Fetal Rhythm and Blues
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- Barrie Walton
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2 Fetal Rhythm and Blues John Cotton, MD Professor of Pediatrics Division of Pediatric Cardiology Director, Fetal Cardiology Program UNC Chapel Hill, School of Medicine
3 Objectives To review methods used to assess fetal cardiac rhythm To understand and identify abnormal fetal cardiac rhythms To learn typical therapy for common fetal arrhythmias
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5 Rhythm who cares? Total-239 Normal 141 (59%) Arrhythmia AVSD HLHS VSD Coarc t Effusion Pulm Atresia TOF Vent Assym TTTS Misc Abnormal Axis Single Ventric le Valve Rg 2 0
6 Cardiac Rhythm Observe rhythm throughout examination Wide variation in rate is normal Short bradycardic or tachycardic rates are normal Occasional ectopic beats Measure heart rate - Doppler or M-mode Normal mean HR bpm at 20 wks Normal mean HR bpm at term Tachycardia - > 180 bpm Bradycardia - < 100 bpm Frequent irregular beats > 1 in 10 beats
7 Rhythm Method M-Mode line through back wall of atrium and ventricular free wall Pulse Doppler Pulse Doppler sector between mitral valve and aorta Pulse Doppler sector between superior vena cava and aorta Tissue Doppler Feto-Magnetocardiography (fmcg)
8 M-Mode Rhythm Assessment Pros Familiar Simple to perform Adequate for majority of cases Cons Poor echo windows common Difficult to get correct angle Timing may be difficult to determine Can be difficult with poor function
9 Normal Sinus Rhythm
10 Pulse Doppler Rhythm Assessment Inflow Outflow View Place cursor between mitral valve and aortic valve with larger sample volume SVC-Ascending Aorta View Place cursor between SVC and aorta in long axis three vessel view
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12 SVC- Ascending Aorta
13 SVC-AA Normal Doppler
14 Common Arrhythmias Tachycardia (> 180 beats per minute) Thyroid disease, maternal medications, structural heart disease, extracardiac disease Bradycardia (< 100 beats per minute) Maternal autoimmune diseases, medications, structural heart disease, hydrops Irregular Rhythms Caffeine intake, medications, structural heart disease
15 Tachycardias 1. Sinus tachycardia - < 200 bpm 2. Ectopic atrial tachycardia bpm 3. Supraventricular tachycardia bpm 4. Ventricular tachycardia bpm 5. Atrial flutter bpm
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17 Sinus Tachycardia
18 Supraventricular Tachycardia
19 Supraventricular Tachycardia Simpson J, Ultrasound in Obstet Gynecol 2006:27;599
20 Supraventricular Tachycardia
21 Ventricular Tachycardia V = 220 A = 150 Simpson J, Ultrasound in Obstet Gynecol 2006:27;599
22 Atrial Flutter
23 Atrial Flutter
24 Atrial flutter inflow outflow
25 Atrial Flutter
26 Bradycardia Blocked premature atrial contractions Sinus bradycardia Complete heart block Atrial flutter with high grade AV block Prolonged QT syndrome (bradycardia or 2:1 block)
27 Blocked premature atrial contractions
28 Blocked premature atrial contractions
29 Complete Heart Block Atrium Ventricle
30 Complete Heart Block
31 Irregular Rhythms Sinus rhythm Premature atrial contractions Premature ventricular contractions Chaotic atrial tachycardia
32 Premature Atrial Contractions
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35 Blocked Premature Atrial Contraction Simpson J, Ultrasound in Obstet Gynecol 2006:27;599
36 Premature Ventricular Contractions
37 Treatment of Common Arrhythmias Premature atrial contractions no treatment needed Intermittent tachycardia observation with close follow-up Sustained tachycardia SVT, Atrial Flutter Digoxin, Flecanide, Sotalol Ectopic Atrial Tachycardia Digoxin, Amiodarone Worse prognosis with hydrops Deliver if fetus is mature or as last resort Bradycardia >60 bpm- observation <60 bpm- Terbutaline, delivery
38 New Techniques Multipoint Pulse Tissue Doppler Imaging Fetal Magnetocardiography (fmcg)
39 Multipoint Pulse Doppler TDI
40 Fetal Magnetocardiography (fmcg) Maternal ECG signal is x stronger than fetus As cardiac tissue depolarizes, currents are generated and a magnetic field is generated Strength is about one millionth the strength of the earths magnetic field Maternal signal 50 pt, fetus pt
41 SQUID Superconducting Quantum Interference Device Supercooled and shielded Filter for background noise Identify maternal signal and then attenuated Result is a signal analagous to a surface ECG
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45 Case 1
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52 Case 2
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58 Case 3
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61 Case 4
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75 Summary Fetal rhythm disturbances are common and mostly benign Rhythms can be identified through multiple echo modalities A complete fetal echocardiogram should be done to rule out structural heart disease Treatment should be undertaken by an experienced team including high risk OB and pediatric cardiology
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