 Hello everyone, my name is Dr. Seema. I'm going to present a few cases of Kono Trunkle Abnormalities. I work as a radiologist in Janani Scanning Centre. My co-author is Dr. Anand Sagar K. Patil. Kono Trunkle Abnormalities are a broad category of congenital heart diseases that include a variety of conditions like tetralogy of fallow and its variants like absinth pulmonary wall and tetralogy of fallow with pulmonary atresia, double alkyl trite ventricle and its variants, transposition of great arteries and persistent rancous artery uses. These are relatively common anomalies in postnatal series comprising about 10 to 12% of all the congenital heart defects diagnosed after birth. However, the prenatal diagnosis of these anomalies is more challenging since most of these anomalies have a normal fourth chamber view during routine fetal screening. The prevalence in reported series varies from 2.5 to 21% with a diagnostic accuracy of 75 to 90% for achieving a complete diagnosis. The aims and objectives of our study was to identify the fetuses with Kono Trunkle Abnormalities through trans-abdominal ultrasound using standard planes as per ISOG guidelines to study imaging features of Kono Trunkle Abnormalities. So the materials and the methods used were the fetuses were examined trans-abdominally in all antenatal cases between 70 to 26 weeks of gestation, standard axial planes were taken and analyzed, complementary sagittal and parasagital views were also acquired in suspected cases where we had to look at the iotic arch, ductile arch and the bicable view. Findings were confirmed by prenatal autopsy and or review of images by the experts. 763 fetuses between the gestational age of 17 weeks to 26 weeks were examined in the period of 24 months from June 2019 to June 2021. 20 fetuses were diagnosed with structural defects consistent with Kono Trunkle Abnormalities out of which we are presenting 10 cases. Diagnosis was confirmed by post-mortem examination or expert review. With careful survey of atrial ventricular and ventricular arterial concordance, we could diagnose 5 cases of 20 weeks at 20 weeks, 1 at 19 weeks, 2 cases at 21 to 22 weeks, 1 at 17 weeks and 1 at 26 weeks. History of consign unity was present in two cases. All of them were terminated. We could convince one patient for autopsy and confirm the findings. Now coming to the case one. The clinical history, 30-year-old Prani came for an anomaly scan at 20 weeks. Second degree consign unity was present and no significant family history was present. The ultrasound findings where there was no, in the outflow tract views, we could see that there was no crossover. Parallel course of two arteries was seen. Diota was arising from the anterior right ventricle, but as a pulmonary artery is connected posteriorly with the left ventricle. Ventricular arterial discordance was found whereas there was atrial ventricular concordance with right ventricle connected to the aorta and the left ventricle connected to the pulmonary artery. In three vessel trachea view, we could see only two vessels with a typical eye sign and all these findings were consistent with transposition of great arteries. Coming to the images, in this image we confirmed that there was cytosolitis. The fetus was in cephalic presentation, so the vertebral body, this funding bubble and the apex all should be in clockwise direction as it was so. So it was a cytosolitis. We confirmed the cytos. Next thing what we did was we had to confirm the cytos of the heart. That is the right side was the right side, that is the right atrium was draining into the right ventricle and the left atrium was draining into the left ventricle. So we confirmed that there was atrium ventricular concordance but in the outflow tracts we could visualize the paralleling. And the careful examination of the outflow tracts showed us that there was a non-branching vessel, non-branching vessel which was arising from the anterior ventricle that was the right ventricle and that made us conclude that it was the aorta which was arising from the right ventricle. And in the three vessel trachea view we could see only eye sign. Only one vessel was seen. That was the superior vanakeva and the single large vessel was seen in three vessel trachea view. So we confirmed the diagnosis that it was a complete transposition of great arteries. Coming to our next case it was a 25 year old primie who came to us for a routine scan at 26 weeks. In non-consanguous marriage there was no significant family history. The ultrasound findings where the connections of the systemic and the pulmonary veins was normal that was the pulmonary veins were draining into the left atrium and the inferior superior vanakeva were draining into the right atrium. But when we went on to see the atrium draining into the ventricle what we found was an abnormal connection of the atria and the ventricle that is atrioventricular discordance. And the position of the ventricles was reversed. The morphological right ventricle was seen connecting the left atrium and the morphological left ventricle was seen connecting the right atrium. So the ventricular anatomy showed us there was a atrioventricular discordance. Minimal fluid was seen in the pericardium and the great vessels when we had a look at the great vessels there was no crossover and both the arteries were following a parallel cross course instead of the criss-crossing. So the aorta was arising from the anterior right ventricle and the pulmonary artery was arising from the left ventricle. This findings that's consistent with corrected transposition of great arteries. Let's have a look at the images. So first of all it was a breach presentation. So we expect the vertebral body, stomach and the apex to be in the anticlockwise direction. This is cytosolitis. So the cytos was confirmed, visceral cytos was confirmed. But when we had a look at the cytos of the heart, the left atrium was seen connecting to the right ventricle and the right atrium was seen connecting to the left ventricle. So how did we come to this conclusion was the left atrium was being separated from the lower ventricle by tricuspid wall and there was a moderator band in the ventricle. So we concluded that it was a right ventricle. Now when we concluded that this was a right ventricle, then we went on to look at the outflow tracts. The morphologically looking left ventricle which was draining the right atrium was being drained by the main pulmonary artery which was a dividing vessel. But we know that left ventricle gives rise to a non-branching vessel that is a iota. So here we found that there was double discordance. So double discordance is always consistent with the finding of corrected TGA. And in the sagimages we could see that the iotic arch was arising from the right ventricle and the ductus arch was just beneath it and this confirmed our diagnosis that there is a parallel orientation of the great arteries because of the double discordance there is also corrected TGA. This image shows us that the pulmonary artery, the main pulmonary arteries arising from the left ventricle and giving its branches. The pulmonary artery was normal in its caliber. So this is a 3D image which confirms all our findings. This is a right atrium draining into the smooth wall left ventricle and that is being drained by the pulmonary artery. This is a left atrium draining into the right ventricle and further draining into the iota. So this confirmed our diagnosis. So this is a case 3, 29-year-old Primi who came to us at 22 weeks for an anomaly scan, non-consanguineous marriage, no family history. Here in this case we could find that the position of the ventricles was normal, atrial connections were normal, ventricular and anatomy showed us a 3.6-millimeter size inlet BSD. Great arteries, both the outflow tracts were seen arising from the morphological right ventricle with anterior, large iota and posterior pulmonary artery. In three-veginal trachea view we could see a single large vessel which was iota. Atrial ventricular septum we could see a pulmonic BSD. Ductal arch and iotic arch were seen paralleling. So this made us think about tau-sigbing form of double outlet right ventricle with sub-pulmonic and inlet BSD. So coming to the images. So this was a breach presentation. Again the vertebral body, the stomach and the apex all are on the same side or in the anti-clock direction and this confirms the phytosolitis. The right atrium it was raining into the right ventricle, left atrium into the left ventricle. We could find a inlet BSD there. Then after passing on to the outflow tract we could see that there was a BSD just beneath the great vessels which was beneath this pulmonary artery. And this was called a sub-pulmonic BSD. We could see that the right ventricle was giving rise to the iota as well as the main pulmonary artery. There was paralleling of the arches as seen in this figure, iotic arch and the ductal arch. Iotic arch arising from the anterior ventricle that was the right ventricle. Here in this image you can clearly see the origins of the outflow tract arising from the right ventricle. That concludes us to the diagnosis of tau-sigbing type of double outlet right ventricle. Double outlet right ventricle are of four types depending upon from where exactly are the blood vessels arising. Here in the most important things which we should look at are the relation of the great vessels, the position of the BSD, presence or absence of pulmonary pulmonary stenosis, absence of all mitraiotic and mitra-pulmonary continuity. The diagnosis of DORV is important because they are associated with trisomy 18 and 13. Then the types, DORV with subbiotic VSD, DORV with sub pulmonic VSD, doubly commuted VSD and remote VSD. These are the four kinds of DORVs. Coming to the case for 30 years old primary came for a routine scan at 20 weeks and non-consangular marriage, no family history. Poor chamber showed mild symmetry with right ventricle predominance. The aorta is dilated and overriding. There is a septoietic discontinuity and we could also find a malaligned VSD of 1.9 millimeters. The pulmonary artery in this case was normal. Our diagnosis was isolated finding which is malaligned VSD with overriding of aorta. So this is a four chamber, this is a five chamber view which shows us that the aorta is overriding. It is doubly commuted to the left and the right ventricle. Rest all findings were normal. The pulmonary artery was normal. If the pulmonary artery was smaller, we could have diagnosed it to be a tetralogy of fallow but that wasn't the case. Case number five, 27 year old primary came for a normally scan, non-consangular marriage, no family history. Here what we could see is the cardiac apex was centrally placed that was mesocardia and the great vessels were abnormal. Ventricle arterial discordance was found. Aorta was arising from the right ventricle. Pulmonary artery in this case was erratic. On three vessel view, we could see a single large vessel that was a aorta to the left of the superior vena cava. AVSD was noted. The apex in the center, the atrial ventricular discordance was maintained. The vessels arising from the interior chamber did not show bifurcation that confirmed that it was aorta but it was giving Nick vessels. So this suggested the diagnosis of PGA and in this case the pulmonary artery was smaller so we gave diagnosis of complete transposition of great arteries with atrial ventricular septal defect and pulmonary arteries. These are the findings. There is mesocardia. There is atrial ventricular discordance. There is AVSD and this is the right ventricle giving rise to a non-branching vessel which is aorta. In three vessel, we have a single vessel to the left of the aorta. This is a SAGE view showing us that the aorta is arising from the right ventricle. This is a AVSD. Case 6, 25-year-old tiny anomaly scan at 20 weeks, non-consanguous marriage, no significant family history. On examination of the heart, we could find that there is left-axis deviation. There was 2.2 millimeter perimembranus VSD noted. Aorta and pulmonary artery are seen arising from the right ventricle. Pulmonary artery appeared narrow compared to the aorta. Three vessel trachea view shows only two vessels. Thymus was also absent. This is a complex cardiac case of DO-RV with atritic pulmonary artery and right-sided aortic arch. This is a perimembranus VSD here. This slide shows us there are only two vessels at 3V-TV and the aorta is crossing on the right side of the trachea. This is the right-sided aortic arch. This is to show that the pulmonary artery and the aorta both are arising from the single ventricle, that is the right ventricle. This is case 7. 31-year-old G2P1 came for anomaly scan, second-degree consanguinity, no family history. Cytus was normal. There was septo-iotic discontinuity measuring 4.5 millimeters. Aorta was dilated and overriding. Three vessel trachea view showed that the aorta appeared dilated and short forward flow. This was a case of tetralogy of fallow. This confirms the atrium ventricular concordance from the four chamber view. The five chamber view shows that the aorta is a septo-iotic discontinuity. There is a septo-iotic and discontinuity very nicely shown here. As compared to the aorta, the pulmonary artery was looking very narrow. This made us conclude that it was a case of tetralogy of fallow. There are a few findings on atopsi which was confirmed. There was overriding of aorta. There was ventricular septal defect. There is small, tiny vessel which is in your pulmonary stenosis. Case 8, 18-year-old primary who came to us at 17 to 18 weeks for early anomaly scan in non-consanguinous marriage and no significant family history. Here we could find a single vessel raining both the ventricles committed to more to the left ventricles such as your common arterial trunk, bar, pulmonary atria with VSD. These are the findings showing a single large vessel committed to both the ventricles. This is a color flow which confirmed which tells us that there is only a single vessel raining both the ventricles. Case 9, it was a 21-year-old primary who came for an anomaly scan at 19 weeks, non-consanguinous marriage and no family history. On ultrasound finding, we could find that the dilated right ventricle with perimembranous ventricular septal defect measuring 2.5 millimeters on the right ventricle. When we had a look at the outflow tracks, we could find that the pulmonary artery there was bulbous dilatation of the main pulmonary artery as well as the right and left branches just proximal and distal to the dysplastic pulmonary walls. After cut-off of the pulmonary artery we noted the level of ductus arteriosus due to ductus arteriosus absence. In 3-vessel trachea view, we could find the bulbous dilatation of both the pulmonary arteries and both the branches of the pulmonary artery and the main pulmonary artery. So this made us conclude that there was absent pulmonary, absent pulmonary valve syndrome. So this is a cytosolitis and this is the bulbous dilatation of the pulmonary artery giving rise to the dilated bulbous dilatation of the pulmonary artery branches. So this is the color showing there is a turbulent flow at the level of the pulmonary walls and regurgitation as well. So there was a BSD and this is a right-sided iotic arch and this is the main pulmonary artery this is the dysplastic pulmonary this is the RPA and the LPA this was a case of absent pulmonary valve. The absent pulmonary valve that is leads to post-absent pulmonary wall or abnormal pulmonary wall leads to post-genotic dilatation of main pulmonary artery and its branches. The types are non-top and top type. This was a top type of in our case it was a top type of APVS. There are four important features that is the ballooning of the main pulmonary artery and its branches. Second one is the regurgitation at the pulmonary wall and we find high velocities across the wall. Case 10 24-year-old Primi who came to us for anomalies can at 21 weeks non-consummonous marriage, no family history both the atrium are opening into a single morphological left ventricle at right side was hypoplastic and a left-sided morphological left ventricle was communicating through a VSD and great vessels there was no crossover again and there was a parallel orientation and the iota was arising from the anterior right ventricle whereas the pulmonary artery was connected posterior to the left ventricle. So the ventricular atrial discordance at the rudimentary right ventricle connected to the iota and the left connected to the pulmonary artery. Iota is anterior and right wall position related to the trachea was the only two vessels in the 3VTV and the ventricular connections was reversed coming to the final diagnosis was double inlet left ventricle with anterior and rightward iota. So here we can see that the left atrium and the right ventricle and the left atrium both are draining into the morphological left ventricle right ventricle was hypoplastic, the cytos was maintained. So this is the tricuspid wall this is the mitral wall which has seen opening into the left ventricle on 3VTV two vessels were seen which was the iota. So this is the inlet VSD there is a malposition LBOT was arising from the morphological hypoplastic left ventricle and the RBOT was arising from the left ventricle so the ductus arch arising from the left ventricle and the iotic arch arising from the right ventricle and the pulmonary artery was arising from the left ventricle. So this is the table showing the findings of each case and the outcome and confirmation was done by what the first case was transposition of great arteries confirmed by expert opinion went for termination corrected TGA confirmed by expert opinion they went for termination complex cardiac disease with toxic bing form of DORV with inlet VSD and supalmonic VSD confirmed by expert opinion fourth case was just overriding with malaline VSD termination complete transposition of great arteries with AVSD termination DORV with atritic pulmonary artery and right sided iotic arch terminated tetralogy of fallow went for they went for termination then autopsy and I have shown the images common arterial trunk and pulmonary artery with VSD they just terminated it absent pulmonary valve termination and DILV they went for termination con truncal abnormalities and structural abnormalities involving the outflow tracts the diagnosis becomes difficult here because most of them have normal four chamber view so detailed and extended cardiac examination including the ventricular arterial and the atroventricular connections is a paramount importance so the fatal diagnosis of structural heart disease is currently increasing due to the policy of prenatal screening of cardiac malformations during the routine scans this is very important for us to diagnose these cases the conclusion is fetal echo is a valuable tool in early detection of serious defects such as these con truncal anomalies because they require early fetal early fetal or postnatal interventions especially in cases with high risk positive consignority is a major serious problem in developing countries which is usually associated with serious major problems in the offsprings thus early screening to detect these defects that may need early intervention the findings of our study reflect that the careful survey of outflow tracts would help in diagnosis of con truncal abnormalities not only the fourth chamber view the most common errors that are associated with the determination of rate artery relationship as most of the abnormalities had a warlock low socioeconomic status and lack of awareness about the facilities at the tertiary sent as lead to termination in all our cases in our study we had cases of fallow DORV complete TG and corrected TG in the decreasing order so these are my references thank you so much