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Ultrasound Obstet Gynecol 2001; 17: 367 – 369
Editorial
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Editorial
Examination of the fetal heart by five shortaxis views: a proposed screening method for
comprehensive cardiac evaluation
S. YAGEL, S. M. COHEN and R. ACHIRON*
Department of Obstetrics and Gynecology, Hadassah University
Hospital, Mt. Scopus, Jerusalem and *Department of Obstetrics and
Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Israel
Fetal cardiac malformations, with an incidence of 8 : 1000
among livebirths, are the most common congenital malformations. Their incidence is 6.5 times greater than chromosomal
anomalies and 4 times that of neural tube defects. Furthermore, 4 : 1000 livebirths will be affected by severe congenital
cardiac malformations which account for 20% of neonatal
deaths and up to 50% of infant deaths attributed to congenital
anomalies1–4. There is therefore a clear rationale for including complete fetal echocardiography in every targeted organ
scan.
Moreover, nuchal translucency screening has been shown
to be very effective in identifying fetuses at increased risk for
both chromosomal anomalies and cardiac malformation.
Three to five percent of tested fetuses will be defined as being
at high risk for congenital heart disease following nuchal
translucency examination5–7. This creates a new population
of considerable size that would be candidates for complete
fetal echocardiography. Centers offering nuchal translucency
screening would therefore be expected to complement this
with comprehensive echocardiography.
Though hailed as innovative and effective at its introduction,
the four-chamber view of the fetal heart, when used alone as
a screening tool, reveals only some cardiac anomalies8–13.
Faced with discouraging false-negative rates, many centers
introduced scanning of the great vessels’ outflow tracts
as part of their screening programs. This improved detection rates. Most recently, some centers have started to include
extensive fetal echocardiography as part of all targeted organ
scanning, with significantly higher detection rates for cardiac
malformations8–13. In 1998 the AIUM (American Institute of
Ultrasound in Medicine) published a technical bulletin14
which put forth the institute’s recommendation for standardizing fetal echocardiography. Our method is a natural
progression from this methodology, with several advantages:
the AIUM recommends 18–22 weeks’ gestation as optimal
timing for fetal cardiac examination, while our method is
amenable to early second-trimester transvaginal ultrasound;
ours includes scanning of the mediastinum; we propose that
fetal echocardiography be offered to all gravidae presenting
for routine screening.
The challenge today is to create a comprehensive and precise
method to streamline fetal echocardiography. Traditionally,
EDITORIAL
fetal echocardiography has relied on several short- and longaxis views of the fetal heart. Fetal lie may enable optimal visualization of the short-axis views, but make the long-axis planes
difficult or impossible to obtain, or vice versa. Often the only
recourse is to wait for the fetus to turn. This of course lengthens
examination times considerably. The most difficult and timeconsuming portion of the fetal echocardiographic examination
is the visualization of the aortic arch, which on the one hand
is indispensable in the diagnosis of aortic malformations, and
on the other places the greatest demands on the sonographer,
both in degree of difficulty and time required. These obstacles
are particularly problematic in busy screening programs.
To improve and simplify comprehensive fetal heart examination, we suggest a fetal echocardiographic examination
based on five transverse planes. The first and most caudal
plane is a transverse view of the upper abdomen: moving
cephalad. The next is the traditional four-chamber view,
which remains the key to the fetal echocardiographic examination. The third is the plane commonly termed the fivechamber view, in which the aortic root is visualized. The
fourth transverse view reveals the bifurcation of the pulmonary arteries. Yoo et al15,16 suggested the three-vessel view
of the fetal upper mediastinum, a cross-sectional view of the
major vessels, as a quick and accurate method to identify the
great vessels and diagnose certain anomalies. However,
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Yagel et al.
Figure 1 The five short-axis views for optimal fetal heart screening. The color image shows the trachea, heart and great vessels, liver, and stomach
with the five planes of insonation superimposed. Polygons show the angle of the transducer and are assigned to the relevant gray-scale images
(LT, left; RT, right) (I) The most caudal plane, showing the fetal stomach (ST), cross-section of the abdominal aorta (AO), spine (SP) and liver (LI).
(II) The four-chamber view of the fetal heart, showing the right and left ventricles (RV, LV) and atria (RA, LA), foramen ovale (FO), and pulmonary
veins (PV) to the right and left of the aorta (AO). (III) The ‘five-chamber’ view, showing the aortic root (AO), left and right ventricles (LV, RV) and
atria (LA, RA), and a cross-section of the descending aorta (AO with arrow). (IV) The slightly more cephalad view showing the main pulmonary artery
(MPA) and the bifurcation of left and right pulmonary arteries (LPA, RPA) and cross-sections of the ascending and descending aortae (AO and AO
with arrow, respectively). (V) The 3VT plane of insonation, showing the pulmonary trunk (P), proximal aorta ((P)Ao), ductus arteriosus (DA), distal
aorta ((D)Ao), superior vena cava (SVC) and the trachea (T).
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Ultrasound in Obstetrics and Gynecology
Editorial
the aortic arch and trachea were not included, the former
being perhaps the most demanding aspect of fetal heart examination. Following Yoo, we recently presented17 the three
vessel and trachea (3VT) plane of insonation as the fifth
short-axis view in fetal echocardiography, to complement the
four traditional planes currently in use and facilitate and
expedite thorough fetal heart examination. The 3VT is the
most cephalad transverse view, visualized on a plane crossing
the fetal upper mediastinum. It is easily obtained by moving
the transducer cephalad and slightly oblique from the fourchamber view. When properly executed, the 3VT reveals the
main pulmonary trunk in direct communication with the
ductus arteriosus. A transverse section of the aortic arch is
seen to the right of the main pulmonary trunk and ductus
arteriosus. Cross sections of the superior vena cava and, posterior to it, the trachea, are visualized (Figure 1).
We recently demonstrated the clinical applicability of the
3VT (submitted): in 99% of patients this view was quickly
and easily obtained from the familiar four-chamber view. Its
use shortened the time required to examine the aortic arch,
the most time-consuming aspect of fetal echocardiography.
We consider one of the greatest advantages of our novel
approach the ease with which the examiner can scan the fetal
heart, beginning with the caudal upper-abdomen view. By
sliding the transducer cephalad in one continuous motion, all
the pertinent views are readily visualized.
In our center we demonstrated that five short-axis views
including the 3VT, simplified and streamlined fetal cardiac
examination, without compromising diagnostic effectiveness.
We see it as another step in the integration of complete fetal
echocardiography in routine targeted organ studies.
Yagel et al.
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