 Good evening everyone, I'm Dr. Satish Mohanthi from Amrita Institute of Medical Science and the study which I'd like to discuss today is entitled, prenatal diagnosis of a redundant foramine ovale flap aneurysm, collapsing into the mitral valve, a mimicar of aortic coactation. So the primary aim of this study was to demonstrate the clinical course of a prenatally suspected coactation and how it's related to a redundant foramine ovale flap aneurysm. This is a case which came to us earlier last month. It was a 28 year old woman who was referred to us from another centre for a suspicion of a hypoplastic left ventricle and we took this lady for a fetal echo and this is what we got. So what we can see here is a four chamber view and as we can see here that we have an atrial septum which has become aneurysmal and is actually moved on into the LA. It is also encroaching upon the mitral valve. In the colour view we can actually see the flows across the mitral valve into the NPR miniscule in comparison to the flows across the tricuspid valve into the RV. So we can clearly see a ventricular disproportion in both these images in the 2D as well as the colour image and here we can see a redundant P4 flap which is bulging into the mitral valve. So this again is a four chamber view where we have tried to compare the mitral valve annulus as well as the tricuspid valve annulus and as you can see the tricuspid valve annulus z scores are minus 0.23. There is the mitral valve is even smaller with the z scores of minus 1.66. In the 2 pictures at the bottom of the screen we have basically tried to compare the RV internal diameter as well as the LP internal diameter. As you can see that the RV internal diameter had the z scores of minus 0.7 whereas the LP internal diameter is even smaller with the z scores of minus 1.7. We also took a look at the systemic and the pulmonary venous drainage which were normal. In the first image we can actually see a bi-capal view and in the second image we can see an intact IVC. The pulmonary venous drainage we can see two pulmonary veins which are draining into the LA. Next we have a three vessel view. In this three vessel view we can take a look at the pulmonary artery, the ascending aorta as well as the SVC. What we see here is the is the MPM measures 0.91 with the z scores of 0.60 which is normal. However when we take a look at the ascending aorta annulus sorry at the ascending aorta we have a z scores of minus 1.9. Another clue in this image is the size of the SVC. So every time we see a SVC and the adjacent aorta if the SVC and aorta sizes are equal or if the SVC happens to be more than aorta there are actually hints that the child might be having a smallish ascending aorta or at risk of a co-op. Now next we are taking a look at a three-vt view where we can see the isthmus diameter is 0.2 centimeters with the z scores of minus 5. Also we can see here that there is a significant flow reversal in the aorta again implying the possibility of a co-op. When we see the aortic arch here we can see that the narrow isthmus so the fetal echo diagnosis what we formulate was a hypoplastic arch with isthmus significant ventricular disproportion with great artery disproportion and a redundant PFO which was bulging into the LV inflow. So two weeks later this child was delivered here. The delivery was by LSES in view of a previous LSES. This child happened to be a small fagestation age child with a birth rate of 2.2 kgs. He cried immediately at birth and did not require any active resuscitation. So on the first day itself he was taken up for a postnatal echo. Let us see what the postnatal echo showed. So this is an apical 4-chamber view where we can see how the septum is still papillus and its only difference is it is moving on towards the RA. When we had seen the fetal echo there the septum which was aneurysmus was actually encroaching into the mitral lung. Here we can also see the subcostal short axis view which is again showing us the same papillus for amenovir which is bulging into the right So let us take a look at the arch dimensions. This is the ascending eota which was 6.4 millimeters. We have a transverse arch which was 4.4 millimeters with a Z-pose of minus 2.83 and we have an isthymus with a Z-pose of minus 2.75 which are smallish as seen on day one. On the same day we sorry so this is an echo which has been done on day three of life where we actually saw that the mitral valve as the ticuspid valve annulus G-scores. Here as we can see that the ticuspid valve G-scores is minus 0.84 and the mitral valve G-score is minus 0.5 which is normal. We also can right now see that the sinus as well as the sinus tubular junction. The Z-scores mentions for the for the aortic sinus is minus 0.02 and that for STJ is minus 1.14 again which falls into the normal range. Now this is again a apical fourth chamber view which has been taken on day three where we can see that there is still mild ventricular disproportion even though the ventricular function appears normal. Also we can see that the LB is the apex forming chamber here. Coming to the arch which was a major point of concern and alternately we had actually felt that this patient is actually at a high possibility of getting a co-op later on. So here we can see that the arch is well open and the flows through it are laminar. So the diagnosis which we formulated postnatally was a aneurysmal inter atrial septum mild ventricular disproportion LB being apex forming normal biventricular function left arch with no co-optation. So presently the child has been discharged and scheduled for a one month follow-up at our center. So conclusion or learning points from this case would be since of a redundant for amyroval flap aneurysm can actually mimic the co-optation of aorta we all do understand that the possibility is when a redundant for amyroval flap encroaches upon to the mitral valve it is actually impeding the flow into the left ventricle which is going into the aorta. So because there is less blood flow there is going to be less growth of the left side structures and that's the reason why the left heart structures actually would be growing lesser during the fetal period. So sequential postnatal echoes need to be done postnatally. The reason being we all do understand that when co-optation is one of those entities which actually need to be addressed surgically more so and that too immediately. However when it is going to be associated with a for amyroval flap aneurysm there is a possibility that there might be just a benign course and the child may be never faced to go for a surgery. So to keep in mind a for amyroval flap aneurysm is more or less a benign finding and it's something which we should look for in those patients with co-opt. So these are my references.