ANOMALIES OF FETAL

CARDIAC SYSTEM
BY DR NISHANT RAJ
 INTRODUCTION
• Fetal cardiac defects are common, half of which are fatal or require complex surgery.

• Early identification of these anomalies allows early referral to tertiary care centers with

relevant expertise.

• Routine antenatal ultrasound conducted between 18 and 22 weeks allows the

identification of several of these malformations.

 FETAL CARDIAC ULTRASOUND
• The first step in fetal cardiac ultrasound is to evaluate the orientation of the fetus
within the maternal abdomen—that is, fetal laterality (presentation and lie).

• Orientation is assessed from a transverse section of the fetal abdomen

• Abdominal situs is ascertained in a transverse view of the fetal abdomen.

• After determining fetal laterality from position of the fetus in utero, the stomach
should be identified on the fetal left side with the descending aorta (D. Aorta) and
inferior vena cava (IVC) to the left and right sides of the spine, respectively.
 SITUS SOLITUS
Situs solitus is the normal arrangement of

thoracic and abdominal organs

Upper abdomen view showing situs solitus.

AO, aorta; IVC, inferior vena cava; L, fetal

left; R, fetal right; P, fetal posterior; A, fetal

anterior; S, stomach.
 VIEWS IN CARDIAC ULTRASOUND
• The basic view performed in cardiac ultrasound is the four-chamber view , which
can detect 43–96% of fetal anomalies.

• The four-chamber view is obtained by a transverse projection through the fetal

thorax above the level of the diaphragm, either apical (parallel to the
interventricular septum) or subcostal (perpendicular to the interventricular
septum). This view shows the two atria and ventricles along with atrioventricular
valves (mitral and tricuspid) and septa (interventricular and interatrial).
• Standard cardiac view.

• Basic four-chamber view, which shows

right ventricle , left ventricle , right
atrium , and left atrium . Interventricular
septum (arrow) is also seen in this view
that is acquired perpendicular to
ultrasound beam. Interatrial septum
(arrowhead) is visualized.
 OUTFLOW TRACT VIEWS
• The outflow tracts view (five-chamber view) can be obtained from the four-chamber view
by sliding the transducer to the fetal head that enables the identification of the origin of
the great arteries.
• In a normal RV outflow view (RVOT), the pulmonary trunk can be visualized arising from
RV and crossing the ascending aorta.
• he evaluation of LV outflow view (LVOT) and RVOT helps to identify outflow septal
ventricular defects and conotruncal anomalies.
• The LVOT confirms the aorta arising from the morphological LV as a vessel continuing
the outflow ventricular septum as well the aortic-mitral valve continuity. In this view, the
aortic valve can be recognized and a detailed evaluation of its size and mobility can be
performed.
Image showing the five-chamber view.

Outflow LV tract (LVOT): aorta arising

from LV, aortic valve and the thickness

of the interventricular septum (IVS).

AO, aorta; LV, left ventricle; AOv,

aortic valve; M, mitral valve; IVS,

interventricular septum.
Right ventricular outflow tract (RVOT) view :This view shows a vessel connected to the right
ventricle . In the normal heart this vessel crosses over the aorta, which helps in identifying it as the
main pulmonary artery (PA). The pulmonary valve should not be thickened and should open freely.
The bifurcation of the PA into both pulmonary branches can be seen. The pulmonary valve is
closed.
THREE-VESSEL VIEW AND THREE VESSELS AND TRACHEA
VIEW

• A 3 vessel view provides a transverse view of upper fetal mediastinum.

• In this plane, the main pulmonary artery, ascending aorta and superior vena cava
are arranged in a straight line that extends from the left anterior to right posterior
aspect of the mediastinum with decreasing amplitude of their vessel diameters.
Three-vessel (3V) view. This view best demonstrates the relationship between the pulmonary
artery, aorta and superior vena cava in the upper mediastinum. It is important to note the correct
position and alignment of the three vessels as well as their relative size. The pulmonary artery, to
the left, is the largest of the three and the most anterior, whereas the SVC is the smallest and most
posterior.
Three vessels and trachea (3VT) view. This view best demonstrates the transverse aortic arch and
its relationship with the trachea. In the normal heart, both the aortic arch and the ductal arch are
located to the left of the trachea, in a ‘V’-shaped configuration
SEPTAL DEFECTS
 VENTRICULAR SEPTAL DEFECT
• Ventricular septal defect (VSD) is the most common congenital heart disease, seen
in 1.5–3.5 per 1000 live births, and accounting for 30% of all cardiac anomalies

• The defect is most commonly (80%) seen in the membranous septum and less
commonly in the muscular, outlet, or inlet portions.
Ventricular septal defect. Four-chamber

view shows small defect (arrow) in inlet

portion of interventricular septum

(arrowhead).
 ATRIAL SEPTAL DEFECT
• Atrial septal defect (ASD) is characterized by defect in a portion of the atrial septum.

• It is the fifth most common congenital heart disease, seen in 1 of 1500 live births, and is
caused by abnormal tissue resorption and deposition during development of the atrial
septum.

• According to its location, it is classified as ostium secundum (midatrial septum), ostium

primum (lower atrial septum) sinus venosus (outside the atrial septum in the wall
separating the SVC or IVC from the LA), and coronary sinus defect, which can be partial
or complete.
 ATRIOVENTRICULAR SEPTAL DEFECT
• AV septal defect (AV canal defect or endocardial cushion defect) is caused by failure of fusion
of the endocardial cushion, resulting in defects of the atrial ostium primum, the ventricular
inlet septum common AV valve, and the biventricular AV connections.

• It is associated with trisomy 21 syndrome, left atrial isomerism, hypoplastic left heart,
pulmonary stenosis, coarctation, tetralogy, complete heart block, and extracardiac anomalies.
Atrioventricular canal defect. Four-chamber

view shows large defect in inlet part of

interventricular septum (arrows) and complete

absence of interatrial septum (arrowheads),

with free communication of all cardiac

chambers.
CONOTRUNCAL ANOMALIES
 TETRALOGY OF FALLOT

• Components :

• Ventricular septal defect ;

• Pulmonary stenosis

• An overriding aorta; and.

• Right ventricular hypertrophy.

Tetralogy of Fallot. Outflow tract view shows

aorta overriding ventricular septal defect

(arrows). Pulmonary artery was visualized

separately (not shown). These findings are

consistent with tetralogy of Fallot.

Tetralogy of Fallot. The five-

chamber view showing the

overriding of the aorta and an

outlet VSD.
 TRUNCUS ARTERIOSUS

• Truncus arteriosus is characterized by a single arterial trunk that feeds the

systemic pulmonary circulation and coronary arteries with a single semilunar

valve.
• Outflow tract view shows common arterial

trunk (straight arrow) originating from left

ventricle and right ventricle , overlying

small ventricular septal defect

(arrowhead).
Doppler in outflow tract shows

common arterial trunk (straight arrow)

originating from ventricles. Admixture

of flow is seen in ventricular septal

defect (arrowhead). Curved arrow

indicates small pericardial effusion.

TRANSPOSITION OF GREAT ARTERIES

• Transposition of great arteries is characterized by the abnormal origin of the great

arteries from the ventricles because of abnormal spiraling of the conotruncal

septum. It is broadly divided into D and L types.

D-transposition of great arteries. Outflow

view shows aorta (AO) and pulmonary

artery (PA) parallel to each other, with AO

originating from right ventricle (RV) and PA

from left ventricle (LV).

AORTIC ARCH ANOMALIES
 COARCTATION OF AORTA
• Coarctation of the aorta represents a narrowing of the aortic arch and, in general,
it is located between the origin of the left subclavian artery and the ductus
arteriosus

• Prenatally, coarctation may be difficult to detect mainly in the mild and moderate
forms, because the ductus arteriosus is patent.

• Chromosomal abnormalities are present in about 30% of fetuses with coarctation

of the aorta.
The three vessels view showing

the small size of the transverse

aorta in a case of coarctation of

the aorta.
HYPOPLASTIC LEFT HEART SYNDROME

• Characterized by hypoplastic left-sided cardiac structures, including the LV, mitral

valve, aortic valve, and aorta.

• It is more common in boys and is caused by decreased flow in and out of the LV

during development (e.g., mitral or aortic stenosis or atresia)

• It is associated with aortic coarctation in 80% of cases

Four-chamber view shows small

left ventricle and left atrium ,

associated with ventricular septal

defect consistent with hypoplastic

left heart syndrome..

 HYPOPLASTIC RIGHT HEART
SYNDROME
• Hypoplastic right heart syndrome is characterized by an underdeveloped right side of
the heart, including the RV, tricuspid valve, pulmonary valves, and PA.

• Rarer than the hypoplastic left heart syndrome.

• Caused by decreased blood flow in and out of the RV during development (tricuspid
atresia or pulmonary atresia).

• The most common cause is pulmonary atresia with an intact ventricular septum.
Four-chamber view show thickened

leaflets of tricuspid valve (arrows),

with restricted opening, consistent

with tricuspid stenosis.

THANK YOU