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9/17/2013
Outflow Tract View : Normal and
Abnormal
Anitha Parthiban MD, FAAP
Director , Pediatric Echocardiography
Children’s Mercy Hospitals & Clinics
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Outline
 Review anatomy of normal outflow tracts
 Imaging of the outflow tracts in the fetal
heart
 Differential diagnosis of abnormal outflow
tract view
 Brief review of Conotruncal defects
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Conotruncal Defects
 Defects of the outflow tracts , constitute
15-20% of CHD
 Key events in formation of outflow tracts
 Leftward shift of the conotruncus to
override the muscular septum
 Septation of the contruncus
 Spiraling of the outflow tracts
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Outflow Tracts- Checklist
Are there two outflow tracts?
 Ventriculoarterial concordance ?
 Great arteries cross each other?
 Caliber of pulmonary trunk vs ascending
aorta
 Excursion /size of aortic and pulmonic
valves and sub valvar area
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Short axis view- basal
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Case 1
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Case 1
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Case 1
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Truncus Arteriosus
 Single arterial trunk arises from the heart
giving rise to aorta , pulmonary arteries
and the coronary arteries
 1.2% of CHD
 33% of patients have Di-George syndrome
(Deletion in chromosome 22q11)
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Truncus Arteriosus
 Truncal valve overrides the large
ventricular septal defect
 Truncal valve is dysplastic and often
insufficient (50%), stenotic in about
33% of patients
 Neonatal congestive heart failure
necessitating repair
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Case 2
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Case 2
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Case 2
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Transposition of Great
Arteries (d-TGA)
 4.7% CHD
 VSD may be present (40%) or intact
ventricular septum (IVS)
 Pulmonary/ sub pulmonic stenosis may be
present
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Transposition of Great
Arteries (d-TGA)
 With TGA/IVS, severe cyanosis is present
 Patency of the foramen ovale and ductus
arteriosus for mixing
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Case 3
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Tetralogy of Fallot
 Large ventricular septal defect (VSD)
 Aorta is large and overrides VSD
 Size discrepancy in 3 vessel view
(pumonary trunk smaller than aorta)
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Tetralogy of Fallot
 Ductus arteriosus frequently small
 Absent pulmonary valve – aneurysmal
dilation of the pulmonary arteries
 Pulmonary atresia (valve does not form)
 Reversal of flow in the ductus arteriosus
indicates critical pulmonary stenosis (
ductal dependant)
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Case 4
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Case 4
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Critical Aortic Stenosis
 Severely obstructive aortic valve- thick,
doming
 Dilated poorly functioning left ventricle
 Restricted mitral valve opening
 Mitral regurgitation
 Aortic valve velocity may be normal
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Critical Aortic Stenosis
 Reversal of flow in the aortic arch and
foramen ovale (FO)
 Restrictive FO – cardiomegaly and left
atrial dilation
 Mid gestation severe aortic stenosis may
evolve to hypoplastic left heart syndrome
 Role for fetal aortic valvuloplasty
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Case 5
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Critical Pulmonary Stenosis
 Mild to moderate pulmonary stenosis (PS)
difficult to diagnose
 Severe PS – right ventricular hypertrophy
 Right to left shunt at the FO- left heart
enlargement
 Tricuspid regurgitation
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Critical Pulmonary Stenosis
 Retrograde flow in the ductus arteriosus
 Treatment- balloon valvuloplasty,
radiofrequency perforation, surgical
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Outflow tract view
 Outflow tract evaluation is an essential
aspect of fetal cardiac evaluation
 Normal 4 chamber view does not rule out
critical congenital heart disease
 Systematic imaging key for accurate
diagnosis
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References
Echocardiographic Anatomy in the Fetus :
Chiappa EM, Cook CC, Botta G,
Silverman NH
www.aium.org
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