arsa ab right?

And vice versa. And so we really wanna know the difference

between the two as it gets vein is draining into

the superior vena cava.

They're going in different directions for one.

And so you see here in the demonstration

as it gets going into the SVC, whereas AA

is heading towards the right shoulder.

Okay? And I have a case of that actually this week.

I was able to, um, let me slow this down.

Actually, I wanna slow this down.

Gimme one second

so we can really see this flow.

All right, so your, we have the three vessel tri view,

and I have my, the arsa vessel, which is heading towards the

right shoulder of the fetus and it's red

because it's heading towards the transducer,

whereas the Aus is draining into the SVC.

And so that is heading this direction and it's blue

because it's heading away from the transducer.

And so those are the difference between these two. Okay?

Of course, as you know, is normal, a SSA is

that marker for down syndrome.

And so this is one that you wanna pick up.

And also you want to bump down your PRF scale.

A lot of times these are missed if your PRF scale

is set too high.

Okay? Alright.

And then, let's see. Okay, so this is last slide.

Um, just quick notes.

I hope first that you learn something

or you were able to gather, uh, some clues

to these abnormal wave patterns.

Have you ever encountered them? Um, just key tips here.

Always remember, use color doppler first.

Localize these abnormal jets

or turbulent flow, align your sample gate parallel to flow

for the most accurate velocity.

Okay? Assess your flow direction, your waveform shape,

and it's gonna give you a clue to what a lesion is detected.

Combine your gray scale with your doppler,

that's gonna give you that complete picture.

And then remember your aara principle, okay?

Color doppler findings.

We know with the abnormal flow,

it can e either indicate a blockage

or obstruction depending on the clue that it's giving you.

So remember those clues that we just discussed.

And then also remember that a lot

of these anomalies can be associated

or linked with other, uh, an anomalies in cases.

Most of the time it's VSDs Okay?

Or a mal alignment of the great arteries. Okay?

But see the flow. Know the flow.

Um, and I hope you gain some knowledge tonight.

And that is all it.

I, I do wanna point out Johanna, um, for some,

some may have already purchased this, uh, handy

dandy tool workbook.

Um, but if not, there's a QR code there.

It's, it's so helpful guys.

It's, it is really helpful

and, um, helping you just learn these cool tips

and tips of the trade to help make our job easier when, um,

recognizing these abnormal patterns.

And so I just wanna say thank you and I'm done.

Mastering Doppler in Fetal Heart Imaging: From Flow Patterns to Clinical Correlation

Chapter 1