Embedded Files
You will find the video recordings of the orientation day on the password-protected portal - Fellowship section - How to important modules - Orientation NH-TNE 2025
NH-TNE Orientation and ongoing progress tracking
Reviewed: May 7, 2025
General information:
o Website for program (clickable)
o Objectives and AFC document reviewing structure and activities
o RC Competency Portfolio, RC documents
o ASE guidelines (see document section)
o Review of rotation and program structure
o Session with Jessica Simoneau: SAVING for Ben C.; PREM for Laurence (7-10 days).
o Review of One45 functionality
§ Logbook on One45
§ Milestones / Subtasks to be filed
§ Handouts and documents
§ ITERs
- Health and Safety Policy
- Appeal Policy
- Promotion policy
- Supervision policy
- Wellness policy
o Well Office / ORE
§ Processes if there are any misconduct / mistreatment
o NH-TNE Competency Committee
§ Members
§ Role
o NH-TNE Resident Program Committee
§ Members
§ Roles
§ Presence at meeting to voice concerns, confidentiality and safety
§ Resident representative on NH-TNE RPC – identify.
o Program Administrator (Amber Gumbley) role
o Members of the program:
§ Neonatologists (MCH – JGH)
§ Cardiologists
§ Imaging Technologists
§ Research personnel
§ Research students
§ Administrative Support
§ Nurses, RTs, Allied Health Care professionals, Pharmacists, Unit coordinator
o Quiz:
§ Beginning of the year
§ At mid-year
§ June block
o Space for NH-TNE fellow, computer access.
o Protected time for mandatory academic activities
o Elective at CHU Sainte Justine
o Ongoing “OSCE style” stations.
o Vacations / Study Leave
o NICU Cardio Rounds
o NH-TNE teachings
o Hard Drives with secure data
o Radimage
o Feedback to faculties and teaching
o Supervisory role: expectations regarding teaching and presentation at neonatal rounds / journal club / NICU cardio rounds.
o Every 3 months review with PD.
o Paper documents / protocols
o NeoCardioLab website – material
§ Orientation and Material on the drive
§ Website modules
§ ECHO modules
o Conference allowed – Funds
o Blurb – Bio – Picture (if not already done) for Fellow section
o Post-Graduate Student Society
Rotations, objectives, learning opportunities, EPAs/Subtasks:
- NICU orientation block
- NH orientation block
- Echo lab rotations
- Cardiology rotations
- Cath Lab (3-4 cases in the year to be organized)
- Reseach / Scholar activity
- Call scheduling and notification of absence during rotations
- NH-TNE Junior
- NH-TNE Senior / Junior Staff
- Elective
Clinical NH-TNE rotations
- Role of fellow in the NH-TNE weeks: touch base with teams, touch base with NH-TNE on call neonatologist.
- Indications for TNE
- Pulmonary Hypertension screening for BPD-PH.
- HIE patients (ECHO Day 1 and Day 4) - NECTAR
- Approach to NH Consultation
- TnECHO full protocol
- Neonatal Hemodynamics Report, Oacis/Paper version
- Machine: Philips and GE
o Put your initials, Blood pressure, Weight, Age on first screen page of ECHO.
o Probes
o Knobology
o ECG wires + Monitors
- Setting up patient for ECHO (music, bundling, etc.)
- Booking patients with nursing. Evaluating appropriateness of request. Evaluate for need of pre-emptive Cardiology involvement or involvement after evaluation.
- Communication with teams.
- NIRS machines – NIRS resources, NIRS Atlas, NIRS videos.
- Syngo utilisation
- TomTec utilisation
- DICOM handling, mp4 creation and anonymization, gif production for presentation
- Measurements / Atlas
- Image review
NeoCardioLab resources
- NeoCardioLab Group messaging
- Globalshare drive
- Password protected portal: ressources and textbooks.
- Case reviews.
- Appendix and Books
- Video modules
- Inotropes and Vasopressors
Research / Scholar Work
- Student training for Research (step by step)
- Scholarly project expectation and identifying project
- Review resources:
o Abstract, manuscript preparation.
- Daniela’s role
- NeoCardioLab lab meetings
- NeoCardioLab Student Email Mailing List
- Atlas of data extraction
- CORE / CHHD + webinars / seminars
- Conferences to target: Regan Giesinger Course, NeoHeart, PAS, UCSF PVD conference, McGill Neonatology Day.
- Ongoing research projects: SPEC, SAVING, HOM, EMBLEM, PURPOSE, SANE, SARABI, NECTAR.
- Nagano
- CIM
- Research Tab and Other Research resources
- Research-Portal
- R – Rstudio
- REB templates
- Structure of the Research Institute
- NeoCardioLab Research Half Day
Hospital orientation
a. Hospitals (MCH-JGH) / floors / cafeteria / food / 5th floor and offices
b. NICU orientation, delivery room, forms
c. MSSS Email
d. Computer account – Windows Account
e. Scrubs
f. MUHC ID card, accesses, activation at stations
g. MUHC-RI accesses and documentation: SOP, GOP/CITI.
h. MUHC Library , Visit the Space at MUHC for workspace
i. MUHC-Workshops
ii. MUHC-Links for McGill Library and books available
iii. MUHC Librarians
McGill University level Orientation
i. Email – McGill / MSSS
j. OneDrive
k. EndNote
l. Office
m. Campus/Gym/Academic Facilities – Libraries – On Campus – McGill ID Card
o. One45 – evaluations
p. Calendar
q. McGill Minerva
r. Zoom Account
s. Well Office
t. McGill Librarian
u. ORE – Office of Respectful Education; https://www.mcgill.ca/medhealthsci-respectful-environments/about
Training sessions :
A) Journal Club
B) Neonatal Rounds
C) Academic Half Day of NPM program (only if interested and not conflicting with other clinical or educational activities of the NH-TNE fellow)
D) CANMED sessions
E) OACIS training
F) FDTG, Resident Case Discussion
G) Neonatal Cross-Canada Rounds
H) MockCode, Training Workshop.
I) POCUS day (PURE course)
Please review the documents relative to the program : https://www.neocardiolab.com/neonatal-hemodynamics-fellowship-program-fellow-hémodynamie-néonatale/documents-fellowship
Please review the assessment tools and important links relative to the program : https://www.neocardiolab.com/neonatal-hemodynamics-fellowship-program-fellow-hémodynamie-néonatale/documents-fellowship/assessment-tools
Please review the policies related to the NH-TNE program: https://www.neocardiolab.com/neonatal-hemodynamics-fellowship-program-fellow-hémodynamie-néonatale/documents-fellowship/important-policies
During 2 days:
FDTG, Cardio sign-out.
Daniela = 30 minutes (NeoCardioLab)
Amber = 60 minutes (P.A.)
Laila = 30 minutes (Nicu-Cardio Rounds)
Tiscar = 30 minutes (Cardio blocks)
Always create Radimage request and close it once you are done!
Unless urgent, time TNE with care and nursing team. See protocol / music.
Make sure the images are not identified / anonymized.
Make sure images are ECG-Gated
Name of person who obtained the image (for quality assurance)
Acquisition at minimum of 3 beats capture
On first image - record:
Study-ID (if research study)
Blood pressure (Sys/Dia - Mean)
Day of life ECHO
Weight
Length if available
GA
Indication of TNE and/or important clinical information if TNE (cardiovascular medications; ventilation and oxygen requirements; fluid administration like bolus/blood).
Neonatal Hemodynamics Program Orientation 2025 - 2026 - June 26 and 27, 2025
Neonatal Hemodynamics Program Orientation 2025 - 2026 - June 26 and 27, 2025
Key Personnel and Their Roles
Amber Gumbley (Program Administrator): Amber is the program administrator and is the go-to person for logistical questions, including vacation requests, leave requests, conference budget, and access-related issues within the hospital infrastructure. She manages scheduling for teaching sessions, tracks vacation and leave allowances, and handles reimbursement requests. Amber is highly responsive and available via Teams. Admin Support: Amber is the main administrative contact, but other secretaries like Chloe and Kassandra are also involved, particularly with scheduling the pulmonary hypertension screening program.
Dr. Villeneuve and Dr. Lapointe: Elective at CHU Sainte-Justine, typically scheduled towards the end of the program year, around October or November. They are hemodynamic specialists at Sainte- Justine and oversee the clinical elective rotation. Hemlata Chauhan is the program administrator at CHU-SJ and manages the complex administrative procedures for rotations at their institution.
Daniella Villegas (Research Coordinator of NeoCardioLab): Research echoes for some populations.
Laila Wazneh (Page: Neonatal Cardiology Academic Case Rounds): All fellows are responsible for presenting cardiac/hemodynamics cases, reviewing literature, and discussing findings.
Dr Sarah Spenard: Second attending in the hemodynamics program at MCH.
Cardiology Team (at MCH): The team includes experts like Dr. Tiscar Cavallé (Echo Lab, Fetal, Advanced Echocardiography, Fetal Physiology), Dr. Adrian Dancea (Cath, Pulmonary Hypertension), Dr. Wadi Mawad (Echo, MRI, Cardiac Cath), Dr. Yalin Lin (Fetal Echo, Pulmonary Hypertension), Dr. Claudia Renaud (Advanced Echo, Fetal Echo), and Dr. Luc Jutras (MRI, Fetal Cardiology, Echocardiography). Dr. Virginie Beauséjour-Ladouceur is the EP (Electrophysiology) expert, focusing on impact of arrhythmias n.
Imaging Technologists: Fellows are encouraged to spend time with imaging technologists at MCH, as they can provide valuable tricks for image optimization. Jessica Simoneau, an imaging technologist who also teaches in a College, worked as the research coordinator in the lab for many years. She is responsible for booking sessions for data extraction related to scholar projects.
Program Structure and Rotations
Core Blocks: The year includes rotations in neonatology units orientation, junior hemodynamics, the echo lab, and intensive care cardiology
Echo Lab Exposure: Even during intensive care cardiology blocks, fellows will continue to evolve in the echo lab, focusing on learning the common language, seeing echoes and images of patients not typically seen in hemodynamics (e.g., congenital heart patients), understanding report creation (e.g., Anderson or Van Praagh approach), and attending fetal consults to understand physiological concepts applicable to postnatal care.
Call Locations: Fellows will continue to do calls at the MCH and Jewish General Hospital. At JGH they can encounter a different patient population and engage in point-of-care ultrasound under the supervision of Dr. Nina Nouraeyan.
Fellow Space: A dedicated space for the program is available downstairs on B05, equipped with a computer for measurements and reports.
Sainte Justine Elective: This is a one-month clinical elective focusing on hemodynamic consultation requests from the medical team. Fellows review charts, perform echoes, interpret findings, and translate recommendations for non-echo/hemodynamics personnel. It's a French-speaking environment, and communication in French is beneficial, though supervisors will assist. The schedule is Monday to Friday, and if echoes are quiet, fellows can use mannequins, attend lessons, or work on practical cases or presentations (e.g., TnECHO Quebec Group meetings). Administrative formalities require at least six months lead time for processing through the BCI system, followed by approvals from McGill and University of Montreal.
Administrative Procedure: The process for applying to an internship at Sainte Justine involves several steps:
Submit a BCI (Bureau de Coopération Interuniversitaire) request: This system helps manage inter-university switches. Fellows must follow the instruction guide carefully when filling the request.
Send PDF copy to Program Administrator and Director: After filling the BCI application, fellows must create a PDF copy and send it to their program administrator (Amber) and program director for approval.
Send to Residency Coordinator: Once approved and signed by the program director, the request must be sent to the Residency Coordinator at McGill's PGME office.
Host University Approval: The request then goes to the University of Montreal, where it is reviewed and approved by the Sainte Justine team (Hemlata, Dr. Villeneuve, Dr. Lapointe).
Timeline: It is preferable to start the process at least six months before the rotation dates due to processing times at both universities. The PGME office must receive the request at least two calendar months beforehand, or it will be refused.
Scheduling Alignment: McGill's period schedules may not perfectly align with the University of Montreal's rotation calendar. It is crucial to ensure the dates submitted in the application align with Sainte Justine's period calendar to avoid automatic refusal, even if it means adjusting the McGill period dates slightly. Fellows will coordinate with Hemlata and Amber once specific dates are known.
Curriculum and Learning Resources
Website and Password-Protected Portal
The program's resources are consolidated on a website, accessible via a password-protected portal. The website's "neonatal hemodynamics program" section contains:
Overall grid and objectives of the program.
Subtasks to be completed on one45.
Information on longitudinal blocks and schedules.
Teaching materials and report templates (e.g., standard echo reports).
Documents for fellowship outlining program objectives and Royal College mandatory elements.
Textbooks and Reading Material
Many textbooks are available for download on the password-protected portal, and also accessible through the McGill Library login.
Neonatal Echo Textbooks: Including the full textbook from Dr Shahab Noori, and "Practical Neonatal Echo".
Hemodynamics and Cardiology Textbooks: "Neonatal Questions and Controversies," published recently, is highly recommended for questions and controversies in neonatal hemodynamics.
"Echo in Pediatric and Congenital Heart Disease" by Lai, Mertens Cohen, Geva: The "Bible of Echo," this 929-page textbook is valuable for understanding abnormal cardiac function and applying concepts to functional disorders in patients with normal hearts.
"Congenital Diseases of the Heart" by Rudolph: Considered a "must" for its physiological approach to deconstructing the heart, blood flow, pressures, and resistances. It explains fetal circulation, pressure, and saturation in each chamber, helping to understand oxygen flow and conditions like pulmonary pressure in fetal life. It's particularly useful for transitional physiology, fetal circulation, and postnatal cardiac physiology.
Manual of TNE by Dr Afif El-Khuffash.
Online Modules and Videos
The "How to Important Modules" section on the password-protected portal contains various resources.
Instructor Videos: Contains videos where I reviews topics covered in live sessions, useful for review. These videos focus on echo views, data extraction.
Atlas of the Neocardial Lab: This 95 page atlas details standardized measurements used for research and clinical practice. It follows the order of common data collection on Echo, explaining where to get specific measurements.
Advanced Topics: Modules cover strain analysis and 3D echo, which are primarily research-oriented but important for future clinical relevance. Blood speckle tracking is not covered in detail as it's rarely used clinically.
Technical How-To Videos: Includes step-by-step videos for using programs like Radimage (to create echo requests via Wi-fi), downloading DICOM images, using Syngo (image transfer from Syngo to TomTec), and performing and scoring lung ultrasound. Lung ultrasound is primarily for research projects (e.g., on CDH and preemies), not extensive clinical use in the unit.
Protected Teaching Sessions
Fetal Diagnostic Treatment Group (FDTG): Held every Friday from 8-9 AM, highly encouraged for hemodynamics program members, especially for cardiac cases (congenital heart patients, patients at risk of transitional issues like giant omphalocele, CDH, vein of Galen, hepatic hemangiomas, or vascular malformation of the liver). Attending these helps consolidate neonatology and hemodynamics skills by understanding blood flow in complex congenital heart conditions and issues like pulmonary hypoplasia or hypertension.
Targeted Neonatal Echo (TNE) Curriculum (NHRC): This is an international collaborative program with protected teaching time once a month, on Wednesdays. It involves a one-hour expert lecture followed by a private, unrecorded case-based panelist session for fellows. The curriculum covers basics like neonatal hemodynamics principles (e.g., Frank Starling curve, Winkessel effect), approach to neonatal shock, PDA physiology, acute and chronic pulmonary hypertension. Registration is handled by Laura Thomas.
Phoenix Children's Neonatal Hemodynamics Boot Camp: An additional boot camp on July 9th and 10th, 2025 covers topics such as vasopressors, fetal and neonatal circulation.
Program-Specific Teaching Sessions: Regular live discussion sessions covering views, concepts, normal cardiac anatomy, and other important topics. These are protected teaching times.
NICU Cardio Rounds Presentations: Fellows are responsible for presenting cardiac or functional cases at these rounds.
Quebec TnECHO Collaborative Meetings: A community of TNE specialists in Quebec holds monthly academic discussions, either journal clubs or case presentations, where fellows are expected to attend and present at least one or two cases during their training year.
Self-Paced Learning: Fellows are encouraged to review recorded sessions and materials, especially those on the NeoCardioLab and NHRC YouTube channels, during spare time. This includes topics like vasopressors, inotropes, cardiac hypertrophy, and basic cardiac views.
Assessment and Evaluation
Royal College Mandates
The program complies with Royal College mandatory elements for training.
Competency Portfolio: During rotations in the Echo Lab and Cardiology consults, fellows build competencies by seeing various neonatal, congenital heart, pre-op, and post-op patients. This involves consolidating physiological thinking by tying together physical exam, history, labs, echo findings, reports, physiology, Cath lab, and MRI.
EPAs (Entrustable Professional Activities)/Subtasks: The Royal College requires certain subtasks, such as performing a full echo, formulating reports, and specific observations (e.g., normal heart, preemies, referrals, cardiology, cases of ASD, sepsis, shock, pulmonary venous hypertension). A summary table of these subtasks is available on the website.
Log Book: Fellows are required to maintain a log book using the One45 system to record every echo encounter, including simulations, clinical consults, and research echoes. Mandatory fields include views performed (e.g., parasternal long, short, apical), date, reason for echo (e.g., extreme preterm, pneumothorax, sepsis, simulation, research, etc.), patient age (infantile, newborn), and the fellow's role (creating report, partly done, observation, full scan, data extraction). The log book tracks progression and caseloads for review by the Competency Committee.
The One45 system is a software used for evaluations and log books.
ITERs (Evaluations): At the end of each block (e.g., neonatology unit orientation, junior hemodynamics, echo lab, intensive care cardiology, senior hemodynamics), fellows receive an evaluation through the One45 system.
Competency Committee: This committee, separate from the Resident Training Committee, reviews each fellow's file, focusing on evaluations and procedure logs, including subtasks and progress.
Objective Structured Clinical Examinations (OSCE) stations are a formative training tool, not for evaluation.
Purpose: To expose fellows to a diversity of cases, identify pitfalls, and ensure readiness for real-life TNE consults.
Access: 48 cases are available on the website under the "OSCE cases" button, with a video explaining how to tackle them. The images for these cases are found in the "NeoCardioLab" folder on the protected Global Share (S drive) within the MUHC server, accessible via a remote connection (Citrix receiver) and Syngo.
Format: Each case presents a vignette, requires measurements (e.g., TAPSE, FAC, RVO, EF, shortening fraction, LVO), comments on shunts, metrics of significance (e.g., pulmonary systemic pressure ratio), line positions, infusions, and a synthesis report with a detailed plan.
Review: Fellows are expected to work through these cases at their own pace throughout the year and book one-on-one meetings with the program director (Dr Altit) to review approximately 10-15 cases at a time, typically three times a year. The process, including measurements and report writing, can take up to an hour per case, with encouragement to consult resources for comprehensive recommendations.
A neonatal hemodynamics quiz is available on the program website.
Purpose: It is a formative quiz, not evaluative, designed to help understand the fellow's background knowledge and progression, identify gaps, and tailor reading recommendations.
Schedule: Fellows are asked to complete the quiz three times: during the first block of the year, at the beginning of January (or the first week of July for those starting in January), and during the last block (Block 15).
Feedback: For the first two attempts, fellows will receive targeted feedback on topics to read and work on, without direct answers. Answers are only provided after the final attempt at the end of the year.
Approach: It is recommended not to look up answers during the first attempt, but to use the second attempt as an opportunity to consolidate knowledge by looking up information.
Feedback Mechanisms
Resident Training Committee (RTC): This committee constantly reviews the program, addresses resident concerns (e.g., space, equipment, harassment, competency, resources), and works on improving training. A resident representative from the program is part of this committee.
Faculty Feedback Forms: Fellows are asked to fill in feedback forms for teaching sessions with various faculty members. Other trainees are present during most sessions to ensure truthful feedback without fear of identification.
Quarterly Reviews: Fellows are required to book a one-hour review session with the Program Director every three months to discuss scholar progress, rotations, and overall performance.
Scholar Project
Every fellow in the program must complete at least one scholar project, with the ideal goal of publication and presentation at a conference (e.g., PAS, NeoHeart, American Society of Echo, ATS, UCSF Pulmonary Vascular Disease Conference, or internal McGill conferences).
Important Policies and Support
All important policies are accessible on the program website.
Harassment and Mistreatment: The program has a zero-tolerance policy for harassment, racism, discrimination, feeling unsafe, or unprofessional behaviors. Issues can be flagged to the PGME Office directly if uncomfortable speaking with the program director. The Office for Respectful Environment is the mechanism for reporting mistreatment.
Well Office: A McGill office providing resources for students, including counseling, psychological health, and well-being.
Federation of Residents of Quebec (FMRQ): Offers important information specifically for resident training.
Quebec Physicians Aid Program (PAMQ): Provides programs and support for Quebec physicians experiencing challenging moments.
Office of Medical Learner Affairs: Offers postgraduate wellness support, academic advising, and resources.
Postgraduate Student Society (PGSS): As a member, fellows may have access to health and dental insurance (to verify with them) and can utilize resources like Thompson House on campus (a private house with a restaurant, activities, and rentable rooms for student activities or research projects).
Supervision and Safety Policies: Mandated policies ensuring appropriate supervision and a safe learning environment.
Appeal Process: A process is in place for appealing evaluations or global assessments, which can go through the Competency Committee, Resident Training Committee, and potentially the Department of Pediatrics and PGME Office.
Reimbursements: Fellows are eligible for reimbursements for PGME-related expenses, such as conferences and books.
Technical Aspects and Data Management
Remote Access: Fellows need to obtain a MUHC card with a barcode and unique code to create remote access to the MUHC system. Citrix Receiver is required to access the virtual desktop.
Syngo Program: This MUHC-wide program is used to read images and perform measurements (e.g., volumes, TAPSE). Fellows will be trained in its use.
NeoCardioLab Folder: This shared folder on the global share (S drive) contains the OSCE stations images and other protected resources.
Image Optimization and Machine Familiarity: Fellows will learn to use Philips and GE machines at the MCH and Jewish, and it's important to be familiar with concepts applicable across different vendors (Philips, Siemens, Toshiba, GE, MindRay). Techniques for image optimization include adjusting depth, narrowing the window, zooming, and optimizing compression or probe frequency.
Time Management during Echoes: The goal is to complete echoes within 30 minutes, especially for sick or tiny babies, by aiming for information rather than perfection, focusing on reliable data, and prioritizing views. Fellows are encouraged to track time during echoes and return to difficult views later if time permits.
Standardization of Measurements: Standardized measurement techniques is important for common language with colleagues and relating to the literature.
Data Security: While not detailed in this session, the importance of hard drives and secure data is mentioned, to be discussed further.
Recommended Conferences and Educational Opportunities
Several conferences and courses are highly recommended for fellows, particularly those with a focus on hemodynamics.
Dr Regan Giesinger Course - November 3rd to November 6th 2025 Course: This lecture series is strongly advised due to its concentrated material on hemodynamics. It covers essential topics such as physiology, shock, patent ductus arteriosus (PDA), and various challenges in neonatal care. This four-day course costs approximately $50 for fellows (you can use the PGME reimbursements for that), and provides comprehensive access to all content, including case-based presentations. It is an annual event known for encompassing a broad spectrum of knowledge.
Delphi Conference: Organized by the "Incubator team," this conference is scheduled for January in Fort Lauderdale. Fellows interested in attending should contact Benjamin Courchia MD.
Pediatric Academic Societies (PAS): Considered a "classic" event, PAS is held in Boston this year. Fellows are encouraged to submit their work for presentation, although the November submission deadline may be tight for new fellows in their first year. Submission of preliminary data is also an option.
NeoHeart: The dates for this conference are variable, but it's recognized as a significant event focusing on neonatal cardiovascular sciences. It is multidisciplinary and includes valuable workshops. The 2025 edition is set to take place in San Diego from July 28th to August 3rd.
UCSF Pulmonary Vascular Disease Conference: This is a specialized, "very niche" but highly regarded conference typically held around March. It delves into different conditions related to pulmonary hypertension, including those commonly observed in newborns and other pediatric scenarios (e.g., sickle cell disease). The conference also offers insights into MRI assessment and highlights potential pitfalls in echocardiography (e.g., evaluating TAPSE with significant tricuspid regurgitation).
Fellowship Schedule and Fellow Responsibilities
The fellowship curriculum is structured to provide a comprehensive learning experience.
Program Progression: The year begins with an orientation block, followed by a longitudinal hemodynamics block. This leads into an Echo Lab elective and three longitudinal cardiology blocks, which blend Echo Lab exposure with cardio consultations. The latter part of the year includes a return to hemodynamics and "senior" blocks, serving as a "junior attending" role.
Hemodynamics Block Responsibilities:
Daily Rounds: Fellows are expected to meet with all three clinical teams each morning to identify patients requiring consults or evaluations.
Echo Booking: Based on these discussions, fellows are responsible for booking the appropriate echocardiograms.
Communication with Nurses: It is essential to communicate scheduled echo times with nurses, or to perform urgent evaluations immediately if required.
Responding to Urgent Requests: Fellows should be prepared to respond to urgent requests from colleagues regarding patient evaluations.
Managing Screenings: Pre-booked screenings, such as those on the pulmonary hypertension calendar, are part of the fellow's duties. For these, fellows assess if the patient is on oxygen or respiratory support; if so, an echo is booked. If the patient is on room air or discharged, no echo is necessary. These screenings offer some flexibility in timing (e.g., 36+2 or 36+3 weeks gestation).
Communication Protocols:
Fellows must ensure their communication methods (e.g., a cell phone left on a shared board) are available for new consults.
The NeoCardioLab text messaging group is a primary communication tool for updates on research projects, echo machine availability, and student support. Make sure to keep Daniela Villegas in the loop for echo machine use.
The Philips echo machine is preferred for its quick image transfer, while the GE Venue Go is also available, connected to PACS, for emergency use.
Echo Procedures and Quality Control
Echo Workflow: After consulting with the clinical teams, fellows must validate findings with a supervising physician (either the G Altit or S Spenard at MCH; A Lapointe or A Villeneuve at CHU-SJ), schedule the echo with the nursing staff, perform the scan, take necessary measurements, generate a report, and then review all findings.
Research Echoes: For echoes conducted as part of research studies, proper booking with nursing staff and communication with the patient's clinical team are vital. This ensures awareness and prevents conflicts with ongoing patient care. Clinical teams often value the information from research echoes for patient management.
Quality Assurance and Consultation:
If a fellow is uncertain about echo findings, after review with TNE staff, may need a consult in Cardiology.
For certain patient populations, cardiology may perform the initial echo, but the TNE team often handles routine screenings like those for pulmonary hypertension, unless unusual findings are present.
For new patients, cardiology follow-up before discharge may be recommended. If the TNE team performs the echo and identifies an uncertain finding (e.g., a suspected VSD), they will seek cardiology review.
While the TNE team can independently issue reports within their specialized area, cardiology colleagues can provide opinions and review images, but they do not officially sign off on TNE reports .
In cases of highly complex malformations, direct cardiology consultation is necessary.
The TNE service's role does not include performing echoes for routine "murmur" evaluations prior to discharge, as this falls outside their scope.
Exposure to Cardiac Catheterization and MRI
Fellows are encouraged to gain exposure to other cardiac diagnostic modalities.
Cardiac Catheterization (Cath Lab): It is strongly recommended that fellows attend at least one to three Cath Lab cases during their cardiology blocks with Dr Adrian Dancea. This experience is invaluable for understanding invasive cardiovascular evaluations. It helps in interpreting various hemodynamic pressures, understanding access points, and learning about thermodilution and Fick methods. This knowledge is particularly important for interpreting reports in pulmonary hypertension cases. Since echocardiography often serves as a non-invasive surrogate for Cath Lab findings, understanding both helps "tie together the two". Fellows should proactively arrange these visits, especially if a pulmonary hypertension case is scheduled, as these opportunities are not frequent.
Cardiac MRI: During cardiology blocks, fellows should strive to attend cardiac MRI teaching sessions led by Dr. Luc Jutras (or Dr. Mawad) and ideally observe at least one cardiac MRI study. This exposure provides insight into a different method of assessing cardiac volumes, dimensions, and myocardial characteristics such as scarring and fibrosis. It also demonstrates how 3D constructions are used to evaluate LV and RV morphology. Fellows are encouraged to schedule these opportunities proactively. Usually they start in September on the Tuesday 12:30 and Thursday 8:30.
Research Scholar Activity and Daniela's Role
Active participation in research is a core component of the fellowship.
Research Engagement: Each fellow will be assigned a research project and is expected to make progress. Regular attendance at NeoCardioLab meetings is crucial for discussing advancements, challenges, and future steps for their projects.
Daniela Villegas M. – Project Manager: Daniela plays a pivotal role in supporting research efforts within the NICU . Her responsibilities include:
Patient Recruitment: Actively involved in identifying and recruiting patients for various studies .
REB Management: Manages Research Ethics Board (REB) administration, logistics, and protocol adherence .
Project Facilitation: Assists with both retrospective and prospective studies, ensuring a smooth flow of patient data .
Administrative Support: Helps with administrative tasks, including REB processes, particularly navigating French-language government forms .
Collaborations: Facilitates and maintains collaborations with national (e.g., Quebec City, Jewish General Hospital) and international centers (e.g., Israel, France, Italy) .
Scheduling: Manages Dr. Altit's schedule and books the TomTec workstation for fellows .
General Assistance: Provides support for data collection, poster printing, reimbursement, and general queries, encouraging fellows to contact her directly to streamline communications.
NeoCardioLab Research Day: The second NeoCardioLab Research Day is scheduled for October 30th in the afternoon . A pamphlet summarizing ongoing research studies is available on the hospital's website.
Targeted Neonatal Echocardiography (TNE) Indications and Limitations
The guidelines for performing TNE are well-established.
Indications: The indications for TNE are outlined in the American Society of Echo guidelines and the program's overview document. Common scenarios where TNE is indicated include:
Premature newborns on mechanical ventilation or those requiring oxygen with or without pulmonary hypertension concerns .
Suspected hypertrophy or cardiomyopathy.
Evaluation of infants born to diabetic mothers.
During the initiation or titration of medications with known cardiovascular effects .
Patients with congenital diaphragmatic hernia (CDH).
Monitoring patients receiving inotropes or other hemodynamic therapies.
PDA screening in the context of pulmonary hypertension.
Any instance of cardiorespiratory instability secondary to shock, sepsis, necrotizing enterocolitis (NEC), or inflammatory processes.
Follow-up for acute pulmonary hypertension.
Assessment of cardiac dysfunction.
Guidance for line placements.
Detection of pericardial effusion.
TTTS setup
Limitations: It is important to note that the TNE team's role does not typically include performing echoes for routine "murmur" evaluations in babies being discharged, as this falls outside their primary scope. It is not the role of TNE to evaluate for structural heart defect - this has to pass by Cardiology. Patients with CHD should be evaluated and followed by cardiology and not NH-TNE.
Overview of current NeoCardioLab Research Projects
Prospective Projects:
SPEC Study: This study investigates the cardiovascular and hemodynamic effects of dexamethasone exposure in infants. It involves heart and lung echoes, along with Heart Rate Variability (HRV) measurements at multiple time points: Day 0 (within 24 hours of drug administration), Day 3, Day 7, Day 14, and then 7 and 14 days after stopping treatment, and finally between 35-37 corrected age weeks. Echoes can be flexibly scheduled around weekends . A TNE clinical report is generated for this study due to its safety and clinical relevance.
SAVING Study: This project aims to compare the accuracy of echocardiographic images from the Philips Epic 7 machine with those from the handheld Butterfly device. The goal is to determine if handheld devices can reliably be used for diagnosis and measurements. A cardiac, lung, and brain ultrasound is performed using both devices. Lung ultrasounds include both 2D and M-mode for each lobe, allowing detection of conditions like pneumothorax . The study targets 100 patients and has already recruited 51, in collaboration with Rochester. No clinical report is issued for this low-risk study unless there is a safety element that needs to be flagged and documented.
PURPOSE Study: This study focuses on babies diagnosed with Congenital Diaphragmatic Hernia (CDH), a rare condition. Lung ultrasounds are performed at delivery (post-stabilization), followed by heart and another lung ultrasound within the first 12 hours of life. An additional lung US is done four hours prior to extubation. This is a two-site collaboration with CHOP (Children's Hospital of Philadelphia) . A TNE clinical report is issued for the TNE in this study .
EMBLEM Study: This project investigates early life MRI biomarkers for long-term respiratory morbidity in infants born before 29 weeks gestation. The primary site is CHEO in Ottawa . Echoes (including lung) and an MRI are performed before discharge. MRIs are typically conducted late at night or on weekends due to availability, requiring extensive coordination. Follow-up includes phone questionnaires at various corrected ages and a final visit with a Bayley scores. Parents receive $80 compensation. Six centers are involved, with the NeoCardioLab team acting as the core lab for echoes . A clinical report is issued for this study .
SARABI Study: This research explores the impact of maternal preeclampsia on the cardiovascular function of mothers and infants. Mothers admitted with preeclampsia are enrolled. A technician performs maternal cardiac echo (pre-delivery and 12 weeks postpartum), while the team performs the baby's echo. No clinical report is issued for this study .
Heart of the Matter: A collaboration with Dr. Evelyn Vinet, a rheumatologist, this study examines the cardiovascular outcomes in women with rheumatic diseases (specifically lupus) and their babies. The team coordinates adult echoes (performed by a technician) for mothers and performs echoes for the babies after delivery. Control groups are also included. No clinical report is issued for this study .
SANE: In collaboration with Dr. Wintermark, this study involves performing a TNE on babies on Day of Life 1 and Day of Life 4. It targets infants with Hypoxic-Ischemic Encephalopathy (HIE) presenting with moderate to severe encephalopathy and an abnormal EEG, who are undergoing therapeutic cooling. TNE are conducted within the first 24 hours (Day of Life 1) and after rewarming. These babies also receive an MRI on Day 2 during cooling, which can lead to randomization to sildenafil or placebo if early brain injury is detected. Echoes are performed regardless of randomization . This is a multi-site project spanning Colorado, Calgary, and Edmonton .
NECTAR Study: This national collaboration focuses on babies undergoing therapeutic hypothermia (cooling) across Canada . It standardizes care by requiring a Day of Life 1 echo and a Day of Life 4 echo, performed by the TNE team, irrespective of hemodynamic instability. The initial phase collects data on current drug usage, while subsequent phases aim for comparative effectiveness studies based on different clinical algorithms .
Ninja: This study involves patients similar to the Sildenafil study, but they are 9-10 years old . A one-time heart and renal ultrasound is performed, along with a brain MRI (conducted by another team) . The current team might perform the heart echo . No clinical report is issued for this study .
Other Key Projects:
Dopa vs NorEpi: An ongoing comparative effectiveness study until 2027 for infants with septic shock and necrotizing enterocolitis (NEC). It standardizes the initial approach to vasopressor initiation; one group receives a fluid bolus followed by escalating doses of dopamine, while the other receives norepinephrine. If the initial regimen fails after 90 minutes, other agents like norepinephrine or vasopressin can be used. Echoes are not performed for this study; the focus is on the initial 90 minutes of drug administration. Compliance audits are conducted to monitor adherence to the protocol .
RESET PDA: A multicentric study that extracts data from clinical echoes (cardiology or TNE) performed on infants less than 28 weeks gestation within their first 28 days of life, specifically if a patent ductus arteriosus (PDA) measures 1.5mm or larger. The primary goal is to develop a validated scoring system for PDA significance that correlates with patient outcomes, to be used in future randomized controlled trials (RCTs). This study does not include a control group but collects cumulative data across various time points to identify high-risk populations. While fellows are not directly involved in data extraction, they should ensure that specific echo views are included if performing TNE on eligible patients within the first 28 days .
Fetal Brain Growth: This study involves brain ultrasounds, often performed by Dr. Garfinkle, which can utilize the echo machine for short durations (approximately 3-4 minutes). Fellows may be asked to assist with these quick ultrasounds if needed .
Handling Incidental Findings in Research Studies:
For research projects involving higher-risk populations (e.g., preemies, SPEC, Purpose studies), a TNE clinical report is generated, highlighting any clinical findings for patient safety and care .
For studies on low-risk populations (e.g., Saving, Sarabi, Lupus, Ninja studies), no formal clinical report is issued. If an unexpected finding (e.g., VSD, ASD) is detected, a consultation for pediatric cardiology is filed, and the family is informed. For acute, urgent findings (e.g., large tamponade), direct and immediate cardiology consultation would be sought. The primary care team is always informed of clinically meaningful findings.
Imaging Systems and Workflow
Syngo: When accessing echo images on a desktop, you'll encounter multiple logos. Always open the "Workplace" application, as "Workplace Remote" will not function correctly for this purpose. Access typically starts by selecting 'MCH'.
This is the primary software for reviewing images, performing measurements, and searching for patients.
Viewing Options: Within Syngo, you can view images in thumbnail format, divide your screen for easier comparison, and see acquisition details like date and time.
Measurements: You can view pre-existing measurements, such as those performed by a colleague. To perform your own, use the 'toolbox'. After a measurement, remember to press 'escape' to exit the measurement tool. Calculations like ratios are often done manually, as the system may not perform them automatically.
Archived Studies: Echoes consume significant server space. Images not used for more than a month are automatically compressed by the server and PACS (Picture Archiving and Communication System). Retrieving these "archived" images requires double-clicking, which initiates an uncompression process that can take about 5 minutes.
Navigating Studies: Patients can be searched by MRN, study date, or study type (e.g., "premature study").
Radimage: This system is crucial for creating echo requests within the hospital, ensuring images are properly transferred to the PACS.
Workflow: After logging into (ensuring "Montreal Children's Hospital" and "Cardiology" are selected), you can search for active patients, create new requests, and select the appropriate study type (e.g., "NICU no reports" for TNE).
Critical Step: Always close your request in Radimage only after all images have been transferred to the PACS. Closing a request prematurely will result in lost images. Our machines are set to transfer images as they are acquired, but Wi-Fi dependency means a final check is still necessary.
Data Flow: Information entered in Radimage (like technician names) is primarily for request creation and does not directly appear in the patient's chart or image metadata. The images themselves, once transferred, are accessible via "Syngo" and also through the patient's chart system via "IntelViewer".
PACS/DICOM: Images are stored as Digital Information Communication of Medicine (DICOM) files, which contain 2D/3D images, time, distance information, and metadata for sequence and patient identification. The system uses calibration points to ensure accurate distance measurements on the image.
Cardiac Anatomy and Spatial Relationships
Understanding the spatial relationships of cardiac structures is fundamental for accurate echocardiographic interpretation. Check the morphology section and TnECHO section.
Ventricular Orientation: The right ventricle (RV) is positioned anteriorly, wrapping around the bullet-shaped left ventricle (LV), which is more posterior. In a cross-section, the RV often appears crescent-shaped, hugging the LV.
RV Morphology: The RV is a tripartite organ with an inflow portion, a trabecular portion (the "body"), and an outlet portion (conus). The conus, or RV outflow tract (RVOT), has no fibrous continuity with the tricuspid valve.
Valve Relationships:
Tricuspid vs. Mitral Valve: The tricuspid valve is typically displaced slightly downward and more apical compared to the mitral valve, which is slightly higher. This creates a portion of the LV septum shared with the right atrium, known as the atrioventricular septum. If these valves are on the same plane, they are termed left and right atrioventricular valves, indicative of an AV canal or atrioventricular septal defect.
Gerbode Defect: A hole in the membranous septum (part of the atrioventricular septum) leading to a shunt from the LV to the right atrium, which is called a Gerbode defect or phenomenon. This can cause significant heart failure.
Aortic vs. Pulmonary Valve: In normal anatomy, the aortic valve is typically to the right side of the pulmonary valve, and the pulmonary valve is always anterior to the aortic valve. The great vesses are perpendicular to each other, not parallel.
Great Vessels: The aorta loops around the pulmonary artery, typically going to the left side of the spine. The first vessel branching off is the brachiocephalic trunk, dividing into the right subclavian and right carotid arteries. A right-sided aortic arch would show mirror branching, with the first vessel heading towards the left shoulder.
Assessing Ventricular Function
Ejection Fraction (EF) is a key metric, defined as stroke volume divided by the end-diastolic volume (EDV), where stroke volume is EDV minus end-systolic volume (ESV). While EF can theoretically be calculated for any ejecting structure, the challenge lies in accurately modeling the irregular volumes of cardiac chambers.
Left Ventricular (LV) Volume and Ejection Fraction Measurement Methods
3D Echo Ejection Fraction: This method directly captures the entire walls of the ventricle in 3D, allowing the machine to compute end-diastolic and end-systolic volumes. However, this technology is not universally available.
Simpson's Method: The most common 2D method for EF.
Principle: Dividing the LV into a series of staggered disks (often 20 slices). By staggering discs, the total volume could be estimated.
Biplane Simpson: To account for the LV's non-circular shape, the model was refined to use a biplane approach. It obtains a 4-chamber view (septal and lateral points) and a 2-chamber view (posterior and anterior points). These four points define an oval surface area for each disk, which are then staggered to reconstruct the volume.
Limitations of Simpson's:
Assumes Equal Wall Contribution: It assumes all segments of the LV walls contribute equally to contraction, which is not always true. A "tethering effect" can occur where healthy parts compensate for damaged ones, leading to a "normal" EF by Simpson's even if the LV is struggling.
Abnormal Septal Configuration: If the LV is not bullet-shaped (e.g., due to severe pulmonary hypertension causing the septum to pancaking the LV), Simpson's assumptions for disk areas become inaccurate.
Subjectivity: Tracing the endocardium in diastole and systole is subjective and can be difficult to consistently match contours, especially without freezing the image.
5/6 Method: A technique to model LV volume, which has shown good correlation with MRI.
Principle: It assumes a bullet shape and uses the formula: Length × Cross-sectional Area × 5/6.
Measurement: The length is measured in a 4-chamber view, and the cross-sectional area is taken at the mid-papillary level in a parasternal short axis view (or subcostal view, as originally described).
Application: Doing this in diastole gives end-diastolic volume, and in systole gives end-systolic volume. While effective in specific patient populations (e.g., neonates with Tetralogy of Fallot), it's not widely adopted in clinical workflows.
Right Ventricular (RV) Measurements
Challenges with RV Volume: Simpson's disk method is not suitable for the RV because the RV is not bullet-shaped. It's described as shaped like a "bellow" or a "camel stomach," with its unique geometry making discrete disk staggering inaccurate.
RV Contraction: The RV's contraction involves a peristaltic motion of the tricuspid valve towards the RV outflow tract, with the septum moving inward and the free wall contracting. The lateral wall is the most contractile part of the RV.
3D RV: Similar to the LV, a 3D echo of the RV allows for accurate segmentation of the entire walls to compute volumes and ejection fraction, as 2D methods lack mathematical models to accurately represent the RV's complex shape.
TAPSE (Tricuspid Annular Plane Systolic Excursion):
What it is: TAPSE measures the longitudinal displacement of the tricuspid valve annulus during systole.
How it's done: Using M-mode, a line of interrogation is placed through the RV apex and the lateral attachment of the tricuspid valve. The distance the annulus travels from diastole to systole is measured.
Utility: TAPSE is an easy-to-obtain and reliable marker of RV systolic function, with good intra-rater reliability and normative values.
Key Limitation: Load Dependence: Like most echo metrics, TAPSE is load dependent. A normal TAPSE can be observed even in the presence of severe pulmonary vascular resistance and significant tricuspid regurgitation (TR) if the RV muscle's contractility is appropriate for the given load. This means a "normal" TAPSE doesn't always reflect overall healthy RV function if the heart is facing significant resistance but pumps backward into the right atrium due to severe TR.
RV Fractional Area Change (FAC): It's measured in the RV 4-chamber view, with increasing literature supporting its use in the RV 3-chamber view as well. RV FAC in A4C has some correlation with MRI ejection fraction.
Tissue Doppler Imaging (TDI) of the RV Wall: Measures the speed of the RV muscle tissue motion.
Principle: A pulse wave Doppler is used at the attachment below the tricuspid valve. The machine plots instantaneous tissue speed over time.
Waves: It typically shows a systolic wave and two diastolic waves: an early E' wave (passive filling) and a late A' wave (atrial kick). These waves represent the speed at which the tissue moves during contraction and relaxation/filling phases.
Stiffness Assessment: A blunted E' wave suggests a stiff or hypertrophied tissue, as it struggles to expand during passive filling.
Newborn Considerations: Newborn ventricles are generally stiffer due to their fetal life with systemic RV pressures, making TDI interpretation challenging without longitudinal data. While normative values exist, individual patient trends are often more informative.
E/E' Ratio: This ratio compares the early mitral (or tricuspid) inflow velocity (E, from blood Doppler) to the early tissue expansion velocity (E', from TDI). A high E/E' ratio (e.g., >12 in adults for LV) can indicate diastolic dysfunction, meaning the ventricle is stiff and not relaxing efficiently, causing blood to struggle to enter the cavity despite ventricular expansion.
Echocardiography utilizes several modes to visualize and assess blood flow and tissue motion.
M-mode (Motion Mode): Shows motion over time along a single line of interrogation. Useful for measuring displacement, like in TAPSE.
B-mode (Brightness Mode/2D): Provides a 2-dimensional real-time image of cardiac structures.
Color Doppler: Visualizes blood flow direction and relative speed within a defined "color box".
Convention: Red indicates flow towards the probe, and blue indicates flow away from the probe. This convention can be inverted on the machine, or the baseline (zero velocity line) can be adjusted, which can affect interpretation.
Speed Representation: The intensity of the colour (tinge) indicates the speed of the flow: darker colours (dark red/dark blue) signify flows near the nyquist threshold, while lighter colours (yellow/green/turquoise) signify faster flows.
Directionality: Flow direction is always relative to the ultrasound probe's angle.
Frame Rate: Higher frame rates (images per second) provide more granular time - temporal information, especially for research purposes, while color Doppler inherently has lower frame rates.
Doppler Principles: Doppler ultrasound uses the Doppler shift principle (like the change in pitch of an ambulance siren) to measure the velocity of blood flow or tissue motion.
Pulse Wave (PW) Doppler: Measures instantaneous velocity at a specific point of interrogation. It's ideal for low-velocity flows.
Applications: SVC/IVC flow, pulmonary veins, coronary arteries (perfuse in diastole, except in conditions like HLHS where they perfuse retrogradely in systole). Also used for large shunts (PFO, ASD, VSD, large PDA), especially in newborns where pressure equalization can lead to low velocities.
Velocity Time Integral (VTI): The area under the Doppler velocity curve represents the average distance a blood cell travels over time (a "stroke distance").
Continuous Wave (CW) Doppler: Measures velocity along the entire line of interrogation. It is used for high-velocity flows that might exceed the sampling limit of PW Doppler.
Applications: Stenosis (aortic, pulmonary), constricting ducts, coarctation, regurgitant lesions (TR, MR, PR, AR), and high-velocity arterial flows.
Aliasing: Occurs when the machine cannot accurately determine the direction of flow due to very high velocities and turbulence, resulting in a mix of colours (red and blue) where only one direction is expected. Aliasing, in the context of ultrasound and Doppler, is an imaging artifact that occurs when the velocity of blood flow exceeds the Nyquist limit of the ultrasound system, leading to inaccurate or misleading velocity and direction information. Essentially, the system cannot accurately sample the Doppler shift frequency, causing the displayed velocities to "wrap around" and appear on the opposite side of the baseline.
Nyquist Limit/Velocity Filter: To resolve aliasing, you can adjust the Nyquist limit or velocity filter. Increasing this filter allows the machine to focus on only the fastest flows, filtering out lower-velocity, turbulent components that cause confusion.
Gain: This setting amplifies the returning ultrasound signals. It's crucial to use appropriate gain to ensure sufficient image contrast without over-gaining, which can distort interpretation. In babies, significant gain adjustments are rarely needed.
NICU Cardiology Academic Case Rounds: Structure and Expectations
These rounds are a fundamental part of our ongoing education and patient care discussions.
Frequency and Scheduling: These rounds typically occur Wednesday, generally during the first week of the month. However, dates may shift based on the availability of Dr. Cavalle and Dr Altit.
Structure and Content: Each session is structured around discussing a patient case and a relevant subject.
There are usually two speakers for each round.
One speaker often presents the patient case, while the other covers the pathophysiology. Alternatively, responsibilities can be divided as desired.
Speakers: We aim for diverse perspectives, ideally inviting an allied healthcare professional (such as a Respiratory Therapist (RT), nurse or a nurse practitioner (NP)) and a medical team professional (MD or fellow).
It is generally preferred not to have two fellows present together, but it can occur if necessary. Fellows are typically encouraged to present the pathophysiology, while allied professional present the case.
Timing and Attendees: Rounds start at 8:15 AM on Wednesday mornings, immediately following sign-out. Cardiology, neonatology, and allied healthcare professionals are all on the line.
Presentation Flow: The presentation begins with the patient case. This is followed by a review of imaging, which might include echo images (presented by individuals like NH-TNE or Cardiology), MRI images, or rhythm bands and ECGs for arrhythmia cases.
Pathophysiology Review: Approximately 20 minutes are dedicated to a pathophysiology review specifically tailored to the Neonatal Intensive Care Unit (NICU). The focus is on what to expect in the NICU and the practical implications of findings (e.g., "good sats" in a hypoplastic left heart infant is not good). Detailed explanations of complex procedures (like Fontan for hypoplastic left heart) are generally avoided in favor of NICU relevance.
Pre-Rounds: Dr. Cavalle and other attending physicians will review slides in advance during a "pre-rounds" session. These pre-rounds typically last 30-45 minutes and are scheduled a few days before the official rounds, based on availability.
Commitment: Each team member is expected to present at least two cases.
Format: Most rounds are conducted online via Teams to facilitate showcasing patient information. It's a hybrid format, with some presenting from the main conference room and others from cardiology.
Past Cases: Examples of cases discussed since 2021 include heterotaxy, Long QT, vascular ring, infant of diabetic mother cardiomyopathy, tetralogy of Fallot, BPD pulmonary hypertension, TTTS physiology, PDA management, dilated cardiomyopathy, neonatal Ebstein anomaly, hypoplastic left heart, PAIVS, CCTGA (double discordance), aortic valve stenosis, PALS review, cardiogenic shock, and inotrope vasopressors for the unit.
Targeted Neonatal Echo (TNE) Protocol and Assessment
The website contains a wealth of information to guide your TNE practice.
Comprehensive Approach: A document titled "Comprehensive Approach to TNE assessment" outlines the necessary steps when evaluating a patient. This approach emphasizes integrating all available information:
Reasons for the Echo: Understand why the TNE is being performed.
Patient History: Review the patient's medical history.
Physical Examination: Perform a thorough physical exam, assessing vital sign trends, temperature, NIRS values, pre/post saturation and BP differences, cardiorespiratory status, liver size (e.g., for RV failure), murmurs, and gallops. Remember that echo alone is insufficient; clinical context is crucial.
Investigations: Review laboratory results (lactate, pH, electrolytes, other relevant labs like TSH if indicated) and past ECGs.
TNE and Diagram Integration: Conduct your TNE and integrate the findings into a schematic diagram. This helps visualize parameters like aortic systolic/diastolic pressure, assess flow and SVR issues, and understand shunt direction and its implications for resistance profiles. It helps determine what's happening in various heart chambers (e.g., LV filling, contractility, afterload, coronary perfusion, RV emptying, RA pressures, ASD role).
Management Plan Development: This integrated approach helps in deciding on management strategies and therapies. Components include:
Cardiorespiratory Support Adjustments: For example, optimizing ventilatory support or addressing issues like abdominal compartment syndrome or pneumothorax.
Hemodynamic Interventions: Determining the need for fluid or blood products, inotropes or vasopressors, and pulmonary/systemic vasodilators (e.g., Milrinone). This systematic approach helps in selecting appropriate drugs.
Other Considerations: Checking for and addressing issues like electrolyte imbalances (e.g., calcium levels affecting cardiac function).
Rate Control: When necessary .
Modulating the Duct: If needed.
Adrenal Support: If indicated.
Drainage: For issues like tamponade.
Line Position
Follow-up: Scheduling repeat TNEs, considering official cardiology consults (especially for Congenital Heart Disease (CHD) concerns), and ensuring continued laboratory and imaging follow-ups.
Documentation: Thorough documentation is essential.
Learning Progression: Initially, it is highly recommended to physically plug measurements into the diagram. As you gain experience, you'll integrate information mentally during the echo. Always start with a clear question and expectation before beginning an echo.
Reporting TNEs
TNE reports are an integral part of patient documentation.
Primary System: Reports are typically done on Oacis under the "documents" tab.
Exception: The only time a paper version of the TNE report is used is in the CDH (Congenital Diaphragmatic Hernia) clinic.
Process on Oacis:
Click on patient chart and then on "Chart Clinical O-Word Editor".
Select "inpatient" (they are always inpatient unless in CDH clinic for non-paper report).
For first-time users, navigate to "New Documents" and search "by description" for "Targeted Neonatal Echo".
Add it to your favorites using the code MU 3278.
Double-click the favored option to open the report template.
Fill in details like the echo date and time.
You can include a "late entry" note if the report was initially written elsewhere.
Detailed clinical context, patient history, and the reason for the echo should be included.
Summarize findings (e.g., RV dysfunction, LV/RV dilation, response to interventions like dobutamine/Epi, physical exam findings).
Include measurements (e.g., RV/LV appearance, septal bowing, shortening fraction, TAPSE, pulmonary vein drainage, LV function, assessment of interatrial septum ...).
Measurements: While basic measurements can be done on the echo machine, more complex flow measurements like VTI are often quicker awhen done offline on a computer using syngo software. Syngo Web allows viewing images but not measurements.
Accessibility: Once finalized, the TNE report appears on Oacis under the documents.
Communication: It is recommended to also print the report and place it in the bedside paper chart. Crucially, always communicate the TNE results and recommendations to the clinical team verbally, avoiding an overwhelming list of measurements and focusing on actionable advice.
Using the Echo Machine
Machine Type: The Philips machine is typically used for TNEs.
Setup: It needs to be plugged into an ECG monitor using a cable and auxiliary cable.
Image Management: To maintain patient privacy for potential research use, do not include the patient's name on the image.
Instead, use a study ID.
On the first screen of the echo, include: "TNE requested for [reason]", blood pressure, day of life, patient weight, length (if available), and the name of the person who performed the echo (for quality assurance and image review).
NIRS Monitoring
NIRS machines are used in specific patient populations within our unit.
Standard Indications:
All babies with congenital heart defects (CHD) admitted for the first 7 days of life.
All babies undergoing therapeutic hypothermia (cooling) until rewarming for 24 hours.
Discretionary Use: may be used at the clinical team's discretion for patients in shock, those with CDH, or those on inotropes.
Precautions for Preemies: NIRS is not routinely used in premature infants due to sensor melting on the skin and unclear benefits. If used, precautions like placing a Mepilex under the probes are necessary.
Resources: The website provides a dedicated section on NIRS, including the unit's protocol and guidelines for interpreting regional saturation (e.g., reasons for too low or too high saturation) and reminders for nurses.
Key Resources and Further Learning
Our program offers a variety of resources to support your learning and practice:
The Website/Portal: This is a core hub for physiological principles, normal echo values, and various guides.
Pulmonary Hypertension (PH) Screening: Find the algorithm for screening babies.
Normal Neonatal Echo: Includes normal values for echoes, reviews of inotropes and vasopressors, tables for blood pressure reference (e.g., 5th and 50th percentile values for different ages and corrected conceptual ages), and common NICU drip standards. It also covers less commonly used drugs.
Physiological Principles
Promoting Comfort: Tricks for scanning different gestational ages (e.g., quiet environment for 24-weekers, bundling/music/low light for near/post-term babies, avoiding abdomen first).
Case Examples: Examples of past case presentations are available on the website.
Research Training: Completion of CITI training for research and good clinical practice is required to get credentials at the Research Institute.
The Research Environment:
The MUHC-RI is a major research institute in Canada, organized into different centers and programs.
CORE: Focuses on clinical research.
CTB: Houses individuals and labs conducting wet lab experiments, sequencing, and animal studies.
CIM: Provides research infrastructure, functioning like a "mini hospital" for clinical trials, patient monitoring during treatments for RCTs, and research-specific echo clinics.
Programs: The NeoCardioLab is part of the Child Health Human Development (CHHD) program and is associated with the cardiovascular health program. This gives you access to a wide range of activities and resources.
Resources: You have access to various valuable resources:
Research webinars and seminars, courses and scientific presentations.
To assess hypertrophy or other parameters based on body surface area, you will use Parameter Z, a normative database. You input patient data (height, weight, sex) and measurements (e.g., posterior wall in diastole) to determine if there's hypertrophy. The Lopez data is a commonly used reference for Parameter Z.
Another option is the Boston Children's database.
Other Software:
OneDrive: As part of your McGill or MSSS email account, you have access to a full OneDrive account, which functions like a Dropbox for syncing files. Be aware that access typically lasts for about a year after leaving McGill, so plan to download your files.
Email and ID: Your MED-MSSS email should always be used for patient-related information as it's more secure than the McGill email. Your MCH ID card is essential for hospital access and opening the office door.
Operating the Echo Machine (Philips)
You'll primarily use the Philips echo machine for scans.
Machine Power and Movement:
The power button is located on the machine.
The moon button puts the machine into sleep mode, which is useful for short breaks (e.g., between scans) as it avoids a full restart.
A pedal controls machine movement: completely down means locked, middle allows full movement, and up locks wheels in one direction for more control.
Never unplug the machine when it is on as this can damage circuits; always close it fully or use sleep mode before unplugging.
Ensure the screen never touches the wall when positioning the machine.
Probes and Ports:
Probe ports are always pointed down. To disconnect, unclick and gently remove; to connect, push gently and close.
Probes are labeled (e.g., S.12, S.9-2, L.15-7, X.7-2, C.8) according to their type and frequency.
Sector probes (S series), also known as phase array, have a square footprint and are good for hearts due to their motion capabilities (e.g., S.12, S.9-2, S.5, S.8-3). Higher frequency typically means better resolution.
Curvilinear probes (C series) (e.g., C.8) are typically used for brain and abdomen scans.
Linear probes (L series), or "hockey stick" probes, look like bars and are used for shallow, superficial structures due to their high frequency (e.g., L.15-7).
X-matrix probes (X series) (e.g., X.7-2, X.5-1) are for 3D imaging, sending ultrasound waves in two planes (one direction and cross-sectional). This Philips-specific technology allows for multi-directional imaging.
Additional probes (S.5, X.5-1, S.8-3) are stored in a side box on the machine.
Gel and Electrodes:
Large bottles of gel are available, but for babies, you'll use smaller, warmed individual packs found in a warmer used by multiple departments. Always replace packs you take to ensure supply.
Electrodes for ECG capture are in a separate box. This includes adult and baby electrodes, as well as auxiliary network cables to connect to a monitor if a baby already has electrodes.
Sterile gel covers are also available for procedures.
Sterile gel must be used for those with recent surgeries.
Machine Controls and Features:
The machine features a touch screen and a pull-out physical keyboard. An on-screen keyboard also appears when needed.
Patient names are automatically hidden on transmitted images but can be manually hidden via utilities if necessary.
Max View provides a high zoom, but you can switch it off to see the calculation list on the side.
The trackball acts as a mouse; clicking the "pointer" button switches between a mouse cursor and a line of interrogation for measurements.
The focus bar on the side allows you to concentrate energy wavelengths on your area of interest, even if the machine automatically optimizes focus everywhere. The "focus" button and wheel adjust this.
Image Boost (B) is an AI algorithm that enhances gain; remove it if you see too much "white noise" or spontaneous contrast.
Harmonics ç uses information from intra-tissue ultrasound bouncing for image optimization. Harmonics may be on by default for certain probes (e.g., S.9) but off for others (e.g., S.12).
The trackball's left and right buttons are used to select positions for 2D imaging, cursors, and color boxes.
Color Doppler has a frame rate which should ideally be above 20 Hertz. Narrowing the color box increases the frame rate. The "black and white suppress" button removes the 2D image, showing only the color box. Color compare displays both 2D and color, but at a lower frame rate.
Buttons for Pulse Wave (PW) Doppler, Continuous Wave (CW) Doppler, 2D imaging, and Color Doppler are clearly marked.
Simultaneous mode shows both live image and Doppler but can degrade the Doppler signal due to processing limitations.
M. Mode can be accessed via a button on the touchscreen or keyboard.
Wheels on the machine control gain (amplification of signal) for 2D, PW, CW, and Color Doppler. You can reset gains to presets if needed.
Scale and baseline adjustments are available for Doppler.
Be aware that changing parameters like the color box will restart the image acquisition loop.
Performing an Echo Examination (Normal Baby)
Here’s a general sequence for a standard echo examination on a baby:
Preparation:
Access the baby's chart to gather vital information: gestational age, current age, weight, respiratory status, blood pressure, and most recent length. Who is doing the TNE.
Input this information into the machine.
Set up the baby for comfort: Bundle them to keep their arms still, play calming music (e.g., "Peaceful Piano").
Clean your hands thoroughly before touching the baby.
Apply warm gel from the individual packs to the probe.
Post-Examination Care:
Clean the baby: Remove gel using special wipes (not paper) and warm water, then dry the baby. If a brain scan was performed, clean the head as well.
Redress the baby or help parents with skin-to-skin contact.
Disconnect the ECG.
Clean the probes used during the exam with appropriate wipes.
Ensure all images have been transferred to the patient's chart (PACS/Syngo) – a green light message indicates completion. You can review images and redo measurements in Syngo or on the machine.
Communicate findings to parents and clinical team
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