REVIEW

CURRENT
OPINION Neonatal functional echocardiography
Cecile Tissot a and Yogen Singh b,c

Purpose of review
The role of echocardiography has dramatically changed over the past decade and use of functional
echocardiography has become increasingly popular among neonatologists and pediatric intensivists in
making clinical decisions in sick infants and children. The purpose of this review is to outline the current
capabilities and limitations of functional echocardiography, best practices for its clinical application, and
evidence for its utility.
Recent findings
Functional echocardiography can provide direct assessment of hemodynamics at bedside and can be used
as a modern hemodynamic monitoring tool in the neonatal intensive care unit. It is now being regarded as
a useful extension to the clinical examination and other monitoring tools in the critically ill infant. The
anatomic, physiological, and hemodynamic information functional echocardiography provides can be used
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in targeting specific interventions and evaluating response to treatment.

Summary
This review article is focused on an overview of the most common applications of functional neonatal
echocardiography also called targeted neonatal echocardiography or neonatologist performed
echocardiography. It will review assessment of hemodynamics and cardiac function in neonatal
hypotension and shock, suspected patent ductus arteriosus, suspected persistent pulmonary hypertension of
the newborn with evaluation of pulmonary artery pressure and assessment of pericardial effusion. It will
also emphasize the specific requirements for the practice and training of functional neonatal
echocardiography.
Keywords
functional echocardiography, hemodynamic, neonate, neonatologist performed echocardiography, point-of-c-
are ultrasonography, targeted neonatal echocardiography

INTRODUCTION preload, afterload, and cardiac contractility while

&

Functional echocardiography is the bedside use of choosing inotropic or fluid therapy [6 ].

cardiac ultrasound to assess myocardial function,
systemic and pulmonary blood flow, and intracardiac
and extracardiac shunts. It provides information
about the cardiovascular physiology causing hemo-
dynamic instability in the sick patient and it helps in
providing targeted, timely and accurate therapeutic
&
interventions [1–3,4 ,5]. Functional echocardiogra-
phy is a real-time noninvasive tool that enables the
primary care physician to evaluate response to treat-
ment, allowing for rapid therapeutic adjustments.
Echocardiography has been used historically
primarily by pediatric cardiologists to diagnose
and monitor congenital heart diseases (CHD). Func-
tional echocardiography is being increasingly per-
formed by neonatologists in many neonatal
intensive care units (NICU) managing infants with
neonatal shock, hemodynamically significant pat-
ent ductus arteriosus and acute pulmonary hyper-
tension. It is increasingly being used to assess
There remain significant variations across the
world in the clinical practice and training in func-
tional neonatal echocardiography. Recently, three
expert-consensus statements have been published rec-
ommending its use in the NICU and various termi-
nologies have been used to describe the use of
functional echocardiography performed by the neo-
natologists: neonatologist performed echocardiogra-
phy (NPE), targeted neonatal echocardiography,
a
Centre de Pediatrie, Clinique des Grangettes, 7 ch des Grangettes,
1224 Chêne-Bougeries, Geneva, Switzerland, bDepartment of Pediatric
Cardiology and Neonatal Medicine, Cambridge University Hospitals and
c
University of Cambridge School of Clinical Medicine, Cambridge, UK
Correspondence to Cecile Tissot, MD, Pediatric Cardiology, Pediatric
Center, Clinique des Grangettes, 7 ch des Grangettes, 1224 Chêne-
Bougeries, Geneva, Switzerland. E-mail: cecile.tissot@hotmail.com
Curr Opin Pediatr 2020, 32:235–244
DOI:10.1097/MOP.0000000000000887

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Neonatology and perinatology
KEY POINTS
 Neonatal functional echocardiography is a useful
bedside noninvasive tool for the evaluation of
hemodynamics in sick neonates and allows real-time
monitoring of therapeutic interventions.
 Neonatologist performed echocardiography (NPE)
should complement or enhance the physical
examination and existing monitoring tools but is not
intended to replace them.
 NPE can be used for assessment of hemodynamics and
cardiac function in neonatal hypotension and shock,
suspected PDA, suspected PPHN with evaluation of
pulmonary artery pressure and assessment of
pericardial effusion.
 Proper training is crucial as CHD is a common problem
responsible for hemodynamic instability in the
neonatal period.
point-of-care cardiac ultrasound and clinician per-
formed ultrasound to name a few. All the expert
consensus statements have emphasized developing
a structured training program and accreditation pro-
&&
cess specifically designed for neonatologists [7,8 ,9 ].
Functional echocardiography performed in the
newborn in the neonatal intensive care unit (NICU)
differs significantly from that performed in older
children in the pediatric intensive care unit or pedi-
atric emergency department because newborns with
hemodynamic instability are at a higher risk of
having an underlying undiagnosed CHD, especially
within first 2–4 weeks after birth, and critical or
significant CHD must be ruled out in sick neonates.
For this reason, the European and North American
expert consensus statements have emphasized that
the first echocardiography performed in a newborn
should include a comprehensive cardiac anatomy
assessment to rule out major CHD. This requires
specific training and expertise and close collabora-
tion with pediatric cardiology services. The subse-
quent scans can be functional and focused or
&& &&
targeted to address specific questions [7,8 ,9 ,10].
INDICATIONS AND BASIC REQUIREMENTS
FOR FUNCTIONAL NEONATAL
ECHOCARDIOGRAPHY
The most important concept is that neonatal func-
tional echocardiography is not intended to replace a
thorough examination by a pediatric cardiologist or
by a clinician trained in structural echocardiogra-
phy. If structural CHD is suspected, the first echo-
cardiography should always be comprehensive to
assess cardiac anatomy and function by using the
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segmental sequential analysis approach beginning
with the identification of abdominal and atrial situs
followed by identification of the ventricular and
arterial situs and then atrioventricular and ventri-
culoarterial connection. Ideally, it should be per-
formed by a pediatric cardiologist or reviewed by a
pediatric cardiologist in a reasonable time frame
when performed by a neonatologist. Cyanosis, signs
of circulatory shock, clinical signs of heart failure,
heart murmur, abnormal pulses, and arrhythmia are
criteria raising suspicion for CHD. In a newborn
with hemodynamic instability without clinical sus-
picion of CHD, the initial study should also be
comprehensive but can be performed by someone
with advanced neonatal functional echocardiogra-
&& &&
phy training [8 ,9 ]. Once major CHD has been
excluded, follow-up NPE studies can be performed
in a targeted manner but NPE should not be used to
follow up children with structural CHD.
The scope of NPE comprises:
1. Assessment of hemodynamics and cardiac func-
tion in neonatal hypotension and shock.
2. Suspected patent ductus arteriosus (PDA).
3. Perinatal asphyxia or hypoxic-ischemic enceph-
&&
alopathy.
4. Suspected pulmonary hypertension of the new-
born (PPHN) or acute pulmonary hypertension.
5. Congenital diaphragmatic hernia.
6. Suspected pericardial or pleural effusion.
7. Central line assessment.
8. Extracorporeal membrane oxygenation cannula-
tion.
Table 1 summarizes the recommendations and
echo parameters for the practice of NPE. Ultrasound
machines used for performing NPE should include
two-dimensional, M-mode, and Doppler capabili-
ties. A range of multifrequency probes (6–12 MHz)
should be available. A simultaneous electrocardio-
gram tracing should be displayed. Ideally, the stud-
ies should be stored on a database to be easily
reviewed by other people. A detailed description
of echocardiographic techniques is beyond the
&&
scope of this article [11 ].
ECHOCARDIOGRAPHIC EVALUATION OF
HEMODYNAMICS AND CARDIAC
FUNCTION IN NEONATAL HYPOTENSION
AND SHOCK
Neonatal shock is common in critically ill infants in
NICU and carries a high mortality. The American Col-
lege of Critical Care Medicine guidelines have empha-
sized early recognition and instituting goal-oriented,
time-sensitive interventions. These guidelines have
Volume 32  Number 2  April 2020
 Neonatal functional echocardiography Tissot and Singh

Table 1. Recommendations for functional neonatal echocardiography

Parameter Recommendations for assessment

Left ventricular systolic function  Qualitative assessment (‘eye-balling’) commonly used

 Quantitative assessment requires M-mode measurements of LVEDD and LVESD with thickness
of the septal and posterior wall
 Shortening fraction can be measured by M-mode if there is no regional wall motion
abnormality or abnormal septal motion
 Ejection fraction should be calculated using biplane volumetric Simpson’s measurement
Left ventricular diastolic function  No accurate data are available in the neonate
Volume status  IVC size and collapsibility can be used to estimate right heart filling pressure but no accurate
data are available in the neonate
Right ventricular systolic function  Qualitative visual assessment (most common)
 TAPSE and FAC can be used for quantitative assessment
PFO  Should be systematically assessed
 Shunt direction and pressure gradient between right atrium and left atrium
PDA  The presence of a PDA should be assessed
 Direction of the shunt and pressure gradient between the aorta and pulmonary arteries
 Hemodynamic significance in the case of L-R shunt by studying the degree of volume overload
and left ventricular dimension
RVSP and PAP  Estimation of RVSP and SPAP is based on Doppler measurement of tricuspid regurgitation and
pulmonary regurgitation jet
 Doppler derived pressure gradient across the PDA can also be used
Systemic blood flow  Measurement of cardiac output can be done using the left ventricular output method
 In the presence of a PDA, the left ventricular output method does not reflect systemic blood
flow and the SVC Doppler flow can be used to estimate changes in cardiac output
Pericardial effusion  Measurement should be done at end-diastole

FAC, fractional area change; LVEDD, left ventricle end-diastolic dimension; LVESD, left ventricle end-systolic dimension; PAP, pulmonary artery pressure; PDA,
patent ductus arteriosus; PFO, patent foramen ovale; RVSP, right ventricle systolic pressure; SVC, superior vena cava; TAPSE, tricuspid annular plane systolic
excursion.

suggested using bedside echocardiography in identify-
ing the underlying pathophysiology, evaluating hemo-
dynamics, and managing response to treatment in
patients with neonatal shock [12].
Functional echocardiography can help in assess-
ing preload, cardiac function, and afterload which
may help in understanding the underlying patho-
physiology for hemodynamic instability or poor
cardiac output. This physiological information, in
conjunction with other clinical parameters and
monitoring tools, can be used in choosing fluid
resuscitation therapy or appropriate inotropic or
vasopressor/vasodilator therapy [13]. Although
some infants with septic shock may need fluid
resuscitation therapy, aggressive fluid boluses can
be hazardous in infants with cardiogenic shock.
Similarly, acute pulmonary hypertension is com-
mon in neonatal shock and early recognition of
increased pulmonary afterload may help in early
institution of pulmonary vasodilators [3,14–16].
Quantification of cardiac chambers and cardiac
structure dimensions implies reporting the measure-
&
ments as Z scores [17 ,18]. Increased left ventricular
end-diastolic dimension can be seen in volume load-
ing conditions (shunt lesions or valve regurgitation)
or in left ventricular dysfunction (dilated
cardiomyopathy) [19]. Increased wall thickness can
occur in pressure loading conditions (valve stenosis).
The systolic function of the left ventricle can be
quickly assessed qualitatively by visual inspection
but this method is prone to interobserver variability.
It can also be assessed quantitatively by measuring
the shortening fraction on M-mode from the para-
sternal short-axis or long-axis views (Fig. 1). Ejection
fraction calculated by planimetry using the modi-
fied Simpson’s method may give a more accurate
assessment especially in infants with septal flatten-
ing or paradoxical interventricular septal motion
&
(e.g., in pulmonary hypertension) [20 ]. When
interpreting shortening fraction and ejection frac-
tion, the influence of preload and afterload should
be taken into account. This is especially true when
comparing cardiac function before and after ductal
closure and explains the usual decrease in shorten-
ing fraction and ejection fraction seen immediately
after surgical duct ligation.
The anatomy and geometrical shape of the right
ventricle do not permit using similar parameters for
assessing right ventricle systolic function [18,21–23].
Hence, right ventricle systolic function is often
assessed by visual inspection but this is also prone
to interobserver variability. Tricuspid annular plane

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Neonatology and perinatology

FIGURE 1. Left ventricle shortening fraction (LVSF) obtained from parasternal long-axis or short-axis view with normal LVSF (left
picture) and decreased LVSF (right picture) in a patient with dilated cardiomyopathy. White arrow indicates systolic
contraction of the left ventricular posterior wall. LVEDD, left ventricle end-diastolic dimension; LVESD, left ventricle end-systolic
dimension.

systolic excursion (TAPSE) (Fig. 2) or tissue Doppler
imaging (TDI) S0 -wave velocity (Fig. 3) are good
reflectors of qualitative right ventricle function
[18,23]. Fractional area change is the method of
choice for quantitative assessment although it
requires further validation in the neonatal popula-
&
tion [20 ].
The myocardial performance index (MPI) is a
good way to assess both systolic and diastolic func-
tion with normal values in healthy neonates rang-
ing from 0.25 to 0.38 [24]. The disadvantage of MPI
is that it is nonspecific and influenced by preload
and afterload changes, making it of limited use in
hemodynamically unstable patients.
Assessment of diastolic function relies essentially
on a combination of different measurements
including Doppler mitral or tricuspid inflow and
pulmonary venous flow and TDI velocities at the
mitral or tricuspid annulus. In the newborn period,
important changes are seen during the first weeks of
life with a gradual change from a fetal filling pattern
(more dependent on atrial contraction) with a
Doppler A more than E wave toward a more mature
filling pattern with an E more than A wave (Fig. 3).
This is characterized by a progressive increase in E-
wave velocity and increased E/A ratio. In the new-
born with high heart rate, E and A waves may be
fused rendering assessment of diastolic function
difficult. Moreover, E-wave velocity is sensitive to
change in preload. Infants with PDA and left-to-
right shunt will exhibit increased pulmonary blood
flow and left atrial pressure resulting in increased

FIGURE 2. Tricuspid annular plane systolic excursion (TAPSE) obtained by M-mode from an apical four-chamber view. Left
picture shows normal TAPSE (22 mm) and right picture abnormal TAPSE (10 mm).

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FIGURE 3. TDI obtained from an apical four-chamber view with S0 representing systolic wave, E0 wave representing early
diastolic wave, and A0 wave representing late diastolic wave concomitant to atrial contraction.
mitral E-wave velocity. TDI velocities are routinely
used in adults but have not been well explored in
the neonate.
Assessment of volume status is challenging in
infants although preload is an important determi-
nant of cardiac output in this population. Echocar-
diographic assessment of preload relies on the
evaluation of filling pressure. Inferior vena cava
(IVC) size and collapsibility is the method of choice
to evaluate right heart filling pressure. This can easily
be done in spontaneous breathing infants but utility
is reduced in ventilated patients. In the presence of
cardiogenic shock and increased right heart filling
pressure, the IVC will appear dilated with no respira-
tory variation. Evaluation of left heart filling pressure
is more complicated but can be qualitatively assessed
by filling of the left ventricle and measurement of the
left ventricular end-diastolic dimension but this is
nonspecific. In infants with a patent foramen ovale
(PFO) and left-to-right shunting, mean pressure gra-
dient across the PFO gives information on the filling
pressure difference between the left and right atrium.
Echocardiographic assessment of cardiac output
is a useful adjunct in the evaluation of the hemo-
dynamically unstable infant. The most commonly
used technique uses Doppler estimation of left ven-
tricular stroke volume, although this technique has
some problems with reproducibility. The systemic
blood flow is obtained by multiplying the time-
velocity integral (TVI) obtained by pulsed Doppler
tracing in the left ventricular outflow tract from an
apical five chambers view by the cross-sectional area
obtained from parasternal long-axis view. Normal
values for left ventricular cardiac index range from
1.7 to 3.5 l/min/m2. Trends in TVI are commonly
used to indicate changes in the cardiac output (CO)
in the unstable NICU patient even if an absolute
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Neonatal functional echocardiography Tissot and Singh
quantitative value is not obtained. Unfortunately,
this technique cannot be used in infants with a PDA
where the left ventricular output is not anymore a
surrogate of CO. In those patients, it is proposed to
measure the Doppler SVC as a surrogate for left
ventricular output. This measurement should be
done over 5–10 cardiac beats to account for respira-
tory variation [3].
ECHOCARDIOGRAPHY FOR SUSPECTED
PATENT DUCTUS ARTERIOSUS
Persistent PDA has been suggested as an independent
risk factor for increased risk of intraventricular hem-
orrhage, necrotizing enterocolitis, bronchopulmo-
nary dysplasia (BPD), acute pulmonary hemorrhage
and carries a 4–8-fold increase in mortality [25,26].
The hemodynamic significance of a PDA is not
directly related to the size of the PDA but depends
upon the magnitude of the shunt and the ability of
premature myocardium to adapt to this left-to-right
&
shunt [25,27,28 ,29]. Functional echocardiography
can help in assessing the hemodynamic repercus-
sion of the ductal shunt on pulmonary hyperperfu-
sion and systemic hypoperfusion (Table 2).
Ductal size is measured at the narrowest point,
usually toward the pulmonary end of the duct where
the constriction appears first. Shunt direction
reflects the pressure difference between the aortic
and pulmonary artery pressure (PAP) (Fig. 4). Pure
left-to-right shunt is seen in infants with low PAP
and can cause diastolic flow reversal in the descend-
ing aorta, mesenteric artery, and cerebral arteries. If
PAP is suprasystemic, right-to-left shunt across the
PDA will occur during systole and more rarely in
diastole. The duration of right-to-left shunt and the
level of diastolic flow reversal in the descending
www.co-pediatrics.com 239
Neonatology and perinatology

Table 2. Echo parameters suggestive of hemodynamically aorta at the level of the diaphragm is a good
significant PDA reflector on the degree of pulmonary hypertension
and can be used for follow-up. Measurement of
Echo criteria suggestive of
Echo assessment hemodynamically significant PDA
the peak pressure gradient across the PDA may
require continuous-wave Doppler if the velocity
PDA size  >2 mm is high.
Left atrium enlargement  Left atrium:aorta ratio > 2:1 NPE has also been reported to improve the out-
Left ventricular enlargement LVEDD > Z-score þ2 comes in infants being treated for PDA. Identifying
MPA flow  Continuous L-to-R flow from the patients at risk of post-PDA-ligation syndrome
PDA with higher velocity in systole
 Turbulent flow
may help in reducing the morbidity and mortality
LPA flow  Continuous antegrade flow in diastole
[30]. Similarly, NPE has demonstrated a reduction in
Descending aorta flow  Retrograde diastolic flow >30%
number of indomethacin doses used for treating
Middle cerebral and  Retrograde diastolic flow
PDA [31,32].
coeliac arteries flow
Left ventricular output  >300 ml/min/m2
Transductal flow  Peak systolic velocity <1.5 m/s ECHOCARDIOGRAPHIC ASSESSMENT OF
 Systolic-to-diastolic velocity PULMONARY ARTERY PRESSURE IN
gradient >4 m/s PERSISTENT PULMONARY
HYPERTENSION OF THE NEWBORN
LPA, left pulmonary artery; LVEDD, left ventricle end-diastolic dimension; MPA,
main pulmonary artery; PDA, patent ductus arteriosus. PPHN is a common problem in critically sick infants
being managed in the NICU and still carries high

FIGURE 4. Patent ductus arteriosus (PDA) shunt direction and velocity (Vmax) allowing for estimation of aorta-to-pulmonary (Ao-PA)
gradient and thus for estimation of pulmonary artery pressure (PAP) and pulmonary hypertension. L–R, left-to-right; R–L, right-to-left.

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 Neonatal functional echocardiography Tissot and Singh

FIGURE 5. Tricuspid regurgitation jet obtained from an apical four-chamber view and allowing for estimation of systolic
pulmonary artery pressure (SPAP) through the modified Bernoulli equation (SPAP ¼ TRVmax þ RAP).

mortality. As time-sensitive intervention is often The right atrium pressure is estimated to be 5–

required, NPE helps to rule out CHD, assess the
severity and hemodynamic repercussion of PPHN,
and target-specific therapy [10,33].
The pulmonary artery systolic pressure (PASP) can
be reliably estimated using echocardiography in the
presence of tricuspid regurgitation (Fig. 5). The pres-
sure gradient between the right ventricle and right
atrium is calculated by using the modified Bernoulli
&
equation [3,34 ,35,36,37]. PASP is estimated by add-
ing the right atrium pressure to the peak systolic
pressure gradient between right ventricle and right
atrium obtained by continuous-wave Doppler.
When there is no right ventricle outflow tract
obstruction, the PASP is equal to the RVSP.
PASP ¼ 4  ðTRmax velocityÞ2 þ RA pressure
10 mmHg in a newborn with normal right heart filling
pressure. However, PASP may be underestimated if the
tricuspid regurgitation jet envelope is not complete
and if right ventricle contractility is impaired.
The pulmonary regurgitation jet can also be used to
assess end-diastolic PAP. A good correlation has been
shown between the Doppler peak diastolic velocity of
the pulmonary regurgitation jet and the mean PAP [38].
The severity of pulmonary hypertension can be
qualitatively estimated by studying interventricular
septum (IVS) and left ventricular shape in the para-
sternal short-axis view. Normally, the left ventricular
is seen as circular in shape. With rising PAP, the IVS
will begin to flatten and paradoxical septal move-
ments may be seen in severe suprasystemic PPHN
(Fig. 6). Left ventricular dysfunction can be seen as

FIGURE 6. Left ventricle and right ventricle interaction obtained from a parasternal short-axis view showing flattening and
paradoxical motion of the interventricular septum (IVS) during systole with increasing systolic pulmonary artery pressure (SPAP)
and pulmonary hypertension.

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Neonatology and perinatology
secondary paradoxical septal movement that can
impair left ventricular contractility and loading con-
ditions [3].
The severity of pulmonary hypertension can also
be estimated by the direction and velocity of shunt across
a PDA but may be limited because of the long and
tortuous nature of the duct that renders the Bernoulli
equation not so reliable. A pure right-to-left shunt
across a PDA suggests suprasystemic pulmonary
artery pressure (PAP), whereas a bidirectional trans-
ductal shunt suggests isosystemic PAP (Fig. 4).
The shunt across the PFO is generally bidirec-
tional in the presence of pulmonary hypertension
but can sometimes be left-to-right even in the pres-
ence of severe PPHN. Indeed, the interatrial shunt-
ing depends more on diastolic function of the right
ventricle. Pure right-to-left shunt across the PFO is
always abnormal and suggests elevated right heart
filling pressure. A cyanotic CHD should always be
ruled out in the presence of a pure right-to-left
interatrial shunting.
The pulmonary artery acceleration time (PAAT) to
right ventricular ejection time (RVET) ratio derived
from pulmonary artery Doppler has been shown to
negatively correlate with PAP in premature infants.
PAAT/RVET ratio has been seen to be a good predic-
tor of late-onset chronic lung disease or BPD [39,40].
Other echo parameters such as eccentricity index
may be used for qualitative assessment of pulmo-
nary hypertension.
NPE is useful in establishment of pulmonary
hypertension and may help in early initiation of
pulmonary vasodilator treatment (such as inhaled
nitric oxide) and monitoring the response to treat-
ment. Similarly, early detection of cardiac dysfunc-
tion may help in choosing the appropriate inotropic
or vasopressor support [41].
ECHOCARDIOGRAPHIC ASSESSMENT OF
PERICARDIAL EFFUSION OR CARDIAC
TAMPONADE
Pericardial effusion is uncommon in infants treated
in the NICU. It is most often secondary to infusion
or parenteral nutrition via central line leading to
sudden collapse and unfavorable outcomes have
been published [42,43]. NPE can be used to diagnose
pericardial effusion and allows for timely echo-
guided pericardiocentesis [44].
The hemodynamic repercussion of pericardial
effusion does not depend only on the amount of
pericardial fluid. A large amount of pericardial fluid
can be well tolerated when the fluid accumulates
slowly and if already present in utero. However, small
but rapidly enlarging pericardial effusion can cause
cardiac tamponade. Right atrium collapse at end-
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diastole, right ventricular free wall collapse during
diastole and respiratory variation of Doppler mitral
inflow more than 10% and tricuspid inflow more than
25% are other signs of cardiac tamponade. Distension
of the IVC with no respiratory variation is usually also
seen and reflects increased right heart filling pressure.
TRAINING AND ACCREDITATION FOR
NEONATAL FUNCTIONAL
ECHOCARDIOGRAPHY
All the recently published expert consensus state-
ments have emphasized developing a structured
training program for neonatologists in developing
&& &&
echocardiography skills [5,7,8 ,9 ,45]. The varia-
tion in such recommendations maybe because of
the heterogenicity in clinical practice and the dif-
ferent needs across the countries. All the guidelines
have emphasized developing an accreditation pro-
cess and developing a robust clinical governance
system to improve patient safety.
Studies have reported that significant CHD was
almost always detected on NPE and there is a very
low risk of missing underlying significant CHD [39].
Although this is reassuring, it is important to
emphasize that the first echocardiography should
always include a comprehensive structural assess-
ment of the heart to rule out major CHD. When the
first echocardiography needs to be performed in
emergency situations where detailed assessment is
not possible, a comprehensive echocardiography
should be performed as soon as possible when the
&
infant is stable [6 ,7].
FUTURE TRENDS
TDI is a new technique providing measurements of
myocardial movements and events and may over-
come some of the shortcomings of conventional
techniques [46]. Myocardial deformation analysis
is an emerging quantitative echocardiographic tech-
nique that allows to characterize global and regional
ventricular function. Cardiac strain is a measure of
tissue deformation and strain rate is the rate at
which deformation occurs. These measurements
are obtained in neonates using TDI or two-dimen-
sional speckle tracking echocardiography [47].
Although promising, these techniques are not used
for making bedside clinical decisions in the NICU
practice and are still used primarily as research tools.
CONCLUSION
Bedside functional echocardiography provides real-
time physiological information and is a useful adjunct
to other monitoring tools for critically ill infants. It is
Volume 32  Number 2  April 2020

being increasingly used in making therapeutic clinical
decisions and assessing response to treatment in the
unstable newborns in the NICU. The role of NPE is
rapidly evolving. There is a need for developing a
structured training program for neonatologists to
develop echocardiography skills. Standardized training
and accreditation program, and a close collaboration
with pediatric cardiologists, are essential for ensuring
patient safety and quality assurance in this age group
because the risk of having a critical or major CHD is
higher in infants presenting with hemodynamic insta-
bility compared with older children.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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Volume 32  Number 2  April 2020