The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. M.M. is supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under Award Number R25MD011564.
Resources for the figures, reference values, and training recommendations were adapted from Ruoss et al.30, the TnECHO teaching manual47, the Neonatal Hemodynamics Research Center (NHRC)48, and the Targeted neonatal echocardiography application49.

The authors have nothing to disclose and no conflicts of interest.

TnECHO-guided care has been adopted in many neonatal intensive care units as an adjunct to the clinical assessment of hemodynamic instability in infants by neonatologists4. Accredited training programs have been developed in accordance with the 2011 ASE3 with a focus on a competence-based approach to training. The unique vulnerability of the immature cardiovascular system and the complexity of cardiovascular adaptation during the postnatal transition are key determinants of...

Targeted neonatal echocardiography (TnECHO) refers to the bedside use of echocardiography to longitudinally assess myocardial function, systemic and pulmonary blood flow, and intracardiac and extracardiac shunts1. When TnECHO is integrated with clinical findings, it can provide vital information in diagnosis, the guidance of therapeutic interventions, and the dynamic monitoring of response to treatments2.&#160;TnECHO is frequently performed by trained neonatologists in response to a specific clinical question with the goal of acquiring hemodynamics information that can complement and provide physiologic insights into the clinical status of the patients, resulting in precise cardiovascular care3. Over the past 10-15 years, TnECHO services have been incorporated in multiple tertiary neonatal intensive care units (NICUs) in Australia, New Zealand, Europe, and North America, especially in the management of complex high-acuity cases4,5,6,7,8.&#160;To date, there are eight centers in the USA with trained practitioners providing TnECHO services and a growing number of centers involved in neonatal hemodynamics research. Furthermore, the establishment of the neonatal hemodynamics and TnECHO special interest group (SIG) at the American Society of Echocardiography (ASE) reinforces the academic collaboration with pediatric cardiology and creates a strong political platform for further growth in the field9.
Neonatal hemodynamics training is designed to ensure that individuals who have received the training can achieve high-level imaging and provide comprehensive cardiovascular decision-making. In 2011, training recommendations for TnECHO, endorsed by European and North American professional organizations, were published3. Currently, more than 50 North American neonatologists have completed formal training in TnECHO; of note, more than 50% of hemodynamic clinicians are considered emerging academic leaders in the field, which is an unanticipated but much-needed benefit of formal training. Figure 1 summarizes hemodynamics training and accreditation.
The essential elements of a TnECHO service include access to a dedicated echocardiography machine. This ensures immediate availability for image acquisition and allows longitudinal follow-up (Figure 2 and Figure 3). The database/image archive must include the ability to provide immediate playback without video degradation, standardized reports, and long-term storage as per the recommendations of the Intersocietal Commission for the Accreditation of Echocardiography Laboratories10. A standard TnECHO includes key measurements that allow comprehensive assessments of intricate cardiovascular physiology during the neonatal period. This includes left ventricular (LV) function, right ventricular (RV) function, intracardiac shunt (atrial-level shunt and ductal-level shunt), the hemodynamic effects of patent ductus arteriosus (PDA), right ventricular systolic pressure (RVSp)/pulmonary artery (PA) pressure, systemic and pulmonary blood flow, the presence of pericardial fluid, thrombus, and central line position. Table 1 shows the commonly used echocardiographic terms utilized to acquire some of the data for these measurements. The evaluation may be performed for both symptom- and disease-based indications. Supplementary File 1 and Table 2 outline the comprehensive neonatal echocardiography assessments with recommended measurements, interpretation, and reference ranges for term neonates in the first 7 postnatal days.
The evaluation of LV systolic function is a key component as it assists in the delineation of the etiology and management of hemodynamic instability in critically ill neonates. Quantitative assessment is recommended as qualitative assessment is prone to inter-observer and intra-observer variability11. The calculation of the ejection fraction using a multi-plane method such as Simpson&#39;s biplane or the area-length method is superior to M-mode estimations, which may miss regional wall motion abnormalities and is inaccurate in the presence of septal flattening12. LV diastolic dysfunction is an emerging concept in neonatal hemodynamics. However, the data remain limited13.
An assessment of RV function is crucial in neonatal life because the RV is the dominant ventricle in transitional circulation, and many neonatal diseases are associated with right heart pathology. For a similar reason, in the assessment of LV systolic function, subjective assessment should be avoided14. However, due to the RV&#39;s unusual shape, highly trabeculated surface, and position wrapped around the LV, the measurement of RV function is more difficult. Despite this, several reliable quantitative parameters have been studied, and normative data have been published15,16. Fractional area change (FAC) and tricuspid annular plane systolic excursion (TAPSE) are two of the recommended quantitative measurements used17.
Intracardiac shunt (atrial and ductal level) is another important aspect of the comprehensive neonatal echocardiography assessment. In most situations, left atrial pressures are higher in comparison to right atrial (RA) pressures, resulting in a left-to-right shunt. However, in the neonatal period, a bidirectional shunt can still be normal. Elevated right-sided filling pressures, especially in association with pulmonary hypertension (PH), should be considered when there is right-to-left shunting at the atrial level, but this should not be used in isolation given that variation in ventricular compliance/pressure may also influence atrial pressure at various points during the cardiac cycle.
An assessment of patent ductus arteriosus (PDA) should include the determination of ductal shunt direction and the measurement of ductal pressure gradients, which are used to assist in treatment decisions. An arch-sidedness evaluation is also important, especially when there is consideration of surgical PDA ligation. PDA shunt direction is reflective of the difference between aortic and PA pressures, as well as the relative resistance of the pulmonary and systemic circulation. One factor used to adjudicate hemodynamic significance is the presence of holodiastolic retrograde flow in the descending thoracic or abdominal aorta18. Hemodynamic significance can be further assessed by quantifying the degree of volume overload by comprehensive measurements19. Scoring systems that assess the surrogate consequences of volume loading on the heart and the systemic hypoperfusion associated with PDA shunt, such as the Iowa PDA score, have been published (Table 3)19,20,21 The Iowa PDA score has been adopted clinically at the University of Iowa to enhance objectivity in determining the hemodynamic significance of a PDA shunt. A score of more than 6 is suggestive of a hemodynamically significant patent ductus arteriosus (hsPDA)19.
In the assessment of pulmonary hemodynamics, the absolute value of RVSp is estimated by the measurement of the tricuspid regurgitant (TR) gradient. Continuous wave Doppler is used to measure the maximal tricuspid regurgitation velocity through the tricuspid valve, referred to as the tricuspid regurgitant peak velocity. An assumed RA pressure of 5 mmHg is typically used for the calculation. The RVSp is then calculated using the simplified Bernoulli equation22:
RVSp = 4 &#215; (tricuspid regurgitant peak velocity [m/s])2 + RA pressure
Occasionally an alternative, the Doppler-derived pressure gradient across a PDA, is used for the calculation of PA (pulmonary artery) pressures23. However, a TR jet is only present in approximately 50% of patients with chronic PH24,25,26. In these situations, measurements such as the end-systolic eccentricity index (sEI), which is a measure of LV circularity, may indicate the relative pressure between the ventricles. This measurement should be interpreted with caution in patients with systemic hypertension as the mild disease may go undetected due to elevated LV end-diastolic pressure. Figure 4 gives an example of an algorithm and comprehensive neonatal echocardiography assessment guidelines for pulmonary hypertension.
For the assessment of LV stroke volume, a pulse Doppler tracing in an apical five-chamber view at the level of the aortic valve is measured to obtain the time-velocity integral (TVI). This is combined with a measurement of aortic annulus diameter in the parasternal long-axis view. A calculation with the following formula is used to estimate LV output27:
LV output (mL/min/kg) = (TVI [cm] &#215; &#960; x [D/2]2 [cm2] &#215; heart rate)/weight.
However, in the presence of a PDA, the LV output measurement is not reflective of systemic blood flow secondary to the shunting at the PDA level3. The diastolic flow to peripheral organs by Doppler interrogation of the celiac artery, superior mesenteric artery, and middle cerebral artery can give an indication of a systemic steal by a PDA but may, alternately, reflect organ resistance, with low or absent diastolic flow seen in the setting of high resistance.
TnECHO can also be utilized to assist in detecting the presence of intracardiac thrombus, pericardial fluid, and its hemodynamic significance, guiding pericardiocentesis, as well as assisting in the placement of peripheral arterial lines, peripherally inserted central catheters, and umbilical venous catheters28.&#160;Here, to show the comprehensive approach to obtaining TnECHO and the hemodynamics information, we describe the imaging protocol and the elements of a TnECHO service (Figure 3).

<table><tbody><tr><td>DICOM VIEWER EP</td><td>GEHealthcare</td><td>H45581CC</td><td>DICOM Viewer on MediaThis option provides the ability to export DICOM images including a DICOM viewer to storage media (USB, DVD), for easy access to patient images on offline computers.</td></tr><tr><td>2D Strain</td><td>GEHealthcare</td><td>H45561WF</td><td>Automated 2D EF Measurement tool based upon 2D-Speckle tracking algorithm.</td></tr><tr><td>EchoPAC* Software Only v203</td><td>GEHealthcare</td><td>H8018PF</td><td></td></tr><tr><td>EchoPAC* Advanced Bundle Package</td><td>GEHealthcare</td><td>H8018PG</td><td>Advanced QScan provides dedicated parametric imaging applications for quantitative display of regional wall deformation.</td></tr><tr><td>Multi-Link 3-lead ECG Care cable neonatal DIN, AHA (3.6 m/12 feet)</td><td>GEHealthcare</td><td>H45571RD</td><td>Multi-Link 3-lead ECG Care cable neonatal DIN, AHA (3.6 m/12 feet) Used together with neonatal leads H45571RJ</td></tr><tr><td>Myocardial Work</td><td></td><td>H45591AG&amp;nbsp;</td><td>Myocardial Work adjusts the AFI (strain) results using the systolic and diastolic blood pressure measured immediately prior to the&lt;br/&gt; echo exam. Using the Myocardial Work feature helps achieve a less load dependent strain/ pressure curve and work efficiency index</td></tr><tr><td>12S-D Phased Array Probe</td><td>GEHealthcare</td><td>H45021RT</td><td></td></tr><tr><td>6S-D Phased Array Probe</td><td>GEHealthcare</td><td>H45021RR</td><td></td></tr><tr><td>Sterile ultrasound gel</td><td>Parker labs</td><td>PM-010-0002D</td><td>sterile water solubel single packet ultrasound transmission gel</td></tr><tr><td>Ultrasound gel warmer</td><td>Parker Labs</td><td>SKU 83-20</td><td>ultrasound gel warmer for single gel package.</td></tr><tr><td>Wireless USB adapter</td><td></td><td>H45591HS</td><td>Wireless external G type USB adapter with extension cable and hardware for mounting on the rear panel.</td></tr><tr><td>Vivid* E90 v203 Console Package</td><td>GEHealthcare</td><td>H8018EB</td><td>Vivid E90 w/OLED monitor v203 Console</td></tr></tbody></table>

hemodynamic precision in the neonatal intensive care unit using targeted neonatal echocardiography

Targeted neonatal echocardiography (TnECHO) refers to the use of comprehensive echocardiographic evaluation and physiologic data to obtain accurate, reliable, and real-time information on developmental hemodynamics in sick newborns. The comprehensive assessment is based on a multiparametric approach that overcomes the reliability issues of individual measurements, allows for earlier recognition of cardiovascular compromise and promotes enhanced diagnostic precision and timely management. TnECHO-driven research has led to an enhanced understanding of the mechanisms of illness and the development of predictive models to identify at-risk populations. This information may then be used to formulate a diagnostic impression and provide individualized guidance for the selection of cardiovascular therapies. TnECHO is based on the expert consultative model in which a neonatologist, with advanced training in neonatal hemodynamics, performs comprehensive and standardized TnECHO assessments. The distinction from point of care ultrasonography (POCUS), which provides limited and brief one-time assessments, is important. Neonatal hemodynamics training is a 1-year structured program designed to optimize image acquisition, measurement analysis, and hemodynamic knowledge (physiology, pharmacotherapy) to support cardiovascular decision-making. Neonatologists with hemodynamic expertise are trained to recognize deviations from normal anatomy and appropriately refer cases of possible structural abnormalities. We provide an outline of neonatal hemodynamics training, the standardized TnECHO imaging protocol, and an example of representative echo findings in a hemodynamically significant patent ductus arteriosus.

The following representative results outline the evaluation of a hemodynamically significant patent ductus arteriosus (hsPDA) as an example of the use of TnECHO in clinical settings. As mentioned earlier, a comprehensive assessment with multiple measurements is performed to adjudicate hemodynamic significance. The Iowa PDA score (Table 3) is one of the scoring systems adopted into clinical use as it assists in quantifying the consequences of volume loading and systemic hypoperfusion associated with PDA s...

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Hemodynamic Precision in the Neonatal Intensive Care Unit using Targeted Neonatal Echocardiography

Presented here is a protocol to perform comprehensive neonatal echocardiography by trained neonatologists in the neonatal intensive care unit. The trained individuals provide longitudinal assessments of heart function, systemic and pulmonary hemodynamics in a consultative role. The manuscript also describes the requirements to become a fully trained neonatal hemodynamics specialist.

Targeted neonatal echocardiography (TnECHO) refers to the use of comprehensive echocardiographic evaluation and physiologic data to obtain accurate, ...

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852 Views.  University of Oklahoma Health Sciences Center. 1 Wanneer TnECHO wordt geïntegreerd met klinische bevindingen, 2 maakt het het mogelijk om een diagnostische indruk te formuleren, 3 geïndividualiseerde begeleiding 4 voor het selecteren van cardiovasculaire therapieën, 5 en dynamische monitoring van de respons op behandelingen. 6 Een standaard gerichte neonatale echocardiografie7 omvat belangrijke metingen 8 die uitgebreide beoordelingen mogelijk maken 9 van ingewikkelde cardiovasculaire fysiologie 10 ...

Video: Hemodynamic Precision in the Neonatal Intensive Care Unit using Targeted Neonatal Echocardiography

High-frequency High-resolution Echocardiography: First Evidence on Non-invasive Repeated Measure of Myocardial Strain, Contractility, and Mitral Regurgitation in the Ischemia-reperfused Murine Heart

Ischemia-reperfusion (IR) was surgically performed in murine hearts which were then subjected to repeated imaging to monitor temporal changes in functional parameters of key clinical significance. Two-dimensional movies were acquired at high frame rate (8 kHz) and were utilized to estimate high-quality myocardial strain. Two-dimensional elastograms (strain images), as well as strain profiles, were visualized. Results were powerful in quantitatively assessing IR-induced changes in cardiac events including left-ventricular (LV) contraction, LV relaxation and isovolumetric phases of both pre-IR and post-IR beating hearts in intact mice. In addition, compromised sector-wise wall motion and anatomical deformation in the infarcted myocardium were visualized.  The elastograms were uniquely able to provide information on the following parameters in addition to standard physiological indices that are known to be affected by myocardial infarction in the mouse: internal diameters of mitral valve orifice and aorta, effective regurgitant orifice, myocardial strain (circumferential as well as radial), turbulence in blood flow pattern as revealed by the color Doppler movies and velocity profiles, asynchrony in LV sector, and changes in the length and direction of vectors demonstrating slower and asymmetrical wall movement. This work emphasizes on the visual demonstration of how such analyses are performed. 

High-frequency High-resolution Echocardiography: First Evidence on Non-invasive Repeated Measure of Myocardial Strain, Contractility, and Mitral Regurgitation in the Ischemia-reperfused Murine Heart 

High frequency Doppler ultrasound is a novel technology for assessing regional myocardial function. This work presents first evidence demonstrating applicability of this versatile imaging platform for the repeated measure of myocardial strain, dp/dt, and mitral regurgitation in the ischemia-reperfused (IR) murine heart.

Ischemia-reperfusion (IR) was surgically performed in murine hearts which were then subjected to repeated imaging to monitor temporal changes in ...

Murine Fetal Echocardiography

Transgenic mice displaying abnormalities in cardiac development and function represent a powerful tool for the understanding the molecular mechanisms underlying both normal cardiovascular function and the pathophysiological basis of human cardiovascular disease. Fetal and perinatal death is a common feature when studying genetic alterations affecting cardiac development 1-3. In order to study the role of genetic or pharmacologic alterations in the early development of cardiac function, ultrasound imaging of the live fetus has become an important tool for early recognition of abnormalities and longitudinal follow-up. Noninvasive ultrasound imaging is an ideal method for detecting and studying congenital malformations and the impact on cardiac function prior to death 4. It allows early recognition of abnormalities in the living fetus and the progression of disease can be followed in utero with longitudinal studies 5,6. Until recently, imaging of fetal mouse hearts frequently involved invasive methods. The fetus had to be sacrificed to perform magnetic resonance microscopy and electron microscopy or surgically delivered for transillumination microscopy. An application of high-frequency probes with conventional 2-D and pulsed-wave Doppler imaging has been shown to provide measurements of cardiac contraction and heart rates during embryonic development with databases of normal developmental changes now available 6-10. M-mode imaging further provides important functional data, although, the proper imaging planes are often difficult to obtain. High-frequency ultrasound imaging of the fetus has improved 2-D resolution and can provide excellent information on the early development of cardiac structures 11.

Fetal and perinatal death is a common feature when studying genetic alterations affecting cardiac development. High-frequency ultrasound imaging has improved 2-D resolution and can provide excellent information on early cardiac development and is an ideal method to detect the impact on cardiac structure and function prior to death.

Transgenic mice displaying abnormalities in  cardiac development and function represent a powerful tool for the understanding  the molecular mechanisms ...

Fetal Echocardiography and Pulsed-wave Doppler Ultrasound in a Rabbit Model of Intrauterine Growth Restriction

Fetal intrauterine growth restriction (IUGR) results in abnormal cardiac function that is apparent antenatally due to advances in fetoplacental Doppler ultrasound and fetal echocardiography. Increasingly, these imaging modalities are being employed clinically to examine cardiac function and assess wellbeing in utero, thereby guiding timing of birth decisions. Here, we used a rabbit model of IUGR that allows analysis of cardiac function in a clinically relevant way. Using isoflurane induced anesthesia, IUGR is surgically created at gestational age day 25 by performing a laparotomy, exposing the bicornuate uterus and then ligating 40-50% of uteroplacental vessels supplying each gestational sac in a single uterine horn. The other horn in the rabbit bicornuate uterus serves as internal control fetuses. Then, after recovery at gestational age day 30 (full term), the same rabbit undergoes examination of fetal cardiac function. Anesthesia is induced with ketamine and xylazine intramuscularly, then maintained by a continuous intravenous infusion of ketamine and xylazine to minimize iatrogenic effects on fetal cardiac function. A repeat laparotomy is performed to expose each gestational sac and a microultrasound examination (VisualSonics VEVO 2100) of fetal cardiac function is performed. Placental insufficiency is evident by a raised pulsatility index or an absent or reversed end diastolic flow of the umbilical artery Doppler waveform. The ductus venosus and middle cerebral artery Doppler is then examined. Fetal echocardiography is performed by recording B mode, M mode and flow velocity waveforms in lateral and apical views. Offline calculations determine standard M-mode cardiac variables, tricuspid and mitral annular plane systolic excursion, speckle tracking and strain analysis, modified myocardial performance index and vascular flow velocity waveforms of interest. This small animal model of IUGR therefore affords examination of in utero cardiac function that is consistent with current clinical practice and is therefore useful in a translational research setting.

We describe examination of fetal cardiac function with contemporary functional fetal echocardiography and fetoplacental Doppler ultrasound using the VisualSonics VEVO 2100 microultrasound in a surgically induced model of intrauterine fetal growth restriction in a rabbit.

Fetal intrauterine growth restriction (IUGR) results in abnormal cardiac function that is apparent antenatally due to advances in fetoplacental Doppler ...

State of the Art Cranial Ultrasound Imaging in Neonates

Cranial ultrasound (CUS) is a reputable tool for brain imaging in critically ill neonates. It is safe, relatively cheap and easy to use, even when a patient is unstable. In addition it is radiation-free and allows serial imaging. CUS possibilities have steadily expanded. However, in many neonatal intensive care units, these possibilities are not optimally used. We present a comprehensive approach for neonatal CUS, focusing on optimal settings, different probes, multiple acoustic windows and Doppler techniques. This approach is suited for both routine clinical practice and research purposes. In a live demonstration, we show how this technique is performed in the neonatal intensive care unit. Using optimal settings and probes allows for better imaging quality and improves the diagnostic value of CUS in experienced hands. Traditionally, images are obtained through the anterior fontanel. Use of supplemental acoustic windows (lambdoid, mastoid, and lateral fontanels) improves detection of brain injury. Adding Doppler studies allows screening of patency of large intracranial arteries and veins. Flow velocities and indices can be obtained. Doppler CUS offers the possibility of detecting cerebral sinovenous thrombosis at an early stage, creating a window for therapeutic intervention prior to thrombosis-induced tissue damage. Equipment, data storage and safety aspects are also addressed.

Cranial ultrasound (CUS) is a valuable tool for brain imaging in critically ill neonates. This video shows a comprehensive approach for neonatal (Doppler) CUS for both clinical and research purposes, including a bedside demonstration of the technique.

Cranial ultrasound (CUS) is a reputable tool for brain imaging in critically ill neonates. It is safe, relatively cheap and easy to use, even when a ...

Transcutaneous Microcirculatory Imaging in Preterm Neonates

Microcirculatory imaging (MI) is a relatively new research tool mainly used in the intensive care setting. MI provides a clear view of the smallest capillaries, arterioles and venules. The magnifying effect visualizes the flow pattern of erythrocytes through these vessels.
It's non-invasive character makes it suitable to apply in (preterm) neonates, even in cardiorespiratory unstable patients. In adults and children, MI is mainly performed sublingually, but this is not possible in preterm infants as these cannot cooperate and the size of the probe is problematic. In preterm infants, MI is therefore performed transcutaneously. Their thin skin makes it possible to obtain high quality images of peripheral microcirculation. 
In this manuscript we will demonstrate the method of transcutaneous MI in preterm infants. We will focus on the different techniques and provide tips to optimize image quality. The highlights of software settings, safety and offline analysis are also addressed.

Microcirculatory imaging (MI) is used to monitor peripheral perfusion in critically ill or preterm neonates. This manuscript and video demonstrates the optimal approach for obtaining high-quality images.

Microcirculatory imaging (MI) is a relatively new research tool mainly used in the intensive care setting. MI provides a clear view of the smallest ...

Transthoracic Speckle Tracking Echocardiography for the Quantitative Assessment of Left Ventricular Myocardial Deformation

The value of conventional echocardiography is limited by differences in inter-individual image interpretation and therefore largely dependent on the examiners&#39; expertise. Speckle tracking Echocardiography (STE) is a promising but technically challenging method that can be used to quantitatively assess regional and global systolic and diastolic myocardial performance. Myocardial strain and strain rate can be measured in all three dimensions&#160;&#8212; radial, circumferential, longitudinal &#8212; of myocardial deformation. Standard cross-sectional two-dimensional B-mode images are recorded and subsequently postprocessed by automated continuous frame-by-frame tracking and motion analysis of speckles within the myocardium. Images are recorded as digital loops and synchronized to a 3-lead EKG for timing purposes. Longitudinal deformation is assessed in the apical 4-, 3-, and 2-chamber views. Circumferential and radial deformation are measured in the parasternal short axis plane.
Optimal image quality and accurate tissue tracking are paramount for the correct determination of myocardial performance parameters. Utilizing transthoracic STE in a healthy volunteer, the present article is a detailed outline of the essential steps and potential pitfalls of quantitative echocardiographic myocardial deformation analysis.

Speckle tracking echocardiography is an emerging diagnostic imaging technique for the quantitative assessment of global and regional myocardial performance. Standard view echocardiographic motion images are recorded and deformation parameters are subsequently measured by automated continuous frame-by-frame tracking and motion analysis of speckles within the B-mode images of the myocardium.

The value of conventional echocardiography is limited by differences in inter-individual image interpretation and therefore largely dependent on the ...

Noninvasive Electrocardiography in the Perinatal Mouse

Electrocardiography (ECG) has long been relied upon as an effective and reliable method of assessing cardiovascular (and cardiopulmonary) function in both human and animal models of disease. Individual heart rate, rhythm, and regularity, combined with quantitative parameters collected from ECG, serve to assess the integrity of the cardiac conduction system as well as the integrated physiology of the cardiac cycle. This article provides a comprehensive description of the methods and techniques used to perform a noninvasive ECG on perinatal and neonatal mouse pups as early as the first postnatal day, without requiring the use of anesthetics. This protocol was designed to directly address a need for a standardized and repeatable method for obtaining ECG in newborn mice. From a translational perspective, this protocol proves to be entirely effective for characterization of congenital cardiopulmonary defects generated using transgenic mouse lines, and particularly for analysis of defects causing lethality at or during the first postnatal days. This protocol also aims to directly address a gap in the scientific literature to characterize and provide normative data associated with maturation of the early postnatal cardiac conduction system. This method is not limited to a specific postnatal timepoint, but rather allows for ECG data collection in neonatal mouse pups from birth to postnatal day 10 (P10), a window that is of critical importance for modeling human diseases in vivo, with particular emphasis on congenital heart disease (CHD).

Here, we present a noninvasive electrocardiography (ECG) protocol, optimized for early postnatal mice, that does not require the use of anesthetics.

Electrocardiography (ECG) has long been relied upon as an effective and reliable method of assessing cardiovascular (and cardiopulmonary) function in both ...

Echocardiographic Characterization of Left Ventricular Structure, Function, and Coronary Flow in Neonate Mice

Echocardiography is a non-invasive procedure that enables the evaluation of structural and functional parameters in animal models of cardiovascular disease and is used to assess the impact of potential treatments in preclinical studies. Echocardiographic studies are usually conducted in young adult mice (i.e., 4-6 weeks of age). The evaluation of early neonatal cardiovascular function is not usually performed because of the small size of the mouse pups and the associated technical difficulties. One of the most important challenges is that the short length of the pups&#39; limbs prevents them from reaching the electrodes in the echocardiography platform. Body temperature is the other challenge, as pups are very susceptible to changes in temperature. Therefore, it is important to establish a practical guide for performing echocardiographic studies in small mouse pups to help researchers detect early pathological changes and study the progression of cardiovascular disease over time. The current work describes a protocol for performing echocardiography in mouse pups at the early age of 7 days old. The echocardiographic characterization of cardiac morphology, function, and coronary flow in neonatal mice is also described.

The present protocol describes the echocardiographic assessment of left ventricular morphology, function, and coronary blood flow in 7-day old neonate mice.

Echocardiography is a non-invasive procedure that enables the evaluation of structural and functional parameters in animal models of cardiovascular ...

A Modified Sonographic Algorithm for Image Acquisition in Life-Threatening Emergencies in the Critically Ill Newborn

The use of routine point-of-care ultrasound (POCUS) is increasing in neonatal intensive care units (NICUs), with several centers advocating for 24 h equipment availability. In 2018, the sonographic algorithm for life-threatening emergencies (SAFE) protocol was published, which allows the assessment of neonates with sudden decompensation to identify abnormal contractility, tamponade, pneumothorax, and pleural effusion. In the study unit (with a consulting neonatal hemodynamics and POCUS service), the algorithm was adapted by including consolidated core steps to support at-risk newborns, aiding clinicians in managing cardiac arrest, and adding views to verify correct intubation. This paper presents a protocol that can be applied in the NICU and the delivery room (DR) in relation to three scenarios: cardiac arrest, hemodynamic deterioration, or respiratory decompensation. 
This protocol can be performed with a state-of-the-art ultrasound machine or an affordable handheld device; the image acquisition protocol is carefully detailed. This method was designed to be learned as a general competence to obtain the timely diagnosis of life-threatening scenarios; the method aims to save time but does not represent a substitute for comprehensive and standardized hemodynamic and radiological analyses by a multidisciplinary team, which might not universally be on call but needs to be involved in the process. From January 2019 to July 2022, in our center, 1,045 hemodynamic consultation/POCUS consults were performed with 25 patients requiring the modified SAFE protocol (2.3%), and a total of 19 procedures were performed. In five cases, trained fellows on call resolved life-threatening situations. Clinical examples are provided that show the importance of including this technique in the care of critical newborns.

Here, we present a protocol that can be applied in the neonatal intensive care unit and the delivery room in relation to three scenarios: cardiac arrest, hemodynamic deterioration, or respiratory decompensation. This protocol can be performed with a state-of-the-art ultrasound machine or an affordable handheld device; an image acquisition protocol is carefully detailed.

The use of routine point-of-care ultrasound (POCUS) is increasing in neonatal intensive care units (NICUs), with several centers advocating for 24 h ...

Advancements in Echocardiography-Derived Blood Speckle Imaging Technology

Assessing Intracardiac Vortices with High Frame-Rate Echocardiography-Derived Blood Speckle Imaging in Newborns

The left ventricle (LV) has a unique pattern of hemodynamic filling. During diastole, a rotational body or ring of fluid known as a vortex is formed due to the chiral geometry of the heart. A vortex is reported to have a role in conserving the kinetic energy of blood flow entering into the LV. Recent studies have shown that LV vortices may have prognostic value in describing diastolic function at rest in neonatal, pediatric, and adult populations, and may help with earlier subclinical intervention. However, the visualization and characterization of the vortex remain minimally explored. A number of imaging modalities have been utilized for visualizing and describing intracardiac blood flow patterns and vortex rings. In this article, a technique known as blood speckle imaging (BSI) is of particular interest. BSI is derived from high-frame rate color Doppler echocardiography and provides several advantages over other modalities. Namely, BSI is an inexpensive and noninvasive bedside tool that does not rely on contrast agents or extensive mathematical assumptions. This work presents a detailed step-by-step application of the BSI methodology used in our laboratory. The clinical utility of BSI is still in its early stages, but has shown promise within the pediatric and neonatal populations for describing diastolic function in volume-overloaded hearts. A secondary aim of this study is thus to discuss recent and future clinical work with this imaging technology.

Author Spotlight: Advancing Neonatal Cardiac Diagnostics with Echocardiography-Derived Blood Speckle Imaging 

The present protocol uses echocardiography-derived blood speckle imaging technology to visualize intracardiac hemodynamics in newborns. The clinical utility of this technology is explored, the rotational body of fluid within the left ventricle (known as a vortex) is accessed, and its significance in understanding diastology is determined.

The left ventricle (LV) has a unique pattern of hemodynamic filling. During diastole, a rotational body or ring of fluid known as a vortex is formed due ...

Hemodynamic Precision in the Neonatal Intensive Care Unit using Targeted Neonatal Echocardiography

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