Functional Echocardiography                Targeted neonatal echocardiography (TNE)               Point of care echocardio...
Why should we be able to performand interpret TNE• Rule out structural abnormality• Need for direct measure of cardiovascu...
Increasing use of TNE in NICUEnough of theoretical informationsNeed for good training !www.neonatalechoskills.comThe HIP T...
The HIP Trial is funded by the European Commission within the 7th Framework Programme
Basic rules of TNE• Find a supervisor  - neonatologist with experience in TNE  - pediatric cardiologist• 24/7 access to ul...
Indications for TNE• Suspected patent ductus arteriosus (PDA)• The cyanosed newborn  - suspected persistent pulmonary hype...
Components of TNE•     Left ventricular function•     Right ventricular function•     Ductal shunting•     Atrial shunting...
LV systolic function – Fractional shortening •      FS – derived from an long-axis or short axis view •      M-Mode at the...
LV systolic function – Fractional shortening                   FS = [(LVEDD-LVESD)/LVEDD] x 100 LVEDD – left ventricular e...
LV systolic function – mVCFs  mVCFs - Mean velocity of circumferential fiber shortening          mVCFs = mean [(LVEDD-LVES...
LV systolic function – Ejection fractionEjection fraction (EF) – the proportion of ventricular contents   ejected during s...
Diastolic function – blood inflowVentricular filling velocitiesFrom four chamber viewRatio of E:A wave                    ...
Diastolic function – blood inflow•    Changes during the first week of life from dominance of filling during     atrial co...
LV systolic/diastolic function – MPI• MPI (= Tei index) - Myocardial  performance index• From adjusted four chamber  view ...
LV systolic/diastolic function – MPI• Less usable in high heart  rates                                                    ...
Tissue Doppler• Systolic and diastolic function• Measuring of myocardium movement in 4 chamber view• 2 variables peak velo...
Tissue Doppler                                                              TISSUE DOPPLER ECHOCARDIOGRAPHY               ...
Other modalities• Strain• Strain rate• Speckle trackingUsed in cardiology or for  research The HIP Trial is funded by the ...
Ductal shunting• Ductal diameter• Direction of blood flow, flow pattern – restricted, wide open• Assesment of hemodynamic ...
Atrial shunting• High incidence• From subcostal four chamber view or short axis  view The HIP Trial is funded by the Europ...
Atrial shunting• Usually low velocity flow – colour Doppler, pulsed wave• Dominant shunting is left to right (up to 30% of...
Pulmonary artery pressure (PAP)1. From ductal shunting•       Ductal flow reflects relation of        systemic and pulmona...
Pulmonary artery pressure (PAP)2. From tricuspid regurgitation jet•     Modified Bernoulli equation      PAP = 4 x velocit...
Assessment of systemic blood flow • Systemic blood flow ≠ cardiac output when atrial   and ductal shunt is present Ductal ...
Left ventricular output - LVO • Measuring of ascending aorta • Diameter – from long axis view, end-systolic internal   (tr...
Left ventricular output - LVO                           Normal values 150-300 ml/kg/min The HIP Trial is funded by the Eur...
Right ventricular output - RVO• RVO represent systemic blood flow more than LVO in preterm  infants with PDA and FOA• Meas...
Right ventricular output - RVO                          Normal values 150-300 ml/kg/min The HIP Trial is funded by the Eur...
Superior vena cava flow – SVC flow• Partial cardiac input. Blood from upper body. 70-80% is from  brain• Not confounded by...
Superior vena cava flow – SVC flow • Diameter from parasternal view – 2D or M-mode • Flow – subcostal view, pulsed Doppler...
SVC flow The HIP Trial is funded by the European Commission within the 7th Framework Programme
Central line placement• Appropriate placement – PICC line, UVC, UAC• Identification of complications – thrombosis, abnorma...
Another abnormal conditions• Suspected effusion  pericardial - from 4 chamber view, long axis view  pleural  pneumopericar...
Thanks a lot for your attentionThe HIP Trial is funded by the European Commission within the 7th Framework Programme
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Functional Echocardiography. Targeted neonatal echocardiography (TNE). Point of care echocardiography (POCT ECHO).

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International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)

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Functional Echocardiography. Targeted neonatal echocardiography (TNE). Point of care echocardiography (POCT ECHO).

  1. 1. Functional Echocardiography Targeted neonatal echocardiography (TNE) Point of care echocardiography (POCT ECHO) Kyiv March 2013 Jan Širc Institute for the Care of Mother and Child, Prague, Czech Republic Third Faculty of Medicine, Charles University, Prague, Czech RepublicThe HIP Trial is funded by the European Commission within the 7th Framework Programme
  2. 2. Why should we be able to performand interpret TNE• Rule out structural abnormality• Need for direct measure of cardiovascular function• Effect of treatment• Need for serial assessments• Poor availability of cardiologists 24/7 The HIP Trial is funded by the European Commission within the 7th Framework Programme
  3. 3. Increasing use of TNE in NICUEnough of theoretical informationsNeed for good training !www.neonatalechoskills.comThe HIP Trial is funded by the European Commission within the 7th Framework Programme
  4. 4. The HIP Trial is funded by the European Commission within the 7th Framework Programme
  5. 5. Basic rules of TNE• Find a supervisor - neonatologist with experience in TNE - pediatric cardiologist• 24/7 access to ultrasound machine• Congenital heart defect has to be excluded in the first scan The HIP Trial is funded by the European Commission within the 7th Framework Programme
  6. 6. Indications for TNE• Suspected patent ductus arteriosus (PDA)• The cyanosed newborn - suspected persistent pulmonary hypertension - excluding structural heart disease• The infant with heart failure, hypotension or shock• Newborn with heart murmur• Central line placement• Suspected effusion• Suspected thrombosis The HIP Trial is funded by the European Commission within the 7th Framework Programme
  7. 7. Components of TNE• Left ventricular function• Right ventricular function• Ductal shunting• Atrial shunting• Pulmonary artery pressure• Measurement of blood flow and cardiac output• Superior vena cava flowNot all have to be part of standard TNE ECHO The HIP Trial is funded by the European Commission within the 7th Framework Programme
  8. 8. LV systolic function – Fractional shortening • FS – derived from an long-axis or short axis view • M-Mode at the mitral leaflets tips • Beam perpendicular to septum • One of the most reproducible measurements The HIP Trial is funded by the European Commission within the 7th Framework Programme
  9. 9. LV systolic function – Fractional shortening FS = [(LVEDD-LVESD)/LVEDD] x 100 LVEDD – left ventricular end- diastolic diameter LVESD – left ventricular end- systolic diameter LVESD LVEDD Normal values Term babies 25-41% Preterm 23-40% The HIP Trial is funded by the European Commission within the 7th Framework Programme
  10. 10. LV systolic function – mVCFs mVCFs - Mean velocity of circumferential fiber shortening mVCFs = mean [(LVEDD-LVESD)/LVEDD] x LVETLVET – left ventricular ejection time, from the closure to the opening of the mitral valve LVETLess sensitive to dimensional discrepanciesNormal values 1.5 ± 0.04 circumferences/s The HIP Trial is funded by the European Commission within the 7th Framework Programme
  11. 11. LV systolic function – Ejection fractionEjection fraction (EF) – the proportion of ventricular contents ejected during systole EF = [(LVEDD 3 -LVESD 3)/LVEDD 3] x 100%• Any errors in measurements are cubed• Changes in shape of the ventricular cavity Fractional shortening should be prefered The HIP Trial is funded by the European Commission within the 7th Framework Programme
  12. 12. Diastolic function – blood inflowVentricular filling velocitiesFrom four chamber viewRatio of E:A wave E A The HIP Trial is funded by the European Commission within the 7th Framework Programme
  13. 13. Diastolic function – blood inflow• Changes during the first week of life from dominance of filling during atrial contraction (A wave) to dominance of early contraction (E wave)• Progressive increase of E wave and E/A ratio• More pronounced in preterm infants (developmental changes, diastolic dysfunction after birth?)• Diastolic dysfunction – reduced both waves, dominant A wave• Unusable in high heart rates – merge of waves Normal values term > 0.7:1 (E:A) preterm > 0.6:1 The HIP Trial is funded by the European Commission within the 7th Framework Programme
  14. 14. LV systolic/diastolic function – MPI• MPI (= Tei index) - Myocardial performance index• From adjusted four chamber view – to get inflow and outflow• Combines the isovolumic relaxation and contraction times• Corrected for the ejection time The HIP Trial is funded by the European Commission within the 7th Framework Programme
  15. 15. LV systolic/diastolic function – MPI• Less usable in high heart rates ICT IRT• Influenced by preload and afterloadNormal values 0.25 – 0.38Poor systolic and/or diastolic function > 0.38 ET The HIP Trial is funded by the European Commission within the 7th Framework Programme
  16. 16. Tissue Doppler• Systolic and diastolic function• Measuring of myocardium movement in 4 chamber view• 2 variables peak velocities – S´, E´, A´ wave time intervals – IVC, IVR, TEI index (MPI index) S´ E´ A´ The HIP Trial is funded by the European Commission within the 7th Framework Programme
  17. 17. Tissue Doppler TISSUE DOPPLER ECHOCARDIOGRAPHY ASSESSMENT OF MYOCARDIAL FUNCTION IN EARLY NEONATAL PERIOD Sirc J, Semberova J, Stranak Z ECPM Paris 2013 The HIP Trial is funded by the European Commission within the 7th Framework Programme
  18. 18. Other modalities• Strain• Strain rate• Speckle trackingUsed in cardiology or for research The HIP Trial is funded by the European Commission within the 7th Framework Programme
  19. 19. Ductal shunting• Ductal diameter• Direction of blood flow, flow pattern – restricted, wide open• Assesment of hemodynamic significance 1. diastolic flow in abdominal aorta – steal or not 2. diastolic flow in left pulmonary artery (more than 0:2 m/s) 3. Left atrium to aortic root ratio - LA/Ao ratio (more than 1.5) 4. Flow pattern in pulmonary artery – turbulent flow 5. Left heart overload, mitral regurgitation The HIP Trial is funded by the European Commission within the 7th Framework Programme
  20. 20. Atrial shunting• High incidence• From subcostal four chamber view or short axis view The HIP Trial is funded by the European Commission within the 7th Framework Programme
  21. 21. Atrial shunting• Usually low velocity flow – colour Doppler, pulsed wave• Dominant shunting is left to right (up to 30% of right to left is normal)• Pure right to left shunt – congenital heart disease, pulmonary hypertension of the newborn (PPHN)• Large atrial shunting increases right ventricular output, decreases LA/Ao ratio The HIP Trial is funded by the European Commission within the 7th Framework Programme
  22. 22. Pulmonary artery pressure (PAP)1. From ductal shunting• Ductal flow reflects relation of systemic and pulmonary BP• Derived from colour Doppler, pulsed/continuous Doppler• Supra-systemic pressure when right-to-left flow ≥ 30% of cardiac cycle• bidirectional PDA flow is typical for first hours after birth, changes to L- R as PVR decreases The HIP Trial is funded by the European Commission within the 7th Framework Programme
  23. 23. Pulmonary artery pressure (PAP)2. From tricuspid regurgitation jet• Modified Bernoulli equation PAP = 4 x velocity2 + 5 (atrial pressure)• Most accurate of the indirect methods• 50% of a babies will not have tricuspidal regurgitation The HIP Trial is funded by the European Commission within the 7th Framework Programme
  24. 24. Assessment of systemic blood flow • Systemic blood flow ≠ cardiac output when atrial and ductal shunt is present Ductal shunt – increases left ventricular output Atrial shunt – increases right ventricular output Blood flow • VTI – velocity time integral, area under the systolic envelope • Cross sectional area • Heart rate • Infants weight The HIP Trial is funded by the European Commission within the 7th Framework Programme
  25. 25. Left ventricular output - LVO • Measuring of ascending aorta • Diameter – from long axis view, end-systolic internal (trailing edge to leading edge) diameter beyond the coronary sinus • Velocity – from apical or suprasternal view, average VTI from 5 cardiac cycles LVO = [p x (d2/4) x VTI x HR] / weight The HIP Trial is funded by the European Commission within the 7th Framework Programme
  26. 26. Left ventricular output - LVO Normal values 150-300 ml/kg/min The HIP Trial is funded by the European Commission within the 7th Framework Programme
  27. 27. Right ventricular output - RVO• RVO represent systemic blood flow more than LVO in preterm infants with PDA and FOA• Measuring in the main pulmonary artery• Diameter – low parasternal view, 2-D image at the insertion of pulm.valve leaflets in end-systole• Velocity – just beyond the valve leaflets RVO = [p x (d2/4) x VTI x HR] / weight The HIP Trial is funded by the European Commission within the 7th Framework Programme
  28. 28. Right ventricular output - RVO Normal values 150-300 ml/kg/min The HIP Trial is funded by the European Commission within the 7th Framework Programme
  29. 29. Superior vena cava flow – SVC flow• Partial cardiac input. Blood from upper body. 70-80% is from brain• Not confounded by shunts• Diameter – parasternal view before entry to right atrium Average value from maximal and minimal diameter• Velocity – subcostal view. Average from 10 cycles SVC = [p x (d2/4) x VTI x HR] / weight Normal values 40-120 ml/kg/min in VLBW The HIP Trial is funded by the European Commission within the 7th Framework Programme
  30. 30. Superior vena cava flow – SVC flow • Diameter from parasternal view – 2D or M-mode • Flow – subcostal view, pulsed Doppler The HIP Trial is funded by the European Commission within the 7th Framework Programme
  31. 31. SVC flow The HIP Trial is funded by the European Commission within the 7th Framework Programme
  32. 32. Central line placement• Appropriate placement – PICC line, UVC, UAC• Identification of complications – thrombosis, abnormal position, line fracture, embolization, vessel occlusion• Flush with normal saline may be helpful• Advantage – routine X-Ray after insertion is not necessary The HIP Trial is funded by the European Commission within the 7th Framework Programme
  33. 33. Another abnormal conditions• Suspected effusion pericardial - from 4 chamber view, long axis view pleural pneumopericard – unable to see the heart, echo shadow of air• Suspected thrombosis The HIP Trial is funded by the European Commission within the 7th Framework Programme
  34. 34. Thanks a lot for your attentionThe HIP Trial is funded by the European Commission within the 7th Framework Programme

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