Technique to assess function of heart in neonate

1. “Functional Echocardiography “.
Targeted neonatal echocardiography (TNE).

3. In fetal life the Ductus Arteriosus is a shunt between pulmonary and aorta, for right to left
shunt and it carries most of the Right Ventricular Out( RVO) put to aorta.
Shortly after birth : The shunt reverses due to an increase in systemic vascular resistance
(release from the low-resistance placental circulation) and a decrease in the pulmonary
vasculature resistance (lung inflation). The shunt becomes systemic to pulmonary (left to right,
L -> R) as long as systemic pressure is higher than the pulmonary pressure throughout the
cardiac cycle.
Normally the DA closes soon after birth and the shunt disappears, blood flow decreases
and blood pressure rises in the first few days after birth in healthy term and late in
preterm infants. In contrast, very preterm infants show a rise in blood flow and blood
pressure in the first week of life.
The process of DA closure is often delayed in very preterm and sick newborns
The ductal shunting may be associated with reduced Left Ventricular Output (LVO) but with
a normal venous return from the lower body, increases LVO.

4. How we assess tissue perfusion in neonate ?
Most centers around the world and virtually all centers in our country
assess cardiovascular function by using parameters like -
-Heart rate
- Blood pressure monitoring
- Capillary refill time ( Poorly validated sign).

5. Where is the need for functional ECHO ?
The use of these indirect measures for assessment of tissue perfusion is
Problematic especially in the very preterm neonate during the first few
postnatal days, when complex hemodynamic changes occur during the
transition to postnatal life.
Indirect measures provide only indirect and frequently limited insights
into the -
1. Complexities of cardiac function
2. Changes in peripheral and pulmonary vascular resistance.
3. Intra-cardiac and extra-cardiac shunt
4. and the transitional circulation of the neonate.

6. Functional echocardiography is a growing area of interest in the
management of the preterm transitional circulation. It can provide
1. Objective evaluation of cardiac function and output.
2. Neonatologist can identify whether patent ductus Arteriosus is
Haemodynamically significant or not.
3. and allow evaluation of therapeutic interventions.
Functional echocardiography combined with clinical parameters may
identify neonates who truly have impaired end-organ perfusion and allow
targeted therapy.

7. Targeted Neonatal Echocardiography (TNE)
Functional echocardiography (fn ECHO)
TNE is indicate in New Born when they are Suspected to have -
Patent ductus arteriosus (PDA)•
Cyanosis
Persistent pulmonary hypertension - excluding Structural heart disease•
The infant with heart failure
Hypotension or shock•
Newborn with heart murmur•
Central line placement•
Suspected effusion•
Functional echocardiography is ―The bedside use of echocardiography to longitudinally assess
myocardial function, systemic and pulmonary blood flow, intra-cardiac and extra-cardiac shunts,
organ blood flow, and tissue perfusion‖. Done after ruling out CHD‘s.
Routine screening for Congenital heart disease is must before doing Fn ECHO, as it provide
early diagnosis of congenital heart diseases along with better understanding of neonatal
hemodynamics.

8. What are the indications of Functional
ECHO ?
Standard TNE Focus TNE
Suspected PDA Suspected effusion
Perinatal asphyxia Central line position
Shock ECMO cannulation
Suspected PPHN
Cong. Diaphragmatic
Hernia

9. Technique of ECHO
Pediatric ECHO is done with4-12 MHz Pediatric probes in following planes.

10. 1. Transverse subcostal view To look for abdominal situs
AO
IVc
IVC AORTA

11. 2. Subcostal atrial and four
chamber views
SVC drains into right atrium, pulmonary veins into left atrium
Intact intra-atrial septum (or patent foramen ovale)
Intact intra-ventricular septum
Sweep anterior to ascending aorta and pulmonary artery
LA LA
RA
RV
LV
Ao
liv

12. 3. Apical four chamber view Normal mitral and tricuspid valves, with tricuspid positioned closer to the apex of the heart.
Establish atrio-ventricular concordance
Intact intra-ventricular septum
Rotate to ‗five chamber view‘ to identify normal aortic valve from the left ventricle
Demonstrate pulmonary artery from the right ventricle crossing over aorta, excluding transposition (i.e. establishing
ventriculo-arterial concordance)
Pulmonary veins draining to left atrium
AO
LA
RA
RV
LV

13. 4. Parasternal long axis view Normal motion of mitral and aortic valves
Intact intra-ventricular septum
Identify normal mitral valve
Identify normal aortic valve
LV
MV

14. RA
PA
TV
RV
AO
5. Parasternal short axis view Identify normal (tricuspid) aortic valve
Intact intra-ventricular septum
Identify normal pulmonary valve
Identify bifurcation of main pulmonary artery into right and left branches
Confirm drainage of pulmonary veins into left atrium

15. LA
PA
DAO
Pulsatile PDA flow
A
O
6. Ductal view Check ductal patency and direction of
flow

16. LA
LPA DAO
AO RTA
7. Arch view To demonstrate aortic arch and
Exclude co-arctation

17. View Demonstrates
1. Transverse subcostal view Normal abdominal situs
2. Subcostal atrial and four chamber views SVC drains into right atrium, pulmonary veins into left atrium
Intact intra-atrial septum (or patent foramen ovale)
Intact intra-ventricular septum
Sweep anterior to ascending aorta and pulmonary artery
3. Apical four chamber view Normal mitral and tricuspid valves, with tricuspid positioned closer to the
apex of the heart.
Establish atrio-ventricular concordance
Intact intra-ventricular septum
Rotate to ‗five chamber view‘ to identify normal aortic valve from the
left ventricle
Demonstrate pulmonary artery from the right ventricle crossing over
aorta, excluding transposition (i.e. establishing ventriculo-arterial
concordance)
Pulmonary veins draining to left atrium
4. Parasternal long axis view Normal motion of mitral and aortic valves
Intact intra-ventricular septum
Identify normal tricuspid valve
Identify normal pulmonary valve
5. Parasternal short axis view Identify normal (tricuspid) aortic valve
Intact intra-ventricular septum
Identify normal pulmonary valve
Identify bifurcation of main pulmonary artery into right and left
branches
Confirm drainage of pulmonary veins into left atrium
6. Ductal view Check ductal patency and direction of flow
7. Arch view Exclude coarctation

18. Hypotensive neonate - Fn Echo
Blood pressure and Systemic Blood Flow (SBF) do not enjoy a direct relationship in the newborn.
Often, babies have low SBF with normal blood pressure and vice versa.
The hypotension has varied etiology in the neonate such as
Poor myocardial function as the result of asphyxia,
Pathological vasodilation in septic shock or asphyxia, or, less frequently,
Hypovolemia with cardiac under filling caused by fluid or blood loss.
The appropriate management varies in each case.
Echocardiography differentiates between these situations, combining measurement of cardiac
output, assessment of cardiac filling, and myocardial function and even exclusion of life-
threatening pathology, such as a pericardial effusion tamponade from an extravasation of a
central line or from other causes.

19. Estimation of Preload
This is one of the most valuable uses for functional echocardiography in the NNU, particularly
to guide aggressiveness of fluid resuscitation in the collapsed neonate. However measures
have not currently been standardized, so assessments of filling volume are subjective.
Inferior Vena Caval Filling : To assess IVC filling place the ultrasound transducer in the
midline, just below the xiphisternum, and in the sagittal plane. The probe marker should be
pointing upward, so that the heart appears just visible on the right of the screen. The IVC can
be seen coursing through the liver.
A normally filled IVC will have some pulsation with the cardiac cycle and respiratory motion.
An under-filled IVC will be barely visible, or collapse entirely on inspiration

20. Cardiac tamponed
Pericardial Eff
IVC
No change in diameter of IVC during inspiration and expiration

21. Superior vena cava flow - Systemic Blood Flow (SBF)
The superior vena cava is formed by the confluence of the left and right brachiocephalic veins,
which drain blood from the arms, head, and brain. Approximately 80% of this blood is estimated
to be returning from the brain in infants. Therefore, the measurement of SVC blood flow is
potentially a marker of cerebral blood flow.
A significant number of preterm babies develop low systemic blood flow during the first day of
life which may not be accompanied by hypotension. This low SBF has been associated with both
long and short term adverse outcomes.
SBF in neonates is better measured by superior vena caval flow and not by cardiac output. Low
SBF also relates to larger ductal shunts, so assessment of the early constriction of the ductus
arteriosus is important in early echocardiographic assessments.

22. —After the first 24 hours, SBF is usually low in normotensive neonates whereas hypotensive
babies have normal or high SBF, indicating low peripheral vascular resistance that is
probably due to abnormal regulation of vascular tone.
Low SVC flow may result from an immature myocardium struggling to adapt to increased
extra-uterine vascular resistances.
Critically low flow occurs when this is compounded with high mean airway pressure and large
ductal shunts out of the systemic circulation.
Late IVH is strongly associated with these low flow states and occurs as perfusion improves.

23. Superior vena caval flow
An increase in the SVC flow occurred throughout the first 48 hours, possibly as a result of the
improvement in myocardial function that occurs as the heart adapts to extra uterine life. The
increase might also reflect closure of fetal channels, in particular the ductus arteriosus, which
might be shunting blood away from the systemic circulation.
The term infant group generally had similar SVC flows to the well preterm group, confirming
that well preterm and term infants have a similar circulatory transition to postnatal life.
Marker of upper body blood flow : Since left ventricular output includes blood about to pass
through the PDA and right ventricular output includes blood which has already passed through
the patent foramen ovale neither measure reflects true systemic blood flow. To circumvent this
problem Nick Evans and Martin Kluckow realized the potential of measuring the volume of
superior vena caval flow as a marker of upper body blood flow.

24. The superior vena caval Internal Diameter is measured from the subxyphoid sagittal view or
from a right parasternal view by echo machine with Probe 4-12 Hz, to obtain a more accurate
measurement.
It is especially important to obtain the full diameter, as the SVC can ―hide‖ behind the
ascending aorta. The minimum and maximum diameters were taken at the point where the SVC
starts to open up into the right atrium and averaged from 3 to 5 cardiac cycles.
Flow velocity is measured from the low subcostal view with the probe directed towards the
SVC. Since SVC flow is venous flow, the beat to beat variability is of importance. Spontaneous
respiration will influence flow velocity, therefore it is advised to take at least 10 to 15 cycles
to average flow velocity.
SVC flow and the left ventricular and right ventricular outputs were expressed in ml/kg/min
How to measure SVC flow ?

25. SVC flow is measured using the method described by Kluckow et al. The mean velocity of
blood flow was calculated from the integral of the Doppler velocity tracings and was
averaged from five consecutive cardiac cycles. Diameter measurements were averaged
from three cardiac cycles.
The SVC flow was calculated using the formula:
=
velocity time integral x (π x mean SVC diameter²/4) x Heart rate
𝒃𝒐𝒅𝒚 𝒔𝒖𝒓𝒇𝒂𝒄𝒆 𝒂𝒓𝒆𝒂
Left and right ventricular output using the method described previously in the literature.
The mean velocity of blood flow was calculated from the integral of the Doppler velocity
tracings and was averaged from five consecutive cardiac cycles. Diameter measurements
were averaged from three cardiac cycles.
VLBW infants who had low SVC flow in the first 24 h, may be associated with early
neonatal death and/or severe IVH.
LVO or RVO < 150 mL/kg/min as the definition of low flow.

26. Echocardiogram of a normal superior vena caval pulse wave Doppler ultrasound velocity spectral display.
S
D
A
The SVC flow pattern is pulsatile with two peaks as described previously by Froysaker, the first
associated with ventricular systole (the S wave) and the other with early ventricular diastole (the
D wave). In addition, frequently there is short periods of reverse A wave ( Atrial systole). The
Doppler range gate positioned at the junction of the superior vena cava (SVC) and right atrium. An
example of the spectral display obtained is shown, with the S, D, and A waves. The superior vena
cava (SVC) imaged from the parasternal long axis view as it enters the right atrium.

27. Left ventricular Cardiac Output (LVO)
M mode – Ao Diameter Apical 5 C view Apical 5 C view –> Ao flow -> VTI Apical 5 C view –> Ao flow
–> VTI -> HR
Apical 5 C view –> Ao flow –
-> VTI ->HR -> AO Diameter
Cadiac ouit

28. 2 D ECHO – SVC
Supra sternal long axis Sub costal SVC view

30. an increase in the SVC flow occurred throughout the first 48 hours, possibly as a result of the
improvement in myocardial function that occurs as the heart adapts to extrauterine life. The
increase might also reflect closure of fetal channels, in particular the ductus arteriosus, which
might be shunting blood away from the systemic circulation.
The term infant group generally had similar SVC flows to the well preterm group.
Key messages + Superior vena cava flow oVers a noninvasive means to assess systemic blood
flow in newborn infants + Superior vena cava flow increases over the first 48 hours in well term
and preterm infants F186 Kluckow, Evans confirming that well preterm and term infants have a
similar circulatory transition to postnatal life.
Day 1 Day2
SVCflow –ml/kg/min 76 ( 34-143 93955-111_
SVC velocity time
integral(m/s)
0.109(0.057-0.175 0.147(0.099-0.177)
SVC maximum diameter (mm) 5.3(3.6-6.2) 5 (3.7-6.3)
SVC minimum diameter(mm) 4.3 (2.7-5.2) 4.2 (2.6-5.3)

31. It (Fn ECHO ( TNE) has recently been used to measure vena cava blood (SVC) flow, of which
approximately 80% is estimated to be venous return from the brain.
The aim of Fn ECHO is to assess the relationship between low SVC flow states and adverse
outcome, defined as intra-ventricular hemorrhage (IVH) grade >II and/or early neonatal death.
A secondary objective is to assess the relationship between SVC flow and measures of cardiac
output (right ventricular and left ventricular output).
Original article F368 Arch Dis Child Fetal Neonatal Ed 2008;93:F368–F371.
doi:10.1136/adc.2007.129304 Downloaded from fn.bmj.com on 3 October 2008 end-organ
perfusion (anterior cerebral artery (ACA) velocity parameters).
Superior vena cava flow (SVF) is a novel marker non-invasive means to assess systemic blood
flow in newborn infants.
Superior vena cava flow increases over the first 48 hours in well term and preterm infants

32. Pre-term Term
Mean Range Median Mean Range Median
Birth weight 2.01±0.23 1.5-2.5 1.9 3.10±0.27 >2.5 3.00
Gestational age
(weeks)
35.77±0.86 34-37 35 39.12±1.01 37-41 39
SVC flow
(ml/kg/min)
62.5±20.93
32% of LVCO
18-143 57.83 58.89±19.11
34.5% of LVCO
35-136 56
LV CO (ml/kg/min) 204.88±70.7 115-444 189 203.31±61.88 85-348 205
Clinical characteristics and echocardiography derived normal blood flow in preterm and term
neonates LVCO : left ventricular Cardiac Output

33. GESTATIONAL
AGE (weeks)
LV OUT PUT
(ml/kg/min)
Mean±SD
SVC flow
(ml/kg/min)
Mean±SD
r value P value LVCO/SVC Flow
%
34 - >37 204.88±70.74 62.5±20.93 0.56 <0.0001
32
>37 203.31±61.88 58.89±19.11 0.40 0.002
34.5
Co-relation between SVC flow and LVO in term newborn
on life day one.
Unpublished data

34. LEFT SYSTOLIC VENTRICULAR
FUNCTION
Systolic Functions Image mode
LVFS
Change of LV short axis
dimension
M-mode
LVEF
Change of LV short axis
dimension
M-mode
mVCF M-mode
LA/Ao Left atrial volume loading Color Doppler
Visual Assessment
LV area change/ LV wall
thickening
2D
LV MPI Color Doppler

35. Left ventricular ejection fraction (LVEF)
represents stroke volume as a percent of end-
diastolic volume.
LVEF = LVSV/LVEDV x 100% =
(LVEDV - LVESV)/LVEDV x 100%.
Normal range is above 55 %.[
Left Ventricular Fractional Shortening
FS = (LVIDd - LVIDs) / LVIDd x 100%,
LVIDd - LV internal diameter diastolic,
LVIDs – LV internal diameter systolic.
Normal values – Term babies 25-41%
Preterm 23-40%
>25% (M-mode), >18% (2-D mode)

36. Mean Velocity of Circumferential Fibre
Shortening (MEAN V C F)
. mVCF = LVDD-LVSD/LVDD x LVET
where LVET = left ventricular ejection time
Normal value: 1.5 +/- 0.04 circle/sec.

37. The aortic root is an area stretching from the aortic annulus to the proximal ascending
aorta, including the sinuses of Valsalva and the supra-aortic ridge. There are considerable
differences in diameter of the aortic annulus and sinuses of Valsalva in children and
adults
LVO diameter is obtained in the parasternal long axis view, and
Flow velocity from the subcostal to apical view or the high suprasternal view. LVO measurements
using Doppler ultrasound in newborns

38. Left atrial /aortic ratio (LA/Ao):
Optimal threshold ratio > 1.5
Valve more than > 1.5 suggestive of
Pulmonary hyperperfussion
As in haemodynamically significant PDA hsPDA

39. Tei index is influenced by
High Heart rate
Pre and afterload of ventricle.
Tei index =
𝑎−𝑏
𝑏
Tei index =
𝐼𝐶𝑇−𝐼𝑅𝑇
𝐸𝑇
Normal value : 0.25-o.38
 0.38 indicate poor
systolic/diastolic dysfunction.
ICT IRT
ET

40. In our study we observed –
1. The mean value of LV fractional shortening (LVFS) was 32.19% with a standard deviation of
5.79%, while its 95% confidence limits ranged from 31.05-33.34%.
2. The mean ± SD of LV ejection fraction (LVEF) was 59.90±9.27% and its confidence limits
range was 58.06-61.75%.
3. The mean value of mVCF was 1.72±0.58 circles/sec and its confidence limits ranged from
1.60-1.84 circles/sec .
4. While the mean LA/Ao ratio and its confidence limits were 1.03±0.19 and 0.99-1.06
respectively.
5. The mean value and confidence limits of LV myocardial performance index were 0.79±0.27
and 0.74-0.85.
Unpublished data

41. Parameters Mean±SD Range 95% Confi.
Limit
LVFS 32.19±5.79 19.0-53.0 31.05-33.34
LVEF 59.90±9.27 42.4-86.0 58.06-61.75
mVCF 1.72±0.58 0.90-2.92 1.60-1.84
LA/Ao 1.03 ± 0.19 0.70-1.70 0.99-1.06
LV MPI 0.79±0.27 0.27-1.46 0.74-0.85
Visual
assessment
Good(101)
Left ventricular systolic functions
Normal value
Unpublished data

42. Diastolic
functions
E/A ratio
Mitral inflow
pattern
Pulse wave
Doppler
E/e’ ratio
Mitral annular
velocities
Pulse wave with
TDI
Pulmonary venous
inflow patterns
Pulse wave
Doppler
LEFT DIASTOLIC VENTRICULAR
FUNCTION

43. The normal trans-mitral flow profile has two peaks - an E and an A wave.
The E peak arises due to early diastolic filling. Most filling (70-75%) of the ventricle occurs during
this phase.
The A peak arises due to atrial contraction, forcing approximately 20-25% of stroke volume into
the ventricle.
The deceleration time (DT) is the time taken from the maximum E point to baseline. Normally in
adults it is less than 220 milliseconds.
The E/A ratio is a marker of the diastolic function of the left ventricle of the heart.
It can be measured on echocardiography, an ultrasound-based cardiac imaging modality.
Abnormalities in the E/A ratio on Doppler echocardiography suggest that the left ventricle, which
pumps blood into the circulation, cannot fill with blood properly during left ventricular diastole
that is in between two consecutive LV contractions.
This phenomenon is referred to as diastolic dysfunction and can eventually lead to the symptoms
of heart failure.

44. E/A Ratio
Mitral valve inflow patterns measured
as E/A ratio.
An initial rush of blood in early
diastole, the E wave.
This is followed by a period of low or
no flow, also known as diastasis.
In end-diastole, atrial contraction
produces a final rush of blood into the
ventricle, the A wave.

45. During Fetal life ventricular filling dominant during atrial contraction - Prominent A wave as
compare to E wave.
After birth ventricular filling dominantly occur during early diastole when atrioventricular valve
opens, before atrial contraction – thus E wave become prominent as compare to A wave .
Ventricular filling velocity Ratio of E : A
Term baby >0.7: 1
Preterm >0.6: 1
When there is Diastolic dysfunction
Ventricular filling occur during
Effective atrial contraction that is
At the end of ventricular diastole and
A wave become prominent as compare
to E wave and A:E ratio become
Reverse.
E/A Ratio

46. E/e‘ Ratio
In E/e' ratio the diastolic peak velocities
of the mitral annulus, are measured both
medially and laterally using Tissue Doppler
Imaging (TDI).
The normal E/e' ratio from the medial
annulus is <8 and suggests a normal left
atrial pressure.
While values between 8 and 12 are
indeterminate, a value >12 is indicative of
an elevated left atrial pressure or PCWP
(>18mmHg).
The ranges for E/e' from the lateral
mitral annulus are <5, 5 -10 and >10
respectively.

47. Pulmonary Vein Flow
The normal pulmonary vein flow profile is usually biphasic
with a predominant systolic forward flow (S wave) and a
less prominent diastolic forward flow wave (D wave).
Occasionally, there may be a triphasic flow pattern with
two distinct systolic flow waves of which the initial flow
into the left atrium results from atrial relaxation followed
by a further inflow due to the increase in pulmonary venous
pressure. The D-wave occurs when there is an open conduit
between the pulmonary vein, LA and LV and reflects the
trans-mitral E wave. A retrograde flow wave into the
pulmonary vein (A wave) occurs during atrial contraction
and its amplitude and duration are related to LV diastolic
pressure, LA compliance and heart rate.
Pulmonary venous examination is essential for estimation of left atrial pressure.

48. 1. The mean value ± standard deviation of E/a ratio was 0.99±0.028, the 95% confidence
interval was 0.94-1.05.
2. The mitral valve annular velocities studied at lateral valve had the mean value 10.45 ± 1.49
(95%C.I - 10.16-10.75) while the value at medial valve was 8.02 ± 1.74 (95%C.I - 7.68-8.37).
3. The values of pulmonary inflow patterns i.e mean peak systolic velocity was 43.31 ± 13.11
cm/sec (95% C.I - 40.72-45.90), mean peak diastolic velocity was 26.68±12.00 cm/sec
(95%C.I - 24.31-29.05) ,the mean S/D ratio was 1.89±0.85 and the retrograde pulmonary
flow measured as A wave velocity was 43.25 ± 10.93 cm/sec (95%C.I - 41.09-45.41). The
mean duration of the A wave was 140.80 ± 33.99 millisecond.
Unpublished data

49. Parameters Mean ± SD Range 95% Confi.
Limit
E/A 0.99±0.028 0.60-1.90 0.94-1.05
E/e’ Lateral 10.45±1.49 5.20-16.70 10.16-10.75
E/e’ Medial 8.02±1.74 4.50-14.90 7.68-8.37
Pulmonary venous inflow patterns
Systolic 43.31±13.11 10.80-79.70 40.72-45.90
Diastolic 26.68±12.00 13.20-67.90 24.31-29.05
S/D ratio 1.89±0.85 0.37-4.48 1.52-2.26
A wave velocity 43.25±10.93 11.90-69.20 41.09-45.41
Duration of A
wave (in m sec.)
140.80±33.99 18.0-267.0 134.08-147.52
Left ventricular Diastolic functions
(normal value)
Unpublished data

50. The ductus arteriosus is a connection between pulmonary artery to aorta (systemic shunt during
fetal life, where it carries most of the RVO to Systemic circulation.
Shortly after birth : This shunt reverses due to an increase in systemic vascular resistance
(release from the low-resistance placental circulation) and a decrease in the pulmonary vasculature
resistance (lung inflation). The shunt becomes systemic to pulmonary (left to right, LR) as long as
systemic pressure is higher than the pulmonary pressure throughout the cardiac cycle. The ductal
shunting can be associated with reduced LVO but with a normal venous return from
the lower body.
Normally the DA closes soon after birth and the shunt disappears, blood flow decreases and
blood pressure rises in the first day after birth in healthy term and late-preterm
infants. In contrast, very preterm infants show a rise in blood flow and blood pressure in
the first week of life.
But the process of DA closure is often delayed in very preterm and sick newborns
Persistent Pulmonary Hypertension :
With significant right-to-left (RL) shunt, pulmonary blood flow decreases, ductal shunting can be
associated with LVO but with a normal venous return from the lower body.

51. The dominant direction of ductal shunting in the early postnatal period is left to right.
The early left-to-right shunting results in consequences such as
Reduced systemic blood flow and blood pressure
Increased ventilatory requirements, and
Pulmonary hemorrhagic edema.
These hemodynamic effects may paradoxically be more important in the early hours after birth
rather than later in the clinical course.
These findings, indirect support to the emerging suggestions regarding early/prophylactic
therapy of the PDA and subsequent tolerance of the PDA in older infants who do not have
cardiac failure.
Ductal shunting

52. Measurement of ductal diameter - Ductal diameter is probably the most important parameter
to determine the degree of ductal shunting. Commonly, the duct is wide on the aortic side
with constriction starting at the pulmonary site of the duct.
Maximum LR flow velocity and flow pattern – turbulent in LPA (continuous, pulsatile, bidirectional
including % R->L shunt, that is, the amount of time of the cardiac cycle blood flows right to left).
The ratio between the dimensions of the left atrium and the aorta (LA/Ao ratio), >1.5
Diastolic flow in Left pulmonary artery - > 0. 2m/sec diastolic velocity (LPAd) and
Measuring the flow pattern of the descending Aorta (DAo), the cerebral arteries, or the
abdominal organ arteries. Diastolic flow in ascending of descending aorta – suggestive of steal
phenomenon.
Left side heart volume over load – Mitral regurgitation.
Evaluation of PDA -
Haemodynamically Significant PDA (hs PDA)

53. Evaluation of PDA
Haemodynamically significant PDA - yes /no
PULMONARY HYPER PERFUSION LA/AO > 1.6, INCREASE PUL
VENOUS RETURN
LA/AO < 1.4
LA/AO >1.4

54. PDA CHARACTERISTICS DUCTAL SIZE > 2MM
PULSATILE PDA DOPPLER
NO PDA CONTRICTION
NON RESTRICTIVE L-> R
BIDIRECTIONAL
RESTRICTIVE L-> R
Tiny PDA
PDA reversal Right -> Left
PA
DAO
NON RESTRICTIVE L-> R

55. SYSTEMIC HYPOPERFUSION RETRO GRADE FLOW IN -
DESCENDING AORTA
CELIAC AXIS OR SMA
MCA
RETROGRADE FLOW IN DAO
RETROGRADE FLOW IN CELIAC AXIS

56. Echocardiography A. PDA diameter B. Pulmonary over circulation C. Systemic hypo-perfusion
criteria
Tiny PDA Only Doppler Detectable No No
Small PDA <1.5 MM La:Ao <1.4 normal No
Moderate volume 1.5mm to 3.0mm with At least two of the following Absent diastolic flow in at least
(A + B &/or C) unrestrictive pulsatile flow La:Ao ratio 1.5 – 2.0 Two of the following
shunt (Vmax < 2m/s) IVRT 45 – 55 msec Abd. Aorta, Celiac trunk
E:A ratio 1.0 Middle cerebral artery
LVO 300 – 400 mls/kg/min
Large volume shunt > 3.0 mm with unrestrictive At least two of the following Reversed diastolic flow in
(A + B + C) pulsatile flow (Vmax < 2m/s) La:Ao ratio > 2.0 IVRT flow in at least two
IVRT < 45 msec flow in at least two
LVO > 400 mls/kg/min Abdominal aorta Celiac trunk
Middle cerebral artery

57. Persistent Pulmonary Hypertension of
Newborn
Echocardiography is not only diagnostic of PPHN but also helps in monitoring changes over
time and responses to treatment such as vasopressor-inotropes, inotropes, and
vasodilators.
Echocardiography is a preferred tool for diagnosing and monitoring PPHN, despite a lack
of reliable measures.
1.Tricuspid regurgitant jet peak velocity (TRJV)
2. Interventricular septal shape
3. and direction of Doppler flow across an intra-atrial shunt and patent ductus arteriosus
(PDA) are commonly used indices.

58. Echocardiographic parameter Type of assessment Echocardiographic view
Right ventricular hypertrophy and or dilatation ‗Eyeballing‘ visual assessment (qualitative);
or RV/LV ratio (quantitative)
Apical 4-chamber view, parasternal long and
short axis views
Estimation of PASP Quantitative assessment by measuring TR Apical 4-chamber view
Assessment of ductus arteriosus shunt Qualitative assessment
Right-to-left shunt suggests supra-systemic
pulmonary artery pressure
High left parasternal ‗ductal‘ view
Assessment of shunt via foramen ovale Qualitative assessment
Often bi-directional shunt in PPHN
Sub-costal view or apical 4 chamber view
Evaluation of IVS and LV shape Qualitative assessment on visual inspection –
flattening or bowing on IVS towards LV
suggests pulmonary hyper-tension
Parasternal short axis view
Assessment of cardiac filling (preload) Qualitative assessment on visual inspection Apical 4-chamber view, parasternal long and
short axis views
Assessment of cardiac functions (RV andLV functions) Qualitative assessment on visual inspectionor
quantitative assessment;TricuspidAnnular
Plane Systolic Excursion (TAPSE)Tissue
Doppler imaging – S‘waveMyocardial
performance index of RV and LV functionRV
systolic to diastolic (S/D) duration
Eccentricity index of LV
Apical 4-chamber view, parasternal long and
short axis views

59. Eye balling RV hypertrophy
RV/LV RATIO Dilated RV
Flatting or bowing of IVS towards LV Dilated RV
Pulmonary Arterial Systolic Hypertension
Dilated

60. PDA Right to left flow
PFO Bidirectional flow
TR OR PR PULMONARY ARTERIAL SYSTOLIC PRESSURE
RV function Tricuspid annular plane systolic excursion – TAPSE
Myocardial performance index- MPI RV
RV systolic/diastolic ratio
Pulmonary Arterial Systolic Hypertension
Right to left flow
PAH flow from RV -> PA -> PDA -> DAO

61. Atrial shunting
The atrial septum can be imaged from a subcostal four-chamber view, adding color flow Doppler
mapping with colour scale setting for low velocities to assess shunts across the septum.
The diameter can be measured using the color flow jet across the septum or by using 2D images.
The pulsed wave Doppler gate is placed in the interatrial shunt at the level of the atrial septum
to determine flow direction and flow velocity.
The pattern of flow should then be classified as left to right, bidirectional, or right to left.
Upto 30% right to left shunting is normal in newborn
Persistant right to left shunt with reduce LA/AO ratio Suggest – PPHN Presistant pulmonary
arterial hypertension.
When the pattern is bidirectional, the proportion of the cardiac cycle with right-to-left
shunting could be measured as the time of right-to-left shunting divided by the total length of
the cardiac cycle as described for ductal flow patterns.

62. PFO Bidirectional flow
TR OR PR PULMONARY ARTERIAL SYSTOLIC PRESSURE
RV function Tricuspid annular plane systolic excursion – TAPSE
Myocardial performance index- MPI RV
RV systolic/diastolic ratio

63. RV Systolic to Diastolic duration ratio
Systolic to diastolic duration ratio (S:D ratio) in
children with pulmonary arterial hypertension (PAH) and
its association with right ventricular (RV) performance.

64. PPHN PDA REVERSAL
RV
RA TR
TR
AO
PDA FLOW

65. SYSTOLIC PULMONARY ARTERY PRESSURE
Pulmonary artery pressure is assessed using three methods:
1. Pulmonary artery Doppler acceleration time
2. ductal shunt velocities
3. and tricuspid incompetence (TI) velocities.
The most accurate method to measure systolic pulmonary artery pressure (SPAP) is
accepted measuring Tricuspid regurgitation.
Assessment of SPAP from ductal shunt velocities is used if there is no TI.
If neither is present, then no figure for SPAP can be derived.

66. Pulmonary artery time to peak velocity (TPV) to
right ventricular ejection time (TPV:RVET) ratio
This is measured in the main pulmonary
artery as an index of pulmonary artery
pressure. This ratio is inversely related to
pulmonary artery pressure and is normally
above 0.34. A value of <0.31 suggests
pulmonary hypertension with a sensitivity
and specificity above 90%.
A standard measurement procedure is used
and the ratio is averaged from three to five
cardiac cycles
RVET : 217 MS
TPK : 63 MS

67. Tricuspid annular plane systolic excursion
(TAPSE)
Tricuspid annular plane systolic excursion reflects systolic displacement of the tricuspid annulus
toward the RV apex along the longitudinal axis, and it closely correlates with RV EF.
Even more importantly, TAPSE is not dependent on RV geometry and is less influenced by imaging
artifacts. Normal range 9.2 (6-12) mm. <4 suggest high PAH.
Lammers et al. reported that TAPSE and PAAT are good predictors of RV systolic function.
TAPSE can be indexed to body surface area (TAPSE/BSA). TAPSE and TAPSE/BSA were
significantly lower in PH patients. PAH significantly increased with each 1 mm decrease in TAPSE.

68. TAPSE
TAPSE is usually acquired by
placing the M-mode cursor
through the lateral tricuspid
annulus and measuring the
amount of longitudinal motion
of the annulus in peak systole.
The assessment of TAPSE has
several benefits—it can be
easily measured on
echocardiography in real time
without need of any offline
assessment or special software

69. Right Ventricular Output (RVO)
The right ventricular outflow tract and pulmonary valve lie very close to the anterior chest wall,
making Doppler measurements easy.
Most studies use the parasternal view to visualize the pulmonary annulus for diameter
determinations in end systole, using the hinges of the pulmonary valve as reference point.
The pulmonary artery ID is measured in the parasternal short-axis view distal to the pulmonary
valve i.e., the distance between the luminal bright edges of the pulmonary artery, from a
midsystolic frame.
Flow velocity can be measured using the same view. Diastolic flow and/or turbulent flow
from ductal shunting can make flow velocity measurements difficult, as precise tracing
of the pulmonary waves is not always possible.
LVO or RVO < 150 mL/kg/min as the definition of low flow,

70. Key Messages on the Role of Functional Echocardiography in the NICU
1. First echocardiogram should include a detailed structural assessment to rule out significant congenital heart
defects or define normality.
2. Functional echocardiography is the investigation of choice in diagnosing pulmonary hypertension and assessing its
severity. When clinically suspected, treatment should not be delayed while waiting for the echocardiography.
3. While the treatment of PDA remains controversial, a detailed evaluation of hemodynamics may help in rationalising the
treatment approach - selecting the right patients for the right intervention at right time.
4. Echocardiography is mandatory in infants with PDA before any medical or surgical intervention.
5. Functional echocardiography may give added physiological information in infants with neonatal shock which can help in
identifying the underlying pathophysiology and providing condition specific treatment.

71. Key Messages on the Role of Functional Echocardiography in the NICU
6. Functional echocardiography may help in adopting a physiology-based logical approach to treatment in infants with
hypotension or shock – it may be used in choosing fluid resuscitation therapy or inotropic therapy, and further what type
of inotrope or vasopressor therapy indicated based upon preload, afterload and cardiac function on echocardiographic
assessment.
7. A structured training program specifically designed for the neonatologists to acquire echocardiography skills is
urgently needed. Adherence to standardized protocols and robust clinical governance is the key to ensure that high
standards of echocardiography skills are being delivered in the NICU.
8. A close collaboration with pediatric cardiologists and neonatologists performing functional echocardiography is
recommended.