NeonatalEchoSkills

Standard Views to Exclude Structural Congenital Heart Disease

We believe that the first time any newborn has an echocardiogram that it should not only assess function (e.g. PDA) but also rule out structural congenital heart disease.

It is unrealistic for neonatologists to achieve anything like the expertise which paediatric cardiologists have in diagnosing structural heart disease. However it can be argued that neonatologists performing echocardiograms merely need to recognise what is normal, and what is abnormal.

To define or exclude normality requires a number of views to be performed, and all views should be performed in all infants. In all cases it is essential to follow a structured approach to echocardiography. At every scan we would recommend that standard views are gained in sequence, with at least a minimum ‘checklist’ of normal anatomical features confirmed. The standard views for echocardiography are listed below, and example images and anatomical descriptions are given via the links on the right hand side. The echocardiogram should be performed in a logical sequence, taking care to delineate the venous drainage, all four cardiac chambers, the septae and all four valves. For this reason we suggest starting with the subcostal views, however others prefer to leave these views to last in case pressure on the abdomen disturbs the child.

A suggested sequence for a structural echocardiogram is given below.

View

Demonstrates

1.    Transverse subcostal view

Normal abdominal situs

2.    Subcostal atrial and four chamber views

SVC drains into right atrium, pulmonary veins into left atrium

Intact intra-atrial septum (or patent foramen ovale)

Intact intra-ventricular septum

Sweep anterior to ascending aorta and pulmonary artery

3.    Apical four chamber view

Normal mitral and tricuspid valves, with tricuspid positioned closer to the apex of the heart.

Establish atrio-ventricular concordance

Intact intra-ventricular septum

Rotate to ‘five chamber view’ to identify normal aortic valve from the left ventricle

Demonstrate pulmonary artery from the right ventricle crossing over aorta, excluding transposition (i.e. establishing ventriculo-arterial concordance)

Pulmonary veins draining to left atrium

4.    Parasternal long axis view

Normal motion of mitral and aortic valves

Intact intra-ventricular septum

Identify normal tricuspid valve

Identify normal pulmonary valve

5.    Parasternal short axis view

Identify normal (tricuspid) aortic valve

Intact intra-ventricular septum

Identify normal pulmonary valve

Identify bifurcation of main pulmonary artery into right and left branches

Confirm drainage of pulmonary veins into left atrium

6.    Ductal view

Check ductal patency and direction of flow

7.    Arch view

Exclude coarctation