Benjamin Eidem, MD, FASE

In this communication, I wanted to highlight a recent publication from our council. Recently, there has been an increasing demand for training and utilization of focused echocardiographic examinations by non-cardiologist physicians. Areas that are utilizing these more focused studies include the emergency department, perioperative transesophageal echocardiography, adult intensive care units, pediatric intensive care units, and more recently the neonatal intensive care unit.

An ASE writing group, chaired by Dr. Luc Mertens, and in collaboration with the European Association of Echocardiography and the Association for European Pediatric Cardiologists, recently published an expert consensus statement entitled “Targeted Neonatal Echocardiography in the Neonatal Intensive Care Unit: Practice Guidelines and Recommendations for Training.” The evolving role of echocardiography in the comprehensive care of the neonate without congenital heart disease has been a topic of growing interest, both nationally and internationally. Neonatologists have become very interested and involved in the non-invasive assessment of hemodynamic instability in these neonates, while medical institutions have had a varied response in defining the personnel responsible for the performance and interpretation of these routine cardiac assessments of infants in the neonatal intensive care unit. The goals of this consensus statement were: (1) to review the current indications of targeted neonatal echocardiography; (2) to define recommendations for the performance of these targeted examinations; and (3) to propose training requirements for individuals performing and interpreting these targeted studies in neonates.

A targeted neonatal echocardiogram (TNE) was defined as an examination intended to provide longitudinal quantitative assessment of ventricular function, systemic and pulmonary blood flow, intracardiac and extracardiac shunts, and organ / tissue perfusion in the neonate. Of particular important and emphasis throughout this consensus statement was the following statement: “the initial echocardiographic study should always be a comprehensive evaluation of cardiac anatomy and function and should be performed and interpreted by pediatric cardiologists.” After congenital heart disease has been ruled out, more focused targeted studies can be performed by a trained echocardiographer for specific indications. Therefore, the TNE is not designed to be a substitute for a comprehensive echocardiographic examination in the neonate with suspected congenital heart disease; these studies are to be performed by individuals trained in pediatric echocardiography and should be interpreted by pediatric cardiologists.

Indications for a standard (complete) TNE include: (1) assessment of a clinically suspected patent ductus arteriosus; (2) assessment of infants with perinatal asphyxia; (3) evaluation of infants with hemodynamic instability with hypotension, acidosis or oliguria; (4) evaluation of suspected persistent pulmonary hypertension; and (5) evaluation of infants with congenital diaphragmatic hernias. Indications for a more focused TNE include assessment for a suspected pericardial or pleural effusion and the evaluation of central lines and extracorporeal membrane oxygenation cannula placement. The components of a standard TNE are well delineated in this manuscript and include quantitative assessment of left ventricular systolic and diastolic function as well as right ventricular systolic function, right ventricular systolic pressure, and pulmonary artery pressures. Evaluation of atrial level shunting and the patent ductus arteriosus are also indicated, as is the assessment of systemic blood flow and the exclusion of a pericardial effusion.

Finally, training recommendations defining the cognitive and practical skills that are required to perform TNE were detailed. Two levels of training were defined as core and advanced. Core level training in TNE was defined as a training period of 4-6 months with performance of >150 studies and interpretation of an additional 150 studies. This level of training is expected to allow the trainee to become familiar with normal cardiac anatomy and recognize abnormal patterns suggestive of the presence of structural heart disease. An advanced level of training was defined as an expertise in TNE, with the trainee able to independently perform and interpret neonatal TNE for the defined indications. This individual should be able to reliably rule out congenital heart disease in these neonatal studies. An advanced level of training requires the performance of an additional 150 studies and interpretation of another 150 examinations. It is suggested that the trainee have an additional 4-6 months of training to achieve this level of expertise.

Overall, this document provides an excellent framework and consensus opinion for the optimal utilization of TNE in the neonatal intensive care unit.