ISUOG Basic Training

Obtaining & Interpreting Heart Views Correctly

Alfred Abuhamad, USA

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Basic training
 Learning Objectives 6, 7 & 8

At the end of the lecture you will be able to:

• describe how to assess cardiac situs

• describe the key features of the 4 planes required to assess the

fetal heart correctly

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 Key Questions

• What are the key ultrasound features of plane 7?

• What probe movements are required to move through the 4

cardiac planes correctly?

• What are the key ultrasound features of plane 10?

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Ultrasound Obstet Gynecol 2013; 41: 348–359
 7: Four-Chamber View

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 8: Left Ventricular Outflow

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 9: Right Ventricular Outflow

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 10: Three-Vessel-Trachea

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 7: Four-Chamber View
-Fetal laterality (identify right and left sides of fetus)
-Stomach and heart on left

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Normal Situs – Abdominal Circumference

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 Normal Situs - Chest

Ao

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Practical Guide To Fetal Echocardiography – Abuhamad, Chaoui – 2nd Edition
 Types of Fetal Situs

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 Types of Fetal Situs
Situs Incidence CHD

Solitus Common Not Increased

Inversus* 1/100 Slightly Increased

(0.3 – 5%)

Ambiguous 1/10,000 Increased

*: Kartagener syndrome in 20%

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 Left Isomerism

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Practical Guide To Fetal Echocardiography – Abuhamad, Chaoui – 2nd Edition
 Right Isomerism

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Practical Guide To Fetal Echocardiography – Abuhamad, Chaoui – 2nd Edition
 7: Four-Chamber View
-Fetal laterality (identify right and left sides of fetus)
-Stomach and heart on left
-Heart occupies a third of thoracic area
-Majority of heart in left chest

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 Heart Size

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 Cardiac Position

2/3
L 1/3

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 Cardiac Position

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 7: Four-Chamber View
-Fetal laterality (identify right and left sides of fetus)
-Stomach and heart on left
-Heart occupies a third of thoracic area
-Majority of heart in left chest
-Cardiac axis (apex) points to left by 45◦ ± 20◦

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 Cardiac Axis
L
RV
LV

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 Cardiac Axis
Data From Normal Fetuses (n=183)

• Axis at around 45%

•• Range
Axis atofaround
normal45%
+/- 20 degrees
•• No change
Range with gestation
of normal +/- 20 degrees
• No change with gestation

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Obstet. Gynecol. 1987;70:1987
 Abnormal Cardiac Axis
Left Axis Deviation

• Most abnormal cardiac axis are

left axis deviations
• Most are diagnosed in second
trimester

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Obstet. Gynecol. 1995;85:97
 Cardiac Axis

CAT TGA

TOF DORV
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 7: Four-Chamber View
-Fetal laterality (identify right and left sides of fetus)
-Stomach and heart on left
-Heart occupies a third of thoracic area
-Majority of heart in left chest
-Cardiac axis (apex) points to left by 45◦ ± 20◦
-Four chambers present

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 Four-Chamber View

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Apical
 Four-Chamber View

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Axial
 Four-Chamber View

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Basal
 Atrial Chambers
-Two atria, approximately equal in size
-Foramen ovale flap in left atrium
-Atrial septum primum present (near to crux)
-Pulmonary veins entering left atrium

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Ultrasound Obstet Gynecol 2013; 41: 348–359
 Left Atrium

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 Left Atrium

Ao

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 7 Left Atrium

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 Pulmonary Veins

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 Left Atrium

Closed Esophagus Open Esophagus

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 Left Atrium

TAPVR
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From Practical Guide To Fetal Echocardiography: Normal & Abnormal Hearts– Abuhamad, Chaoui – 3rd Edition
 Right Atrium
RA

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From Practical Guide To Fetal Echocardiography: Normal & Abnormal Hearts– Abuhamad, Chaoui – 3rd Edition
 Right Atrium

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From Practical Guide To Fetal Echocardiography: Normal & Abnormal Hearts– Abuhamad, Chaoui – 3rd Edition
 Right Atrium

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 Interatrial Septum

LV RV

L
RA
LA

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 Ventricular Chambers

-Two ventricles, approximately equal in size

-No ventricular wall hypertrophy
-Moderator band at right ventricular apex
-Ventricular septum intact (apex to crux)

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Ultrasound Obstet Gynecol 2013; 41: 348–359
 Right Ventricle

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From Practical Guide To Fetal Echocardiography: Normal & Abnormal Hearts– Abuhamad, Chaoui – 3rd Edition
 Right Ventricle

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 Right Ventricle

RV
LV
LV
RV

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 Right Ventricle

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 Left Ventricle

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From Practical Guide To Fetal Echocardiography: Normal & Abnormal Hearts– Abuhamad, Chaoui – 3rd Edition
 Left Ventricle

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 Left Ventricle

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 Ventricular Septum

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 Ventricular Septum

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 Ventricular Septum

Muscular
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 Ventricular Septum

Perimembranous
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 Atrioventricular Junction & Valves

-Intact cardiac crux

-Two atrioventricular valves open and move freely
-Differential offsetting: tricuspid valve leaflet
inserts on ventricular septum closer to cardiac
apex than does mitral valve

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Ultrasound Obstet Gynecol 2013; 41: 348–359
 Atrioventricular Valves

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 Atrioventricular Valves

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 7: Four-Chamber View
-Fetal laterality (identify right and left sides of fetus)
-Stomach and heart on left
-Heart occupies a third of thoracic area
-Majority of heart in left chest
-Cardiac axis (apex) points to left by 45◦ ± 20◦
-Four chambers present
-Regular cardiac rhythm
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 Regular Cardiac Rhythm

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 7: Four-Chamber View
-Fetal laterality (identify right and left sides of fetus)
-Stomach and heart on left
-Heart occupies a third of thoracic area
-Majority of heart in left chest
-Cardiac axis (apex) points to left by 45◦ ± 20◦
-Four chambers present
-Regular cardiac rhythm
-No pericardial effusion
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 Four Chamber View

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 Four-Chamber View

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From Practical Guide To Fetal Echocardiography: Normal & Abnormal Hearts– Abuhamad, Chaoui – 3rd Edition
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From Practical Guide To Fetal Echocardiography: Normal & Abnormal Hearts– Abuhamad, Chaoui – 3rd Edition
 8: Left Ventricular Outflow

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 Left Ventricular Outflow

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 Left Ventricular Outflow

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 Left Ventricular Outflow

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 Left Ventricular Outflow

Normal TOF

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 Left Ventricular Outflow

TOF

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 Left Ventricular Outflow

TOF

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 Left Ventricular Outflow

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 Left Ventricular Outflow

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 Left Ventricular Outflow

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 Left Ventricular Outflow

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 Left Ventricular Outflow

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 Left Ventricular Outflow
• Mitral - aortic continuity
• Aorta within left ventricle
• Angle of ascending aorta with ventricular septum
• Aorta does not divide
• Close observation of aortic valves
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 9: Right Ventricular Outflow

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 Right Ventricular Outflow

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 Right Ventricular Outflow

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 10: Three-Vessel-Trachea

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 Three-Vessel Trachea

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 Three-Vessel Trachea

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 Three-Vessel Trachea

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 Three-Vessel Trachea

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 Three-Vessel Trachea

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 Three-Vessel Trachea

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 Three-Vessel Trachea

Blood flows towards the spine

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 Three-Vessel Trachea

Spine
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 Checklist Three-Vessel-Trachea
Thymus present
Course & size of PA, Ao & SVC

Flow assessment by color Doppler

Course & size of DA & Ao Isthmus

Presence of atypical vessels

Ao arch & DA right or left sided LSVC
TAPVR

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 TGA HLHS

RAA

IAA TOF
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 Three-Vessel Trachea

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 Three-Vessel Trachea
PS / PA
Abnormal in: Critical Ao Stenosis
HLHS Coarctation of Ao
HRHS ARSA
TGA LSVC
DORV TA-VSD
TOF RAA
CAT Double Ao Arch
TAPVR Ebstein
PA-VSD Interrupted Ao Arch Courtesy of Dr. Chaoui

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 Conclusion
7 8 9 10

• Normal situs • LVOT arises with an angle • PA anterior • 3 vessels seen

• Normal axis • LVOT does not divide • PA and Ao same size • Ao and PA normal size
• Ventricles equal in size • Normal valves • Normal valves • DA & Ao Arch to left of
and contractility trachea

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