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Functional ECHO.pptx
1. Functional ECHO in NICU
Dr Mohammed Zakiulla
Senior Resident
Dept of Neonatology
AIIMS BBSR
2. Case scenario..
• 4 days old male baby born to 30 yr old G2P1 mother
• At 28+3 wks GA by VD with a birth weight of 1025 gms
• CIAB with APGAR 7 and 7 at 1min and 5 min respect.
• Mother received one dose of antenatal steroids
• Antenatal scan normal.
• NICU Course
• Had respiratory distress at birth SAS score 6/10
• Started on CPAP, received surfactant at 20 min of life
• Started on caffeine for apnea of prematurity
3. Case scenario..
• Vitals
• On day 4 baby is on CPAP with 30% Fio2, 5 cm of H20
• HR: 168/min, pulses palpable in all 4 limbs
• BP: 52/32 mm hg
• RR: 62/min, SAS score: 1/8, Spo2 : 92%
• ESM in left upper parasternal area 3/6
• Chest: clear, Abdomen: Soft
4. Objectives
• Basics of echocardiography
• Where and how to use echocardiography
• How to diagnose and assess its hemodynamics effects on baby
• To assess the severity of the disease
• To monitor the progression of the disease and response to treatment
5. Functional ECHO…
Assessment of the sick
newborn infant
how they can be used in
common clinical scenarios
Patent ductus arteriosus
Pulmonary hypertension
Neonatal shock
Hemodynamic significance
Diagnosis and severity
Hemodynamics and cardiac function
6. Basic principle
• A mechanical, longitudinal wave produced
by passing electric current through a piezo
electric crystal
• Diagnostic ultrasound frequency range: 2.5–14 MHz
Higher frequency probes
(10–12 MHz)
Lower frequency probes
(2-7 MHz)
Poor penetration Better penetration
High resolution of structures closer to
the probe
Lower resolution
Ideal for superficial structures or small
infants
Ideal for deeper structures and better
for older children
7. Basics…
Pressure gradient = 4V2 (Modified Bernoulli
Equation)
Blood flow = Mean Velocity × Cross sectional
area
Beam of ultrasound hitting a moving
object will be reflected back with a:
Longer wavelength if the object is moving
away
Shorter wavelength if the object is moving
towards
The faster the object of interest is moving
the larger the Doppler shift
9. Basics…
Pulse wave doppler Continuous doppler
Velocity assessment at a
particular site trough
operator guided range
gate
Receives signal from
whole line of
transmission
Cannot assess velocities
more than 2 m/s
Can assess higher
velocities
21. Main pulmonary artery doppler
• MPA and LPA dopplers simply and accurately state whether
a duct is patent or not
• Cannot detect a PDA with a right-to-left shunt (because
there is no MPA turbulence)
No Duct Duct is patent
21
26. Case scenario
• Term infant, SVD, Thin MSL, Vigorous
at birth, APGAR 8, 9
• At 1 hr nurse noted baby to be dusky,
with rapid breathing
SpO2 55% in room air Temp 36.6 C
HR 146/min CRT 5-6 sec
Faint murmur MBP = 36 mmHg
Mod retractions RR 60/min
• SpO2 69% / 50% in FiO2 100
• Intubated [CMV 24/6, 50/m, Ti 0.35s]
FiO2 100%, SpO2 85 / 69%
• Art Gas: 7.01/79/35/16/-12
27. ECHO in PPHN
• Rule out structural heart disease
• Features of PPHN on ECHO:
• Pulmonary artery systolic pressure (PASP) can be reliably
estimated using echocardiography in the presence of
tricuspid regurgitation
• Size of RV,RA and PA
• Flattening or left deviation of the interventricular septum
in systole
• Measurement of the direction of ductal and foramen ovale
shunt
• Evaluate right and left ventricular function
28. Modified Bernoulli Equation
P= 4V2
• Pressure gradient
• V= peak velocity in m/s
• RV pressure- RA pressure= 4 x ( TR jet velocity)2
• Systolic Pulmonary pressure= RV pressure if no PS
• PA pressure= 4 x ( TR jet velocity)2 + RA pressure( 3-5 mm of Hg)
29. TR Jet..
Only 60% with
PPHN have TR
Agarwal et al, Early Human Dev. 2015
30. IVS Septal wall orientation
Short axis papillary muscle level cut
RV
LV
IVS
• Larger RV than LV
• IVS with convexity towards LV
LV Configuration Estimated RVP
O- Shaped LV < 50 % of LVP
D- Shaped LV 50 - 100 % of LVP
Crescent- Shaped LV > 100 % of LVP
Bendapudi et al, Pediatric Respiratory Reviews. 2016
LV
RV
36. TPV and TPV/RVET ratio
• TPV(Time to peak velocity) or PAAT (The pulmonary artery acceleration time) is
shortened in presence of pulmonary hypertension.
• PAAT to right ventricular ejection time (RVET) ratio derived from pulmonary
artery Doppler has been shown to negatively correlate with PAP in premature
infants TPV/RVET -
>0∙31 (Normal )
0∙23-0∙31( Mod PAH)
<0∙23( Sev PAH)
TPV or PAAT
< 90 ms s/o PAH
< 40 ms s/o Sev PAH
Levy et al, J. Am. Soc. Echocardiogr. 2016
37. Assessment of PPHN
Method Modality and sample
gate
Mild PAH Moderate PAH Severe PAH
Eyeballing for RA/RV
Dilatation/ hypertrophy
Apical 4 chamber No mild Severe(bowing)
PASP measurment Apical 4 chamber
(By TR jet )
IVS position Modified parasternal
SA
Flat (bowing in
RV in systole)
Flat (bowing in LV in
diastole)
Paradoxical motion
PA doppler (TPV/RVET) PWD in PA in
parasternal SA
≥0.31 0.23-0.31 ≤0.23
PDA doppler Ductal view L-R shunting Bidirectional
shunting, R-L >30%
of cardiac cycle
Bidirectional
shunting ,R-L>50% of
cardiac cycle or pure
R-L shunt
Doppler at PFO/ASD, RV and LV systolic function
38. Case scenario..
• 4 days old male baby born to 25 yr old primi mother with h/o leaking
for 24 hours
• At 38 wks GA by LSCS with a birth weight of 2.7 kg
• CIAB with APGAR 8 and 9 at 1min and 5 min respect.
• On day 3 of life
• Not feeding well
• Lethargic
O/E: Mottled, gasping, cyanosed with poor peripheral pulses
39. Case scenario..
• HR 100/min
• CFT > 5 sec
• BP: Not recordable
• SpO2: Preductal – 69%
Post ductal – Unrecordable
• Grade 2 murmur in left upper parasternal area
DDs
Sepsis
Cardiac causes- PDA dependent obstructive
lesions
Inborn error of metabolism
40. Cardiac function
• Rule out structural heart disease
• Left Ventricular function/ contractility:
• Eye balling (Hypercontractile, normal, mildly reduced or poor)
• Fractional Shortening
• Ejection Fraction: By simpsons method
• Rt Ventricular SF:
• Eye balling
• TAPSE
• Diastolic function:
E/A ratio at AV valve
• Preload assessment
42. Fractional shortening
• Normal range: Adult: 25-45%
Term: 25-41%
Preterm: 23-40%
• Affected by preload and after load
• Less reliable in first few days of life due to high RV pressures which
affects septal wall motion
Wyllei et al, ECHO for the neonatologist, 2000
43. Ventricular function
• LV output
• RV output
• SVC flow
• Normally CO=LVO=RVO
• LVO: normal value125-310ml/kg/min
• In presence of shunt in initial few days it may not be equal to
total cardiac output(LVO increases in presence of Lt to rt shunt)
Stroke volume = VTI X CSA (𝜋𝑟2)
LVOT/RVOT (ml/k/min)= SV x HR/ Body weight
44. Ejection fraction (Simson’s method)
1.EF by Simson’s method is
preferred over M-Mode
method
2.Normal values 35-65%
3. Over all less implication
as compared to FS in
neonate(Due to septal
hypertrophy)
45. SVC flow..
SVC diameter
Measured in modified right high parasternal view
with pointer towards 1 O’clock position
SVC VTI
Probe at subcoastal view pointer pointing at 3
O’clock position
• Normal value 40-160ml/kg/min
• <40ml/kg/min lower limit for systemic hypo perfusion
48. Trans mitral flow (E/A Ratio)
Normal E/A ratio in PT infants: 0.8:1 , FT infants: 1.1:1
If E/A ratio <0.6:1 in PT infants or <0.7:1 in term infants s/o diastolic failure
49. Preload assessment
• Collapsibility index = Max Diameter-Min
diameter/ Max diameter * 100 (value more
than 50% significant)
• Usued for non ventilated, spontaneously
breathing babies
• IVC diameter minimum in inspiration and maximum in expiration
• Diameter is measured within 1-2 cm of RA-IVC junction in subcoastal longitudinal
view either in 2D or M mode
• Average of 3-5 cardiac cycle taken for calculation
50. Estimation of CVP by assessing IVC diameter and its degree of respiratory variation
IVC IVC respiratory variation CVP Estimation
Diameter < 8 > 50 % Collapse Low (Fluid responsive)
Diameter < 8 < 50 % Collapse Low normal (can give fluids)
Diameter > 8 < 50 % Collapse Normal
Diameter > 8 No inspiratory collapse High (RV Failure, high pulmonary
pressures, hypervolemia)
51. Cardiac function
• Rule out structural heart disease
• Left Ventricular function/ contractility:
• Eye balling (Hypercontractile, normal, mildly reduced or poor)
• Fractional Shortening
• Ejection Fraction: By simpsons method
• Rt Ventricular SF:
• Eye balling
• TAPSE
• Diastolic function:
E/A ratio at AV valve
• SVC flow
• Preload assessment
52. OTHER USES
Condition Look for
Birth asphyxia LV Function
Congenital diaphragmatic hernia PPHN
Hydrops (Immune and Non immune) Pericardial and pleural effusion
Central lines UAC, UVC and PICC line position
53. Conclusion
• ECHO is a simple, bedside, non invasive test to assist in diagnosis and
management
• ECHO findings should be correlated clinically
• First ECHO in all the babies should be done thoroughly to rule out any
congenital heart disease
• Person should have adequate training in ECHO to avoid misuse
Editor's Notes
bedside use of cardiac ultrasound to assess myocardial function
evaluate response to treatment, allowing for rapid therapeutic adjustments
Good understanding of cardiac anatomy and the ability to obtain and understand 2-D images from each of the four main ultrasound windows
converting a 3-D structure into a series of 2-D cuts, if you understand the anatomy in spatial terms, the 2-D images will explain themselves
The hemodynamic significance of a PDA is not directly related to the size of the PDA but depends upon the magnitude of the shunt and the ability of premature myocardium to adapt to this left-to-right shunt
cardiac filling (preload), afterload (systemic or pulmonary vascular resistance), cardiac function and cardiac output Increased left ventricular end-diastolic dimension can be seen in volume loading conditions
Increased wall thickness can occur in pressure loading conditions
a fetal filling pattern (more dependent on atrial contraction) with a Doppler A more than E wave toward a more mature filling pattern with an E more than A wave
Diminished TAPSE (<4 mm) is predictive for the need of ECMO and death in infants with PPHN
cardiac filling (preload), afterload (systemic or pulmonary vascular resistance), cardiac function and cardiac output Increased left ventricular end-diastolic dimension can be seen in volume loading conditions
Increased wall thickness can occur in pressure loading conditions
a fetal filling pattern (more dependent on atrial contraction) with a Doppler A more than E wave toward a more mature filling pattern with an E more than A wave
