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 Left Atrium
The right & left atria are identified morphologically by their respective atrial appendages and veins emptying into them.
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

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

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
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. Interrupted IVC is seen in
Situs inversus
Situs solitus
Right isomerism
Left isomerism

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

51. 3. True about right atrial appendage
Narrow based
Triangular
Posterior
None of the above

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

53. 5. Straddling means
Papillary muscle of the valve attached to contralateral ventricle.
Papillary muscle attached to septum
Absence of papillary muscle
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
Aorta posterior and to right
Aorta posterior and to left
Aorta anterior and to right
Aorta anterior and to left

58. 10.Segmental expression of L TGA is
S , D , S
I , L , I
S, D , D
S , L , L

59. Interrupted IVC is seen in
Situs inversus
Situs solitus
Right isomerism
Left isomerism

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

61. 3. True about right atrial appendage
Narrow based
Triangular
Posterior
None of the above

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

63. 5. Straddling means
Papillary muscle of the valve attached to contralateral ventricle.
Papillary muscle attached to septum
Absence of papillary muscle
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
Aorta posterior and to right
Aorta posterior and to left
Aorta anterior and to right
Aorta anterior and to left

68. 10.Segmental expression of L TGA is
S , D , S
I , L , I
S, D , D
S , L , L

69. THANK YOU