A Practical Approach to Fetal Heart Scanning

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-
C ing about 8 o f 1,000 pregnancies. However,
only about 3 of 1,000 are serious and readily
detectable prenatally. It is important to detect
serious forms of congenital heart disease in the
fetus as they are associated with a significant
morbidity and mortality in affected children.
All forms of congenital heart disease nowadays
can be treated, although at varying levels of
risk and quality of outcome. A clear understand-
ing in early pregnancy o f the prognosis for the
child allows parents to make informed decisions
concerning the management. In continuing
pregnancies, the o u t c o m e for the affected child
can be improved by optimizing perinatal man-
agement. T h e r e are some categories of preg-
nancy in which there is an increased risk of
congenital heart disease and these mothers
should be referred to a fetal echocardiographer
for detailed study. These include mothers with a
family history of congenital heart disease, mater-
nal diabetes, exposure to cardiac teratogens in
early pregnancy, and the detection of fetal ar-
rhythmias or extracardiac abnormalities. This
last group include those with extracardiac mal-
formations, especially those with nuchal edema,
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
congenital heart disease being detected is for
something abnormal being recognised during
the obstetric scan. For this reason, the c o n c e p t
o f "screening" the fetal heart in a simplified
fashion during routine obstetric scanning was
introduced. 1
Cardiac assessment during an anatomical ob-
stetric survey is r e c o m m e n d e d to include at least
a four-chamber view o f the heart, 2 and this sin-
gle view will detect about 60% of serious malfor-
mations or abnormalities in about 2 of 1,000
pregnancies scanned. Despite the fact that al-
most all pregnancies are scanned at some time
during gestation and that the four-chamber view
should be part of every ultrasound assessment,
many forms of congenital heart disease recogni-
sable in this view continue to be overlooked
during obstetric e v a l u a t i o n / M a n y authors have
suggested a more detailed study be p e r f o r m e d
during obstetric evaluation to increase the de-
tection o f congenital heart disease by including
identification o f the great artery connections. 4
Accurate evaluation of the great arteries connec-
tions will detect up to 90% of serious cardiac
malformations.
Practical Scanning

For the perinatologist the following aspects o f

From the Department of Pediatric Cardiology, New York Presbyterian
Hospital, New Yark, NY.
Address reprint requests to Lindsey D. Allan, MD, FRCP, FACC,
Babies Hospital 2N, 3959 Broadway, New York, NY 10032; e-mail:
la48@columbia.edu
Copyright 9 2000 by W.B. Saunders Company
O146-0005/00/2405-0002510. 00/0
doi: 10. 1053/sper. 2000.16551
cardiac structure or function should be estab-
lished: (1) The heart lies on the left side of the
fetus, on the same side as the stomach; (2) T h e
four-chamber view is normal; (3) T h e ventriculo-
arterial connections are normal; and (4) T h e
arch and duct are normal.

324 Seminars in Perinatology, Vol 24, No 5 (October), 2000: pp 324-330

 A Practical Approach to Fetal Heart Scanning
The Heart Lies on the Left Side o f the
Fetus (on the Same Side as the Stomach)
Normally, when the u l t r a s o u n d b e a m is swept
cranially f r o m a transverse section o f the ab-
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
same side of the fetus (Fig 1). This will almost
always m e a n that they are b o t h o n the left side
b u t if they are discrepant, the side o f each
must be d e t e r m i n e d . Also, a l t h o u g h rarely,
they can b o t h be n o r m a l but b o t h lie o n the
right (situs inversus). T h e t e c h n i q u e o f Cordes
et al 5 for d e t e r m i n i n g "sidedness" appears to
be reliable. T h e first step is to orientate the
t r a n s d u c e r in the long-axis o f the fetus with
the h e a d to the right o f the screen. T h e trans-
d u c e r is then t u r n e d t h r o u g h 90 ~ in a clock-
wise direction. If the spine is posterior, the left
side o f the fetus will be o n the right o f the
screen. Conversely, if the spine is anterior, the
left side o f the fetus wilt be o n the left o f the
screen.
The Four-Chamber View is Normal
A f o u r - c h a m b e r view o f the fetal h e a r t is ob-
tained in a horizontal cross-section of the tho-
rax j u s t above the d i a p h r a g m . A n o r m a l four-
c h a m b e r view excludes m a n y forms o f
c o n g e n i t a l h e a r t disease. It must be evaluated
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.
325
in a systematic fashion, which includes an as-
sessment o f h e a r t size, position, structure, a n d
function.
Size. Normally, the heart occupies about one
third of the thorax. If there is d o u b t about the
heart size on a visual assessment, the area or the
circumference of the heart can be measured and
c o m p a r e d to n o r m a l values. 7
Position. Normally, the midline of the tho-
rax passes t h r o u g h the left atrium, f o r a m e n
ovale, the right atrium, a n d the a n t e r i o r cor-
ner o f the right ventricle, such that most of the
h e a r t lies in the left chest (Fig 2). The inter-
ventricular s e p t u m forms an angle o f a b o u t
40 ~ with the midline, s An a b n o r m a l angle o f
the s e p t u m can indicate a cardiac malforma-
tion or a space-occupying lesion within the
chest. 9
Structure. To o r i e n t in the f o u r - c h a m b e r
view, it is useful to relate the h e a r t to the
spine. O p p o s i t e the spine is the a n t e r i o r
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 left o f the spine is the d e s c e n d i n g aorta
a n d anterior to that is the left atrium. T h e
right atrium a n d left ventricle can t h e n be
deduced.
In the four-chamber view, the following as-
pects of structure should be seen:
326 Lindsey D. Allan
Figure 2. The interventricular septum forms an an-
gle of about 40 ~ to the midline of the thorax. The
right ventricle lies below the sternum. The left atrium
is anterior to the descending aorta, which is, in turn,
anterior to the spine.
1. Two equally sized atria
2. Two equally sized ventricles
3. Two equally o p e n i n g atrioventricular valves,
no valvar regurgitation
4. An intact "crux" of the heart, with differential
insertion, or "off-setting" of the atrioventric-
ular valves.
5. T h e p u l m o n a r y veins enter the back of the
left atrium
6. T h e f o r a m e n ovale defect occupies the mid-
dle third of the atrial septum
7. T h e ventricular s e p t u m is intact
In the last 10 weeks of pregnancy, there can be
mild, or close to t e r m even fairly marked, dis-
crepancy in the sizes of the ventricles with right
heart dilatation, even w h e n the heart is normal.
However, pathological causes of right h e a r t di-
latation should be excluded, such as coarctation
of the aorta a~ or totally anomalous p u l m o n a r y
venous drainage, before attributing any discrep-
ancy to gestational age.
T h e a t r i o v e n t r i c u l a r valves should be e x a m -
i n e d by c o l o r flow m a p p i n g to e n s u r e that the
orifices are o f e q u a l size a n d that b o t h ventri-
cles fill equally in diastole. In addition, t h e r e
s h o u l d be n o r e g u r g i t a t i o n f r o m e i t h e r valve.
However, with s o m e o f the m o s t r e c e n t ultra-
s o u n d e q u i p m e n t , trivial tricuspid regurgita-
tion can be seen in a n o r m a l heart. H o w e v e r a
cause for tricuspid r e g u r g i t a t i o n s h o u l d be
e x c l u d e d b e f o r e d e n o t i n g this "physiological,"
as it is n o t as c o m m o n in the fetus as it is in
p o s t n a t a l life. n
In the normal heart, the atrial s e p t u m meets
the ventricular septum at the site of insertion o f
the 2 atrioventricular valves, f o r m i n g a "cross" at
the crux or center of the heart (Figs 1 a n d 2).
Because the septal leaflet o f the tricuspid valve is
inserted slightly lower in the ventricular s e p t u m
than the septal leaflet of the mitral valve, this
gives the a p p e a r a n c e o f "off-setting" or a cross
that is not quite straight. This is an i m p o r t a n t
n o r m a l finding that is lost in s o m e cardiac mal-
formations.
O n examination of the atrial septum, the fo-
r a m e n ovale can be seen to occupy the middle
third o f the septum, although the size of the
f o r a m e n appears larger if it is i m a g e d in apical
projections. T h e flap valve is p u s h e d o p e n by a
j e t of b l o o d f r o m the ductus venosus via the
inferior vena cava a n d lies in the cavity o f the left
atrium during most of the cardiac cycle. It has,
however, a biphasic m o t i o n drifting toward the
atrial s e p t u m towards the e n d of systole a n d
closing for a b o u t 20% o f the cardiac cycle dur-
ing atrial contraction. 12 A right to left s h u n t
t h r o u g h the f o r a m e n can be d o c u m e n t e d
t h r o u g h o u t most of the cardiac cycle, although a
brief j e t of left to right flow can occur during
atrial systole. T h e flap valve can sometimes be
r e d u n d a n t and impinge on the left atrial wall in
the n o r m a l fetus.
Finally, it is i m p o r t a n t to focus on the ven-
tricular s e p t u m in o r d e r to e x c l u d e a ventric-
ular septal defect. T h e s e p t u m s h o u l d b e
i m a g e d f r o m the a p e x to the c r u x in the four-
c h a m b e r view, thus i m a g i n g p a r t o f the mus-
cular a n d inlet s e p t u m a n d t h e n the b e a m
swept u p to the aortic outflow, which i m a g e s
m o s t o f the rest o f the m u s c u l a r s e p t u m a n d
the p e r i m e m b r a n o u s a n d o u t l e t parts o f the
s e p t u m . It should be i m a g e d in b o t h apical
p r o j e c t i o n a n d lateral p r o j e c t i o n s (Fig 3). I f
t h e r e is a real v e n t r i c u l a r septal defect, c o l o r
flow will be seen to b r e a c h the s e p t u m in a
lateral view w h e n the s e p t u m is p e r p e n d i c u l a r
to the b e a m . However, small defects, especially
in the p e r i m e m b r a n o u s region or m u l t i p l e de-
 A Practical Approach to Fetal Heart Scanning 327

T h e Ventriculo-Arterial C o n n e c t i o n s
are N o r m a l

The great artery connections can be assessed in

Figure 3. There is equal color flow into both ventri-
cles through the atrioventricular valves. Here the
beam is almost at right angles to the septmn. No color
is seen breaching the septum indicating it is intact.
fects in the m u s c u l a r septum, can be over-
l o o k e d particularly in early p r e g n a n c y when
they may be below the resolution of the ultra-
s o u n d machine.
a variety o f different views, b o t h transverse and
longitudinal. The transverse views are usually
easier to obtain and involve sweeping cranially
from the four c h a m b e r view to show the aorta
arising in the center of the heart just above
the two atrioventricular valves (Fig 4). It is im-
portant to note that the posterior leaflet of the
aortic valve is in continuity with the anterior
leaflet of the mitral valve and that the anterior
wall of the aorta is continuous with the ventric-
ular septum. Slight transducer angulation so
that the beam cuts between the right shoulder
and left hip often "opens out" the left ventricu-
lar outflow tract optimally. The aorta sweeps out
to the right of the thorax before turning left-
wards to form the aortic arch. The p u l m o n a r y
artery arises anterior and cranial to the aorta, is
seen in a transverse section just above the aortic
origin, and crossing over it. The pulmonary ar-
tery, and its c o n n e c t i o n to the arterial duct, lie
in an almost straight antero-posterior line,
slightly to the left o f the midline. In the trans-
verse section (Fig 5), this view is known as the
"three vessel view" as it shows the p u l m o n a r y
artery in a long axis projection, with the aorta

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 5. Just above the aortic origin, the pulmonary

connection to the duct is shown in the three vessel Figure 7. The transverse arch crossing the midline of
view. Normally the pulmonary artery is the largest, the thorax in front of the spine and meet with the
most anterior and leftwards of the three vessels, with duct (D), which lies to the left and below the arch.
the'superior vena cava (SVC) the smallest, most pos-
terior and rightwards. The ascending aorta lies be-
tween these two vessels. I n t h e l o n g i t u d i n a l sections, t h e r i g h t v e n t r i c -
u l a r o u t f l o w tract c a n b e s e e n a r c h i n g o v e r t h e
left v e n t r i c l e or, j u s t to t h e r i g h t o f this view,
a n d s u p e r i o r v e n a cava lying to t h e r i g h t o f it. ~3
a r c h i n g over t h e a o r t a c u t in short-axis (Fig 6).
T h e p u l m o n a r y a r t e r y is t h e largest, m o s t a n t e -
W h a t e v e r views o f t h e g r e a t a r t e r i e s a r e s e e n , t h e
r i o r a n d leftwards o f t h e t h r e e vessels with t h e
p o i n t s to b e n o t e d i n c l u d e : (1) T h e n o r m a l
s u p e r i o r v e n a cava t h e smallest, m o s t p o s t e r i o r
cross-over o f t h e g r e a t arteries. (2) T h e n o r m a l
a n d r i g h t wards. T h e a o r t a is in b e t w e e n b o t h in
size r e l a t i o n s h i p o f t h e 2 vessels. (3) N o r m a l
size a n d p o s i t i o n .

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
unaliased color flow m a p p i n g across each arte-
rial valve with no regurgitation. Normally, the
p u l m o n a r y artery is slightly larger than the aorta
in size. If there is a suggestion of discrepancy in
the great artery sizes, they should be m e a s u r e d
a n d c o m p a r e d to n o r m a l ranges. 6 Calculation of
the A o / P A ratio is often useful, as some degree
of outflow tract obstruction or an arch anomaly
may be present where this is abnormal. 1~ T h e
arterial valves must be interrogated by either
pulsed or color Doppler, obtained as close as
possible to parallel to the direction of b l o o d
flow. Color flow m a p p i n g is m u c h quicker a n d
easier. If there is unaliased, n o n t u r b u l e n t flow
across the arterial origin this indicates b l o o d
flow at a n o r m a l velocity. However, if there is
aliasing of the color signal, either because of the
d e p t h of the fetus or the transducer frequency,
or because of an abnormally high velocity,
pulsed D o p p l e r must be used to obtain the exact
velocity across the valve in question. T h e velocity
of flow should not exceed 1 m / s e c across nor-
mal arterial valves.
T h e Arch and Duct Are N o r m a l
T h e arch and duct can be imaged in either
transverse or longitudinal views but all views are
n o t essential to image in every n o r m a l fetus. T h e
transverse aortic arch is seen immediately above
the three vessel view as a curved vessel arising in
the middle of the thorax and crossing the mid-
line in front of the spine and trachea. This con-
firms a normal left arch. By slight transducer
angulation in the n o r m a l fetus, the aortic arch
a n d duct can be imaged simultaneously. This
allows the arch to be seen to the right o f the
duct. T h e p u l m o n a r y artery branches laterally
into the right p u l m o n a r y artery a n d duct. T h e
aortic arch and duct should be similar in size
and join just in front and to the left of the spine
(Fig 7). In the long axis views, the duct can be
seen just to the left of, and below, the aortic
arch. The aortic arch forms a tight "hook" shape
a n d gives off 3 cranial branch~es (Fig 8). T h e
direction of flow in the arch and duct should
b o t h be entirely antegrade in any projection a n d
show no sites of turbulence. M e a s u r e m e n t s of
vessel or c h a m b e r sizes are useful w h e n they
a p p e a r a b n o r m a l but are not required routinely.
329
Comments
T h e accuracy of all ultrasound is d e p e n d e n t on
o p e r a t o r knowledge a n d e x p e r i e n c e and the im-
age quality obtained. T h e image quality in turn
is d e p e n d e n t on the c o m b i n a t i o n of o p e r a t o r
skill and experience, m a c h i n e resolution, the
thickness o f the m a t e r n a l a b d o m e n , fetal posi-
tion and gestational age. By 18 weeks of gesta-
tion, the f o u r - c h a m b e r view a n d the two outflow
tracts can be i m a g e d transabdominally in t h e
vast majority of patients by an e x p e r i e n c e d
s o n o g r a p h e r with m o d e r n equipment. In obese
patients, or in late pregnancy, a limited study
may have to be a c c e p t e d after a range of trans-
ducer frequencies a n d aids such as h a r m o n i c
imaging have b e e n tried. However, even where a
study is o p t i m u m in quality, there are confi-
dence limits to fetal h e a r t scanning. Small ven-
tricular septal defects will be overlooked and
lesions such as aortic or p u l m o n a r y stenosis, car-
diomyopathies a n d cardiac tumors may evolve in
later pregnancy, t5 In addition, the atrial septum
and the arterial duct are always patent prenatally
and persistent patency after birth, which are
b o t h forms of congenital h e a r t disease, albeit
minor, c a n n o t be predicted f r o m the fetal study.
Also, the p o o r e r the image quality, the wider the
confidence limits. Although the technique of
fetal h e a r t scanning appears c o m p l e x at first
sight, b r o k e n down into the above c o m p o n e n t s
and in the hands of a motivated operator, a
t h o r o u g h assessment can usually be accom-
plished in minutes. 16 In a fetus in an ideal posi-
tion, sweeping f r o m the a b d o m e n to the inlet of
the thorax and down again by using color flow
mapping, provides comprehensive information
providing p r o o f of normality. If the fetal posi-
tion or imaging is difficult, as long as the essen-
tials listed above are seen, m a j o r anomalies will
rarely be overlooked.
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3. Montana E, Khoury MJ, Cragan JD, et ah Trends and
outcomes of prenatal diagnosis of congenital cardiac
malformations by fetal echocardiography in a well de-
330 Lindsey D. Allan
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