Standard Views to Exclude Structural Congenital Heart Disease

We are convinced that the initial echocardiogram of any newborn should not only assess function (e.g., PDA) but also rule out structural congenital heart disease.

The Necessity of Thorough Assessment

While it’s unrealistic to expect neonatologists to possess a level of expertise akin to pediatric cardiologists in diagnosing structural heart diseases, the former can arguably be trained to distinguish between normal and abnormal conditions.

Procedure for Evaluation

Defining or ruling out normal conditions requires a series of views to be performed, applicable to all infants. In every case, a structured approach to echocardiography is essential. Each examination should adhere to a sequence of standard views, confirming at least a minimum checklist of normal anatomical features. The echocardiogram should unfold in a logical sequence, meticulously outlining venous drainage, all four cardiac chambers, septae, and all four valves. We propose beginning with subcostal views, though some practitioners prefer these as final steps to avoid unsettling the child due to abdominal pressure.

Suggested Sequence for Structural Echocardiogram

Below is a recommended sequence of views, each aiming to identify specific features:

  1. Transverse Subcostal View
    • Indicates normal abdominal situs
  2. Subcostal Atrial and Four Chamber Views
    • Demonstrates SVC draining into the right atrium, pulmonary veins into the left atrium
    • Confirms intact intra-atrial septum (or patent foramen ovale)
    • Verifies intact intra-ventricular septum
    • A sweep anterior to the ascending aorta and pulmonary artery
  3. Apical Four Chamber View
    • Shows normal mitral and tricuspid valves, with the tricuspid positioned closer to the heart's apex
    • Establishes atrioventricular concordance
    • Validates intact intra-ventricular septum
    • Rotates to the ‘five-chamber view’ to identify the normal aortic valve from the left ventricle
    • Exhibits pulmonary artery from the right ventricle crossing over the aorta, ruling out transposition (i.e., confirming ventriculo-arterial concordance)
    • Portrays pulmonary veins draining into the left atrium
  4. Parasternal Long Axis View
    • Displays normal motion of mitral and aortic valves
    • Affirms intact intra-ventricular septum
    • Identifies normal tricuspid valve
    • Detects normal pulmonary valve
  5. Parasternal Short Axis View
    • Recognizes normal (tricuspid) aortic valve
    • Confirms intact intra-ventricular septum
    • Pinpoints normal pulmonary valve
    • Identifies the bifurcation of the main pulmonary artery into right and left branches
    • Validates drainage of pulmonary veins into left atrium
  6. Ductal View
    • Checks ductal patency and direction of flow
  7. Arch View
    • Excludes coarctation

These views serve as pivotal steps in diagnosing and ruling out structural congenital heart diseases, enabling physicians and specialists to provide precise and effective care to newborns.