NeoCardio Lab - NECTAR Study

g. CW-Doppler of tricuspid valve to obtain Tricuspid regurgitant jet – even if unavailable, please record so that we can do a systolic-diastolic time ratio.

h. Color on left atrium with low-velocity filter for pulmonary vein

i. PW-Doppler in right upper pulmonary vein

i. M-Mode in A4C for the Lateral wall of the RV to get TAPSE (line of interrogation should ideally cross the Apex).

j. Apical 3 Chamber view of LV in 2D-grayscale

i. Apical 3 chamber view in 2D-Color to see flow from mitral through Aortic Valve

1. PW at LVOT

k. Apical 2 Chamber view of the LV in 2D in 2D grayscale (make sure to have all the LV walls)

l. RV-Apical 3 Chamber view in 2D grayscale (make sure to have all the RV walls). RV "Tet" view.

m. RV-A3C for TRJ for best angle if not obtained in previous views, and for PW-Doppler of RVOT if not obtainable in PLAX/PSAX.

4) Subcostal

a. Subcostal long axis:

i. 2D-grayscale and 2D color over the inter-atrial septum (for inter-atrial shunt)

b. Subcostal short axis:

i. 2D-grayscale and 2D color over the inter-atrial septum (for inter-atrial shunt)

ii. 2D-colour over the descending aorta

iii. PW of the descending aorta.

5) Suprasternal notch:

a. Arch view in 2D and Colour

b. PDA view with sweep: Colour and 2D

i. PW and-or CW of the PDA flow

Imaging Protocol

Make sure the images are not identified / anonymized. Also make sure that the DICOMs are exported de-identified.
Make sure images are ECG-Gated
Name of person who obtained the image (for quality assurance)
Acquisition at minimum of 3 beats capture
Ideally, avoid sending DICOMS that had their frame rate compressed. We would prefer obtaining the files that are encoded with their original frame rate (beware as certain GE machines send images to the PACS or to USB/drives in 25 or 30 fps even if it was acquired at a higher frame
Make sure to obtain all walls and apex for the RV and LV in the apical views.
On first image - record:
- Study-ID
- Blood pressure (Sys/Dia - Mean)
- Day of life ECHO
- Weight
- Length if available

Parasternal Long Axis View

2D-grayscale at Aorta-Mitral valve level

2D-color at Aorta-Mitral valve level

2D-grayscale at Aorta-Mitral valve level

2D-color at Aorta-Mitral valve level

2D-grayscale of zoom of Aortic Valve (to measure LVOT)

2D-colour on zoom of Aortic Valve

M-Mode at Left Atrium / Aorta junction for : LA/Ao ratio

M-Mode at tip of mitral valve

2D-grayscale of tricuspid valve (scan posteriorly)

2D-color of tricuspid valve

CW Doppler of tricuspid valve to obtain Tricuspid regurgitant jet if present.

2D-grayscale sweep to RVOT

2D-colour at RVOT

2D-Zoom of Pulmonary valve

PW-Doppler at RVOT

CW-Doppler through RVOT (especially for pulmonary insufficiency jet)

Parasternal Short Axis View

2D-grayscale at Pulmonary valve and Aortic valve level

2D-Colour at Pulmonary valve and Aortic valve level

PW-Doppler at RVOT

M-Mode at left atrium – aorta junction (if not obtained in PLAX or misaligned)

2D-grayscal Sweep from aortic valve to LV apex

2D-grayscale at Mitral valve

M-Mode at Tip of mitral valve in PSAX (if not obtained in PLAX or misaligned)

2D-grayscale view (at least 3 beats) at mid-papillary muscle level

2D-sweep to apex

Colour in PSAX to obtain TRJ

TRJ velocity by CW-Doppler

Apical Views

2D-grayscale Apical 4 chamber view in 2D – LV focused with Left Atrium

2D-colour over Mitral valve

2D-grayscale Apical 4 chamber view in 2D – RV focused with Right Atrium

2D-colour over Tricuspid valve

RV focus in A4C. We can see well the endocardial border, the apex and the full right atrium.

LV focus in A4C. We can see well the endocardial border (all the walls of septum and anterolateral wall of LV), the apex and the full left atrium.

PW below the tricuspid valve for E/A velocities

PW below the mitral valve for E/A velocities

CW-Doppler of tricuspid valve to obtain Tricuspid regurgitant jet – even if unavailable, please record so that we can do a systolic-diastolic time ratio.

Color on left atrium with low-velocity filter for pulmonary vein

PW-Doppler in right upper pulmonary vein

M-Mode in A4C for the Lateral wall of the RV to get TAPSE (line of interrogation should ideally cross the Apex).

Apical 3 Chamber view of LV in 2D-grayscale

Apical 3 chamber view in 2D-Color to see flow from mitral through Aortic Valve

PW at LVOT

Apical 2 Chamber view of the LV in 2D in 2D grayscale (make sure to have all the LV walls) - with left atrium.

RV-Apical 3 Chamber view in 2D grayscale (make sure to have all the RV walls). RV "Tet" view.

RV-A3C for TRJ for best angle if not obtained in previous views, and for PW-Doppler of RVOT if not obtainable in PLAX/PSAX.

Subcostal Views

2D-grayscale and 2D color over the inter-atrial septum (for inter-atrial shunt). Subcostal long axis.

2D-grayscale and 2D color over the inter-atrial septum (for inter-atrial shunt). Subcostal Long Axis.

2D-colour over the descending aorta

PW of the descending aorta.

Suprasternal Notch

PDA view with sweep: Colour and 2D

PW-Doppler in the PDA. CW-Doppler to be done if high velocities

Arch view and colour

Data extraction

1) LV Function / Left-sided Dimensions:

a. LVO

i. LVOT-VTI

ii. HR

iii. LVOT diameter

b. EDV, ESV and EF by Simpsons Biplane

c. A4C-EDV; A4C-ESV and EF by A4C only

d. LV-EDD and LV-ESD, Calculate Shortening Fraction

e. E of mitral valve; A of mitral valve.

f. LA/Ao ratio

2) RV Function:

a. TAPSE

b. RVO

i. RVOT-VTI

ii. HR

iii. RVOT diameter

c. RV-FAC in A4C

i. RV-EDA and RV-ESA

d. E of tricuspid valve, A of tricuspid valve.

3) Estimation of Pulmonary Pressure

a. Septal curve at peak of systole: Round, Flat, Bowing

b. Eccentricity Index at peak of systole

c. PAAT/RVET

d. TRJ velocity

e. PDA patency:

i. Yes – No present

ii. Directionality: Left to right, Bidirectional, Right to left.

iii. Peak velocity gradient in systole.

iv. Diameter in 2D (narrowest)

v. Retrograde holodiastolic flow in post-ductal Aorta: yes-no

f. Inter-atrial shunt:

i. Yes – No present

ii. Directionality: Left to right, Bidirectional, Right to left.

Standardization of the data measured

LA and Ao diameter on M-Mode

End diastolic diameter and end systolic diameter of LV in M-mode for SF

LVOT diameter for LVO estimation

Here the LVOT is 0.61 cm

E and A velocity of LV

VTI and heart rate for LVO estimation

A2C Disc Method for EDV at peak of diastole - mitral valve closed (QRS)

A2C Disc Method for ESV at peak of systole - mitral valve closed

A4C Disc Method for EDV at peak of diastole - mitral valve closed (QRS)

A4C Disc Method for ESV at peak of systole - mitral valve closed

RV Function

RV-End Systolic Area at A4C - closed valve. Hinge of tricuspid valve connected by straight line (ASE method). For RV-FAC calculation.

RV-End Diastolic Area at A4C (at QRS) - closed valve. Hinge of tricuspid valve connected by straight line (ASE method). For RV-FAC calculation.

RV-End Systolic Area at RV-A3C - peak of contraction valves closed. For RV-FAC calculation.

RV-End Diastolic Area at RV-A3C - peak of dilatation valves closed (at QRS). For RV-FAC calculation.

TAPSE

E and A velocity of RV

VTI assessment and heart rate assessment for RVO

RVOT diameter in PLAX for RVO

Estimation of Pulmonary Pressure

PAAT/RVET

Septal curve at peak of systole: Round, Flat, Bowing / Eccentricity Index at peak of systole

TRJ velocity

PDA patency:

i. Yes – No present

ii. Directionality: Left to right, Bidirectional, Right to left.

iii. Peak velocity gradient in systole.

iv. Diameter in 2D (narrowest)

v. Retrograde holodiastolic flow in post-ductal Aorta: yes-no

Right to left component of a PDA that is patent. Measurement in blue.

CW-Doppler example of a PDA. Measurement of Peak diastolic velocity of 1.53 cm/s and Peak systolic velocity of 1.18 m/s. Because it is a low-velocity profile, we will favour a PW-Doppler (seen below).

PW Doppler - Peak DIASTOLIC Velocity (1.39 m/s)

PW Doppler - Peak SYSTOLIC Velocity = 0.93 m/s

PW of the descending aorta.

Presence of holodiastolic retrograde flow. In this particular example, there was NO PDA. However, we can see that in HIE with cerebral vascular loss of autoregulation and steal within the brain vasculature during diastole.

Inter-atrial shunt:

i. Yes – No present

ii. Directionality: Left to right, Bidirectional, Right to left.

Left to right component to an inter-atrial shunt

Right to left component to an inter-atrial shunt

PDF of measurements standardization

measurements.pdf

Centers also participating in the SANE Study

For the SANE (ClinicalTrials.gov NCT06098833), we will also add:

Tissue Doppler Imaging
Deformation analysis by Speckle-Tracking Echocardiography.

Tissue Doppler Imaging

s' = systolic velocity / vitesse systolique

e' = early diastolic velocity / vitesse diastolique précoce

a' = late (atrial) diastolic velocity / vitesse diastolique tardive

Myocardial performance index (rarely used) = (a-b)/b = (isovolumetric contraction time + isovolumetric relaxation time) / ejection time

Indice de performance myocardique (rarement utilisé) = (a-b)/b = (temps de contraction isovolumétrique + temps de relaxation isovolumétrique) / temps d'éjection

a = ejection time / temps d'éjection

c = isovolumetric contraction time / temps de contraction isovolumétrique

d = isovolumetric relaxation time / temps de relaxation isovolumétrique

Tissue Doppler at Septal Leval

s' (systolic velocity - vécolité systolique) = 10 cm/s

e' (early diastolic velocity - vélocité précoce diastolique) = 13 cm/s

a' (late/atrial diastolic velocity - vélocité tardive/auriculaire diastolique) = 10 cm/s

Myocardial Performance Index (MPI) / Indice de performance myocardique = (1 - 2)/2 = (426 - 229)/229 = 0.86

Tissue Doppler at Lateral Mitral Valve Level

Lateral wall TDI - Paroi latérale par Doppler tissulaire

s' (systolic velocity - vécolité systolique) = 13 cm/s

e' (early diastolic velocity - vélocité précoce diastolique) = 17 cm/s

a' (late/atrial diastolic velocity - vélocité tardive/auriculaire diastolique) = 13 cm/s

Myocardial Performance Index (MPI) = (1 - 2)/2 = (426 - 292)/292 = 0.46

Tissue Doppler at Lateral Tricuspid Valve Level

s' (systolic velocity - vécolité systolique) = 14 cm/s

e' (early diastolic velocity - vélocité précoce diastolique) = 12 cm/s

a' (late/atrial diastolic velocity - vélocité tardive/auriculaire diastolique) = 13 cm/s

RV-MPI = (412-310)/310 = 33

IPM-VD = (412-310)/310 = 33

Deformation analysis by Speckle-Tracking Echocardiography

As part of the SANE protocol, we will also be extracting deformation analysis parameters for the RV, LV and LA.