The document describes a segmental approach to describing congenital heart disease. It involves systematically assessing the 3 cardiac segments (atria, ventricles, great vessels) and their connections. Key aspects include determining visceroatrial situs, atrial and ventricular morphology, atrioventricular and ventriculo-arterial connections, and relationships between the great arteries. This approach allows complex CHD to be methodically characterized and expressed segmentally.

1. ECHO : SEGMENTAL APPROACH
Dr Binjo J Vazhappilly
SR Cardiology
MCH Calicut

2. Segmental Approach to Imaging Congenital
Heart Disease (CHD)
• Systematic and sequential method to describe the cardiac segments
and connections.
• Three cardiac segments : atria , ventricle and great vessels.
• Connections : specific relationship between the segments .

5. Determine visceroatrial situs
• Situs refers to spatial arrangement of the viscerae .
Three types of visceroatrial situs
• S – solitus (normal arrangement)
• I – inversus (or the mirror-image arrangement)
• A - ambiguus
• Situs ambiguus : defined as an abnormality in which thoracic and
abdominal organs are positioned with respect to each other, in such
a way that it cannot be clearly lateralized.

6. Situs Solitus

7. Situs Inversus

8. Right Isomerism(Asplenia)

9. Left Isomerism (polysplenia)

10. Cardiac Position & Orientation
• Position of the heart in the chest with regard to its location and
orientation of its apex.
Location of heart in the chest
• Levoposition : to the left
• Mesoposition : central
• Dextroposition : to the right
Cardiac orientation is the base to apex orientation of heart
• Levocardia : apex directed to left of midline.
• Mesocardia : apex oriented inferiorly in the midline
• Dextrocardia: apex directed to right of midline.

11. Atrial Morphology
Right Atrium
• Triangular, broad based,
anterior appendage .
• Receives IVC, SVC & coronary
sinus.
• Septum secundum (limbus of
fossa ovale) lies on RA side.
• Crista Terminalis is in RA.
Left Atrium
• Narrow, fingerlike posterior
appendage .
• LA receives all 4 pulmonary
veins
• Septum primum lies on LA
side .
• LA is smooth with fewer
trabeculations
The right & left atria are identified morphologically by their
respective atrial appendages and veins emptying into them.

12. Atrial Morphology

13. Pulmonary veins to LA

14. Atrial Situs
• Atrial Situs Solitus (S)
• Atrial Situs Inversus (I)
• Atrial Situs Ambiguous (A)
Right isomerism (bilateral right atria) or
Left isomerism (bilateral left atria).

15. Ventricular Looping
• Embryonic heart is a linear tube with bulbus cordis (future RV )
being cephalad to the developing left ventricle (LV) .
• In normal development the tube bends over on itself to right
forming a D-loop resulting in positioning of the bulbus cordis to the
anatomic right of the left ventricle
• Folding to left results in L-loop with the morphologic right ventricle
being to the left of the morphologic left ventricle

16. Ventricular Looping

17. D Loop L Loop

18. Identification of the ventricles
Tricuspid Valve ⇒ RV
• Septal chordal attachments
• Apical septal annular
attachment
• 3 leaflet
• Multiple small papillary
muscles
• Triangular orifice
Mitral valve ⇒ LV
• No septal chordal
attachments
• Basal septal annular
attachments
• 2 leaflet
• 2 large papillary muscles
• Elliptical orifice.
AV valve morphology directly correlates with ventricular type

19. RV Morphology
• Large apical trabaculations
• Coarse septal surface
• Moderator bands
• Cresentic in cross section
• Tricuspid – pulmonary
discontinuity

20. LV Morphology
• Small apical trabeculations
• Smooth upper surface
• No moderator band
• Mitral – Aortic continuity

21. Atrio-ventricular Connections
• Concordant ( Normal : RA to RV & LA to LV)
• Discordant ( RA to LV & LA to RV)
• Univentricular AV connections
Absent AV connection
Common AV valve
Double inlet connections

22. Concordant AV Connection

23. Univentricular AV Connections
• Absent AV connection (right / left)
Tricuspid / mitral atresia
• Common AV valve
With single ventricle
• Double inlet ventricle
Connection of both AV valve to the same ventricle
Anatomically left
Anatomically right
Undetermined
(rudimentary chamber always present)

24. Univentricular AV connections

25. Univentricular AV connections
Absent Rt AV Connection Absent Lt AV connection

26. Univentricular AV connections
Double inlet : RV Morphology Double inlet : LV Morphology

27. Overriding & Straddling
• Overriding :
Biventricular emptying of AV Valve or biventricular origin of a
semilunar valve.
• Straddling :
Chordae or papillary muscle of the valve attach to contralateral
ventricle.
Involve AV Valves and requires presence of VSD.

28. Arterial Morphology
• Aorta : artery that gives rise to the coronary arteries and the
brachiocephalic vessels.
• Pulmonary artery : branches into two but does not give rise to any
vessels.

29. Ventriculo-Arterial Connection
• Concordant :
Aorta connected to LV and pulmonary artery to RV .
• Discordant :
Aorta connected to RV and pulmonary artery to LV .
• Double Outlet : Both great arteries arise from a single ventricle.
• If more than 50% of an artery overrides a ventricle it is said to be
committed to it.

30. Commitment
• Commitment describes possible abnormalities of flow through
valves into ventricles and great vessels.
• In TOF, atria, AV valves & ventricles are positioned normally and
concordant.
Aorta overrides a VSD and is doubly committed to both ventricles.
• In univentricular heart both AV valves are usually doubly
committed to the single ventricle.

31. Ventriculo-arterial connections
• Concordant (normal)
Ventricular septal defect, tetralogy of Fallot
• Discordant
Transposition
• Double outlet ventricle
With subaortic VSD
subpulmonary VSD
doubly committed VSD
non-committed VSD
• Common arterial trunk

32. Conus
• Subpulmonary:
Absence of subaortic infundibular free wall, found in normal heart.
• Subaortic:
Absence of subpulmonary infundibular free wall, found in D-loop
TGA.
• Bilaterally present :
In double outlet RV , but rarely in TGA.
• Bilaterally Absent:
In double outlet LV.

33. Relation b/w semilunar Valves
• Solitus : Aorta posterior and to right.
• Inversus : mirror image : Aorta posterior and to left
• D-malposition : aortic valve anterior and to the right.
• L-malposition : aortic valve anterior and to the left.
• Anterior malposition : aortic valve anterior in the middle.
• Parasternal and high parasternal short axis and subcostal short axis
views are used to recognize the positions of AV and PV.

34. Possible Great vessel relations

35. Normal
PSX Suprasternal long and short axis

36. d TGA

37. cc TGA

38. DORV

39. TOF

40. Truncus Arteriosus

41. Assessment of Associated Anomalies
Abnormalities in each segment should be assessed
 Septal defects
 AV valve abnormalities like Ebstein’s
 Outflow tract stenosis
 Aortic arch branching and sidedness
 Pulmonary artery and branches
 PDA
 Coronary abnormalities

42. Ebstein anomaly

43. Pulmonary valve pathology

44. LV outflow
Subaortic membrane Supravalvular AS

45. COARCTATION OF AORTA

46. Sequential Segmental Approach
• Identify situs of the thoraco-abdominal organs.
• Determine cardiac position within thorax.
• Atrial Situs.
• Ventricular Situs.
• Atrioventricular connection and alignment.
• Ventriculo-arterial connection and alignment.
• Conal (infundibular) anatomy.
• Relationship between the great arteries.
• Description of associated malformations

47. Segmental Expression
1 . Visceroatrial situs : S , I or A.
2 . Ventricular situs : D or L
3 . Position of great vessels : S , I , D , L or A
 Normal : S , D , S
 Situs inversus Dextrocardia : I , L , I
 D TGA : S , D , D
 D TGA with situs inversus : I , L ,L
 L TGA with situs solitus : S , L , L

48. QUIZ

49. 1. Interrupted IVC is seen in
A) Situs inversus
B) Situs solitus
C) Right isomerism
D) Left isomerism

50. 2. Morphological feature of right atrium
A) Finger like posterior appendage
B) Smooth surface
C) Presence of cristae terminalis
D) Septum primum lies on RA side

51. 3. True about right atrial appendage
A) Narrow based
B) Triangular
C) Posterior
D) None of the above

52. 4.True about ventricular morphology
A) LV is cresentic in cross section
B) Moderator band is seen in RV
C) Trabaculations are less in RV
D) RV has smooth septal surface

53. 5. Straddling means
A) Papillary muscle of the valve attached to contralateral
ventricle.
B) Papillary muscle attached to septum
C) Absence of papillary muscle
D) Fusion of papillary muscle

54. 6. In d TGA true about connection is
A) AV discordant , VA concordant
B) AV concordant , VA discordant
C) Both AV and VA concordant
D) Both AV and VA discordant

55. 7. In TOF true about connection is
A) AV discordant , VA concordant
B) AV concordant , VA discordant
C) Both AV and VA concordant
D) Both AV and VA discordant

56. 8. Conus is bilaterally absent in
A)DORV
B) TGA
C) DOLV
D) Normal heart

57. 9. In d malposition of great arteries
A) Aorta posterior and to right
B) Aorta posterior and to left
C) Aorta anterior and to right
D) Aorta anterior and to left

58. 10.Segmental expression of L TGA is
A) S , D , S
B) I , L , I
C) S, D , D
D) S , L , L

59. 1. Interrupted IVC is seen in
A) Situs inversus
B) Situs solitus
C) Right isomerism
D) Left isomerism

60. 2. Morphological feature of right atrium
A) Finger like posterior appendage
B) Smooth surface
C) Presence of cristae terminalis
D) Septum primum lies on RA side

61. 3. True about right atrial appendage
A) Narrow based
B) Triangular
C) Posterior
D) None of the above

62. 4. True about ventricular morphology
A) LV is cresentic in cross section
B) Moderator band is seen in RV
C) Trabaculations are less in RV
D) RV has smooth septal surface

63. 5. Straddling means
A) Papillary muscle of the valve attached to contralateral
ventricle.
B) Papillary muscle attached to septum
C) Absence of papillary muscle
D) Fusion of papillary muscle

64. 6. In d TGA true about connection is
A) AV discordant , VA concordant
B) AV concordant , VA discordant
C) Both AV and VA concordant
D) Both AV and VA discordant

65. 7. In TOF true about connection is
A) AV discordant , VA concordant
B) AV concordant , VA discordant
C) Both AV and VA concordant
D) Both AV and VA discordant

66. 8. Conus is bilaterally absent in
A)DORV
B) TGA
C) DOLV
D) Normal heart

67. 9. In d malposition of great arteries
A) Aorta posterior and to right
B) Aorta posterior and to left
C) Aorta anterior and to right
D) Aorta anterior and to left

68. 10.Segmental expression of L TGA is
A) S , D , S
B) I , L , I
C) S, D , D
D) S , L , L

69. THANK YOU