Neonatal Echocardiography Research Articles

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

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. 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. 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. 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. · 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..

Evaluation of neonatal presurgical echocardiographic requests for noncardiac surgery at the University of Uyo Teaching Hospital, Nigeria

Abstract Context: There is a well-established association of congenital heart disease (CHD) with surgically correctable malformations particularly those of the gastrointestinal tract, genitourinary and central nervous systems. These malformations are typically corrected during the newborn period. Clinically significant and severe CHDs may worsen surgical outcomes. Aims: This study aimed to determine the prevalence of CHD diagnosed by echocardiography in neonates having noncardiac surgery at the University of Uyo Teaching Hospital. The study also aimed to assess if echocardiographic findings correlated with the severity of clinical presentation. Settings and Design: This was a retrospective review of the clinical and echocardiographic records of neonates who underwent noncardiac surgery between October 2020 and March 2023 at the University of Uyo Teaching Hospital. Subjects and Methods: Echocardiographic studies were done on all participants on a GE Vivid Iq® machine using standard views. M-mode and two-dimensional data were recorded. Statistical Analysis: Data were analyzed using the Statistical package for socials sciences (SPSS) version 25. Results: Thirty patients had presurgical echocardiography done in the period accounting for 41% of all neonatal echocardiography requests. Twenty percent of the patients had a CHD identified. Atrial Septal Defects were the commonest CHD identified in 50% of patients. The association between clinical symptoms, gender, surgical diagnosis and the presence of CHDs were not statistically significant. Conclusions: Neonatal surgical anomalies are commonly associated with CHDs. The nature of most of the CHDs however appears to be mild. A preoperative assessment by a pediatric cardiologist is recommended to avoid undue delays.

Diastolic Dysfunction in Neonates With Hypoxic-Ischemic Encephalopathy During Therapeutic Hypothermia: A Tissue Doppler Study.

Diastolic dysfunction often complicates myocardial ischemia with increased mortality rates. However, less is known about diastolic function after perinatal asphyxia in neonates with hypoxic-ischemic encephalopathy (HIE) during therapeutic hypothermia (TH) and rewarming.AimThe aim of this study was to assess diastolic function with tissue Doppler imaging (TDI) in neonates with moderate–severe HIE during TH and rewarming.MethodNewborns at >36 weeks' gestation with moderate–severe HIE treated with TH were evaluated with targeted neonatal echocardiography (TNE), including TDI, within 24 h of TH initiation (T1), at 48–72 h of treatment (T2), and after rewarming (T3). These retrospective data were collected and compared with a control group of healthy babies at >36 weeks' gestation that was prospectively evaluated following the same protocol.ResultsA total of 21 patients with HIE + TH and 15 controls were included in the study. Myocardial relaxation before the onset of biventricular filling was prolonged in the HIE + TH group during TH with significantly longer isovolumic relaxation time (IVRT') in the left ventricle (LV), the septum, and the right ventricle (RV). This was associated with slower RV early diastolic velocity (e') and prolonged filling on T1. Total isovolumic time (t-IVT; isovolumic contraction time [IVCT'] + IVRT') and myocardial performance index (MPI') were globally increased in asphyxiated neonates. All these differences persisted after correction for heart rate (HR) and normalized after rewarming. TDI parameters assessing late diastole (a' velocity or e'/a' and E/e' ratios) did not differ between groups.ConclusionTDI evaluation in our study demonstrated a pattern of early diastolic dysfunction during TH that normalized after rewarming, whereas late diastole seemed to be preserved. Our data also suggest a possible involvement of impaired twist/untwist motion and dyssynchrony. More studies are needed to investigate the impact and therapeutic implication of diastolic dysfunction in these babies, as well as to clarify the role of TH in these findings.

Neonatologist Performed Echocardiography for Evaluating the Newborn Infant.

The interest in the use of cardiac ultrasound for hemodynamic evaluation in neonates has increased in the last decades. Several overlapping terms exists, and a non-comprehensive list includes point-of-care ultrasound, clinician-performed ultrasound, focused cardiac ultrasound, targeted neonatal echocardiography, and neonatologist performed echocardiography. This review will use the term neonatologist performed echocardiography. Neonatologist performed echocardiography is primarily echocardiography to obtain snapshots of hemodynamics and heart function, usually as repeated exams during intensive care. It provides the neonatologist with in-depth information on the hemodynamics not available by blood pressure, pulse oximetry, capillary refill time, and various blood tests. The review provides a brief overview of some relevant methods for assessment of hemodynamics and heart function. It does not discuss training, implementation, accreditation, and certification nor in-depth technical aspects and detailed use of neonatologist performed echocardiography. If the information obtainable by neonatologist performed echocardiography had been accessible easily (e.g., via a sensor put on the neonate similarly to a pulse oximeter), neonatologist performed echocardiography would have been more widely used. Acquiring skills for neonatologist performed echocardiography take time and resources. Future developments probably include a stronger focus on education, training, and certification. It is likely that echocardiographic methods will evolve further, probably involving establishing new indexes and methods and implementing artificial intelligence in the analyses procedure to improve accuracy and workflow. It is important to acknowledge that neonatologist performed echocardiography is not a therapeutic intervention; it is a diagnostic tool providing additional information.

Coarctation of the aorta and persistent left superior vena cava: HDlive Flow features at 14 weeks of gestation

Abstract Objectives A significant discrepancy between a large ductus arteriosus and a smaller aorta at their connection is key to diagnose coarctation of the aorta (CoA) at 14–16 weeks of gestation. CoA was associated with persistent left superior vena cava (PLSVC) in 21.3% of fetuses. HDlive Flow findings for CoA or PLSVC were obtained only in the third trimester of pregnancy. To the best of our knowledge, there has been no report on the prenatal findings of CoA and PLSVC using HDlive Flow with spatiotemporal image correlation (STIC) before 20 weeks of gestation. Case presentation We present the trans-abdominal HDlive Flow features of CoA and PLSVC at 14 weeks of gestation. With a three-vessel trachea view on multiplanar view using color Doppler with STIC, PLSVC on the left side of the pulmonary artery was noted, and a narrowing aortic isthmus was suspected. A narrowing isthmus was also suspected with an aortic arch view. HDlive Flow clearly showed the spatial relationships among the right superior vena cava, aorta with narrowing isthmus, pulmonary artery, and PLSVC. A preductal ‘shelf’ was also suspected. No other fetal anomaly was noted. Neonatal echocardiography after delivery confirmed CoA and PLSVC. Conclusions To the best of our knowledge, this is the first report on HDlive Flow features of fetal CoA and PLSVC using STIC early in the second trimester of pregnancy.

Methodological rigor in both targeted neonatal echocardiography training and study design are essential to understanding the impact of ultrasound on neonatal pain.

Methodological rigor in both targeted neonatal echocardiography training and study design are essential to understanding the impact of ultrasound on neonatal pain.

Evaluation of pain and physiological stress during targeted neonatal echocardiography.

Targeted neonatal echocardiography (Tn-Echo) is a non-invasive examination which may cause pain/discomfort and physiological instability in neonates, but there is little evidence for the same. We conducted this study to evaluate whether targeted neonatal echocardiography causes pain or physiological stress to newborn infants. This cross-sectional study was conducted in a tertiary level NICU. Neonates undergoing targeted neonatal echocardiography were enrolled in this study. Pain was assessed using Premature Infant Pain Profile-Revised (PIPP-R) score before, during and after targeted neonatal echocardiography examination. Heart rate, oxygen saturation, perfusion index and blood pressure were also recorded at the same time points. A total of 88 neonates were enrolled. Mean (SD) PIPP-R score during Tn-Echo was 8.18 (2.6) versus 3.60 (1.8) and 4.24 (2.0) before and after respectively (p value < 0.001). Heart rate and respiratory rate were significantly higher during targeted neonatal echocardiography; oxygen saturation and perfusion index were significantly lower during targeted neonatal echocardiography. Preterm infants had higher PIPP-R score compared to term neonates before, during and after the Tn-Echo [8.76 (2.4) versus 6.81 (2.4); p value < 0.001]. Targeted neonatal echocardiography causes significant pain/discomfort and physiological instability in neonates.

Cross-sectional study on clinical utility of neonatal echocardiography

Background and Aim: Congenital heart disease (CHD) is a prevalent anomaly associated with various risk factors and the influence of early diagnosis of neonate cardiac abnormalities on postnatal outcomes has been a topic of controversy in the literature. The present study aimed to assess the clinical utility of neonatal echocardiography. Patients and Methods: This cross-sectional study was carried out on 86 neonates for echocardiography (FE) in the Cardiology Department of Mardan Medical Complex (MMC), Mardan from March 2021 to September 2021. A comprehensive maternal interview gathered extensive information encompassing details such as the ages of parents, consanguinity, and family history of congenital heart disease (CHD). Neonatal echocardiography was conducted to identify any structural or rhythm abnormalities in the neonate heart. Results: The overall mean for paternal and maternal ages were 31.76±5.48 years and 27.52±6.24 years respectively. Of the total 86 cases, the incidence of neonate cardiac abnormalities, congenital heart defects, neonate arrhythmias, cardiomyopathy, cardiac mass, and rhythm abnormalities were 47.8% (n=41), 34.9% (n=30), 9.3% (n=8), 3.5% (n=3), 2.3% (n=2), and 2.3% (n=2) respectively. Out of 30 cases of CHD, the prevalence of complex heart lesions, common atrioventricular canal, and conotrunchal anomalies was 60% (n=18), 26.7% (n=8), and 13.3% (n=4) respectively.

Hemodynamic dysfunction in neonatal sepsis.

Cardiovascular disturbances are a frequent occurrence in neonatal sepsis. Preterm and term infants are particularly vulnerable due to the unique features of their cardiovascular function and reserve, compared to older children and adults. The clinical manifestations of neonatal sepsis are a product of the variable inflammatory pathways involved (warm vs. cold shock physiology), developmental state of the cardiovascular system, and hormonal responses. Targeted neonatal echocardiography has played an important role in advancing our knowledge, may help delineate specific hemodynamic phenotypes in real-time, and supports an individualized physiology-based management of sepsis-associated cardiovascular dysfunction. IMPACT: Cardiovascular dysfunction is a common sequela of sepsis. This review aims to highlight the pathophysiological mechanisms involved in hemodynamic disturbance in neonatal sepsis, provide insights from targeted neonatal echocardiography-based clinical studies, and suggest its potential incorporation in day-to-day management.

Prenatal cardiac biometry and flow assessment in fetuses with bicuspid aortic valve at 20 weeks' gestation: multicenter cohort study.

To investigate prenatal changes in cardiac biometric and flow parameters in fetuses with bicuspid aortic valve (BAV) diagnosed neonatally compared with controls with normal cardiac anatomy. This analysis was conducted as part of the Copenhagen Baby Heart Study, a multicenter cohort study of 25 556 neonates that underwent second-trimester anomaly scan at 18 + 0 to 22 + 6 weeks' gestation and neonatal echocardiography within 4 weeks after birth, in Copenhagen University Hospital Herlev, Hvidovre Hospital and Rigshospitalet in greater Copenhagen, between April 2016 and October 2018. From February 2017 (Rigshospitalet) and September 2017 (Herlev and Hvidovre hospitals), the protocol for second-trimester screening of the heart was extended to include evaluation of the four-chamber view, with assessment of flow across the atrioventricular valves, sagittal view of the aortic arch and midumbilical artery and ductus venosus pulsatility indices. All images were evaluated by two investigators, and cardiac biometric and flow parameters were measured and compared between cases with BAV and controls. All cases with neonatal BAV were assessed by a specialist. Maternal characteristics and first- and second-trimester biomarkers were also compared between the two groups. Fifty-five infants with BAV and 8316 controls with normal cardiac anatomy were identified during the study period and assessed using the extended prenatal cardiac imaging protocol. There were three times as many mothers who smoked before pregnancy in the group with BAV as in the control group (9.1% vs 2.7%; P = 0.003). All other baseline characteristics were similar between the two groups. Fetuses with BAV, compared with controls, had a significantly larger diameter of the aorta at the level of the aortic valve (3.1 mm vs 3.0 mm (mean difference, 0.12 mm (95% CI, 0.03-0.21 mm))) and the pulmonary artery at the level of the pulmonary valve (4.1 mm vs 3.9 mm (mean difference, 0.15 mm (95% CI, 0.03-0.28 mm))). Following conversion of the diameter measurements of the aorta and pulmonary artery to Z-scores and Bonferroni correction, the differences between the two groups were no longer statistically significant. Pregnancy-associated plasma protein-A (PAPP-A) multiples of the median (MoM) was significantly lower in the BAV group than in the control group (0.85 vs 1.03; P = 0.04). Our findings suggest that fetuses with BAV may have a larger aortic diameter at the level of the aortic valve, measured in the left-ventricular-outflow-tract view, and a larger pulmonary artery diameter at the level of the pulmonary valve, measured in the three-vessel view, at 20 weeks' gestation. Moreover, we found an association of maternal smoking and low PAPP-A MoM with BAV. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Comparison of Cardiac Output Measurement by Electrical Velocimetry with Echocardiography in Extremely Low Birth Weight Neonates

Introduction: Electrical velocimetry (EV) offers a noninvasive tool for continuous cardiac output (CO) measurements which might facilitate hemodynamic monitoring and targeted therapy in low birth neonates, in whom other methods of CO measurement are not practicably feasible. Methods: This prospective observational study compared simultaneous cardiac output measurements by electrical velocimetry (COEV) with transthoracic echocardiography (COTTE) in extremely low birth weight (ELBW) neonates in the neonatal intensive care unit (NICU). Echocardiography was performed by 1 single examiner. Data were analyzed by Bland-Altman analysis and independent-samples analysis of variance. A mean percentage error (MPE) of <30% and limits of agreement (LOA) up to ±30% were considered clinically acceptable. Results: Thirty-eight ELBW neonates were studied and yielded 85 pairs of COEV and COTTE measurements. Bland-Altman analysis showed an overall bias (the mean difference) and LOA of −126 and −305 to +52 mL min−1, respectively, and an MPE of 66%. Patients with patent ductus arteriosus had a higher bias with LOA and MPE of −166.8, −370.7 to +37 mL min−1, and 69%, respectively. The overall true precision was 58%. Conclusion: This study showed high bias and lack of agreement between EV and TTE for measurement of CO in ELBW infants in NICU, limiting applicability of EV to monitor absolute values.

4 Educational Impact of Targeted Neonatal Echocardiography (TNE) on Neonatal-Perinatal Medicine (NPM) Subspecialty Residents

Abstract Primary Subject area Neonatal-Perinatal Medicine Background Targeted Neonatal Echocardiography (TNE) is a real-time cardiac imaging modality used by neonatologists who have completed a minimum of one-year training in cardiovascular physiology and imaging methodology, to optimize management of neonatal cardiorespiratory compromise. TNE is provided as a clinical service, to aid in diagnosis, treatment, and monitoring of neonatal cardiovascular illness. Potential impacts of TNE on trainee education are unknown. Objectives This study aimed to describe trainees’ perspectives on existing neonatal hemodynamics education and perceived impacts of TNE on their education. Design/Methods This was a mixed quantitative and qualitative study that surveyed NPM subspecialty residents in Canada and the United States of America (USA), at centres both with and without TNE. Survey questions sought to explore current perspectives on cardiac and hemodynamics curriculum in training programs. Results 92 residents responded to the survey, of whom 24 (26%) were enrolled in a program with an active TNE service, 64 (70%) were training at a non-TNE centre, and 4 (4%) were unsure. Trainees at TNE centres were more satisfied with their overall hemodynamics training (91% vs. 69%, p=0.040; Table 1). 25% of all trainees felt they do not have sufficient hemodynamics training to prepare them for independent practice. On analysis of curriculum content, cardiac development, myocardial functioning in prematurity, and cardiac mechanics emerged as areas of knowledge gaps among all residents (Table 2). TNE centre trainees reported that bedside TNE teaching offers immediate insights into how patients respond to management decisions, while didactic TNE teaching allows for learning at a slower pace, with appropriate knowledge consolidation. Only 9% of respondents at TNE sites reported a formal process of hemodynamics review between clinical and TNE teams. 90% of respondents believed that a TNE service would positively impact their hemodynamics education by improvement in knowledge of cardiovascular physiology and management decisions. Conclusion Most trainees believed that TNE may be a valuable educational tool, with current perceived satisfaction with overall hemodynamics training higher among residents training at TNE centres. 25% of all trainees felt unprepared for transitioning to independent practice. Hence, thoughtful curriculum design for real-time and consolidation learning, with specific emphasis on content gaps, as well as working toward a formal process of hemodynamics review, should be considered.

46 Impact of early versus late medical treatment of a hemodynamically significant patent ductus arteriosus on time to reach full feeds in preterm neonates

Abstract Primary Subject area Neonatal-Perinatal Medicine Background Prolonged exposure to a hemodynamically significant patent ductus arteriosus (hsPDA) in preterm infants has been associated with an increase in neonatal morbidities. Objectives To examine the effect of timing of medical treatment (within first 7 days of life versus after 7 days of life) for a hsPDA on the duration to achieve full feeds in infants born at &amp;lt;30 weeks of gestation. Design/Methods This was a retrospective cohort study in a quaternary neonatal intensive care unit (NICU) with a targeted neonatal echocardiography service. Infants admitted between July 2015 – June 2019 who received medical treatment for an hsPDA were included and grouped based on those who received first medical therapy within 7 days of life (early treatment) and after 7 days of life (late treatment). An hsPDA was defined using both clinical (worsening ventilation, pulmonary hemorrhage/edema, or hypotension requiring inotrope or hydrocortisone) and echocardiographic findings (LA/Ao ratio &amp;gt;1.4; LVO &amp;gt;350 mL/kg/min, PDA &amp;gt;1.4 mm, IVRT &amp;lt; 35 ms). Duration to reach full feeds was calculated based on number of days to reach a total enteral feed ≥ 120 mL/kg/day with no parenteral source of nutrition. Results Forty-six infants met the inclusion criteria. Of the 46 infants, 24 were identified as receiving early treatment and 22 received late treatment. Infants in the early treatment group had lower median birth weight than the late treatment group (802 g vs. 1016 g, p=0.022). All other clinical characteristics were not significantly different. No significant difference was found in the use of indomethacin, ibuprofen, or acetaminophen as the initial medical treatment (Table 1). The late treatment group had elevated left ventricular output (median: 286 vs. 369 mL/kg/min, p=0.013) and tricuspid annular plane systolic excursion (median: 6 vs. 8 mm, p=0.002) (Table 2). Infants in the early treatment group reached full feeds earlier than those in the late treatment group (19 vs. 30 days, p=0.042) (Table 1). Conclusion Early medical treatment of hsPDA was associated with shorter duration to reach full feeds in our cohort of preterm infants. Further larger scale study is needed to understand the association between the timing of medical therapy and prolonged exposure of splanchnic circulation to hemodynamically significant ductus.

Targeted neonatal echocardiography service in neonatal intensive care in Manitoba, Canada.

To evaluate the impact of a targeted neonatal echocardiography (TNE) service on patient management in the neonatal intensive care units (NICU)in Winnipeg, Canada. Retrospective cohort study of neonates who had TNEs from 2014 to 2019. The primary outcome was the change in clinical management based on TNE recommendation. Multivariate logistic regression analysis was used to identify predictors of the primary outcome. A total of 747 echos were performed on 307 neonates. Patent ductus arteriosus assessment was the most common indication for TNE followed by evaluation of pulmonary hypertension and systemic hemodynamics. TNE led to a change in clinical management following 492 (66%) echos. Mechanical ventilation [Odds ratio (OR) 2.4, 95% CI: 1.7-3.4, P < 0.001) and receiving inhaled nitric oxide (1.9, 95% CI: 1.3-3.0, P = 0.003) were the predictors for the change in clinical management following TNE. TNE has enhanced patient care by altering the management of patients in the NICU.

Isolated fetal pericardial effusion: A case report treated by in utero pericardiocentesis

Little is known about the characteristics and outcomes of fetuses with pericardial effusion (PE) [1] , [2] , [3] , [4] . We report the case of a fetus for who a cystic hygroma was discovered at 12 weeks of gestation. An isolated apical right ventricular diverticula (2.5 mm) with large pericardial effusion was diagnosed at the second trimester ( Fig. 1 , Fig. 2 ). No other malformation was seen. Amniocentesis did not shown chromosomal abnormality. There was no atypical antibodies. The fetal infectious screen was negative for syphilis, toxoplasmosis, varicella, enterovirus, herpes simplex virus, cytomegalovirus and parvovirus B19. In utero drainage by pericardiocentesis of PE was performed at 20 weeks of gestation. Laboratory data of the pericardial effusion did not show any inflammatory. The lungs compressed by the large PE returned to their place. There was no adverse effects nor recurrence. The pregnancy was terminated at 39 weeks of gestation by vaginal delivery. A 2840 g female baby was born with an Apgar score of 10 and 10 at one and five minutes. The neonatal outcome was good and the neonatal echocardiography was normal.

Assessment of superior vena cava flow and cardiac output in different patterns of patent ductus arteriosus shunt

Despite the widespread use of superior vena cava (SVC) flow as a marker of systemic blood flow from the upper body, no previous studies have systematically evaluated the correlation between SVC flow and other echocardiography measures of systemic blood flow in the context of different patterns of patent ductus arteriosus (PDA) shunt direction METHODS: A retrospective cohort study of preterm infants (<30weeks,<21 days of life) who underwent comprehensive targeted neonatal echocardiography (TnECHO) was performed. Patients were categorized as follows: (i) Hemodynamically significant left-to-right shunt; (ii): Bidirectional shunt; (iii) No PDA or insignificant shunt. SVC flow, as measured by two distinct methods, was compared to left and right ventricular outputs (LVO and RVO). Intra- and inter-observer reliability testing was performed RESULTS: In total, 45 patients were included (15 in each group) with a median [IQR] weight of 720 [539, 917] grams at the time of assessment. SVC dimensions and flow measurements were not different between the groups, although patients with left-to-right shunt had higher LVO/RVO ratio. SVC flow, as estimated using the modified method, had a strong correlation with LVO (r=.63, p=0.012) and RVO (r=.635, p=0.011) in patients with no PDA. Inter- and intra-observer reliability were both stronger for LVO and RVO when compared to SVC flow measurements CONCLUSION: SVC flow was comparable across all three groups irrespective of higher LVO and LVO/RVO ratio in patients with left-to-right shunts. This may reflect poor measurement reliability or compensation for left-to-right ductal shunt by increased LVO to maintain systemic perfusion.

Non-invasive cardiac output measurement by electrical cardiometry and M-mode echocardiography in the neonate: a prospective observational study of 136 neonatal infants

BackgroundElectrical cardiometry (EC) is a continuous, non-invasive method for measuring cardiac output (CO). This study investigates the correlation and consistency of CO values in newborns obtained by using EC and M-mode echocardiography (Teichholz formula).MethodsIn this prospective observational study, simultaneous measurement of CO was implemented with EC (COec) and M-mode echocardiography (COm) in neonates. The absolute values of CO measured by the two methods were converted to Z-scores. Following that, Pears’s correlation analyses and the Bland–Altman index were employed to analyze the correlation and consistency of COec Z-scores and COm Z-scores.ResultsA total of 136 neonates (93 preterm infants) were enrolled in this study, and EC and M-mode echocardiography comparative studies were conducted 155 times. The mean value of COec and COm demonstrated significant statistical differences (P<0.001). A moderate correlation (r=0.601; P<0.001) was found between the two methods. The Bland-Altman index value was 3.2%, which remained less than 5% in the low birth weight (LBW) (2.1%), non-LBW (3.4%), spontaneous respiration (3.1%), nasal continuous positive airway pressure (nCPAP) (4.0%), mechanical ventilation (2.9%), hemodynamic significance of the patent ductus arteriosus (hsPDA) (4.3%), and non-hsPDA (3.7%) groups, respectively.ConclusionsAlthough the absolute values of CO measured by EC and M-mode echocardiography were not interchangeable, the distribution of CO in EC and M-mode echocardiography was similar.

The evolution of cardiac point of care ultrasound for the neonatologist.

Cardiac point of care ultrasound (POCUS) is increasingly being utilized in neonatal intensive care units to provide information in real time to aid clinical decision making. While training programs and scope of practice have been well defined for other specialties, such as adult critical care and emergency medicine, there is a lack of structure for neonatal cardiac POCUS. A more comprehensive and advanced hemodynamic evaluation by a neonatologist has previously published its own clinical guidelines and specific rigorous training programs have been established to achieve competency in neonatal hemodynamics. However, it is becoming increasingly evident that access and training for basic cardiac assessment by ultrasound enhances bedside clinical care for specific indications. Recently, expert consensus POCUS guidelines for use in neonatal and pediatric intensive care endorsed by the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) have been published to guide the clinicians in using POCUS for specific indications, though the line between cardiac POCUS and advanced hemodynamic evaluation remains somewhat fluid.Conclusion: This article is focused on neonatal cardiac POCUS and its evolution, value, and limitations in the modern neonatal clinical practice. Cardiac POCUS can provide physiological and hemodynamic information in making clinical decisions while dealing with neonatal emergencies. However, it should be applied only for the specific indications and should be performed by a clinician trained in cardiac POCUS. There is an urgent need of developing cardiac POCUS curriculum and certification to support a widespread and safe use in neonates. What is Known: • International training guidelines and curriculum have been published for neonatologist-performed echocardiography (NPE) or targeted neonatal echocardiography (TNE). • International evidence-based guidelines for use of point of care ultrasound (POCUS) in neonates and children have been recently published. What is New: • Cardiac POCUS is increasingly being incorporated in neonatal practice for emergency situations. However, one must be aware of its specific indications and limitations, especially for the neonatal clinical practice. • Cardiac POCUS and NPE/TNE are continuum of cardiac imaging with different indications and training requirements.

Size of Patent Ductus Arteriosus and Echocardiographic Markers of Shunt Volume in Preterm Infants Based on Postnatal Age.

Objective: This study was conducted in order to compare the strength of correlation between echocardiographic markers of shunt volume and patent ductus arteriosus (PDA) diameter based on postnatal age.Methods: This retrospective study focused on preterm infants (aged <32 weeks of gestation) admitted to the Neonatal Intensive Care Unit of Korea University Ansan Hospital, between April 2014 and December 2017, who studied serial targeted neonatal echocardiography (TNE) for PDA during hospitalization. The association between echocardiographic characteristics and duct size was divided into the following days: within 3 days (very early, VE), 4–7 days after birth (early, E), and after 8 days of birth (late, L).Results: We found 113 assessments conducted on 57 infants in the VE period, 92 assessments on 40 infants in the E period, and 342 assessments on 37 infants in the L period. Median gestational age and birth weight were 28+2 weeks of gestation and 1,115 g, respectively. In the univariate regression analysis, we found a statistically significant correlation between PDA diameter and all TNE markers in the E and L days, but not in the VE period. Only ductal velocity [coefficient of determination (R2) = 0.224], antegrade left pulmonary artery diastolic flow velocity (R2 = 0.165), left ventricular output (LVO)/superior vena cava (SVC) flow ratio (R2 = 0.048), and E/A wave ratio (R2 = 0.092) showed weak correlations with PDA diameter in the VE period. The slopes of the regressions showed significant changes based on postnatal age in the maximum ductal velocity, left atrium/aorta ratio, LVO/SVC flow ratio, and LVO.Conclusions: It is difficult to predict the echocardiographic markers of shunt volume based on the PDA diameter in preterm infants younger than 4 days. A better understanding of the changes in the hemodynamic consequences of PDA based on postnatal age is needed when considering treatment.

Impact of Acute and Chronic Hypoxia-Ischemia on the Transitional Circulation.

The transition from intrauterine life to extrauterine existence encompasses significant cardiorespiratory adaptations. These include rapid lung aeration and increase in pulmonary blood flow (PBF). Perinatal asphyxia and fetal growth restriction can severely hamper this transition. Hypoxia is the common denominator in these 2 disease states, with the former characterized by acute insult and the latter by utero-placental insufficiency and a chronic hypoxemic state. Both may manifest as hemodynamic instability. In this review, we emphasize the role of physiologic-based cord clamping in supplementing PBF during transition. The critical role of lung aeration in initiating pulmonary gas exchange and increasing PBF is discussed. Physiologic studies in animal models have enabled greater understanding of the mechanisms and effects of various therapies on transitional circulation. With data from sheep models, we elaborate instrumentation for monitoring of cardiovascular and pulmonary physiology and discuss the combined effect of chest compressions and adrenaline in improving transition at birth. Lastly, physiologic adaptation influencing management in human neonatal cohorts with respect to cardiac and vascular impairments in hypoxic-ischemic encephalopathy and growth restriction is discussed. Impairments in right ventricular function and vascular mechanics hold the key to prognostication and understanding of therapeutic rationale in these critically ill cohorts. The right ventricle and pulmonary circulation seem to be especially affected and may be explored as therapeutic targets. The role of comprehensive assessments using targeted neonatal echocardiography as a longitudinal, reliable, and easily accessible tool, enabling precision medicine facilitating physiologically appropriate treatment choices, is discussed.