Evaluation of echocardiography on the neonatal unit

Impact of targeted neonatal echocardiography consultations for critically sick preterm neonates

RATIONALE

Preterm neonates needing rescue treatments with inotropes and/or inhaled nitric oxide (iNO) (acute critical illnesses, ACIs) in neonatal intensive care units (NICUs) are at high risk of mortality. While targeted neonatal echocardiography consultations (TNE) are increasingly used to guide management, its clinical impact need evaluation.

OBJECTIVES

To investigate clinical outcomes in relation to TNE utilisation during episodes of ACIs among preterm neonates.

METHODS

This retrospective cohort study, conducted at two tertiary NICUs over 10 years, included neonates<37 weeks gestational age (GA) who developed ACIs. Patients receiving TNE-guided care (TNE within 24 hours of treatment initiation) were compared with non-TNE management. Outcomes included predischarge mortality, episode-related mortality (<7 days) and a new diagnosis of intraventricular haemorrhage≥grade 3 (IVH-3). Inverse probability of treatment weighting (IPTW) using propensity score was used to account for confounders, including site, birth years and baseline illness severity.

MEASUREMENTS AND MAIN RESULTS

Of 622 included patients, 297 (48%) had TNE; median (IQR) GA at ACI was 26.4 (25.0-28.4) weeks. TNE group demonstrated higher baseline mean airway pressure, oxygen requirement and heart rate and frequently received both inotrope and iNO during ACI. IPTW analysis revealed TNE was associated with lower mortality (adjusted OR (95% CI) 0.75 (0.59 to 0.95)), episode-related mortality (0.54 (0.40 to 0.72)) and death or IVH-3 (0.78 (0.62 to 0.99)). TNE group received more varied inotropic agents, demonstrated earlier improvements in blood pressures, without increasing overall inotrpoic burden.

CONCLUSIONS

Among preterm neonates requiring rescue treatments with inotropes/iNO, TNE utilisation to guide clinical management may be associated with improved survival.

Educational Impact of Targeted Neonatal Echocardiography and Hemodynamics Programs on Neonatal-Perinatal Medicine Fellows

OBJECTIVE

Targeted neonatal echocardiography (TNE) is a real-time cardiac imaging modality used by a hemodynamics program to aid in diagnosis, treatment, and monitoring of neonatal cardiovascular illness. This study aimed to describe trainees' perspectives on existing hemodynamics education and perceived impacts of TNE and hemodynamics services on their education.

STUDY DESIGN

This was a mixed quantitative and qualitative study that surveyed neonatal-perinatal medicine (NPM) fellow trainees in Canada and the United States, at programs both with and without a hemodynamics service.

RESULTS

Ninety-two fellows responded to the survey, of whom 24 (26%) were enrolled in a program with an active hemodynamics service, 64 (70%) were training at a program without a hemodynamics service, and 4 (4%) were unsure. Trainees at centers with a hemodynamics service were more satisfied with their cardiovascular physiology education (91 vs. 69%, p = 0.040). Twenty-five percent of all trainees felt they do not have sufficient hemodynamics training to prepare them for independent practice. Areas of knowledge gaps were identified. Bedside teaching combined with didactic teaching was identified as useful means of teaching.

CONCLUSION

Most trainees believed that TNE and a hemodynamics service are valuable educational assets. Thoughtful curriculum design for real-time and consolidation learning, with specific emphasis on content gaps, should be considered.

KEY POINTS

· NPM Fellows perceive TNE & Neonatal Hemodynamics service as a valuable educational opportunity.. · Incorporation of TNE/Hemodynamics teaching into NPM curriculum can enrich trainee experience.. · Combining bedside and classroom teaching is key to successful cardiovascular training..

Targeted Neonatal Echocardiography in the Management of Neonatal Pulmonary Hypertension

Pulmonary hypertension (PH) in neonates, originating from a range of disease states with heterogeneous underlying pathophysiology, is associated with significant morbidity and mortality. Although the final common pathway is a state of high right ventricular afterload leading to compromised cardiac output, multiple hemodynamic phenotypes exist in acute and chronic PH, for which cardiorespiratory treatment strategies differ. Comprehensive appraisal of pulmonary pressure, pulmonary vascular resistance, cardiac function, pulmonary and systemic blood flow, and extrapulmonary shunts facilitates delivery of individualized cardiovascular therapies in affected newborns.

Echocardiographic Evaluations in Sick Neonates in Neonatal Intensive Care Unit: A Clinical Study

Introduction Echocardiography is pivotal in neonatal care by providing valuable insights into cardiac function, anatomy, and hemodynamics. The ability of echocardiography to guide clinical decision-making is evident in its capacity to influence and change management strategies. Therefore, the goal of the current study was to know the prevalence of heart disease and the association between echocardiographic indications and neonatal outcomes and interventions. Materials and method This prospective cross-sectional study was conducted in the Neonatology Department, Datta Meghe Institute of Higher Education and Research, Sawangi, Wardha. Ill neonates admitted to the neonatal intensive care unit (NICU) were selected in a randomized manner, and echocardiography was performed. The decision was made on the indications for echocardiography, the echocardiographic findings, and any modifications to the clinical care. Mean differences were compared using an unpaired Student's t-test. A significant level is defined as a p-value of less than 0.05. Results Of all the ill neonates, heart disease was present in 60 (52.6%) neonates. The most frequent indication for echocardiography was respiratory distress in 39 (34.21%). In neonates with heart disease, 27(45%) had acyanotic heart disease, nine (15%) had cyanotic heart disease, and 24(40%) had miscellaneous heart disease. The mean appearance, pulse, grimace, activity, and respiration (APGAR) score at five minutes in neonates without heart disease was 9.05, and for those with heart disease, it was 8.95, with no statistically significant difference. Out of 114 neonates, the mean NICU stay of neonates without heart disease was 6.59 days, and those with heart disease was 9.95 days with a p-value of 0.0001, hence showing statistically significant differences. Out of all the 114 neonates, 57.89% underwent no intervention, 36.85% underwent medical intervention, and 5.26% underwent surgical interventions. Out of 114 neonates, 101 neonates were discharged, and 13 neonates were dead. Out of the 54 neonates with no cardiac abnormality, 50 (92.59%) were discharged, and four (7.41%) neonates were dead. Out of the 60 neonates with cardiac abnormality, 51 (85%) were discharged, and nine (15%) were dead, with a p-value of 0.203, showing no statistical significance between cardiac abnormality and neonatal outcome. Conclusion Our study emphasizes the pivotal role of echocardiography in the NICU for evaluating ill neonates. The findings underline the significance of early detection and precise diagnostic insights provided by echocardiography, contributing to tailored management strategies. The study highlights the transformative impact of echocardiography on clinical decision-making, facilitating timely interventions and improving overall neonatal care. Echocardiography is essential to improving outcomes for these susceptible newborns in the NICU as we continue to expand our knowledge of neonatal heart health.

Echocardiography performed by the neonatologist: the impact on the clinical management

BACKGROUND

The aim of this study was to assess whether neonatologist-performed echocardiography (NPE) changed the previously planned hemodynamic approach in critically ill newborn infants.

METHODS

This prospective cross-sectional study included the first NPE of 199 neonates. Before the exam, the clinical team was asked about the planned hemodynamic approach and the answer was classified as an intention to change or not to change the therapy. After being informed about the NPE results, the clinical management was grouped as performed as previously planned (maintained) or modified.

RESULTS

NPE modified the planned pre-exam approach in 80 cases (40.2%; 95% CI: 33.3-47.4%), and variables associated with an increased chance of this modification were exams to assess pulmonary hemodynamics (prevalent ratio (PR): 1.75; 95% CI: 1.02-3.00) and to assess systemic flow (PR: 1.68; 95% CI: 1.06-2.68) in relation to those requested for patent ductus arteriosus, pre-exam intention of changing the prescribed management (PR: 2.16; 95% CI: 1.50-3.11), use of catecholamines (PR: 1.68; 95% CI: 1.24-2.28) and birthweight (per kg) (PR: 0.81; 95% CI: 0.68-0.98).

CONCLUSION

The NPE was an important tool to direct hemodynamic management in a different approach from the previous intention of the clinical team, mainly for critically ill neonates.

IMPACT

This study shows that neonatologist-performed echocardiography guides the therapeutic planning in the NICU, mainly in the more unstable newborns, with lower birthweight and receiving catecholamines. Exams requested with the intention of modifying the current approach were more likely to change the management in a different way than planned pre-exam.

Implementing a successful targeted neonatal echocardiography service and a training program: The ten stages of change

Implementing any new service or program in the health care system is not always straightforward; a multi-stage implementation process is required most of the time. With the advancements in neonatal care and increased survival rates, there has been an increased need for ongoing assessment of hemodynamic stability. At the Children's Hospital of Eastern Ontario and the Ottawa Hospital Neonatal Intensive Care Units (NICUs), University of Ottawa, Canada, Targeted Neonatal Echocardiography service (TnEcho) was successfully established and has led to improvement in the hemodynamic evaluation and decision making in neonatal intensive care. In this article, we describe our experience establishing this program and the process of ensuring its success. This review article highlights the ten steps taken by multiple stakeholders to achieve this goal; this may help other centres implement a similar program.

Utilisation of neonatologist-performed echocardiography in shock among neonatologists with interest in haemodynamic: International survey

AIM

Neonatologist-performed echocardiography (NPE) is recommended during shock. We aimed to assess factors associated with NPE utilisation in the NICU and physiological information obtained during management of shock.

METHODS

An Internet-based survey, sent to neonatologists with interest in haemodynamics, studying NPE utilisation in shock management through a real clinical case and correlating its use with responders' training and NICU settings.

RESULTS

Fifty-nine completed surveys were received from the United Kingdom: 38%, Western Europe: 32%, Canada: 23% and other countries: 7%. Whilst managing the given clinical case, 90% of responders expected first NPE to exclude congenital heart disease-although only 61% could exclude it confidently (71% in trained clinicians vs. 29% without training; p < 0.01). NPE utilisation prior to initiate treatment was significantly correlated with mean number of neonatologists able to perform NPE in the NICU (4.9 vs. 2.9 neonatologists per unit; p = 0.02). Similarly, for ongoing therapeutic guidance, NPE was more used in trained clinicians (p < 0.01). 88% and 81% of responders studied a combination of multiple parameters to assess filling and systemic flow, respectively.

CONCLUSION

Neonatologist-performed echocardiography during shock management differs with previous training and number of doctors able to perform echocardiography in NICU. This study highlighted the need for enhanced training implementation.

The impact of neonatologist performed echocardiography in an Italian neonatal unit

BACKGROUND

The main goal of neonatologist performed echocardiography is to timely assess hemodynamic changes in order to properly manage unsteady neonates. Detailed structural heart assessment remains the domain of pediatric cardiologists. Nonetheless, many neonatologists take on an additional role in diagnosis of congenital heart defects, mostly compelled by the lack of in-house pediatric cardiology services. The experience of neonatologist performed echocardiography in an Italian neonatal unit was reported and the risk benefit profile of this practice was discussed.

MATERIAL AND METHODS

We retrospectively reviewed the echocardiograms undertaken by the neonatologist on infants admitted to the neonatal unit and postnatal ward of the Hospital San Pio in Benevento, over a 2-year period. Details of scans and concordance between neonatologist and cardiologist were analyzed.

RESULTS

A total of 160 echocardiographic studies were done by the neonatologist on 136 infants. The ECG was requested in a minority of infants. The most common reason for performing the echocardiogram was admission to the neonatal care unit. Around half of the echocardiograms were normal. The remaining scans resulted in functional and structural abnormalities, transitional changes, and doubtful findings. Cardiac anomalies were significantly more likely found in cases of echocardiograms performed for fetal indications. Only 28 patients were eventually referred to the cardiology services. The inter-rater agreement was satisfactory.

CONCLUSIONS

The hemodynamic assessment of sick infants, as well as triaging and referral of neonates with structural heart diseases are valuable advantages of the echocardiography run by neonatologists.Collaboration with pediatric cardiologists and robust training and accreditation programs are essential to ensure safety and quality service.

Birth prevalence and late diagnosis of critical congenital heart disease: A population-based study from a middle-income country

Aims:

There are limited data regarding critical congenital heart disease (CCHD) from middle-income countries (MIC). This study aims to determine the birth prevalence, rate of late diagnosis, and influence of timing of diagnosis on the outcome of CCHD.

Setting and Design:

Retrospective observational cohort study in the State of Johor, Malaysia.

Subjects and Methods:

All infants born between January 2006 and December 2015 with a diagnosis of CCHD, defined as infants with duct-dependent lesions or cyanotic heart disease who may die without early intervention. The late diagnosis was defined as a diagnosis of CCHD after 3 days of age.

Results:

Congenital heart disease was diagnosed in 3557 of 531,904 live-born infants and were critical in 668 (18.7%). Of 668, 347 (52%) had duct-dependent pulmonary circulation. The birth prevalence of CCHD was 1.26 (95% confidence interval: 1.16–1.35) per 1000 live births, with no significant increase over time. The median age of diagnosis was 4 days (Q1 1, Q3 26), with 61 (9.1%) detected prenatally, and 342 (51.2%) detected late. The highest rate of late diagnosis was observed in coarctation of the aorta with a rate of 74%. Trend analysis shows a statistically significant reduction of late diagnosis and a significant increase in prenatal detection. However, Cox regression analysis shows the timing of diagnosis does not affect the outcome of CCHD.

Conclusions:

Due to limited resources in the MIC, the late diagnosis of CCHD is high but does not affect the outcome. Nevertheless, the timing of diagnosis has improved over time.

Functional echocardiography training in the neonatal intensive care unit: comparing measurements and results with the pediatric cardiologist

OBJECTIVES

Functional echocardiography is a valuable tool in the neonatal intensive care unit, but training programs are not standardized. The aim was to report an functional echocardiography training program for neonatologists and to describe the agreement of their measurements with the pediatric cardiologist.

METHODS

Functional echocardiography training lasted 32h. After training program, the neonatologists performed functional echocardiography in the neonatal intensive care unit and were required to measure left cardiac chambers dimensions, left ventricle systolic function, right and left ventricular output, ductus arteriosus diameter, and flow pattern. Images were recorded by the equipment and reviewed offline by the pediatric cardiologist. The Bland-Altman test was used for quantitative variables and the kappa test, for qualitative variables.

RESULTS

Twenty-two trained neonatologists performed 100 functional echocardiography exams. Ductus arteriosus identification and flow pattern had substantial agreement (kappa=0.91 and 0.88, respectively), as well as its diameter (mean difference=0.04mm). The mean difference for the aortic root was -1.2mm; left atrium, 0.60mm; left ventricle diastolic diameter, -0.90mm; left ventricle systolic diameter, -0.30mm. Shortening fraction and ejection fraction correlated well with broad limits of agreement, -2.96% (14.88; -20.82%) and --3.43% (15.54; -22.40%), respectively. Right and left ventricular output had broad limits of agreement, 16.69mL/kg/min (222.76; -189.37) and 23.57mL/kg/min (157.88; -110), respectively. There was good agreement between interpretations of normal or low cardiac output (76.7% for right ventricular output; 75.7% for left ventricular output).

CONCLUSION

This functional echocardiography training program enabled neonatologists to obtain adequate skills in performing the images, obtaining good agreement with the cardiologist in simple hemodynamic measurements and ductus arteriosus evaluation.

The Future of Cardiac Ultrasound in the Neonatal Intensive Care Unit

Cardiac ultrasound is increasingly used to guide hemodynamic decision making in the neonatal intensive care unit (NICU). This article focuses on likely future progress in training, accreditation, digital connectivity, miniaturization, and modality development. Many documents have been published internationally to guide cardiac ultrasound training, accreditation, and implementation in the NICU, but challenges remain in providing assessments of hemodynamic status without risking missed structural diagnoses. Advances in simulation training and digital connectivity provide an opportunity to standardize approaches across institutions and continents. Development of machine learning and ultrasound modalities in turn provide huge scope for improving robustness and completeness of assessment.

Point of care ultrasound in the neonatal unit: Applications, training and accreditation

Point-of-care, or clinician-performed ultrasound (CPU), is increasingly utilised within neonatology as a valuable adjunct to clinical examination. The ability to perform and interpret rapid, real-time, serial assessment of patient physiology at the bedside has seen the potential uses of CPU expand, with an evolving list of clinical and research applications. Benefits of functional assessment of neonatal haemodynamics in particular have been described across a range of gestational ages and disease states. Devising suitable curricula for trainees and ensuring robust processes for the training and credentialing of clinicians performing CPU is essential. Challenges to universal implementation of CPU in the neonatal intensive care setting exist, and regional differences in training and accreditation are well described. Appropriate integration into clinical decision-making and ensuring competency-based locally appropriate training programs, which build on an expanding evidence base, are key priorities in ensuring newborns receive optimal benefit from the modality.

Neonatologist performed echocardiography (NPE) in Italian neonatal intensive care units: a national survey

Background

Neonatologist performed echocardiography (NPE) has increasingly been used to assess the hemodynamic status in neonates. Aim of this survey was to investigate the utilization of NPE in Italian neonatal intensive care units (NICUs).

Methods

We conducted an on-line survey from June to September 2017. A questionnaire was developed by the Italian neonatal cardiology study group and was sent to each Italian NICU.

Results

The response rate was 77%. In 94% of Italian NICUs functional echocardiography was used by neonatologists, cardiologists or both (57, 15 and 28% respectively). All the respondents used NPE in neonates with patent ductus arteriosus and persistent pulmonary hypertension, 93% in neonates with hypotension or shock, 85% in neonates with perinatal asphyxia, 78% in suspicion of cardiac tamponade, and 73% for line positioning.

In 30% of center, there was no NPE protocol. Structural echocardiography in stable and critically ill neonates was performed exclusively by neonatologists in 46 and 36% of center respectively.

Conclusions

NPE is widely used in Italian NICUs by neonatologists. Structural echocardiography is frequently performed by neonatologists. Institutional protocols for NPE are lacking. There is an urgent need of a formal training process and accreditation to standardize the use of NPE.

Echocardiographic Evaluation in Neonates with Heart Murmurs

Auscultation of the heart is one of the most important tools of physical examination in neonates, which is very helpful in the diagnosis or rejection of congenital heart diseases (CHDs). The aim of this study is to investigate the causes of heart murmur in neonates hospitalized in neonatal unit in Imam Reza Hospital, Kermanshah, Iran. This cross-sectional study was conducted within the period of 18 months on neonates hospitalized in neonatal unit whose heart murmur, diagnosed through examination, and echocardiography was conducted to investigate the existence of CHD. In 62.1% of the cases, murmuring was auscultated within the first week after birth. Among 172 neonates with heart murmur, 25 subjects (14.5%) had normal echocardiogram, and others had abnormal echocardiogram in which ventricular septal defect (31.4%) was the most common CHD. Patent ductus arteriosus (23.3%) was the second common CHD found. Other defects were atrial septal defect, persistent foramen ovale, pulmonary stenosis, and tricuspid regurgitation. Among the neonates with CHD, 55 subjects were females and 92 cases were males. There was CHD history in previous siblings in 10 cases. In 73 neonates with CHD, the mother had not taken folic acid in the first trimester of pregnancy. A total of 14.5% of the hospitalized neonates suffered from innocent murmur, and the rest with heart murmur had abnormal echocardiography and suffered from CHD (85.5%). Heart murmur in neonates could be a symptom of CHD, and timely echocardiography is very important in diagnosing the type of disease.

Four-Dimensional Ultrasound for Evaluating Newborn Cardiac Output: A Pilot Study of Healthy Infants

BACKGROUND

There is currently no reliable non-invasive method of measuring cardiac output in neonatal intensive care. Spatiotemporal image correlation (STIC) is a novel four-dimensional (4D) ultrasound technique that was developed to assess the foetal heart, and it may be a useful way to assess neonatal haemodynamics.

OBJECTIVE

This study aimed to evaluate the feasibility and reproducibility of determining neonatal cardiac output using STIC ultrasound in newborn infants.

DESIGN

Infants were recruited opportunistically from a neonatal intensive care unit and then examined by 2 independent observers. STIC was used to obtain images of the heart. End-diastolic and end-systolic ventricular volumes were measured using virtual organ computer-aided analysis (VOCAL) and used to calculate cardiac output. Reproducibility was assessed with intraclass correlation coefficients (ICC) and agreement with Bland-Altman analysis.

RESULTS

Twenty-four clinically stable infants of 34-43 weeks corrected gestational age were assessed. Both observers successfully acquired 4D STIC volumes in all infants. Left ventricular output showed good reproducibility, with an intra-observer ICC of 0.86 (0.69-0.94) and inter-observer ICC of 0.87 (0.70-0.95). Right ventricular output also showed good reproducibility, with an intra-observer ICC of 0.88 (0.70-95) and inter-observer ICC of 0.84 (0.63-0.93).

CONCLUSIONS

Determining cardiac output using 4D STIC ultrasound is feasible and reproducible in well newborn infants. With further evaluation, this technique may provide valuable information about haemodynamic status in newborn infants requiring intensive care.

Targeted neonatal echocardiography (TNE) consult service in a large tertiary perinatal center in Canada

OBJECTIVE

To describe the utilization and study the factors associated with the impact on clinical management of a new TNE consultation service in a perinatal center.

METHODS

This retrospective cohort study included all neonates who underwent TNE consultation at the neonatal unit of Mount Sinai Hospital in Toronto, Canada (November 2011 and July 2015). The consults that had "impact" were defined as those that led to a TNE suggested change in the clinical management within 6 h of its recommendation. Logistic regression analysis was performed to identify factors associated with a change in clinical management following the consultation.

RESULTS

A total of 553 consults were performed for 268 infants (gestational age: 27 ± 4 weeks and age at initial consult: 16 (5, 34) days). Patent ductus arteriosus (PDA, 61%), suspected pulmonary hypertension (PH, 27%), and systemic hypotension (SH, 9%) were the common indications. The average consultations increased from 9 in 2012-2013 to 20 per month in 2014-2015. Forty eight percent of consults had an impact on clinical management (PDA scans: 38%, PH: 58%, and SH: 81%, p < 0.01 between all). Male gender (adjusted odds ratio (95% confidence interval): 1.9 (1.0, 3.5); p = 0.04), mechanical ventilation (2.43 (1.2, 4.9); p = 0.01), and scans for PH (7.1 (2.2, 23.2); p < 0.01) and SH (2.6 (1.1, 6.5); p = 0.03) were independently associated with the impact on clinical management. TNE consults identified all incidental cases of major structural defects (n = 4), and six out of ten minor diagnoses.

CONCLUSIONS

TNE consult service demonstrated an increasing utilization and a significant impact on clinical management over time especially for non-PDA indications and in situations of high-illness severity. Although, all major cardiac defects were identified, some minor congenital defects were missed by TNEs.

Neonatologist-performed point-of-care functional echocardiography in the neonatal intensive care unit

Functional echocardiography (fECHO) refers to a bedside, limited assessment of the ductus arteriosus, myocardial performance and pulmonary or systemic haemodynamics that is brief in nature and addresses a specific clinical question or management dilemma. This point-of-care ultrasonography is increasingly used internationally and locally among neonatal units to assist with management of neonatal haemodynamic conditions. This article intends to explain the modality, its indications, interpretation and implications for management, and how it impacts long-term outcomes, particularly in chronic lung disease for premature infants born before 32 weeks of gestation. This review will focus on fECHO as a clinical tool to assess the haemodynamics of sick neonates and how it assists in the logical choice for cardiovascular support. Training should be approached as a combined effort between the paediatric cardiology service and neonatology service.

Cardiac Function Assessments in Left Bochdalek's Hernia: Clinical Relevance

The objectives of this study were to characterize peri-operative echocardiographic (ECHO) assessments of right ventricular (RV) function and pulmonary hypertension (PH) and ascertain correlation with clinical outcomes in infants with left Bochdalek's hernia (LBH). This retrospective study in a quaternary neonatal intensive care unit involved electronic database search for infants with LBH during January 2009 to July 2017. Demographics, outcomes, and ECHO parameters were accessed from archived databases. Thirty-one infants with mean gestational age and birthweight (BW) 38.4 ± 1.4 weeks and 3079 ± 450 g were included. Postnatal age at surgery was 4.3 ± 2 days. Two infants died before surgery (none after surgery). The survival rate in this cohort of late preterm and term infants with LBH not accompanied by congenital heart disease was 29/31 (93.5%). PH was noted in 28 (90%). Significant changes in biventricular function and pulmonary vascular haemodynamics were noted when reassessed after surgery [RV area change (%), 28 ± 3 vs. 34 ± 4, p = 0.007 and pulmonary artery capacitance (PAC) (ml³ × mmHg^-1), 0.05 ± 0.03 vs. 0.09 ± 0.05, p = 0.02]. The median duration of all respiratory support in those who were operated was 14.7 days (8.5, 25). Significant correlations were noted between pre-operative ECHO assessments and the duration of respiratory support (tricuspid regurgitation, r = 0.63, p = 0.0001 and PAC, r = - 0.52, p = 0.004). Peri-operative functional ECHO provided information about the evolution of cardiac function in infants with LBH.

Education, training, and accreditation of Neonatologist Performed Echocardiography in Europe-framework for practice

There is a growing interest worldwide in using echocardiography in the neonatal unit to act as a complement to the clinical assessment of the hemodynamic status of premature and term infants. However, there is a wide variation in how this tool is implemented across many jurisdictions, the level of expertise, including the oversight of this practice. Over the last 5 years, three major expert consensus statements have been published to provide guidance to neonatologists performing echocardiography, with all recommending a structured training program and clinical governance system for quality assurance. Neonatal practice in Europe is very heterogeneous and the proximity of neonatal units to pediatric cardiology centers varies significantly. Currently, there is no overarching governance structure for training and accreditation in Europe. In this paper, we provide a brief description of the current training recommendations across several jurisdictions including Europe, North America, and Australia and describe the steps required to achieve a sustainable governance structure with the responsibility to provide accreditation to neonatologist performed echocardiography in Europe.

How to assess hemodynamic status in very preterm newborns in the first week of life?

BACKGROUND

Assessing hemodynamic status in preterm newborns is an essential task, as many studies have shown increased morbidity when hemodynamic parameters are abnormal. Although oscillometric monitoring of arterial blood pressure (BP) is widely used due to its simplicity and lack of side effects, these values are not always correlated with microcirculation and oxygen delivery.

OBJECTIVES

This review focuses on different tools for the assessment of hemodynamic status in preterm newborns. These include the measurement of clinical (BP, capillary refill time and urinary output (UO)) or biological parameters (lactate analysis), functional echocardiography, and near-infrared spectroscopy (NIRS). We describe the concepts and techniques involved in these tools in detail, and examine the interest and limitations of each type of assessment.

CONCLUSIONS

This review highlights the complementarities between the different parameters used to assess hemodynamic status in preterm newborns during the first week of life. The analysis of arterial BP measured by oscillometric monitoring must take into account other clinical data, in particular capillary refill time and UO, and biological data such as lactate levels. Echocardiography improves noninvasive hemodynamic management in newborns but requires specific training. In contrast, NIRS may be useful in monitoring the clinical course of infants at risk of, or presenting with, hypotension. It holds the potential for early and noninvasive identification of silent hypoperfusion in critically ill preterm infants. However, more data are needed to confirm the usefulness of this promising tool in significantly changing the outcome of these infants.

Extensive use of vasodilator agents and functional echocardiography to monitor extremely-low-birth-weight infants in Japan

National surveys were conducted in Japan to assess the current practices for circulatory management of extremely-low-birth-weight infants (ELBWIs) in acute phases. Approximately 80 and 100 institutions were surveyed in 2006 and 2011, respectively. Echocardiography was identified as an important diagnostic tool at 95% of the surveyed institutions. Furthermore, 74% of the institutions survey in 2011 used vasodilator agents. In 2011, the mean velocity of circumferential fiber shortening (mVcfc) and left ventricular end-systolic wall stress (ESWS) were used by 60% of the surveyed institutions to evaluate the relationship between afterload of the left ventricle and left ventricular contractility. Overall, the data collected from these national surveys clarified the current practices for circulatory management of ELBWIs in Japan, particularly the use of echocardiography and cardiovascular agents, including catecholamines and vasodilators.

Neonatal cardiac ultrasound: How accurate are we?

Introduction

To assess the accuracy of neonatal clinician-performed cardiac ultrasound (CPU) in detection of congenital heart disease (CHD) in newborn infants with no antenatally suspected cardiac abnormality.

Methods

We reviewed records of all infants diagnosed with CHD, identified all new cases of CHD detected by CPU and classified them as 'severe' or 'other'; the 'severe CHD' was further classified as 'critical' or 'non-critical CHD'. We compared the CPU diagnosis to the final diagnosis as per paediatric cardiologist echocardiography.

Results

A total of 357 infants identified to have any form of CHD; 50 newly diagnosed by neonatal CPU: 21 'severe' and 29 'other' CHD. The neonatologist CPU had a high concordance rate with the final diagnosis. There were three incorrect diagnoses identified by CPU.

Conclusion

This audit demonstrates high accuracy, in our unit, of neonatal CPU in identifying new cases of CHD not suspected antenatally. A neonatal CPU could enhance the pickup rate and, with appropriate referral to a paediatric cardiologist, improve the clinical care of infants born with CHD.

Use of Targeted Neonatal Echocardiography and Focused Cardiac Sonography in Tertiary Neonatal Intensive Care Units: Time to Embrace It?

Focused cardiac sonography and targeted neonatal echocardiography refer to goal-directed cardiac imaging using ultrasound, typically by noncardiologic specialists. Although the former consists of a rapid qualitative assessment of cardiac function, which is usually performed by acute care practitioners, the latter refers to detailed functional echocardiography to obtain quantitative and qualitative indexes of pulmonary and systemic hemodynamics in sick neonates and is typically performed by neonatologists. Although the use of these modalities is increasing, they still remain unavailable in most North American centers providing acute care to neonates, partly because of limited data regarding their direct impact on patient care. Here we present a series of 5 cases from a large perinatal unit in which immediate availability of relevant expertise led to important and arguably life-saving clinical interventions. In 4 of these cases, focused cardiac sonography was sufficient to make the diagnosis, whereas in 1 case, clinical integration of detailed systemic hemodynamics measured on target neonatal echocardiography was required.

Expert consensus statement 'Neonatologist-performed Echocardiography (NoPE)'-training and accreditation in UK

Targeted echocardiographic assessments of haemodynamic status are increasingly utilised in many settings. Application in the neonatal intensive care units (NICU) is increasingly demanded but challenging given the risk of underlying structural lesions. This statement follows discussions in UK led by the Neonatologists with an Interest in Cardiology and Haemodynamics (NICHe) group in collaboration with the British Congenital Cardiac Association (BCCA) and the Paediatricians with Expertise in Cardiology Special Interest Group (PECSIG). Clear consensus was agreed on multiple aspects of best practice for neonatologist-performed echocardiogram (NoPE)-rigorous attention to infection control and cardiorespiratory/thermal stability, early referral to paediatric cardiology with suspicion of structural disease, reporting on standardised templates, reliable image storage, regular skills maintenance, collaboration with a designated paediatric cardiologist, and regular scan audit/review. It was agreed that NoPE assessments should confidently exclude structural lesions at first scan. Practitioners would be expected to screen and establish gross normality of structure at first scan and obtain confirmation from paediatric cardiologist if required, and subsequently, functional echocardiography can be performed for haemodynamic assessment to guide management of newborn babies. To achieve training, NICHe group suggested that mandatory placements could be undertaken during core registrar training or neonatal subspecialty grid training with a paediatric cardiology placement for 6 months and a neonatology placement for a minimum of 6 months. In the future, we hope to define a precise curriculum for assessments. Technological advances may provide solutions-improvements in telemedicine may have neonatologists assessing haemodynamic status with paediatric cardiologists excluding structural lesions and neonatal echocardiography simulators could increase exposure to multiple pathologies and allow limitless practice in image acquisition.

CONCLUSION

We propose developing training places in specialist paediatric cardiology centres and neonatal units to facilitate training and suggest all UK practitioners performing neonatologist-performed echocardiogram adopt this current best practice statement.

WHAT IS KNOWN

Neonatologist-performed echocardiogram (NoPE) also known as targeted neonatal echocardiography (TNE) or functional ECHO is increasingly recognised and utilised in care of sick newborn and premature babies. There are differences in training for echocardiography across continents and formal accreditation processes are lacking.

WHAT IS NEW

This is the first document of consensus best practice statement for training of neonatologists in neonatologist-performed echocardiogram (NoPE), jointly drafted by Neonatologists with interest in cardiology & haemodynamics (NICHe), paediatric cardiology and paediatricians with expertise in cardiology interest groups in UK. Key elements of a code of practice for neonatologist-performed echocardiogram are suggested.

Functional Neonatal Echocardiography: Indian Experience

INTRODUCTION

Functional echocardiography, as opposed to echocardiography as performed by the cardiologist, is the bedside utilization of cardiac ultrasound to take after functional and haemodynamic changes longitudinally. Information reflecting cardiovascular capacity and systemic and pulmonary blood flow in sick preterm and term neonates can be observed utilizing this strategy. Information is lacking on its use in neonatal units in India.

AIM

To characterize the impact of Functional neonatal echocardiography (FnECHO) programme on decision making in a tertiary care centre in India by evaluating its frequency of use, patient characteristics, and indications.

MATERIALS AND METHODS

Prospective observational study of neonates in a tertiary Neonatal Intensive Care Unit (NICU) in Pune (India) from February 2014 to January 2015. All the neonates undergoing FnECHO during this 12 month period based on clinical findings were included in the study. Data extracted from the review of the clinical notes included gestational age, birth-weight, mode of delivery, Apgar scores, details of respiratory and cardiovascular support, timing of FnECHO and any other clinical diagnosis. The findings of echocardiography were recorded and correlated with the clinical and other laboratory or X-ray findings. If these findings indicated a change in management, it was instituted.

RESULTS

A total of 348 echocardiographic studies were performed in 187 neonates (mean 1.86; SD 2.02). The most frequent indication was Patent Ductus Arteriosus (PDA) assessment (n= 174, 50%), followed by haemodynamic instability (n=43, 12.36%). The results of FnECHO modified treatment in 148 cases (42.50%) in the form of addition and/or change in the treatment or avoidance of unnecessary intervention.

CONCLUSION

FnECHO is frequently used in the NICU setting and may be a useful tool to guide treatment. PDA assessment and haemodynamic instability are the most frequent indications. To validate its usefulness, well co-ordinated large prospective studies are needed.

Utility of Targeted Neonatal Echocardiography in the Management of Neonatal Illness

OBJECTIVES

To describe the impact of targeted neonatal echocardiography on management of neonatal illness in a tertiary perinatal center neonatal intensive care unit (NICU).

METHODS

We conducted a retrospective analysis of consecutive targeted neonatal echocardiographic studies that were performed over an 18-month period in a regional perinatal center NICU in Canada. All studies were performed with a cardiovascular ultrasound machine and transducer and read on a workstation with storage and analysis software. Reporting was done on a standardized document, and any management change resulting from targeted neonatal echocardiography was documented.

RESULTS

A total of 303 consecutive targeted neonatal echocardiographic studies were performed on 129 neonates. The mean gestational age ± SD was 27.8 ± 4.3 weeks (range, 23-41 weeks), and the mean birth weight ± SD was 1196 ± 197 g (range, 490- 4500 g). The median number of studies per neonate was 2 (range, 1-8), with most repeated studies for a patent ductus arteriosus (PDA). The most common indication for echocardiography was assessment of a PDA (52.1%), followed by early global hemodynamic assessment of very low birth weight (16.2%) and pulmonary hypertension (12.2%). Of the 303 studies, 126 (41.5%) resulted in management changes. The contribution to management was significantly related to the timing of echocardiography. Around half of the echocardiographic examinations during first the week of life resulted in management changes, compared to 22% of studies after 1 week of age (P = .002). Patent ductus arteriosus management accounted for almost half of the interventions.

CONCLUSIONS

Targeted neonatal echocardiography is a valuable tool in the NICU and can contribute substantially to hemodynamic management in the first week of life, PDA management in the first 2 weeks of life, and cases of hypotension or shock at any time during the hospital stay.

Cardiac sonography by the neonatologist: clinical usefulness and educational perspective

OBJECTIVES

Clinicians are increasingly using cardiac sonography in clinical practice. The objectives of this study were to assess the current state of clinician-performed cardiac sonography practice in the Australia-New Zealand region, with particular reference to the scope of clinical practice and type of training offered.

METHODS

A prospective cross-sectional survey was conducted, and an electronic Web-based questionnaire was e-mailed to neonatologists and advanced trainees in the region. Information was collected on respondents (demographics, clinician-performed cardiac sonography experience, and opinions), equipment use, and training frameworks. Main outcome measures ascertained were clinical use and educational perspectives.

RESULTS

The overall survey response rate was 64% (113 of 176). Eighty-five percent of respondents reported that clinician-performed cardiac sonography was performed in their units, most commonly to use the physiologic information obtained in conjunction with clinical information to refine decision making. The most common clinical indication was evaluation of a hemodynamically relevant ductus arteriosus. A dedicated echocardiographic machine was available to 80% of respondents. Most respondents reported "self-directed" learning as the most common method of training. More than 85% of respondents reported having access to either on-site or off-site pediatric cardiology services.

CONCLUSIONS

Widespread availability and use of clinician-performed cardiac sonography in units across the Australia-New Zealand region was noted. The need for a structured training program was identified.

Transthoracic echocardiography in pediatric intensive care: impact on medical and surgical management

OBJECTIVES

Although transthoracic echocardiography is commonly performed in the PICU, its utility is not specifically known. The purpose of this investigation was to evaluate the clinical impact of echocardiography in the PICU in terms of frequency of unanticipated findings and the frequency and nature of clinical management changes attributed to the results of echocardiography.

DESIGN

Prospective cohort study.

SETTING

Nineteen-bed combined medical-surgical-cardiac PICU at a tertiary care children's hospital.

PATIENTS

All patients in PICU undergoing transthoracic echocardiography.

INTERVENTIONS, MEASUREMENTS, AND MAIN RESULTS

Data collected included echocardiography indications, pre-echocardiography clinical assessment of anticipated echocardiography findings, height, weight, primary diagnosis, age, and urgency (stat vs routine) of echocardiography. Input of the attending care team (intensivist, cardiologist, and/or cardiovascular surgeon) allowed classification of echocardiography results as either confirming the pre-echocardiography impression, altering the pre-echocardiography clinical impression regarding the indication for which the test was performed, or altering the impression by virtue of new findings unrelated to the specific indication. The nature of the new findings were recorded and categorized. The team recorded clinical management changes made in response to the echocardiography results; the nature of these were listed and categorized. Echocardiograms (n = 416) were performed in 132 patients. Of these, 244 echocardiograms (59%) were ordered on male patients, 31% were under 30 days old, median age was 103 days, 379 (91%) had a primary cardiac diagnosis, and 92 (22%) were ordered stat. Sixty-three percent of echocardiograms confirmed and 24% altered the pre-echocardiography impression regarding the indication for the echocardiography; 13% introduced new findings unrelated to the indication. Cardiac surgical revision was the management change required in 26 patients (6.3%). Stat echocardiography was more likely to alter the pre-echocardiography assessment than routine echocardiography (p < 0.001). Management changes were more commonly associated with stat echocardiograms (p = 0.002) and those with new unexpected findings (p < 0.001) but had no demonstrable association with age less than 30 days (p = 0.332).

CONCLUSIONS

Unanticipated echocardiography results are common in the PICU, and they often alter the clinical impressions that prompted the echocardiogram or introduce new findings unrelated to the reason for which the echocardiogram was recorded. Clinical management changes attributable to echocardiography findings are frequent in the PICU, including occasional surgical intervention. Echocardiography adds diagnostic value and contributes to the management approach in the PICU, accounting for its frequent use.

Management of asymptomatic cardiac murmurs in term neonates

Approximately 2 % of newborn infants are noted to have cardiac murmur on routine postnatal examination. Our aim was to look at current evidence and practice in the management of asymptomatic cardiac murmur in term neonates. We performed a systematic literature review and a telephone survey of all neonatal units in the United Kingdom (UK). The systematic review of the literature did not support the routine practice of four-limb blood pressure (BP), chest X-ray (CXR), and electrocardiogram (ECG) in the assessment of asymptomatic cardiac murmur in term neonates. The survey had participation from 132 (68 %) of 193 neonatal units in the UK. In an asymptomatic term neonate with cardiac murmur, 124 (94 %) units perform pulse oximetry, 100 units (76 %) measure four-limb BP, 36 units (27 %) perform a CXR, and 52 units (39 %) perform an ECG. Eight-six units (65 %) have availability of in-house echocardiography services provided mainly by paediatricians with cardiology interest in special care units and neonatologists in neonatal intensive care units. Currently there is wide variation in practice in the management of asymptomatic cardiac murmur in term neonates. There is no evidence to support the routine use of four-limb BP, CXR, and ECG in the assessment of asymptomatic cardiac murmur in term neonates. Based on the evidence available, both structured clinical examination (including determining presence and quality of bilateral femoral pulses) and universal use of pulse oximetry are most important in identifying CHD in asymptomatic term neonates with cardiac murmur before discharge home.

Investigating the European perspective of neonatal point-of-care echocardiography in the neonatal intensive care unit--a pilot study

Point-of-care functional neonatal echocardiography (fnECHO) is increasingly used to assess haemodynamic status or patency of the ductus arteriosus (PDA). In Australasia, 90 % of neonatal intensive care units (NICUs) practice point-of-care fnECHO. The Australian Society of Ultrasound Medicine offers a training certificate for fnECHO. In Europe, the use and indications of fnECHO and the extent of point-of-care fnECHO training and accreditation are unknown. We aimed to assess utilisation and training of fnECHO in Europe. For this, we conducted an email survey of 45 randomly chosen tertiary NICUs in 17 European countries. The recall rate was 89 % (n = 40). Neonatologists with skills in fnECHO worked in 29 NICUs (74 %), but paediatric cardiologists would routinely perform most fnECHOs. Twenty-four-hour echocardiography service was available in 31 NICUs (78 %). Indications for fnECHO included assessment of haemodynamic volume status (53 %), presence or absence of pulmonary hypertension of the neonate (55 %), indication for and effect of volume replacement therapy (58 %), PDA assessment and monitoring of PDA treatment (80 %). Teaching of fnECHO was offered to trainees in 22 NICUs (55 %). Teaching of fnECHO was provided by paediatric cardiologists (55 %) or by neonatologists (45 %). Only six (15 %) national colleges accredited fnECHO teaching courses.

CONCLUSION

fnECHO is widely practiced by neonatologists across Europe for a broad range of clinical questions. However, there is a lack of formal training and accreditation of fnECHO skills. This could be addressed by designing a dedicated European fnECHO training programme and by agreeing on a common European certificate of fnECHO.

Investigating the European perspective of neonatal point-of-care echocardiography in the neonatal intensive care unit--a pilot study

Point-of-care functional neonatal echocardiography (fnECHO) is increasingly used to assess haemodynamic status or patency of the ductus arteriosus (PDA). In Australasia, 90 % of neonatal intensive care units (NICUs) practice point-of-care fnECHO. The Australian Society of Ultrasound Medicine offers a training certificate for fnECHO. In Europe, the use and indications of fnECHO and the extent of point-of-care fnECHO training and accreditation are unknown. We aimed to assess utilisation and training of fnECHO in Europe. For this, we conducted an email survey of 45 randomly chosen tertiary NICUs in 17 European countries. The recall rate was 89 % (n = 40). Neonatologists with skills in fnECHO worked in 29 NICUs (74 %), but paediatric cardiologists would routinely perform most fnECHOs. Twenty-four-hour echocardiography service was available in 31 NICUs (78 %). Indications for fnECHO included assessment of haemodynamic volume status (53 %), presence or absence of pulmonary hypertension of the neonate (55 %), indication for and effect of volume replacement therapy (58 %), PDA assessment and monitoring of PDA treatment (80 %). Teaching of fnECHO was offered to trainees in 22 NICUs (55 %). Teaching of fnECHO was provided by paediatric cardiologists (55 %) or by neonatologists (45 %). Only six (15 %) national colleges accredited fnECHO teaching courses.

CONCLUSION

fnECHO is widely practiced by neonatologists across Europe for a broad range of clinical questions. However, there is a lack of formal training and accreditation of fnECHO skills. This could be addressed by designing a dedicated European fnECHO training programme and by agreeing on a common European certificate of fnECHO.

Benefits of predischarge echocardiography service for postnatal heart murmurs

AIM

To review the findings and outcomes of predischarge echocardiography service for postnatal heart murmurs provided by neonatologists.

METHODS

We retrospectively reviewed all predischarge echocardiograms performed on babies from the postnatal wards (PNW) over the last 3 years. We evaluated the indications, median age, findings and outcome.

RESULTS

A total of 408 echocardiograms were performed on 350 babies on the PNW. The most common indication was presence of a murmur (58%). In babies with a heart murmur, 26% had a normal echocardiogram, 2% had major structural heart defects, 38% had minor structural heart defects and 34% had transient circulatory changes. 32% were discharged with no follow-up, 28% were followed up in the local cardiac clinic and 40% were referred to the cardiologist.

CONCLUSION

Predischarge echocardiography service for postnatal heart murmurs provided by neonatologists has the benefit of providing an early diagnosis, counselling of the parents and arranging appropriate follow-up. It helps to triage the referrals to the cardiologist. We felt that we were able to alleviate parental anxieties by providing a definitive diagnosis and written information prior to discharge from hospital. We strongly believe that this service should only be provided by those appropriately trained and skilled in echocardiography.

Point-of-care ultrasound in the neonatal intensive care unit: international perspectives

To explore international variation in implementation of point-of-care ultrasound in the neonatal intensive care unit (NICU), contributions were invited from neonatologists and paediatric cardiologists in six countries. The contributors show variation in national implementation that ranges from almost total coverage through to a minority of NICUs having point-of-care ultrasound capability. To a varying degree in all systems the main barriers have been concerns from the consultative specialties that traditionally use ultrasound, relating to the risk of misdiagnosis but also involving different clinical needs, liability concerns and lack of outcome-based evidence. All contributors agreed that safe point-of-care ultrasound depends on close collaboration with the consultative specialties and also that there is a need to develop training and accreditation structures for neonatologists using ultrasound.

Neonatologist-performed functional echocardiography in the neonatal intensive care unit

The use of point-of-care functional ultrasound to assess cardiovascular function is gaining interest in the neonatal intensive care unit (NICU). The modality has been in use in adult intensive care units for some time and has often guided management. Clinical signs such as heart rate, blood pressure, and capillary refill time, which physicians traditionally have relied upon, provide limited insight into the adequacy of systemic blood flow and organ perfusion. Enhanced cardiovascular imaging and hemodynamic evaluation offers novel insights regarding the contribution of the ductus arteriosus, myocardial performance and pulmonary hemodynamics to ongoing clinical instability. In addition, it allows more accurate delineation of the nature of the underlying disease process and facilitates the evaluation of response to therapeutic intervention. This review examines the potential clinical role of ultrasound methods in the NICU; specifically, its applications in different disease states, and how the technology may be introduced safely in the NICU.

Cardiac assessment in the neonatal population

Congenital heart defects are not uncommon among neonatal patients. Although most are benign, the prompt identification of a life-threatening anomaly is essential for rapid intervention and a positive treatment outcome. Cardiac defects may be identified in the newborn nursery with thorough and systematic physical assessment, including inspection, palpation, auscultation, and measurement of blood pressure and oxygen saturations. The ability of the nurse to identify irregular findings during physical assessment aids rapid identification and treatment.

Functional echocardiography; from physiology to treatment

Functional echocardiography (fECHO) is the bedside use of ultrasound to longitudinally assess myocardial function, systemic and pulmonary blood flow, and intra and extracardiac shunts. This review will focus on fECHO as a tool for the clinician to assess the hemodynamic condition of sick neonates and describe situations where fECHO can help determine a pathophysiological choice for cardiovascular support. The very low birth weight infant with hypotension during the first 24h of life, assessment and monitoring of the ductus arteriosus, assessment and response to treatment of infants with pulmonary hypertension, the infant with perinatal asphyxia and the infant with sepsis and cardiovascular compromise are reviewed. Close cooperation with pediatric cardiology, proper logistics and training programs are mandatory to achieve a 24h a day fECHO service run by bedside clinicians.

Echocardiography and management of sick neonates in the intensive care unit

To evaluate the influence of echocardiographic examination in the clinical management of the sick neonate, 241 patients, admitted to the neonatal intensive care unit of a tertiary referral center that had echocardiograms with data available for review, were enrolled in a retrospective study. Asymptomatic murmurs (45%) followed by extracardiac anomalies/dysmorphic features (24%) were the most common clinical indications for requesting an echocardiogram. Congenital structural abnormalities (33%), hemodynamically significant patent arterial duct (3%), persistent pulmonary hypertension of the newborn (6%), and left ventricular dysfunction (3%) were the echocardiographic findings that subgrouped as structural or functional abnormalities. Patent oval foramen and hemodynamically nonsignificant patent arterial duct (20%) and physiologic pulmonary artery stenosis (1%) were categorized as normal structural group. Thirty-four percent of neonates had normal heart anatomy. This investigation changed the clinical management in at least 66% of newborns scanned, including emergency surgical intervention for 7%, medical treatment for 22%, and routine cardiologic follow-up for 37% of patients. Asymptomatic murmur in our critically ill neonates has been associated with a higher incidence of cardiac disease. Hence, echocardiography is an important tool for diagnosis of cardiac abnormalities that can influence the management and outcome of the sick newborn in the intensive care unit. A preliminary echocardiogram performed by the neonatologist under the supervision of a pediatric cardiologist for interpretation and review is an alternate when there is not a cardiologist "in house."

Does point-of-care functional echocardiography enhance cardiovascular care in the NICU?

Although the last two decades have seen major advances in the care of sick, extremely premature newborns, the approach to cardiovascular assessment and monitoring remains suboptimal owing to an overreliance on poorly predictive clinical markers such as heart rate or capillary refill time. Point-of-care functional echocardiography (PCFecho) enables real-time evaluation of cardiac performance and systemic hemodynamics to characterize acute physiology, identify the exact nature of cardiovascular compromise and guide therapeutic decisions. In this article, we will review four clinical scenarios where bedside functional cardiac imaging enabled delineation of the real clinical problem and refinement of the therapeutic care plan with direct patient benefits.

Echocardiography and the neonatologist

Pediatric echocardiography as performed and interpreted by pediatric cardiologists provides details of cardiac structure and function as well as hemodynamic data. Functional echocardiography, in contrast to echocardiography as performed by the cardiologist, is the bedside use of cardiac ultrasound to follow functional and hemodynamic changes longitudinally. Data reflecting cardiac function and systemic and pulmonary blood flow in critically ill preterm and term neonates can be monitored using this method. Functional echocardiography is being developed and driven by neonatologists as an extension of their clinical skills. A wealth of hemodynamic information can be derived from functional echocardiography used for the sick neonate, which provides clinical information different from the assumed underlying physiology. Lack of access to appropriate training programs and interdisciplinary politics is limiting the use of this potentially valuable clinical information. Without the use of functional echocardiography, clinicians are left to speculate as to the underlying pathophysiology of circulatory compromise, and the assumptions they make often are incorrect. For functional echocardiography to fulfill its clinical potential, it needs to be available at any time and at short notice in the neonatal intensive care unit (NICU). Because most NICUs do not have external diagnostic services to provide longitudinal hemodynamic follow-up assessment at the bedside, neonatologists should be able to develop appropriate echocardiographic skills in close collaboration with their cardiologist colleagues.

Echocardiography and the neonatologist

Pediatric echocardiography as performed and interpreted by pediatric cardiologists provides details of cardiac structure and function as well as hemodynamic data. Functional echocardiography, in contrast to echocardiography as performed by the cardiologist, is the bedside use of cardiac ultrasound to follow functional and hemodynamic changes longitudinally. Data reflecting cardiac function and systemic and pulmonary blood flow in critically ill preterm and term neonates can be monitored using this method. Functional echocardiography is being developed and driven by neonatologists as an extension of their clinical skills. A wealth of hemodynamic information can be derived from functional echocardiography used for the sick neonate, which provides clinical information different from the assumed underlying physiology. Lack of access to appropriate training programs and interdisciplinary politics is limiting the use of this potentially valuable clinical information. Without the use of functional echocardiography, clinicians are left to speculate as to the underlying pathophysiology of circulatory compromise, and the assumptions they make often are incorrect. For functional echocardiography to fulfill its clinical potential, it needs to be available at any time and at short notice in the neonatal intensive care unit (NICU). Because most NICUs do not have external diagnostic services to provide longitudinal hemodynamic follow-up assessment at the bedside, neonatologists should be able to develop appropriate echocardiographic skills in close collaboration with their cardiologist colleagues.

Patent ductus arteriosus evaluation by serial echocardiography in preterm infants

BACKGROUND

Patent ductus arteriosus (PDA) is associated with morbidity and mortality in premature neonates.

METHODS

The effect of serial echocardiography performed by a neonatologist and early targeted medical PDA treatment was evaluated and compared to historical controls. One hundred ninety-two infants <1,500 g were included and 45 infants had a PDA.

RESULTS

Serial echocardiography allowed significantly earlier identification and treatment of PDA versus awaiting the evolution of clinical signs. Severe intraventricular haemorrhage and ventilator days were significantly decreased in the studied cohort following the introduction of echocardiography. In addition, hospital stay was also reduced in the non-PDA group and other outcomes were unchanged.

CONCLUSION

Serial echocardiography for PDA evaluation, performed by a neonatologist trained in echo, may reduce morbidity in preterm infant.

Left atrial appendage mimicking an intra-cardiac vegetation in preterm neonates

Infective endocarditis is emerging as a significant cause of morbidity in the neonatal intensive care with an incidence ranging from 0.07 to 4.3%. The rise in incidence may be explained by the increasing availability of echocardiography facilities in the neonatal unit. The diagnosis of infective endocarditis has major therapeutic implications as the neonate is treated with potentially toxic drugs and exposed to prolonged intravenous catheters. However, the consequences of a missed diagnosis of endocarditis in preterm neonates are unknown and may potentially lead to significant long-term cardiac complications. Onsite echocardiography in the neonatal unit by neonatologists may improve the speed of diagnosis in cases of endocarditis. However, lack of adequate training and experience in normal echocardiographic views may increase the false-positive rate. The posterior mitral valve leaflet is rarely affected due to the low velocity of blood passing through and because of the absence of prosthesis. We report 2 cases of the left atrial appendage rarely mimicking a posterior mitral valve leaflet vegetation, leading to an erroneous diagnosis of infective endocarditis. The features which distinguish the left atrial appendage from a posterior mitral valve leaflet vegetation are illustrated.

Managed Care Network for the assessment of cardiac problems in children in a district general hospital: a working model

AIM

To assess a model for cardiology assessments in children with suspected heart disease by a general paediatrician with special expertise in paediatric cardiology (PsePC) in a district general hospital.

METHODS

A new monthly "screening" clinic was established in May 2004 by the PsePC to reduce the burden of new referrals on outreach tertiary paediatric cardiology services. All patients were to have echocardiograms as part of their referral for cardiac assessment. Over a one year period (May 2004-April 2005), through audit, details of referrers, indications for referral, echocardiography assessments, and subsequent management were recorded. This was compared with the pattern of patients seen in the joint paediatric cardiology outreach clinics over a two year period (May 2003-April 2005).

RESULTS

In the "screening" clinic, there were 75 appointments for 65 patients seen in 12 months. Fifty five of these patients had normal echocardiographic studies. Of the 47 referrals with heart murmurs in asymptomatic children, four had structurally abnormal hearts on echocardiographic assessment. Between May-October 2003 and November 2003-April 2004, the number of new patients with normal echocardiographic studies seen in the paediatric cardiology outreach clinic was 33/106 (31%) and 28/110 (25.4%) respectively. Following the introduction of the "screening" clinic, the number decreased to 21/99 (21%) during May-October 2004, and 10/102 (9.8%) during November 2004-April 2005.

CONCLUSION

This model can work effectively in order to identify pathology requiring input of a paediatric cardiologist more appropriately. Paediatricians with specific training in paediatric cardiology are potentially well equipped to provide this basic screening service.

Accuracy of echocardiography in low birth weight infants with congenital heart disease

OBJECTIVE

Echocardiography has been shown to be highly accurate in infants and children, but its accuracy has not been studied in detail in low birth weight (LBW) infants with structural congenital heart disease (CHD). This study was undertaken to examine the diagnostic accuracy of echocardiography in the evaluation of CHD in these infants.

METHODS

All echocardiograms performed between 1995 and 2000 on infants who had structural CHD and weighed <or=2.5 kg were reviewed (n = 251). Infants who weighed >2.5 kg, matched for type of CHD, were control subjects (n = 319). The results of initial echocardiograms were compared for diagnostic accuracy with consensus diagnoses on the basis of all confirmatory data available. An observer who was blinded to patient group graded a sample of randomly selected echocardiograms (n = 100) for technical quality.

RESULTS

There were 13 major diagnostic errors in the LBW infants (5.2%) and 6 in the control subjects (1.9%). There were 20 minor errors in the LBW group (8.0%) and 21 in the control subjects (6.6%). The technical quality scores of the 2 groups were not significantly different, but a higher proportion of the LBW studies were graded as "poor" or "borderline" quality, compared with the control subjects (40% vs 28%). The majority (54%) of major errors in the LBW infants could potentially be explained by alterations in blood flow secondary to pulmonary hypertension.

CONCLUSIONS

Although echocardiography is an accurate imaging modality in premature and LBW infants with structural CHD, the incidence of clinically important diagnostic errors is higher than in infants who weigh >2.5 kg. As surgical and transcatheter interventions are extended to this population, heightened awareness of clinicians to pitfalls of echocardiography in this group of patients is warranted.

A study of congenital cardiac disease in a neonatal population--the validity of echocardiography undertaken by a neonatologist

OBJECTIVES

To estimate the incidence of, and profile the spread of, congenital cardiac defects, and to assess the accuracy of the echocardiographic diagnosis as performed by a neonatologist.

DESIGN

Hospital-based study.

METHODS

All neonates meeting our criterions, specifically those with a persistent murmur 48 hours after birth, underwent an echocardiographic examination to exclude an underlying congenital cardiac defect. All scans performed by the neonatologist were videotaped and reviewed by a paediatric cardiologist. We assessed concordance according to inter-rater agreement.

RESULTS

Out of 11,085 live births, there were 83 infants with a congenital cardiac defect, giving an incidence of 7.49 per 1000 live births, with 95% confidence interval from 5.88 to 9.09. Of the infants with a murmur persisting at or greater than 48 hours after birth, who had a median age of 4.5 days, 75% had a congenital heart defect, with ventricular septal defect being the commonest, encountered in 56.7% of cases. Concordance between the neonatologist and the cardiologist was good, with Cohen's Kappa coefficient being calculated at 0.68, and 95% confidence interval from 0.51 to 0.85.

CONCLUSION

The incidence of congenital cardiac malformations as determined in our hospital-based study in the United Arab Emirates is similar to that described in the Gulf region and worldwide. A persistent murmur at or greater than 48 hours after birth is strongly suggestive of an underlying congenital cardiac malformation. Our experience shows that a neonatologist appropriately trained in echocardiography can perform as well as a paediatric cardiologist. Where specialist resources are limited, this allows for early diagnosis, earlier referral if necessary, and early institution of appropriate therapy.