Abnormalities of the Four Chamber View

  • Owen I. MillerEmail author
  • John Simpson
  • Vita Zidere


The four-chamber view (4ChV) is fundamental to fetal echocardiography, as it will show some, but not all the evidence for most fetal cardiac abnormalities. The 4ChV provides the base view from which further views can be developed and is fundamental in the assessment of ventricular proportions and imbalance, ventricular inlets, evaluation of the crux and for septal defects. Additionally, the 4ChV is the ideal view for initial evaluation of heart rhythm and extracardiac abnormalities such as a pericardial effusion, mass lesions and abnormalities of heart position. This chapter will explore abnormalities seen in the 4ChV and discuss common associations and outcomes for each lesion to guide counselling.


Congenital heart disease Septal defects Coarctation of the aorta Hypoplastic left heart Aortic stenosis Pulmonary atresia Tricuspid atresia Double inlet left ventricle Ebstein’s anomaly of the tricuspid valve Primary cardiac tumours 

Supplementary material

Video 7.1

The four-chamber view demonstrates cardiomegaly in this example of critical aortic stenosis. A dilated, echogenic and non-apex forming left ventricle is seen. The left atrium appears dilated due to mitral regurgitation and a restrictive atrial septum which are confirmed on colour flow Doppler (MP4 1445 kb)

Video 7.2

The fetal heart is displaced into the right chest and the cardiothoracic ratio is decreased due to congenital diaphragmatic hernia (MP4 2670 kb)

Video 7.3

A large perimembranous ventricular septal defect with inlet extension is seen in an apical four-chamber view in this fetus. There is the loss of off-setting of the atrioventricular valves. However, this is not an atrioventricular septal defect as there two separate atrioventricular valves and the primum atrial septum is present (MP4 3182 kb)

Video 7.4a

A moderate mid-muscular ventricular septal defect with a bidirectional flow pattern seen on colour flow Doppler (MP4 3750 kb)

Video 7.4b

In this case a small mid-muscular ventricular septal defect seen on colour flow Doppler in the four-chamber view on the right panel. Note that there is no obvious defect seen on 2D grey-scale, left sided panel (MP4 3837 kb)

Video 7.5a

A transverse sweep from abdomen to great arteries is demonstrated in this video. Cross-section of the abdomen confirms normal situs. The loss of “off-setting” and straight atrioventricular valves in ventricular systole is indicative of a complete atrioventricular septal defect. The great artery connections and transverse aortic arch are normal (MP4 26700 kb)

Video 7.5b

Another example of a complete atrioventricular septal defect is seen in this video. Normal cardiac situs and normal great artery connections are also confirmed (MP4 14865 kb)

Video 7.5c

A large atrioventricular septal defect is seen in this four-chamber view (MP4 3808 kb)

Video 7.5d

This early fetal heart examination demonstrates loss of off-setting due to an atrioventricular septal defect (MP4 8846 kb)

Video 7.6

In the sagittal plane the short axis view of the left ventricle and the right ventricle are obtained. The right ventricle is anterior just below the sternum and the left ventricle is located more posteriorly. There is the appearance of a common atrioventricular valve which spans across the ventricular septum in a case of atrioventricular septal defect (MP4 5342 kb)

Video 7.7

An unbalanced atrioventricular septal defect with dominant right ventricle and atrioventricular valve regurgitation is seen in this fetus and the additional finding of a pleural effusion. Trisomy 21 was confirmed on invasive testing (MP4 7395 kb)

Video 7.8

The transverse sweep from abdomen to great arteries is demonstrated in this 2D grey-scale video. Cross-section of the abdomen confirms normal situs. The apical four-chamber view shows a diminutive, slit-like left ventricle which is not forming the apex of the heart. Only one patent atrioventricular valve is seen on the right side which is the tricuspid valve. This appearance is indicative of mitral valve atresia in the four-chamber view and the further sweep demonstrates a diminutive transverse aortic arch as seen in the setting of classical hypoplastic left heart (MP4 15472 kb)

Video 7.9

In this four-chamber view there is only one patent atrioventricular valve seen, the tricuspid. There is no flow across the mitral valve or within the left ventricle on colour flow Doppler indicating mitral atresia (MP4 5856 kb)

Video 7.10

In this case mitral stenosis and aortic atresia are demonstrated. With this variation there is a globular left ventricle with increased echogenicity. A small jet of antegrade flow across the mitral valve is visible on colour flow Doppler within the left ventricle. Antegrade flow is seen across the pulmonary valve and arterial duct but the aortic arch is hypoplastic with reversal of flow seen in 3VT view (MP4 7985 kb)

Video 7.11

The four-chamber view demonstrates a dilated, poorly contracting, echogenic and non-apex forming left ventricle. This is a typical example of critical aortic stenosis. In addition, a restrictive atrial septum is seen. The right-hand panel demonstrates flow across the right atrioventricular valve and within the right ventricle only (MP4 7773 kb)

Video 7.12a

There is significant asymmetry of the ventricles seen in this four-chamber view. The mitral valve is patent, but with a narrow annulus. The left ventricle is also slender, but apex-forming (MP4 6231 kb)

Video 7.12b

The colour flow Doppler confirms flow across the mitral and tricuspid valves with filling of the ventricles, however the left side appears significantly smaller (MP4 5854 kb)

Video 7.12c

This 3VT view demonstrates a hypoplastic aortic arch in this case of severe coarctation of the aorta (MP4 6272 kb)

Video 7.13

An unbalanced atrioventricular septal defect with a dominant right ventricle is seen in this fetus (MP4 6188 kb)

Video 7.14

This apical four-chamber view shows tricuspid atresia. The tricuspid valve is not present and there is no connection between the right atrium and the right ventricle. This results in a small right ventricle (MP4 3854 kb)

Video 7.15

There is no flow across the right atrioventricular valve seen on colour flow Doppler confirming the diagnosis of tricuspid atresia (MP4 3743 kb)

Video 7.16

The four-chamber view demonstrates no connection between the right atrium and the right ventricle. The right ventricle is small and a moderate-sized muscular inlet ventricular septal defect is also seen. A further sweep demonstrates normally connected and balanced great arteries and transverse aortic arch (MP4 6320 kb)

Video 7.17a

Looking towards the outflow tracts there is an abnormal appearance of the ventricles and the great arteries. The left ventricle is dominant and the right ventricle is hypoplastic and an outlet ventricular septal defect is seen. The great arteries are parallel indicating ventriculoarterial discordance (transposed great arteries). The aorta is smaller than the pulmonary artery suggestive of coarctation of the aorta (MP4 7087 kb)

Video 7.17b

Further colour flow Doppler confirms forward flow in the parallel great arteries. The aorta is smaller than the pulmonary artery (MP4 3629 kb)

Video 7.18

This is an example of an abnormal four-chamber view in a case of pulmonary atresia with intact ventricular septum. The right ventricle is hypertrophied and hypoplastic. On the right-hand panel, colour flow Doppler demonstrates flow within both ventricles including the hypoplastic right ventricle. There was a small but patent tricuspid valve. In addition, dilated coronary arteries crossing the interventricular septum are seen on colour flow Doppler (MP4 5783 kb)

Video 7.19

The 3V view in this same fetus shows the pulmonary artery is slightly smaller than the aorta. The pulmonary artery branches are slender but confluent. On the right-hand panel, retrograde flow in the main pulmonary artery is seen using colour flow Doppler (MP4 6513 kb)

Video 7.20

In this clip an example of double inlet ventricle is seen. In the four-chamber view, there are two atria and two atrioventricular valves opening into a single, anatomically left ventricle. There is loss of offsetting of the atrioventricular valves and no ventricular septum is seen dividing the ventricular mass. Further sweep shows hypoplastic right ventricle which is superior to the left ventricle. The great arteries are transposed, a large pulmonary artery arises from the left ventricle and a small aorta arises from the right ventricle. There is a ventricular septal defect, which is in an abnormal plane but in typical location for this condition. The colour flow Doppler confirms a forward flow in both great arteries on the right-hand panel (MP4 3908 kb)

Video 7.21

Tricuspid valve regurgitation is seen in this case of Ebstein’s anomaly of the tricuspid valve. Typically, the regurgitation starts much closer to the apex of the heart than in a normally attached tricuspid valve (MP4 3724 kb)

Video 7.22

This sweep from four-chamber to the great artery view confirms displacement of the tricuspid valve into the right ventricle but with normally connected great arteries. The pulmonary artery appears smaller than the aorta but with forward flow across the valve and the arterial duct (MP4 7139 kb)

Video 7.23

The four-chamber view demonstrates an example of tricuspid valve dysplasia. The tricuspid valve appears thickened but not displaced. There is marked cardiomegaly due to severe enlargement of the right atrium caused by tricuspid regurgitation (MP4 3378 kb)

Video 7.24

In this video an apical four-chamber view demonstrates atrioventricular discordance. The pulmonary venous chamber (left atrium) is anterior to the spine. This connects to a ventricle with a moderator band at the apex. There is reversed off-setting of the atrioventricular valves. The left-sided atrioventricular valve arises closer to the apex indicating that this is the tricuspid valve. This indicates the morphological right ventricle is on the left side. The right-sided ventricle is smooth walled indicative of a morphological left ventricle. These features are consistent with atrioventricular discordance (MP4 6145 kb)

Video 7.25

The outflow tract assessment reveals that the pulmonary artery arises from the morphological left ventricle and is seen first on sweeping cranially. The aorta arises anterior and to the left of the pulmonary artery from the morphologic right ventricle (MP4 5712 kb)

Video 7.26

There is reversed flow in the aortic arch during diastole. This is seen in cases of fetal growth restriction due to the ‘brain sparing effect’ (MP4 3761 kb)


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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation TrustLondonUK
  2. 2.King’s College Hospital NHS Foundation TrustLondonUK

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