This document discusses sequential segmental analysis of the heart. It begins by introducing the concept and origins in the 1960s. It then explains that sequential segmental analysis involves evaluating the heart in segments using a pattern recognition approach. This allows for comprehensive examination and minimizes error in detecting defects. The remainder of the document details the specific segments analyzed - atrial, ventricular, ventriculoarterial, and arterial - and describes the Van Praagh classification system for analyzing each segment.

1. SEQUENTIAL SEGMENTAL ANALYSIS OF
HEART
Dr Kunwar Sidharth Saurabh
MS (Gen Surgery)
M.Ch. CTVS (Resident)

2. So, That was the day…

3. AND NOW..

4. BASICALLY THE SEGMENTAL ANATOMY
MEANS..

5. DOES THAT MAKES ANY
SENSE????

6. OBJECTIVES
• Identify cardiac segments and components.
• Understand and apply segmental approach.
• Review variations in cardiac connections.
• To see basic imaging techniques.
• Employ knowledge with case review.

7. 1960
• RICHARD VAN PRAAGH
• AMERICA
1960
• MARIA VICTORIA DE LA CRUZ
• MEXICO
1970
• ECHO CARDIOGRAPHY BROUGHT THE TERM SEQUENTIAL
SEGMENTAL ANALYSIS

8. SEGMENTAL ANALYSIS.
• Sequential approach to evaluating heart.
• Evaluates the cardiovascular system in
“segments”.
• Based on pattern recognition of
Normal.
• Allows comprehensive examination of
cardiac structure.

9. BUT WHY????

10. THE ANSWER IS ..
• Congenital heart defect : Simple to very
complex
• Cardiac segment are constant (most of the
time)
• Approaching in sequence minimizes error rate.
• Pattern recognition of normal is best for
defect detection.
• Early defect detection improves clinical
outcomes.

11. • Congenital heart defect : Simple to very complex
• Cardiac segment are constant (most of the time)
• Approaching in sequence minimizes
error rate.
• Pattern recognition of normal is best for defect
detection.
• Early defect detection improves clinical
outcomes.
THE ANSWER IS ..

12. THE ANSWER IS ..
• Congenital heart defect : Simple to very complex
• Cardiac segment are constant (most of the time)
• Approaching in sequence minimizes error rate.
• Pattern recognition of normal is best
for defect detection.
• Early defect detection improves clinical
outcomes.

13. THE ANSWER IS ..
• Congenital heart defect : Simple to very complex
• Cardiac segment are constant (most of the time)
• Approaching in sequence minimizes error rate.
• Pattern recognition of normal is best for defect
detection.
• Early defect detection improves clinical
outcomes.

14. VAN PRAAG CLASSIFICATION SYSTEM
{ __ , __ , __ }
VISCERO ATRIAL
SITUS VENTRICULAR
LOOP
ORIENTATION
POSITION
AND
RELATION
OF GREAT
VESSELS

16. BASIS
• Cardiac connections are identified as :
–Venoatrial
–Atrio ventricular
–Ventriculo arterial

17. BASIS
• Cardiac connections are identified as :
–Venoatrial
–Atrio ventricular
–Ventriculo arterial

18. BASIS
• Cardiac connections are identified as :
–Venoatrial
–Atrio ventricular
–Ventriculo arterial

19. ATRIAL SEGMENT
•PULMONARY VENOUS CONNECTIONS
•Usually 4 veins: 2 from each lung
•SYSTEMIC VENOUS CONNECTIONS
•Single SVC to RA roof.
•Hepatic veins convergence with IVC to floor

20. ATRIAL SITUS
ATRIAL SITUS SOLITUS
• Position the atria normally occupy
• Almost always corresponds to visceral situs
– Viscero atrial situs is often used term

21. ATRIAL SITUS
• ATRIAL SITUS INVERSUS
– The viscera and atria are opposite (Mirror Image )
to normal.

22. ATRIAL SITUS
ATRIAL SITUS AMBIGUOS
• Atrial isomerism or Heterotaxy syndrome
• “Bilateral sidedness” of structures
– Left atrial isomerism
– Right atrial isomerism

23. HETEROTAXY FEATURES- VENOATRIAL
Left Atrial Isomerism
• Interrupted IVC
• Bilateral SVC
• LSVC to CS
• Atrial septum primum +
• Pulmonary veins ipsilateral
• CAVSD
Right Atrial Isomerism
• Continuos IVC
• Bilateral SVC
• Absent CS
• Common Atrium
• TAPVC
• CAVSD

24. VANPRAAG SYSTEM (VISCEROATRIAL)
{X , __ , __ }
VISCERAL SITUS
THORACO-
ABDOMINAL SITUS
ATRIAL SITUS
• THREE TYPES OF SITUS –
– SITUS SOLITUS { S,__,__}
– SITUS INVERSUS { I,__,__}
– SITUS AMBIGUOS {A,__,__}

25. VANPRAAG SYSTEM (VISCEROATRIAL)
{X , __ , __ }
• Determining the position of visceral
organs.
– SOLITUS (S)
– INVERSUS (I)
– AMBIGUOS (A)
VISCERAL SITUS
THORACO-
ABDOMINAL SITUS
ATRIAL SITUS

26. VANPRAAG SYSTEM (VISCEROATRIAL)
{X , __ , __ }
• Pulmonary Sidedness usually
reflects atrial sidedness
• Useful for identifying morphologic
RA
VISCERAL SITUS
THORACO-
ABDOMINAL SITUS
ATRIAL SITUS

27. VANPRAAG SYSTEM (VISCEROATRIAL)
{X , __ , __ }
• Identify the morphologic RA.
• Atrial situs and thoracoabdominal
situs are usually concordant.
VISCERAL SITUS
THORACO-
ABDOMINAL SITUS
ATRIAL SITUS

28. VANPRAAG SYSTEM (VISCEROATRIAL)
{X , __ , __ }
• DESIGNATION –
– If ALL letters recorded as S  { S,__,__}
– If ALL letters recorded as I  { I,__,__}
– If ANY letter recorded as A  {A,__,__}

29. ATRIOVENTRICULAR CONNECTION

30. ATRIOVENTRICULAR CONNECTION
• Type and mode of connection between atria
and ventricles.
• Types of AV connection –
– Concordant
– Discordant
– Common
– Double inlet
– Single

31. Concordant (NORMAL)

32. Discordant
RA TO MORPHOLOGIC LV
LA TO MORPHOLOGIC RV
SEEN IN –
•VENTRICULAR
INVERSION
•CORRECTED
TRANSPOSITION

33. Common
BOTH ATRIA CONNECTED TO BOTH
VENTRICLE BY COMMON VALVE
SEEN IN –
COMPLETE
AVSD

34. Single
Usually seen in
Tricuspid Atresia

35. Double Inlet

36. VENTRICULAR SEGMENT
• Described based on morphology
• Morphology best defined by internal features.
• “LOOPING” pertains to the RV position in
relation to the LV.
– Normal is rightward loop (“D” for dextro)
• Describes the spatial position of the
ventricles.

37. VENTRICULAR SEGMENT
• Ventricular Looping –
If RV loops to the Right –
“D” Loop
If RV loops to the left –
“L” Loop

38. VANPRAAGSYSTEM(Ventricular loop orientation)
{__, x , __ }
• Relation of Morphologic
RV as compared with
Morphologic LV
– Dextro loop { __, D, __}
– Levo loop { __, L, __}
– Cannot be determined
{__, X, __}

39. VENTRICULOARTERIAL CONNECTION
• CONCORDANT
– MPA arises from
morphologic RV
– Aorta arises from
morphologic LV
Irrespective of spatial
location of ventricles
NORMAL – Great Arteries
typically cross

40. VENTRICULOARTERIAL CONNECTION
• DISCORDANT-
Aorta arises from
morphologic RV
MPA arises from LV
PARALLEL VESSELS
Usually seen in TGA

41. VENTRICULOARTERIAL CONNECTION
• DOUBLE OUTLET
VENTRICLE

42. ARTERIAL SEGMENT
• Position of Aorta in
relation to Pulmonary
Artery.
• NORMALLY Aorta is
located posterior and
to the right of MPA ( at
the level of semilunar
valves)
• Conus anatomy may
be useful

44. VANPRAAGSYSTEM(POSITIONAND RELATIONOF GREAT VESSELS)
{ __,__,X}
• Aorta is posterior to and rightward of MPA
• Situs solitus {__,__,S}
• Aorta is posterior to but inverted leftward of MPA
• Situs Inversus {__,__,I}
• Transposition : Usually applies when Aorta from RV
and MPA from LV
– Aorta is anterior and Right of MPA
• D – Transposition {__,__, D-TGV}
– Aorta is anterior and left of MPA
• L – Transposition {__,__,L-TGV}

45. Example
Step 1 – Determine Viscero-Atrial Situs
Visceral situs
RECORD LETTER “S”

46. Cont..
• Step 1 - Determine Viscero-Atrial Situs
Thoracoabdominal
situs
RECORD LETTER “S”

47. Cont..
• Step 1 - Determine Viscero-Atrial Situs
Atrial situs
RECORD LETTER “S”

48. Cont..
If ALL letters recorded as “S” – Situs Solitus
{S,__,__}

49. Cont..
• Step 2 – Determine Ventricular Loop
Orientation
Morphologic RV
on Left : Levo
Loop
{__ ,L, __}

50. Cont..
• Step 3 – Position and relation of great vessels
Aorta is anterior
and leftward of
MPA :
L Transposition
{__,__,L-TGV}

51. Cont ..
• So, findings are – {S, L , L-TGV}
– Situs solitus with levocardia
– Levotransposition of great vessels
– Atrio-ventricular and Ventriculo arterial
Discordance
Diagnosis – Congenitally Corrected L-TGA.

52. RED BULL, GOOGLE AND WIKIPEDIA FOR MAKING THIS POSSIBLE