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The most important points to note when evaluating the great arteries are that there normally is continuity be-tween the ventricular septum and the anterior wall of the aorta, and that the great arteries cross at right angles to

each other as they exit the heart. The aorta crosses from left to right, and the PA from right to left. Demonstration of these two normal relationships helps exclude abnormali-ties of the great arteries such as TOF, truncus arteriosus, and transposition anomalies.

Overriding Aorta

Although the aorta normally courses over the plane of the ventricular septum as it leaves the heart, the septum is in-tact. With an overriding aorta, one observes a VSD and the aorta displaced toward the right side. This disrupts the normal continuity of the ventricular septum and the wall of the aorta. It is possible, however, to falsely produce an image of aortic overriding. The origin of this artifact is un-certain, although it may be due to partial volume artifact of the more superior PA or of a sinus of Valsalva. If overriding is seen, then it needs to be confirmed with slightly differ-ent angulation of the transducer.46At least in some cases of pseudooverriding, close observation of the site of apparent discontinuity will show that it is actually distal to the aor-tic valve, whereas with true overriding, the discontinuity is proximal to the aortic valve.

TOF is the primary diagnosis to consider when ing of the aorta is seen (Fig. 16–13). The VSD and

overrid-16 Family History of Congenital Heart Disease

183

Figure 16–12 Cardiac tumor. A moderate-sized hyperechoic mass (arrow) fills much of the left ventricle in this four-chamber view. Ad-ditional cardiac tumors were also seen in this fetus. The pregnancy progressed uneventfully, and no hydrops or arrhythmias occurred.

Figure 16–13 Tetralogy of Fallot. Left ventricular outflow tract views shows a ventricular septal defect (asterisk) and overriding of the aorta. The overriding appears as a lack of continuity between the ventricular septum (thin arrow points to upper end of ventricular sep-tum) and wall of the aorta (thick arrow). The aorta is shifted toward the right ventricle and appears to “straddle” the ventricular septum.

Additional views showed the pulmonary artery arising normally from the right ventricle, helping to confirm tetralogy of Fallot.

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Summary

Although the 4C view is the basic view for evaluating the fetal heart, further evaluation of both outflow tracts will improve the sensitivity of obstetric ultrasound for CHD. If the sonographer and sonologist can adequately evaluate the six key features discussed here, four on the 4C view and two on the outflow tract views, then the majority of congenital heart anomalies can be diagnosed before birth, both in patients at higher risk for CHD and in those at lower risk.

In the future, more widespread use of late first tri-mester ultrasound to evaluate the heart in patients at higher risk for CHD will likely contribute to earlier diagno-sis of CHD. Newer techniques such as three-dimensional and four-dimensional ultrasound may also play a role.82,83

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Maternal Serum–Alpha-Fetoprotein