Wyman W. Lai, MD, MPH, FASE

Adults and children share many of the same basic principles of cardiovascular anatomy and physiology: the heart in the left chest (exceptions: dextrocardia and ectopia cordis); blood travels through the circulatory system in the same direction: veins to atria to ventricles to arteries (exception: Fontan circulation); oxygenated blood comes back from the lungs (exception: partially anomalous pulmonary venous return); unobstructed blood flow is good (exception: atrial or ventricular septal defects); there are 4 cardiac chambers and 4 heart valves (let’s not go there); and a weak pump is bad (almost no exceptions). If these basic principles differ so greatly, are there any fundamental truths in cardiac imaging shared by both adult and pediatric echocardiographers? I believe so.

First, cardiac imaging is improved with the use of standard views obtained within the framework of a prescribed protocol . The ASE first came out with recommendations for nomenclature and standards in 2D echocardiography in 1980. These standards covered the imaging of both adults and children, and sought to advance the technique of 2D imaging of the heart and improve communication between laboratories. Unfortunately, adult echocardiography laboratories universally adopted the option of displaying the apical 4-chamber view with the apex up, while pediatric echocardiography labs accepted the display of the same view with the apex down as gospel.

The ASE Guidelines and Standards for Performance of a Pediatric Echocardiogram came out 26 years later, in 2006. These guidelines borrowed many of the standard imaging views from our adult echocardiography colleagues, but chose to shift some of the emphasis to the subxiphoid and right parasternal views. In the performance of both adult and pediatric echocardiograms, imagers have learned that non-standard views are sometimes needed to better demonstrate the pathology present. The standards now being set for 3D echocardiography provide an opportunity to bring the adult and pediatric echocardiography communities back closer together.

Second, it is important to quantify chamber size and function. While recognized in both the adult and pediatric cardiology communities long ago, our adult echocardiography colleagues published an important ASE update on Recommendations for Chamber Quantification in 2005. This time, only 5 years later, we will soon be coming out with Recommendations for Quantification Methods during the Performance of a Pediatric Echocardiogram . The document will outline the methods for standard pediatric measurements and will serve as a starting point for collecting additional normative data for children. We have borrowed many of the elements of the adult quantitative echocardiogram, but differ on some key points. For instance, measurements of vascular diameters in pediatric echocardiography are performed at the moment of maximum expansion (mid to end-systole). More importantly, pediatric measurements should be adjusted for body size by converting to Z -scores based on body surface area. The concept of adjusting for body size has recently been applied in many, but far from all, of the standards used in adult echocardiography.

At national and international meetings, it is now common to find pediatric imaging specialists at adult cardiology sessions dealing with diastolic function, tissue Doppler, myocardial strain, torsion, etc. As a pediatric subspecialist, I find that there is much to be borrowed from my adult echocardiography colleagues in the area of ventricular function assessment. An increasing number of pediatric echocardiographers are specializing in the assessment of myocardial function in congenital heat disease. Meetings on adult echocardiography now routinely contain sessions on adult congenital heart disease. The divide between adult and pediatric echocardiographers seems to be shrinking again.

Will the bond continue to strengthen and grow into in a marriage? In the future, when holographic 4D displays of the heart become routine, will our adult cardiology colleagues still want to display the heart with the apex up? Perhaps that isn’t such a big deal after all. Both adult and pediatric echocardiographers have much to gain by nurturing the strong working relationship that has developed between the two groups.