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UOG Journal Club: October 2011

UOG Journal Club: October 2011. Pulsed-wave tissue Doppler echocardiography for the analysis of fetal cardiac arrhythmias B. Tutschek and K. G. Schmidt Volume 38, Issue 4, Date: October 2011, pages 406–412. Journal Club slides prepared by Dr Aly Youssef (UOG Editor for Trainees). Background.

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UOG Journal Club: October 2011

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  1. UOG Journal Club: October 2011 Pulsed-wave tissue Doppler echocardiography for the analysis of fetal cardiac arrhythmiasB. Tutschek and K. G. Schmidt Volume 38, Issue 4, Date: October 2011, pages 406–412 Journal Club slides prepared by Dr Aly Youssef (UOG Editor for Trainees)

  2. Background • Fetal arrhythmias may lead to fetal cardiac failure, hydrops and death • Precise evaluation of the type and mechanism of a fetal arrhythmia is mandatory in order to define prenatal treatment options and prognosis

  3. Background:Current assessment of fetal arrythmias • M-mode • High temporal resolution • Dependent on fetal position • May require multiple attempts to acquire appropriate tracings Pulsed-wave tissue Doppler echocardiography (current study) • Pulsed-wave Doppler of blood flow • (e.g. at the pulmonary artery/vein) • Displays diastolic and systolic flow events in one recording • Mostly independent of fetal position • Different pulsed-wave propagation times may interfere with the analysis of electromechanicalcoupling

  4. Pulsed-wave tissue Doppler echocardiography for the analysis of fetal cardiac arrhythmias Tutschek and Schmidt, UOG 2011 Objective:To study normal and abnormal fetal cardiac rhythm using pulsed-wave tissue Doppler echocardiography (PW-TDE) Patients: 100 fetuses 15–40 weeks referred for cardiac evaluation 55 Normal anatomy and function 45 Cardiac arrhythmias • All fetuses had a complete fetal echocardiographic examination before entry into the study • Axial excursions of the ventricular wall at the atrioventricular (AV) valve annulus were recorded using PW-TDE • Both PW-TDE and pulsed-wave Doppler of the blood flow through the AV valves were recorded simultaneously in several of the normal fetuses (in order to study the temporal correlation between flow and tissue signals)

  5. Pulsed-wave tissue Doppler echocardiography for the analysis of fetal cardiac arrhythmias Tutschek and Schmidt, UOG 2011 Methods Ultrasound system Several different high resolution ultrasound systems equipped for prenatal or neonatal studies, but without specific tissue Doppler probes or software Ultrasound settings ↓ Pulse repetition frequency (PRF) (to about ± 15 cm/sec) ↓ Wall filter (minimum) ↓ Receive gain (to remove blood flow signals) Technique • The heart is imaged in an apical (or close to apical) insonation angle • Pulsed Doppler sample volume adjusted in size and placed over the area covering the entire valve annulus excursion during systole and diastole • Data acquired during fetal and maternal apnea and absence of fetal body movements

  6. Pulsed-wave tissue Doppler echocardiography for the analysis of fetal cardiac arrhythmias Tutschek and Schmidt, UOG 2011 Results: Correlation with blood flow Doppler mitral inflow, aortic outflow / left ventricular TD tricuspid inflow / right ventricular TD tissue Doppler (TD) signals blood flow Doppler signals Note that blood flow and wall movements are synchronous, but run in opposite directions The temporal relation of PW-TDE and conventional blood flow Doppler signals was depicted in such tracings, confirming the interpretation of the PW-TDE signals

  7. Early diastole Late diastole Isovolumetric contraction Isovolumetric relaxation Away from the apex Towards the apex Systole Pulsed-wave tissue Doppler echocardiography for the analysis of fetal cardiac arrhythmias Tutschek and Schmidt, UOG 2011 Results: Normal pattern of PW-TDE • Best signal-to-noise ratio was usually obtained from • right ventricular wall (tricuspid valve annulus) • Separate E’ and A’ were often seen, followed by S’ • Fusion of E’ and A’ occurred if rates are > 130bpm

  8. Pulsed-wave tissue Doppler echocardiography for the analysis of fetal cardiac arrhythmias Tutschek and Schmidt, UOG 2011 Results: PW-TDE in fetal arrhythmias Premature ventricular contractions (PVC) Non-conducted premature atrial contraction (PAC) Conducted premature atrial contraction (PAC) • Atrial activity (A’) is regular • Interval preceding PVC (dashed red bar) plus post-ectopic interval (solid red bar) equals interval between two normal sinus beats (white bar) i.e. compensatory pause • In post-ectopic pause (post PVC), E’ and A’are separate • PAC is followed by systolic excursion (&) • Conducted PAC shows an early atrial activation with associated ventricular response (&), but also a non- compensatory pause • Atrial activity is irregular due to PAC • Absence of systolic excursion (S’) after PAC (non-conducted) • Interval between pre- and post-ectopic atrial activation is shorter than the expected interval between two normal beats (non- compensatory pause)

  9. Pulsed-wave tissue Doppler echocardiography for the analysis of fetal cardiac arrhythmias Tutschek and Schmidt, UOG 2011 Results: PW-TDE in fetal arrhythmias 2nd degree atrioventricular block, type Wenckebach Ventricular tachycardia with AV dissociation Supraventricular tachycardia (SVT) • There was progressive lengthening of conduction time in successive cardiac cycles until ventricular response was skipped (*) • There were regular atrial activations (A), but much more rapid and dissociated ventricular contractions (S) • E’ and A’ (below baseline) always coincided • There was a 1:1 association of atrial and ventricular motion

  10. Pulsed-wave tissue Doppler echocardiography for the analysis of fetal cardiac arrhythmias Tutschek and Schmidt, UOG 2011 Results: PW-TDE of complete fetal atrioventricular block Ventricular contractions Atrial contractions Atrial activations obscured by ventricular activation Atrial activity immediately after ventricular emptying (large amplitude) Atrial activation occurring after S’, associated with separation of E’ and A’

  11. Pulsed-wave tissue Doppler echocardiography for the analysis of fetal cardiac arrhythmias Tutschek and Schmidt, UOG 2011 Discussion: Comparison with pulsed-wave blood flow Doppler

  12. Pulsed-wave tissue Doppler echocardiography for the analysis of fetal cardiac arrhythmias Tutschek and Schmidt, UOG 2011 In this case M-mode proved to offer complementary help to both techniques

  13. Pulsed-wave tissue Doppler echocardiography for the analysis of fetal cardiac arrhythmias Tutschek and Schmidt, UOG 2011 • Conclusion • The study demonstrated that high-resolution ultrasound systems for fetal imaging without specific hard- or software can be used for the recording of tissue motion and detailed characterization of fetal arrhythmias • The study provided detailed descriptions of normal PW-TDE recordings and provided examples of PW-TDE recordings in common fetal arrhythmias • The study showed potential of PW-TDE for estimating AV conduction time, depicting directly tissue movement These findings may improve the ability to analyze precisely fetal arrhythmias and to select appropriate therapeutic options

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