TnECHO Echocardiography Protocol and Approach to Evaluation

Targeted Neonatal Echocardiography protocol

Promoting Comfort During TNE

Example of playlists we used during the TNE as a strategy to reduce stress

TnECHO Report at the Montreal Children's Hospital developed by Dr. G. Altit

Approach to the neonatal hemodynamics evaluation and diagrams

Targeted Neonatal Echocardiography protocol

Protocol_Echocardiograhpy.pdf

1) Parasternal Long Axis View – Full sweep Anterior-Posterior (2D and then Colour)

a. 2D-grayscale and 2D-color at Aorta-Mitral valve level

b. 2D-grayscale and 2D-colour of zoom of Aortic Valve (to measure LVOT)

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

d. M-Mode at tip of mitral valve for Shortening fraction, LV measurements, and LV-Mass

e. 2D-grayscale of tricuspid valve (scan posteriorly) + 2D-color of tricuspid valve

i. CW Doppler of tricuspid valve to obtain Tricuspid regurgitant jet if present (and Systolic-Diastolic time ratio)

ii. PW Doppler of RV inflow

f. 2D--grayscale and 2D-Color of Pulmonary valve (scan anteriorly). 2D will be used for measurement of RVOT and 2D-Color to evaluate flow and presence of pulmonary insufficiency.

i. PW-Doppler at level of RVOT

ii. PW-Doppler at tip of Pulmonary Valve (will be used for PAAT/RVET and for velocity time integral [VTI])

iii. CW-Doppler for pulmonary insufficiency.

g. If VSD detected (to be done in every view): 2D and Colour zoom

i. Obtain PW if low velocity

ii. Obtain CW-Doppler

2) Parasternal short axis (PSAX) view: Full sweep from Aortic Valve to LV Apex (2D and then Colour)

a. 2D-grayscale and 2D-Colour at Pulmonary valve and Aortic valve level

i. PW-Doppler at Tip of Pulmonary Valve

ii. CW-Doppler of pulmonary valve if pulmonary insufficiency

b. M-Mode at LA-Ao junction and M-Mode at Tip of mitral valve in PSAX

c. 2D-grayscale view (3 beats) at mitral valve level

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

e. 2D-grayscale view (3 beats) at LV apex level

f. Scan with 2D-Color septum from Base to Apex to rule out septal defect – if septal defect detected, CW-Doppler of the flow.

g. If tricuspid regurgitant jet present in PSAX: CW-Doppler

3) Apical View – Full sweep from Anterior to Posterior (2D and then Colour)

a. 2D-grayscale Apical 4 chamber view in 2D – LV focused

i. 2D-color box (low velocity) over the pulmonary veins in the left atrium

ii. PW of the pulmonary veins in A4C from the left atrium

b. 2D-grayscale Apical 4 chamber view in 2D – RV focused

c. 2D-color for Tricuspid and Mitral valve.

i. PW below the tricuspid valve for E/A velocities

ii. PW below the mitral valve for E/A velocities

iii. CW of Mitral valve for dp-dt if present.

iv. 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. Dp-Dt of RV to be done if 2 m/s reached.

d. PW of each pulmonary veins

e. A4C: Zoom on LA for dimensions

f. A4C: Zoom on RA for dimensions

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

h. Tissue Doppler Imaging (TDI)

i. TDI on RV free wall below the tricuspid valve

ii. TDI on LV free wall below the mitral valve

iii. TDI of septum below the attachment of mitral valve

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

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

1. PW just above the tip of the aortic valve for the LV-VTI

2. PW inflow-outflow

j. Apical 2 Chamber view of the LV in 2D: Colour and 2D grayscale

i. PW at inflow of mitral valve

ii. CW of Mitral valve for dp-dt if present.

iii. Zoom on LA for dimensions (Biplane)

k. Slide from the Apical 2 Chamber view of the LV towards the sternum to obtain a RV Inflow to Outflow tract (RV “3 chamber view”).

i. PW of RVOT

ii. PW of inflow of RV

iii. CW of tricuspid valve

iv. Colour view recorded

v. 2D gray scale recorded

l. 3D LV, 3D RV (Probe X7; use the High Volume Capture for each and at least 4Q capture for each).

i. Only if 3D volumes available

4) Subcostal:

a. Subcostal long axis: (Full Sweep from IVC to RVOT: 2D and Colour)

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

ii. Doppler of subhepatic veins and IVC + Colour flow

iii. PW and/or CW through the inter-atrial shunt (especially if concern of RV and/or LV diastolic dysfunction)

b. Subcostal short axis: (Full Sweep Anterior to Posterior).

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.

iv. Doppler of subhepatic veins and IVC + Colour flow

v. RVOT PW-Doppler

vi. PW and/or CW through the inter-atrial shunt (especially if concern of RV and/or LV diastolic dysfunction)

c. Sweep in 2D-grayscale to get anatomy in short and long-axis

5) Suprasternal view:

a. Long axis - Aortic Arch in 2D-grayscale and 2D-color

i. PW in Ascending Aorta

ii. PW in Descending Aorta pre ductal

iii. PW in Descending Aorta post-ductal

iv. Sweep to confirm bifurcation of brachiocephalic artery towards the right

b. Short axis

i. Sweep to confirm bifurcation and arch sidedness (color and 2D)

ii. SVC in 2D and Colour

1. PW of SVC (retrograde flow presence? Torrential flow presence?)

6) Patent Ductus Arteriosus View

a. 2D grayscale for measurement and 2D color for flow. Please record to confirm closure if no flow.

b. CW through the ductus arteriosus if present.

c. PW through the ductus arteriosus if unrestrictive and large.

d. 2D and Colour (simultaneous views).

7) Branch Pulmonary artery (Moustache view)

a. 2D-grayscale and 2D-Color

i. PW in MPA, LPA and in RPA

b. Crab view for pulmonary veins – 2D-color with low velocity (Nyquist). Obtain PW in each pulmonary vein (if possible) at osteum.

8) Head ultrasound (Cebrovasculature)

a. Transcranial view (temporal bone) for MCA Doppler

b. Sagittal view with 2D-color over the anterior cerebral artery (ACA)

i. PW- Doppler of ACA

c. Coronal view with 2D-Color over the circle of Willis

i. PW-Doppler of ACA and MCA

Promoting Comfort During TNE

Important note: As part of our imaging protocol, our TNE team plays piano-derived classical music (neo-classical) from a portable device placed on the echocardiography machine holder for every TNE performed, regardless of the infant's condition or age.

To ensure optimal comfort for newborns during TNE, we have developed a multi-strategy approach that complements music. This approach is thoughtfully implemented at each encounter and includes the following measures:

Family-Centered Support: Encourage the presence of parents and caregivers during the procedure (when possible) to provide reassurance and promote a calming environment for the baby.
Calm and Soothing Environment: Use a darkened room to minimize sensory stimulation.
Coordinate with nursing staff to align imaging with routine care to avoid unnecessary disturbances.
Infant Positioning and Comfort: Bundle the newborn securely to provide a sense of containment and security.
Ensure the use of warm ultrasound gel to prevent discomfort caused by cold gel on the baby’s skin. We use single individual gel packs and not bottles, which could contribute to infection transmission. As such, we strongly discourage the use of bottles that are shared between patients.
Minimizing Disturbances: Keep the incubator doors closed as much as possible to maintain warmth, reduce noise, and protect the baby’s microenvironment. Some incubators have a air boost function to promote a warm environment and minimal temperature instability.
Streamlined Imaging Process: Focus on acquiring the most essential views needed for assessment. Aim to complete imaging in the least amount of time necessary without compromising diagnostic quality. We aim for 15 to 30 minutes (max).

By integrating these strategies, we aim to create a safe, comfortable, and minimally invasive experience for the newborn while ensuring accurate and efficient imaging for clinical or research purposes.

Example of playlists we used during the TNE as a strategy to reduce stress

TnECHO Report at the Montreal Children's Hospital developed by Dr. G. Altit

TnECHO.pdf

ECHO REPORT.pdf

Approach to the neonatal hemodynamics evaluation and diagrams

Below are some schematics that I find particularly useful (inspired from Dr Rudolph) when discussing a patient’s hemodynamic condition. I encourage trainees/fellows to include detailed information in their assessments, such as: Pressures (systolic/diastolic/mean) and oxygen saturations in all vessels and cardiac chambers (measured, estimated, or inferred). Presence of shunts, their directionality, and volume of shunting, which are critical for understanding the trajectory of blood flow. I also recommend incorporating additional elements into these schematics:

Cardiac systolic function and outputs: Specify the impact on right and left ventricular function.
Pulmonary and systemic blood flow: Highlight any imbalances or alterations.
Pulmonary and systemic venous return, filling.

This approach provides a comprehensive visual representation of the patient’s hemodynamics, which can significantly aid in tailoring management strategies. By mapping out these details, it becomes easier to identify the optimal course of action for the patient. Additionally, I have provided guidelines for performing Neonatal Hemodynamics evaluations as part of a comprehensive assessment.

Comprehensive Approach to Targeted Neonatal Echocardiography.pdf

Approach:

History
Physical exam and other findings
1. 1. Vital signs: HR, pre and post-ductal saturations, blood pressure, arterial waveform on the arterial line or saturation probe
  2. Temperature
  3. Cardio-resp status: intubated vs not, MAP (which can influence venous return and RV afterload)
  4. NIRS values
  5. PE: Liver, perfusion, pulses, pre and post areas, auscultation (gallops? murmur? S1/S2?), pulmonary auscultation, femoral pulses.
    1. 1. Is the pre really a pre? (situs inversus)
      2. Is there a duct? Is there a post-tricuspid shunt?
      3. Is there an inter-atrial shunt?

On the cardiac graph:

Saturations in each vessels and presumed saturations in each cardiac chambers and in pulmonary veins
Pressures in each chamber and the direction of shunt (and volume of the shunt)
Current medications: cardiovascular, sedation, analgesia, anti-seizure (is the baby seizing?), dexmedetomidine (will drop HR), opiates and benzos (will make you more vasoplegic)
Laboratory and Xray
1. 1. Hemoglobin, gaz (pre- vs post-ductal; arterial vs venous; central venous; capillary), PaO2 (if arterial; pre- vs post?), CO2, pH
  2. XRAY: white, black, lung disease, patchy?
  3. TSH, Calcium level, Sodium, Lactate, NTproBNP
  4. ECG / RVH hypertrophy, Arrhythmias, tachycardia?
  5. Other investigations: IVH? sites of bleed? third spacing? Restriction due to body wall edema?
Findings on TNE:
1. Cardiac function (RV, LV - systolic; diastolic is a controversy but if hypertrophy or tachycardia?)
2. Hypertrophy
3. Output and/or obstruction of output
4. Valvular stenosis
5. Valvular insufficiency
6. PDA/ASD/VSD: Shunt size and direction
7. PA pressure and concerns about PVR
8. Systemic venous return
9. Pulmonary venous return
10. Line positions
11. Subjective filling
12. Effusions
Management plan:
1. 1. Cardio-resp approach: MAP too high? MAP too low (derecruited)?
    1. 1. Pleural effusion, Pericardial effusion, Abdomen distension compartment syndrome…
  2. Electrolytes
  3. Filling
  4. Inotropy vs Vasopressor?
  5. Pulmonary vasodilation?
  6. Systemic vasodilation?
  7. Adrenal Support?
  8. Outside the box: Hypothyroidism, Graves disease, Aspiration?, Dehydration? Drainage?…
  9. Other investigations
  10. Follow-up plan?

TNE approach.pdf