Segmental echocardiographic approach to congenital heart disease

# Evaluation of cardiac anatomy
Echocardiographic evaluation of congenital heart disease requires segmental and systematic approach.

# 1. Assess atrial situs
- Subcostal views are optimal
- Situs Solitus= Normal anatomy (morphologic right atrium is to the right and morphologic left atrium is to the left)
Morphologic right atrium:
Always contains eustachian valve
Appendage: shorter and broader than left atrium
Morphologic left atrium:
Lacks eustacian valve
Rounded shape
Appendage: thinner, longer and narrower atrail junction compared to right atrium
- Morphologic right atrium:
Always contains eustachian valve
Appendage: shorter and broader than left atrium
- Always contains eustachian valve
- Appendage: shorter and broader than left atrium
- Morphologic left atrium:
Lacks eustacian valve
Rounded shape
Appendage: thinner, longer and narrower atrail junction compared to right atrium
- Lacks eustacian valve
- Rounded shape
- Appendage: thinner, longer and narrower atrail junction compared to right atrium
- Situs inversus is mirror image (morphologic right atrium is to the left, left atrium to the right)

# 2. Assess venous inflow patterns
- Transverse imaging plane through abdomen
- Abdominal aorta lies to left of spine (aorta more rounded, pulsatile)
- Inferior vena cava lies to the right of spine
- Assess pulmonary inflow patterns: often difficult in the adult to identify all 4 pulmonary veins.

# 3. Evaluate artrioventricular connections
- Evaluate morphologic atrium and ventricular connection.
- Must assess ventricular morphology to confirm

# 4. Define ventricular morphology and position
- 4-chamber view for locations and valvular morphology, short axis views for papillary muscle evaluation
- Can use appearance to determine morphology of left and right ventricles:
Right ventricle: has trabeculations
Left ventricle: smooth endocardial surface
- Right ventricle: has trabeculations
- Left ventricle: smooth endocardial surface
- Atrioventricular valves are also helpful in determining ventricular morphology:
Tricuspid valve (right ventricle): 3 leaflets, 3 papillary muscles and chordal insertions into septum
Mitral valve (left ventricle): 2 leaflets, 2 papillary muscles, no septal chordal insertion
- Tricuspid valve (right ventricle): 3 leaflets, 3 papillary muscles and chordal insertions into septum
- Mitral valve (left ventricle): 2 leaflets, 2 papillary muscles, no septal chordal insertion

# 5. Evaluate ventriculoarterial relationship
- Short axis views most helpful for ventricular-artery attachments, parasternal views for artery morphology, rightward aorta seen on suprasternal views.
- Normal orientation:
Pulmonary artery: orientation is anterior and leftward
Aorta: orientation rightward and posterior
Two possible transposition forms
D-transposition: normal morphologic ventricular relationship
L-transposition: atrioventricular discordance: morphologic right ventricle on left, morphologic left ventricle on right
- Pulmonary artery: orientation is anterior and leftward
- Aorta: orientation rightward and posterior
- Two possible transposition forms
D-transposition: normal morphologic ventricular relationship
L-transposition: atrioventricular discordance: morphologic right ventricle on left, morphologic left ventricle on right
- D-transposition: normal morphologic ventricular relationship
- L-transposition: atrioventricular discordance: morphologic right ventricle on left, morphologic left ventricle on right
Back to Echo in congenital heart disease

# Other links
Yale Echo in Congenital Heart Disease

# Reference
- Feigenbaum's Echocardiography 6th Ed.