the ultrasonic evaluation of

the human fetal

cardiovascular system

A test using sound waves to

show the structure of an
unborn baby's heart

The primary diagnostic tool

used to assess fetal cardiac
structure and function
 A demonstration
course of the
of the visceral
great arteries
and cardiac situs

A complete fetal
echocardiographic
examination

ventriculoarte
a four
rial
chamber view
connections
Ultrasound systems should have capabilities for
performing

2-dimensional

M-mode

Doppler imaging
 The choice of transducer frequency
3- to 5-MHz abdominal transducers allow in most patients

A lower-frequency transducer (2–2.25 MHz) in an obese

patient

During early pregnancy, a 5-MHz abdominal transducer or a

5- to 10-MHz or higher vaginal transducer
 4-chamber view
(BCEE)

Fetal
echocardiograph 3-
outflow
y included : vessels
tract
trachea
view
view
(OTV)
(3VTV)
 4-
chamb the
the er view main
right pulmon
ventric ary
ECEE
ular artery
outflow the left and its
tract ventric branch
ular es
outflow
tract
Indications for Fetal Echocardiography
Timing of Examination

The optimal timing for

performance of a
comprehensive 18 to 22 weeks gestation
transabdominal fetal
echocardiogram
Equipment
Ultrasound systems used for fetal echocardiography should
have capabilities for performing 2-dimensional, M-mode, and
Doppler imaging

Although the goal is to achieve visualization of each of the

essential components,not all will be visualized in every fetus at
every examination

Fetal position in the uterus or increased activity may limit the

ability to ontain visualization of each of the components
Examination Technique
Cardiovascular anatomy and fetal circulation
 Fetal Heart Circulation
A baby's heart begins to develop at
conception, but is completely formed by
eight weeks into the pregnancy.
Congenital heart defects happen during
this crucial first eight weeks of the
baby's development.

The Fetal Circulation: The ductus venosus carries the most highly oxygenated blood sequentially across the
foramen ovale (FO) to the left atrium (LA), the left ventricle (LV), and then out of the aorta (Ao) to supply the
coronary arteries and brain. The superior vena cava directs the most deoxygenated blood across the
tricuspid valve into the right ventricle (RV) and then out the pulmonary artery and ductus arteriosus to the
lower half of the body and the placenta
• Although the goal is to achieve visualization of each of the essential
components,not all will be visualized in every fetus at every
examination
• Fetal position in the uterus or increased activity may limit the ability
to ontain visualization of each of the components
Essential components
of the fetal
echocardiogram
Fetal cardiac sweep. During the standardized transverse scanning planes for fetal echocardiography the sonographer is
sweeping the transducer beam in a transverse plane from the level of the four-chamber view towards the fetal neck as
presented in the left of the image. By doing so, the following views become apparent: Four-Chamber View (4CV),
arterial outflow tracts: Left Ventricular Outflow Tract (LVOT), Right Ventricular Outflow Tract (RVOT) and the Three-
Vessel and Trachea View (3VTV)
Cardiac sweep in the first trimester in duplex
mode: gray-scale (left of each pair of
images) and color Doppler (on the right).
1. Four-chamber view plane
2. left ventricular outflow tract plane
3. Crossing of the great vessels.
4. Three vessels and trachea view plane
Prenatal diagnosis of congenital heart disease
I. Frequency and Timing of Screening
II. Examiner
III. Observations Condition
• Ultrasonic tomography devices.
• Probe.
• Pre-set functions provided by the manufacturer
• Frequency
• Gain
• Zoom
• Frame rate
• Persistence
• Focus
• Frame-by-frame advance or slow playback
• Video
IV. Views and points to observe
a. Confirming Position

Fig. 1 Sagittal section of the fetus with the

head on the right.
b. Abdominal Section

Fig. 2 Horizontal section of the fetal

trunk viewed from above
Upper abdominal view, used to determine the abdominal situs. This can be made when
the Abdominal Circumference (AC) is measured. L, left; R, right; St, stomach; UV, umbilical
vein; Dao, descending aorta; IVC, Inferior Vena Cava, Sp, spine.
Standardized transverse scanning planes for fetal echocardiography include an evaluation of the 4-chamber view (1),
arterial outflow tracts (2 and 3), and the 3-vessel and trachea view (4). Ao indicates descending aorta; Asc Ao,
ascending aorta; LA, left atrium; LV, left ventricle; PA, pulmonary artery; RA, right atrium; RV, right ventricle; and Tra,
trachea.
c.Four Chamber View :
- Cardiac Position

Fig. 3 Cardiac position. LA, left atrium; LV,

left ventricle; RA, right atrium; RV, right
ventricle.
Schematic presentation of the four-chamber view and sonographic assessment in duplex mode (Gray-scale and
color Doppler) in Diastole (D) and Systole (S). Note that the mitral valve has a slightly more apical insertion at
the crux cordis. The atrio-ventricular Doppler flow is red because of the direction toward the direction during
diastole. When the atrio-ventricular are closed, during systole, the atrio-ventricular flow is absent.
Schematic presentation of left ventricular outflow tract view and sonographic assessment in duplex mode
(Gray-scale and color Doppler) in Diastole (D) and Systole (S). Note the continuity of the Ventricular Septum
(VS) with the aortic wall, namely the Septo-Aortic Continuity (SAC). When the Aortic Valve (AoV) is closed,
during dystole, the aortic flow is absent.LV, left Ventricle; RV, Right Ventricle; LA, Left Atrium; RA, Right Atrium;
Ao, Aorta
Schematic presentation of right ventricular outflow tract view (RVOT) and sonographic assessment in duplex
mode (Gray-scale and color Doppler). Note that the short axis view offers a better image of the conection
between the right ventricle and the main pulmonary artery. RV, Right Ventricle; MPA, Main Pulmonary Artery;
DA, Ductus Arteriosus; RPA, Right Pulmonary Artery; SVC, Superior Vena Cava; DAo, Descending Aorta; pv,
Pulmonary Valve
Schematic presentation Three Vessel and Trachea View (3VTV) and sonographic assessment in duplex mode
(Gray-scale and color Doppler). In a slightly cranial plane of the fetal chest, we note that the ductus arteriosus
is fading, as the aorta is still well-seen.
Aortic arch longitudinal view, branching and continuity with the
descending aorta
Ductal and Aortic arches in longitudinal view. The differnces mentioned in
the text are obvious, regarding the origin, curvature and branching
Bicaval view. IVC, Inferior Vena Cava; SVC, Superior Vena Cava; RA, Right
Atrium
Cardiac Size
Cardiac Axis
Cardiac Lateral Differences

Fig. 4 Cardiac axis. LA, left atrium; LV, left

ventricle; RA, right atrium; RV, right
ventricle
Low and high short-axis views of the fetal heart. Ao indicates aortic valve; LV, left ventricle;
PA, pulmonary artery; RA, right atrium; and RV, right ventricle.
Fig. 8 Tilting the probe from the four-chamber view toward the head. (a) Four-chamber view; (b) three-vessel
view; (c) three-vessel trachea view. aAo, ascending aorta; DA, ductus arteriosus; dAo, descending aorta; LA, left
atrium; LPA, left pulmonary artery; LV, left ventricle; MPA, main pulmonary artery; RA, right atrium; RPA, right
pulmonary artery; RV, right ventricle; SVC, superior vena cava.
Sagittal views of the superior and inferior venae cavae (1), aortic arch (2), and ductal arch (3). The scan angle between
the ductal arch and thoracic aorta ranges between 10° and 19° during pregnancy, as illustrated by the 4-chamber view
diagram (Espinoza J, et al. J Ultrasound Med 2007; 26:437–443). Ao and Desc Ao indicate descending aorta; Ao Root,
aortic root; DA, ductus arteriosus; IVC, inferior vena cava; LA, left atrium; LV, left ventricle; PV, pulmonary valve; RA, right
atrium; RPA, right pulmonary artery; RV, right ventricle; and SVC, superior vena cava.
d. Observation of Outflow Tract :
 two major arteries of approximately the same size
 two major arteries that intersect in space
 the connection of one major artery to each of the ventricles
The ascending aorta, pulmonary artery and descending aorta make a V-
shape in a normal fetus. The trachea is located between the ascending
aorta and the spine.
The great arteries in order from right to left in the chest cavity of a
normal fetus: superior vena cava, ascending aorta, pulmonary
artery.
Doppler Imaging : color Doppler
sonography should accompany
the greyscale evaluation, to
evaluate the normal flows in the
respective cardio-vascular
structures
Analysis of arrhythmia using M-mode
Heart Rate and Rhythm echocardiography: setting the M-mode cursor to
Assessment pass through the aortic valve and left ventricle.

Cardiac Biometry
Cardiac Function Assessment