 Hello all, welcome to Sonobas. I am Dr. Mohit Shah and I am going to take you through the basics of Vitalico and touch upon few advanced features of Vitalico as well. So I am going to talk about the basics of Vitalico which I am following by the ISOA guidelines and all my images are basically from Alfredo Mohamed and Rabi Choy's book. So it always boils down to a correct protocol and methodology and therefore we need a sequential segmental analysis where we assess cytos, identify arterial arrangements, AV valves, ventricular arrangements, ventricular arterial connections, identify the arterial trunk arrangement at the free vessel view and the systemic and permanent venous connections. Now if I have to look at the abdominal cytos, I would actually go down into the abdomen and look at the arrangement of the IVC and the aorta. The aorta if you draw a line in the midline just falls to the left of the midline whereas the IVC is more anterior and it is to the right. So this section is of paramount importance to assess the cytos. Of course there are various ways where you could have otherwise assess the cytos but I believe imagining yourself to be the baby helps you better assess the cytos abnormality than relying on the different formulas. So you have got to actually check the checklist for cytos where the stomach and the cardiac apex has to be the left, the aorta anterior and the aorta is posterior and to the left of the spine. The IVC is slightly anterior and to the right of both the aorta and the spine. So the relation of the aorta and the IVC is of paramount importance. The axis is slightly pointing to the left by 45 degrees. There could be a range of 20 degrees here and there to the right or the left. You calculate the size by eyeballing but actually measure it by calculating the cardiothoracic circumference of the ratio which has a mean value of 0.45 at 17 and 0.5 at term. So roughly the heart has to be the half the size of the thorax. You look at the four chamber view and you look at the atrial chambers. You have to have two atrial chambers approximately of equal size. The forearm and the valve flap opens into the left atrium. The interatrial septum has to be seen and the pulmonary veins enter the left atrium. Similarly the ventricular chambers in the fetal life have to be approximately equal in size. There has to be no ventricular wall hypertrophy. The modulator band is seen at the right ventricular apex and the interventricular septum has to be intact right from the apex down up to the cucks of the heart. The right atrium is anteriorly located to the right of the left atrium. It receives the IVC and the SVC and also the coronary sinus. It contains the sinoatrial node and the AV nodes. This information is important in cases of isomerism. In the bicable view you can see the IVC and the SVC opening into the right atrium. The right ventricle is the anterior most chamber of the heart abutting the sternum. It has got a modulator band in the apical region. The tricuspid valve is more apically inserted on the septum than the mitral valve and we will as we will see later that the cordy tendon is inserted directly over the apex. The left atrium is the posterior most cardiac chamber just lying anterior to the aorta. It receives 4 pulmonary veins. However, when you see in the 4 chamber view, you see the inferior ones opening into the left atrium. The left atrial appendage is actually narrower than the right one. You can actually look at the normal coronary sinus. It is situated behind the left AV groove and it is seen as two parallel echogenic lines that open into the right atrium. So, all you need to do is identify the mitral valve and try and take a section posterior to the mitral valve when you see a coronary sinus which normally has to be between 1 and 3. If it is larger than 3 then it is dilated and then you have to look for a venous abnormality like an persistent SVC or pulmonary venous drainage abnormalities. The left ventricle like the right appears apparently larger because it does not contain a moderately band. However, it is of equal size as that of right ventricle and it is more conical because of lack of again the moderately band. The biker speed valve is slightly placed higher or inserted over the septum than the tricuspid valve and as we will see the cordy tendon of the biker speed valve insert onto the lateral aspect of the left ventricle. So, the differentiating point always remains that left ventricle is longer because the moderately band is absent there and the tricuspid valve is more apically placed than the mitral valve. You look at the AV junctioned valves and the semilunary valves and you appreciate the offsetting there. The tricuspid is more apically placed inserted than the biker speed and you should be able to see good movements opening and closing of the valves that it actually denote the anatomy and the function of the ipsilateral chambers. So, tricuspid valve in fact is more apically placed and the biker speed is not biker speed is slightly higher inserted on the septum, but more important feature is that called a tendinane. This is appreciated on the lateral fore chamber in the case of right ventricle go right up to the apex. Now, this is a feature seen only in the right ventricle and becomes important when you have cases where you would have a morphological right ventricle on the left side and a morphological left ventricle on the right side. This feature is extremely important that the chorda tendinane on the right has to insert on the apex of the heart whereas the chorda tendinane on the left side insert midway to the apex either anteriorly or on the lateral valve of the left ventricle. This is a feature that was best seen in the lateral fore chamber. So, always appreciate the offsetting and the opening and closing of the AV valves and this and the sebilunar of course, have to continuously blink. If you see the valves opening and closing in real dynamic screens and you know that the valves are functioning normally. If you see them persistently throughout the cardiac cycle then we are talking of atresia. It means that the valves are failing to open and that is an abnormal scenario but normally you would see them opening and closing in with every cardiac cycle. The interventricular septum is best seen left in the lateral fore chamber view. It consists of four parts. The inlet septum is at the level of AV valves. The muscular septum is the one that actually separates the chambers. The perimembranus septum is seen only at the five chamber view under the origin of the ascending aorta and the outlet septum is seen under the origin of the pulmonary artery. So, denoting terminology is extremely important when it comes to abnormalities of the septal defects. Interatal septum has two components, septum primum and secondum and the foranimate oval lies in the septum secondum. What is the most important feature here is a septum primum is embryologically related to foramen ovale. So, whenever you have a doubt whether you are seeing the septum primum or is it present or is it absent look at the foramen oval flap. If it is seen then the septum primum has to be present because they are immunologically derived from the same entity and the foramen oval flap opens into the left atrium. The direction of flow is from the right to the left to the flap has to open there. Crux of the heart is the heart of the matter. It is where the interatal septum joins the interventricular septum and the two AV valves insert. So, you have to see the crux in each and every patient. The great arteries have to be seen in all and seen to arise and to see the origin of the arteries. See the size, patency and flow, ventricular connections and position relative to the aorta. Now the PA divides into the left and the right branches. This is an important feature that differentiates it from the ascending aorta. So ideally the aorta curves to form an arch whereas the pulmonary artery you know after it comes out of the right ventricle immediately divides into right and the left branches. This is how you identify the great arteries and venous system of course you have the SVC and the IVC. So the key spanning planes include a four chamber view, the LVOT and the five chamber view, RVOT3, vessel 3 with each view, the archer's view and the bi-caval view. So basically the four chamber view can be seen in three planes, the apical, the basal as well as the lateral four chamber. But all you need to know is that you have to have a checklist and the checklist should start for the four cardiac chambers where you see the two atria and the two ventricles, the ventricles and the atria have to be equal in size. They have to be two patent AV valves moving freely with a normal offset. There has to be a modulator band in the RV. The crux, the IVS has to be intact right from the apex to the crux and you should see the foramen ovale flap opening into the left ventricle and you would see the descending aorta in front and to the left of fetal spine and the pulmonary vein should drain into the left atrium. So once you've seen the four chamber view we prefer the apical four chamber view for all our cardiac evaluations except that the lateral four chamber gives you a better perspective of the interventricular septum. When you switch on color with the normal heart, if they both AV valves are functioning well, you would see a parallel inflows and outflows without any flow across the interventricular septum and that's the normal flow. Never forget to look at the area behind the heart. As I said the left atrium is the most posterior chamber. The most posterior valve of the left atrium has to be not more than four millimeters on the anterior valve of the aorta. This is a space that you need to watch for. You can have masses that actually invade this space and widen it but more often than not you would have abnormalities of pulmonary venous circulation that is going to increase this space and you got to watch for this space in every patient. The LVOT begins mostly in the center and you should see the semilunar valve and the aorta goes forward without dividing till the arch and that's the differentiating feature. You have to look for the septo aortic continuity in the sense that interventricular septum is parallel to the anterior valve of the aorta. They are in continuity there. But if you lose the continuity there and if you see that this forms normally an obtuse angle but if it almost becomes parallel to each other then you are looking for an aortic override where the aorta is overriding the interventricular septum and therefore this angle instead of obtuse becomes more and more 180 degrees or so. The RVOT is shorter as it comes out to the pulmonary right ventricle. You will see that the pulmonary artery divides into the right and the left ventures and it continues as a doctor's arteriosis opening into the descending aorta. The aortic arch arises in the middle of the thorax is more circular in shape and the most important differentiating feature is it gives rise to cranial vessels from the arch. As opposed to it the ductile arch begins more anteriorly because it comes from the anterior chamber that the right ventricle. It is more angular as compared to the aortic arch when it does not have any branches in the chest. We have discussed the bicavel view where you see the SVC and the IVC opening into the right atrium. The three vessel view is one syphilag section about the fore chamber where you will see the pulmonary artery the aorta and the SVC in line and from the left to the right in descending order of size. So what it means is a pulmonary artery will be slightly larger than the aorta which will be slightly larger than the SVC but all will be in one line. If you go one section above you will actually see that the aorta and the pulmonary artery joined the descending aorta in the form of a V to the left of the spine. Everything that I say is here is important. The PA connects the aorta by the doctor's arteriosis and the part of the aorta beyond the origin of the subclavian is called isthomas. So you have the three vessel and the three vessel trachea view when we switch on color both these vessels should be of equal size and should show anti-grade flow direction. If there is a discrepancy in the flow direction then we talk of a valvular abnormality of the heart. So if you measure the PA to aorta ratio normally the PA is just about larger than the aorta and the ratio is 1.16. So any discrepancy in the sizes of the PA or the aorta points to a four chamber abnormality or valvular abnormality of the heart. So you look at this vessel size alignment arrangement number of vessels abnormal location of transverse aortic arch as I said both have to have an anti-grade flow and if anyone has a turbulent flow it all points to abnormalities or the four chamber that you can pick up on the three vessel view. So normally you should see a criss cross which happens immediately after both great arteries originate from the ventricles. If you try and look at the criss cross more distally, more distally they come parallel to each other. So look at the criss cross just after they have originated from the ventricles. If you do not see them crossing remember that to look for the parallel walls. If the walls are parallel to each other that means you are dealing with parallel outflows. So the more stringent definition of outflows is when you see that the semilunar walls are parallel to each other that denotes a parallel outflow. So when you look at the three vessel view the structure anterior to the three vessels is the thymus and this is an important anatomical landmark that you know is bored. You have the thymic box on color where you see the intramamary arteries on either side of the thymus and this feature is important. Thymus is important because an absent thymus points towards 20 to Q11 deletion. But of course the machines have more advanced now you have sticks you have multiple technologies where you just draw a line and the machine actually gives you all the information all the sections that we just discussed at the click of a button. So I would advise patients on perseverance remember methodology is important. So sequential analysis and following guidelines will help you actually identify normality better to pick up abnormalities in a much accurate way. Document your heart images in magnified sections and as I said prove normality and that is what we are seeking here. Thank you so much.