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. 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 Republic
The HIP Trial is funded by the European Commission within the 7th Framework Programme
2. Why should we be able to perform
and 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. Increasing use of TNE in NICU
Enough of theoretical informations
Need for good training !
www.neonatalechoskills.com
The HIP Trial is funded by the European Commission within the 7th Framework Programme
4. The HIP Trial is funded by the European Commission within the 7th Framework Programme
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. 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. 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 flow
Not all have to be part of standard TNE ECHO
The HIP Trial is funded by the European Commission within the 7th Framework Programme
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. 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. LV systolic function – mVCFs
mVCFs - Mean velocity of circumferential fiber shortening
mVCFs = mean [(LVEDD-LVESD)/LVEDD] x LVET
LVET – left ventricular ejection
time, from the closure to the
opening of the mitral valve
LVET
Less sensitive to dimensional
discrepancies
Normal values 1.5 ± 0.04
circumferences/s
The HIP Trial is funded by the European Commission within the 7th Framework Programme
11. LV systolic function – Ejection fraction
Ejection 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. Diastolic function – blood inflow
Ventricular filling velocities
From four chamber view
Ratio of E:A wave
E
A
The HIP Trial is funded by the European Commission within the 7th Framework Programme
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. 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. LV systolic/diastolic function – MPI
• Less usable in high heart
rates
ICT IRT
• Influenced by preload and
afterload
Normal values 0.25 – 0.38
Poor systolic and/or diastolic
function > 0.38
ET
The HIP Trial is funded by the European Commission within the 7th Framework Programme
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. 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. Other modalities
• Strain
• Strain rate
• Speckle tracking
Used in cardiology or for
research
The HIP Trial is funded by the European Commission within the 7th Framework Programme
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. SVC flow
The HIP Trial is funded by the European Commission within the 7th Framework Programme
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. 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. Thanks a lot for your attention
The HIP Trial is funded by the European Commission within the 7th Framework Programme