Dr. Lisa Hornberger discusses the topic of early gestation imaging. This in-depth review will provide an update for your clinical practice.
Dr. Elena Sinkovskaya discusses the topic of 3D fetal echo. This in-depth review will provide an update for your clinical practice.
Dr. David Schidlow discusses the topic of maternal hyper-oxygenation and the therapeutic implications. This in-depth review will provide an update for your clinical practice.
Dr. Bettina Cuneo discusses the topic of telemedicine in fetal cardiology. This in-depth review will provide an update for your clinical practice.
Yeah. Mm hmm, mm, mm hmm. Yeah, yeah. Mhm. Hello, Welcome back. It's 1 15. I trust everyone's had time to grab a bite and see the latest imaging that's offered by the different platforms from the companies that in the exhibit hall today. I'm rajesh and I am one of the little cardiologists here at Mount Sinai first. I'd like to thank ken and me will and jen for putting up such a wonderful symposium virtual but still pretty enjoyable. Uh we have for excellent speakers and to introduce them. I call on my good friend and colleague from my days at Einstein. Dr peer to peer. Hi everyone, can you see me or hear me? Yes, it's a little loud. Speak a little louder. Okay, uh can you see me? My yes, we can see you speak a little louder. Okay. Hello everyone and thank you raj for the introduction. I'm Theodore. I'm professor for a big guy in it. Of that Einstein College of Medicine in new york. And this afternoon we're going to have a great session with excellent speakers. Our first speaker is dr lisa Hornberger. We'll talk about pushing the envelope. Her legislation imaging. Dr Hornberger is a professor of pediatrics and adjustment professor obituary in and she is the section head of pediatric fetal echocardiography in the University of Alberta Canada. Our next speaker is dr Elena sin copious sink of Scalia. She will talk about what's new and three D fetal echoes. Dr cajkovskij is associate professor for Virginia and she is the director of ultrasound research and education at Eastern Virginia Medical school at Norfolk Virginia. The third talk will be given by Dr David should look dr Sheila will tell us about maternal hyper oxygenation, prognostic and therapeutic implications. Doctor She law is an assistant professor of pediatrics and he's joining us from the department of pediatric and fetal cardiology in Harvard Medical School in boston Children's Hospital. And last but not least, is dr Bettina kono. She will teach us about telemedicine and fetal cardiology, remote monitoring and other applications. Dr kono is a professor of pediatrics and obstetrics. She's the director of fetal cardiology and fiddle tele medicine at the University of Colorado School of Medicine and Children's Hospital in colorado. After the four talks will have an opportunity for Q and A. As uh was in the sessions before. Just please write your questions so we can pick up And the most common questions. And after that we'll have a 15 minutes break. So let's go. I want to begin by thanking the symposium organizers. Dr Stern Geiger and young for having invited me to give this presentation. It's a topic that I've been passionate about since the 90s. So why do we want to do early foetal echo for most? It provides reassurance of normal sees normalcy in the high risk pregnancies. And really, this is the true for the majority of patients that we assess. But when there is a theocratic diagnosis, it provides more time for decisions regarding the pregnancy, for further testing. An option for earlier termination of the pregnancy as well. For the woman at a time that may be emotionally and physically a little less difficult. And in fact, many do choose this option. It also provides an insight into the natural evolution if you don't create disease, including what is and is not tolerated by the feudal early fetal circulation and earlier diagnosis of potential lesions. For intervention referral indications for early Flacco are largely comparable to those of the second trimester uh and divided into maternal fetal and familiar categories. But the highest yield indications, unlike later in gestation, when a suspicious uh fetal ultrasound for uh cardiac pathology, uh in the fetus is the highest yield, increased nuclear translucency, especially above 3.5 mm. Extra credit pathology and markers of fetal cardiovascular compromise, including a valve regurgitation, a reversal in the next video sis and you know, high drops are really the indications with the highest yield for fetal cardiac pathology. One must take into consideration what can and cannot be evaluated in the first trimester and what may or may not be present in terms of who you will see Most forgot. All major structural heart disease will be present, settle in progressive lesions may not be august until later, and that's including obstructive legions, assumed here, some lesions don't develop until later. I gave you blocking maternal autoantibodies cream, up to these other arrhythmias and cardiac tumors, such as wrapped in my oma. So that should be taken into consideration when choosing to do it early assessment. This is just to remind everyone this dramatic evolution in the morphology and size of the heart. During this period. At eight weeks, you can see the hearts quite a bit larger relative the fetal testis of midline access, globular looking ventricles and bigotry and a pericardial effusion. But as you progress with every week, the heart becomes more and more what we're used to seeing by about 12 to 14 weeks. The heart Roland looks much like it does in the mid to later mid trimester. Um The size of the heart goes from being about the science of a lentil to the size of a chickpea, just in this very short period of time. And this is why the resolution is so much better. And then you can see the difference in size from 14 weeks to a typical mid trimester time for fetal echo. So while we can see four chambers and about 50% by two dimensional imaging a little bit more about color showing inflows at the eighth week. In fact, it's really the majority of frequencies. We can see the four chamber in after the 11 plus zero weeks, only up to the 14th weekly. So this will help you get some idea of what you want to be seeing these moms looking at outflows again, 11th week onward, we're seeing them much better. The hatch marks use of color and color Doppler is definitely helpful, especially at these earlier ages. This is an example where you're seeing a four chamber and a nine week old, uh, feed us where the particular outflow show your, the aortic outflow and the aortic arch with actually usually you can see crossing by color. So color can be very helpful in defining the outflow anatomy and the arch anatomy again by 11th week. And the majority we could see the aortic and ductile arches and document that they're left sided as well. And colour that helps us, especially with the LNG stations where we have the greatest difficulties in assessing systemic poverty AIDS. The iBc is a little bit easier and by color it can be quite helpful, especially at these earlier ages, poverty venous anatomy can be very challenging, especially at earlier ages. So you will not always be able to be absolutely certain about poverty vein anatomy. Use of HD features can be quite helpful that we just have not done the routinely. But I think that would be one thing that you can do to improve uh detection of your public aids or assessment of public aids. So technical considerations include use of the highest frequency transducers available, I would argue you don't want to use anything less than nine megahertz if you can get if you don't have to because you really need to resolve small structures. We use high frame rates, reducing death, narrowing your sector with use of zoom features not too much, you know, sometimes that doesn't help you. This will also help reduce your M. S. And T. I. S. Which is important for, from a safety perspective of these role infestations, closer proximity to feel hard, especially at less than 10 weeks, uh needs to be less than four centimeters as we've shown in Darren Hutchinson's paper, you want to keep your M. S. And T. Is low and the systems will show you this Will display and usually less than or equal to 1.0, if you can. And then we use Doppler sparingly, that's color and pulse. Doppler and keep track of the time that we're using it. We're using it for brief periods. In fact, this is just to show that for any vaginal imaging. In fact, the majority of pregnancy is less than 11 weeks. We tend to need to use it to get the resolution that we need to see all of the cardiac structures after the 11 plus zero weeks, though the majority do not require individual imaging. So that may be helpful if you don't want to be um Doing the assessments and you only feel comfortable trans abdominal assessments only bring about the later stage. This is just an example of all referred at 13 a half weeks. It was quite obese and you really almost saw nothing trans abdominal. So we would individually, it saw a large aorta that was overriding the particular septum balanced ventricles. This is starting to look like a tetralogy in the three vessel view confirm this diagnosis of the much smaller public air artery uh and a large aorta, normal spc. Uh And then by color that was and a great flow to the polling outflow. This is in keeping with the technology form of public stenosis. That was in fact confirmed both at a later echo uh and then by autopsy. Uh limitations include that the resolutions never as good as it is later, but it's not a reason not to be looking say this assessment can be consistently done pretty much trans abdominal lee, at least when you see the heart and stomach. But it will, it's quite difficult to do through a trans vaginal approach. You lose your orientation of the fetus valves can be very difficult to resolve. The navy valve offset, difficult to consistently assess in less than 12 weeks. You need to keep that in mind and looking at these that there may be uh issues with making those diagnoses, for instance, of a subtle A. V. Septal defect. Doppler interrogation with adequate alignment also is difficult via trans vaginal imaging unless it. But the one good thing is that the babies are usually quite active so you can use that to your advantage to be able to do interrogations and then probably dates again are challenging at all gestations. So how do we do with the general heart disease diagnoses? This was a review by Clarin gallardo in 2019 of nine reports describing their experience of less than 14 foetal echo, uh and these were studies published between 2000 and four and 2014 or uh and included over 18 81 100 exams. Their overall said Stevie was 79% of specificity, about 99%. 3 quarters showed concordance between early and mid trimester exams and the mist pathology included vertical septal defects in regard to branching anomalies settled two trilogies and 80 septal defects. Ta BBC valvular stenosis, which are progressive and systemic Vaid anomalies. It's just a note. There have been more recent publications that suggest a sensitivity of 89% and specificity of 100% for basic general heart disease diagnoses uh in experienced hands, just to show you a few cases is a 12 plus week uh pregnancy referred from one of our cardio sister kind of Roma. And we thought there was an interrupted ibc with a circus dilation back here. So keep it was probably loved it twice. Colorism. There was a dexter cardiac with the right side, left ventricle, left side and right ventricle that it gave rise to both outflow tracts. As we'll see at the very end. There's a comment, a V valve uh and pretty much the details we could we could see at this early age, there was a T valve regurgitation, There was aortic insufficiency. So things that we were quite concerned about in addition to the bradycardia that we were seeing in the pericardial effusion. In fact, this baby had 2-1 day. Be blocked by M. mode. We can confirm this and ventricle rate of 60. So this is a left a choice terrorism complex with 80 septal defect, double outlet, right ventricle aortic insufficiency and the valve regurgitation. We were quite concerned. That was also known compaction crime up at the and the mountain chose because of a likely high likelihood of fetal demise, termination of 13 weeks. The full anatomy was confirmed at autopsy. This is another 13 weeks for all that we felt before chambers look normal but sweeping up. Uh the great vessels didn't have a normal relationship. We thought they were kind of normal but not entirely. And they were looking more side by side. So I wondered about the possibility of double our eventual could not be certain. And we suggested the mobile come back in a few days. She came back five days later. And in fact we could show that there were parallel great vessels. Uh and they were transposed to the public arteries. Back here coming off a poster of authentic all the aorta is interior coming off the right ventricle and by color there was nice laminar flow and they had symmetric outflows. There was no obvious which go simple defect. So we got that diagnosis right based on the later gestation assessment. But um this is where you know, bringing them back and be very, very helpful. 13 week center Di Di twins product of IVF. This is to show you IBC is on the right, the stomachs of the left livers dominantly on the rights of the site of solid us. With the holidays coming back to the left side of the atrium that he's sending the orders on the left, just giving you an idea of the, the amount of detail that you can get in some of these pregnancies. There were two involves a smaller one on the left, a larger one on the right and the outflow tracts is going to come out here on the right by color. So we thought this was a form of double and authentic all you can see a valve accreditation and sweeping to the outflows. There was a single outflow coming off kind of override the cost of the septum. Uh, this is the aorta and there was the public artery back here by color. You can see that was such a great flow. And keeping with critical quality apple obstruction. Uh This is a form of double life identical. Were quite worried about the valve regurgitation of the mom, chose selective termination and had a healthy baby. Uh We have a true was quite healthy. One other product of IBF singleton for chamber of you looked pretty normal. Uh This one we sell purely for IBF, but we saw one single outlet that was over in the ventricle septum as you can see here. And that outlet gave rise to both branch poultry arteries, but also in a sending that was quite small. We started thinking about the possibility of a trunk us with an eruption where jr the sagittal view looks normal from the particular standpoint and see one large great vessel and sweeping up. Not only did we see two sbcs confirmed that the very end you start seeing that a sending aorta in keeping with an interrupted aortic arch. We do make diagnoses earlier. There's just a lot less common because of the referrals. Typically you were later later a little bit later on. I don't receive referred 11 or 12 weeks. So we see that they're after. This is a balanced and the subtlety of the comedy valve. You can see about from the short axis. It's very hard to see the details of attachments have my muscles. Uh And you really you're not really say maybe because you have to be very careful about the way you counsel. And then finally what you get, what you see is not what you get in all pregnancies. You always have to think about the possibility of progression. We don't have a lot of data on this for early diagnoses. This was a case forward for increased nuclear transition see along the weeks big right atrium for short and right ventricle. But it wasn't so small, it just wasn't functioning well and a good LV function as shown here, sweeping up because the valve regurgitation, which is why they are a was big I think. But also we're worried that there was some pulmonary outflow obstruction of pulmonary arteries a bit smaller than this, much larger. A worker showed here the public areas, this little thing here and we weren't sure whether it was critical or not. But we said you know, we thought the progression of this would include uh progressive my pleasure of the right vegetable. So we talked about the possibility that maybe may require supervision, retaliation after birth just because it was so early. So that was the discussion we had. This is what we found in the end. So back here, you see, the RV is quite a bit smaller, just by 22 weeks. But the other finding was that the aortic valve was very dis plastic. In fact starting to become obstructed. This has been a very dis plastic aorta valve in addition to basically a single vegetable lesion with critical poverty outflow obstruction, right. Great ductile flow shown here. This is not only bad for a single vegetable after birth, having bilateral outflow obstruction, but also could be very, very poorly tolerated by fetus. Uh and so we were starting to discuss the possibility that maybe you could get into trouble before birth and that's in fact what happened within a few weeks of this, the maybe start to develop high drops. You just have to keep in mind the possibility of progression. One other at 13 plus weeks who was no turner syndrome fetus uh based on the finding of cystic fibrosis and genetic testing. You can see academic tapping muscles but pretty normal. Otherwise a sagittal view. The four chamber was normal as well, but there was mild gradient through the aortic outflow. As you can see a little turbulence by Doppler and a peak creative about eight. So we said, well this is a more expeditious. We thought it was mild, it could be quite progressive um uh and end up being a child, like just could be really progressive and end up with a baby with high traffic or be progressed slowly. And whether baby just requires any or about dilation. So presenting the gamut of possibilities is really, really important or uncertainty about how it's going to progress. In fact, within a few weeks this baby's left her was blowing out secondary, critical stenosis was still some patients with aortic valve, but richard reid uh rhetoric, art flow. This baby had critical aortic stenosis that went on to develop H. L. A. Just by term. And she's since had a Fontane in fact. So really you need to think about the possible ways that there could be a progression. So in summary, the best time for an early foetal Echo isn't about 11 to 14 weeks when fetal critic structures and blood flows can be demonstrated in most pregnancies. High frequency, high resolution transducers, optimized frame rates and at times and vaginal imaging. Especially at these earlier gestations are important for early foetal echo. The use of color, impulsive Doppler can also help with further defining anatomy and function. Advanced. Early foetal echo, especially at 11 to 14 weeks, permits the diagnosis of a full spectrum of credit pathologies. But I would say more often or these early diagnoses represent a more severe end of the spectrum. In making it excluding congenital heart disease diagnoses. You need to think about these earlier gestations as well as reporting it counseling. You need to consider what can be resolved the potential aggression and missed or settle pathology uh When you're not sure bring him back bring it back within a few days or within a couple of weeks. Um I want to thank you for your time. Uh I hope you enjoyed the talk volume imaging including three D. Four D. And stick out. The sound has become an important tool in fetal echocardiography in the last decade. In this presentation we will review the principles of volume imaging as well as the clinical applications of three D. Sonography for evaluation of the people, heart volume visualization and could three main modes of imaging static three D spatial temporal image correlation or stick and three D. In real time also called food imaging. This Williams can be acquired from grayscale only when combination that the flow without the modalities including color power. High definition of slow flow mode studied three D. Acquisition refers to the acquisition of three D. Volume and the single random moment of times it in the cardiac cycle so they quiet William contains a multitude of to distill ultrasound planes with no regard to the temporal of the special motion stick opposition is in direct motion gated off line mode based on the concept of the using tissue excursion concurrent to the cardiac motion to extract the temporal information regarding cardiac cycle. As a result single virtual cardiac cycles reconstructed and root giving an impression of beating heart. And finally for the imaging enables acquisition of the multiple volumes of the time, allowing three D. Visualization in real time. Yeah, the demonstration of the result of the volume of position on the screen is called volume display after the volume acquisition. Different options available volume display and manipulation. Multiplatinum mode is based on the display A three D. Volume by three artisanal two D planes conventionally termed plane A. B. And C. The reference point, which is in this case, located in the descending thoracic aorta corresponds to the point of intersection of those three artisanal, clean and can be useful for you manipulation, Demographic ultrasound imaging or T. U. I. is the modification of the multi planet imaging where the numerous parallel to deplane as simultaneously displayed, giving a substantial anatomical view of the region within the quiet 40. The number of the display planes and inter playing distance and the thickness of the anatomical region can be manipulated. Yeah, volume rendering describes the display of the external internal surface of the quiet volumes. That the reader can adjust the rendering direction and the thickness of the rendering box of the target anatomical region within the volume manipulation. Well, the inversion mode inverts the exogenous city of the volume content displays display of the rendering three D volumes. Using the inversion mode provides information similar to the volumes acquired, the power dog obi flow. With recent software development, the use of the white source can be emphasised the effect of the depth of the structures demonstrated and provided the better spatial impression. Here, you can see two examples how the look of the image can be changed by placing the source of the light in front of the image and on the back color. Doppler powered off where high definition flow and the slow flow can be combined to the volume of positions. Options for branded display of such volumes include color information along the grayscale information along a combination of both, but also trump the glass body mode, which is presented here. How about the clinical applications of the volume imaging advantages of the three distinct position of the fetal heart include its speed of a position, which usually takes up to two seconds in the east of the volume manipulation. Therefore, the static three D. Acquisition can be very helpful than the peters is very mobile. Here you can see two examples of the three D. Stick volume applied to the assessment of the people cardiac anomaly. This is the case of baby canal, an assessment of the malformations at the upper abdominal level, presenting the typical image of the persistent right and vehicle being. Mhm. Three D. Image position. Also can let us to take a look at the planes which are not available to obtain using to the imaging. This is a reconstructed plane C. In this case we can clearly demonstrate not just the size and the shape of the ventricular septal defect but also its relationship to the other cardiac structures such as the tree casted valve and the palm drivel assessment of the anomalies of the umbilical portal circulation is very easy using the three D. Technology in particular if we use the body body glass mode and here you have an example of the normal medical portal circulation that include the umbilical being portal sinus in the portal veins. And here is the example of the persistent right and medical being that the stenosis and in particular the abnormalities of this vessel can be easily diagnosed using three D. Imaging. And here is the normal course and the length of the doctor's diagnosis. And here we have the extra hypnotic course of the vehicle being. The drains straight to the coronary sinus. That the doctor stenosis, a genesis assessment of the vessels. In particular um multiple vascular structures at the superior media steinem is very good application for the three D. Imaging. And here we have the case of the aortic arch station and the typical shelf sign that can be found Um in this case is in particular using the three D. Imaging. Cool assessment of the vascular rings. Um The three D. Can help a lot in particular showing the special relationship of the right side that they were the coach left side that they were uh west side and dr sartorius is uh in the course of the vascular structures in relationship to the trachea and esophagus. But usually it's not enough to make the diagnosis of the vascular ring. Here we have the example of the double aortic arch, you can see the palm tree a tree. We can see that charisma violation of the doctor sartorius is very typical situation that we have the hypoplastic left uh aortic arch and normal size, the right aortic arch. And here we can see the complete encirclement of the trachea and esophagus and more common type of the vascular rain, which is um created by the right step in the aortic arch. And in this case behind the tricky and esophagus we have the uh current right left latvian artery. And the three D. Imaging can easily help to make this diagnosis. And here you can see three fetuses diagnosed with this type of vascular ring. So right sided arch, left sided doctors and aberrant force of the left subclavian artery. Assessment of the thymus is important component in particular than the anatomical anomaly suspected and the suspicious for Division 22 Q. Here you can see the box technique that can be very helpful to assess the size of the Patmos and internal security countries are used as the markets for the lateral borders and three D. Imaging that allows us to get the bigger slice can be very helpful to navigate through and see the lateral borders of the famous three D. Imaging. Using the local tool, we can apply to measure the volume of the famous in those cases. And here you can see the normal case and how that tool can be used for a variation of the volume of the thymus, assessment of the different uh tumors in particular sacral procedural terra toma. That tend to have a lot of complications from the cardiac side and in particular may result in the congestive heart failure is very easy. And here you can see how the three D. Imaging can be used to follow along patients like this and monitor very closely the size of division the stick or E. Stick, which is available on the electronic metrics probe. Can give us a very different perspective and can help to look at the anatomical details in normal heart. And here you can see the correlation, how we can see the people hard in relationship to the anatomical specimen, which is very similar. So we can look at the normal heart and recognize all four chamber views and inter cardiac structures the more details or we can navigate through the complex cardiac anomalies. In this case we deal the single identical universe particular heart and three D. Imaging allowed us to see a small outlet chamber that presented here. Uh This is another example how the rendering stick volume can be looked at, in particular for assessment of the anatomy of the common bath. In this very complicated case of the common uh A. B. C. D. And also we can get the reconstructed seaplane that allows us to take the end face, look at the valves and here is the two normal valves strike hospital Michael. And this is again the common valve that is typical for a particular septal defect. So here the size of the leaflets and the distribution of the left foot can be varied, precise diagnosis of the ventricular septal defects also can be enable using the three D. Imaging and the sticker position. Here, we have the masculine D. S. D. And clearly looking at this volume and manipulating this. They can recognize the specific um features of the E. V. S. D. Which is also not a mid masculine but volunteer three D. Imaging and sticker position is very helpful in the first trimester and I personally use it all the time and here you can see the combination of sticker position that colorado play, allowing us to see the inflows and recognized normal structures within the four chamber view and as well as the three vessel and tricky of you. But um different manipulations of the volume and use of different color modes and manipulations that the source of light allows us to differentiate between different anatomical structures and highlights such as structure as the inter ventricular septum. Here we have the atrial ventricular septal defect that topics gestation the significant degree of regurgitation of the commonwealth that easily can be visualized using the three D. Technology, The Hypo plastic record syndrome and 13 weeks gestation. Very helpful picture to um do counseling and also to present to cardiac surgeons because all the anatomical characteristics even though the heart is very small a present and clearly seen here. Um the hyperplasia of the right side consistently tricastin treasure complex, hard anomaly that also demonstrates the interruption of the hypnotic segment of the ibc. And we can see dilated as it is at the abdominal level and here behind the four chamber view. So we can look not just at the fortune review and the great vessels but also we can look through the entire volume including the abdomen and make the accurate diagnosis as early as 12 extra station. So the Four D. Technologies in the evaluation in three D. In life time online probably still requires some work. But one technology that I would like to present here, this is the biplane mode which is available on the electronic Matics transducers nowadays. That is very helpful in particular if you're trying to assess for the artist is shown here or if you have some intra cardiac lesions that you don't know what it is. And if you try to describe precisely its location in relationship to the other cardiac structures that the bi plane allows you to take a look life in two orthogonal planes. And usually it's very helpful tool. You can use it to perform the measurements And also very important aspect of the 3D ultrasound, which I believe can be very um interesting to investigate in the future. As you know now, the artificial intelligence probably gonna be the part of the imaging in the cardiac imaging in the next few years. So, the automated multi planet imaging, the concept that was formulated back in 2004, probably can play a significant role to improve our detection rate of the cardiac anomalies and also to and help minimize the operated dependency. So the concept of the ultimate multi planet imaging is that the volume data set of the particular anatomical structure which is acquired using the video for this pornography contains all the anatomical too deep planes which are required for the complete evaluation of this structure. And um also there's two D. Planes um they organized in the constant and atomic relationship to each other. So it can be described using the medical formula. So that formulas can be programmed in the special software can actually automatically display those targeted diagnostic planes out of the three D. Volume. So in this technique was um explored and actually available on this uh equipment of the different manufacturers uh in each manufacturer has its own algorithm. But here you can see that acquiring the volume. Using the reference plane as the fortune review. We can then get this information about the heart in the volume and and applying the special software which is available on the machine. And now it's getting more and more automated and looking at the Sochi and review. You need just to draw the line across the septum and place the dot in the descending in order. And after that the software takes it from here. And just by pushing a different buttons, you can see that the software manipulates the volume for you. Place it in the standard position as shown here and then retrieves the targeted uh images which we usually obtained, mainly looking at the heart doing the fetal echocardiography. So here you have the four chamber view here we have the outflow tract for the left ventricle. We have the identical outflow track. We can see the site is an arrangement of the organs to abdominal level, including stomach, liver, in ibc and descending aorta. Uh we can look at the bike able you which is the right part of sagittal plane. We can look at the doctor arch and again we can recognize all the landmarks for this view. And finally we can take a look at them aortic arch and um as quickly we were clicking through the slides the same time, probably will take you to complete the entire fetal echocardiogram so that this exam can be significantly streamlined using this technology. And uh if you machine has this technique, it has been improved dramatically in the last few years. So I would highly recommend you to explore what it can do for you in the clinical settings. In conclusion, the main advantages of the volume imaging modalities lies in the ability to display spatial relationship between the different cardio vascular structures and that can be in particular helpful differential diagnosis of different cardiac confirmations. Um, and also this is what we use in our clinical practice all the time. We find that the three D. For the imaging is very helpful for interdisciplinary discussions and prenatal counseling to use the explanation of the complex findings to the patient into the other medical professionals. And also it can be very helpful for teaching of the medical students and junior faculty and fellows so that this I hope that we will explore that modality and I think that we will have a very bright future using that. And thank you very much for your attention. Thank you to the organizers of this meeting for inviting me to participate. I'm very happy to be here. My name is Dave Szydlo. I'm a pediatric cardiologist at Boston Children's Hospital and I've been asked to speak today on maternal hyper oxygenation, prognostic and therapeutic implications. Over the next 15 minutes, I'll cover several aspects of maternal hyper oxygenation. I'll begin with fetal pulmonary vasculature. Basics continue with an overview of maternal hyper oxygenation testing. I'll follow this by how maternal hyper oxygenation testing can be used to predict perinatal physiology. And then finally, I'll conclude with a brief review of where we are with maternal hyper oxygenation as a therapy and some of the controversies surrounding it. So, first in order to frame the discussion, it's important to have an understanding of fetal pulmonary vasculature basics um, on the right is a little bit of a reduction version of fetal circulation but hopefully illustrates the key points. Um as many of you know, in the fetus, the oxygenated blood from the superior vena cava is preferentially directed into the right ventricle. And then from there it's directed into the main pulmonary artery. And because of high fetal pulmonary artery vascular resistance, most of the blood leaving the right ventricle crosses the ducting arterial sis, And very little blood on the order of about 10 enters the branch pulmonary arteries. And really the key point here is that the fetal pulmonary vascular resistance is normally high. Um Now, like all arterial vessels, the branch pulmonary artery flow pattern can be assessed using spectral Doppler, as seen in this picture from the abu hamad practical guide to fetal echo. And while sometimes considered elusive, the branch pulmonary arteries can be readily visualized in a transverse plane between the four chamber view uh and the three vessel trachea view. Uh And like all arterial vessels, the flow can be characterized in a number of ways, including the pulse utility index. And this is basically calculated by subtracting the diastolic velocity from the systolic velocity uh and dividing it by the mean velocity and on the right, what you can see is a typical branch pulmonary artery spectral Doppler pattern. And uh the branch pulmonary arteries have a very characteristic um flow pattern with a high pulse utility index due to their high systolic velocity, but relatively minimal flow in diastolic. So where does maternal hyper oxygenation come in? So, uh maternal hyper oxygenation is basically a way of delivering increased oxygen to the fetus. So oxygen is administered to the mother of a non re breather. That increased oxygen reaches the placenta or the venus return to the fetus and that oxygen eventually reaches among other areas the fetal lungs and not dissimilar to the child who is undergoing pulmonary vaso dilator, testing the fetal pulmonary vasculature under normal circumstances. And I should say at certain times during gestation exhibits a response to uh increase oxygen and specifically, with maternal hyper oxygenation, there's increased diastolic flow, which results in increased diastolic velocity and increased mean velocity. And as you can see here, uh the overall pulse utility index actually decreases and this decrease actually indicates increased flow to the fetal lungs. Um there is important, important things to note. Um this response is not uniform throughout pregnancy and it really um increases as the pregnancy progresses. Um as you can see from this study from 2012, Basically, it's very unlikely early in pregnancy through the second trimester, but is relatively reliable as pregnancy progresses and certainly beyond 35 weeks or so. So this brings us to the important question. Um is the response to maternal hyper oxygenation, altered in congenital heart disease. And can these alterations be used to predict outcomes? And as it turns out in various fetal diseases, there are certain fetuses uh that exhibit a normal response to maternal hyper oxygenation and those that don't. Um And to be clear, those that are reactive exhibit a decreased pulse utility index, indicating increased pulmonary blood flow and also increased pulmonary venous return. As you can kind of see on the diagram to the rights. Um and this response or lack thereof can indeed be used to predict post natal physiology. And over the next few slides, I'll show how this has been used to characterize uh perinatal physiology uh in uh lung masses, aneurysm of the atrial septum, uh hypoplastic left heart syndrome, transposition of the great arteries and totally anomalous pulmonary venous connection. So, I'm going to start with pulmonary hyperplasia. And this is a very nice work that was done by Richard Broth and colleagues in 2002 and hear what they were doing was observing the response to maternal hyper oxygenation uh in a number of lesions with pulmonary hyperplasia. And this included a congenital diaphragmatic hernia. Uh Allah go hydra manioc can skeletal dysplasia, twin to twin transfusion syndrome and a significant pleural effusions. Um And as you can see uh some fetuses were reactive uh and as you can see between the top and the bottom panel and is pointed out by the arrow, um There is increased diastolic flow, decreasing the pulse utility index and the fetuses that were reactive. In contrast, some fetuses were not reactive. And here you can, I think clearly see that there was no change in the diastolic flow and therefore no change in the pulse utility index. And in their small series, a reactive test predicted 92 of surviving infants, whereas a non reactive test predicted 79 of deaths from pulmonary hyperplasia. And overall there was good sensitivity specificity uh and positive and negative predictive values. Um Just shifting gears a bit more formally to the heart. A good place to start is aneurysm of septum prime. Um uh This is a relatively commonly encountered entity late in gestation, where septum premium becomes redundant um and in some cases not just redundant, but actually impairs flow into the left atrium and the left ventricle and one can even see decreased or retrograde flow across the aortic arch. Um And that's important because retrograde arch flow is an important finding associated with co optation. In contrast with aneurysm of the atrial septum, which is generally thought to be benign. So, in this very nice work, by channing and colleagues from Children's hospital of philadelphia, they were able to show that with maternal hyper oxygenation they were able to reverse these findings. So specifically, the theory was that with maternal hyper oxygenation there was decreased pulmonary vascular resistance, increased flow into the lungs, increased flow into the left atrium and left ventricle and increased flow across the aortic arch. And what you can see here is that at baseline, a fetus with aneurysm of septum premium and ostensibly decreased left sided filling had retrograde flow in the arch, but with increased filling with maternal hyper oxygenation that was able to be reversed. So what about other, more serious, if you will, forms of congenital heart disease? Um, Well, maternal hyper oxygenation can be applied to hypoplastic left heart syndrome. Um, a detailed discussion of hypoplastic left heart is beyond the scope of this talk, but I'm sure everyone is familiar with the fact that for a baby to survive with hypoplastic left heart and mitral aortic atresia, um there simply must be uh an open atrial septum uh in order for the oxygenated blood to flow into the right ventricle and then make its way out to the body. Um There are instances where there is an intact or highly restrictive atrial septum and post natally. These babies have no left atrial egress, pulmonary oedema, low cardiac output and often require urgent intervention and have a high mortality. Um and you may start to see a theme emerging here, but in this nice study um from doctors West and colleagues, also from philadelphia, uh they were able to show that fetuses with an open atrial septum or another way of thinking about this is those that didn't require an urgent intervention. Um Maternal hyper oxygenation resulted in a decrease in the branch pulmonary artery, pulse utility index, and that is to say that they were normally reactive or nearly normally reactive. And among those requiring immediate intervention on the atrial septum, there was no significant change, meaning that they were essentially non reactive. And the authors concluded that testing has a role in identifying hypoplastic left heart fetuses requiring urgent intervention, so predicting perinatal outcomes. Yeah. So what about other forms of congenital heart disease? Um Well, it may have a role in other heart defects. Uh This is a pilot study from Children's National uh where uh dr mary Donofrio and I um assess the utility of maternal hyper oxygenation testing in a number of different forms of congenital heart disease. And I can't go into each one, but I can briefly focus on total veins and transposition. So, um as many of the people listening are familiar um with uh infra diaphragmatic, totally anomalous pulmonary venous connection. All the pulmonary veins drained by a vertical vein which courses below the diaphragm. Um um And uh as it courses and makes its way back up to the right atrium, it can become obstructed and uh in some ways similar to um hypoplastic left heart with an intact atrial septum, there's obstruction to pulmonary egress. Uh These babies also can have a low cardiac output and the need for urgent surgery. So, um in our series, we were able to show that uh in this one patient, um the mean vertical vein gradient uh was two of mercury. but with maternal hyper oxygenation interestingly there was pulmonary basil reactivity perhaps indicating that the lungs themselves were relatively healthy. But the vertical vein gradient did increase quite substantially to 12 millimeters of mercury, which was very consistent with the post natal observation, vertical vein obstruction. Um Just moving on briefly to transposition. This is I think a very interesting topic because as we all know, some fetuses with transposition exhibit pulmonary hypertension, post natally, for reasons that we don't quite understand. Um And so we were able to use maternal hyper oxygenation and a small group of fetuses with transposition. And um the responses were variable. Uh Some exhibited pulmonary Visa re activities, uh visa reactivity. Um Others did not. Among those that did. We were able to see shifts in the flow at the atrial level, as you can see in this picture. Before maternal hyper oxygenation testing, a fetus had right to left flow and with hyper oxygenation uh and um increased left atrial filling. There was actually left to right flow. So some physiologic characteristics possibly associated with post natal pulmonary hypertension, and also some anatomical characteristics that perhaps could give us a sense for what the atrial septum would look like after birth, I think an area of increased study. Um But uh certainly um something that we're interested in. So um I'm gonna move on now to can maternal hyper oxygenation be used to treat congenital heart disease. Um So there are few studies which have demonstrated perhaps some utility. Um This is a paper that comes from dr aruna mana and colleagues um from uh Seattle. And here they used maternal hyper oxygenation actually to constrict a ductile arteriosclerosis. Um That was permitting circular shunt in a patient with Epstein anomaly. And they were able to show with um persistent um use of maternal hyper oxygenation. Um They were able to uh decrease that circular shunt and ostensibly improve the outcome of the baby. Now this baby did still require ethno support, but eventually went on to have a try custom veil of repair and is reportedly doing well as an outpatient. Um so what about hypoplastic left heart? Uh and of course alleviating hypoplastic left heart before birth is an attractive target. Um and this is a pilot study published by Lara and colleagues in 2016 and they employed chronic maternal hyper oxygenation after about 30 weeks gestation. And um what they were able to show was that um the rates of aortic and mitral growth were greater with chronic maternal hyper oxygenation, although this didn't quite reach statistical significance, but definitely um compelling nonetheless. Um So a few examples there. Um but uh it was uh you know, it's important to note that maternal hyper oxygenation is not without controversy. So i this is where I'm gonna kind of wrap up the talk um and just kind of go over some of the some of the current controversies so interestingly, in a follow of secondary analysis of that initial pilot study um the same group. Um This time Edwards first author and all were able to show that there was a significantly slower by parietal diameter growth and a smaller head circumference. Uh Z score among six months old, the six month olds exposed to chronic maternal hyper oxygenation. And this is actually substantiated by some very elegant work from Germany by Mark Hurt. Uh and and colleagues at the University of Rostock. And in this study in fetal mice, they showed that chronic maternal hyper oxygenation beginning early in gestation, resulted in decreased mitosis and cortical cells. And as you can see in this figure from their study, I would draw your attention to the middle panel, which exhibits tagged my topic cells exhibiting exhibiting immune efflorescence, and what you can see is that compared to controls, there are decreased or my topic or dividing cells in the mouse cortex in the chronic maternal hyper oxygenation group. Um and this has led some to wonder whether hyper oxygenation study should be curtailed as abraham Rudolph uh reminded us, reminded us with an increased pulmonary venous return. There might actually be because of a shift in atrial pressures decrease in for Raymond a valley flow, and that while pulmonary artery flow may increase, cerebral cerebral blood flow may in fact decrease. And this would be corroborated by um earlier observations and fetal sheep, that cerebral blood flow actually does decrease with hyper oxygenation, as did the glucose delivery and consumption. And this is really all to say that it's prudent to be cautious as we consider the future of maternal hyper oxygenation studies. So, in summary transient maternal hyper oxygenation decreases fetal pulmonary vascular resistance, increases pulmonary blood flow and increases pulmonary venous return. And this response and the aberrations in this response can be reliably observed on fetal echo and associations with neonatal physiology can be identified. The responses to maternal hyper oxygenation can be incorporated into delivery planning in congenital heart disease. And while some studies suggest a therapeutic benefit from chronic maternal hyper oxygenation, there are some concerns regarding cerebral blood flow and metabolism and further study uh seems to be uh merited. So thank you again so much to the organizers of the meeting for inviting me to participate. And I'm looking forward to the discussion at the end of the session. Thank you. Good morning. I'd like to thank the advisory committee of Mount Sinai for inviting me to speak at You've got to have heart. My talk is on telemedicine and fetal cardiology, remote monitoring and other applications. I am funded by the N. H. L. B. A recent paper was published by Anita christian and the fetal heart Society Research collaborative, which evaluated the prenatal detection and the barriers to prenatal detection. Over 1500 patients with hypoplastic left heart and d transposition of the great vessels. What Doctor Krishnan from Washington found out was that there is a lower prenatal rate of detection of these two cardiac defects in mothers who are of hispanic ethnicity who live in a rural home and a greater distance from the cardiac Center of Excellence. Well, the traditional solutions deal with patients who live far away from a cardiac center of Excellence is whether and travel and the two don't often go hand in hand. Either the team can travel to the distant site with the plane or patients from the local site can travel to the distant site, usually in a car. However, this does not always work In my home state of Colorado, for example, I-70, which is the major thoroughfare from the west to the east and the east to the west Between 2015 and 20 between 2012 and 2015. This thoroughfare was closed an average of 280 times for 2.4 days and less than a month occurred without a closure at least. You think it's our winter weather that causes closures in this major artery. We also have forest fires in the summer and we live with the consequences of being in a mountain state. However, there is another solution besides travel and that is the telematics solution. The goal of telemedicine is to provide equal and extraordinary health care for all patients regardless of their location or circumstance. The purpose, of course, is to equalize differences between the distant site which we see here, which has expertise and experience and to equalize that difference with that site and the local site, which is in desperate need of real time diagnosis and ambulatory monitoring. We know that telemedicine is active in many different areas but is still being defined in the fields of fetal cardiology. We've had the opportunity in colorado to develop a telemedicine site between Denver, which is here in the Yellow and Grand Junction, which is in the western part of the state, about 280 miles from Denver. All of these sites, all of these towns in green are towns that can be serviced by travel to Grand Junction. So you see this is a large population of patients who could benefit from live and real time evaluation of the local site data. That is a grand junction by direct communication with the distant site. And we were able to provide real time diagnosis for this population which is which had limited access to care and expertise. And for the next few minutes I'll report some of those results. Our protocol consisted of a virtual weekly clinic in which mothers with risk factors for fetal congenital heart disease were scheduled for an echocardiogram. We also saw mothers on the same day that they were evaluated if there was a suspicion of congenital heart disease, which was not scheduled at another time. Because of the distance between the sites, we wanted to decrease the amount of travel for these mothers as much as possible. The fetal echo was performed at the local site by sonography furs. Obstetrical stenographers who were previously trained at our cardiac center, the local site connected with us at the cardiac center, the distance site and we were able to establish report with the mother and review her history and then review the images that the stenographer had performed. The beauty of this is if the images were incomplete or non diagnostic, we could ask the stenographer to look again without having to reschedule an appointment with the mother. The combination of obtaining the history in reviewing the images, then allowed us to provide results to the mother and the provider and develop a care plan for the pregnancy. Moving forward, looking at the results of our fetal tell a cardiogram fi program. We were very pleased that the acceptance of the program was very high. In fact, all mothers who participated in the program would be would prefer in subsequent pregnancies to again do fetal tell a cardiogram fee rather than make the long distance right to denver. Our results were also surprisingly accurate. We performed 455 echoes on 368 mothers. 340 of these fetuses had no congenital heart disease, and among them only one defect was missed are false positive rate was 0.3%. And the defect that was missed Was an inlet ventricular septal defect on a patient with trisomy. 21 Which was repaired at three months of age. 28 of the fetuses. Of the 368 fetuses had fetal congenital heart disease or arrhythmia. And we had one false positive patient who had a quotation of the orders suspected but turned out to be normal and have a normal arch. When the doctor sartorius is closed, no mother had to return to grand junction for a non diagnostic scan. No infant was admitted with undiagnosed critical congenital heart disease compared to 12 who had been admitted. That is undiagnosed in the three years prior to the tele choreography. Since Denver is the site that receives the vast majority of post natal diagnoses, Even though we did not check every single patient that delivered during that time period, we're fairly confident that none were overlooked. We also found substantial cost savings for the families as far as driving distance and actual money out of Almost 200,000 miles were saved with our television programs that the parents did not have to drive. And of course that resulted in gas savings, money for gas, money savings. We were able to save over $200,000 in total costs for the families As well as a reduction in the cost per visit of over $500. Therefore, our telemedicine program resulted in an accurate diagnosis, appropriate risk stratification, high patient and provider satisfaction and a cost savings to patients. The next topic I'd like to speak of, his ambulatory monitoring using telemedicine that is detecting an event that can occur fleetingly or infrequently in no other diseases. Telemedicine. More important than an anti ro esa media, anti biting mediated disease. As a brief review, about 1% of pregnant women carry anti R. O. S. S. A. Antibodies and in these mothers there's a 2% risk of fetal A. B. Block developing between 19 and 26 weeks. While the recurrence is about 18%. The perinatal mortality is significant, ranging from 17 to 35%. We know that emergent complete a V block that is first or second creative block can transition to complete black overnight. So frequent monitoring is important. We also know that as of today there is no evidence based protocol that is universally accepted for the surveillance of these pregnancies. So the question is how to surveil for a serious yet fleeting event. That is the development of a. V. Block that occurs rarely and it's continuous fetal heart rate monitoring over many weeks is not possible. What is the feasibility of frequent heart rate monitoring performed by mothers in the ambulatory setting? And as many of you know, we evaluated this in our study called Heart sounds at home, which many of you participated in. The protocol for Heart sounds at home consisted of anti rO antibody positive mothers being seen by echocardiography at 17 to 18 weeks. And at that same visit, they were instructed on the use of a fetal heart rate and rhythm monitor. We asked these mothers to listen to the fetal heart rate two times a day every day between 17 and 25 weeks of gestation. In addition undergo bi weekly that is every other week fetal echocardiograms. If the fetal heart rate monitoring was abnormal, then they were instructed to call their provider to get an echo within six hours of hearing the initial arrhythmia. If there was second degree block, the patients receive treatment. If there was no second degree block, the patients continued monitoring. Their final visit was at 25 weeks. They had a monitor satisfaction questionnaire and then went on to receive routine obstetrical care followed by 12 E. G. On the infant after birth. Well the results of this study showed us that timing is very important. That is the time from the detection of second degree A. B. Block which as you know is in regular rhythm if it's type one second degree block and bradycardia. If it's type two second degree block. So that time from the detection by the mothers to the timing of aggressive treatment with I. V. I. G. Index or logistics and methadone affects the outcome. If there if the time is greater than or equal to about 24 hours between detection and treatment, the rhythm is either already at their degree black or progressive to their degree of the block, which does not transition back to normal. If however The time from detection to treatment is less than or equal to about 12 hours. Prompt treatment can improve the conduction 2121 and the babies are born in normal rhythm. We see this here with the three patients who were when 24 hours between detection and treatment all had third degree block after birth. And of those who were less than 24 hours, most of them less than 12 and treated. They received. They improved to first degree every block and they in fact had presented mostly between second degree block. So this is only seven patients. And this is obviously not enough to change practice but it is enough to think about studying a little bit more. And that is why we proceeded to go on to a study would call stop block. This is a multi center open label trial looking at fetal heart rate monitoring and treatment with I. V. I. G. Index for methadone. And what we hope to learn from this five year study is can fetal heart rate monitoring. Obviate. The need for weekly echocardiograms can 1st and 2nd degree every black be reversed with aggressive and prompt treatment. And of course our goal is going to be to finally develop an evidence based management protocol for these high risk pregnancies. This is funded. The study is funded by the NHL B. There are other fetuses who can benefit from ambulatory monitoring. There's not a lot of published data but many of us have been doing this clinically for years. Babies that can benefit from this ambulatory monitoring include those with the suspected general apathy, those with complex atrial and ventricular arrhythmias, those with intermittent SPT and finally those with successfully treated SPT. During maintenance dose reduction. We believe the maintenance dose can be reduced because of the natural history of the accessory connections balanced with no employer rhythmic risk of certain anti arrhythmic. So we were able to study this. Amanda Macintosh was the head author on this. We evaluated 27 fetuses who presented with S. V. T. That had been successfully treated and we reduced their maintenance those over several weeks once the babies had been converted and the high drops if present had been resolved. And during the times we decrease the maintenance dose we performed fetal heart rate monitoring. Before each dose, the mothers were instructed to audio text the physician with the monitoring if they suspected it was abnormal. And we had a protocol for continuing to decrease or to increase if SPT rickard. Our goal was to reduce the dose to very low doses of all the anti arrhythmic results of this study were positive. Seven mothers detected recurrence by fetal heart rate monitoring and all were confirmed by audio text. Um And the physician, four out of seven of these patients. We're able to have their maintenance dose increased at home. Sinus rhythm was restored without in person visit. And the dose was later weaned to the lower dose. Three out of the patients didn't need to come to the hospital. Um But a second wean later on still resulted in the maintenance of the lower dose. There were no false positive fetal heart rate monitoring and there was no undetected SPT during clinic visits or after dose reduction. So ambulatory monitoring worked in this case and that the mothers were able to successfully no when they needed to increase the dose and when they could just continue monitor the tele cardio solution does exist. We just need to know what we need to do to make it more widespread. And as a reminder, tele cardiology is an ongoing commitment to engage local resources to provide quality care regardless of zip code or circumstance with a high degree of patient satisfaction while still maintaining the integrity of the physician patient relationship. In other words, respect, engage, commit, teach, learn and repeat in the pandemic necessity was the mother of invention. As telemedicine visits boomed. What the future of telemedicine and especially tell a cardiogram fee in fetal care will be up to us. Thank you. Yeah, so that was a great session from uh a wonderful speakers. I'm gonna start off with a question for Dr Hornberger and let me see, I can get the question now. So dr hamburger, are there any special requirements for equipment of software that you use? Just a regular clinically available probes and viewing platforms that we have for early gestation, free local radio. Your voice is quite faint. Uh How much better now? I'm going to do this little bit easier otherwise I'll just pull it and talk. Can you hear me now? Oh, good. Okay. Um we actually, I started just using the same uh platforms that we use for general echo for general foetal echo, I should say. But for sure one of the things that we discovered is the need a for high frequency transducers. So, and we're we won't use anything less than nine MHz and and I have a few of my favorites. But I think um we even we're doing that. We're using the old uh huh. The old Sequoia as an example with a 10 maker hurts phased array probe. Like we realized quite early on you need high frequency, uh, you need to use high frame rate so that's narrowing your sector really honing in that. You're getting really good frame rates. You know, you have to realize that heart rates are obviously very high at this early gestation, Um, and then getting close. So we, what we were looking at, especially at the early, early age, is if you're not within four cm, you just don't get image quality that you can rely on. So it was more about the technique of the different things. The strategies to really optimize those images get as close as you could possibly get. I'll tell you that most often when, when we have fellows that are imaging and I go in and take the probe. Usually they're not pushing hard enough. So you need to push a little bit hard, get as close as you can and usually the moment I don't make them have a full bladder, I think that is torture. I don't believe in torture, but we do have to get very, very close to the fetus to get those images. So those are kind of key strategies to optimize your image resolution and feel more confident about your diagnoses. Thank you dear. Uh yeah, so I have here two questions maybe to get a very technical questions for dr Quijano. The first one is rather training of the pornographers that work remotely. I think one of the things we all of us are concerned with technicians that don't work with us and how do they perform? So how do you train them? And the second question is uh from Canada about the billing, how you build for them. Well thank you, thank you for the questions the training um just requires really incredible commitment on the part of the fetal cardiogram for and also the ability to continue to teach after the stenographers initially trained. So we have a program where we have a stenographer obese Niagara for come to the fetal heart center and they spend a few days with us and they go in on all the patients. We do allow them to scan the normal patients. And the goal is really for them to learn the protocol. And once they've done that then about a month later or several weeks later we go out to their place where they're doing the scan so we can watch them on their machines. That's really important that a stenographer be comfortable And then we review the protocol with them. We give them some ideas for image optimization. Really all the things dr Tacy said were important during the imaging part of of learning fetal echocardiography. And then we go and see them that couple times a year. Sometimes it's just social but we we do always stop by and and watch what they're doing and give them some tips, some refreshers and we extend an invitation for them to come back any time to learn more. As far as the billing. There are specific building codes for telemedicine um in cardiology and this is of course become even more of an option during covid. So you should talk to your building people about those codes that are necessary. But it's not only the consultation code that we would have if we were in person, but there's also a code for consultation via telemedicine and as long as you have a face to face encounter in most states that will be paid for. I could if I could um could I just clarify? Thank you Bettina. But my question was more about the home monitoring uh telemedicine. Sorry, that's ok. Um so how do we pay for it? Well if you know you need, if you join our study um the patients get the monitors free. We have a grant from one of the companies that donated these monitors for us. Um the other way is to is to go on Amazon uh and there are about $40 most of them and they worked very, very well. You really found that have a commitment though from from the person who is going to be listening. Yeah, I found that patients really appreciate the constant monitoring and the 24-7 availability of a physician. But I'm frustrated that you know this is all basically our our own donated time. And I'm looking forward to the results of the stock block study and to maybe this group uh petitioning CMS to let us actually build for this monitoring that we're doing because it is useful. Yeah. That would be a one a wonderful idea. It really would. People have been concerned about the time commitment and the false positives that that can come from the home monitoring. And we've been doing stop block now four or five months. We've had to uh in two times when the mothers heard in a regular rhythm. It's been confirmed by me as an irregular rhythm. And they've gone in and they haven't had heart block luckily or unluckily I guess. But they have had premature atrial contractions so it really does work uh as dr syncope sky a couple of questions once been answered. But I'd like to have dr syncope Scalia's opinion as to whether three D. And 40 ft like color imaging can be exported as Dycom files to be read by other three D. Software and as to which echocardiography platforms or companies offer three D. And for the color functionality usually it's vendor specific. Yes, it's possible to obtain the three D. Volumes into the in combination of different types of colors. But keep in mind that those volumes usually has the last resolution and you need to make sure that you increase the quality of the acquisition to the maximum level and the three D. Manipulation of the volumes. We were very lucky because our reporting system has the program and software for three D. Manipulation of the required Williams embedded in the reporting system. And I know that some manufacturers are doing this so they're comparable to have it like pretty much should be a fingertip at any place at any time, which is very convenient. So. But again um if you have one type of the system, usually you need a specific software for volume manipulation. There is no universal program or like format that would allow you to manipulate the three D. Volumes from different systems. So that that is unfortunate. Yeah. Yes. There's a question for dr chabot. Uh did you do a case control perspective study in order to assess if the changes in the reverse of the flaw in that standing order were due to the approach vegetation and not to the due to the increase aortic valve area growth. Yeah. If you're muted, you muted the. Sorry about that. Um You think I'd have mastered that by now this far into the pandemic? Um I think that question might be referring to the study that dr channing and her colleagues from Children's Hospital of philadelphia. Um That was they demonstrated that they were able to change the flow from retrograde to integrate with transient maternal hyper oxygenation. Uh So there was no case control. Uh As part of that study this is one session which has engendered a lot of discussion and I see a lot of unanswered questions in the Q. And A box as well as in the chat. But we are pressed for time and have to honor the exhibitors of so generously supported the sections. I would urge the speakers and the panelists to look at the Q. And A box and answer those questions individually in the Q. And A box. Meanwhile I would like to thank the speakers on behalf of the organizers and dr Dhar thank you very much for your wonderful and very, very illuminating talks. We'll meet again after the break and exhibits. Thank you. Thank you. Thanks everyone. Thank you. You. Mm. Mhm. Okay. Mhm. Mhm mm hmm. Mhm. Yeah. Mm. Yeah. Yeah. Mm hmm. Mhm mm. Yeah. Yeah. Yeah. Mhm. Mhm. Mhm mm mm mm mm. Oh yeah. Mm hmm. Mhm mm hmm. Yeah. Mhm.
