Table 1 The practical guideline for performing a comprehensive sequential segmental TTE in the CHD patient
View (modality) | Anatomy | Measurement ± explanatory note | Image |
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Subcostal: Transverse / axial plane (2D & CFD) | Visceral / inferred atrial situs | Indicator @ ~ 3 o’clock Situs view with IVC, Ab. Ao. and spine in cross section to assess their relative position Normal (situs solitus): Aorta to left of spine, IVC rightward (± slightly anterior). Rotation and angulation to exhibit long axis of the IVC can be utilised to demonstrate IVC draining into RA |
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Subcostal: Longitudinal / sagittal plane (2D & CFD) | IVC in long axis Hepatic vein | Indicator @ ~ 12 o’clock. In situs solitus, slightly rightward tilt for IVC IVC: – As detailed by BSE minimum dataset [10] – Presence, connection, size, RAP estimation [15] – MM imaging can also be adopted, if perpendicular Normal: Hepatics return to the IVC, near IVC/RA junction. CFD and PWD in the dominant hepatic vein can be used to inspect for systolic dominance or diastolic reversal (which can infer TR severity and/or restrictive RV physiology) |
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Ab. aorta in long axis | Visually assess for pulsatility and for any abnormal flow pattern. From the IVC view, keep indicator at same position and sweep to the left of the patient (in situs solitus) to open Ab. Ao Note: Depending on probe position celiac trunk/superior mesenteric artery may also be visualised |
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Subcostal: Longitudinal / sagittal plane (PWD) | Ab. aorta | Assess for pulsatility to confirm Ab. Ao. and assess for any abnormal flow pattern. In situs solitus, leftward tilt for Ab. Ao Normal: Triphasic signal. Some patients may exhibit reduced aortic elastic compliance and loose triphasic profile, but still be considered normal (i.e. older populations, aortic arch repair) Differential diagnosis: If continuous pulsatile forward flow, consider; – Contamination with celiac trunk/superior mesenteric artery flow – If also blunted/spectral broadening, consider upstream obstruction, i.e. coarctation If holo-diastolic diastolic flow reversal, likely significant aortic regurgitation, but also consider (particularly if within paediatric practices); – PDA with significant pulmonary “run-off” – Aortopulmonary window defect – Major aortopulmonary collateral arteries – Unrepaired truncus – Large Blalock-Taussig shunt – Duct dependent flow; i.e. AoV atresia, interrupted aortic arch |
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Subcostal: Long axis / coronal plane (2D & CFD) | Heart orientation & position | Indicator @ ~ 3 o’clock Establish laterality/cardiac position and apex position of the heart Normal: Left-sided with leftward apex Entire cardiac morphology, particularly with optimal windows may be appreciated; – Veno-atrial drainage/connection—Detailed throughout, but if anomalous veno-atrial return (i.e. shunt), – Atrium morphology—Can be appreciated from multiple windows. Detailed in PSAX window – Atrioventricular connection and function—Can be appreciated from multiple windows. Detail in A4C description (Fig. 3) – Ventricular morphology and function—Can be appreciated from multiple windows. Detailed in A4C description. * = septal leaflet chordal attachment of the tricuspid valve – Shunts—ASD, VSD, PDA – Ventriculoarterial connection and function – Can be appreciated from multiple windows (subcostal, PSAX, apical); Normal: Keeping indicator at @ ~ 3 o’clock, tilt anterior to demonstrate outflows sequentially. A sweep stored loop is valuable. Pulmonary outflow is anterior and leftward of the aortic outflow ( →). Branching pattern may help decipher outflow morphology. Other spatial arrangements exist (Fig. 4) |
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Pericardium | Pericardial effusion assessment |
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Atrial septum | Indicator @ ~ 4/5 o’clock ± anterior tilt Lengthen IAS. Assess for ASD Can also visualise RLPV/RUPV and LLPV Image may require optimising to ensure adequate resolution (frame rate), particularly in adults, in whom the heart is often imaged in the far-field |
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Subcostal: Bicaval Short axis (2D & CFD) | Atrial septum RSVC RAA | Indicator @ 5/6 o’clock Exhibit veno-atrial drainage/connection Assess IAS. Assess for ASD Note: Generally, the recomended image plane (or slightly modified) to interrogate for inferior and superior sinus venous shunt defects. A high right parasternal view with the probe in a super-inferior orientation can also be adopted. Eustachian valve (IVC) is often seen and if prominent directs flow towards the IAS Abnormal diastolic flow reversal may be seen with restrictive RV physiology and/or with significant TR severity May be appreciated on lateral aspect of RA, towards RSVC ostium. Detailed in PSAX window description |
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Ventricular morphology Full heart sweep Pulmonary outflow | Look for chordal septal attachment of TV (*) to help infer RV morphology and equally MV anatomy & apparatus (this can be confirmed in multiple windows, particularly when there is a sub-optimal subcostal window, i.e. most adult cohorts) Pulmonic outflow assessment; –Inspect and interrogate for obstruction (sub-, valve, supra-) and/or regurgitation as detailed by BSE minimum dataset [10, 13, 15] Note: The pulmonary outflow is sometimes best aligned for interrogation from the subcostal window. This is particularly true for the typically anterior located RV-PA conduits, that are often not always easily identified Can assess full cardiac morphology, as previously detailed. Sweep laterally from bicaval to LV apex (akin to PSAX window) |
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MV/LAVV | Detailed in PSAX window. Qualitative assessment of leaflet morphology, thickness, excursion, regurgitation, chordae and papillary morphology/apparatus abnormalities Normal MV: The AMVL is parallel to the ventricular septum as depicted (versus perpendicular orientation to the ventricular septum for LAVV anatomy) |
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Subcostal: RV inflow/outflow (2D & CFD) RAO view AKA “ToF View” | AoV, IAS, RA, TV, RV, RVOT, PA, MPA & PA branches | Indicator @ 1 o’clock. A similar RV inflow/outflow window ( →) can be replicated from a modified apical RV 3 chamber window Offset between the AoV and PV can often be well appreciated, with PV morphology being superior Assess for VSD, abnormality of outlet septum, RVOT obstruction and/or double chambered RV anatomy; Normal (sub-pulmonary): The right ventricle—pulmonary artery junction has a complete circumferential muscular outlet-septum boundary, resulting in discontinuity between the tricuspid valve and pulmonary outflow. The left ventricle—aortic outflow does not, which results in aortomitral continuity |
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Apical: A4C (2D & CFD) | Full heart sweep | State sweep direction: Can assess full cardiac morphology, as previously detailed Note: Although IAS mobility and competence can be appreciated, caution must be adhered to with regards to potential ASD interrogation, sizing and shunt direction due to lateral resolution “drop out” artefact. Assess for ASD; A modified A4C where the septum is orientated more perpendicular will help minimise error. * = moderator band → = atrioventricular valve offset |
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Pulmonary veins: RLPV/RUPV & LLPV | Pulmonary vein identification; –As detailed by BSE minimum dataset [10, 15] RLPV is most likely seen when adjacent to the IAS in A4C with RUPV more likely to be visualised when more anteriorly tilted LLPV is generally well appreciated from A4C Note: Identification and interrogation for pulmonary veins is important with respect to; –Anomalous drainage/connection –Isolated obstruction –Atrioventricular valve regurgitation –Diastolic function |
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A4C (PWD/CWD) | Pulmonary veins | Pulmonary vein interrogation; –A higher sweep speed (i.e. > 75 mm/s) will facilitate greater accuracy of atrial reversal duration measurement. As detailed by BSE minimum dataset [10, 15] |
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Atrio-ventricular connection & ventricular morphology | The atrioventricular valve directly correlates to the morphological ventricle; – Left ventricle = MV: Inserts further from apex – Right ventricle = TV: Inserts closer to the apex (A) – Atrioventricular valve offset: If offset is reversed (B), the TV is abnormally apically inserted (Ebsteins: > 8 mm/m2, C), or not offset (D), question underlying atrioventricular anatomy (Fig. 3) |
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Morphology can then further be interrogated from the following; – Leaflet morphology (in absence of common atrioventricular valve): TV: Trileaflet triangular orifice with septal leaflet attachment into the ventricular myocardium MV: Bileaflet elliptical orifice with typically two distinct papillary muscles inserted antero-laterally and postero-medially (SAX and A2C windows) – Moderator band: Increases likelihood of RV morphology – Wall smoothness: RV more likely to have a courser septal surface with apical trabeculation versus a smooth walled LV – Ventricular shape: RV is crescentic versus cone-like LV appearance |
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A4C (2D & CFD) | MV/LAVV | Caution must be adhered to when assessing systemic TVs or LAVVs with respect to BSE adult quantification data, as it will not be directly applicable Systemic regurgitation assessment; – If MV, as detailed by BSE guidelines [11, 15] –Dominant MV scallops in A4C: A3/A2 & P1 |
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Left atrium | Systemic stenosis assessment; – As detailed by BSE guidelines [11, 15] LA size (end systolic volume): Biplane |
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MV/LAVV | Caution must be adhered to when quantifying regurgitation and/or stenosis in the presence of intracardiac shunts Systemic regurgitation assessment; |
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Systemic stenosis asessment; |
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A4C (PWD) | MV/LAVV | Caution must be adhered to when quantifying inflow with respect to atrial switch biventricular repair anatomies or univentricular physiology Systemic inflow; |
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A4C (TDI/MM) | Basal lateral and basal septal annulus | Caution must be adhered to when quantifying TDI with respect to atrial switch biventricular repair anatomies or univentricular physiology Systemic systolic and diastolic assessment; -As detailed by BSE minimum dataset [10, 11, 15] Note: Limited utility when RWMA are present or expected (i.e. VSD patch, atrioventricular valve repair/replacement) |
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Lateral annulus | MAPSE |
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A5C (2D & CFD) | Outflow/root | Ventriculoarterial connection and function; Tilt anterior to demonstrate outflows sequentially. A sweep stored loop may be of value Normal: Pulmonary valve/outflow is anterior and leftward of the aortic valve/outflow. Branching pattern may help decipher outflow morphology. Spatial orientation of the ventriculoarterial connections can be appreciated (Fig. 4) Systemic outflow assessment; – Inspect and interrogate for obstruction (sub-, valve, supra-) and/or regurgitation as detailed by BSE minimum dataset [10, 12] Normal: Aortomitral continuity as sub-pulmonary outlet septum morphology In atrioventricular septal defect anatomies, there is unwedging of the aorta with absence of atrioventricular—ventriculoarterial continuity. Aortomitral discontinuity will also be noted with respect to systemic RV physiology |
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Coronaries | In addition to PSAX window, coronary ostia and their course can sometimes be appreciated when interrogating the aortic outflow with further anterior modified angulations ( →) |
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A5C (PWD/CWD) | Outflow/root | Systemic outflow assessment; -Inspect and interrogate for obstruction (sub-, valve, supra-) and/or regurgitation as detailed by BSE minimum dataset [10, 12, 15] Note: Supra-valvular outflow obstructions are often well visualised and quantified from suprasternal and right parasternal windows |
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A4C 2D Zoom | Left ventricle | Systemic LV assessment; –As detailed by BSE minimum dataset [10, 15] –A4C LV ( →): IS: Infero-septum wall AL: Antero-lateral wall Measures should be indexed to BSA or Z-scored (if paediatrics) |
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A2C (2D, CFD, PWD, CWD), 2D Zoom | Left ventricle Left atrium | Systemic LV assessment; –As detailed by BSE minimum dataset [10, 15] –A2C LV ( →): I: Inferior wall A: Anterior wall LA size (end systolic volume); Biplane |
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MV/LAVV | If MV: P3/A2 (enface)/P1. Assess for stenosis and/or regurgitation as detailed by BSE guidelines [10, 11, 15]. Assessment of papillary muscle number and location with modified angulations Note: X-plane enface imaging or 3D helpful when interrogating anatomy [11], especially if LAVV | ||
Pulmonary veins | LUPV is seen adjacent to LAA, separated by the coumadin ridge. |
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Coronary sinus | RLPV/RUPV may also be appreciated with modified angulation CS may also be appreciated enface, adjacent to the basal inferior wall, within the atrioventricular groove | ||
Ab. aorta | Further posterior angulation will demonstrate the Ab. Ao. in its long axis | ||
A3C (2D, CFD, PWD, CWD), 2D Zoom | Left ventricle | Systemic LV assessment; – As detailed by BSE minimum dataset [10] – A3C LV ( →): IL: Infero-lateral wall AS: Antero-septum wall |
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MV/LAVV Outflow/root | IF MV: Likely A2/P2. Assess for stenosis and/or regurgitation as detailed by BSE guidelines [10, 11, 15] Systemic outflow assessment; –Inspect and interrogate for obstruction (sub-, valve, supra-) and/or regurgitation as detailed by BSE minimum dataset [10, 12, 15] | ||
A4C RV (2D & CFD, MM, TDI) | Right ventricle RA | Subpulmonic RV assessment; - As detailed by BSE minimum dataset [10, 14, 15] - If RV: Lateral RV “free” wall Note: Systemic RV assessment is largely qualitative, with measurement parameters adopted for longitudinal follow-up comparison RA size (end systolic area); |
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Obtain a RV focussed view to allow entire RV free wall to be interrogated and RV dimensions to be measured from. As detailed by BSE minimum dataset [10, 14, 15] |
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TV/RAVV | Caution must be adhered to when assessing subpulmonic MVs or RAVVs with respect to BSE adult TV quantification data, as it will not be directly applicable Subpulmonic TV inflow stenosis/regurgitation; – Assess as detailed by BSE guidelines [13, 15] – If TV: Likely anterior (A) & septal (S) leaflets – Posterior (P) leaflet if CS angulated in view Note: X-plane enface imaging or 3D helpful when interrogating anatomy [13] |
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Coronary sinus | With posterior angulation, CS can be appreciated, draining back into the RA within the left posterior atrioventricular groove. In LSVC anatomy, a dilated CS is often seen (right example). Note: The LSVC is a left atrium morphological structure If CS is unroofed/fenestrated, thus shunting physiologically, haemodynamically will act as an ASD with left to right shunting |
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RSVC | Sometimes noted very anterior | ||
RAA | Broad based orifice and anterior. Christa terminalis (prominent muscle bar separating RSVC—RAA) may be seen |
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Eustachian valve | → = Eustachian valve (EV)/ridge can sometimes be seen and if may be noted to change inflow profile. It is typically a relatively rigid structure, inserting more caudally (infero-posterior), but can also be mobile and fenestrated. It is different to the Chiari network due to its insertion point, which inserts superior-anterior This is a normal anatomical variant. Possible erroneous pathologic interpretation typically includes mass lesion or Cor triatriatum dexter |
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Modified apical RV 3 chamber Inflow/outflow (2D & CFD) | RA, TV, RV, RVOT, PA, MPA & PA branches | Anterior probe tilt with indicator rotated between 12–2 o’clock, akin to the subcostal RV inflow-outflow window ( →) Depending on rotation of probe, aortic valve may be seen enface [13], if TV: – Adjacent to AoV and no septum—anterior (A) TV leaflet – Liver noted/inferior RV wall—posterior (P) TV leaflet Offset between the AoV and PV can then be appreciated with PV morphology being superior Assess for abnormality of tricuspid valve (i.e. Ebstein’s), VSD, outlet septum, RVOT obstruction and/or double chambered RV anatomy |
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A4C RV (PWD/CWD) | TV/RAVV | Caution must be adhered to when quantifying regurgitation and/or stenosis in the presence of intracardiac shunts Est. RVSP = TR Vmax + RAP – If no valvular stenosis, regurgitation, or downstream stenosis (i.e. branch pulmonary arteries), use as surrogate for PASP Note: RVSP/PASP will be underestimated with severe/free TR and should not be relied upon |
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Subpulmonic TV stenosis/regurgitation; |
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Modified A4C PV (2D, CFD, PWD, CWD), | Outflow/root | Ventriculoarterial connection and function; Tilt further anterior than A5C to demonstrate pulmonary outflow, if required. In some patients, branch pulmonary arteries can also be appreciated Typically, a rib-space higher with lateral or medial modification will optimise this pulmonary outflow window, which can be fully examined Normal: Pulmonary valve/outflow is anterior and leftward of the aortic valve/outflow. Branching pattern may help decipher outflow morphology. Spatial orientation of the ventriculoarterial connections can be appreciated (Fig. 4) |
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Left PLAX (2D & CFD) | Full heart sweep | State sweep direction: “VSD sweep” Can assess full cardiac morphology, as detailed in previous sweep descriptions Note: Parasternal imaging often exhibits best VSD visualisation and quantification Ventriculoarterial connection; Pulmonary valve/outflow is anterior and leftward of the aortic valve/outflow. Branching pattern may help decipher outflow morphology. Spatial orientation of the ventriculoarterial connections can be appreciated (Fig. 4) |
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Left PLAX (2D & CFD) | Pericardial/pleural space MV/LAVV LA | Increase scan depth Assess annulus, mobility, thickness, calcification, supra or sub valvular apparatus Systemic stenosis/regurgitation assessment; – If MV, measures as detailed by BSE guidelines [10, 11, 15] MV scallops usually demonstrated are; Standard PLAX: A2 & P2 Modified RV inflow tilt: A3 & P3 Modified RV outflow tilt: A1 & P1 MM may help demonstrate pathology Note: X-plane enface imaging or 3D helpful when interrogating anatomy [11], especially if LAVV |
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Left ventricle | Systemic LV assessment; – As detailed by BSE minimum dataset [10, 15] – PLAX LV ( →): IL: Infero-lateral wall AS: Antero-septum wall |
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Coronary sinus | CS (enface): Posterior within left posterior atrioventricular groove. If dilated, a high index of suspicion is warranted for persistent LSVC anatomy | ||
Prox. RVOT | Note: Ab. Ao. is seen posterior, outside of the pericardium As detailed by BSE minimum dataset [10, 15] If RV: Anterior RV wall | ||
Pulmonary veins | LLPV: Adjacent to inferolateral LV annulus Other veins may also be interrogated with modified imaging windows |
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Left PLAX: 2D Zoom (2D & CFD) | LVOT/outflow | Systemic outflow assessment; – Inspect and interrogate for obstruction (sub-, valve, supra-) and/or regurgitation as detailed by BSE minimum dataset [10, 12, 15] Normal: If trileaflet aortic valve: right coronary cusp (RCC) is seen anteriorly, extending from ventricular septal aspect. Depending on tilt, either non (NCC)- or left- coronary cusp may been seen posteriorly with continuity to the AMVL, due to normal outlet (sub-pulmonary) septum morphology * = sub-aortic ridge |
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Root | Aortic root appearance and dimensions. Moving up a rib-space/superiorly will often optimise view Outflow measurements should be made as detailed by BSE minimum dataset, documenting method of quantification (i.e. edge: inner to inner [i2i] or leading to leading [L2L] and timing: end diastole or end systole) alongside absolute values; – BSE Height index (mm/m)—end diastole [15] – Z-score (label which dataset) – BSA correction (cm/m2): i.e. Turners |
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RCA | RCA ostium may be appreciated arising from the sinus. The RCA typically courses rightward (in PLAX) behind the pulmonary artery and below the right atrial appendage along the right atrioventricular groove Note: High take-off (superior to sinus) may also be appreciated as a normal variant |
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Left PLAX: RV inflow (2D & CFD) | RA TV/RAVV Atrial septum | Inflow stenosis/regurgitation; – As detailed by BSE minimum dataset [10, 15] – Note: A PMVSD jet may contaminate TR The beam tilt will dictate which TV leaflets are likely visualised [10, 13, 15], if TV; – Anterior (A) and posterior (P) leaflets when LV/ventricular septum and CS are no longer visualised – Anterior and septal (S) leaflets when ventricular septum and CS ostia to RA noted Note: X-plane enface imaging or 3D helpful when interrogating anatomy, especially if RAVV A modified “RV inflow” with more lateral and caudal probe positioning (i.e. a rib space lower) can exhibit IAS. Assess for ASD |
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Right ventricle IVC, CS | When LV/ventricular septum is no longer visualised, RV inferior wall is seen adjacent to diaphragm/liver with contralateral RV anterior wall noted If RV: A: Anterior RV wall I: Inferior RV wall Can be identified with modified inflow tilt. Remnant Thebesian valve from the CS (*), Eustachian valve from the IVC (#) and/or Chiari network (mobile net-like structure) may be identified and noted to change the inflow profile. It is typically a relatively rigid structure, inserting more caudally (infero-posterior), but can also be mobile and fenestrated. It is a normal anatomical variant. Possible erroneous pathologic interpretation typically includes mass lesion or Cor triatriatum dexter |
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TV/RAVV | Inflow stenosis/regurgitation; – As detailed by BSE minimum dataset [10, 13, 15] – Note: a PMVSD jet may contaminate TR |
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Left PLAX: RV outflow (2D & CFD) | Distal RVOT PV, MPA & PAs | Tilt superior and centralise Pulmonic outflow assessment; – Inspect and interrogate for obstruction (sub-, valve, supra-) and/or regurgitation as detailed by BSE minimum dataset [10, 13, 15] Ventriculoarterial connection; Pulmonary valve/outflow is anterior and leftward of the aortic valve/outflow. Branching pattern may help decipher outflow morphology. Spatial orientation of the ventriculoarterial connections can be appreciated (Fig. 4) Notes: –LPA is left-sided in PLAX –PDA can sometimes be examined here if Ductal view is non-obtainable |
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Left PLAX: RV outflow (PWD/CWD) | Distal RVOT PV outflow, MPA & PAs | Pulmonic outflow assessment; – Inspect and interrogate for obstruction (sub-, valve, supra-) and/or regurgitation as detailed by BSE minimum dataset [10, 13, 15] |
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Can also do in PSAX | Measures; –Sub-valvular PWD (Vmax, VTI, SV). Use PWD “step-through” if suspected sub- or supra-valvular obstruction – Sub-pulmonic obstruction CWD (Vmax, VTI, mean PG) | ||
– Sub-pulmonic regurgitation CWD (density, contour, PHT, PR Vmax, PR Vend, PR index) – Est. Mean PAP: PR Vmax + RAP – Est. End diastolic PAP: PR Vend + RAP – If notching is noted: likely raised pulmonary pressures Note: Severe PR is likely if flow reversal is noted on CFD and Doppler within the branch PAs |
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Left PSAX: (2D & CFD) | Full heart sweep Pericardial / pleural space | State sweep direction: “VSD sweep” Can assess full cardiac morphology, as detailed in previous sweep descriptions In order to maintain adequate frame rate, it is recommended CFD “box-size” is reduced to cover myocardial lateral and septal aspects individually when inspecting for VSDs Note: Parasternal imaging often exhibits best VSD visualisation and quantification Increase scan depth |
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Left PSAX: AoV level (2D & CFD) | Aortic valve RVOT, PA, MPA & PA | Qualitative assessment of cusp morphology and function – As detailed by BSE minimum dataset [10] Spatial orientation of the ventriculoarterial connections can be appreciated (Fig. 4) Normal: Pulmonary valve/outflow is anterior and leftward of the aortic valve/outflow. Branching pattern may help decipher outflow morphology. RV inflow-outflow demonstrated ( →) |
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Coronary origins | Coronaries in almost all cases arise from the aortic sinuses facing the pulmonary valve. The non-facing sinus/non-coronary cusp is always the cusp adjacent to the IAS Use coronary specific imaging settings (i.e. high frequency, low compress, increased 2D gain, zoom). If normal, they arise slightly superior (i.e. up a rib-space) to the respective cusps. By TTE; – LCA: indicator ~ 2/3 o’clock (sometimes further clockwise rotation is warranted) with ostium originating typically at 3 o’clock and courses rightward (in PSAX) before bifurcating into left anterior descending (upward in PSAX: #) and left circumflex arteries (downward in PSAX: *) – RCA: indicator ~ 1 o’clock with ostium originating typically at 11 o’clock and coursing leftward (in PSAX) |
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For increased diagnostic accuracy (i.e. to rule out erroneous pericardial fold/coronary vein), origins can be demonstrated with CFD (reduced Nyquist scale), exhibiting predominantly diastolic antegrade flow in the structurally normal heart without known occlusive coronary artery disease |
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Modified left PSAX: AoV level (2D & CFD) | Atrial septum RA TV/RAVV | A focused image is recommended. Assess for ASD Inflow stenosis/regurgitation; – As detailed by BSE minimum dataset [10, 13, 15] – Note: A PMVSD jet may contaminate TR If TV: Leaflet cusps will vary depending on level of valve interrogation [13] Note: X-plane enface imaging or 3D helpful when interrogating anatomy [13], especially if RAVV |
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Atrium morphology LAA | Atrial arrangement is largely inferred from the abdominal visceral situs as direct visualisation of both atrial appendages (particularly RAA) is challenging by TTE. Therefore, site of the appendages is mostly complimentary (Fig. 1) Following PSAX branch PA bifurcation image optimisation, which is typically a rib-space higher than standard, tilt posterior from RPA to “open” LAA and respective pulmonary veins LAA: Typically, narrow orifice and posterior (modified PSAX or A2C), finger-like appearance by TTE |
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RAA | Typically, a rib-space higher with medial probe positioning for right atrial appendage. It lies near RSVC insertion RAA: typically, triangular with broad based orifice and anterior (modified PSAX), Christa terminalis (prominent muscle bar separating RSVC—RAA) may be seen. Pectinate muscles are course and extend towards the tricuspid valve |
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LSVC | If present, further modified imaging planes (indicator towards 1 o’clock) can visualise the LSVC in its long axis. Typically, a persistent LSVC passes anterior to the LPA before coursing infero-posterior along the left atrioventricular groove into the coronary sinus before draining into the right atrium. In adults, the proximal course of the LSVC is best appreciated from the SSN window |
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Modified left PSAX:AoV level (2D & CFD) | RVOT, PV outflow, MPA & PAs | Pulmonic outflow assessment; –Inspect and interrogate for obstruction (sub-, valve, supra-) and/or regurgitation as detailed by BSE minimum dataset [10, 13, 15] Notes: – A rib-space higher may aid branch PA bifurcation optimisation (right pane) – LPA is right sided in PSAX indicator projection – Large margins of error can exist with respect to RVOT/outflow dimensions and the rib space the probe is positioned within |
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Pulmonary veins | By TTE, it is generally accepted within CHD that at least 3 pulmonary veins are observed returning to the LA (from any imaging plane) LAA (bi-directional CFD) & LUPV posterior, when in PSAX window |
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LLPV—red |
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RLPV—red RUPV—blue (often difficult to appreciate in this view) Note: Pulmonary veins can be appreciated from numerous windows. It may also be possible in some populations to appreciate pulmonary veins via the SSN “Crab" view |
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Eustachian valve/Chiari network | Eustachian valve (#) can sometimes be seen and may be noted to change inflow profile. It is typically a relatively rigid structure, inserting more caudally (infero-posterior), but can also be mobile and fenestrated. It is different to the Chiari network (= →) due to its insertion point, which inserts superior-anterior This is a normal anatomical variant. Possible erroneous pathologic interpretation typically includes mass lesion or Cor triatriatum dexter |
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Modified high “ductal view” (2D, CFD, CWD) High left parasternal longitudinal / sagittal plane | Proximal LPA with isthmus/Desc. aorta in long axis | Sweep to assess for PDA. Indicator towards 12/1 o’clock, at least one rib space higher and typically immediately adjacent to the left side of the sternum Often patient needs to be in an extreme left lateral decubitus position to optimise |
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Left PSAX: Basal level (2D & CFD) | MV/LAVV TV/RAVV | Qualitative assessment of leaflet morphology, thickness, excursion, regurgitation * = Anterolateral commissure # = Posteromedial commissure Note: Xplane or 3D imaging is useful to appreciate atrioventricular anatomy in both SAX and the corresponding LAX projection [11], especially if LAVV/RAVV |
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Left ventricle | Qualitative assessment of radial function/RWMA (n: 6) | ||
Right ventricle | Qualitative assessment of radial function. If RV; A: Anterior RV wall I: Inferior RV wall L: Lateral RV “free” wall | ||
Left PSAX: Mid-level (2D & CFD) | Left ventricle Right ventricle MV/LAVV TV/RAVV | Qualitative assessment of radial function/RWMA (n: 6) Can assess septal curvature loading in systole (pressure) and diastole (volume). Can utilise Eccentricity index (just below level of MV leaflets), ensuring correct measurement alignment Normal Eccentric index: < 1.2 Qualitative assessment of radial function A: Anterior RV wall I: Inferior RV wall L: Lateral RV “free” wall Assess chordae and papillary morphology/apparatus abnormalities * = Lateral papillary muscle # = Medial papillary muscle |
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Left PSAX: Apical level (2D & CFD) | Left ventricle | Qualitative assessment of radial function/RWMA (n: 4) |
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SSN long axis (2D & CFD) | Aortic arch | Have good head tilt/shoulders raised. This standard window should be modified to appreciate optimised vessel calibre, including; – Asc. Ao – Transverse Arch (between BCA/IA & LCCA) – Desc. Ao – RPA (enface) – Head and neck vessels (BCA/IA, LCCA, LSA) Abnormal colour patterns. Assess for coarctation, PDA or anomalous pulmonary vertical vein Note: A right sided aortic arch will require a degree of rightward angulation to appreciate Desc. Ao., and LPA in their respective long axis projections |
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SSN long axis (PWD/CWD) | Aortic arch | Individual vessels can be interrogated by Doppler (including Pedof probe if warranted); – Distal Asc. Ao: CWD – Desc. Ao.: PWD (stepdown if warranted) & CWD Normal: Triphasic signal. Some patients may exhibit reduced elastic compliance and loose triphasic profile, but still be considered normal –Head and neck vessels (BCA/IA, LCCA, LSA) If there is evidence of continuous antegrade diastolic forward flow (“diastolic tail”), likely to reflect a degree of narrowing/coarctation of the aorta |
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If holo-diastolic diastolic flow reversal, likely significant aortic regurgitation, but consider; – PDA with significant pulmonary “run-off” – Aortopulmonary window defect – Major aortopulmonary collateral arteries – Unrepaired truncus – Large Blalock-Taussig shunt – Duct dependent flow; i.e. AoV atresia, interrupted aortic arch |
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Leftward modified SSN long axis (2D, CFD, PWD, CWD) | LPA Innominate vein | Sweep left lateral to open LPA in long axis (LPA is anterior to Desc. Ao.), assess for obstruction, flow reversal and/or use if PDA and if LPA not well seen previously in other imaging windows (typically adult cohorts) Note: In the presence of valvular or supravalvular pulmonary obstruction, mixed/residual flow acceleration is often exhibited in the LPA, which itself may be of normal calibre Often seen in many SSN views but may run retro-aortic as a normal variant |
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LSVC | If present, further modified imaging planes can visualise the LSVC in its long axis. Typically, a persistent LSVC passes anterior to the LPA before coursing infero-posterior along the left atrioventricular groove into the coronary sinus before draining into the right atrium Sometimes bilateral SVCs anatomies will have a bridging vein, that is often difficult to appreciate by TTE |
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SSN short axis (2D & CFD) | Arch sidedness | Indicator at 3 o’clock. Further rotation of indicator to 4/5 o’clock can help illustrate the BCA/IA in its long axis projection Sweep superior/anterior and follow first head and neck vessel and follow branching pattern Note: First arch vessel is typically BCA/IA and arch sidedness is typically contralateral to its direction Normal: Left sided aortic arch: BCA/IA is rightward and bifurcates |
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Right sided aortic arch: BCA/IA is leftward and in normal head and neck vessel arrangement will also bifurcate Note: Left and right aortic arch refers to which side the bronchus/trachea are crossed by the aortic arch, not which side of the midline the aortic root or Desc. Ao. takes There are many variations of head and neck vessel arrangement. Of which, TTE is often sub-optimal to provide detailed diagnosis |
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SSN short axis (2D & CFD) | RPA Venous anatomy | Assess calibre and flow pattern, if not assessed earlier in study. Optimise Doppler angle. The more perpendicular, the less reliable due to angle of incidence principle Long axis Innominate vein to RSVC Normal: Innominate vein (AKA brachiocephalic vein) is typically anterior to the Asc. Ao. and drains to the RSVC |
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SSN short axis: “Crab view” (2D & CFD) | Pulmonary veins: LLPV LUPV RLPV RUPV | Pulmonary veins can be appreciated from numerous windows. It is largely accepted that “crab view” in adult populations is often sub-optimal Normal; LLPV—red LUPV—blue |
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Normal; RLPV—red RUPV—blue |
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High right parasternal: Longitudinal view (2D, CFD, PWD, CWD) | Outflow/aortic root | Indicator at ~ 11–1 o’clock. Ascending aortic vessel can be interrogated (Pedof probe is recommended) for obstruction. Often useful in interrogating any valvular/supra-valvular obstruction with eccentric forward flow jets that are often difficult to align optimally elsewhere |
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IAS, RSVC, IVC | Indicator at ~ 12 o’clock Often patient needs to be in the right-sided decubitus position |
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Supraclavicular view (2D, CFD, PWD, CWD) | SVC | Indicator at ~ 12 o’clock A right supraclavicular view may be used where necessary (i.e. assessment in Fontan circuit: RSVC Glenn ± distal conduit anastomosis sites). The same interrogation may also be performed in the left supraclavicular view for left SVC anatomy In adult populations, RSVC is not always best appreciated from the SSN SAX imaging, and this window can be adopted |
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