Segmental echocardiographic approach to congenital heart disease

Editors: Eli V. Gelfand, MD and Keri Shafer, MD (Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA)

Evaluation of cardiac anatomy
Echocardiographic evaluation of congenital heart disease requires segmental and systematic approach.

1. Assess atrial situs

 * Subcostal views are optimal
 * Situs Solitus= Normal anatomy (morphologic right atrium is to the right and morphologic left atrium is to the left)
 * Morphologic right atrium:
 * Always contains eustachian valve
 * Appendage: shorter and broader than left atrium
 * Morphologic left atrium:
 * Lacks eustacian valve
 * Rounded shape
 * Appendage: thinner, longer and narrower atrail junction compared to right atrium


 * Situs inversus is mirror image (morphologic right atrium is to the left, left atrium to the right)

2. Assess venous inflow patterns

 * Transverse imaging plane through abdomen
 * Abdominal aorta lies to left of spine (aorta more rounded, pulsatile)
 * Inferior vena cava lies to the right of spine
 * Assess pulmonary inflow patterns: often difficult in the adult to identify all 4 pulmonary veins.

3. Evaluate artrioventricular connections

 * Evaluate morphologic atrium and ventricular connection.
 * Must assess ventricular morphology to confirm

4. Define ventricular morphology and position

 * 4-chamber view for locations and valvular morphology, short axis views for papillary muscle evaluation
 * Can use appearance to determine morphology of left and right ventricles:
 * Right ventricle: has trabeculations
 * Left ventricle: smooth endocardial surface
 * Atrioventricular valves are also helpful in determining ventricular morphology:
 * Tricuspid valve (right ventricle): 3 leaflets, 3 papillary muscles and chordal insertions into septum
 * Mitral valve (left ventricle): 2 leaflets, 2 papillary muscles, no septal chordal insertion

5. Evaluate ventriculoarterial relationship

 * Short axis views most helpful for ventricular-artery attachments, parasternal views for artery morphology, rightward aorta seen on suprasternal views.
 * Normal orientation:
 * Pulmonary artery: orientation is anterior and leftward
 * Aorta: orientation rightward and posterior
 * Two possible transposition forms
 * D-transposition: normal morphologic ventricular relationship
 * L-transposition: atrioventricular discordance: morphologic right ventricle on left, morphologic left ventricle on right

Back to Echo in congenital heart disease

Other links
Yale Echo in Congenital Heart Disease

Reference

 * Feigenbaum's Echocardiography 6th Ed.