Neonatal Echocardiography—Different Approaches in Different Continents: Reply to a Letter by Evans and Kluckow

We thank Drs. Evans and Kluckow for their interest in our recently published guidelines for neonatal echocardiography. We read their comments with interest, and we take note of the differences between their approach and the one outlined in the combined North American–European initiative. The aim of our writing group was to define minimum standards for neonatal echocardiography to guarantee high-quality diagnostic imaging performed by well-trained professionals. This was based on a collaborative model between cardiologists and neonatologists.

We chose the term targeted neonatal echocardiography to make distinction between the diagnostic information provided by a test and the clinical decision making based on the information provided by the imaging. This distinction is not as well defined when using the term point-of-care ultrasound . Additionally, point-of-care ultrasound includes imaging of other organ systems apart from the heart, which is beyond the scope of our guidelines. The two different names clearly illustrate two different approaches.

Evans and Kluckow suggest that our guidelines are too focused on congenital heart disease (CHD). The statement in our document that every first study performed in a neonate should exclude CHD is based on a prevalence rate of about 2% to 3%. We agree with Evans and Kluckow that when CHD is not suspected clinically, the chance of an incidental finding of CHD is relatively low. However, the therapeutic consequences of a diagnostic error can be very significant. On the basis of these considerations, the writing group recommended a comprehensive structural and functional echocardiographic evaluation before any therapeutic decision making. Evans and Kluckow mention that excluding CHD is not the job of the neonatologist. We agree with this concept and therefore suggested that a pediatric cardiologist or neonatologist with advanced training in pediatric echocardiography review every first echocardiography study to ascertain normality of cardiac structure. We further encourage collaboration between neonatologists and cardiologists also in infants without structural heart disease. Especially in children with persistent cardiac dysfunction, the cardiologist’s input remains important.

We disagree with the statement that “studying infants using these guidelines will not provide the information required to understand function and physiology.” The guidelines are a comprehensive assessment of cardiac function in line with the recent recommendations of the American Society of Echocardiography on the quantification of echocardiographic measurements in children. In our opinion, Evans and Kluckow’s statement is subjective and not supported by any scientific data. We appreciate the work by Evans and Kluckow on superior vena cava flow in preterm infants, and we refer to their work in the guidelines. The writing group could not reach consensus to include this as a routinely used measurement in clinical practice, on the basis of concerns regarding the reliability of the measurement and the effects of different physiologic parameters on superior vena cava flow (including atrial and intrathoracic pressure). A recent study comparing neonatal echocardiographic measurements with cardiac magnetic resonance imaging showed poor agreement for cardiac output measurements. This illustrates that good evidence is lacking for the basic hemodynamic echocardiographic measurements we included in the guidelines. Further research into neonatal hemodynamics will hopefully provide a better scientific basis for the use of echocardiography-based decisions on treatment of preterm and term neonates with cardiovascular compromise. The guidelines are to be considered a starting point and by no means the last word in this process.

The European and North American approach to training is clearly different from the Australian approach. We take note of these differences, as our writing group has defined more extensive training guidelines compared with the Australian approach outlined in Evans and Kluckow’s letter. We acknowledge that this will probably limit initially the number of neonatology trainees who will be trained in echocardiography in North America and Europe. We do not believe that it is a realistic goal to train every neonatologist in echocardiography. Just as not every cardiologist is an echocardiographer, not every neonatologist will need to be able to perform echocardiography. We also think that basic training requirements for neonatologists should match those for cardiologists with respect to transthoracic echocardiography, and thus attending a course and performing 75 studies do not meet the North American and European basic training standards.

Finally, we disagree with the statement that our proposal is based on a consultative cardiology approach. The basis for the document is a collaborative approach to echocardiographic diagnosis in infants reflected in the constitution of the writing group with a nearly even balance of echocardiographers representing cardiology and neonatologists (with academic track records in echocardiography in North America and Europe) representing neonatology in the writing group, as well as one dual-trained member in the group. Indeed, the guidelines are intended to go beyond traditional distinctions between cardiology and neonatology in the hope that echocardiography in the neonatal intensive care unit will be able to provide accurate and useful information in preterm and term infants.

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Jun 11, 2018 | Posted by in CARDIOLOGY | Comments Off on Neonatal Echocardiography—Different Approaches in Different Continents: Reply to a Letter by Evans and Kluckow

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