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Targeted Neonatal Echocardiography in the …

EXPERT CONSENSUS STATEMENTT argeted Neonatal Echocardiography in the NeonatalIntensive Care Unit: Practice Guidelines andRecommendations for TrainingWriting group of the American Society of Echocardiography (ASE) incollaboration with the European Association of Echocardiography (EAE)and the Association for European Pediatric Cardiologists (AEPC)Luc Mertens, MD, PhD, FASE, FESC, Istvan Seri, MD, PhD, HonD, Jan Marek, MD, PhD, FESC,Romaine Arlettaz, MD, Piers Barker, MD, FASE, Patrick McNamara, MD, MB, FRCPC,Anita J. Moon-Grady, MD, Patrick D. Coon, RDCS, FASE, Shahab Noori, MD, RDCS,John Simpson, MD, FRCP, FESC, and Wyman W.

EXPERT CONSENSUS STATEMENT Targeted Neonatal Echocardiography in the Neonatal Intensive Care Unit: Practice Guidelines and Recommendations for Training

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1 EXPERT CONSENSUS STATEMENTT argeted Neonatal Echocardiography in the NeonatalIntensive Care Unit: Practice Guidelines andRecommendations for TrainingWriting group of the American Society of Echocardiography (ASE) incollaboration with the European Association of Echocardiography (EAE)and the Association for European Pediatric Cardiologists (AEPC)Luc Mertens, MD, PhD, FASE, FESC, Istvan Seri, MD, PhD, HonD, Jan Marek, MD, PhD, FESC,Romaine Arlettaz, MD, Piers Barker, MD, FASE, Patrick McNamara, MD, MB, FRCPC,Anita J. Moon-Grady, MD, Patrick D. Coon, RDCS, FASE, Shahab Noori, MD, RDCS,John Simpson, MD, FRCP, FESC, and Wyman W.

2 Lai, MD, MPH, FASE,Toronto, Ontario, Canada; Los Angelesand San Francisco, California; London, United Kingdom; Zurich, Switzerland; Durham, North Carolina;Philadelphia, Pennsylvania; New York, New York(J Am Soc Echocardiogr 2011;24:1057-78.)Keywords:Echocardiograp hy, Neonatal intensive care unit, Neonatologists, pediatric cardiologists, Pretermneonate, Term neonateTABLE OF CONTENTSA bbreviations 10581. Targeted Neonatal Echocardiography : Background and Indications Cardiovascular Adaptations in the Neonatal Period Indications for TNE Indications for TNE With Standard Imaging (Standard TNE) Indications for TNE With Focused Imaging (Focused TNE)10622.

3 Targeted Neonatal Echocardiography : Practical Aspects General Aspects of TNE Technical and Safety Requirements for Performing TNE Guidelines for Image Acquisition in the NICU Components of Standard TNE Evaluation of LV Systolic Function AssessmentofLVDiastolicorCombinedFunctio n Evaluation of RV Function Assessment of Atrial-Level Shunt Assessment of PDA Assessment of RVSp and PA Pressures Assessment of Systemic Blood Flow Assessment of Pericardial Fluid TNE for Specific Neonatal Conditions Suspected PDA Perinatal Asphyxia Neonatal

4 Hypotension Suspected Persistent Pulmonary Hypertension of the Newborn(PPHN) CDH Suspected Effusion Central Line Placement ECMO Cannulation 1071 From The Labatt Family Heart Center, The Hospitalfor Sick Children, Toronto, Ontario,Canada ( , ); Children s Hospital Los Angeles, Los Angeles, California ( , ); Great Ormond Street Hospital, London, United Kingdom ( ); UniversityHospital Zurich, Zurich, Switzerland ( ); Duke University Hospital, Durham, NorthCarolina ( ); the University of California, San Francisco, California ( );The Cardiac Center at the Children s Hospital of Philadelphia, Philadelphia,Pennsylvania ( ); Evelina Children s Hospital, London, United Kingdom ( );and Morgan Stanley Children s Hospital of New York Presbyterian, New York, NewYork ( ).

5 The following authors reported no actual or potential conflicts of interest in relation tothis document: Luc Mertens, MD, PhD, FASE, FESC, Jan Marek, MD, PhD, FESC,Romaine Arlettaz, MD, Piers Barker, MD, FASE, Patrick McNamara, MD, MB,FRCPC, Anita J. Moon-Grady, MD, Patrick D. Coon, RDCS, FASE, Shahab Noori,MD, RDCS, John Simpson, MD, and Wyman W. Lai, MD, MPH, FASE. The followingauthor reported a relationship with one or more commercial interests: Istvan Seri,MD, PhD, HonD, served as a scientific consultant for Somanetics Corporation(Troy, MI) until ASE Members:ASE has gone green!

6 Earn free continuing med-ical education credit through an online activity related to this article. Certificatesare available for immediate access upon successful completion of the will need to join ASE to access this great member benefit!Reprint requests: American Society of Echocardiography , 2100 Gateway CentreBoulevard, Suite 310, Morrisville, NC 27560 Group of the American Society of Echocardiography (ASE)in collaboration withthe European Association of Echocardiography (EAE) and the Association forEuropean PaediatricCardiology (AEPC).0894-7317/$ 2011 by the American Society of Training and Accreditation in Tar-geted Neonatal Echocardiogra-phy Overview of Existing Train-ing Guidelines US Pediatric Echocar-diographic Guide-lines European PediatricEchocardiographicGuidelines Proposal for Training inTNE Core Training inTNE Advanced Training inTNE Supervision of Train-ing Evaluation Maintenance of Compe-tence and Quality Assurancefor TNE 10741.

7 Targeted NEONATALECHOCARDIOGRAPHY:BACKGROUND ANDINDICATIONSThe role of Echocardiography inthe Neonatal intensive care unit(NICU) has changed over thepast few years. Previously, nearlyall echocardiographic studies inthe NICU were performed bypediatric cardiologists to diag-nose or monitor congenital heartdisease (CHD) and to screen forpatent ductus arteriosus (PDA).More recently, neonatologistshave become interested in theechocardiographic assessmentof hemodynamic instability in in-fants. The termsfunctional echo-cardiographyandpoint-of-careechocar diographyhave been in-troduced to describe the useof Echocardiography as an ad-junct in the clinical assessmentof the hemodynamic status increasingavailability of Echocardiography ,with miniaturization of thetechnology.

8 Has resulted in more widespread use ofechocardiography in NICUs around the the most sig-nificant challenge for the application of so-called functional studies isthat newborns in the NICU with hemodynamic instability are ata much higher risk for having underlying CHD. In addition, newbornsin the NICU are unique in that they are in the process of transitionfrom fetal to postnatal this document, we make clear distinctions between initial echo-cardiographic studies in neonates with the suspicion of CHD andstudies performed on infants without any clinical suspicion ofCHD.

9 If CHD has been excluded, subsequent studies in childrenwith structurally normal hearts can focus on hemodynamic or func-tional assessment. The initial echocardiographic examination shouldalways be a comprehensive study of both anatomy and functionthat is to be interpreted by a pediatric cardiologist within a reasonabletime frame. Some structural defects, such as anomalous pulmonaryvenous return or coarctation of the aorta, can be difficult to detect us-ing Echocardiography and require extensive training and continuedpractice. Once significant congenital defects have been ruled out,more focused studies can be performed and interpreted by a trainedechocardiographer for specific indications, as defined later in this doc-ument.

10 We propose to use the termtargeted Neonatal Echocardiography (TNE) for themore focused studies. The aimsof the current documentare: (1) to review the current indications of TNE; (2) to define recom-mendations for the performance of TNE; and (3) to propose trainingrequirements for the operators performing and interpreting Cardiovascular Adaptations in the Neonatal PeriodThe Neonatal cardiovascular system differs from those of fetal, pediat-ric, and adult patients. At term, a neonate must successfully transitionthrough abrupt changes in the cardiorespiratory system, includingchanges in lung volume and compliance and changes in left and rightheart preload and afterload.


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