Targeted Neonatal Echocardiography in the Neonatal Intensive Care Unit: Practice Guidelines and Recommendations for Training: Writing group of the American Society of Echocardiography (ASE) in collaboration with the European Association of Echocardiography (EAE) and the Association for European Pediatric Cardiologists (AEPC)

American Academy of Pediatrics Association for European Paediatric Cardiology American Society of Echocardiography Congenital diaphragmatic hernia Congenital heart disease European Association of Echocardiography Extracorporeal membrane oxygenation Ejection fraction Left ventricular Myocardial performance index Mean velocity of circumferential fiber shortening Neonatal intensive care unit Pulmonary artery Patent ductus arteriosus Right atrial Right ventricular Right ventricular systolic pressure Shortening fraction Superior vena cava Transesophageal echocardiography Targeted neonatal echocardiography Time-velocity integral Two-dimensional Very low birth weight The role of echocardiography in the neonatal intensive care unit (NICU) has changed over the past few years. Previously, nearly all echocardiographic studies in the NICU were performed by pediatric cardiologists to diagnose or monitor congenital heart disease (CHD) and to screen for patent ductus arteriosus (PDA). More recently, neonatologists have become interested in the echocardiographic assessment of hemodynamic instability in infants. The terms functional echocardiography and point-of-care echocardiography have been introduced to describe the use of echocardiography as an adjunct in the clinical assessment of the hemodynamic status in neonates.1–4 The increasing availability of echocardiography, with miniaturization of the technology, has resulted in more widespread use of echocardiography in NICUs around the world.5 Perhaps the most significant challenge for the application of so-called functional studies is that newborns in the NICU with hemodynamic instability are at a much higher risk for having underlying CHD. In addition, newborns in the NICU are unique in that they are in the process of transition from fetal to postnatal circulation. In this document, we make clear distinctions between initial echocardiographic studies in neonates with the suspicion of CHD and studies performed on infants without any clinical suspicion of CHD. If CHD has been excluded, subsequent studies in children with structurally normal hearts can focus on hemodynamic or functional assessment. The initial echocardiographic examination should always be a comprehensive study of both anatomy and function that is to be interpreted by a pediatric cardiologist within a reasonable time frame. Some structural defects, such as anomalous pulmonary venous return or coarctation of the aorta, can be difficult to detect using echocardiography and require extensive training and continued practice. Once significant congenital defects have been ruled out, more focused studies can be performed and interpreted by a trained echocardiographer for specific indications, as defined later in this document. We propose to use the term targeted neonatal echocardiography (TNE) for the more focused studies. The aims of the current document are: (1) to review the current indications of TNE; (2) to define recommendations for the performance of TNE; and (3) to propose training requirements for the operators performing and interpreting TNE. The neonatal cardiovascular system differs from those of fetal, pediatric, and adult patients. At term, a neonate must successfully transition through abrupt changes in the cardiorespiratory system, including changes in lung volume and compliance and changes in left and right heart preload and afterload. Intracardiac and extracardiac shunts via the foramen ovale and ductus arteriosus, physiologic in the fetus, have varying effects on immediate postnatal hemodynamics. The neonatal heart may also have to cope with structural heart disease and/or extracardiac congenital and acquired conditions, such as congenital diaphragmatic hernia (CDH), sepsis, or pulmonary hypertension, that are tolerated differently compared with an older child. In the setting of a preterm delivery, the immaturity of the cardiovascular system and other organ systems makes it more difficult for the neonate to appropriately respond to the challenges of postnatal transition and extrauterine existence. Detailed understanding of fetal, transitional, and neonatal cardiovascular physiology is necessary to enable understanding of echocardiographic information obtained during the perinatal period. It is important for those performing to the normal of the and and preterm may this In the fetus, are and have a compared with the that are the has a higher the fetal is at the with unit of a an higher and a of In addition, the heart is within a a of the fetal heart is and a term or adult are in the fetal to changes in preload or with heart changes the to fetal to preload The fetal right and left also in with the right to in more to the ventricular the left during fetal The fetal pulmonary also significant from the adult pulmonary In the fetus, the pulmonary and significant in with a of pulmonary in to the more and have a of pulmonary in the and the most with all in the fetal pulmonary by fetal pulmonary from to of the from to The is to the fetal system the a ductus arteriosus, the right ventricular to the and a patent foramen of the ductus and vena venous with left atrial normal a in fetal is and a in of of the and the pulmonary and of to the fetal If this process is as in the of and delivery, is an abrupt in with of the and via in to the and the by to the extrauterine to the right heart of the of venous is a in pulmonary to lung and pressure of in the and the of the pulmonary to higher pulmonary artery pressure of and and pulmonary changes to and a of the right within the pressure is also with that are changes the left to the preload from pulmonary venous In the term the ductus is with of venous the of the foramen ovale the in the setting of higher left atrial by pulmonary venous return and left ventricular The ductus arteriosus more over the or in to a higher pressure of and and other and a Myocardial is also by of and the that with and The transition from fetal to postnatal is more in the preterm The preterm is to an abrupt in and may be of the changes in preload on by the of atrial and The preterm is also with immaturity of all organ the that to preterm delivery, and the for and can be a clinical adjunct to the assessment of the cardiovascular status of preterm and term neonates during normal and transition to extrauterine systolic function can be using and the and of atrial and ductus arteriosus can be and pressure of the right and can be echocardiographer performing and interpreting should be with the normal neonatal cardiovascular and the of and disease on the neonatal cardiovascular is to understanding the of TNE. is to the use of echocardiography to and pulmonary and extracardiac organ and The of are to information on the underlying cardiovascular hemodynamic instability and the to in an over We are that the current indications for have been on the of clinical studies or of clinical in a of neonatal and studies. it is difficult to define the most use for it a It is important to that is as a for the of a neonate with CHD by a pediatric If structural CHD or significant is in a the should be by a pediatric and echocardiography should be performed by a trained in pediatric echocardiography as defined later in this and by a pediatric suspicion the of of clinical of heart the of a and in and/or In infants without any clinical suspicion for the echocardiographic study must be a comprehensive examination both and initial study can be performed by a with at training in or a pediatric The initial of this comprehensive study can be by an it is that the study be within a reasonable time by a pediatric If this of is in the the use of or of in a is In this document, we between with and with focused or is a study including the as defined in and in the of this document. The indications are in low birth weight neonates during the to postnatal and of infants with perinatal cardiovascular with or during the postnatal and in infants to diagnose low pulmonary in neonates of left of left or Extracorporeal membrane oxygenation of indications for focused we performing a for the other any the study must always be a comprehensive or focused is performed in such as this should be by a comprehensive study as as the has been can be as a functional study for without structural heart The with studies can be performed in the NICU is the of the current as on If clinical suspicion of CHD or is in a the should be by a pediatric and comprehensive echocardiography should be performed and interpreted by a pediatric In newborns without any clinical suspicion of the initial echocardiographic examination should always be a comprehensive study that can be performed by a and interpreted by an it is that this initial study be by a pediatric cardiologist within a reasonable time period. In the of children in CHD has been excluded, can be performed as a targeted functional study for of studies training in and they should be interpreted by a with training in TNE. may be for the and for a of specific indications and should be in the of structural heart for a of of studies and training requirements for the performance of initial echocardiography in neonates of studies and training requirements for the performance of initial echocardiography in neonates systems for neonatal hearts should and and should a of should be that the can the on the of the the and the information that is to be should be on the in the should be to neonates and infants. performing on may to be to cardiorespiratory instability in this are to the The systems for should be for the neonatal a neonate or is for the of of and of cardiorespiratory to and of is of preterm and term infants have an system and a of from the in use to the system, of for should be to neonatal it is that for during echocardiographic studies be and that of be of and to to of and the the should be and should be should be to the of on the of should be at a with the use of for of the and term neonates may become with and pressure on the and can and venous return to the heart in infants. the is focused on by for cardiorespiratory during the may be The of should be in infants. The echocardiographic study performed in a neonate should a and hemodynamic assessment of anatomy and physiology using a American Society of Echocardiography and for the performance of pediatric echocardiography have been and should be to neonatal to that congenital defects are and that a functional is on the of echocardiography should be and studies should the and to the assessment of should of atrial and of the heart in the venous and of an atrial and and ventricular and function of the of a artery and pulmonary venous and of during the initial should the pediatric cardiologist the study to CHD. this initial more targeted studies can be The has also on in pediatric We performing TNE. the of as as the of this the as are targeted neonatal echocardiographic study should The targeted neonatal echocardiographic examination and the are in of systolic function of function of function of of of systolic pressure and of of instability in the neonate can be by and assessment of systolic function is a of TNE. The pediatric can be in the neonatal for the of systolic function can be to neonates and preterm infants. assessment of systolic function can be it is to and are for systolic functional assessment are on the assessment of or should be on the of or obtained from the or at the to the of the at has higher can be an in of heart low Two-dimensional echocardiography has higher for in term and preterm infants have been volume the of or or can be a of in the of in can in the of pressure or of systolic function is on by shortening fraction or by fraction The pediatric recommendations from the of obtained from or with over In neonates and in preterm infants with heart and with disease or lung be an to using In the use of or can be by or of the ventricular to the between the and right and the left In of or ventricular of using the and are to lung can be an important for in newborns have been interpreting the and the of preload and should be may be important and of the and of the pulmonary pressure and afterload. it is that and are the of of function may be heart velocity of circumferential fiber shortening as time for heart is preload as an it is is as a in If is is a between and can be as a of The clinical of the is in neonates and with on the and in a preterm is that with in the neonatal are functional echocardiographic including and and have been in and are they can be for use in clinical assessment of systolic function is an of TNE. It the of on the of or and and should be the of or can be are and is In the of or should be using a or and In to systolic the of on neonatal is clear and more difficult to define by In children and of function on a of including pulmonary venous and velocity of the In the on function assessment are and on of In normal important changes in are during the and of the of is a from a fetal with more on during atrial a more with higher is by in in the and In preterm this is more The using the and in infants is that the and are to heart are also to changes in as in with with pulmonary left atrial in the The use of pulmonary venous is by heart shunts at the or ventricular the pulmonary venous for the assessment of function have been in the neonatal in have been in both are on the of disease on use in clinical practice. is in the neonatal and of volume status and on are in term and preterm infants. preload is an important of in this and preload can be an important for of compliance and the of the neonatal heart to cope with can be assessment of status be for neonatal it is to are as a for It is difficult to and status in neonates using or vena cava or and of have been as of preload in may be in those on The use of of as an of status must including heart and the assessment of volume status is to be integral of the clear recommendations for can be at assessment on the of vena cava and by an with of the clinical status of the neonate may be the most The performance index has been as a to systolic and performance of the heart the and for the time time in neonates from to with higher obtained in the of of time with to The of are that it is with to of systolic function and it is by preload and makes it of use in infants. In addition, the of in infants with higher heart has been the assessment of function and should be of are to any the use of echocardiographic in the of neonates and infants. this should be an of The of function should be an integral of in with pulmonary hypertension, it is difficult to is for the assessment of the of the pediatric the of at the and and and in the assessment of the pediatric such as and systolic require in the neonatal systolic is on heart the normal with and have In assessment of function is this in the and The assessment of and function should be of TNE. assessment the most in clinical practice. Two-dimensional including systolic and can be for of is the assessment of and extracardiac and to hemodynamic or of the atrial foramen ovale or atrial is a of the TNE. can be from or of the atrial is to the atrial and can be it be necessary to the the most important is left atrial are higher compared with right atrial and a is a can be normal in the neonatal period. is and in the of structural heart disease to pulmonary and and can to from or can be to the pressure the atrial The of the information on the pressure between left and right and the in should for the and of of of and of pressure are an important of targeted neonatal echocardiographic should the of a ductus arteriosus, the and of the the and the pressure between the and the The hemodynamic is by the of volume by of the The can be from the left and in infants using the in the or using a to the in a and/or left may of the in the left and the may be to significant may be in the of significant lung or of is is is by at the is the pulmonary of the it of and of the and of the of through the the between and and the of the pulmonary and circulation. It is to have a to and a is can in the The of in the information on the of through the If are during and more also in the of the and the or of by in the at the of the important information on the of pulmonary and can be during and or should be performed to the of the as on can be to by the and to systolic and The pressure is is of the may require the use of information on the of may be by in pulmonary during the of the assessment of is an important of targeted neonatal echocardiography The most to is of the velocity of a In the of systolic is necessary to of the the of pressure should be to the pressure can be in the NICU or can be infants and children with pressure of is the of the velocity of the can be using the as velocity The pulmonary may also be to also of the to and also of It has also been that a between the velocity of the pulmonary and the pressure during is a pressure is an important in the of pulmonary in the the and pressure a can be for assessment of It should be that for the assessment of pressure a application of the may be of the and of the of and is an of and is on of and pulmonary The pressure a can also be for assessment of can be to to the for the index from to It should be that the are and are by the in the significant with may be of the is with in the of and of in can be to changes in an is the of a this of assessment of a for the have vena cava as a for The is from a and a is to the of the using or are over to to for the of low during the postnatal is an risk for in preterm the of to the and of in this is In addition, this has significant and can be significant of with the of and the of and is by and atrial The use of clinical practice. can a of index using the and to be and to In the of a The may be to changes in a is is interpreting the instability in a term or preterm can be by the of a Echocardiography is an to detect the of hemodynamic and may be to the with clinical it is to with a pediatric pediatric or pediatric to or of may be tolerated by the the or in a may of at the of and in are of hemodynamic of the vena cava may also of venous pressure is studies have in in may be difficult to in infants. in velocity may be to and to in may be for as and of heart in The of a pediatric cardiologist is for the of functional and hemodynamic information a of in of can and should and use that can be a is from the of the heart to on at is for the of of the at with of the is should be for the normal fetal may have significant effects in preterm or term infants. are in of at of and/or and is a in the of with the normal in pulmonary in a The may pulmonary and/or both of may be with significant The clinical is on the of the conditions, and the of the neonate to The pulmonary and of to the to lung The effects of increasing or requirements may the risk for lung infants have a for increasing volume in to volume on the and this be more in preterm infants compliance be The volume with the of from the to a ductus in significant with that and pressure can is by of hemodynamic of a significant including and If a is on clinical echocardiography may be The study should always be a comprehensive echocardiographic study to CHD. study can be performed by a and interpreted by an It is that this initial study be by a pediatric can be performed to of the ductus or to the of on The targeted neonatal should be performed in the of with including the of the hemodynamic of a can be performed by echocardiographic the to is a significant The and volume of the is on the is by the between the and pulmonary and by the and is The of the of volume to the through the can be on the of or left the of a The left can be as an of with a a significant In the of a pulmonary venous and the in left atrial pressure in the of a significant atrial an in can the of the of an atrial or significant In neonates with the can in an The to the preterm the is of in and is to be in the of a patent foramen ductus with in significant from the and The of may be of in neonates with a on and artery velocity have been as in assessment of the of the of to At assessment of the the or of is the of at a of ductus preterm infants become of changes in preload and can be in the underlying In neonate with a clinical suspicion of a a comprehensive echocardiography study should be performed or to congenital heart defects and define in the hemodynamic of the and is in clinical or the of In preterm infants with hemodynamic instability ductus can be in the is defined by low for and or on an Neonatal and is a with an of to of is the of of all neonatal In have been the of in both and in infants. has been in studies to in significant pulmonary and in including and changes with in to of as a of to the may perinatal and to and including and the use of such as and can have hemodynamic and/or pulmonary through increasing and heart assessment and of cardiovascular of and in the setting of low may be to for patients. may be as that to of infants with perinatal echocardiographic of ventricular by systolic and neonates with clinical of should be for by clinical hemodynamic and the use of for If is clinical of cardiovascular and of is to be If are clinical comprehensive echocardiography may be for underlying structural or functional heart If are can be to monitor functional and the hemodynamic effects of The initial study should be a comprehensive studies should use the targeted neonatal echocardiographic the of of to without in to with and hypertension, and low of both and significant between infants and infants in the of and the for volume and to pressure or may have an on and the use of of and volume the and the assessment of may be and may be a for the use of in hemodynamic studies are to define and during the and echocardiography is in neonates with perinatal with clinical or of cardiovascular including the assessment of pulmonary hypertension, and can in The role of in the and of is increasing in the neonatal that as the organ is of the of The use of pressure is on an between pressure and The between and is to the preterm has been to become pressure a is that neonates with and oxygenation are at risk for other have a of between pressure and studies have a between and studies have to any between pressure and that the is much more any of pressure on and may the that is an and a of In to other cardiovascular such as heart and can be are and of assessment using echocardiography has the of structural heart disease as an underlying and the heart is it can the underlying physiology of the assessment of pulmonary hypertension, and a comprehensive echocardiographic examination to be performed in a with structural heart disease has been excluded, can be in the care of the preterm is an important for and current are to as a of care for this In any neonate with of CHD to be by comprehensive In the of structural heart can be in the of it can be in the underlying assessment and for neonates with and clinical to the of clinical that be in such as and the use of and information for the underlying and in the of neonates in structural heart disease has been ruled study the role and use of for this is it can be a of care in the NICU for this is a with an of in and of to It may be with perinatal and with pulmonary It is defined by a of the normal postnatal in pulmonary to and low of preload a of pulmonary venous return and the effects of a right on The right heart is at higher pressure and can and in and can to and in pulmonary hypertension, and can to the that or pulmonary with or Pulmonary can also be in infants. Pulmonary in this setting is by an that has of of and and in the changes are also in preterm infants with to pulmonary hypertension, in may to by the or of to this pulmonary and Echocardiography should be in any or neonate with pulmonary The comprehensive echocardiographic study should be at structural heart defects with pulmonary pulmonary venous return or heart pulmonary with structural heart using can be to the of on and at the and atrial Echocardiography in the setting of may be of the of lung disease and the heart from the should be may be in to the clinical is or difficult to of the of the In with pulmonary hypertension, comprehensive echocardiography should be performed to structural heart In neonates with assessment of the of on and at the atrial and with is between in in to in The from the of the during fetal to lung and of the pulmonary in ventricular In to neonates with have normal pulmonary anatomy with or without of the pulmonary with have to the in the lung and may also be pulmonary in and of the can in to and The for effects and the in pulmonary is the of with effects such as low and cardiorespiratory infants with should a comprehensive echocardiographic assessment of anatomy in the of postnatal of CHD is in the setting of has a to of CHD from atrial foramen ovale and atrial to more a higher More of those are with such a that may be Once CHD has been excluded, targeted neonatal echocardiographic studies can be in In with focused can also be for may be difficult to of a comprehensive echocardiographic study should CHD and a assessment of function and studies should focus on the assessment of pulmonary hypertension, right and and the and of and atrial the ductus arteriosus is it is to the to the of a the focus of be on pulmonary and function should also a more assessment of pulmonary anatomy and pulmonary venous The of a on the of the can be If are of should be with a should a comprehensive echocardiographic study to CHD and to the of can be to the of on and at the atrial and can be for or in of and in preterm or term infants in the NICU may have a of including of the and to with or or of from an of an The use of focused in an with may be is At the echocardiography can be to the has been the of the to be and this the performance of comprehensive echocardiography to underlying heart disease such as and Echocardiography may be of use in the

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.