PEDIATRIC ECHO I

____in _____children are born with Congenital Heart Defects *****

8 in 1000 children are born with Congenital Heart Defect

Some forms of CHD cause how big of a problems with growth and development of a child

Some forms of CHD cause little to no problems with growth and development of a child

Others may cause significant what?

if detected late, the child may suffer from what defcts

Others may cause significant morbidity and mortality

•If detected late, the child may suffer from neurologic defects

Performing a pediatric echo will help to identify what?

Performing a pediatric echo will help to identify any malformations of the heart

Pediatric echo includes age ranges from what?

Pediatric echo includes age ranges from newborn to 18 yrs

INDICATIONS FOR PEDIATRIC ECHO,

what is the #1 reason why?

1. Suggested heart disease through symptoms or family history of heart disease

(#1 reason family history)

INDICATIONS FOR PEDIATRIC ECHO

name the rest other reasons why? 4 others to name

known heart disease

symptoms that suggest heart disease

presence of structural heart disease

acquired heart disease and non - cardiac disease

INDICATIONS FOR PEDIATRIC ECHO

known heart disease name 5

1. check on progression of disease

2. valve function

3. growth of cardiovascular structures

4. LV function

5. interrogation of surgical intervention and treatments

INDICATIONS FOR PEDIATRIC ECHO:

3. Symptoms that suggest heart disease, name 11

whats the #1 most common (???) symptom?

1. Cyanosis (low O2 sats) #1 most common symptom

2. Failure to thrive (no weight gain) ****

3. Chest pain

4. Syncope

5. Respiratory disease

6. Murmurs

7. Cardiomegaly

8. Arrhythmias

9. Congestive Heart Failure

10. Abnormal arterial pulse - BP’s on all 4 limbs to rule out CHD ****

(different BP of the Limps point to CHD)

INDICATIONS FOR PEDIATRIC ECHO

4. Presence of Structural Heart Disease name 7

1. Shunting lesions •

2. Obstructive lesions •

3. Regurgitant lesions •

4. Abnormal systemic or pulmonary venous connections •

5. Conotruncal anomalies •

6. Coronary artery anomalies

7. • arrhythmias

INDICATIONS FOR PEDIATRIC ECHO

5. Acquired Heart Disease and Non-Cardiac Disease name 8

1. Cardiomyopathies •

2. Infective endocarditis •

3. Kawasaki disease •

4. Rheumatic fever •

5. Systemic lupus erythematousus •

6. Myocarditis •

7. Cardiotoxic drug exposure •

8. Teratogen influences (maternal diabetes, rubella, etc.)

what is O2 SATS

pulse oximetry is a ______,_______,_______ what test performed on ____ infants

pulse oximetry is a painless, simple, timely, noninvasive test performed on all infants

O2 SATS

what is it used to detect?

Used to detect the amount of oxygen in arterial blood

O2 SATS is a ______ nerborm critical ______ screnning endorsed by the AAP, AHA, ACC

its a universal newborm critical CHD screening

O2 SATS, screening should be performed when?

Screening should be performed after 24 hours of life or as late as possible if early discharge is planned

(when babies are born the Rt - side pressures drop - so babies O2 sats are checked before the leave to make sure they are good and not blue)

Oxygen saturation (SpO2) is measured in the which hand (____) and on either ____(____).

Oxygen saturation (SpO2) is measured in the right hand (preductal) and on either foot (postductal).

O2 SATS

what normal?

what % will have CHD if they fail an O2

Normal is above 95%

20-25% will have CHD if they fail an O2

Done prior to discharge there by minimizing complications associated with delayed diagnosis. name 3

May not look cyanotic initially

Anemia may hide it

May only be cyanotic (blue) at 60- 70% pulse ox

The what approach divides the heart into three basic segments and then the junctions between them

The segmental approach (or can be called the sequential approach) divides the heart into three basic segments and then the junctions between them

what are the Basic Segment:

Basic Segment: •

Atria •

Ventricles •

Great arteries

Junctions between the segments and Venous and arterial connections

name 4

Venoatrial • (SVC, IVS, Pul vein, and how they attach to the atria )

Atrioventricular and Inflow valves (chamber connection and inflow valves, the valve always follow the ventricle)

Infundibulum • (RV is more muscular and LVOT has the fibrus mitral continity)

Semilunar valves and Arterial trunks

SEGMENTAL APPROACH explain the first and secound steps

Start with Subcostal view and determine abdominal thoracic situs

Second position of apex and cardiac position

SEGMENTAL APPROACH

determines what? name 2

define the relationship of the what?

Determine atrial situs •

Determine Ventricular looping •

Define the relationship of the arterial trunks

SEGMENTAL APPROACH

whats the 3rd step (look at what 3 things and this defines the relationships of what?

whats the finally steps

Look for the venous to atrium connections

Look at the atrioventricular connection and inflow valves

Look at the outflow tract morphology

Define the relationships of the semilunar valves and connections

Next look for shunting lesions, abnormal connections, and any anomalies

ABDOMINAL VISCERAL SITUS SOLITUS

explain where each lay

RA, AO, Liver, IVC, trilobed lung, bi lobed lung, stomach, spleen

RA is on the right •

Aorta on the left •

Liver on the right

• IVC anterior and to the right of the aorta

• Right sided trilobed lung

• Left sided bi lobed lung •

Left sided stomach

• Left sided spleen

SITUS INVERSUS

describe where the following lay

AO, IVC, liver, RA, trilobed lung, bi lobed lung, stomach, spleen

Situs Inversus •

Aorta on the right •

IVC anterior and to the left of the aorta •

Liver on the left • RA is on the left •

Left sided trilobed lung •

Right sided bi lobed lung •

Right sided stomach •

Right sided spleen

what does SITUS AMBIGUOUS includes

Includes Left isomerism and right isomerism

Situs Ambiguous Left Isomerism

what sign ?

has interrupted what?

where is the liver?

what is wrong with the LA

whats wrong with the ling?

what is the stomach position

how many spleen

Double vessel sign with Aorta and “vein stacked” •

Interrupted IVC with Azygous continuation •

Liver is midline •

Will have two left atrium •

Bilateral bilobed lung •

Variable stomach position •

Multiple spleen

SITUS AMBIGUOUS:

Asplenia – (what syndrome?)

has what sidedness?

which atrial isomerism

Asplenia – (Ivemark’s syndrome)

bilateral right sidedness, right atrial isomerism

Asplenia – (Ivemark’s syndrome)

what wrong with the lungs?

where is the liver?

how many gallbladders?

how many splees?

Two right lungs, midline liver, two gallbladders, no spleen

which SITUS AMBIGUOUS is Almost always associated with CHD of the severe spectrum?

Asplenia – (Ivemark’s syndrome)

Polysplenia

what sidedness

what atrial isomerism

Polysplenia – bilateral left sidedness, left atrial isomerism.

Polysplenia

what is wrong with the lungs

where is the liver?

how many spleens?

75% have what forms of what?

Two left lungs, midline liver, multiple spleens

•75% have mild forms of CHD

APEX AND THORACIC POSITION! • Apex Position

name the 3 different postion?

Levocardia • Dextrocardia • Mesocardia

Thoracic cavity position

name 3 different position

Levoposition • Dextroposition • mesoposition

TOPOLOGY (HAND RULE) •

the thumb is for which flow?

the pointer is for which flow?

when we use the right hand what kind of looping is that?

when we use the left hand what kind of looping is that?

Thumb is for the inflow

pointer is for the outflow

Right hand D-Loop

Left hand L -loop

The point of this rule is to determine the looping of the ventricle

ATRIAL SEG MENTAL SITUS

what does S mean

what does I mean

what does A mean and what is it associated with?

S - situs solitus - (normal heart)

•I - situs inversus - all anatomy is flipped •

A - situs ambiguous - Associated with isomerism of atria (two left or two right)

The LAA has a what shape?

what are the two best views we can see the LAA? and name another two that we can use

pinky shape

SAX - great artery level and 2 chamber are the best two views

5 chamber sweeping to AV, and 4 chamber

what is the shape of the RAA

what is the first view we see the RAA

and name 3 more

1st view is RVIF view

Bicaval

subcostal 4 chamber

subcostal bicaval view (both vena cava attached to the RA)

what is ANOTHER IDENTIFIER OF RA?

CRISTA TERMINALIS IS ANOTHER IDENTIFIER OF RA

VENTRICULAR SEGMENTAL SITUS

D-Loop= explain the twist

D-Loop (normal heart) Bulboventricular loop twists to the right

VENTRICULAR SEGMENTAL SITUS

L-Loop= explain the twist

L-Loop (dextrocardia) Bulboventricular loop twists to the left

VENTRICULAR SEGMENTAL SITUS

X-Loop= explain the twist

Single ventricle is present. Unable to determine looping

VENTRICULAR LOOPING

The usual what looping of the heart tube (D—loop) leads to the morphological right ventricle being to the what of the morphological left ventricle

The usual rightward looping of the heart tube (D—loop) leads to the morphological right ventricle being to the right of the morphological left ventricle

VENTRICULAR LOOPING

what looping (L— loop) results in the morphological right ventricle being to the what of the morphological left ventricle

Leftward looping (L— loop) results in the morphological right ventricle being to the left of the morphological left ventricle

VENTRICULAR LOOPING

(x-Loop) what about the looping?

• (X-Loop) Cannot determine looping

GREAT ARTERY SITUS

S- Solitus; explain the relatipn between the AO and PV

S- Solitus; (normal) aorta is rightward and posterior to pulmonic valve

GREAT ARTERY SITUS

I – Inversus; = explain the relatipn between the AO and PV

I – Inversus; aortic valve is leftward and posterior to pulmonic valve

GREAT ARTERY SITUS

D – D-malposed;= explain the relatipn between the AO and PV

•D – D-malposed; aortic valve is rightward and anterior to pulmonic valve

GREAT ARTERY SITUS

L – L-malposed;= explain the relatipn between the AO and PV

L – L-malposed; aortic valve is leftward and anterior to pulmonic valve

GREAT ARTERY SITUS

A – Anterior= explain the relatipn between the AO and PV

•A – Anterior; aortic valve directly anterior to pulmonic valve.

Normal heart with situs solitus:

Normal heart with situs inversus (mirror image of normal): •

D-TGA:

•L-TGA with situs solitus:

VENO-ATRIAL CONNECTION – SYSTEMIC VEINS

Systemic vein connections

Subcostal long axis of IVC connecting into

Subcostal long axis of IVC connecting into RA

VENO-ATRIAL CONNECTION – SYSTEMIC VEINS

Subcostal bicaval view connecting the SVC into the

• Subcostal bicaval view connecting the SVC into the RA

VENO-ATRIAL CONNECTION – SYSTEMIC VEINS

Hepatic veins draining into the

• Hepatic veins draining into the IVC

VENO-ATRIAL CONNECTION – SYSTEMIC VEINS

Apical 4 Chamber with posterior tilt to show what into what?

Apical 4 Chamber with posterior tilt to show Cononary sinus ostia into RA

VENO-ATRIAL CONNECTION - PVEINS • Pulmonary vein connections

follow the veins entering what and use what to show drainage in what views

and do you need to do with the scale?

Follow the veins entering atrium and use color flow to show drainage in SSN Short axis •

Lower color scale

ATRIOVENTRICULAR CONNECTION

Time to assess whether the heart is biventricular, univentricular, and the mode of AV connection

Remember the inflow valves follow the what?

Remember the inflow valves follow the ventricle •

Features of TV?

• Features of MV?

• What are the different features of the ventricles?

START WITH ____TO VENTRICLE CONNECTION

START WITH ATRIA TO VENTRICLE CONNECTION

UNIVENTRICULAR CONNECTIONS

The word “univentricular” refers just to the type of what and not to the number of ventricles?

The word “univentricular” refers just to the type of connection and not to the number of ventricles

UNIVENTRICULAR CONNECTIONS

The term univentricular AV connection describes the connection of one or two atrial chambers to?

The term univentricular AV connection describes the connection of one or two atrial chambers to only one (dominant) ventricle

UNIVENTRICULAR CONNECTIONS

Univentricular hearts commonly have a one what ventricle and a second what ventricle

Univentricular hearts commonly have a one functional dominant ventricle and a second (rudimentary) ventricle

UNIVENTRICULAR CONNECTIONS •

When describing the type of AV connection…we should determine whether it’s what?

When describing the type of AV connection…we should determine whether it’s biventricular or univentricular

MODES OF CONNECTION INCLUDE name 5

MODES OF CONNECTION INCLUDE TWO PERFORATE VALVES, COMMON AV VALVE, ONE IMPERFORATE AND ONE PERFORATE VALVE AND AV VALVE STRADDLING AND OVERRIDING

VENTRICULO-ARTERIAL CONNECTION AND RELATIONSHIP BETWEEN THE GREAT ARTERIES

how is the PA anatomic orination

Pulmonary artery is Anterior and leftward

pulmonary artery is characterized by what?

pulmonary artery is characterized by bifurcation into the right and left pulmonary arteries

Aorta gives rise to what?

and whats its anatomic orination

Aorta gives rise to coronary arteries and systemic arteries (Brachiocephalic arteries) •

Posterior and rightward

VENTRICULO-ARTERIAL CONNECTION

Which great artery is connected to which ventricle

• For types of connections name 4

Concordant •

Discordant •

Double outlet

• Single outlet

•Normal heart with situs solitus: S, D, S

•Normal heart with situs inversus (mirror image of normal): I, L, I •

D-TGA: S, D, D

•L-TGA with situs solitus: S, L, L

CONCORDANT/DISCOR DANT

which one is the two wrongs make a right?

Atrial – ventricular discordance; ventricular – arterial discordance. Two wrongs make a right!

WHAT IS THE CONNECTION?

WHAT IS THE CONNECTION?

WHAT IS THE CONNECTION?

what are the morphological features of the ventricle

AO

PA

RA and LA

RV - MB, muscular

LV - bullet shaped, smooth, false tendon

AO 3 head and neck branched / vessels

PA branches

RA and LA appendages

for the SEGMENTAL APPROACH, what are all the steps

what situs is this

situs solitus

what situs is this

situs inversus

what situs is this

situs ambiguous, rt atrial isomerism

what situs is this

situs ambiguous lt atrial isomerism

which situs ambiguous has 100% association very sever congential heart defects ? more severe !!!

situs ambiguous, rt atrial isomerism

what APEX AND THORACIC POSITION is this

Dextrocardia

what APEX AND THORACIC POSITION is this

Levocardia

what APEX AND THORACIC POSITION is this

Mesocardia & mesoposition (equally divded by the RT and LT side of the chest)

Use the atrial what to determine right situs

Use the atrial appendages to determine right situs

what kind of looping is this? concordance vs discordance?

D- Looping and concordance

what kind of looping is this? concordance vs discordance?

L-Looping and discordance

Normal heart with situs solitus

SDS

Normal heart with situs inversus (mirror image of normal):

ILI

D-TGA

SDD

L-TGA with situs solitus

SLL

DORV is determine the amount of override is what %?

> greather than or equal to 50%