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  • 1. Normal Four Chamber View Dr.Sameer Dikshit MD DGO FCPS FICOG
  • 2.  Nowrosjee Wadia Maternity Home BSES MG Hospital S L Raheja-Fortis Hospital
  • 3.  Approximately 8 per 1000 live births ◦ 3 times more common than identifiable chromosomal disease ◦ 4 times more common than neural tube defect
  • 4. 4 Chamber view of the fetalheart
  • 5. Advantages Easy to obtain Move up from AC view Easy to identify
  • 6.  Easy to standardize Can be easily included in mid trimester scan protocol without incurring additional expense/ time/ personnel
  • 7.  Axis Size Pericardial effusion 2 Atria roughly equal
  • 8.  2 Ventricles roughly equal AV valves with offset IVS
  • 9.  Inter- atrial septum with foraminal flap Pulmonary veins A & V rhythm Colour Doppler for flow across the AV valves
  • 10. #1) Determine SitusStomach tothe left side& Liver to theright SitusSolitus
  • 11. #2) Position of the HeartAll of theheart except abit of RA lie inthe Left Half
  • 12. #3) Axis450 +/- 150Apex Pointingto the LeftLevocardia
  • 13. #4) 4 Chamber ViewAnatomicalv/sMorphological
  • 14. #5) AV valvesOffsetTricuspid isapical thanMitral
  • 15. #6) IVS & IASSeptum PrimumSeptum Secundum
  • 16. #7) Heart Rate and Rhythm-1M Mode
  • 17. #8) Heart Rate and Rhythm-2Pulsed WaveDoppler
  • 18. #9) Colour Doppler 12 streamsfrom A to V
  • 19. #10) Colour Doppler 2Aortic outflow
  • 20. #11) Pulm VeinsPV open intoLA
  • 21. #12) PV pulsed wavedoppler
  • 22. #13) Foramen OvaleFlow
  • 23. #12) Lateral 4 chamber viewGood view ofIVS
  • 24. #13) Lateral 4 chamber colour DopplerColourDoppler formuscular VSD
  • 25. #14) First TrimesterHeart-1
  • 26. #15) First TrimesterHeart-2
  • 27. #15) First TrimesterHeart-3
  • 28. CHDs associated withabnormal 4 Ch view Abnormal Situs Inequality of chambers ◦ Hypoplastic Right/ Left Heart syndrome Septal defects ◦ Large VSD ◦ AVSD Valvular abnormalities
  • 29. CHDs associated withabnormal 4 Ch view..contd. Severe abnormalities of vessels ◦ Coarctation of aorta/ aortic stenosis ◦ Pulmonary stenosis Pericardial effusion Myocardial hypertrophy Cardiac Tumours
  • 30. “Is 4 chamber view a goodscreening test ?”
  • 31.  Only 40% of CHD can be diagnosed with 4 Ch view Various studies quote a range from 15-60%
  • 32. Screening Test DRRisk Factors approach 11%4 Chamber View 40%
  • 33. Why 4 Ch view fails?
  • 34. CHDs NOT associated withabnormal 4 CH view1. Abnormalities of great vessels not associated with any defect on cardiac chambers2. CHDs with progressive evolution3. CHDs not detectable in utero
  • 35. (1) Abnormalities of great vesselsnot associated with effect onchambers  Mild Aortic stenosis, Coarctation  Tetralogy of Fallot of aorta , Pulmonary stenosis  Transposition of great vessels  Double outlet ventricle  Truncus Arteriosus  Pulmonary atresia with VSD
  • 36. (2)CHDs with progressiveevolution Pulmonary stenosis Aortic Coarctation Ventricular hypoplasia
  • 37. (3)CHDs NOT detectable inutero  Isolated ASD  (Postnatally) Patent ductus  Small VSD arteriosus  Partial anomalous pulmonary venous  (Postnatally) connection Patent foramen ovale
  • 38. Can we do something to improve thepick up rate of 4- chamber view??
  • 39. Inadequate examination Heart is examined at inappropriate angle Maternal Habitus “Lack of time” Sub-Optimal magnification
  • 40.  Heart fills 1/3 to ½ of the screen
  • 41.  Introduce protocol of measuring ventricles in systole and diastole Many times the 4 chamber view of the heart may “look normal” but the measurements may be outside the normal limits
  • 42.  Use cine loop to see the heart in all phases of cardiac cycle
  • 43.  Use colour doppler and PW doppler
  • 44. Pitfalls in 4 chamber view My Experience
  • 45. Case #1 Extra vessel noted while moving up from AC view
  • 46. Aorta far offfrom LA
  • 47. Leash ofvesselsbehind LA
  • 48. Anomalous PulmonaryVenous Return Schimitar vessel
  • 49. Case #2
  • 50. Hypoplastic Left Heart Poor flow across Mitral Valve
  • 51. Case #3
  • 52. Ebstein’s
  • 53. AVSD
  • 54. Septum Primum ASD
  • 55. Case#4
  • 56. Perimembranous VSD
  • 57. Perimembranous VSD
  • 58. Rt Aortic Arch
  • 59. Abnormal 4 chamber views Fetal Medicine Foundation videos
  • 60. Ventricular Septal Defect
  • 61. Atrio Ventricular SeptalDefect
  • 62. Tricuspid Regurgitation
  • 63. Ebstein’s Anomaly
  • 64. BiventricularRegurgitation
  • 65. Corrected Transposition
  • 66. CongenitalDiaphragmatic Hernia
  • 67. Rhabdomyomas
  • 68. Dextrocardia
  • 69. Anemia
  • 70. Take home message
  • 71.  What is 4 chamber  Pick up rate view  Why 4 chamber What structures to view fails see in 4 chamber view  Abnormal 4 chamber view examples