Introduction by Dr. Jason Cox

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, but first we're gonna go through some housekeeping and talk about what we do here at IAME.

Webinar Housekeeping

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About the Institute for Advanced Medical Education (IAME)

About an Institute for Advanced Medical Education. We've been around for about 30 years. We're the largest educator of sonographers and physicians that practice sonography and interpret sonography in the United States and by extension the world. We are accredited by the ACCME to provide category one credits for physicians, which can also be used for sonographers and non-physicians like nurse practitioners and nurses in all 50 states. We're also an accredited ARDMS accepted sponsor. We work closely with them. And when you're a member, we take care of you. And if you have any kind of problems with your credits, we talk to the ARDMS for you. Our credits are instantly transferred over, and that goes for state medical boards through the ACCME. If you're a physician. It goes for the other boards that you may have, like if you're a vascular surgeon, or cardiologist. And then all of our credits, of course, are accepted by ARDMS, APC, CCI, ABMS, Federation of State Medical Boards, Sonography Canada, and many others. You also have access to the course 24/7. Once this has been released, we'll record it and anybody who's a member will get to watch that. You can take this course on your phone, your tablet, on your computer with our proprietary learning management system. Also, lastly, just ask your friends. Hundreds of thousands of physicians and sonographers have taken our courses and have trusted us for over 30 years.

Training Philosophy

Just a little bit about our training philosophy. Our courses are built for both sonographers and for physicians and others who practice in sonography. Whether you're a echo tech or a sonographer, or a radiologist, or a vascular surgeon, or OB/GYN doctor, we design our courses to work as a team because sonography is the only category of medicine where we work so closely as a team. We believe that learning together is how you perform better for your patient and have better outcomes. And research shows this.

ACCME Accreditation Statement

Just a little bit of housekeeping here. As an ACCME credited provider, we're required to read this statement to you every time so that you understand that this is an evidence-based educational program and that there's no kind of funny business going on. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education. The IAME is accredited by the ACCME to provide continuing medical education for physicians. IAME designates this live online webinar for a maximum of one AMA PRA Category One Credit. Physicians and attendees should claim only the credit commensurate with the extent of their participation in the activity. In compliance with the essentials and standards of the ACCME, the authors of this CME activity are required to disclose any significant financial or other relationships that they may have with commercial interests. Myself, Jason Cox, MD and the author of tonight's presentation, Lashelle Jones, disclose no such relationships exist. IAME has assessed any conflicts of interest with its faculty, authors, editors, and moderators, and any individuals who were in a position to control the content of the CME activity. And any identified relevant conflicts of interest have been mitigated. IAME planners, content reviewers and editorial staff disclose no relationships with ineligible entities.

Introduction by Lashelle Jones

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. 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 I promise to hit on some points that will be helpful during your screenings.

Objectives

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 negative side of this view is that it's known for having the dropout artifact. And so you may suspect VSD in this view, but upon further investigation, you see it was just an artifact. So just keep that in mind if you suspect VSD, 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 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 use this view in assessing the myocardial function and contractility.

Congenital Heart Anomalies in the Four Chamber View

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 ventricular and the atrial septal defects, your endocardial cushion defects, your hypoplastic left and right heart syndrome defects, as well as the truncus arteriosus. 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 mild 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 heart syndrome, which you can see here.

Limitations of the Four Chamber View

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, tetralogy of Fallot 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.

When to Visualize the Four Chamber View

All right, so when should you notice a four chamber view? Yes, it's possible. And I know with our advanced equipment that we have these days, 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 imaged 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 abnormally 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 descending 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-viable 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 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, levocardia 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 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.

The Crux of the Heart

Alright? All right. Now this, this is my favorite one here, the crux of the heart. I simply look at this. It's like the anchor of the four chamber. 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 tricuspid and your mitral valves. Okay? So it brings the heart together, 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 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 tricuspid 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 valves moving.

Offset of the AV Valves

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 offset is to a seagull. Now notice, I lined up the AV valves to the seagull in flight and notice the similarity there. So the tricuspid 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 shape, or I compared it to a eagle soaring its wings. And so notice how they're all aligned together. And this is the abnormal finding. So when you see the linear insertion, you wanna suspect either AV septal defect present, okay? But you could clearly see the difference of this one compared to the apical offset.

Importance of Measurements in the Four Chamber View

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 outline of the shape here. And why is this important? Because a subtle change could be the first sign of a fetus 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 its importance. A quick tip before you measure this cardiac ratio, you want to ensure and avoid oblique views. 'Cause then you're gonna have some inaccuracy with the measurement. 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 as you see here, we advance 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 usually seen in the four chamber view. This was news to me. 'Cause right away, when you think of growth restricted fetuses, you're thinking, okay, let me sample the cord Doppler, yes, we're looking at the heart. But to think, oh, okay, yeah, I really need to pay attention to the shape and structure. And so with those growth restricted fetuses, you see they have more of round or globular 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.

Morphological Markers of the Four Chambers

All right, so my favorite part, I'm excited. We're gonna now get into the morphological markers of the four chambers. 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 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. And so yes, it looks weird, but notice, okay, we see our descending 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 apical offset with that. So this is our tricuspid. This is a mitral, but a moderator band. What's happening here? It's not there. So right away, as 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 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 the annotations wrong as you can see here. So I just want to 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 surprised that we picked it up. But as you see, 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 ovale unique placement is within the left atria. You should see the flap within the atrial, which you can see here. And upon further investigation, you want to follow the flow, the flow of the foramen ovale should have a right to left shunt, which you can see clearly in the picture present. Okay? Also, if you wanna try this out, it's not a normal blood flow that we sample, but just, I thought it was cool to see the waveform that it gives, it gives 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 ovale. And why is this important? Let's take a look at the foramen ovale aneurysm. Now with the aneurysms, your flapless 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 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 foramen ovale aneurysm. In advanced cases with the aneurysms, I've noticed that it could have arrhythmia in those advanced cases. So these are 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 descending 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 descending 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 IVC, there was a form of heterotaxy syndrome. So it was a very complex cardiac defect present, but it was upon me observing the double vessel here at my four chamber view. That's when I did my further investigation and noticed the other defects as well. So 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 azygos vein, a dilated azygos vein adjacent to the descending aorta.

Okay? All right, last but not least, we're gonna talk about the pulmonary veins. Now, pulmonary veins, what's the purpose? It's very important actually to notice where their drainage are, are there in the right left, you should have them drain 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 have to sample both the pulmonary vein and pulmonary arteries, both right and left for level twos in our normal screening. 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 pulmonary venous return or associated anomalies in a heterotaxy or complex defect. And I want you to take a look at one that I had. I was amazed actually. 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. And it was confirmed by the cardiologist to be a partial anomalous pulmonary venous return. And so that's why it's helpful to make it a known thing to recognize where the pulmonary veins are draining towards.

Detecting VSD

All right, so we're getting towards the end. I do want to end with just talking about some steps on how to detect 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 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 during 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 shunt. 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 really will highlight that indeed is a VSD present. I do wanna note in the neonatal cases that the perimembranous is the, it's 80% seen of those VSDs, and that's commonly seen in the five chamber view, so your LVOT.

Okay, all right, so let's take a look. So some may say, well, 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 perimembranous it dominate postnatally, the muscular VSDs are still the most commonly seen prenatally. Okay?

Recap and Sneak Peek of Part Two

Now this here is a quick recap of what we discussed. I really advise that if you wanna get the full effect of everything that I talked about within the course, I highly recommend taking the part one on the website. This was just like a sneak peek in, but there is much more, you actually will have more access to the slides and the charts that I have listed here for your records and your just reference for later on. So please keep in mind 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. 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. 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.

Q&A Session

I am all done. 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. But Johanna, if you wanna jump in, I am actually all completed here. If we wanna take some questions, I can stop sharing. Yeah, thank you so much Lashelle for the presentation. 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 message 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 how would a small heart suggest pulmonary hypoplasia? Oh, that is a good question. 'Cause if you think pulmonary hypoplasia small, but how small heart, I would have to do my research more research on that, that I'm not quite sure how to break that down. Courtney, could you leave your email address so I can get back to you on that one? Because I think unless the lungs, it's hard to say honestly. I am not sure about that question. Is anybody, 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. Hold on, 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 cardiothoracic area ratio. It was there. No, no, no. You didn't misunderstand. It was definitely there. Okay. We have another one. Mm-hmm. They're asking about the color Doppler on chroma map. What are my thoughts? I mean, I use color Doppler always. Well, chroma, no chroma. But I only use it to confirm if I notice like in a case with that extra vessel that was near my descending aorta, if I was in my chroma map setting, I would've turned it on then. So, I mean, it's helpful. It's definitely helpful. And I would say giving you more confirmation to what you may suspect or what you're seeing in your congenital heart defect. I always utilize everything on my machine to enhance diagnosing. So I would say yes. Okay, perfect. We have another question here. It wasn't, I never have an issue. Usually seeing the foramen ovale, you should clearly, especially in your apical view, if you're four chamber view, you should see your, even if it's subtle, but you should see that flap within that left atrium. 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, the blue shunting where 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 seen. Perfect. Mm-hmm. We have another question here. Sure. 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. Let's go here. Yeah, they wanna see it again, so, okay. Sure. So let me go to that. I'll share it again and I'll just go back. Okay. So 45 degree angle. 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 descending 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 would not know. Yeah, I'm not, why they said that? Yeah, I must, I use Samsung mostly majority of the time. And then we also have access to GE. But I, it's interesting, 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. But honestly, 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, my favorite Samsung, but we have GEs as well. The, my, oh, that's a great question. So this one is saying what's the gestational age 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 scan. I wanna say yes, it's not as prominent as when you get to your event stages, of course. 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 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, is standard. But we at our practice, we do our echos starting at 22 weeks to 24 weeks. Now, if there is a 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 by your ARDMS that says 18 to 22. Mm-hmm. Yeah, that's all I was thinking. I was assuming that you were talking about the chroma and color flow, but I'm not sure why Phillips has that rule or I guess they prefer for you not to. 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. And since it couldn't be excluded adding an aortic coarctation, taking much more sort of blame difficult exam due to active fetus, it was body habitus. Yeah. And that could be difficult. The body habitus could make it extremely hard to diagnose any of these defects. But recommendation was to reassess at birth. Yeah. A lot of times if 'cause I mean we have cases where some 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 think that recommendation is still helpful in that case, just to be safe. Just to make sure if it's there or if it's not second trimester, I'm assuming that's talking about 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. So yes, I definitely agree the Samsung and the GE a certain frame rate about 50 to be accurate diagnosis about the VSD. 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 don't know. I will have to play with my frame rate to assess it. I still bump my frame rate down to 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, you're seeing maybe a tiny one. I don't know. I am, we still utilize both high frame rate, low frame rate. I can understand that in accuracy, but it's hard to say about the VSD about the frame rates there. It's tricky. It's very tricky. But I would say still assess it though in both high and low, 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 treat every fetus whether low or high risk the same. And so our protocols are pulmonary veins. We're assessing moderator band. We're sampling, we're looking at ductus venosus for all of our fetuses that come into the office at 20 weeks, not just those that have a history of a heart defect. And 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 have to stay on board and do all the reading and studying just to 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, Lashelle. 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

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