5 Views

5 Transverse Views for screening the heart

1. What are the 5 Transverse Views?

The 5 Transverse Views (5TV) is a guide to screening a baby's heart before birth at around 20 weeks.  The fetal cardiac anomaly scan is usually performed as a sweep of the heart, that takes in these 5 key views.

To be effective, prenatal screening should be part of an integrated, managed screening programme that ensures health professionals are properly trained and experienced, equipment is correctly set-up and all referrals are audited (with feedback from referrals used to verify that audit and highlight any training issues).

Prenatal heart screening should aim to detect virtually all major cardiac anomalies (which occur in approx. 4 births per 1,000) in a practical and timely way.

2. The Basics

The routine 20-week ultrasound anomaly scan is ideal for picking up heart problems, yet detection rates are still relatively low on average across the UK (approx. 23% in 1999 and are estimated to be around 30% in 2010, with widespread postcode variation - see CCAD).

One problem has been the lack of a consistent and practical standard for fetal cardiac screening - hence the need for the 5 View protocol.

The 5 Transverse Views is a systematic examination of the normal fetal heart using a series of 5 views, roughly transverse to the fetal chest, ref. Yagel, Silverman, Gembruch (2008)

The "5-view" protocol is designed to detect (but not diagnose) almost all forms of fetal heart disease in a practical and timely way, at around 20 weeks gestation

If a heart is normal, then 5 normal views in a transverse plane should be seen.  Sometimes a view cannot be seen clearly due to limb artefact (shadowing), old equipment, probes or set-up, fetal lie or maternal factors

If a normal view is NOT seen, then it is reasonable to be suspicious and seek a second opinion or refer for a full fetal echo.  This will depend on local protocols.

3. More information:  the 5 Views in detail  ||  Our 5TV Poster

Changes in screening (2002 - 2008)

In 2008, the Fetal Anomaly Screening Programme (FASP) did an Ultrasound Survey of England.
FASP recommendations: ‘Fetal echocardiography involving the four chamber view of the fetal heart and outflow tracts is recommended as part of the routine anomaly scan.’ (ref. NICE Antenatal guidlines, 2008)

1. Improvements in structures routinely examined by surveyed units at the 2nd trimester anomaly scan (2002 - 2008):

Four-chamber view: 98% --> 100%
Outflow tracts:         57% --> 75%

2. Percentage of units by region offering routine examination of coronal lips and fetal cardiac outflow tracts at the 2nd trimester routine anomaly scan (2008)

SHA - Outflow tract %
East Midlands - 78%
East of England - 100%
London - 100%
North East - 75%
North West - 66%
South East Coast - 93%
South Central - 83%
South West - 73%
West Midlands - 12%
Yorkshire and the Humber - 87%