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Basic Fetal


Transverse Sweep

Major fetal cardiac


The normal 4chamber

It is abnormal in




About 40% of major congenital

heart malformations are only
seen in the great artery views

The normal 4-chamber view

It must be analyzed systematically
in terms of heart: size, position,
structure and function
-It is ideally imaged when the fetal
spine is down (apical view).
-Equally good assessment may be
achieved with (the lateral view )
or even the spine up (back-up

Heart size
occupies one third of the
area of the chest.
The normal C/T ratio is
around 0.55 (range 0.50.6).

The fetal heart42.flv

Heart position
Most of the heart lies in the left chest.
The left atrium (LA) is the most
posterior chamber in the normal
heart and it the nearest chamber to
the spine.
The descending aorta lies anterior to
the spine and behind the left atrium
The right ventricle (RV) lies behind the

Heart position
The heart normally lies
with the inter-ventricular
septum at about 45
(range 25-70) to the
midline of the thorax
with the apex pointing
out of the left anterior
chest wall

Heart position


Heart structure
approximately equal size


There are two ventricles of

approximately equal size
There are two atrio-ventricular
valves opening equally, the
mitral valve on the left and
the tricuspid valve on the right

The apex of the right ventricle is more

trabeculated than the left and contains a
(moderator band) which is of variable
There is normally a small amount of fluid in
the pericardium producing a dark line
around the myocardium.
The crux or centre of the heart is formed by
the junction of the atrioventricular septum
and the septal leaflets of the mitral and
tricuspid valves

Heart structure

The tricuspid valve inserts more apically than

the mitral and therefore there is offsetting (or differential insertion) of the
two valves into the crux
In a normal heart, as a result of differential
insertion, the two valves do not form a
straight line across the crux.
In a normal heart the ventricular septum is
intact from the apex to the crux

The primum atrial septum attaches to the

crux. There is a defect in the middle third of
the atrial septum (the foramen ovale),
guarded by the foramen ovale flap, which
lies in the left atrium.
There is one vessel lying behind the heart (the
descending aorta), just to the left of the
midline, between the spine and left atrium
The pulmonary veins attach to the back of the
left atrium. Their connection must be
confirmed on colour flow mapping

Heart function
The two ventricles contract equally and briskly
The two atrioventricular (AV) valves open
equally and freely
On colour flow mapping, there is equal filling
of both ventricles and there is no significant
AV valve regurgitation
A small amount of tricuspid regurgitation on
colour flow mapping is not uncommon with
modern sensitive ultrasound machines and is
usually of no significance in the midtrimester
The atria and ventricles contract synchronously
and regularly at a rate of about 140 beats per
minute with a range of 120-180

The 4-chamber view:
Is the most important of the cardiac views
It must be checked systematically in terms
of size, position, structure and function
It is the starting point for initiating the
transverse sweep or for turning the
transducer into the longitudinal views
Correct analysis and interpretation of this
view depends on a thorough familiarity with
the normal
Normality of the 4chV excludes over 60% of
the major congenital heart malformations

In the normal heart the moderator band lies
in the left ventricle
The 4-chamber view is abnormal in all major
cardiac malformations
In the normal heart the tricuspid valve inserts
more apically than the mitral valve
The normal heart lies equally in the left and
right chest
The two ventricles are normally of equal size

Normal great artery views

About 40% of major heart defects are seen in
the great artery views. It is therefore
important to extend cardiac evaluation
from the 4-chamber view to image the great
artery views
The great arteries should be analyzed
systematically, with


position, structure and function



The great artery views include:

Left ventricular outflow tract (aortic origin)
3-vessel view
Transverse aortic arch view
Long axis view of the left ventricle
Arch and duct view
Long axis view of the duct
Long axis view of the arch
Short axis view of the left ventricle
Tricuspid-aorta view
Caval vein view

If you can recognize an abnormal

appearance of any of these views and
describe accurately why it is different from
normal, you can reach the correct diagnosis

Left Ventricular out flow tract(Aortic origin view)

In the normal heart, the first great artery,
seen just above (cranial to) the 4-chamber
view, is the aorta
The aorta arises wholly from the left
ventricle and initially sweeps out towards
the right shoulder

Left Ventricular out flow tract(Aortic origin view)

There are no visible branches of the aorta
close to the valve
The anterior wall of the aorta is continuous
with the ventricular septum
The posterior wall of the aorta is continuous
with the anterior leaflet of the mitral valve

Left Ventricular out flow tract(Aortic origin view)

The aortic valve opens freely during systole
(the valve cusps disappear in systole)
On color flow mapping there is laminar (nonturbulent) forward flow across the aortic
valve and no regurgitation

Arterial cross over

Just above the aortic valve, the pulmonary
artery arises from the right ventricle. The
blue arrows indicate the direction of flow in
the great arteries at their origin. Note that
they arise almost at right angles to each
other: the flow is directed cranially and
rightwards in the aorta and directly
posteriorly in the pulmonary artery

Arterial cross over

As the beam is moved up towards the head from
the view of the aortic origin, the pulmonary
artery is seen to cross over the aortic origin
By moving the ultrasound beam back and
forward between the view of the aortic origin
and the three vessel view (which images the
pulmonary artery), the relative size and
position of the two great arteries can be noted.

The 3-vessel view

The pulmonary artery is normally slightly
bigger than the aorta. (For example, at 20
weeks the pulmonary artery is about 3.5
mm and the aorta is about 3.0 mm).
The pulmonary valve is anterior and cranial
to the aortic valve.
The pulmonary valve opens freely with
laminar flow across it

The 3-vessel view

The pulmonary artery continues as the






descending aorta. The pulmonary artery

branches laterally soon after the valve. The
branches of the pulmonary artery are seen
just below the level of the arterial duct,
therefore just below the 3-vessel view

Transverse aortic arch view

The transverse aortic arch is seen just above
the 3-vessel view. The arch:
Lies above the arterial duct
Crosses the midline of the thorax from right
to left in front of the trachea
Has an even caliber along its length
Demonstrates forward flow on color Doppler

Long axis view of the left ventricle

This view is obtained when the ultrasound
beam is angled on the 4-chamber view
A longer portion of aorta can be seen arising
from the left ventricle
No major branches are seen arising from the
The continuity of the septum and anterior
wall can be more clearly seen than in the
aortic origin view
There is laminar flow across the whole length
of the left ventricular outflow tract

Arch and duct view

When the ultrasound beam is angled on the
transverse arch, the arch and duct can be
imaged simultaneously. In this view:
The duct and transverse arch are of similar
The direction of flow is the same in the arch
and duct

Long axis view of the duct

In this scan plane:
The aorta, cut in its short axis, lies in the centre
The right heart structures wrap around the
aorta anteriorly:
the inferior vena cava crosses the
diaphragm and enters the right atrium
the tricuspid valve lies below the aorta
the right ventricle lies in front of the aorta
and the pulmonary valve lies above the

The main pulmonary artery and the ductal

connection to the descending aorta is seen
in long axis
The pulmonary artery is slightly bigger than,
and lies anterior and cranial to, the aorta
There is laminar forward flow in the
pulmonary artery and arterial duct

Short axis view of the left ventricle

In this scan plane:
The right ventricle is banana-shaped and lies
anterior to the left ventricle
The pulmonary valve is seen at the cranial end
of the right ventricle
The left ventricle appears as a circle, contracting
briskly and concentrically with the fishmouth appearance of the mitral valve within
The septum is intact
There is forward flow from the right ventricle to
the pulmonary artery

The great artery views:
Familiarity with the typical appearance will
allow the normal features of great artery
size, position, structure and function to be
checked during a routine ultrasound scan
The transverse views usually provide all the
necessary information about normality in
the fetal heart

The sagittal views can also be used for
analysis and can add information in
defining and documenting a cardiac defect
The rules for the analysis of each view are the
same no matter what the fetal position and
orientation of the sections

Please answer with a yes or no if the
the following statements are correct:

The aorta branches laterally

In the normal heart the aortic valve lies
anterior to the pulmonary valve
In the normal heart the pulmonary artery
branches laterally and the aorta superiorly
In the normal heart the aorta is always larger
than the pulmonary artery at their origin
In the normal heart the aortic arch crosses the
midline in front of the trachea