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Echocardiography 5 minutes before starting  

Examples of pathological findings

—Echocardiographic examinations

—Cardiac function and PA pressure

—Examples of pathological

Valvular heart disease
Intracardiac masses
Pericardial disease
Aortic dissection
Congenital heart disease

Congenital heart disease

Complex congenital heart disease | More examples of congenital heart disease

Interatrial shunt

Cross section of the right atrium as seen from the right side. At the top the superior vena cava (VCS), at the bottom the inferior vena cava (VCI), to the right the tricuspid valve (TV).

1: Patent foramen ovale
2: ASD II = ostium secundum atrial septal defect
3: ASD I = ostium primum atrial septal defect
4: Sinus venosus defect
5: Anomalous drainage of one or more pulmonary veins
6: Sinus coronarius defect

An interatrial shunt may be suspected in the presence of following findings in transthoracic echocardiography (TTE): dilated right ventricle with preserved systolic function, dilated right atrium, as well as increased velocities over the pulmonary valve.

To define localisation and morphology, as well as depiction of the shunt, a multiplane transesophageal echocardiography (TEE) should be performed.

Non-invasive assessment of shunt magnitude (Qp:Qs) can be made with the following formula: (CSARVOT x VTIRVOT)/(CSALVOT x VTILVOT). Cross sectional area (CSA) calculated from the diameter of the right (RVOT) and left ventricular outflow tract (LVOT) measured in the bidimensional mode and velocity time integral (VTI) with PW-Doppler at the same place during passive end expiration.

Next 4 animations apply to an ostium secundum atrial septal defect (ASD II).

Left: TEE examination at 0° shows a large ASD II in the upper part of the fossa ovalis.

Right: ASD II at 90°.

Left: demonstration of a large left-to-right shunt with color Doppler.

Right: negative contrast effect showed with an non-transpul- monary ultrasound contrast agent, with partial crossing from RA to LA.

Next 7 animations apply to ano- ther ASD II case.

Left: Four chamber view. The RV is dilated with not severely decreased systolic function. The RA is severely dilated. An atrial shunt is suspected. A TEE exami- nation should follow.

Right: short axis view shows a dilated RV.

Left: TEE view at 100° shows an ASD II at the superior portion of the foramen ovale.

Right: Shunt depiction with color Doppler. The Nyquist limit lies at 60-70 cm/s, slow velocities speak for a moderate to severe shunt.

Left: ASD II depiction with "real- time 3D echocardiogra- phy" (RT3D-TEE).

Right: The ASD II as seen from the LA (arrow), superior vena cava (VCS) confluence and right atrial appendage (RAA) are labeled here.

Left: ASD II as seen from the right atrium (RA). Depiction with RT3D-TEE uses colors to give the impression of deepness: light blue lies on a deeper level than light brown.

Right: Shunt depiction with color 3D echocardiography, as seen from the RA.

Next 4 animations apply to diffe- rent cases of patent foramen ovale (PFO) and/or atrial septal aneurysm (ASA).

Left: several small left-to-right shunts depicted with color Doppler (PFO fenestrations).

Right: ASA and PFO with massive right-to-left ultrasound contrast agent passage at the end of a Valsalva maneuver.

Left: spontaneous right-to-left shunt can be depicted with color Doppler in cases of large PFO.

Right: this can cause a reduction in oxygen saturation and dyspnea during changes in body position (platypnea-orthodeoxia).

Left: here a case of a complete atrioventricular (AV) canal defect, with ASD I and a large superior located VSD. Septal insertion of AV valves (mitral and tricuspid) lies at the same level.

Right: a malformation of the AV valves, especially of the mitral valve (cleft) cannot be seen in this case.


Complex congenital heart disease

Approach to echocardiographic diagnosis

1. Anatomic orientation

- Situs solitus
- Situs inversus
- Dextrocardia
- Dextroposition

2. Atrioventricular relationship

- Concordant
- Discordant

3. Great vessels

- 2 or 1
- Parallel course
- Ventricular-arterial concordance or discordance

4. Shunts

- Atrial
- Ventricular
- Great vessels: aortopulmonic window, Ductus arteriosus

5. Valves

- Pulmonic stenosis
- Tetracuspid valve (truncus arteriosus)
- Aortic stenosis: valvular, subvalvular
- Bicuspid aortic valve/aortic isthmus stenosis
- Ebstein's anomaly

Extensive and excellent Flash-animations from congenital heart disease can be seen at the Health Center Encyclopedia from the Cincinnati Children's Hospital Medical Center.

Next 4 animations apply to a D-transposition of the great vessels (D-TGA).

Left: parallel course of the great vessels. The aorta lies ventral and the pulmonary artery dorsal.

Right: short axis of the aortic (above) and pulmonary valve (below).

Left: four-chamber view, there is an atrioventricular concordan- ce. However, the RV is the systemic ventricle. Mustard baffle can be seen right below at the RA.

Right: pulmonary vein flow can be seen in and at the intersection of the Mustard baffle to the RA.

Next 4 animations apply to a Fallot's tetralogy.

Left: 50 to 60 % overriding aorta and large outlet VSD as seen from the parasternal long axis.

Right: pulmonary stenosis as seen from the parasternal short axis.

Left: apical five-chamber view of the overriding aorta and the VSD.

Right: RV hypertrophy can be clearly seen from the four-cham- ber view.

Next 4 animations apply to a persistent truncus arteriosus.

Left: from the parasternal long axis view it looks like a Fallot's tetralogy.

Right: VSD shunt can be seen with color Doppler.

Left: the truncus can be followed in a modified parasternal view. Pulmonary artery originates dorsal from the truncus (below in the image), approx. 4 cm distal to the truncus valve.

Right: truncus valve is in this case bicuspid, and not tetracuspid as expected.


More examples of congenital heart disease

Next 4 animations apply to an univentricular heart.

Left: four-chamber view, a rudimentary RV and a large VSD can be seen.

Right: examination with an ultra- sound contrast agent. Anatomic and rheologic characteristics of a double inlet LV (DILV), but without transposition of the great vessels or ventricular inversion.

Left: modified parasternal long axis view.

Right: with an ultrasound contrast agent can be seen, that blood flow from the caval veins fill the rudimentary RV and the LV.

Next 4 animations apply to an aortopulmonic window.

Left: parasternal long axis view.

Right: severe RV and LV hyper- trophy can be seen from the short axis view.

Left: short axis view of the aortic and pulmonary valves shows a severe pulmonary artery dilatation.

Right: a modified view above this level shows an approx. 2 cm large window between aorta and pulmonary artery.

Patent ductus arteriosus (PDA).

Left: retrograde flow in the pulmonary artery as seen with color Doppler.

Right: typical, systolic-diastolic flow with high velocities as depicted with CW-Doppler.

Membranous subvalvular aortic stenosis.

Left: subvalvular membrane can be clearly seen in five-chamber view.

Right: turbulence with color Doppler shows stenotic effect of the membrane.