Fetal Echocardiography: Normal Views and Anatomy

Dr. Ahmed Esawy
MBBS M.Sc
MD
Dr/AHMED ESAWY

Fetal Echocardiography
Part 1
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Normal Fetal
Echocardiography
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Weeks Length
mm
Event`
1-2 1.5 No heart or great vessel
4 2 Single median cardiac tube, ineffective
contraction
5 4 Bilobed atrium
5 4 Begining of circulation
5 7.5 AV orifices, 3 chamber heart
6 8.5-13 Septum secundum, complete inferior
septum, divided truncus arteriosus,
7 20 4 chamber heart
Cardiac embryology
Dr/AHMED ESAWY

Time
•The best time to do a fetal cardiac exam is 18-22
weeks
•Images can be more difficult to obtain after 30
weeks gestation, as the ratio of fetal body mass-
to-amniotic fluid increases ,rib shadowing
•Adequate exam depends on fetal position and
maternal habitus
•Some pathologies become obvious with fetal age
Dr/AHMED ESAWY

Rate and rhythm
•The heart rate is usually 120-160/min,
the rhythm is regular but transient
bradycardia is normal in the 2nd trimester
but not in the 3rd
Dr/AHMED ESAWY

Scanning Technique
• 1st Step: Check the heart is beating
• 2nd Step: M-mode heart rate - should be between 120
and 180 beats per minute
• 3rd step : Situs-
• 4th step four chamber view.
• 5th and 6th Step Outflow Tracts
• 5th step : LVOT
• 6TH step : RVOT
• 7th step : 3 Vessel View
• 8th step: Interventricular Septum
IVS (a false positive for septal defect).
It should be assessed in both B-mode and Colour
Doppler.
• 9th step : Aortic Arch
• The 'arches' are best assessed when the foetus is prone.
• 10th step : Ductal Arch
This is the ductus arteriosus:
Dr/AHMED ESAWY

1st step Check the heart is beating
Dr/AHMED ESAWY

2nd Step: M-mode heart rate - should be between
120 and 180 beats per minute
Dr/AHMED ESAWY

3rd step: Situs
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• Establishing laterality. Schematic diagram and
ultrasound through abdomen show spine and
stomach. A, In this fetus, fetal head was
located below plane of abdomen (vertex
presentation), making left side lower; hence,
stomach was located on left side of Fetus.Dr/AHMED ESAWY

Abdominal situs
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4TH STEP FOUR CHAMBER VIEW
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The Four Chamber View
1. Heart fills one third of the chest
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3. Size of right chambers approximates left chambers
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2. Apex points to the left (45 degree angle)
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Scan plane valves
Angle the probe cephalad to get
the 4 chamber view of the fetal
heart.
The valvular movement should
simulate birds wings.
Dr/AHMED ESAWY

four chamber view
Axis
• 45+20o towards the left
• Abnormal axis increases the risk of a cardiac
malformation
• The heart may also be displaced from its normal
position in dipaphragmatic hernia or cystic
adenomatoid malformation
• The atrium nearest the spine is the left atrium
• The atrium nearest the fetal anterior thoracic wall is
the right
Dr/AHMED ESAWY

•Done on a 4 chamber view
•Heart mostly in left chest
•Occupies 1/3rd of thoracic area
•Normal cardiac situs, axis and
position
•No pericardial effusion
General
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•Both of same size
•Foramen ovale flap in
left atrium
•lower end of atrial septum
(septum primum) present
•Foramen ovale
Atria
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•Equal size
•Intact septum
•Moderator band
identifies right ventricle
Ventricles
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• The heart should be angled 45degrees to the
left and occupy approximately 1/3 of the chest
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• Confirm that the heart is on the fetal left
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4 chamber heart.
• LA= Left Atrium
• LV= Left ventricle
• RA= Right Atrium
• LV left Ventricle
The prominant papillary muscles make the right
ventricle appear to be a much smaller
chamber.
Dr/AHMED ESAWY

• The atrio-ventricular valves should arise from
the crux of the heart as an offset cross.
• The Foramen ovale is clearly seen.
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•Both valves move freely
•Tricuspid valve inserted
more apically than mitral
AV Valves
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•Fetus cephalic
•Probe marker to mother’s left
•Fetal spine posterior
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•Fetus breech
•Probe marker normal
•Fetal spine posterior
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vertex presentation.
the ascending aorta (arrow).
Arrowhead ductus arteriosus
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breech presentation.
the ascending aorta (arrow).
Arrowhead ductus arteriosus,
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breech presentation. the ascending aorta ( arrow). Arrowhead ductus arteriosus
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vertex position with
left side down
vertex position with
right side down
breech position
with left side
down.
breech
position
with right
side down
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• A thoracic section
suitable for
measurement. The
cardiac
circumference
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• Four-chamber
view of the
heart:
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Differences Between the Morphologic
Right and Left Ventricles on
Prenatal Ultrasound
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Four-chamber view
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Four-chamber view of normal fetal heart
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normal fetal thorax shows four cardiac
chambers.
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• Normal papillary muscle on four-chamber view of heart.
Bright echogenic focus (arrow) within left ventricle
corresponds to a papillary musdc and is a normal finding.
Dr/AHMED ESAWY

5TH step LVOT biew
Dr/AHMED ESAWY

Extended basic cardiac
examination
•The outflow tracts are imaged by tilting
the probe towards the fetal head
•The great vessels should be of equal size
and should cross at approximately 90o as
they emerge from their respective
ventricles
Dr/AHMED ESAWY

SCAN PLANE LVOT
SCAN PLANE LVOT
Left Ventricular Outflow Tract:
(Aortic Root)
Dr/AHMED ESAWY

The outflow tracts cross at around 90o
Pulm trunk Aortic arch
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• Left ventricular outflow
tract (LVOT).
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Left ventricular
outflow.
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Left ventricular outflow tract (LVOT) view
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Long-axis view of normal left ventricular
outflow tract
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6th step RVOT biew
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RVOT Right Ventricular Outflow Tract:
(Pulmonary Trunk)
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• Right ventricular outflow tract
(RVOT).
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Right ventricular outflow tract (RVOT) view
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• Extended cardiac views.
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• Right
ventricular
outflow.
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7th step: 3 Vessel View
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SCAN PLANE PAV OR 3 VESSEL VIEW
3 vessel or PAV view
•P = Pulmonary artery exiting the right ventricle
•A = Ascending aorta
•V = Vena Cava (superior)
These should be in order of descending size. (otherwise suspect coarctation of the aorta)
If the aorta and pulmonary artery are not in perpendicular planes, suspect transposition
Dr/AHMED ESAWY

Normal relationship of three vessels (ascending aorta (Al, main
pulmonary artery [P1, superior vena cava IV]). a = descending aorta, d ı
ductus arteriosus, c =carina, It = left, rt = right
Dr/AHMED ESAWY

• Three-vessel view of the fetal heart.
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Vascular structures
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• Normal three-
vessel view.
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Three-vessel (3V) view
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Three vessels and trachea (3VT) view
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• (a,b) Venous return (IVC & SVC); (c) color
doppler angio of the venous return
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The pulmonary artery bifurcates
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8th step: Interventricular Septum
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1. MV and TV move on real time imaging
4. Ventricular septum symmetric
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6. Portion of the atrial septum present (crus)
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INTERVENTRICULAR SEPTUM
Beware of false positives with the
interventricular septum:
The part of the interventricular
septum closest to the crux of the heart
is the membranous portion and
naturally tapers. If your angle is poor, it
may be invisible simulating a
venticular septal defect(VSD
To avoid this, ideally, the integrity of the
interventricular septum should be
confirmed from a perpendicular approach
Dr/AHMED ESAWY

• Four-chamber view of the fetal heart.
Dr/AHMED ESAWY

9th step: Aortic Arch
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The aortic arch
•The aortic arch can
be identified
•The aortic cusps can
be seen
Dr/AHMED ESAWY

AORTIC ARCH
Demonstrate the aortic arch as it
leaves the left ventricle.
It will have a 'walking stick' curve.
Sagittal View of the Aortic Arch
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• (a,b) Aortic Arch; (c) color doppler angio of the
aortic arch
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• Three-dimensional power Doppler ultrasound of
the crossing of the great vessels in a 28-week fetus.
AOA, aortic arch; DA, ductus arteriosus; LPA, left
pulmonary artery; TP, pulmonary trunk.
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• Arch of aorta.
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10th step: ductal Arch
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DUCTAL ARCH
The ductal arch demonstrates the correct
orientation and communication between
the Aorta and the pulmonary trunk.
It will have a flatter curve like a 'hockey
Ductal Arch
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• (a,b) Ductal Arch; (c) color doppler of the
ductal arch
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• Ductal arch.
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ANTERIORLY POSITIONED DUCTAL ARCH
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• The components of the
sagittal view of the
ductal arch (A) as
determined by the
mutiplanar display are
displayed in B, including
the right ventricular
outlet (RV),
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• A, where the fetal aorta was aligned with the crux of the
heart in the vertical plane. The reference dot was
positioned in the aorta, allowing visualization of the
coronal view of the descending aorta in panel C.
Dr/AHMED ESAWY

• In panel C, the image was rotated to display the aorta in a
vertical position, when necessary. This allowed for the
visualization of the longitudinal view of the ductal arch in
panel B.
Dr/AHMED ESAWY

• Mutiplanar display of the sagittal view of the
ductal arch in a fetus with tetralogy of Fallot. The
root of the ductal arch was displaced downward,
toward the aortic root.Dr/AHMED ESAWY

• Diagram
representi
ng normal
relationshi
p of two
great
arteries
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Five-chamber view
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•Five-chamber view in real-time (left) using color
Doppler (right). The aorta, arising from the left
ventricle, is seen and color shows the laminar flow
across the aortic valve during systole.
Dr/AHMED ESAWY

Five short-axis views of heart
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Short-axis view of normal great arteries
• : aorta(straight solid arrow) is seen in
cross section .whereas a longitudinal
section of pulmonary artery (curved
arrow) is seen. Arrowhead = right
pulmonary artery; open arrow =
ductus arterlosus,RV = right ventricle.
Dr/AHMED ESAWY

Sonogram shows normal echogenic
focus (arrow) in left ventricle
Dr/AHMED ESAWY

Sonograms of echogenic focus at
edge of myocardium.
• A, Four-chamber view shows small echogenic
focus (arrow) at apex of left ventricle.
• B, If transducer is rotated into a plane that
shows a longer section of rib (arrow), pitfallcan
be recognized.
Dr/AHMED ESAWY

• Sonograms of eustachian valve and Chiari’s
network in right atrium. Septum primum (curved
arrow) is seen in left atrium.
• A In this slightly oblique four-chamber view,
eustachian valve (straight arrow) appears as a
linear structure within right atrium (RA).
• B In another fetus, thin curvilinear structures
(straight arrows) are present in right atrium and
were observed to move freely at real-time
sonography. We believe that these thin
structures represent Chiarl’s network.
Dr/AHMED ESAWY

Sonograms of eustachian valve and Chiari’s
network in right atrium
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Sonograms of pseudothickening of
tricuspid valve
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Normal coronary sinus (straight arrows) is seen on sonogram
angled slightly inferoposteriorly
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• Sonograms of pericardial fluid.
• A, A trace of penicardial fluid (curved arrow) is seen in this four-chamber view of a normal
fetus.Fluid is peripheral to myocardium, which itself can be relatively hypoechoic peripherally
(straight arrow). Note that fluid does not surround entire heart but is seen adjacent to a small
segment of heart.
• B, On short-axis view through ventricles of another fetus, normal peripheral hypoechoic part of
myocardium (curved arrows) can be distinguished from true fluid by observing its continuation
into ventricular septum (straight arrow).
Dr/AHMED ESAWY

• Sonograms of pseudooverriding of aorta. A, Long-axis view of left ventricular outflow tract suggests
discontinuity and overriding (arrowhead) between wail of aorta (Ao) and ventricular septum (curved arrow). in
this case, apparent interruption is immediately distal to aortic valve (straight arrow), suggesting that artifact
may sometimes be related to a sinus of Valsalva.
• B, Artifactual nature of this finding is confirmed with a slightly different imaging plane with which overriding is
not seen, that is, the septum and aorta appear continuous (arrowhead). LV = left ventricle.
Dr/AHMED ESAWY

• Sonograms of normal slight dilatation of
pulmonary artery.
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Standardized transverse
scanning planes for fetal
echocardiography
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Sagittal views of the superior and
inferior vena cava (1),
aortic arch (2),
and ductal arch (3).
The scan angle between the ductal
arch and thoracic aorta ranges
between 10° and 19°
Dr/AHMED ESAWY

Low and high short-
axis views of the fetal
heart.
Dr/AHMED ESAWY

Situs and general aspects
• 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
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
Dr/AHMED ESAWY

Ventricular chambers
• Two ventricles, approximately equal in size
• No ventricular wall hypertrophy
• Moderator band at right ventricular apex
• Ventricular septum intact (apex to crux)
Atrioventricular junction and 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
Dr/AHMED ESAWY

Cardiac Biometry
• Cardiac Biometry (Optional but Can Be Considered in the Presence of
Structural Anomalies)
• • Aortic and pulmonary artery diameters at the level of the valve annulus
• • Aortic arch and isthmus diameter measurements;
• • End-diastolic ventricular dimensions just inferior to the atrioventricular
valve leaflets
• • Thickness of the ventricular free walls and interventricular septum just
inferior to the atrioventricular valves.
• • Additional measurements may be taken if warranted, including:
• • Systolic dimensions of the ventricles;
• • Transverse dimensions of the atria; and • Diameter of branch pulmonary
arteries.
Dr/AHMED ESAWY

Prinicipal findings in upper fetal abdomen
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DD of suspected abnormalities of cardaic position
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DD of suspected abnormalities of cardaic
position
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DD of prinicipal right heart finding in four
chamber view
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DD of prinicipal left heart finding in
four chamber view
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DD of overriding aorta
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FETAL CARDIOLOGY
RHYTM
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Limitations of Fetal Echo
• Small VSDs
• Minor valve abnormalities
• Coronary Anomalies
• Coarctation of the Aorta
• TAPVR
• 20 ASDs & other rare forms
• PDA
Dr/AHMED ESAWY

Heart rate
This then increases progressively over the subsequent 2 - 3
weeks becoming
• ~ 110 bpm (mean) by 5 - 6 weeks
• ~ 170 bpm by 9 - 10 weeks
This is followed by a decrease becoming on average.
• ~ 150 bpm by 14 weeks
• ~ 140 bpm by 20 weeks
• ~ 130 bpm by term
Although the healthy fetus the heart rate is usually regular, a
beat-to-beat variation of approximately 5 - 15 beat per
minute can be allowed
Dr/AHMED ESAWY

A slow fetal heart rate is termed a fetal bradycardia : this is
usually defined as
• a heart rate below 100 bpm before 6.3 weeks' gestation or
• a heart rate below 120 bpm at 6.3 - 7.0 weeks
A rapid fetal heart rate is termed a fetal tachycardia: this is
usually defined as
• a heart rate above 160 - 180 bpm .
• a rate of 170 bpm may be classified as a borderline fetal
tachycardia
A rapid and irregular fetal heart rate is usually termed a fetal
tachyarrythmia
Dr/AHMED ESAWY

Fetal bradycardia
• refers to an abnormally low fetal heart rate. It is regarded as a
sustained first trimester heart rate below 100 beats per minute
(bpm).
• underlying conduction abnormality
• following cordocentesis
• vagal cardiovascular reflex (especially if transient during 2nd
trimester): this may occur from
– fetal head compression
– umbilical cord occlusion / compression
– maternal exertion : possibly from indequate maternal gas exchange
– hypoxia caused by myocardial depression
– stimulation of the stretch receptors in aortic arch and / or carotid sinus
walls
Dr/AHMED ESAWY

Fetal bradycardia
Classification
• Fetal sinus bradycardia
• Fetal bradyarrythmias
– Fetal partial atrioventricular block PAVB
– Fetal complete atrioventricular block AVB
– commonest type of bradyarrhythmia
Blocked premature atrail contraction
Associations
• increased risk of chromosomal anomalies : especially trisomy 18
• maternal connective tissue disease : particularly with
bradyarrhythmias
Differential diagnosis
• General considerations include transient sinus bradycardia from
excessive transducer pressure
Dr/AHMED ESAWY

Fetal Tachyarrhythmia
• The normal fetal heart rate ranges are
approximately 120-160 bpm at 30 weeks and
110-150 bpm at term. Frequencies up to 170
bpm are considered mildly abnormal, whereas
overt tachycardia is usually defined as a heart
rate exceeding 170 bpm or 180 bpm.
Dr/AHMED ESAWY

premature atrial contraction (PAC)
• premature atrial contraction (PAC) is caused
by an early electrical impulse coming from
somewhere in the atria outside the sinus
node.
• A PAC is a premature contraction coming from
a piece of tissue in the atria not transmitted to
ventricle
Dr/AHMED ESAWY

Premature Atrial Contractions
• M-mode echocardiography of a premature
atrial contraction (PAC).
Dr/AHMED ESAWY

• M-mode echocardiography of a
premature atrial contraction (PAC).
Dr/AHMED ESAWY

CARDIAC DYSRHYTHMIAS
Dr/AHMED ESAWY

• M-mode Doppler images
show premature atrial
contraction (arrow) with
subsequent early ventricular
contraction (arrowhead).
Dr/AHMED ESAWY

`
• Cardiac Rhythm, Normal and Abnormal (Fetus) /
Systemic vein, Systemic artery / Ultrasound-Doppler /
Fetus / Premature atrial contractions: isolated
blocked (upper panel), conducted (lower panel)
premature atrial contractions
Dr/AHMED ESAWY

Complete Atrioventricular block:
In complete atrioventricular block, the atria beat at their own rhythm, and none of their
impulses is transmitted to the ventricles. The ventricles have a slow rate (40-70 bpm).
Dr/AHMED ESAWY

• A. Fetal M-mode tracing of
complete atrioventricular (AV)
block, demonstrating atrial wall
motion occurring out of phase
with the much slower ventricular
wall motion.
• B. Fetal supraventricular
tachycardia (SVT). The atria and
ventricles are contracting
• rapidly, with a 1:1
atrioventricular relationship.
Irregularity of fetal SVT could be
due to transient interruption and
reinitiation or could reflect
transient alterations in AV
• conduction during ongoing atrial
tachycardia. This distinction
could prove important when
establishing medical therapy.
Dr/AHMED ESAWY

Atrial Flutter
• an atrial rate ranging from 250
• up to 500 bpm with a fixed or variable AV
block,
Dr/AHMED ESAWY

• M-mode echocardiography of AF. Flutter contractions
of the atrium are indicated by the small arrows;
atrioventricular conduction is 2:1 and ventricular
contractions are indicated by the large arrows.
Dr/AHMED ESAWY

Tachyarrhythmias:
Dr/AHMED ESAWY

Supraventricular tachycardia
• defined by a 1:1 atrioventricular conduction in
which the atrial contraction precedes the
ventricular contraction. Heart rates in SVT
most commonly range from 200-300 bpm, is
either paroxysmal or incessant in nature and
associated with fetal hydrops in 36 - 64 %
Dr/AHMED ESAWY

• M-mode echocardiography of a SVT with a short VA
interval. First white line placed on the peak excursion of
the left atrium wall, second line placed on the peak
excursion of the right ventricle wall, third line on the
consecutive peak atrial wall excursion. The AV interval
is markedly longer than the VA interval.
Dr/AHMED ESAWY

• M-mode echocardiography of a SVT with a long
VA interval
Dr/AHMED ESAWY

• 22 weeks of pregnancy;
Transverse scans
through the fetal thorax
showing the four-
chamber view of the
heart and and
pericardial effusion.
Dr/AHMED ESAWY

• 22 weeks of pregnancy; Image 3
shows the M-mode examination of
the heart with the fetal heart rate
231 bpm. Image 4 shows transverse
scans of the fetal abdomen with
ascites
Dr/AHMED ESAWY

Supraventricular
tachycardia
• 22 weeks of pregnancy;
Reverse flow at the level
of the ductus venosus was
present during fetal
tachycardia
Dr/AHMED ESAWY

M-Mode Doppler images show
supraventricular tachycardia–atrial
heart rate (arrowhead) is fast as
well as ventricular heart rate
(arrow).Dr/AHMED ESAWY

• Cardiac Function (Fetus) / Heart / Ultrasound-Doppler /
Fetus / Diastolic dysfunction in cardiomyopathy:
prolonged isovolumetric relaxation (IRT; 88 ms),
increased myocardial performance index (MPI = 1)Dr/AHMED ESAWY

FETAL CARDIOLOGY R-L
SHUNT
Dr/AHMED ESAWY

Dr/AHMED ESAWY
Cardiac Anomalies with Abnormal Four-Chamber View
Mitral Atresia
Triscuspid Atresia
Aortic Atresia
Pulmonary Atresia
Atrioventricular Septal Defect (AV-canal)
Severe Aortic Stenosis
Severe Pulmonary Stenosis with Intact Interventricular Septum Complete Anomalous
Pulmonary Venous Drainage without Pulmonary Venous Obstruction
Severe Coarctation of the Aorta
Interrupted Aortic Arch
Double Inlet Ventricle
Severe Ebstein's Anomaly with Tricuspid Dysplasia
Large Ventricular Septal Defect
Very Large Atrial Septal Defect

Dr/AHMED ESAWY
I. Communications between systemic and pulm. Circuits
LT RT. shunt.
• Inter-atrial communications. Patent F. oval , ost. 1 defect, sinus
venosus, ost.2 defect, endocarial cushin defect.
• Inter-ventricular communications.
-simple VSD.
-VSD with AI
-Single ventricle
-Gerbode defect
-Endocar. Cushion
• Aorto-pulmonary communications:
a. Persistent ductus arteriosus (P.D.A.)
b. Aorto-pulmonary window.
c. Truncus arteriosus.
d. Ruptured sinus of valsalva.
e. Coronary arterio-venous fistula.

Ventricular Septal Defect (VSD)
• Most frequent cardiac defect (20-30%) [4]
• IV septum: inlet, trabecular, infundibular
and membranous portions (muscular and
membranous)
• Maldevelopment of muscular septum or
endocardial cushion; improper resorption of
the muscular ridge
• Left to right shunt
Dr/AHMED ESAWY

VSD
4 Chamber View
4 Chamber View
LVOT
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VSD
4 Chamber LVOTDr/AHMED ESAWY

VSD
RV
4 Chamber
4 Chamber
LVOT
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VSD
4 Chamber Color
(left to right shunt)Dr/AHMED ESAWY

• Ventricular septal defect at
12 weeks gestation. The
fetus had trisomy 18
Dr/AHMED ESAWY

Dr/AHMED ESAWY
(b) Small ventricular septal defect (VSD) with shunting into left ventricle during systole. (c) VSD
with an overriding aorta, with perfusion from both ventricles into the ascending aorta
suggesting the letter ‘Y’.

• VSD in a fetus with a breech presentation.
Dr/AHMED ESAWY

• the anatomy appears to be normal. The use of color
Doppler demonstrates the presence of a muscular
ventricular septal defect during the phase of a shunt
(blue) between the right and left ventricles.
Dr/AHMED ESAWY

• Color flow ultrasound image shows flow
across the ventricular septal defect (VSD).
Dr/AHMED ESAWY

VSD (Ventricular Septal Defect):
VSD in the muscular part of the ventricular
septum of the fetal heart. This type of VSD is
called a trabecular ventricular septal defect.
Dr/AHMED ESAWY

Ventricular septal defect.
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• Ventricular septal
defect
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• Ventricular Septal Defect (VSD)
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VENTRICULAR SEPTAL DEFECTS
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Two-dimensional gray scale imaging of ventricular
septal defects
Two-dimensional gray scale imaging of ventricular septal defects
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Color and pulsed Doppler of blood shunting across a
muscular ventricular septal defect
:Color and pulsed Doppler of blood shunting across a muscular ventricular septal
defect Dr/AHMED ESAWY

Muscular ventricular septal defect
Muscular ventricular septal defect Dr/AHMED ESAWY

Inlet ventricular septal defect
Inlet ventricular septal defect Dr/AHMED ESAWY

Outlet ventricular septal defect
Legend:Outlet ventricular septal defect: the arrow indicates a large defect of the
outlet portion of the ventricular septum associated with malalignment of the great
vessels Dr/AHMED ESAWY

Perimembranous ventricular septal defect
Perimembranous ventricular septal defectDr/AHMED ESAWY

Apical ventricular septal defect
Apical ventricular septal defect Dr/AHMED ESAWY

Pitfalls: PseudoVSD
• When the IV septum parallels the US beam, resultant echo drop out
looks like VSD
• IV septum normally tapers near the AV valves
• Corrected by changing the angle of view
IV septum parallels US beam
(echo dropout)
Changing Angle
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• Pseudo-VSD in a fetus with a cephalic
presentation.
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Single ventricles
Types of single ventricles: atresia of the tricuspid valve and double inlet single ventricleDr/AHMED ESAWY

• Two-chambered heart. The image shows a single
ventricle (V) and a single atrium (A). Note the
pericardial effusion (EFF)
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UNIVENTRICULAR HEART
• This term defines a group of anomalies characterized by
the presence of an atrioventricular junction that is entirely
connected to only one chamber in the ventricular massDr/AHMED ESAWY

Dr/AHMED ESAWY
in pulmonary atresia and in (e) in tricuspid atresia with ventricular septal defect (VSD). In the
latter the right ventricle is filled in late diastole via the VSD.
Example (f) demonstrates a wide stripe in a large atrioventricular septal defect (A, atrium; RA,
LA, right and left atrium; RV, LV, right and left ventricle; V, ventricle; VSD, ventricular septal
defect).

Fetus of22 weeks’ gestation with severe tubular hypoplasia of aortic
arch and ventricular septal defect
Dr/AHMED ESAWY

Endocardial cushion defect
(complete atrio-vent. canal)
• Considered as a severe degree of ostium primum defect.
Differing in:
• 1. One valve-ring for mitral and tricuspid valves free
communication between 4 chambers.
• 2. Large inter-ventricular defect = VSD
• 3. 1ry pulm. hypertension is almost always present ( bi-
directional shunt cyanosis.
• 4. Early failure and death in early childhood
Dr/AHMED ESAWY

Endocardial Cushion Defect
• 5% of CHD
• Recur risk = 3% (1 sib), 10% (2 sibs), 1%
(dad), 14% (mom)
• Freq assoc with other anomalies; strong
assoc with Trisomy 21
• Large defect at the crus of heart on four
chamber view
Dr/AHMED ESAWY

• Several types depend on how AV valves
attach. Most common is type III,
complete AV canal and common AV valve
• Endocardial cushions fail to fuse; cause
defect in both the atrial and ventricular
septae (AV canal)
Dr/AHMED ESAWY

atria
vents
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4 Chamber View
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• Endocardial cushion defect
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vents
atria
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Heart anomalies with two color stripes in diastole in the four-chamber view (compare
with Figure 3 left). Two stripes with a connection are seen in:
(a) ventricular septal defect,
(b) (b) atrioventricular septal defect with the ‘H’ sign, or in
(c) (c) double-inlet ventricle with
two atrioventricular valves but no septum. Two stripes with differing chamber size are
seen in coarctation of the aorta (LV:RVdisproportion)
Dr/AHMED ESAWY

• Atrioventricular
canal defect.
Dr/AHMED ESAWY

AVSD
• There is a
ventricular
septal defect
involving the
upper part of the
septum.A large
atrial septal
defect (ASD) is
also seen in
these ultrasound
images.
Dr/AHMED ESAWY

Atrioventricular septal defect
• Four-chamber view in a fetus with Down syndrome
demonstrating a complete atrioventricular septal defect
(AV canal).
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• Atrioventricular septal defect.
Dr/AHMED ESAWY

Complete atrioventricular canal
Complete atrioventricular canal
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Partial atrioventricular canal
Partial atrioventricular canal: two separate atrioventricular valves insert at the same
level on the ventricular septum, and there is a defect of the atrial septum primum
Dr/AHMED ESAWY

Truncus arteriosus ( rare)
• Failure of truncus arteriosus to differentiate
into aorta and pulm. arteries thus both arise
from a common trunk having a common valve
and connected to Lt. vent.
• VSD is essential for the patient to survive.
Dr/AHMED ESAWY

Truncus Arteriosus
• Other associated pathology: VSD, abnormal
trucal valve, ASD…
• 20% overall mortality (surg < 6mo to avoid
pulmonary HTN)
• Differentiate from tetralogy of Fallot = no
RVOT; look for origin of PAs from truncus
Dr/AHMED ESAWY

Truncus Arteriosus
Four Types (Van Praagh Classification)
1. Main PA arises from truncal root and divides
2. Both PAs arise from the truncal root
separately
3. Left PA supplied by collaterals from aortic
arch
4. Aortic arch interrupted; desc aorta supplied
by ductus (10-15%)
Dr/AHMED ESAWY

TRUNCUS ARTERIOSUS COMMUNIS
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Truncus arteriosus communis
Truncus arteriosus communis: a single large vessel with a thickened valve arises from
the base the heart and give rise to the aortic arch and main pulmonary arteryDr/AHMED ESAWY

Truncus Arteriosus
Dr/AHMED ESAWY

Dr/AHMED ESAWY
Truncus arteriosus communis Type 1
with the truncus (Tr) bifurcating into
the aorta (Ao) and pulmonary trunk

• Fetus of 34 weeks’ gestation with truncus arteriosus. Three-
vessel view on sonography shows only two vessels: superior
vena cava (v) on right (rt) and common arterial trunk (Tr) on
left (It). a = descending aorta, S = spine
Dr/AHMED ESAWY

• Persistent truncus arteriosus
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Truncus arteriosus.
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Truncus arteriosus
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ductus Arteriosus
• Connect bifurcation of main pulm. artery
with infer. surface of aorta just distal to Lt.
subclavian a.
• <1% CHD
Dr/AHMED ESAWY

• Fetus of 35 weeks’ gestation with tortuous ductus arteriosus. Three-vessel
view on sonography shows tortuous ductus arteriosus (d), which forms
vascular loop a left posterior aspect of main pulmonary artery (P) and
should not be mistaken for abnoro mal additional vessel. A = ascending
aorta, a = descending aorta, It = left, rt = right, S =right, S = spine. spine, v
= superior vena cava.Downloaded from f t
Dr/AHMED ESAWY

Fetal Echocardiography: Normal Views and Anatomy

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