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Lindsey D. Allan
Evaluation o f the fetal heart can be readily incorporated into the obstetric ultrasound examination
and n e e d not add more than a few minutes to the examination. Correct analysis of the four-chamber
view and both outflow tracts will exchule the majority o f serious congenital heart disease. Where
cardiac malformations are identified during pregnancy, parents should be referred to a pediatric
cardiologist with expertise and experience o f fetal heart scanning for further counseling. This allows
for management o f the pregnancy to be tailored to the parents wishes and the type o f malformation
found.
Copyright 9 2000 by W.B. Saunders Company
ardiac malformations are common, affect- congenital heart disease being detected is for
C ing about 8 o f 1,000 pregnancies. However, something abnormal being recognised during
only about 3 of 1,000 are serious and readily the obstetric scan. For this reason, the c o n c e p t
detectable prenatally. It is important to detect o f "screening" the fetal heart in a simplified
serious forms of congenital heart disease in the fashion during routine obstetric scanning was
fetus as they are associated with a significant introduced. 1
morbidity and mortality in affected children. Cardiac assessment during an anatomical ob-
All forms of congenital heart disease nowadays stetric survey is r e c o m m e n d e d to include at least
can be treated, although at varying levels of a four-chamber view o f the heart, 2 and this sin-
risk and quality of outcome. A clear understand- gle view will detect about 60% of serious malfor-
ing in early pregnancy o f the prognosis for the mations or abnormalities in about 2 of 1,000
child allows parents to make informed decisions pregnancies scanned. Despite the fact that al-
concerning the management. In continuing most all pregnancies are scanned at some time
pregnancies, the o u t c o m e for the affected child during gestation and that the four-chamber view
can be improved by optimizing perinatal man-
should be part of every ultrasound assessment,
agement. T h e r e are some categories of preg-
many forms of congenital heart disease recogni-
nancy in which there is an increased risk of
sable in this view continue to be overlooked
congenital heart disease and these mothers
during obstetric e v a l u a t i o n / M a n y authors have
should be referred to a fetal echocardiographer
suggested a more detailed study be p e r f o r m e d
for detailed study. These include mothers with a
during obstetric evaluation to increase the de-
family history of congenital heart disease, mater-
tection o f congenital heart disease by including
nal diabetes, exposure to cardiac teratogens in
identification o f the great artery connections. 4
early pregnancy, and the detection of fetal ar-
rhythmias or extracardiac abnormalities. This Accurate evaluation of the great arteries connec-
last group include those with extracardiac mal- tions will detect up to 90% of serious cardiac
formations, especially those with nuchal edema, malformations.
or fetal hydrops. However, 90% of mothers who
give birth to infants with congenital heart dis-
ease have no high risk features noted in their
pregnancy. The only h o p e these patients have o f Practical Scanning
The Heart Lies on the Left Side o f the in a systematic fashion, which includes an as-
Fetus (on the Same Side as the Stomach) sessment o f h e a r t size, position, structure, a n d
function.
Normally, when the u l t r a s o u n d b e a m is swept
Size. Normally, the heart occupies about one
cranially f r o m a transverse section o f the ab-
third of the thorax. If there is d o u b t about the
d o m e n to the apex o f the heart, it can be seen
that b o t h the s t o m a c h a n d the h e a r t lie o n the heart size on a visual assessment, the area or the
same side of the fetus (Fig 1). This will almost circumference of the heart can be measured and
always m e a n that they are b o t h o n the left side c o m p a r e d to n o r m a l values. 7
b u t if they are discrepant, the side o f each Position. Normally, the midline of the tho-
must be d e t e r m i n e d . Also, a l t h o u g h rarely, rax passes t h r o u g h the left atrium, f o r a m e n
they can b o t h be n o r m a l but b o t h lie o n the ovale, the right atrium, a n d the a n t e r i o r cor-
right (situs inversus). T h e t e c h n i q u e o f Cordes ner o f the right ventricle, such that most of the
et al 5 for d e t e r m i n i n g "sidedness" appears to h e a r t lies in the left chest (Fig 2). The inter-
be reliable. T h e first step is to orientate the ventricular s e p t u m forms an angle o f a b o u t
t r a n s d u c e r in the long-axis o f the fetus with 40 ~ with the midline, s An a b n o r m a l angle o f
the h e a d to the right o f the screen. T h e trans- the s e p t u m can indicate a cardiac malforma-
d u c e r is then t u r n e d t h r o u g h 90 ~ in a clock- tion or a space-occupying lesion within the
wise direction. If the spine is posterior, the left chest. 9
side o f the fetus will be o n the right o f the Structure. To o r i e n t in the f o u r - c h a m b e r
screen. Conversely, if the spine is anterior, the view, it is useful to relate the h e a r t to the
left side o f the fetus wilt be o n the left o f the spine. O p p o s i t e the spine is the a n t e r i o r
screen. chest wall or s t e r n u m a n d below this is the
right ventricle. I m m e d i a t e l y a n t e r i o r and to
The Four-Chamber View is Normal the left o f the spine is the d e s c e n d i n g aorta
A f o u r - c h a m b e r view o f the fetal h e a r t is ob- a n d anterior to that is the left atrium. T h e
tained in a horizontal cross-section of the tho- right atrium a n d left ventricle can t h e n be
rax j u s t above the d i a p h r a g m . A n o r m a l four- deduced.
c h a m b e r view excludes m a n y forms o f In the four-chamber view, the following as-
c o n g e n i t a l h e a r t disease. It must be evaluated pects of structure should be seen:
Figure 1. (A) The stomach in the abdomen in the usual position. (B) Sweeping cranially, the four-chamber
view in seen in the thorax just above the diaphragm, with the apex on the same side of the fetus as the
stomach.
326 Lindsey D. Allan
T h e Ventriculo-Arterial C o n n e c t i o n s
are N o r m a l
Figure 4. (A) A diagramatic representation of the transducer beam is shown as it is swept though tile heart from
the four chamber view successively to the aortic (AoV) and pulmonary valves. The most superior slice shows the
aorta forming the arch just above the pulmonary artery and duct. 4oh, four chamber; 3V view, three vessel view.
(B) Moving cranially from the four-chamber view allows the aortic origin from the left ventricle to be imaged.
Angling slightly between the apex and the right shoulder helps to "open out" this view.
328 Lindsey D. Allan
Figure 6. The arterial duct (D) in a long axis view of Figure 8. The characteristic "hook" shape of the aor-
the fetus. The aorta (Ao) lies in the center of this scan tic arch with the head and neck vessels arising from
plane. the superior aspect of the arch.
A Practical Approach to Fetal Heart Scanning 329
fined birth population. Atlanta Georgia 1990-1994. J Am grown fetuses and those with intrauterine growth retar-
Coll Cardiol 28:1805-1809, 1996 dation. Ultrasound Obstet Gynecol 9:374-382, 1997
4. Achiron R, Glaser J, Gelernter I, et al: Extended fetal 12. Schmidt KG, Silverman NH, Rudolph AM: Assessment of
echocardiographic examination for detecting malforma- flow events at the ductus venosus-inferiorvena cavajunc-
tions in low risk pregnancies. B M J 304:671-674, 1992 tion and at the foramen ovale in fetal sheep by use of
5. Cordes TM, O'Leary PW, SewardJB, et al: Distinguishing multimodal ultrasound. Circulation 93:826-833, 1996
right from left: A standardized technique for fetal echo- 13. Yoo SJ, Lee YH, Kim ES, et al: Three-vessel view of the
cardiography. J Am Soc Echocardiogr 7:47-53, 1994 fetal upper mediastinum: An easy means of detecting
6. Allan LD: The normal fetal heart, in Allan LD, Horn-
abnormalities of the venu-icular outflow tracts and great
berger LK, Shartand GK (eds): Fetal Cardiology. Green-
arteries during obstetric screening. Ultrasound Obstet
wich Medical Publishers. 2000 (in press)
Gynecol 9:173-182, 1997
7. Paladini D, Chita SK, Allan LD: Prenatal measurement
14. Allan LD, Chita SK, Anderson RH, et al: Coarctation of
of cardiothoracic ratio in evaluation of congenital heart
the aorta in prenatal life: An echocardiographic, ana-
disease. Arch Dis Child 65:20-23, 1990
8. Comstock CH: Normal fetal heart axis and position. tomical, and functional study. Br Heart J 59:356-360,
Obstet Gynecol 70:255-259, 1987 1988
9. Allan LD, Lockart S: Intrathoracic cardiac position in 15. Yagel S, Weissman A, Rotstein Z, et al: Congenital heart
the fetus. Ultrasound Obstet Gynecol 3:93-96, 1993 defects. Natural course and in utero development. Cir-
10. Hornberger LK, Sahn DJ, Kleinman CS, et al: Antenatal culation 96:550-555, 1997
diagnosis of coarctation of the aorta: a multicenter ex- 16. Stumpflen I, Stumpflen A, Wimmer M, et al: Effect of
perience. J Am Coll Cardiol 23:417-423, 1994 detailed fetal echocardiography as part of routine pre-
11. Gembruch U, Smrcek JM: The prevalence and clinical natal ultrasonographic screening on detection of con-
significance or tricuspid valve regurgitation in normally genital heart disease. Lancet 348:854-857, 1996