Targeted Neonatal Echocardiography and Cardiac Point-of-Care Ultrasound in the Neonatal Intensive Care Unit
Publication Date: February 1, 2024
Last Updated: February 1, 2024
Summary of Recommendations
LVEF should be measured using either the area-length or Simpson biplane method.
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All standard TNE studies should consider including transmitral flow (E/A ratio, IVRT) and a measure of LA size. Measurement of pulmonary vein velocities may be considered.
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LVO should be routinely measured. Imaging to determine the diastolic flow direction centrally (descending aorta) and peripherally (celiac artery, superior mesenteric artery, middle cerebral artery) should be performed where ductal shunt significance is in question.
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Objective measurement of RV systolic function including TAPSE, RV FAC, and RVO should be performed.
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All standard TNE studies should include continuouswave Doppler of any TR and/or PI jet, systolic EI, and evaluation of PA Doppler waveform for PVR index and the presence of notching.
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All standard TNE should include an assessment for the presence and directionality of shunts. Evaluation of the PDA should include measures of LA volume loading and SBF as detailed in Section 3.
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All standard TNE evaluations should include an assessment of the position of any central lines (Table 3, Figures 21 and 22), an exclusion of pericardial effusion (Table 3, Figure 23), and surveillance for potential complications such as thrombosis and/or vegetations (Table 3, Figure 24).
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Where normative data exist, Doppler tissue imaging provides additional information on myocardial performance and should be included in a standard TNE assessment as part of a multiparametric appraisal of heart function. Myocardial velocities should be considered when there is suspected heart dysfunction and disagreement between other modalities (e.g., TAPSE, RV FAC).
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When performing standard TNE, STE may provide ancillary data regarding systolic performance, segmental abnormalities, and load dependency; however, natural history data are limited to date in the neonate, and further research is needed.
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A neonatologist with advanced training in TNE may perform standard TNE as the first study in patients with a low index of suspicion for CHD, but the study should include the essential views and sweeps to enable anatomic assessment. At centers with on-site pediatric echocardiography laboratories, these studies should be reviewed within a timely manner on the basis of local standards. At centers without on-site pediatric cardiology, when significant CHD is suspected or diagnosed, transfer to a site with pediatric cardiology or remote pediatric cardiology study review should occur.
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A neonatologist-performed cPOCUS evaluation may include evaluation of central catheter tip location, identification of pericardial or pleural effusions, subjective (‘‘eyeballing’’) evaluation of inferior vena caval collapsibility as a surrogate of hypovolemia, and subjective evaluation of myocardial systolic performance. If a cPOCUS study is the first patient evaluation, a timely standard TNE evaluation or complete pediatric cardiology echocardiography evaluation is recommended.
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In every neonate with clinical suspicion for PDA, or those <28 weeks’ gestation, the first standard TNE study to characterize hemodynamic significance of PDA should be sufficiently comprehensive to exclude major CHD, especially ductal-dependent systemic or pulmonary blood flow lesions. Subsequent TNE may be useful in follow-up to document spontaneous closure or the effect of treatment. Patients suspected of an additional cardiovascular malformation should be referred for pediatric cardiology review, or transfer if indicated, in a timely manner.
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Preterm infants with persistent need for respiratory support (continuous positive airway pressure or mechanical ventilation) and/or prolonged oxygen need should be considered for standard TNE evaluation to screen for the presence of PH and rule out CHD. Infants born before 29 weeks’ gestation should be considered for a screening TNE assessment at 8 postnatal weeks or 36 weeks’ postmenstrual age (whichever is sooner) to assess for the presence of BPD-associated PH. TNE allows assessment of the effect of treatment on PAP, RV function, shunt direction at the atrial and ductal levels, and screening for pulmonary vein stenosis.
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Infants with HIE and hemodynamic instability and/or oxygenation failure should undergo standard TNE as soon as feasible to appraise pulmonary pressures, myocardial function, and cardiac output. Hemodynamically stable patients with moderate to severe HIE may benefit from screening to evaluate for subclinical disease and support prognostication.
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In IDMs with clinical signs of low cardiac output or PH, standard TNE should be performed to exclude CHD and evaluate the degree of dynamic obstruction to the LV outflow tract, diastolic and systolic dysfunction, and impact on the pulmonary vasculature.
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Infants with TTTS, regardless of antenatal treatment with SLPCV, should undergo standard TNE assessments to identify pulmonary or systemic hemodynamics, characterize loading conditions and assess myocardial performance.
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Infants with confirmed or suspected DS should undergo standard TNE assessment soon after delivery to assess structural integrity, presence of PH, and adequacy of myocardial performance. Postdischarge follow-up is recommended and should be determined on the basis of the initial findings.
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Standard TNE might provide additional diagnostic information regarding causality and guide medical management in hypotensive neonates or those with suspected low–cardiac output state. TNE should be considered in in any neonate who presents with sepsis-like symptoms, especially in the setting of a known maternal viral prodrome. These infants should be serially monitored for cardiomyopathy, arrhythmias, and potential circulatory collapse.
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In a patient with hypoxemia, standard TNE is important to facilitate diagnostic appraisal, guide the institution of pulmonary vasodilators, inotropes or vasoactive agents, and enable rapid triage of patients for pediatric cardiology review when anatomic abnormalities are unexpectedly identified. Longitudinal hemodynamic assessment with echocardiography can guide monitoring and refinement of therapeutic intervention.
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Standard TNE, which includes the essential views and sweeps to enable exclusion of major CHDs, should be performed in patients with CDH, omphalocele, and vein of Galen malformation. Longitudinal hemodynamic assessment through TNE can aid in characterizing the underlying physiology, defining phenotypes and guiding therapeutic intervention.
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cPOCUS or TNE should be routinely used to confirm UVC tip position after placement. Given the significant risk for migration with UVCs, it warrants surveillance imaging (while the line is in situ) to determine the accuracy of the tip position and thrombus formation. Similarly, PICC lines and ECMO cannulation should be performed under image guidance. When TNE is performed for other indications, all imaging protocols should include appraisal of indwelling catheters (where feasible) to document correct positioning.
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Pericardial effusion should be ruled out in any infant with sudden unexplained deterioration with hemodynamic compromise, especially when a central line is in situ. This should be differentiated from pleural effusion. Pericardiocentesis should be performed under ultrasound guidance, when the pericardial effusion results in hemodynamic compromise or tamponade physiology, or occasionally for diagnostic purposes.
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Programs in which standard TNE or cPOCUS assessments are performed must include a plan for ongoing quality assurance with oversight performed by an appointed director. This should include regular review of archived cases and challenging clinical dilemmas.
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Programs in which standard TNE or cPOCUS assessments are performed must have access to dedicated echocardiography machines, probes with a range suitable for neonatal studies, and a centralized storage system that allows study retrieval and remote viewing.
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- ASE: American Society Of Echocardiography
- BPD: Bronchopulmonary Dysplasia
- CDH: Congenital Diaphragmatic Hernia
- ECMO: Extracorporeal Membrane Oxygenation
- NHTNE: Neonatal Hemodynamics And Targeted Neonatal Echocardiography
- NICU: Neonatal Intensive Care Unit
- PDA: Patent Ductus Arteriosus
- PICC: Peripherally Inserted Central Catheters
- POCUS: Point Of Care Ultrasound
- SLPCV: Selective Laser Photocoagulation Of The Communicating Vessels
- TNE: Targeted Neonatal Echocardiography
- TTTS: Twin To Twin Transfusion Syndrome
- UVC: Umbilical Venous Catheter
- cPOCUS: Cardiac Point Of Care Ultrasound
The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.
Title
Targeted Neonatal Echocardiography and Cardiac Point-of-Care Ultrasound in the Neonatal Intensive Care Unit
Authoring Organization
American Society of Echocardiography
Publication Month/Year
February 1, 2024
Last Updated Month/Year
February 2, 2024
Country of Publication
US
Document Objectives
Targeted neonatal echocardiography (TNE) involves the use of comprehensive echocardiography to appraise cardiovascular physiology and neonatal hemodynamics to enhance diagnostic and therapeutic precision in the neonatal intensive care unit. Since the last publication of guidelines for TNE in 2011, the field has matured through the development of formalized neonatal hemodynamics fellowships, clinical programs, and the expansion of scientific knowledge to further enhance clinical care. The most common indications for TNE include adjudication of hemodynamic significance of a patent ductus arteriosus, evaluation of acute and chronic pulmonary hypertension, evaluation of right and left ventricular systolic and/or diastolic function, and screening for pericardial effusions and/or malpositioned central catheters. Neonatal cardiac point-of-care ultrasound (cPOCUS) is a limited cardiovascular evaluation which may include line tip evaluation, identification of pericardial effusion and differentiation of hypovolemia from severe impairment in myocardial contractility in the hemodynamically unstable neonate. This document is the product of an American Society of Echocardiography task force composed of representatives from neonatology-hemodynamics, pediatric cardiology, pediatric cardiac sonography, and neonatology-cPOCUS. This document provides (1) guidance on the purpose and rationale for both TNE and cPOCUS, (2) an overview of the components of a standard TNE and cPOCUS evaluation, (3) disease and/or clinical scenario–based indications for TNE, (4) training and competency-based evaluative requirements for both TNE and cPOCUS, and (5) components of quality assurance.
Inclusion Criteria
Male, Female, Infant
Health Care Settings
Emergency care, Hospital, Laboratory services, Radiology services, Operating and recovery room
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Assessment and screening, Management
Diseases/Conditions (MeSH)
D007363 - Intensive Care Units, Neonatal, D004452 - Echocardiography
Keywords
NICU, neonatal intensive care unit, Neonatal Echocardiography, Cardiac Point-of-Care Ultrasound
Source Citation
Patrick J. McNamara, Amish Jain, Afif El-Khuffash, Regan Giesinger, Dany Weisz, Lindsey Freud, Philip T. Levy, Shazia Bhombal, Willem de Boode, Tina Leone, Bernadette Richards, Yogen Singh, Jennifer M. Acevedo, John Simpson, Shahab Noori, Wyman W. Lai, Guidelines and Recommendations for Targeted Neonatal Echocardiography and Cardiac Point-of-Care Ultrasound in the Neonatal Intensive Care Unit: An Update from the American Society of Echocardiography, Journal of the American Society of Echocardiography, Volume 37, Issue 2, 2024, Pages 171-215, ISSN 0894-7317, https://doi.org/10.1016/j.echo.2023.11.016