 Once again, I would like to thank Professor Sanjib and Professor Maxielanski and the Organized Committee for the opportunity to give this talk about the new era of early diagnosis of congenital heart disease at 12 to 13 weeks of gestation, and once again, I want to say that tasted so much to be with you today. We planned it for long ago. And in this regard I would like to dedicate this talk to our many friends and colleagues who were victims of the heinous terrorist attacks committed against Israel on the 7th of October. So there is a restinking of the timing of the anatomy scanning and the nuclear translucency in the light of the several free DNA revolution. And actually I published this cartoon at January 21 and I think that now I come to the conclusion that it is really feasible. So what I recommend I like what we have previously that any dating scan and NAPT about 10 weeks. NAPT is covered by many authorities around the world and he plays an anti-anatomy scan which integrates the nuclear translucency and the scanning and then makes your master's anatomy scan and sets your master's anatomy scan when indicated. And this is what is depicted here, so the cell-free DNA now about two years ago and the nuclear translucency and to check for anomalies in the fetal heart and other systems in the fetal body, but we will concentrate on fetal heart today. And now there is evidence, meta-analysis or the first semester detection of fetal anomalies, we can say that this is many many kinds of fetal heart anomalies and the sensitivity of the first semester scan mostly abdominal is about 56% of specificity in high risk group, in low risk group and about 68% in high risk group with very high positive predictive value, you can see from topia cordis is about most of them and rabda bioma is the least of them. And actually we published several months ago the new is for guidance for fetal echo and it could be accomplished not only mid semester scan by first semester scan or early second semester scan by these five slices transfer section of the fetal heart. Let's go to the first one of them. This is trans-adominal scan you can see at the stomach and wherever I ask and I will, in here is one side this color, one without it, you can see here the stomach, you can see the ductus venousus, you can see the infirvina cava and the aorta, not the resolution I have to admit not as superb as the mid semester but really this is enough or more than enough for the scanning and this is the second one, the 4 chamber view of the late scan, you can see here the ejection of blood from the right atrium and the left atrium and all the component of the heart and this is the same what we see here, this is the right atrium and the left atrium you can see here the pulmonary veins and with the color you can see the red jet from the right atrium and the left atrium, this is for the 4 chamber view and this is another example and what we can see here here which is quite better than before, actually is an advantage in our time to do it earlier because there are some machines with a slow flow which is really suitable for early scan, one you can see you can see here the flow in the right ventricle, in the left ventricle, you can see the septum and even you can see here the pulmonary vein and the pulmonary flow in the lung, for the left ventricle outflow tract as in the guidelines you can see here and here in early scan you can see the LVOT coming from the left ventricle and one can see even the aortic valve and you can see here the flow, the reddish flow, the reddish flow from the LVOT here and another example, in different case you can see here the LVOT and you can see here the color and the next step is the most difficult to achieve, it's the identricular outflow tract, you can see the main pulmonary artery and by a vocation in meter scan and here one can see it again, it's not so easy to do and I really recommend to use the color and to see the bifurcation of the pulmonary artery and another example here, one can see here, you can see here, you can go very slowly and you can use your AVI to do that and one can see here, if you go very slowly you see the bifurcation of the pulmonary artery here, for example you can see one here and one here, this is the main pulmonary artery and here you can see the bifurcation of the two pulmonary arteries and the last one is the three vessels in the trachea view, again one can see it here, you can see here, this is the main pulmonary artery and the pulmonary artery and on the right for it you can see the aortic arch and on the side you can see the infirvina cava, let's do it from here, the main pulmonary artery and the two sartariosus, the aortic arch, the trachea and the supravenacava and sometimes even better, you can see the four chamber view, you can see the LVOT and then you can see the three vessels and the trachea view, we cannot depict here the pulmonary artery and the pulmonary artery, the main pulmonary artery, the main pulmonary artery but you can see how beautiful you can get with this and sometimes as I said the advantage of the slow flow, you can see the timic perks and internal mammary arteries coming out the supravina arteries here and as you can see even because as I said the slow flow is suitable for that and this is again all what we need for the scanning. As I said in my previous talk, there's an advantage of the slow flow not only for the heart but also for the veins that come in the precordial veins here, you can see the infirvina cava, you can see here the ductus venousus, here you can see the azigos vein and at the end of the cycle you can see here the bifurcation of the odor, if you add to your scan the longitudinal approach for examination of the heart, one can see beautifully the bifurcation. Now let's have several examples of very early, you can see here this is a case of hypoplastic left heart, here you can see here this is the right ventricle on this side you can see the right ventricle and here in the left ventricle look here the right ventricle here and the left this small left ventricle, an example of plastic left heart and when you use the color one can see you see the retrograde flow the red retrograde flow of the odor because of critically stenose aortic valve and you can see a back flow in in the aortic arch and you can see here the main pulmonary artery which is delated in this occasion more than that actually what you can see here you can see only one flow from the atrium to the ventricle because there is no flow on the left side only the right side gets some this reddish flow in a case of early hypoplastic left heart here we have bilateral nexus which i think we have a clue for some heart anomalies and i like to use always a 3d or 4d what you can see here you can see here a larger jet on the right ventricle and a smaller jet in the left ventricle and what what you can see here that we have only one big vessel in the three vessel in the back of you you don't see here the odor just because it's it's so tiny in a case of plastic left heart and you can see לוגיטודinally if you look very very carefully here you can see a glimpse of the stenose and a bad flow in the aortic arch as i can show you just here you can see here in the upper part you can see only a retrograde flow in a stenose odor in a case of 16 weeks of gestation and again when i use this you can see here there is a teeny aortic arch with a retrograde reddish flow in a case of your plastic left heart this is right aortic atreasia you can see a large uh vessel coming from uh from uh the right ventricle in a case of again with very wide nuclear translucency and you can see here in red only of aortic atreasia it was a very teeny odor and a retrograde flow through the odor in a case another case of aortic stenosis or aortic atreasia it can be on the opposite side it's simple plastic right heart you can see here this is a left ventricle at 12 weeks of gestation this is the left ventricle this is the right very very narrowed uh a tratic um a right ventricle and with the advent of the color here and with the 3d what we can see here what you can see here uh this is the blue jet only entrance of blood from the left atrium to the left ventricle and what you can see here you can see here this is the red one this is the odor dilated odor because there is no flow in the main pulmonary in this case of early hypoplastic right heart this is a very very rare case one can see here on the left side this is the left ventricle this is right ventricle right atrium left atrium you can see a tumor in in the left ventricle and while using the color and the stick you can see entrance of blood to the right ventricle very very uh narrow jet from the right atrium because of of this tumor and actually what you can see here coming only from the right right heart and very very you know narrow uh odor with with a retro get flow in the odor because of this tumor in the left ventricle quite common is a early case of the trilogy of fallot one can see here that is only one vessel overriding vessel this is the right ventricle the left ventricle this was proved to be um the trilogy uh of fallot here one can see here you see coming from both ventricle overriding odor of of the trilogy of fallot early and one can see here from the literature you can see here the supervenacava here this is normal this is the narrow pulmonary artery the the dilated odor the overriding odor in is a beautiful case of dilated odor override in in first semester in a retrograde flow in a narrow pulmonary artery here and here so all of them just uh exemplify the our ability to see in another case of the trilogy of fallot and this is a very uh narrow pulmonary artery the trilogy of fallot overrides and over all the v s d in the trilogy of fallot an early case in 13 week of the station only one vessel coming out of both ventricle the right one and the left one this is the persistent tungו סתרסו communities at a very very early stage overrides uh the v s d and this is transposition of the great arteries very early one can see here one can see here the uh this is the odor on the right side coming from the right ventricle and here you can see the pulmonary artery overrides uh the right ventricle and the left ventricle in a case of detance position the uh the pulmonary artery coming out from both ventricle and the odor from uh the right ventricle in detance position of the great arteries quite common to see that is the upper right right subclavin artery when you see the 3d in 2d here is a 3d example of uh of of uh uh arson in this case which you know dictate follow up and evaluation this case is not that easy to detect it only 12 weeks of the station so one can see only one ventricle here one vessel and what is the most important thing to me was that I couldn't see here in the case of uh hetero taxi I didn't see properly um the drainage of the pulmonary veins into the left artery and you can see even in the regular color I was not sure what's going on and here again I told you before the advent of the slow flow in this case one can see you can see here there is no connection between the pulmonary veins and the left artery and you can see here that we have a similar uh right and left right and left atrium in a case of hetero taxi with the right isomerism this is a case again of hetero taxi syndrome a complicated case in 13 weeks of gestation left isomerism and one can see here uh you can see here the נוקל uh edema and the nukal bleves and when we go further here one can see easy that we have here only one one uh we can see here only one valve this is an AV canal and it looks like that both of them are similar and once again with the color we see one jet here only one jet here and what we can see more there is no uh in fear of vena cava which is interrupted in fear of vena cava in hetero taxi syndrome with left isomerism and one can see here that that you can see here only you see the דהמי אזיגוס ויין coming um uh to disappear of vena cava there is no in fear of vena cava and uh again with the with the stick one can see here that there is let's let's take this picture these slides for example they're one in one jet coming from the common artery into the common ventricle and you can see here it's that uh the both of the atria are left uh atria in in a case of last isomerism more than that the left port of cover shunt can be seen easily this for example is this here uh the umbilical vein drain directly to the inferior vena cava as can be seen here all cases of veins anomaly can be depicted at this uh uh uh that area it was a case very old case many years ago of uh super ventricular tachycardia of almost 100 bits per minute you can see here the the edema one the head and we treated uh you can see again the uh the the svt and the reverse flow in uh because of of of this of uh in uh in the ductus venousus but after treatment with digesting several days later we got a complete recovery to the sinus rhythm of about 100 bits per minute so early impregnancy so what i my conclusion is that early first first semester the a-sector master complete fetal acardovic can be achieved and seeing the area of the npt in our area we recommend me and others a combination of the nuke and sufficiency the first semester screening weighs a complete targeted organ screening to detect many anomalies especially anomalies of the fetal heart system thank you