Transcript

Hi, this is Dr. Jason Cox, practicing radiologist

and program director of the Institute

for Advanced Medical Education.

I'd like to welcome you to our webinar series, uh,

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and the author of tonight's presentation, Lashelle Jones,

disclose No Such relationships exist,

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My screen now, hello everyone. Welcome, welcome. Tonight.

I'm so excited to be able to share with you guys.

So I'm gonna share the screen here so we can get started.

I, when I first came up with wanting

to go over the four chamber view, I feel like it's a view

that's often forgotten about.

And so for some, it may just be a quick refresher,

but it's some, I promise to hit on some points that, um,

will be helpful during your screenings.

Now, just to go over the objectives for tonight,

we will discuss some fetal cardiac foundations

of the four chamber view.

We'll talk about the morphological markers

that are seen within the four chamber view, some normal

and abnormal findings.

We'll talk about the importance of the measurements

that are done in the four chamber view.

And then I'll go over a quick sneak peek of part two

to the series of the four chamber view.

All right, so let's get started.

We're gonna start with the three basic views

of the four chamber view, starting with my favorite,

the apical view.

There's nothing like when you first get started scanning,

and as soon as you put the probe down, you look in, voila,

the heart's in this perfect apical position right away,

I'm ready to get started with my heart views.

And so the importance of the apical view,

you can clearly see the heart as well as the AV valves,

the chambers, you can assess your AV valves.

There is a, uh, I guess you could say a negative, um,

side of this view is that it's known

for having the dropout artifact.

And so you may suspect A VSD in this view,

but upon further investigation,

you see it was just an artifact.

So just keep that in mind if you suspect of ESD,

change your plane just to confirm if it's truly there.

Okay. Now, from your apical view, you have your basal view.

I find this view to be my go-to view,

especially when I'm sampling my pulmonary veins.

And so from this view, you can sample both the right

and left pulmonary veins.

This view is also helpful in enhancing the view

of the atriums as well as the foramen.

And you can detect the atrial septal

defects from this plane.

The last view is the axi view.

Now, this plane is my second plane that I usually use

to confirm if A VSD is present.

Another key benefit for this view is to

evaluate the septal thickness,

which you can clearly see here.

And you want to, uh,

use this view in assessing the

myocardial function and contract.

Okay? All right.

Now, which congenital heart anomalies can be identified

using your four chamber view.

And the ones that are mentioned are, we already discussed

the septal defects.

That's both the ventricle

and the atrial septal defects,

your endocardial cushion defects,

your hypoplastic left

and right syndrome defects, as well

as the truncus arteriosis.

So these are the common congenital heart anomalies

that are identified using the four chamber view.

Now, one example that I had was the hypoplastic left.

I want to point out, in the mal cases

of hypoplastic left, it may not be as obvious

as seen in this example.

So early on, just keep that in mind.

You may have a normal four chamber view,

but then at your level two,

you may notice a hypoplastic left syndrome,

which you can see here.

All right, now there is some limitations

of the four chamber view.

Now, the congenital heart defects that can be missed,

which simply means that there's a normal four chamber view,

but there's still a heart defect present.

And that's gonna, you usually see that

with your truncal defects, the transposition

of the great arteries, tetrology of fall low

and aortic coarctation.

I do wanna point out,

however, with aortic coarctation in your severe cases,

there may be a disproportionate left side.

So it may show

a abnormal four chamber view in the advanced stage

of the aortic coarctation.

So just keep that in mind.

All right, so when should you notice

a four chamber view?

Yes, it's possible.

And I, I know with our advanced equipment

that we have these days, you, you're able

to see a four chamber view in your first trimester.

So by 11 weeks, you should clearly see

a fully developed symmetric four chamber structure,

which is image here in these two examples.

Now, I do wanna point out

that the axis seen within the four chamber view can act

as a early screening marker for a congenital heart defect.

Now, the axis in the first trimester normally ranges

between 34 degrees

and 56 degrees with an average

of 47 notice.

In this particular case,

we're at a roughly 75 degree angle.

So you can clearly see that this is, uh,

abnormally, uh, advanced.

This axis is way off.

And as you can see, there isn't a great proportion

of the four chambers there either.

Also, I wanted to point it out, notice the distance

between the left atria and the descendant aorta.

And so it clearly, from the axis

and the other structure seen, you can see

that there's something going on

with this heart defect early on.

You can pick this up.

Okay, so let's take a look at some other examples.

On the left side, you can see a heart

and you can see the fluid surrounding the heart.

But notice you're not quite seeing the four chambers view,

and it's only because this is a non week fetus.

So we're not quite at 11 weeks,

but you can see that there is some

fluid surrounding the heart.

And on the right side, this is the previous case

with the 75 degree angle, you could clearly see that

that left atrium is underdeveloped.

And notice that wide space that we were seeing early.

So the axis, the abnormal axis

that we saw was a early indicator

that there was a defect happening.

And clearly it's shown here.

All right. Now, once we're out of the first trimester,

we're now into the second trimester.

I, I guess you can stay at your 16 week genetic scans

or your 20 week screenings.

Normal cardiac axis is roughly around 45 degrees plus

or minus 15 degrees.

Now, level cardia is simply normal axis.

So that's towards the left side in which you

can see an example.

Now, normal occupation of the heart should be one third

of the thoracic area.

So notice here, and I, I wanted to show

where you can see the lungs.

So you have the one third, one-third here from that, on

that left side and the center, and then the other one third.

So this is a normal area of the four chamber heart.

Alright? All right. Now this, this is my favorite one here,

the crux of the heart.

I, I simply look at this.

It's like the anchor of the four chamber.

Um, what brings the chamber together.

Now, the crux of the heart is the central intersection

of the four chamber view,

and that includes your IVS, your IAS

and the two AV valves, which is your cusip

and your mitral valves.

Okay? So it brings the heart together, the,

the anchor and so forth.

So it maintains that chamber separation, the coordination

of the flow of the blood,

and it ensures the unidirectional flow between the atrias

and the ventricles.

Okay? So you wanna just make sure it's intact.

All right. So I have a video here. Let's see.

We can start plan. I'm gonna slow it down so we can actually

look at it a little slower if, if it's possible.

Let's see. Okay, yeah, let's slow it down so we can watch.

So when you're assessing these AV valves, you want

to first ask yourself how freely are they moving?

Is the crux of the heart intact?

Where is the trius valve insertion compared to the mitral?

Are they linear or is it abnormal?

So you really wanna pay attention to those AV valves.

And once you turn on your color

and spectral doppler, that is when you're assessing

for regurgitation.

Okay? So this is all the questions you should be asking

yourself as you're looking at this four chamber view

and the vows moving.

All right?

Okay. Now, why is it important to notice this offset?

I'd like to compare the offset, the normal offset

of the apical, uh, apical offset is to a seagull.

Now notice, i, I lined up the AV valves

to the seagull in flight and notice the similarity there.

So the trius has a more apical

insertion compared to the mitral valve, and that's normal.

That's normally how the valves should be offset.

And this is what you wanna look at

as you're evaluating your four chambers.

Now notice in the case of a linear insertion,

you have more of a T shake,

or I compared it to a eagle soaring its wings.

And so notice how they, they're all aligned together.

And this is the abnormal finding.

So when you see the linear insertion, uh,

you wanna suspect either if is there a av septal defect

present, okay?

But you could clearly see the difference

of this one compared to the apical offset.

All right, so now we're getting into

why are the measurements important in the four chamber view?

What's the purpose?

Now, quick scan tip,

when you're looking at the four chamber view,

you're not just assessing

that there are four chambers present.

You want to look at the shape of these chambers.

And so clearly you can see the, uh, outline

of the shape here.

And why is this important?

Because a subtle change could, it could be the first sign

of a fetal under stress.

And so it's important to notice the shape

and structure of these chambers as you're assessing.

Now, let's take a look at the cardiothoracic area ratio

and it's importance.

A quick tip be as

before you measure this cardiac ratio, you want to ensure

and avoid oblique views.

'cause then you're gonna have some, um,

inaccuracy with the measurement.

Uh, this is a proper view of how it should be assessed.

Notice on the left side where I broke down

the normal ratio for the gestational age.

'cause it's important to know the difference.

And so in your first trimester, it's more about 0.4.

If you wanna round up

and at, as you see here, we advanced to the gestational age,

it's up to about 0.5,

but it should never exceed that at any stage

of the gestational period.

Now, if you do notice a small heart,

you either suspect pulmonary hypoplasia

or restricted lung volume.

If you notice a enlarged heart, then you suspect either

fetal anemia, some sort of infection

or cardiac failure happening.

Okay, just to keep in mind.

Now, just to go back over the shape

and structure of those chambers and why it's important.

I was reading the study recently

and with growth restricted fetuses, it showed

that there is a abnormal shape

u usually seen in the four chamber view.

Uh, this was news to me.

'cause right away, when you think

of growth restricted fetuses, you're, you're thinking, okay,

let me sample the cord Doppler, yes,

we're looking at the heart.

Um, but to think, oh, okay, yeah, I really need

to pay attention, attention to the shape and structure.

And so with those growth restricted fetuses,

you see they have more of round

or gular, uh, structure of the hearts instead

of the elongated

or oval shape that is seen in the normal fetuses.

So that's why it's important to always assess the structure

of the heart as you're evaluating your four chambers.

Okay? So that's why the measurements are really important.

All right, so my favorite part, I'm excited.

We're gonna now get into the morphological markers

of the four chambers.

I I look at these morphological markers as birthmarks.

And so we're gonna start with the moderator band.

I'm gonna first present the importance of,

or its unique presence of its structure

and where it belongs.

And then we'll follow up with a case study to why it,

it is important to notice.

And so with the moderator band,

it is unique within the right ventricle.

It's a key landmark, and it's usually noticed at the top

or at the apical region of that ventricle.

Okay? So you wanna make it a common thing to do

as you evaluate your four chamber view.

Where is your moderator band?

Once you locate it, say, okay, that's my right ventricle.

And why is that important?

You'll see with this case we have now, let's go

and look at the picture on the right side.

So here on the right, we have a four chamber view.

Right away looking at it, you can say, oh,

that four chamber view looks weird.

Uh, and so yes, it looks weird,

but notice, okay, we see our descendant aorta that tells us

that this is what left atrium,

and then here's your right atrium.

So then it should be followed by a right ventricle here,

left ventricle, you can even see the

seagull appearance, right?

So we have a av, a apical offset with that.

A So this is our cusa.

This is a mitral, but a moderator band.

What's what's happening here? It's not there.

So right away, as I, this wasn't a case

that I personally did,

but looking at the pictures I evaluated

with the doctor right away,

you could clearly see there is no moderator band present.

Clearly the moderator band is on the opposite side,

and clearly this is a elongated

or conical shape appears to be the left ventricle.

Okay, so we, we did confirm that yes,

the ventricles were switched.

So this was indeed the left ventricle on the right side.

This is indeed the right ventricle on the left side.

And so we wanted to know if the system would

recognize these markers.

Well, as you see, it did not,

and so it's still labeled, uh, the annotations, um,

wrong as you can see here.

So I just want to, uh, reiterate how

to not depend on the auto annotations in the cases of

recognizing the morphological markers.

This was a case of congenitally corrected transposition.

It was confirmed by the cardiologist.

She was actually, uh, surprised that we picked it up.

But, um, but as you see, why, why is it important

to recognize the morphological markers in this case?

Because the moderator band was indeed on the opposite side.

So it's very helpful, okay, to recognize these markers.

All right, moving on to the foramen,

foramen unique placement is within the left atria.

You should see the flap within the atrial,

which you can see here.

And, uh, upon further investigation, you want

to follow the flow, the flow

of the foramen should have a right to left, hun,

which you can see clearly in the picture present.

Okay? Also, if you wanna try this out,

it's, it's not a normal, uh, blood flow that we sample,

but just, I thought it was cool to see the waveform

that it gives, it gives this this cute little

biphasic waveform.

And so upon your screening tomorrow,

when you go into work, just sample it.

And so you can see the biphasic waveform that it gives.

And this is a normal biphasic waveform of the foramen.

And why is this important?

Let's take a look at the foramen v aneurysm.

Now with the aneurysms, your flatless you notice

is more, it's closer into the left atrium wall,

and it kind of gives the appearance of a ballooning

or a bulging of that left atrium.

Notice you will notice once you

put on the color doppler, you're gonna notice a pooling

of blood within the atrium.

It's, it's gonna be pretty significant,

and it is possible that you will not see that normal

biphasic pattern in your spectral doppler if you sample it.

Okay? So here's the example of a foraminal valve.

In advanced cases with the aneurysms, I've had noticed that,

uh, it could have arrhythmia in those advanced cases.

So these are, uh, ones that you would like

to follow if you do notice them.

Okay? All right.

So normal placement of the descending aorta.

Now, as you notice here, upon doing a normal cardiac

axis, your descending aorta will align on the left side

with the cardiac axis or apex.

And so clearly it lines up with the spine,

and you'll get that nice 45 degree angle in cases

where there's right sided aorta,

which you can see here at the bottom

that descendant aorta is on the right side

of the spine, which you could clearly see here.

We could take a further look at that.

So I tried to do a angle

with the descending aorta, not the spine.

So I'm not getting a cardiac axis in this example,

but I just wanted to show the offset

of the right-sided aorta compared to that other axis

that we, how it was properly aligned,

but it was impossible to achieve

a correct alignment with the spine

because of the displacement of this aorta.

And so from there, I lined it up

and I was almost getting about a 60 degree angle

with this right sided aorta.

So I did want to point out the differences there.

Okay, so let's take a look at example.

Where I noticed I was, this was a personal case of mine.

I was scanning. I had my four chamber view was sort

of a four chamber view, and I noticed

that there was a extra vessel adjacent

to my descendant aorta.

And so in this particular case,

I'm like, Hmm, what's going on here?

I put on my color right away.

You see the color differences there.

Upon further investigation, I did notice

that interrupted IBC, there was a form of, uh,

hetero taxii syndrome.

So, uh, it was a very complex cardiac defect present,

but it was upon me observing the double vessel,

uh, here at my four chamber view.

That's when I did my further investigation

and noticed the other defects as well.

So, uh, keep that in mind if you notice a extra structure.

'cause sometimes it could be esophagus, so you want

to rule out that in that case.

But you see here in this particular case,

there was the asus vein, a dilated asus vein adjacent

to the descendant air water.

Okay? All right, last

but not least, we're gonna talk about the pulmonary veins.

Now, pulmonary veins, what, what, what's the purpose?

It's very important actually, um, to notice where

their drainage are, are there in the right left,

you should have them drain it into that left atrium.

And once again, this is my favorite view where I like

to assess both the right and left pulmonary vein.

We, we have to sample both the pulmonary vein

and pulmonary arteries, both right

and left for, uh, level twos in our normal screening.

So, um, so it's a thing that we do

and it's very helpful to find a view

that will help you achieve this fast before the fetus moves.

Of course. Now, in the apical view, which was our first view

that we discuss, you'll notice

that the flow will be towards the transducer within the

pulmonary veins.

So you'll notice the red

'cause that's coming up towards the transducer.

If there is a displacement of these vessels,

you wanna suspect either partial

or total anomalous, some obstruction of venous return

or associated anomalies in a hetero taxii or complex defect.

And I want you to take a look at one that I had.

I, I was amazed actually, um,

I was seeing this patient

and we,

it never was mentioned about the

pulmonary veins or anything.

We knew that there was, as you can see,

a complex cardiac defects involved.

But upon me just trying to see what else is happening,

I notice the pulmonary veins

and I tried, I labeled them here

where you can see three the pulmonary veins,

they're attached to a like vessel there kind of adjacent.

It's not quite in the left atrium or in the right,

but it's more like in the center there.

Um, and it was confirmed by the cardiologist

to be a partial anomalous pulmonary venous return.

And so, um, so that's why it's helpful to, uh,

make it a known thing to, uh, recognize

where the pulmonary veins are draining towards.

All right, so we're getting towards the end.

I do want to end with just talking about some steps on

how to detect A VSD

and why I felt it important to talk about the VSD is

that it is the most common congenital heart defect.

So we want to, uh, keep in mind how to detect it properly.

Now, as I discussed earlier, initially,

especially if you start in your apical view,

you may suspect the VSD within that view,

but upon your second plane switching to

that transverse plane, you want to confirm

that is it truly there?

Now here's the example of both the gray scale

and the color scale where it shows

that there clearly is a disruption in the septum.

And you want to confirm your VSDs with your color Doppler.

And just to kind of take a look at all the several types,

there are several types of VSDs and their location.

So not all are present doing, uh, your four chamber view,

but your muscular one, which is the most commonly one seen

is detected during your four chamber view

and its unique flow is the bidirectional shunted.

I am gonna talk about that more in the next slide.

I do wanna point out what the muscular VSD,

it could be difficult to see on gray scale,

but with this unique presence of that blood flow, that

that really, uh, will highlight that,

that indeed is a VSD present.

I do wanna note in the neonatal cases

that the paramus is the, it's 80% seen of those

VSDs, and that's commonly seen in the five chamber view,

so your LVLT.

Okay, all right, so let's take a look.

So some may say, well, what, what do you mean by

what is bidirectional?

Basically you wanna show the blood

flowing to and from.

So you'll say left to right, right to left,

which are demonstrated in this VSD here present.

And so that's commonly seen in your muscular VSDs.

Always use your color to suspect, change your planes.

You have to show it and confirm it in both planes

and your gray scale as well as your color flow.

Okay? Now,

although your paramus, it dominate postnatally, the muscular

VSDs are still the most commonly seen prenatally.

Okay? Now this here is a quick recap of what we discussed.

I, I really advise that if you wanna get the full effect

of everything that I talked about within the course,

I highly recommend taken the part

one on the website.

Um, this was just like a sneak peek in,

but there is much more, you actually will have more access

to the slides

and the, the charts that I have listed here for your records

and your just reference for later on.

So please keep in mind to, um, to take that course

as well as part two.

Part two's coming up

and I'm really excited to discuss part two.

So this is just a recap of

what we discuss here on the slide,

and this is what I have to offer in the part two.

It should be launching soon, hopefully by next month.

Um, in the part two course, we will reiterate the purpose

of the four chamber view.

We're going to break down more of the heart defects

that are seen and that are not seen.

And so we're really gonna go in depth with these defects.

We're gonna talk about the significance

of an absent moderator band.

I didn't even know there was a thing.

And so yes, it is a thing

where there is a significance if it's not present, um,

we'll talk about abnormal heart positioning,

the heart sizes deviations, we'll talk about the clues

and the causes of that.

I'll break down heart tumors.

I'll talk about pericardial effusion,

and then I'll also go into the other techniques

and views that will complement the four chamber view

and diagnosing congenital heart defects.

I am all done.

Um, Johanna, if you want to join in,

here are my references from my course here,

and it's just from the webinar, of course,

with the course one and two, I have many more references.

Um, but Johanna, if you wanna jump in, I am,

I'm actually all completed here.

If we wanna take some questions,

I can stop sharing.

Yeah, thank you so much Lashelle for the present. Sure.

It was great. Thank you everyone to join us today.

We would like to know if you have any questions.

So we're gonna give you some minutes.

If you wanna just type the question

and send it to us through the, through the message, um,

option that you have here.

So we're gonna be answering questions. Okay?

It is one, let's just put it here.

Hold on. This one. Okay.

Lashelle, can you see it?

Yes. Okay, great.

So when someone's asking about, uh,

how would a small heart suggest pulmonary,

pulmonary hypoplasia?

Oh, that is a good question. Uh, let's see.

Uh, 'cause if you think pulmonary hypoplasia

small, but how small heart, uh, I would have to do

my research, um, more research on that, that I'm not,

I'm not quite sure how to, uh, break that down.

Courtney, Courtney F could you leave your email address

so I can get back to you on that one?

Because I think Amelia, unless,

unless the the lungs, it, it's hard to say honestly.

I, I am not sure about that question.

Is anybody,

She, she could leave an email address

and I can get back to her, Courtney.

Okay. Courtney is saying mm-hmm. Something.

Yes. Okay. So she say, okay, let's see.

Chroma, chroma, Hold on, let, let,

let's go back to Courtney.

Mm-hmm. Okay.

Yes, yes, it was, it was on the slide.

It was on the slide with the cardiac thoracic area ratio.

It, it was there. No, no, no.

You, you, you didn't misunderstood. It was definitely there.

Okay. We have another one. Mm-hmm.

They're, they're asking about the color doppler

on, uh, chroma map.

What are my thoughts? I I mean, I,

I use color doppler always.

Well, chroma, no chroma.

Um, it, it,

but I only use it to confirm if,

if I notice like in a case with that extra vessel

that was near my dis descendant aorta,

if I was in my CHRO map setting,

I would've turned it on then.

So, I mean, it's helpful. It's definitely helpful.

And, um, I would say giving you more confirmation to, uh,

what you may suspect

or what you're seeing in your congenital heart defect.

I, I, I always utilize everything on my machine

to enhance, uh, diagnosing.

So I would say yes.

Okay, perfect. We have another question here.

It wasn't, I, I never have an issue.

Um, usually seeing the reen, you, you should clearly,

especially in your apical view, if you're four chamber view,

you should see your, even if it's settled,

but you should see that flap within that left atrium.

Um, and if you are having a hard time seeing it,

I would put on my color doppler

and just see if you could see that shunting, um,

the blue shunting where it's, it's going from right to left.

If you clearly can't see that flap inside the left atrium,

I would try, if you don't see it in your apical view,

just try turn into another plane

and see if you can see it in another plane if it's not

easily, uh, seen.

Perfect. Mm-hmm. We have another question here.

Sure. The, they wanna see the slide

of the four chamber heart

with the 45 degree angle diagram.

It's, I can want me put, show it again.

I can show that again. Uh, let's go here.

Yeah, they wanna see it again, so, okay.

Sure. So let me, let me go to that.

I'll share it again

and I'll just go back.

Okay. So 45 degree angle.

Uh, if I could remember, I mean, we,

I have this one,

I don't know if they're talking about this one when I was

talking about the descendant aorta

or the one, I think I did one earlier.

Let's see, this one,

anybody were talking about this particular one,

What we have is that one.

Mm-hmm. Okay.

Was that the one? Can you please let us know

if this one is the one that you were asking for?

Let's wait. Mm-hmm. Yeah, they say yes. Mm-hmm.

Okay, perfect. So let's take a look

on another question.

Sure. It's gonna be this one.

Oh, Phillips. See, but I,

and I'm assuming, are you talking about chroma

and the color flow?

Philip said not to use both together, huh?

I that I am, I haven't used the Philip system.

I, I would not know.

Uh, yeah, I'm not, why,

uh, they said that?

Yeah, I must, I use Samsung mostly majority of the time.

And then we also have access to ge.

Um, but I, it's, it's interesting, I, my rep is,

my Samsung rep is there with me tomorrow.

I can ask her why that will be a reason

to not use the two together.

Um, but honestly, I, I'm not sure,

I have not heard that before.

So it must be something about Phillips,

I'm not sure, but I haven't heard that.

I use Samsung, the, is it the Z 20, the new one.

And we also have, uh, my favorite Samsung,

but we have G GEs as well.

The, my, oh, that's a great question.

So this one is saying, uh, what's the h

to see the moderator band in the right heart?

And I must admit to you, now that I'm looking back,

I'm trying to recall if I recognized the

moderator band at like a 16 week genetic skin.

I wanna say yes, it's, it's, it's not as prominent

as when you get to your event stages, of course.

Um, but in the first trimester, no, I'm not

recognizing a moderator band in the first trimester,

but I wanna say once, not 14 weeks.

'cause that's still, you know, that's coming

into our second trimester.

I wanna say by 16 weeks you should see a, uh,

moderator band present.

Definitely by your 20 week scan you will be able to identify

the moderator band for sure.

Fetal echo, they say standard, especially on our boards,

they say standard fetal echo 18, starting at 18 to 22 weeks,

um, is standard.

But we at, um, our practice, we do our echos

starting at 22 weeks to 24 weeks.

Now, if there is a, um, history

of congenital heart defects

and so forth, of course we do a early assessment,

not quite a echo, but a early look at the heart,

but a standard echoes are done, uh, by, uh,

your A-R-D-M-S that says 18 to 22.

Mm-hmm. Yeah, that's all I was thinking.

I-I-I-I-I, I was assuming

that you were talking about the chroma and color float,

but I'm not sure why Phillips, um, has that rule

or I guess they, they prefer for you not to.

I, I have honestly have never heard that

before, so I'm not sure about why you would

not do the two together.

Okay. We have another question.

It's a little long. You have it there

Mm-hmm. Yep.

Before something,

and they didn't definitely say it was there

but could exclude it and much more assertively,

we were able to get results

so they couldn't exclude the VSD due to the baby being busy,

which I could understand that.

Um, and since it couldn't be excluded adding an aortic cord,

taking much more sort of blame difficult exam due

to active fetus, it was body habitus.

Yeah. And that, and that could be difficult.

Um, the body habitus could make it extremely hard to, uh,

diagnose any of these defects.

Um, but recommendation was to reassess at birth. Yeah.

A a a lot of times if, if,

'cause I mean we have cases where some, uh,

congenital heart defects aren't clearly seen.

And even the ones that are seen, we have VSDs

that were present at the second trimester,

even seen at the fetal echo,

but then it appeared they closed

by the time you get into the third trimester.

But we still recommend them to be reassessed at birth.

'cause I mean, there are limitations in your ultrasounds.

And so I, I, I think that recommendation is still helpful in

that case, just to be safe.

Um, just to make sure if it's there

or if it's not second

trimester, I'm assuming that's talking about, um,

the moderator band.

I will say yes, the moderator band is present

by the second trimester.

Yes. Mm-hmm.

I agree. They're both equally nice.

Um, so yes, I, I definitely agree the Samsung

and the ge a certain frame rate about 50

to be accurate diagnosis about the VSD.

Um, but interesting I want to

test out, because with that frame rate at 50,

what in the smaller scale cases, the,

it could be missed though.

So I, I don't know.

I will have to play with my frame rate to, uh, assess it.

I, I still bump my frame rate down to, um, for

that sensitive flow because I've seen

where I didn't see it at 50 frame rate,

but then when I bumped it down, um,

you're seeing maybe a tiny one.

Um, I don't know.

I am, we, we still utilize both, uh,

high frame rate, low frame rate.

I, I can understand that in accuracy,

but I, I, it's, it's hard to say

about the VSD, um, about the frame rates there.

It's tricky. It's very tricky.

But, um, I will, I would say still assess it though in both

high and low, just, just to see, you know,

and if you still suspect it and you're low setting,

but you're not quite sure, follow up with

that recommendation postnatally

when you view the heart, is this the general fetal?

Yes. I,

I treat every fetus whether, uh, low

or, uh, low risk, high risk the same.

And so, um, our protocols are

pulmonary veins.

We're, we're assessing moderator band.

We're sampling, we're looking at ductus osis for all

of our fetuses that come into the office at 20 weeks,

not just those that have a history of a heart defect.

Um, and I, I love the fetal heart, by the way, so

I'm always reading and studying the fetal heart just to,

because there's so much to know

and learn about the fetal heart so much.

So you, you have to stay on board

and, you know, do all the reading

and studying just to, you know,

stay focused and on the board.

Well, It's a lot to know, Johanna.

Yeah. We have like, we have answered all the questions.

Okay. Okay. We wanna thank you, uh, Lashelle. Okay.

Uh, the presentation was great.

Everyone is saying thank you that you have a lot

of knowledge and thank you so much for sharing

that too with us.

Mm-hmm.

Decoding the Four-Chamber Heart View: Mastering Ultrasound Insights

Chapter 1