Fetal echo and Fetal Echo F^

• Obtain a 4-chamber cine clip from fetal stomach to 4-chamber view of the heart noting the following anatomy:

o Right and left atria, should appear equal in size, with pulmonary veins seen entering the left atrium.

o Foramen ovale and flap should be seen moving in the left atrium.

o Right and left ventricles should appear equal in size and contractility. Right ventricle contains the moderator band and seen closest to chest wall.

o Ventricles are separated by intact septum.

o Tricuspid (R) and mitral (L) valves are seen moving freely during cardiac cycle with tricuspid valve seen slightly lower on IVS than mitral valve.

• Obtain a 4-chamber cine clip using color flow Doppler from fetal stomach to 4-chamber view of the heart.

o Include the anatomy listed above in clip from fetal stomach to 4-chamber view.

• Obtain thoracic circumference measurement, anteroposterior diameter and transthoracic diameter.

o Thoracic circumference should be measured in the axial plane at the level of the four-chamber view of the heart, parallel with the ribs, by placing an ellipse around the bony thorax

o The distance between spinal front edge and sternum rear edge is the thoracic anteroposterior diameter.

o A straight line drawn perpendicular to the anteroposterior diameter and between the two thoracic inner edges is the thoracic transverse diameter

• Obtain a still image of the 4-chamber heart

o Right and left atria, should appear equal in size

o Right and left ventricles should appear equal in size. Right ventricle contains the moderator band and seen closest to chest wall.

o Ventricles are separated by intact septum.

o Tricuspid (Rt) and mitral (Lt) valves are seen. Note the more apical insertion of the tricuspid valve in relation to the mitral valve.

• Obtain a cardiac axis.

o The cardiac axis in a 4-chamber view is measured as the angle between the line tracing the long axis of the heart and the line bisecting the thorax in the anteroposterior direction.

• Obtain cine clip of the intraventricular septum using color flow Doppler at the level of the 4-chamber heart.

• Obtain pulmonary veins with and without color flow Doppler.

o Show right and left pulmonary veins entering into the left atrium at the level of the 4-chamber heart.

• Identify cardiac outflow tracts:

o LVOT originates from left ventricle, arching shortly after aortic valve.

 Obtain image by tipping cranially from the 4-chamber heart view.

o Image aortic valve using color flow Doppler.

o RVOT is seen originating from right ventricle and is seen to bifurcate shortly after pulmonary valve.

 Obtain image by continuing cranially from LVOT view.

o Image pulmonary valve using color flow Doppler.

o Image pulmonary bifurcation

 The bifurcation is seen around the aortic root between the ductus arteriosus and the right pulmonary artery.

• Obtain 3VV and 3VTV with color flow Doppler.

o Obtain the 3VV by angling to fetal right shoulder including long pulmonary vein, aorta and transverse SVC

• Obtain cine clip of aortic and ductal arches.

• Obtain a cine clip of aortic and ductal arches using color flow Doppler.

• Identify cardiac arches

o Obtain an image of the aortic arch.

 Aortic arch arises from midline of fetal chest. This view should include the entire arch: ascending, arch with cranial branches and descending portions.

o Obtain an image of the ductal arch.

 Ductal arch is connection between main pulmonary artery and descending aorta. Ductal arch arises from anterior ventricle of the heart.

• Identify and image the superior vena cava (SVC) and the inferior vena cava (IVC)

o Obtain in a bicaval view with SVC and IVC draining into the right atrium.

• Image SVC and IVC using color flow Doppler.

• Image short axis view.

o Short axis view of the ventricles.

• Image short axis view of ventricles using color flow Doppler.

• Image short axis view of outflow tracts

o This is a short axis view at the level of the aortic valve and the pulmonary valve.

o The main pulmonary artery branches into the ductus arteriosus and the right pulmonary artery.

• Obtain a ductus venosus measurement using color flow Doppler.

o May be obtained in mid-sagittal, longitudinal view of fetal trunk, OR transverse view of upper fetal abdomen.

o Use color to isolate aliasing seen near where the umbilical vein courses abruptly right. Use zoom box and a narrow color box to optimize the image

o Doppler gate should be positioned directly over aliasing.

o Waveform is bi-phasic with forward flow during the entire cardiac cycle.

o Perform only when the fetus is NOT breathing.

• Obtain image of diaphragm in longitudinal view with heart seen above, and stomach seen below.