• 4 chamber view: most easily obtained.
• Anomalies detected in this view are generally major
• Anomalies of outflow tract may not be appreciated.

Basic definitions

• Mitral valve: More cranial, no septal attachment, bi-leaflet
• Tricuspid valve: More apical, septal attachment, tri-leaflet
• Left ventricle: Smooth wall, no apical trabeculations, no moderator band.
• Right ventricle: Rough wall, moderator band

4 chamber view

• LV Left ventricle
• RV Right ventricle
• LA Left atrium
• RA right atrium
• IVS inter ventricular septum
• L: Left side

Arrow head:
Moderator band and
trabeculation of right
ventricle
Arrow: Smooth walled
left ventricle

Situs solitus, levocardia

• Left atrium: close to spine/ posterior, left sided, receives pulmonary veins
• Right atrium: Anterior , receive systemic venous drainage , rightward
• Left ventricle: More posterior and leftward
• Right ventricle: retro sternal, rightward

Analyzing 4 chamber view

Cardiac defects can have variety of morphology.

• 4 chamber heart
• Not 4 chambered heart/ small ventricle/ absent or hypoplastic Av valve
• Not so normal 4 chambered heart
• Lesions not seen on 4 chamber view

Anomalies diagnosed on 4 chamber view

• 4 chambered heart
• Ostium primum defect
• Complete AV canal defect
• Large VSD
• Ebstein Anomaly
• Congenitally corrected trans position of great arteries
• Cardiac masses
• Fetal arrhythmias
• Cardiomyopathy: Dilated / hypertrophic
• Pericardial effusion
• Not 4 chambered heart
• Hypoplastic left heart syndrome ( some verities)
• Hypoplastic right ventricle ( some varities)
• Univentricular heart
  • Double inlet ventricle,
  • mitral atresia,
  • tricuspid atresia

A not so normal 4 chamber view

• Endomyocardial fibroelastosis
  • Aortic stenosis/ HLHS etc
• Discrepancies in sizes of ventricles and AV valves
  • Coarctation
  • Hypoplastic mitral valve/Varieties of HLHS,
  • Hypoplastic tricuspid valve/ Hypoplastic RV
  • Total anomalous pulmonary venous connection

Anomalies may NOT be suspected on
apical 4 chamber view

These are mainly conotruncal anomalie

• Aortic stenosis
• Pulmonary stenosis
• Tetralogy of Fallot
• Coarctation of aorta
• Truncus arteriosus
• Double outlet right ventricle
• Pulmonary atresia
• List is not exhaustive

Anomalies seen on 4 chamber view
with 4 chambered heart

• All 4 chambers are well formed.
• Most defects are amenable to good surgical repair or palliation.
• Most conotruncal anomalies like TOF/ TGA/ DORV can have a normal 4 chamber view.

Ostium primum ASD

Ostium primum ASD Salient feature

• Absent septum primum at its normal position
• Both AV valves are at same level
• Regurgitation of Rt and/or left AV valve
• No defect on ventricular side

Complete AV canal defect

Salient features:

• Single atrioventricular valve draining both atrium into respective ventricle
• Generally regurgitating commoc AV avlve
• Primum atrial septal defect and Inlet ventricular septal defect
• Associated with: Down’s , isomerism, DORV.

Ebstein anomaly

Salient feature

• Hugely dilated RA and RV
• Few of the largest heart: High cardio thoracic ratio
• Severe TR
• May have functional pulmonary atresia
• Larger the RA , worse the prognosis

Ventricular septal defect

• Most challenging diagnosis
• Mere presence of septal dropout is not diagnostic
• Look for hyper echoic margin
• Verities: Perimembranous / inlet/ muscular/
• outlet
• Perimembranous most common
• Vey large VSD can behave as single ventricle

Congenitally corrected transposition
of great arteries

• In either situs, morphological atria at normal position
• Morphological right ventricle is more posterior and
• leftward (RV) ( Solitus)
• Morphological Left ventricle is more anterior and
• rightward
• Cardiac axis can be anteroposterior ( mesocardia)
• Left sided AV valve is more apical (Tricuspid valve
• Arrow) than right sided valve ( Mitral valve Arrow
• head)
• Chances of AV block

Dilated cardiomyopathy

Salient features:

• Cause: Maternal lupus, infective myocarditis, tachy arrhythmias, AV blocks, genetic/ inherited
• Dilated ventricles with decreased contractility
• Increased cardio thoracic ratio
• Features of hydrops fetalis
• IUGR and IUFD quite common

Hypertrophic cardiomyopathy

Salient features:

• Causes: Diabetic mother, Noonan syndrome, Glycogen storage disease, Hereditary ( HCM)
• Can present anytime from utero to 20 years
• Excessively thick myocardium ( check ‘z’ score for gestational age )
• May be localized to IVS or generalized
• Risk of IUGR and IUFD
• Generally hereditary
• Storage disorders

Pericardial effusion

Salient features:

• Generally secondary to hydrops fetalies, Down’s syndrome, chromosomal anomalies
• There is free fluid around heart.
• Mild to moderate effusion will improve, however large ones
• need special attention.

Cardiac masses

• Causes: Rhabdomyoma, teratoma, fibroma, hemangioma,
• Rhabdomyoma: Tuberous sclerosis, multiple, intra myocardial affecting ventricles, rhythm disturbances. Regress spontaneously.
• Teratoma: Intra pericardial with effusion, mainly Rt side, near aortic / pulmonary root,
• Can cause obstructive symptoms.

Anomalies seen on 4 chamber view: which don’t have 4 chambered heart.

• One of the ventricle along with AV valve is very small or absent.
• These defects require multistage palliative surgical correction ( single ventricle repair).
• They may be associated with outlet defect like aortic/ pulmonary stenosis/ atresia, TGA, DORV etc.

Hypoplastic left heart syndrome

Hypoplastic left ventricle

Salient features:

• Left ventricle : small size, not reaching up to apex, sometimes may be absent
• Mitral andaortic valve : small / stenosis/ atretic
• Flow reversal in oval foramen and distal aortic arch is characteristic.
• Endocardial fibroelastosis of left ventricle
• One of the most challenging heart defect to treat.
• Quite common

Hypoplastic right heart PA IVS

Salient features:

• Right ventricle: small, not apex forming. May be absent
• Tricuspid Valve: if present, it is at normal position. Generally hypoplastic , dysmorphic or atretic , frequently severe TR with dilated RA
• Pulmonary valve: Atretic.
• Flow reversal in PDA ( PDA dependent pulmonary circulation)
• Challenging disease to treat.

Tricuspid atresia

Salient feature

• Tricuspid valve: atretic/ not formed. No forward flow across the valve.
• Right ventricle: Usually very small
• VSD : generally present
• Pulmonary valve: May be normal/ small / atretic
• Mitral valve and left ventricle: Dominant
• Great arteries: Normal/ trans position/ other combinations possible.

Mitral atresia

Salient features

• Mitral valve not formed, no forward flow
• Left ventricle: usually small or absent
• Aortic valve: Small / absent/ from RV
• VSD : may be present
• Oval foramen : flow reversal
• Tricuspid valve and RV dominant:
• Flow reversal in distal aortic arch may be present

Double inlet ventricle / single ventricle

Salient feature

• Inter ventricular septum : very large VSD, absent or abnormal deviation to one side
• LV is generally dominant
• Both atria drain into single ventricle through two or one AV valve
• AV valves may be normal/ common/ atresia of one AV valve
• Great vessels: Pulmonary artery from main ventricle/ Aorta from outlet chamber or vice versa. Many possibilities.

Anomalies seen on 4 chamber view: A not so normal 4 chamber view

• These lesions include are sitting on fence of above 2 categories. GREY ZONE.
• On of the ventricle is smaller than usual with possibility that it can function independently.
• Careful evaluation of all parameters will help to decide management plan.
• Close follow up during gestation generally helpful.

Unequal sizes of ventricle

• LV or RV smaller for gestational age ( second trimester)
• Always check for Z score of mitral, tricuspid, aortic and pulmonary valve, long and short diameter of LV, aortic arch, isthmus, pulmonary artery.
• Indirect evidence for coarctation / aortic arch interruption/ TAPVC / PA IVS/ HLHS.
• Aortic arch may be difficult to see

Endocardial fibroelastosis

Salient feature:

• Endocardial border hyperechoic
• Associated with LV systolic as well as diastolic dysfunction Common associated lesions: Aortic stenosis/ hypoplastic left heart syndrome/ viral myocarditis/ autoimmune / Autosomal or X linked
• Leads to hydrops fetalis , IUGR/ IUFD

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