FIG 19.10 When scanning from the subcostal position (arrow), the transducer beam moves more in the planes of the body than in the planes of the heart Thus a series of paracoronal cuts of the heart is obtained (inset) Rotating the transducer through 90 degrees will produce a series of parasagittal cuts Transthoracic Echocardiography A full echocardiographic study involves a complete description of cardiac anatomy, valvar function, and cardiac systolic and diastolic function Transthoracic windows are excellent in the majority of infants and children, so that interrogation from these windows can provide all anatomic, hemodynamic, and functional information required for diagnosis and treatment of most of the congenital and acquired cardiac lesions encountered by the pediatric echocardiographer The majority of children are currently referred for cardiac surgery based only on transthoracic echocardiographic studies However, for those aged between 3 months and 3 years, lack of cooperation can be a limiting factor, and sedation is generally required to permit performance of an adequate echocardiographic study Transesophageal imaging in children is mostly limited to perioperative imaging The description of cardiac anatomy is best accomplished by using the segmental anatomic approach By combining different echocardiographic windows, it is possible to recognize the precise anatomy of each cardiac segment, along with their interconnections and relations This chapter concentrates on normal findings The echocardiographic images of congenitally malformed hearts are described in other chapters A detailed discussion of functional echocardiography is beyond the scope of this text; instead, our focus is mainly on the description of cardiac anatomy and valvar function When starting a full cross-sectional study in a new patient, most echocardiographers will prefer to start with subcostal imaging because this allows inferential determination of the arrangement of the abdominal organs and the heart The study then proceeds with obtaining parasternal long-axis, shortaxis, apical, and suprasternal views A study performed for the purposes of follow-up will often start with parasternal long-axis views, deferring the subcostal imaging until the end of the examination To help the echocardiographer to reconstruct the three-dimensional anatomy, twodimensional sweeps can be recorded using the different cuts For instance, a subcostal coronal sweep from posterior to anterior provides extra information in the third dimension All images should be presented in their correct spatial, or attitudinally appropriate, position on the screen The anterior and superior structures, therefore, are displayed at the top of the screen, and the rightward structures are generally placed on the left side of the display, with the exception of the parasternal long-axis cut when, by convention, the cardiac apex is displayed on the left of the screen The standard views required for a pediatric echocardiographic study, as defined by the American Society of Echocardiography, are all obtained as part of a routine examination.5 These are the subcostal, apical, parasternal, suprasternal notch, and right parasternal cuts Subcostal Views Different subcostal views can be obtained Typical sections are obtained in a coronal plane, giving long-axis views, in the sagittal plane producing short-axis sections, and in the transverse plane Subcostal images are presented in the anatomic orientation as the heart is positioned in the chest (apex down) Subcostal imaging begins with a transverse section to determine the arrangement of the abdominal organs by inference from the location of the abdominal aorta and inferior caval vein relative to the spine (Fig 19.11).6 The abdominal vessels can also be imaged in a long-axis view by rotating the probe 90 degrees counterclockwise Color imaging will help to distinguish the identity of the abdominal great vessels Posterior long-axis sections, with the transducer directed to the left of the midline, provide excellent views of the atrial septum (Fig 19.12) As the transducer is tilted anteriorly, the superior caval vein, the ventricles, and the left ventricular outflow tract can be imaged (Fig 19.13) Further anterior tilting of the probe provides views of the right ventricular outflow tract A long-axis sweep from posterior to anterior is obtained Counterclockwise rotation of the transducer, with the transduced notch positioned inferiorly at 6 o'clock, will produce different short-axis sections as the transducer is swept from right to left in a parasagittal plane A section through the atriums allows imaging of the superior and inferior caval veins and the atrial septum (Fig 19.14) As the transducer is moved toward the left, the subcostal short-axis section of the left ventricle and the right ventricular outflow tract can be imaged (Figs 19.15 and 19.16) In this view, the right ventricular apex and outflow tract are seen, together with the pulmonary valve and proximal pulmonary trunk (see Fig 19.15) By tilting the transducer further to the left, the midapical and apical portions of both ventricles can be imaged, along with the corresponding portions of the ventricular septum ... of the parasternal long-axis cut when, by convention, the cardiac apex is displayed on the left of the screen The standard views required for a pediatric echocardiographic study, as defined by the American Society of Echocardiography, are all obtained as part of a routine examination.5 These are