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Normal transthoracic echocardiogram in a child


Transthoracic echocardiography is the first-line imaging modality for the diagnosis of congenital and acquired heart conditions in children. It allows a detailed morphological and functional examination of different cardiac structures. A standard echocardiographic study consists of two-dimensional (2D) imaging, motion mode (M-mode), and Doppler imaging.

The analysis of cardiac anatomy is based on cross-sectional visualization of the heart in conventional 2D planes, which show the real-time movement of cardiac structures. Standard views include subcostal, apical, parasternal, and suprasternal views. M-mode echocardiography is a one-dimensional imaging technique that records the real-time movement of cardiac structures over multiple cardiac cycles.

Doppler imaging comprises color flow and spectral Doppler modalities. Color flow mapping (CFM) is a 2D representation of the direction and velocity of blood flow within a predefined sector that is superimposed on the 2D image. By definition, flow toward the probe is red and flow away from the probe is blue. Depending on the selected Nyquist limit, lighter color shades show higher flow velocities. Spectral Doppler is a record of blood flow velocity over time. It is further divided into pulsed-wave Doppler used for low blood flow velocities, and continuous-wave Doppler for high blood flow velocities.

Two-dimensional echocardiography, color flow Doppler

Figure 1, Location of different echocardiographic windows. Subcostal window (yellow), apical window (green), parasternal window (blue), suprasternal window (red).

Subcostal views

A standard echocardiographic study begins with subcostal views. The probe is placed on the upper abdomen, just below the lower edge of the sternum. Images of the cardiac and vascular structures are acquired through the liver. In very small children, it is possible to perform the entire echocardiogram from subcostal approach.

Figure 2, (A) Subcostal “situs” view (transverse plane). In normal abdominal situs, the abdominal aorta is to the left and the inferior vena cava to the right of the spine. (B) The probe marker is at the 3 o'clock position. Ao , aorta; IVC , inferior vena cava.

Figure 3, (A) Color flow Doppler of the abdominal aorta from the subcostal view. Pulsed-wave Doppler interrogation of the abdominal aorta is performed from this view. (B) The probe is at the 6 o'clock position, angulated inferiorly. Ao , aorta; COE T , celiac trunk; DIAPH , diaphragm; SMA , superior mesenteric artery.

Figure 4, (A) Subcostal view showing the drainage of the inferior vena cava and the hepatic veins into the right atrium. (B) The probe at the 6 o'clock position, tilted inferiorly and slightly to the patient's left. DIAPH , diaphragm; HV , hepatic vein; IVC , inferior vena cava; LA , left atrium; RA , right atrium.

Figure 5, (A) Subcostal long-axis (four-chamber) view. The cardiac chambers, atrial and ventricular septae, and upper pulmonary veins are visualized. (B) The probe is at the 3 o'clock position, angulated inferiorly. alPM , anterolateral papillary muscle; aMV , anterior mitral valve leaflet; IAS , interatrial septum; IVS , interventricular septum; LA , left atrium; LAA , left atrial appendage; LUPV , left upper pulmonary vein; LV , left ventricle; pMV , posterior mitral valve leaflet; RA , right atrium; RUPV , right upper pulmonary vein; RV , right ventricle.

Figure 6, (A) Subcostal long-axis view showing the entire left ventricular outflow tract with the proximal ascending aorta. (B) Corresponding color flow Doppler. (C) The probe is further angulated inferiorly as compared to the previous figure. The marker remains at the 3 o'clock position. alPM , anterolateral papillary muscle; Ao , aorta; DIAPH , diaphragm; IAS , interatrial septum; IVS , interventricular septum; LV , left ventricle; MV , mitral valve; PA , pulmonary artery; pmPM , posteromedial papillary muscle; RA , right atrium; RV , right ventricle; SVC , superior vena cava.

Figure 7, (A) Subcostal long-axis view showing both ventricles and the right ventricular outflow tract. (B) This view is obtained by a maximal inferior angulation of the probe. The marker is at the 3 o'clock position. alPM , anterolateral papillary muscle; IVS , interventricular septum; LV , left ventricle; PA , pulmonary artery; PAV , pulmonary valve; pmPM , posteromedial papillary muscle; RV , right ventricle.

Figure 8, (A) Subcostal short-axis (bicaval) view showing both caval veins and atria. (B) Flow across the superior and inferior caval veins. (C) The probe is at the 5 o'clock position, tilted slightly to the patient's left. DIAPH , diaphragm; EUST V , Eustachian valve; HV , hepatic vein; IAS , interatrial septum; IVC , inferior vena cava; LA , left atrium; RA , right atrium; RPA , right pulmonary artery; SVC , superior vena cava.

Figure 9, (A) Subcostal short-axis view showing the left ventricular outflow tract and the mitral valve. The interventricular septum is visualized en face. (B) The probe is slightly tilted to the patient's right as compared to the previous figure. aMV , anterior mitral valve leaflet; Ao , aorta; AoV , aortic valve; IVS , interventricular septum; LV , left ventricle; PA , pulmonary artery; pMV , posterior mitral valve leaflet; RV , right ventricle; TV , tricuspid valve.

Figure 10, (A) Subcostal short-axis view showing the entire right ventricular outflow tract. (B) Corresponding color flow Doppler. (C) The probe is further tilted to the patient's right as compared to the previous figure. alPM , anterolateral papillary muscle; IVS , interventricular septum; LV , left ventricle; PA , pulmonary artery; PAV , pulmonary valve; pmPM , posteromedial papillary muscle; RV , right ventricle.

Figure 11, (A) Subcostal short-axis view with cross-sectional view of both ventricles. (B) The probe is further tilted to the patient's right as compared to the previous figure. IVS , interventricular septum; LV , left ventricle; RV , right ventricle.

Figure 12, (A) Subcostal short-axis view demonstrating both atria, the tricuspid valve, and the entire right ventricular outflow tract. (B) This view is obtained by rotating the probe marker to the 1 o'clock position. The probe is slightly tilted to the patient's left. Ao , aorta; IAS , interatrial septum; LA , left atrium; LPA , left pulmonary artery; PA , pulmonary artery; RA , right atrium; RPA , right pulmonary artery; RV , right ventricle; TV , tricuspid valve.

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