The document discusses fetal echocardiography, outlining its importance in diagnosing congenital heart disease (CHD) and the best practices for performing these scans between 18-22 weeks of gestation. It emphasizes the prevalence of CHD, particularly in high-risk pregnancies, and the necessity of utilizing advanced imaging techniques to enhance detection rates. Additionally, it describes the equipment, techniques, and various views necessary for an effective evaluation of the fetal cardiovascular system.

1. Fetal Echocardiography
DR. TARIQUE AJIJ
JUNIOR RESIDENT
MEDICAL COLLEGE, KOLKATA

2. Learning objects…
 INTRODUCTION
 TIMING OF FETAL ECHOCARDIOGRAPHY
 EQUIPMENT
 LATERALITY OF FETAL BODY AND IMAGE ORIENTATION
 CARDIAC POSITION AND AXIS ORIENTATION
 SEGMENTAL ANALYSIS
 ECHOCARDIOGRAPHIC PROJECTIONS
 ROLE OF PULSED WAVE DOPPLER
 3D TECHNIQUES
 M MODE AND ADVANCED TECHNIQUES

3. Introduction…
 Congenital malformations of the heart and arterial trunks are the most
common form of congenital anomalies found in humans.
 It accounts for more than half of the deaths from congenital abnormalities
in childhood

4. Prevalence
 Prevalence of CHD in live
born Indian child
 Total CHD at birth 130-270,000/year
 Critical CHD (requiring intervention in
infancy): 80,000
 Critical CHD receiving treatment is
only 3.04%
 CHD mortality as a fraction of infant
mortality: 3-17%
fetalechocardiography
*Based on available data of CHD prevalence at birth
In developed countries and present birth rates in India

5. Antenatal Cardiac Diagnosis
 Importance in developing world
 Limited resources to treat complex heart
problems.
 Relatively few centres in public sector
offering treatment for complex CHD.
 Very limited infrastructure for transporting
sick neonates with critical CHDs which are
correctable.
Early diagnosis is a solution for this

6. Prevalence….only tip of iceberg!
The incidence of CHD is much higher in the fetal population. Because…
 Number of unidentifiable cause for CHD is more than identifiable cause, so
only high risk pregnancy are screened
 A good number of fetuses with complex cardiac anomalies succumb in the
first trimester itself, even before the cardiac anomaly is suspected;
 Some parents opt for termination of pregnancy after the diagnosis is made
in the mid-trimester
 Some cardiac anomalies are progressive and end in intrauterine death.
Thus, the incidence quoted above may be only the tip of the iceberg.

7. Need for Fetal Echo!
 Fetal echocardiography, or the use of ultrasonic technologies to evaluate
the fetal cardiovascular system, enables diagnosis of structural heart
defects, and offers a way to observe complex physiological processes prior
to birth
 Apart from training of sonographers / radiologists, high level of suspicion
and detailed anatomic knowledge are mandatory
 Some automated 3D US also increase the sensitivity of detection

8. Indications for fetal echocardiography
A. Maternal indications
 Congenital heart disease
 Cardiac teratogens
 Isotretinoin ,lithium, ethanol, phenytoin
etc
 Maternal metabolic disorders
 Diabetes, phenylketonuria , gestational
diabetes
 Autoimmune disorders
 Sjogrens syndrome , SLE
 Intrauterine infections
 Rubella
B. Fetal indications:
 Extra cardiac anamolies
 Chromosomal and Anatomic(increased NT ,
GIT , RENAL , CNS )
 Fetal cardiac arrythmias
 Irregular rhythm , tachycardia(absence of
amnionitis) , bradycardia
 Non immune hydrops
 Abnormal fetal situs
 Suspected fetal heart anomaly by screening
ultrasound
 Chromosomal abnormalities
 Monochorionic twin gestation
 Twin twin transfusion syndrome, conjoint
twins

9. Indications for fetal echocardiography
C. Familial indications :
 History of CHD
 Previous sibling , paternal
 Mendalian syndromes
 Williams syndrome , Digeorge
syndrome
 Consanguinity
D. Indications for converting a routine
scan into fetal echocardiography
 Chamber asymmetry
 Altered cardiac axis
 Altered position of the fetal heart
 Enlarged fetal heart
 Arrhythmia

10. TIMING OF FETAL
ECHOCARDIOGRAPHY
 Fetal echocardiography is best performed between 18 and 22 weeks of
gestation.
 After 30 weeks gestation,
 the shadowing effects of the fetal ribs,
 ratio of fetal body mass-to-amniotic fluid increases
so acquisition of images more difficult.
 Early maternal transabdominal or trans-vaginal scan at 11 to 14 weeks of
gestation, in pt with Increased nuchal translucency.
 In the first trimester (11–14 weeks), cardiac details may not be elicited well, but
the presence of a pulsatile ductus venosus or tricuspid regurgitation can be
a very strong marker for cardiac and chromosomal anomalies.

11. Equipment &Technical aspects
 High frequency transducers probes
for resolution and details
 Phased array transducers with
fundamental frequencies between 4
and 12 MHz are generally used.
 Curvilinear probe with wider near-
field of view.
 High frequency transducers with a
narrower footprint
 Low frequency transducers and
harmonic imaging ---3rd trimester and
 axial resolution of 1 mm or less
this is particularly important given
the small size of critical fetal cardiac
structures.
 Frames rates of 80 to 100 Hz are
frequently needed to view important
events occurring at heart rates in
excess of 140 beats per minute

12. Equipment &Technical aspects
 The system should have the ability to zoom the image without causing
deterioration of image quality.
 A higher pulse repetition frequency (PRF) is required for colour Doppler in
the fetus as compared to the settings used for routine obstetric colour
Doppler.
 Role of Color Doppler:
 Increase accuracy
 Speed up examination

13. Role of Color Doppler: Image optimization
 Smallest color box possible to
maintain the frame rate as high as
possible (20-25 fps is real time to eye)

14. Role of Color Doppler: Image optimization
 Velocity Scale / PRF:
 High-velocity range (> ± 30 cm/sec):
atrioventricular valves, the semilunar
valves, and the great vessels
 Low- to mid-velocity scales (10 - 20
cm/sec): pulmonary and caval veins

15. Role of Color Doppler: Image optimization
 Color Filter / Wall Filter:
 high filter: for aorta
 Low filter: for pulmonary artery
 Low Color Persistence
 Optimum color gain: The color gain in
cardiac imaging should
therefore be initially set on low and
gradually increased until the color
information is optimized.
 Color Doppler Image Resolution and
Color Line Density: compromise
between high resolution and frame
rate.

16. Image orientation
 First step in the ultrasonographic
evaluation of the fetal heart is the
assessment of the fetal visceral situs
 Allows for an accurate determination
of ventricular and atrial situs
 Abnormal situs associated higher CHD
Fetal situs determination can be done by:
 Position of the stomach and heart in
the abdomen and chest respectively
 Position of the aorta and inferior
vena cava below the diaphragm
 Presence of bowel dilatation
 The presence of a gallbladder
 The presence and location of the
spleen

17. Image orientation
Techniques:
 Determine the presenting part
 Determine the fetal lie within the uterus by
obtaining a sagittal view of the fetal spine.
 determine the location
of the fetal left side with regard to the maternal
abdomen
 Fetal left side is anterior [closer to the transducer]
 Posterior [closer to the posterior uterine wall]
 Right lateral [closer to maternal right uterine wall]
 Left lateral [closer to maternal left uterine wall]
 Obtain a transverse view of the fetal abdomen by
rotating the transducer 90 degrees from the
sagittal view of the lower thoracic spine

18. Image orientation
 The fetal stomach is imaged in the left
side of the abdomen, the descending
aorta is posterior to the left, and the
inferior vena cava is anterior to the
right
 sliding the transducer toward the fetal
chest, a four-chamber view of the
heart is imaged
 the apex of the heart is pointing
toward the left side of the fetal chest

19. Image orientation
 Most common used method for assesing
laterality is proposed by Cordes et al.
 It is easy when fetus is in transverse position
Procedure:
1. Obtaining sagittal view of fetal body. Align
transducer in long axis of fetus (spine)
1. Orient the transducer so that fetal head is on
the right side of observer on the screen
2. Rotate the transducer 90* clockwise to obtain a
transverse view of fetal body
3. Tranverse section thus aquired is caudocranial
axis

20. Image orientation

21. Image orientation
 Another method reported by
Bronshtein et al
 right-hand rule for abdominal
scanning and the left-hand rule for
transvaginal scanning
 hand corresponds to the face of the
fetus, and the examiner holds
the hand according to the side of the
fetal face
 the fetal heart and stomach are shown
by the examiner’s thumb

22. Image orientation
 Craniocaudal
 Caudocranial (standard view)
 anatomical

23. Cardiac position and Axis orientation
 Cardiac position and axis can be assessed in four chamber view
 In this view by tracing sagittal and coronal planes through centre of thorax
four quadrants are identified
 Lv and most of RV and anterior part of LA lie in left anterior quadrant

24. Cardiac Axis
Normal value: 45˚ ± 20˚

25. Cardiac Axis
 Left Axis Deviation: tetralogy of Fallot,
coarctation of the aorta and Ebstein
anomaly
 Right Axis Deviation: double outlet
right ventricle, atrioventricular septal
defect, and common atrium
 Abnormal cardiac axes are also noted in fetuses with
abdominal wall defects such as omphaloceles and
gastroschisis
 In rare occasions involving complex congenital heart
disease, the apex of the heart may not be identifiable

26. Cardiac Position
Position of the heart within the chest and
is independent of the fetal cardiac axis,
fetal situs, cardiac anatomy, or chamber
organization.
 Dextrocardia
 Mesocardia
 Levocardia

27. Cardiac Position
Dextroposition and Dextroversion
 Dextroposition of the heart, a form of
dextrocardia, refers to a condition in
which the heart is located in the right
chest and the cardiac apex points
medially or to the left occurs in results
from extrinsic factors like diaphragmatic
hernia, left lung mass, left pleural
effusion, agenesis of the right lung
 When the heart is located in the right
chest with the cardiac axis pointing to
the right side, the term dextroversion
has been used and is found in situs
inversus and situs ambiguous

28. Cardiac Position
 Levocardia can be associated with
normal situs (normal anatomy), situs
inversus, or situs ambiguous
 Levoposition is usually in association
with a space-occupying lesion on the
right side
 Mesocardia associated with abnormal
ventriculoarterial connections such as
transposition of great vessels and
double outlet right ventricle

29. Cardiac dimensions
 Cardiothoracic (C/T) ratio: fairly constant
throughout gestation, with a mean value of
0.45 at 17 weeks and 0.50 at term (range:
0.25 - 0.35)
 Cardiomegaly: C/T area greater than 2
standard deviations
An increased C/T circumference can also be observed in the
presence of reduced chest volume rather than an enlarged
heart, and thus, it is important to compare the measured
chest circumference to gestational age nomograms as part
of this evaluation
May be seen in skeletal dysplasia, pulmonary hypoplasia.

30. Sequential cardiac examination
Identify the chamber by
morphology not by
anatomy!

31. Internal Cardiac anatomy: RA

32. Internal Cardiac anatomy: Tricuspid
valve
 three leaflets—anterior, septal, and
posterior
 chordae tendineae
 papillary muscles: Ant, post and septal
 Chordae tendineae from the valve
leaflets insert directly into the septal
wall, a feature found only in the right
ventricle
 Unlike the mitral valve, a subpulmonic
conus separates the tricuspid valve from
the pulmonary valve, resulting in no
fibrous continuity between the two

33. Internal Cardiac anatomy: RV

34. Internal Cardiac anatomy: LA

35. Internal Cardiac anatomy: Mitral valve
 Two leaflets – anteromedial &
posterolateral
 anterolateral and posteromedial
papillary muscles
 anteromedial leaflet, attaches
primarily to the anterolateral
papillary muscle and is in fibrous
continuity with the aortic valve

36. Internal Cardiac anatomy: LV
The ventricles are separated by the ventricular septum. The apical
portion (near the cardiac apex) is muscular in origin, and the basal
portion (near the atrioventricular valves) is membranous.

37. Echocardiographic projections:
 Abdominal circumference
 Four-chamber view
 Five-chamber view
 Three-vessel view
 Transverse view of the arterial duct
(ductus arteriosus)
 Transverse view of the aortic arch
 Three-vessel-trachea view (transverse
view of aortic and ductal arches)

38. Echocardiographic projections:
Technique
 Determine the fetal situs
 Obtain a four-chamber view
 left ventricular outflow tract (the aorta), referred to as the
five-chamber view, can be imaged by a slight tilt or
rotation of the medial aspect of the transducer in the
direction of the fetal head
 From the four-chamber view, the three-vessel view can
be imaged by sliding the transducer cranially while
maintaining the transverse orientation in the chest
 From the three-vessel view, the transverse view of the
arterial duct can be obtained by a slight cranial tilt of the
transducer
 From the transverse view of the arterial duct, the
transverse view of the aortic arch can be obtained by a
slight cranial slide of the transduce
 From the transverse view of the aortic arch, the three-
vessel-trachea view can be obtained by slightly
angulating the transducer caudally and to the left

39. Abdominal plane
 Upper Abdomen: to see hepatic veins,
umbilical veins and ductus venosus.
 This plane is also useful to describe
vein anomalies in suspected
heterotaxy and R/O ductus agenesis

40. 4 Chamber View
Scanning Technique
1. Determine the fetal situs
2. Obtain a transverse plane of the fetal
abdomen: full length rib is visible
3. slide the transducer toward the fetal
chest till proper 4 chamber view is
obtained
Criteria of good view:
 Complete rib on both side
 Apex
 Inferior pulmonary vein draining
posteriorly in LA

41. 4 Chamber View
Types of Four-chamber View:
 apical four-chamber view
 basal four-chamber view
 apex of the heart, the ventricles, the atrioventricular valves, and longitudinal atrial and ventricular
dimensions
 long-axis or axial four-chamber view
 atrial and ventricular septae

42. Role of Color Doppler: Image planes
 The four-chamber plane in color
Doppler is best visualized from an
apical (A) or a basal (B) view in order
to demonstrate ventricular filling
either in red (A) or in blue (B) in
diastole.
 In these orientations, the course of
blood flow is nearly parallel to the
angle of insonation.
 No flow is present during ventricular
systole unless TR is present.

43. 4 Chamber View

44. The Five-chamber View
Five-chamber view of the fetal heart demonstrating the
continuity of the posterior wall of the aorta with the mitral valve (small
arrows) and the continuity of the anterior wall of the ascending aorta
(AAo) with the ventricular septum (asterisks). The inflow and outflow
components of the left ventricle (LV) are seen in one view (open arrow).
The right and left superior pulmonary veins (RSPV, LSPV) enter the
posterior wall of the left atrium at this level. RV, right ventricle; LA, left
atrium; DAo, descending aorta; L, left.
Five-chamber view of the fetal heart demonstrating the wide
angle between the direction of the ventricular septum and the anterior
wall of the ascending aorta (AAo). This important anatomic observation
is commonly absent in conotruncal malformations. LV, left ventricle; RV,
right ventricle; LA, left atrium; DAo, descending aorta; L, left.

45. Role of Color Doppler: Image planes
 Five-chamber View:
 Demonstrating aortic blood flow in
blue color within the ascending aorta
or from a basal view (right side of
fetus) demonstrating aortic blood
flow in red color within the ascending
aorta
 Color Doppler of the five-chamber
view in the normal fetus shows the
septo-aortic continuity, the absence
of turbulences in systole, and
insufficiency in diastole across the
aortic valve

46. The Five-chamber View

47. The Three-vessel View
 pulmonary trunk in an oblique section
and the ascending aorta and the
superior vena cava in transverse
sections

48. Role of Color Doppler: Image planes
 Short-axis or Three-vessel View: show
pulmonary blood flow in
blue color demonstrating the
nonturbulent flow across the
pulmonary valve and the bifurcation
into the right and left pulmonary
arteries

49. The Three-vessel View

50. The Transverse View of the Arterial
Duct
 main pulmonary artery with the ductal
branch joining the descending aorta
to the left
of the spine

51. The Transverse View of the Aortic Arch
 the transverse aortic arch and the
superior vena cava

52. Three-vessel-trachea View (Transverse
Duct and Aortic Arch View)

53. Role of Color Doppler: Image planes
 Three-vessel-trachea View:
 Most important plane
 aortic and ductal arches forming a ‘‘V-
configuration
 Turbulent flow, reversal flow, size
discrepancy, or even absence or
interruption of a vessel can be easily
assessed

54. Sagittal Views
 Inferior and superior vena cava view
 Aortic arch view
 Ductal arch view

55. Sagittal Views
Techniques:
1. Determine the fetal situs
2. Obtain a sagittal view of the thoracic
fetal spine.
3. sliding the transducer from the right
parasagittal to the left parasagittal chest
while maintaining a sagittal orientation,
three ultrasound planes can be imaged:
i. the superior and inferior venae cavae
ii. the aortic arch
iii. the ductal arch

56. Sagittal Views : The Inferior and Superior Vena
Cava View

57. Sagittal Views : The Aortic Arch View

58. Role of Color Doppler: Image planes
 Longitudinal Views of Aortic and
Ductal Arches: often power doppler
and bidirectional HD color may be
needed.

59. Sagittal Views : The Ductal Arch View
 sagittal or parasagittal approach

60. Sagittal Views : The Ductal Arch View (Sagittal)

61. Sagittal Views : The Ductal Arch View (Parasagittal)

62. Oblique Views
 Right ventricular outflow view (short
axis)
 Left ventricular long-axis view
 Ventricular short-axis views

63. Oblique Views
Scanning techniques:
 Determine the fetal situs
 Obtain a midsagittal plane of the fetal
chest
 The right ventricular outflow view:
angling the transducer to an oblique
plane that is oriented from the right iliac
bone to the left shoulder of the fetus
 The left ventricular outflow view: angling
the transducer to an oblique plane that
is oriented from the left iliac bone to the
right shoulder of the fetus

64. Oblique Views : Right Ventricular Outflow View

65. Oblique Views : Left Ventricular Outflow View

66. Short Axis view
Scanning Technique
1. Determine the fetal situs
2. Obtain a four-chamber-view
3. rotate the transducer 90 degrees to
obtain short-axis views of the heart
4. Serial short-axis views of the heart,
from the apex of the left ventricle to
the pulmonary artery bifurcation, can
be obtained by slight anterior-to-
posterior (apical-to-basal) angulation
of the transducer

67. Short Axis view
Utility:
 spatial relationship of cardiac
chambers
 ventricular size, ventricular wall,
and septal thickness
 orientation of the great vessels and
their divisions

68. Short Axis view: At the ventricular level
 Compare both ventricular wall
thickness
 Right ventricle identified by irregular
wall
 Compare the papillary muscles of left
ventricle (anteromedial vs
posterolateral)
 IVS

69. Short Axis view: At the AV valve
 mitral valve, with its anterior and
posterior leaflets, is crescent shaped
and has the appearance of a fish
mouth
 tricuspid valve is more apically placed
in the heart than the mitral valve

70. Power doppler and bidirectional HD
color
 Enhanced sensitivity: amplitude of Doppler
signals instead of their frequency shift is
detected
 Improved noise differentiation: In power
Doppler, noise signals are encoded in a
uniform color
 Enhanced edge definition: This is because
color signals, which extend partially beyond
the edges, have lower signal amplitude due
to the lack of moving erythrocytes and are
thus not displayed
 Flow detection irrespective of angle
insonation: The amplitudes of the positive
and negative components of the flow tend to
add up, resulting in a powerful signal
 Disadvantages of power Doppler in
fetal cardiology include the lack of
information on direction of blood flow
and on the presence or absence of
turbulence
 combining the Doppler frequency
shifts with signal amplitude, digital
broadband assessment of Doppler
signals is applied providing a very
sensitive tool known as advanced
dynamic flow or ‘‘high-definition (HD)
flow’’
higher resolution, good lateral
discrimination, and higher sensitivity

71. Power doppler and bidirectional HD
color

72. Role of Pulsed wave Color Doppler
 Δf = (2f0Vcosθ)/c
 Doppler frequency shift therefore
reflects but does not actually measure
the velocity of blood flow
 To obtain absolute value, we need to
insonate within 10-15˚
 Sample volume is kept distal to the
valve
 Multiple measures taken and also
during fetal apnea
 Color Doppler is used to direct
placement of the sample volume

73. Doppler Indices
 Peak velocity: The maximum velocity on
the Doppler spectrum (cm/sec)
 Time-to-peak velocity (TPV): The time
from onset to peak velocity (msec), also
referred to as acceleration time
 Deceleration time: The time from the
peak of the waveform to the
intersection of the descending slope
with the baseline (msec)
 Time-velocity integral (TVI): The
measurement of the area under the
Doppler waveform over one cardiac
cycle (cm)
 Time-averaged velocity (TAV): TVI
divided by the period time (cm/sec)

74. Doppler Indices
 E/A ratio: A measurement used to
quantify Doppler waveforms across
the atrioventricular valves. E
represents peak velocity during early
ventricular filling, and A represents
peak velocity during the atrial
contraction
 Filling time: The diastolic time of the
cardiac cycle (msec)
 Ejection time: The systolic time of the
cardiac cycle (msec)

75. Doppler Indices
 Percent reverse flow: A measurement
used to quantify Doppler waveforms
in the inferior
vena cava. It represents TVI of the
reverse flow segment (atrial
contraction) divided by the TVI of the
total forward flow and multiplied by
100

76. Doppler Indices
 S/A: A measurement used to quantify
Doppler waveforms in the ductus
venosus. S represents maximum
systolic velocity and A represents the
atrial nadir

77. Doppler Indices

78. Calculation of CO

79. PW Doppler at AV valve
 Doppler waveform across
the mitral valve shows aortic flow during the
systolic component due to leaflet continuity
between the mitral and aortic valve annuli
 The E/A ratio is an index of ventricular
diastolic function
 in the fetus the velocity of the A wave is
higher than that of the E wave
 As ventricular stiffness decreases with
advancing gestation, E/A ratio increases from
0.53 ± 0.05 in the first trimester to about 0.70
± 0.02 in the second half of pregnancy
 The rise in E/A ratio with advancing gestation
suggests a shift of blood flow from late to
early diastole

80. PW Doppler at semilunar valve

81. PW Doppler at IVC
 These waveforms are triphasic with
the first phase corresponding to
ventricular systole (S); the second
phase corresponding to early diastole
(D); and the third phase (reverse flow)
corresponding to the atrial
contraction (A)
 The percentage of reverse flow, which
is a ratio of the time velocity integral
during the atrial contraction divided
by the time velocity integral during
total forward flow, is used for Doppler
waveform quantification in the inferior
vena cava

82. PW Doppler at Ductus Venosus
Approach to imaging of the ductus venosus (DV) on color Doppler. In A, a coronal plane of
the chest shows the DV as it joins the inferior vena cava (IVC) toward the right atrium (RA).
The hepatic vein (HV) is also seen in this plane. In B, a parasagittal plane shows the DV
originating from the umbilical vein (UV), and in C, a transverse plane of the abdomen shows
the DV as it originated from the UV. Note the presence of color aliasing in the DV in the
three planes.

83. PW Doppler at Ductus Venosus
 Doppler waveforms are biphasic in
morphology with a first peak
concomitant with systole (S); a second
peak concomitant with early diastole
(D); and a nadir concomitant with the
atrial contraction (A)
 forward flow is present throughout
the entire cardiac cycle in the ductus
venosus in the normal human fetus
 Two such indices were developed based
on peak velocities during systole and
during the atrial contraction (S/A,
S-A/S)

84. PW Doppler at Pulmonary veins

85. 3D Ultrasound
 3-D ultrasound provides a volume of a
target anatomic region, which contains
an infinite number of 2-D planes
 Optimization of 3D image needs
optimization of reference image which is
2D image
 Infinite number of planes are acquired
parallel to reference plane
 Images are reconstructed in orthogonal
and oblique planes or volume / surface
rendered
 Resolution is best in reference & its
parallel planes
 reference plane should therefore be
chosen based on the anatomic region
of interest within the heart
 4 chamber plane: cardiac
chambers, origin of great vessels, and
the three-vessel and three-vessel-
trachea views
 Sagittal plane: aortic, ductal arches
and venous connections

86. 3D Ultrasound: few terms
 ROI box: height and width,
corresponding to the x and y axes. It
should be smallest for fastest acquisition
and better resolution
 Angle of acquisition: sweep angle of the
elements within the probe and is
adjusted by the operator. It refers to the
depth of a volume, corresponding to the
z axis
 For static 3D: 40 – 45˚
 For STIC: 20 - 35˚
 Smaller angle: fastest acquisition
 Quality of acquisition: number of planes
acquired within a volume.
 For static 3D: low, medium or high
 For STIC: 7.5, 10, 12.5, or 15 seconds

87. Static Three-dimensional (Direct
Volume Scan: Nongated)
 contains an infinite number of 2-D still
ultrasound planes with no regard to
temporal or spatial motion
 Rapid acquisition & easy volume
manipulation and also large volumes
 Acquisition can be compiled with
power doppler or B flow image
 inability to assess events related to
the cardiac cycle, valve motion in the
heart, and myocardial contractility

88. Spatio-temporal Image Correlation
(STIC) (Indirect Volume Scan, Motion Gated: Offline Four-
dimensional)
 It is an indirect, motion-gated, offline mode
based on the concept of using tissue
excursion concurrent with cardiac motion to
extract the temporal information regarding
the cardiac cycle
 The acquired volume is processed internally,
where the systolic peaks are used to calculate
the fetal heart rate and the volume images
are then rearranged according to their
temporal events within the heart cycle, thus
creating a cine-like loop of a single cardiac
cycle
 assess atrial and ventricular wall
motion and valve excursion and combined
with Doppler
 delayed acquisition time

89. Real-time Three-dimensional (Direct
Volume Scan, Real Time, Online Four-dimensional)
 Done by mechanical transducer
rotation or by matrix transducer
 gating of the heart rate is not required
and volumes of the beating heart are
displayed instantaneously without any
transfer or postprocessing of the data
 Color Doppler can also be added
 acquired volume, often too small

90. Volume manipulation
 Volume Display in Two-dimensional
Planes:
 Single Two-dimensional Planes or
Multiplanar Orthogonal Display
 Both for static 3D or STIC
 Multiplanar Tomographic Ultrasound
Imaging
 Volume Display in Rendering: display
of external or internal surfaces of
acquired volumes

91. Volume manipulation
Manipulation of a spatio-temporal image
correlation (STIC) volume.
A: The original
STIC data set is shown in an orthogonal plane
display.
The four-chamber plane as a ‘‘single
plane’’ is demonstrated in systole (B) with closed
atrioventricular valves and in diastole (C) with
opened valves.
Scrolling through the volume demonstrates the
upper abdomen with the stomach
(ST) (D),
the slightly oblique five-chamber view (E),
the three-vessel-trachea view in the upper
thorax (F)
a reconstructed longitudinal plane (G) of the
aortic arch.

92. Volume manipulation
Spatio-temporal image correlation (STIC) volume
in a fetus with an atrioventricular septal defect. In
plane A, the defect is not clearly demonstrated as
the valve leaflets are closed. By scrolling through
the cursor (open arrow), the interventricular septal
defect is clearly demonstrated (asterisk) in plane B
when the valve leaflets are open.
Tomographic ultrasound imaging of spatio-temporal
image correlation (STIC) volume of the fetal heart in
gray scale. In the upper left image, the orientation
plane A is seen (highlighted in yellow) with the parallel
vertical lines referring to the planes shown in the
display (-4 to +4). Interplane distance and total
number of planes are chosen by the examiner

93. Volume Display in Rendering
 Surface Mode Display

94. Volume Display in Rendering
 Transparent Minimum Mode:
anatomic details of structures are
limited, but the projection of
anechoic structures such as the
cardiac chambers and great vessels
allows for a useful display
of cardiac anatomy.

95. Volume Display in Rendering
 Inversion Mode:

96. Volume Display in Rendering
 Three-dimensional Color Doppler and
Glass Body Mode

97. Volume Display in Rendering
 Three-dimensional B-flow Rendering

98. M-mode Echocardiography
 The M-mode display is a linear
representation of adjacent cardiac
structures as a function of time
 accurate and reproducible
measurements of various cardiac
chambers and great vessel diameters
 The M-mode cursor is often placed to
intersect an atrium and a ventricle so
that the relationship of atrial to
ventricular contractions is recorded

99. Color Doppler M Mode
 Colors are added to accurate the
systole and diastolic component.

100. Tissue Doppler Imaging
 By sampling atrial and ventricular wall
motion, however, tissue Doppler can
provide accurate
measurements of cardiac intervals and
cardiac wall velocities

101. Calculation of MPI (myocardial
performance index)

102. Reporting