The 4 chamber view of the fetal heart allows visualization of the situs, size, and anatomy of the atria and ventricles. It is easy to obtain and can be included in routine mid-trimester scans. However, it only detects around 40% of congenital heart defects. Some defects are not visible in the 4 chamber view due to progressive evolution or lack of effects on cardiac chambers. Improving imaging techniques like measuring chambers, using color Doppler, and examining throughout the cardiac cycle may increase detection rates. Abnormal 4 chamber views can indicate issues like septal defects, arrhythmias, and structural abnormalities.

1. Normal Four Chamber View
Dr.Sameer Dikshit
MD DGO FCPS FICOG

2.  Nowrosjee Wadia Maternity Home
 BSES MG Hospital
 S L Raheja-Fortis Hospital

3.  Approximately 8 per 1000 live births
◦ 3 times more common than identifiable
chromosomal disease
◦ 4 times more common than neural tube
defect

4. 4 Chamber view of the fetal
heart

6. Advantages
 Easy to obtain
 Move up from AC view
 Easy to identify

7.  Easy to standardize
 Can be easily included in mid
trimester scan protocol without
incurring additional expense/ time/
personnel

8.  Axis
 Size
 Pericardial effusion
 2 Atria roughly
equal

9.  2 Ventricles
roughly equal
 AV valves with
offset
 IVS

10.  Inter- atrial septum
with foraminal flap
 Pulmonary veins
 A & V rhythm
 Colour Doppler for
flow across the AV
valves

11. #1) Determine Situs
Stomach to
the left side
& Liver to the
right Situs
Solitus

12. #2) Position of the Heart
All of the
heart except a
bit of RA lie in
the Left Half

13. #3) Axis
450 +/- 150
Apex Pointing
to the Left
Levocardia

14. #4) 4 Chamber View
Anatomical
v/s
Morphological

15. #5) AV valves
Offset
Tricuspid is
apical than
Mitral

16. #6) IVS & IAS
Septum Primum
Septum Secundum

17. #7) Heart Rate and
Rhythm-1
M Mode

18. #8) Heart Rate and
Rhythm-2
Pulsed Wave
Doppler

19. #9) Colour Doppler 1
2 streams
from A to V

20. #10) Colour Doppler 2
Aortic outflow

21. #11) Pulm Veins
PV open into
LA

22. #12) PV pulsed wave
doppler

23. #13) Foramen Ovale
Flow

24. #12) Lateral 4 chamber
view
Good view of
IVS

25. #13) Lateral 4 chamber
colour Doppler
Colour
Doppler for
muscular VSD

26. #14) First Trimester
Heart-1

27. #15) First Trimester
Heart-2

28. #15) First Trimester
Heart-3

29. CHDs associated with
abnormal 4 Ch view
 Abnormal Situs
 Inequality of chambers
◦ Hypoplastic Right/ Left Heart syndrome
 Septal defects
◦ Large VSD
◦ AVSD
 Valvular abnormalities

30. CHDs associated with
abnormal 4 Ch view..contd.
 Severe abnormalities of vessels
◦ Coarctation of aorta/ aortic stenosis
◦ Pulmonary stenosis
 Pericardial effusion
 Myocardial hypertrophy
 Cardiac Tumours

31. “Is 4 chamber view a good
screening test ?”

32.  Only 40% of CHD can be diagnosed
with 4 Ch view
 Various studies quote a range from
15-60%

33. Screening Test DR
Risk Factors approach 11%
4 Chamber View 40%

34. Why 4 Ch view fails?

35. CHDs NOT associated with
abnormal 4 CH view
1. Abnormalities of great vessels not
associated with any defect on
cardiac chambers
2. CHDs with progressive evolution
3. CHDs not detectable in utero

36. (1) Abnormalities of great vessels
not associated with effect on
chambers  Mild Aortic
stenosis, Coarctation
 Tetralogy of Fallot of aorta , Pulmonary
stenosis
 Transposition of
great vessels  Double outlet
ventricle
 Truncus Arteriosus
 Pulmonary atresia
with VSD

37. (2)CHDs with progressive
evolution
 Pulmonary stenosis
 Aortic Coarctation
 Ventricular hypoplasia

38. (3)CHDs NOT detectable in
utero
 Isolated ASD  (Postnatally)
Patent ductus
 Small VSD arteriosus
 Partial anomalous
pulmonary venous  (Postnatally)
connection Patent foramen
ovale

40. Can we do something to improve the
pick up rate of 4- chamber view??

42. Inadequate examination
 Heart is examined at inappropriate angle
 Maternal Habitus
 “Lack of time”
 Sub-Optimal magnification

43.  Heart fills 1/3 to ½ of
the screen

44.  Introduce protocol of measuring ventricles
in systole and diastole
 Many times the 4 chamber view of the
heart may “look normal” but the
measurements may be outside the normal
limits

45.  Use cine
loop to see
the heart in
all phases of
cardiac cycle

46.  Use colour doppler and PW doppler

47. Pitfalls in 4 chamber view
My Experience

48. Case #1
Extra vessel
noted while
moving up
from AC view

49. Aorta far off
from LA

50. Leash of
vessels
behind LA

51. Anomalous Pulmonary
Venous Return
Schimitar
vessel

52. Case #2

53. Hypoplastic Left Heart
Poor flow
across Mitral
Valve

54. Case #3

55. Ebstein’s

56. AVSD

57. Septum Primum ASD

58. Case#4

60. Perimembranous VSD

61. Perimembranous VSD

62. Rt Aortic Arch

63. Abnormal 4 chamber views
Fetal Medicine Foundation videos

64. Ventricular Septal Defect

65. Atrio Ventricular Septal
Defect

66. Tricuspid Regurgitation

67. Ebstein’s Anomaly

68. Biventricular
Regurgitation

69. Corrected Transposition

70. Congenital
Diaphragmatic Hernia

71. Rhabdomyomas

72. Dextrocardia

73. Anemia

74. Take home message

75.  What is 4 chamber  Pick up rate
view
 Why 4 chamber
 What structures to view fails
see in 4 chamber
view  Abnormal 4
chamber view
examples