define the position of the apex, atrial situs, the AV connections, and the ventriculoarterial relationship (Figs. 6-8). Apical and subcostal views are projected in the anatomically correct position (apex down) to permit better interpretation, especially of complex lesions.

Surgical scars and deformities of the thoracic cage may make transthoracic examination difficult, and views from all available windows—including additional or nonstandard views—should be acquired whenever necessary. The transthoracic examination should be comprehensive, with special attention given to the questions that need answers. Sonographers in nonspecialized centers should not hesitate to seek help from those so specialized.

The two-dimensional (2D) examination should assess all four chambers, valves, great vessel relationships, aortic arch anatomy, and pulmonary vein connections. Doppler (color flow, pulsed wave [PW], continuous wave [CW]) examination of flow patterns (including direction and velocities) within cardiac and extracardiac structures including all valves, defects, conduits, and shunts should be performed. Assessment of tricuspid regurgitation velocity is important and provides a measure of pulmonary artery pressures. Ventricular function assessment—both systolic and diastolic—is integral (see Chapter 5).

Transesophageal Echocardiography

In adults with CHD, TEE has major advantages over TTE and its role is now indispensable in the management

Table 5

The Segmental Approach by Echocardiography

Step 1: Position of the apex Levocardia Dextrocardia Mesocardia Step 2: Situs of the atrium Situs solitus Situs inversus

Situs ambiguous (isomerism) Step 3: AV relationship AV concordance AV discordance Double inlet Absent connection Step 4: VA relationship VA concordance VA discordance Double inlet

Solitary (common) arterial trunk

AV, atrioventricular; VA, ventriculoarterial. Reproduced from Therrien J. Echocardiography. Adult congenital heart disease. In: Gatzoulis MA, Webb GD, Daubeney PEF, eds. Diagnosis and Management of Adult Congenital Heart Disease. London: Churchill Livingstone, 2003:35-49.

of a broad spectrum of pediatric and adult patients with CHD. Complex lesions require optimal anatomic definition, and the windows provided by TEE greatly aid in their evaluation. Pulmonary venous structures, prosthetic valves, baffles, shunts, conduits, closure devices, residua, and other contiguous mediastinal structures are often best evaluated by TEE. Monitoring percutaneous interventions (e.g., patent foramen ovale [PFO] and atrial septal defect [ASD] closure and intra-operative monitoring) is best performed by TEE.

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