Views in Paediatric Echocardiography

Various vies in paedilatric echocardiography are as follows:

Sub-costal/Sub xiphoid view

In children excellent images can be obtained by this window. For the subcostal views, the transducer is placed in the abdomen just below the xyphoid process of the sternum and is tilted caudally and cranially to obtain various views (sweep).

1) Subxiphoid Long Axis Sweep

This sweep begins with keeping the transducer at subxiphoid region, positioning directly posterior with marker pointing towards left. This cut provide the relationship between abdominal aorta and IVC (aorta towards left of the IVC and spine in visceral situs solitus and towards right in situs inversus). This view decides the situs of viscera as well atrial situs because

Sub-xiphoid long axis

Transducer Position for Subxiphoid long axis and short axis visceral situs has good correlation with atrial situs. Now transducer is moved cranially .The most posterior plane demonstrates systemic veins, right and left upper pulmonary veins entering into the heart together with the coronary sinus at posterior aspect of interatrial septum. In the next view all four chambers can be evaluated. In this view fossa ovalis area is seen. Next two views are obtained by angulating transducer further cranially. These views provide structural details of semilunar valve, origin of great vessels, defects of perimembranous and muscular interventricular septum.

Subcostal long axis view

Subcostal long axis view

To obtain the subxiphoid short axis view transducer should be rotated by 90 degree clockwise, fi-om the previous position so that pointer points inferiorly.Sweep should start from right to left gradually until apex of heart is seen. Atria including its venou$ connections and interatrial septum are visualized in right sided cuts. All type of atrial septa1 defects, right upper and right lower pulmonary veins cauld be seen in this view. Atrial morphology can be decided in this view.

Ttansducer positions for subxiphoid short axis sweeps

When transducer is rotated further towards left, aortic valve along with proximal ascending aorta, mitral and tricuspid valves are seen. Further rotation of transducer provide view of pulmonary valve and main pulmonary artery. One may decide the location of VSD in this view, sub infundibular muscle bundle and mal-alignment of outlet septum, relationship between semilunar valves and AV valves can be seen in this view by slight rotation of the transducer. Hence these view are important while making the more complex diagnosis. Ventricles can be seen in short axis view (circular LV and crescent shape RV). Muscular VSDs at various plane can be located by this sweep.

Atrial septum in subxiphoid short axis view

Interventricular septum as seen in subxiphoid short axis view

Apical View

For the patient with dextrocardia transducer is kept on right chest with marker towards left side. Morphological parameters to identify the ventricles are seen in this view. Gradient across both AV valves and semilunar valves can be taken.

Apical View-Transducer Position taken

This view is also helpful in recognizing various types of VSDs, displacement of tricuspid leaflet (~bs/tein's anamoly of tricuspid valve) and AVSD. ASD is nevern diagnosed in this vidw because false dropouts are common due to angle between ultrasound beam and inter atrial septum. A good four chamber apical view is very helpful in makibg structural as well as functional diagnosis of heart disease.If symmetry of four chamber view is lost one should look for dilatation or hypoplasia of chambers. Total anomalous pulmonary venous drainage is suspected if left atria is bald i.e. no pulmonary venous opening seen and PFO/ASD is shunting right to left along with dilated RARV. Partial anomalous pulmonary venous cbnnections (PA PVC) of single or multiple pulmonary veins should be looked foi if right sided chambers are enlarged in absence of ASD and RVOT obstruction. Pulmonary veins are best seen in sub-costal, apical, parasternal views. Tkicuspid atresia or Hypoplastic Tricuspid Valve are easily recognized in this view. Dilated LV, presence of MR with glistening of papillary muscles gives clue about ALCAPA. Hypertrophied LV may be seen when coarctation of aorta Cs associated. If LA and LV are dilated one should suspect PDA. In a new b o d having hypertrophied LV, if apex is formed by RV, critical aortic stenosis is a Ejossibility. However, one has to decide about adequacy of LV in such a situation.


Para-stern!al View

Various congenital anamolies can be detected in this view are perimembranous VSD (transducer anbled towards right hip), doubly committed VSD (transducer angulated towards lbft shoulder), aortic sinus prolapse, RSOV, abnormal origin of great vessels and atdnormalities related to pulmonary valve and main pulmonary artery.

This view provides unique opportunity to recognize bicuspid aortic valve, the type of VSD, aortic! valve prolapse, pulmonary valve stenosis, evaluation of branch pulmonary arteries, abnormal origin of coronary arteries and coronary AV fistula. Inter atrial septum, pulmonary veins and left atrial appendage can also beinterrogated in this view. Angulation of the transducer towards left hip joint images mitral valve in short axis view and papillary muscles (4 and 8 O'Clock position). By sweeping the transducer towards left hip inter ventricular septum can be scanned for muscular VSDs.

High Para-sternal or Ductal View

This view is obtained by sliding transducer one or two spaces upward and medially from PLAX view. This view is specifically used to visualize patent ductus arteriosus and adjacent structures.

High Parasternal Short Axis Views

Structures seen in apical 4 and 5 chamber views

These views are obtained form first and second intercostals spaces just left of the sternum. The transducer orientation is similar to the conventional parasternal short axis view. This view is helpful in demonstration pulmonary artery anatomy in patients withy TOF-physiology/pulmonary atresia.

Suprasternal Views

To complete the echocardiography in the patients with CHD these views are essential. For optimal windows patient should lie supine with the neck extended by a pillow or a rolled-up shet placed underneath the shoulder. First view is obtained by keeping transducer at 3 O'clock position (marker towards left shonlder). By angulating the transducer about 45" posteriorly, aorta is seen in oblique section and entire length of right pulmonary artery is seen just below the aorta. SVC lies just right to the aorta innominate view seen at an anterior plane.

The LSVC if present, can be seen in this view. Side of arch can also be decided by seing the direction of first branch and its bifurcation as well as by visualizing the descending aorta in relation to the tracheal rings. Absence of bifurcation should give rise suspicion about aberrant origin of subclvian artery. Suprasternal long axis view shows the aortic arch and proximal descending aorta. This view can be obtained by rotated the transducer 30" counter clockwise from the previous position. By tilting the transducer towards left LPA can be seen.

The high Parasternal or "Ductal" view

Echocardiography in Neonates

In symptomatic neonates echocardiography is more challenging. Usually babies are more sick and may require emergency intervention. Diagnosis of CHD may be more complex in this group of patients. One should make the mental ch,ecklist in such a case and go for quick and systemic scan to rule out criticai PS, critical AS, transposition of great vessels, tricuspid atresia.,mitral atresia, hypoplastic right and left heart syndrome, obstructed TAPVC,coarctation of aorta and interrupted aortic arch. Recognizing restriction at interatrial level and PDA dependency are of utmost importance in these situations.