TnECHO Echocardiography Protocol

Important note: As part of our imaging protocol, our TNE team plays piano-derived classical music from a portable device placed on the echocardiography machine holder for every TNE performed, regardless of the infant's condition or age. In addition to music therapy, a multi-strategy approach is implemented at each encounter. This includes the presence of parents and nurses (when possible), a darkened room, coordination with care, bundling of the newborn, warm ultrasound gel, maintaining closed incubator doors and focusing image acquisition to the most essential views during the least amount of time possible.

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

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