ECHO : SEGMENTAL APPROACH
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ECHO : SEGMENTAL APPROACH
Dr Binjo J VazhappillySR CardiologyMCH Calicut
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Segmental Approach to Imaging Congenital Heart Disease (CHD)
• Systematic and sequential method to describe the cardiac segments and connections.
• Three cardiac segments : atria , ventricle and great vessels.
• Connections : specific relationship between the segments .
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Determine visceroatrial situs • Situs refers to spatial arrangement of the viscerae .
Three types of visceroatrial situs • S – solitus (normal arrangement) • I – inversus (or the mirror-image arrangement) • A - ambiguus
• Situs ambiguus : defined as an abnormality in which thoracic and abdominal organs are positioned with respect to each other, in such a way that it cannot be clearly lateralized.
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Situs Solitus
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Situs Inversus
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Right Isomerism(Asplenia)
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Left Isomerism (polysplenia)
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Cardiac Position & Orientation
• Position of the heart in the chest with regard to its location and orientation of its apex.
Location of heart in the chest• Levoposition : to the left • Mesoposition : central• Dextroposition : to the right
Cardiac orientation is the base to apex orientation of heart• Levocardia : apex directed to left of midline.• Mesocardia : apex oriented inferiorly in the midline• Dextrocardia: apex directed to right of midline.
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Atrial Morphology
Right Atrium • Triangular, broad based,
anterior appendage .• Receives IVC, SVC & coronary
sinus.• Septum secundum (limbus of
fossa ovale) lies on RA side.
• Crista Terminalis is in RA.
Left Atrium• Narrow, fingerlike posterior
appendage . • LA receives all 4 pulmonary
veins • Septum primum lies on LA
side . • LA is smooth with fewer
trabeculations
The right & left atria are identified morphologically by their respective atrial appendages and veins emptying into them.
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Atrial Morphology
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Pulmonary veins to LA
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Atrial Situs
• Atrial Situs Solitus (S)
• Atrial Situs Inversus (I)
• Atrial Situs Ambiguous (A)
Right isomerism (bilateral right atria) or Left isomerism (bilateral left atria).
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Ventricular Looping
• Embryonic heart is a linear tube with bulbus cordis (future RV ) being cephalad to the developing left ventricle (LV) .
• In normal development the tube bends over on itself to right forming a D-loop resulting in positioning of the bulbus cordis to the anatomic right of the left ventricle
• Folding to left results in L-loop with the morphologic right ventricle being to the left of the morphologic left ventricle
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Ventricular Looping
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D Loop L Loop
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Identification of the ventricles
Tricuspid Valve RV⇒
• Septal chordal attachments• Apical septal annular
attachment• 3 leaflet • Multiple small papillary
muscles• Triangular orifice
Mitral valve LV⇒
• No septal chordal attachments
• Basal septal annular attachments
• 2 leaflet• 2 large papillary muscles• Elliptical orifice.
AV valve morphology directly correlates with ventricular type
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RV Morphology
• Large apical trabaculations
• Coarse septal surface
• Moderator bands
• Cresentic in cross section
• Tricuspid – pulmonary discontinuity
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LV Morphology
• Small apical trabeculations
• Smooth upper surface
• No moderator band
• Mitral – Aortic continuity
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Atrio-ventricular Connections
• Concordant ( Normal : RA to RV & LA to LV)
• Discordant ( RA to LV & LA to RV)
• Univentricular AV connections Absent AV connection Common AV valve Double inlet connections
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Concordant AV Connection
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Univentricular AV Connections
• Absent AV connection (right / left) Tricuspid / mitral atresia
• Common AV valve With single ventricle
• Double inlet ventricle Connection of both AV valve to the same ventricle Anatomically left Anatomically right Undetermined (rudimentary chamber always present)
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Univentricular AV connections
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Univentricular AV connections
Absent Rt AV Connection Absent Lt AV connection
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Univentricular AV connections
Double inlet : RV Morphology Double inlet : LV Morphology
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Overriding & Straddling
• Overriding : Biventricular emptying of AV Valve or biventricular origin of a
semilunar valve.
• Straddling : Chordae or papillary muscle of the valve attach to contralateral
ventricle. Involve AV Valves and requires presence of VSD.
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Arterial Morphology
• Aorta : artery that gives rise to the coronary arteries and the brachiocephalic vessels.
• Pulmonary artery : branches into two but does not give rise to any vessels.
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Ventriculo-Arterial Connection
• Concordant : Aorta connected to LV and pulmonary artery to RV .• Discordant :
Aorta connected to RV and pulmonary artery to LV .
• Double Outlet : Both great arteries arise from a single ventricle. • If more than 50% of an artery overrides a ventricle it is said to be
committed to it.
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Commitment
• Commitment describes possible abnormalities of flow through valves into ventricles and great vessels.
• In TOF, atria, AV valves & ventricles are positioned normally and concordant.
Aorta overrides a VSD and is doubly committed to both ventricles.
• In univentricular heart both AV valves are usually doubly committed to the single ventricle.
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Ventriculo-arterial connections
• Concordant (normal) Ventricular septal defect, tetralogy of Fallot• Discordant Transposition• Double outlet ventricle With subaortic VSD subpulmonary VSD doubly committed VSD non-committed VSD• Common arterial trunk
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Conus
• Subpulmonary: Absence of subaortic infundibular free wall, found in normal heart.• Subaortic: Absence of subpulmonary infundibular free wall, found in D-loop
TGA.• Bilaterally present : In double outlet RV , but rarely in TGA.• Bilaterally Absent: In double outlet LV.
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Relation b/w semilunar Valves
• Solitus : Aorta posterior and to right.
• Inversus : mirror image : Aorta posterior and to left
• D-malposition : aortic valve anterior and to the right.
• L-malposition : aortic valve anterior and to the left.
• Anterior malposition : aortic valve anterior in the middle.
• Parasternal and high parasternal short axis and subcostal short axis views are used to recognize the positions of AV and PV.
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Possible Great vessel relations
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Normal
PSX Suprasternal long and short axis
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d TGA
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cc TGA
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DORV
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TOF
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Truncus Arteriosus
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Assessment of Associated Anomalies
Abnormalities in each segment should be assessed
Septal defects AV valve abnormalities like Ebstein’s Outflow tract stenosis Aortic arch branching and sidedness Pulmonary artery and branches PDA Coronary abnormalities
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Ebstein anomaly
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Pulmonary valve pathology
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LV outflow
Subaortic membrane Supravalvular AS
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COARCTATION OF AORTA
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Sequential Segmental Approach
• Identify situs of the thoraco-abdominal organs.• Determine cardiac position within thorax.• Atrial Situs.• Ventricular Situs.• Atrioventricular connection and alignment.• Ventriculo-arterial connection and alignment.• Conal (infundibular) anatomy.• Relationship between the great arteries.• Description of associated malformations
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Segmental Expression
1 . Visceroatrial situs : S , I or A.2 . Ventricular situs : D or L3 . Position of great vessels : S , I , D , L or A
Normal : S , D , S Situs inversus Dextrocardia : I , L , I D TGA : S , D , D D TGA with situs inversus : I , L ,L L TGA with situs solitus : S , L , L
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QUIZ
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1. Interrupted IVC is seen in
A) Situs inversusB) Situs solitusC) Right isomerism D) Left isomerism
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2. Morphological feature of right atrium
A) Finger like posterior appendageB) Smooth surfaceC) Presence of cristae terminalisD) Septum primum lies on RA side
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3. True about right atrial appendage
A) Narrow basedB) TriangularC) PosteriorD) None of the above
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4.True about ventricular morphology
A) LV is cresentic in cross sectionB) Moderator band is seen in RVC) Trabaculations are less in RVD) RV has smooth septal surface
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5. Straddling means
A) Papillary muscle of the valve attached to contralateral ventricle.
B) Papillary muscle attached to septumC) Absence of papillary muscleD) Fusion of papillary muscle
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6. In d TGA true about connection is
A) AV discordant , VA concordantB) AV concordant , VA discordantC) Both AV and VA concordantD) Both AV and VA discordant
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7. In TOF true about connection is
A) AV discordant , VA concordantB) AV concordant , VA discordantC) Both AV and VA concordantD) Both AV and VA discordant
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8. Conus is bilaterally absent in
A)DORVB) TGAC) DOLVD) Normal heart
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9. In d malposition of great arteries
A) Aorta posterior and to rightB) Aorta posterior and to leftC) Aorta anterior and to rightD) Aorta anterior and to left
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10.Segmental expression of L TGA is
A) S , D , SB) I , L , IC) S, D , D D) S , L , L
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1. Interrupted IVC is seen in
A) Situs inversusB) Situs solitusC) Right isomerism D) Left isomerism
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2. Morphological feature of right atrium
A) Finger like posterior appendageB) Smooth surfaceC) Presence of cristae terminalisD) Septum primum lies on RA side
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3. True about right atrial appendage
A) Narrow basedB) TriangularC) PosteriorD) None of the above
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4. True about ventricular morphology
A) LV is cresentic in cross sectionB) Moderator band is seen in RVC) Trabaculations are less in RVD) RV has smooth septal surface
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5. Straddling means
A) Papillary muscle of the valve attached to contralateral ventricle.
B) Papillary muscle attached to septumC) Absence of papillary muscleD) Fusion of papillary muscle
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6. In d TGA true about connection is
A) AV discordant , VA concordantB) AV concordant , VA discordantC) Both AV and VA concordantD) Both AV and VA discordant
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7. In TOF true about connection is
A) AV discordant , VA concordantB) AV concordant , VA discordantC) Both AV and VA concordantD) Both AV and VA discordant
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8. Conus is bilaterally absent in
A)DORVB) TGAC) DOLVD) Normal heart
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9. In d malposition of great arteries
A) Aorta posterior and to rightB) Aorta posterior and to leftC) Aorta anterior and to rightD) Aorta anterior and to left
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10.Segmental expression of L TGA is
A) S , D , SB) I , L , IC) S, D , D D) S , L , L
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