functional echocardiography. targeted neonatal echocardiography (tne). point of care...
DESCRIPTION
International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)TRANSCRIPT
The HIP Trial is funded by the European Commission within the 7th Framework Programme
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
• Rule out structural abnormality
• Need for direct measure of cardiovascular
function
• Effect of treatment
• Need for serial assessments
• Poor availability of cardiologists 24/7
Why should we be able to perform
and interpret TNE
The HIP Trial is funded by the European Commission within the 7th Framework Programme
www.neonatalechoskills.com
Increasing use of TNE in NICU
Enough of theoretical informations
Need for good training !
The HIP Trial is funded by the European Commission within the 7th Framework Programme
The HIP Trial is funded by the European Commission within the 7th Framework Programme
• 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
Basic rules of TNE
The HIP Trial is funded by the European Commission within the 7th Framework Programme
• 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
Indications for TNE
The HIP Trial is funded by the European Commission within the 7th Framework Programme
• 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
Components of TNE
The HIP Trial is funded by the European Commission within the 7th Framework Programme
• 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
LV systolic function – Fractional shortening
The HIP Trial is funded by the European Commission within the 7th Framework Programme
LVEDD – left ventricular end-
diastolic diameter
LVESD – left ventricular end-
systolic diameter
Normal values
Term babies 25-41%
Preterm 23-40%
LV systolic function – Fractional shortening
FS = [(LVEDD-LVESD)/LVEDD] x 100
LVEDD LVESD
The HIP Trial is funded by the European Commission within the 7th Framework Programme
LVET – left ventricular ejection
time, from the closure to the
opening of the mitral valve
Less sensitive to dimensional
discrepancies
Normal values 1.5 ± 0.04
circumferences/s
LV systolic function – mVCFs
mVCFs - Mean velocity of circumferential fiber shortening
mVCFs = mean [(LVEDD-LVESD)/LVEDD] x LVET
LVET
The HIP Trial is funded by the European Commission within the 7th Framework Programme
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
LV systolic function – Ejection fraction
The HIP Trial is funded by the European Commission within the 7th Framework Programme
Ventricular filling velocities
From four chamber view
Ratio of E:A wave
Diastolic function – blood inflow
E A
The HIP Trial is funded by the European Commission within the 7th Framework Programme
• 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
Diastolic function – blood inflow
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
• 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
LV systolic/diastolic function – MPI
The HIP Trial is funded by the European Commission within the 7th Framework Programme
• Less usable in high heart
rates
• Influenced by preload and
afterload
Normal values 0.25 – 0.38
Poor systolic and/or diastolic
function > 0.38
LV systolic/diastolic function – MPI
ICT IRT
ET
The HIP Trial is funded by the European Commission within the 7th Framework Programme
• 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)
Tissue Doppler
S´
E´ A´
The HIP Trial is funded by the European Commission within the 7th Framework Programme
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
• Strain
• Strain rate
• Speckle tracking
Used in cardiology or for
research
Other modalities
The HIP Trial is funded by the European Commission within the 7th Framework Programme
• 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
Ductal shunting
The HIP Trial is funded by the European Commission within the 7th Framework Programme
• High incidence
• From subcostal four chamber view or short axis
view
Atrial shunting
The HIP Trial is funded by the European Commission within the 7th Framework Programme
• 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
Atrial shunting
The HIP Trial is funded by the European Commission within the 7th Framework Programme
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
Pulmonary artery pressure (PAP)
The HIP Trial is funded by the European Commission within the 7th Framework Programme
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
Pulmonary artery pressure (PAP)
The HIP Trial is funded by the European Commission within the 7th Framework Programme
• Systemic blood flow ≠ cardiac output when atrial
and ductal shunt is present
Ductal shunt – increases left ventricular output
Atrial shunt – increases right ventricular output
Assessment of systemic blood flow
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
• 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
Left ventricular output - LVO
The HIP Trial is funded by the European Commission within the 7th Framework Programme
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
• 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
Right ventricular output - RVO
The HIP Trial is funded by the European Commission within the 7th Framework Programme
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
• 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
Superior vena cava flow – SVC flow
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
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
SVC flow
The HIP Trial is funded by the European Commission within the 7th Framework Programme
• 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
Central line placement
The HIP Trial is funded by the European Commission within the 7th Framework Programme
• Suspected effusion
pericardial - from 4 chamber view, long axis view
pleural
pneumopericard – unable to see the heart, echo shadow of air
• Suspected thrombosis
Another abnormal conditions
The HIP Trial is funded by the European Commission within the 7th Framework Programme
Thanks a lot for your attention