An error occurred while setting your user cookie. Please set your. browser to accept cookies to continue. NEJM. org uses cookies to improve performance by remembering your. ID when you navigate from page to page. This cookie stores just a. ID no other information is captured. A 10 step approach. S tep 1 Check the heart is beating. Step 2 Mmode heart rate should be between 120 and 180 beats per minute. Hover your cursor over images to. Rfrences Woodward, Kennedy, Sohaey. EXPERT DDX Obstetrics. AMIRSYS 2009. D. Gaillard, E. Alanio, C. Leroy. Pathlogie foetale et placentaire. Review Article. Current Concepts. Computed Tomography An Increasing Source of Radiation Exposure. David J. Brenner, Ph. D., D. Sc., and Eric J. Hall, D. Phil., D. Sc. Accepting the NEJM cookie is. ULTRASOUND OF THE FETAL HEART Normal. Step 1 Check the heart is beating. Step 2 M mode heart rate should be between 1. Hover your cursor over images to see highlighted anatomy or pathology. Rhino 3D 4 Torrent. Step 3 SITUSStep 4 4 CHAMBER VIEW AND VALVES4 chamber view scan plane scan plane This image shows the scan planes to obtain From the 4chamber view, by angling cranially rather than sliding the probe the outflow tracts are easily seen. VALVES visible on the 4 chamber view. Pulmonary Vein Drainage. STEP 5 Left Ventricular Outflow Tract LVOT  SCAN PLANE LVOTThe LVOT is seen by scanning through the right chest wall. The aorta arises from the left ventricle and  is just above and between the AV valves. The aortic valve moves freely. Left Ventricular Outflow Tract Aortic Root It should always be assessed in both B Mode and colour imaging. No branching should be seen in this view. STEP 6 Right Ventricular Outflow tract RVOT. RVOTThe probe is angled cephalically from the LVOT view and a slight rotation of the probe to the right fetal shoulder. Callen Ultrasonography In Obstetrics And Gynecology 6Th Edition' title='Callen Ultrasonography In Obstetrics And Gynecology 6Th Edition' />The pulmonary artery is superior to the aorta and it arises from the right ventricle. Right Ventricular Outflow Tract Pulmonary Trunk. Pulmonary Arteries. STEP 7 3 Vessel view PAV view. STEP 8 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 defectVSD. Note the descending aorta is on the left. To avoid this, ideally, the integrity of the interventricular septum should be confirmed from a perpendicular approach. STEP 9 AORTIC ARCHSTEP 1. DUCTAL ARCHUltrasound of the Fetal Heart Protocol. Role of Ultrasound. To confirm normal anatomy to the best of our ability. To progress, or elaborate on, known foetal heart pathology. Limitations. Fetal lie and large maternal habitus will inhibit the scan. With patience, the difficulties posed by foetal postion can usually be overcome. Equipment Selection. Depending on the gestational age and maternal habitus, a curvilinear probe between 3 9. Mhz. A linear probe may be used on thin patients. If 3rd trimester with very large maternal habitus, a 2. Mhz annular array may be needed. Low dynamic range B mode. High PRF colour and doppler settings with low persistance. Scanning Technique. Step Check the heart is beating. Step M mode heart rate should be between 1. Step    Situs check which is the left side of fetus then do a dual image in a tranverse axial plane of the fetus with firstly the thorax showing the heart apex orientated to the left at an angle of approximately 4. The transverse section should only contain 1 rib. The second image showing the stomach on the left ensuring the left and right side is labelled. Step Four Chamber View Angling cephalad from a transverse axial view of the abdomen. The heart should occupy approximately 13 of the chest. The ventricles should be of similar size and the atria should be of similar size. The moderator band is in the right ventricle. The left ventricle extends more apically. Assess the AV valves atrioventricular ie The tricuspid valve on the right is more apical than the mitral on the leftvalve insertion onto the interventricular septum. Watch ,in real time, the opening and closing of the valves in systole and diastole. The pulmonary venous connections can be identified. Step. Outflow Tracts. From the 4chamber view, angle further cephalad to see the Left ventricle and the aorta Left outflow tract in the same view. The aorta will be coursing to the right posterior direction. It should be assessed in colour Doppler also looking for any stenosis. Step RVOT From the LVOT view, the probe is angled further towards the head and slightly towards the fetal left shoulder. This show the pulmonary trunk heading directly posteriorly towards the spine. It will divide into the pulmonary arteries. Image and look in bmode and Colour Doppler. Step 3 Vessel View This view is a slightly oblique, axial view. It cuts the upper part of the arches and transversally the Superior Vena Cava. This is an image with. A full length view of the Pulmonary Artery P which arises from the right ventricle. A cross section of the ascending aorta AThe superior vena cava VIt is commonly labelled PAV on the image. It is important to have the 3 vessels in line with each other in order of largest P to smallest V. The aorta and pulmonary artery must be perpendicular to each other, otherwise there is a serious heart defect such as transposition of the great vessels. Step Interventricular Septum. IVS inter ventricular Septum Should be assessed when the foetus is in a decubitus position so the ultrasound beam is perpendicular to the septum. This will avoid anisotropy and a false positve for septal defect. It should be assessed in both Bmode and Colour Doppler. Step Aortic Arch. The arches are best assessed when the foetus is prone. Aortic Arch Turn the probe 9. The Aortic arch arises from the centre of the heart and is commonly referred to as a cane. Coarctations may be visualised in this view. Step Ductal Arch This is the ductus arteriosis The junction between the pulmonary trunk and the aorta. Utilise a similar scan plane to the aortic arch. The ductal arch is referred to as a hockey stick appearance, with the arch arising from the anterior of the heart. Bmode and colour assessment. Common Pathology. Basic Hard Copy Imaging. A foetal heart series should include the following minimum imaging Situs and orientation. Chambers. Inter ventricular septum. Left Ventricular outflow tract. Right ventricular outflow tract. Aortic arch Vs ductal arch. Document the normal anatomy. Any pathology found in 2 planes, including measurements and any vascularity. REFERENCESCallen PW. Ultrasonography in Obstetrics and Gynecology, Fourth Edition. W. B. Saunders Company, 2. Nyberg DA, Kapur RP, Mahony B, Pretorius DH. Ultrasound of Fetal Anomalies. Mosby,Inc., 1. 99. FOETAL HEART ULTRASOUND    How,Why and When June 2. Catherine Fredouille, MD, Jean Eric Develay Morice, MD, Ultrasonographer.