Role of echocardiogram in ICU

Dr Haifa Abdul Latiff

Senior Consultant Peediatric Cardiologist

Institut Jantung Negara

2nd Neonatal & Paediatric Cardiac Critical Care Conference

Managing the Storm

29th September 2018

ECHO in critically ill newborn

• Previous lectures: • Critical Cardiac Lesions

• Stabilization of critically ill newborn with cardiac lesions

• HOW CAN ECHOCARDIOGRAM HELP?

• Determine the CAUSE: CARDIAC AND NON CARDIAC

• Guide the management – stabilization, intervention

• Assess the response to treatment

Outline

• ECHO features of critical cardiac lesion

• Duct dependent lesions

• PPHN like lesions

• Cardiomyopathy

• Others: cardiac tamponade (post procedure)

• Roles of ECHO in patient’s management

Role of Echo in ICU

Echo features suggesting critical cardiac lesionsPossible duct dependent lesions

Role of echo in ICU

• Right to left shunt across PFO

• Hypoplastic R/L ventricle

• Abnormal AV Valve: atresia, dysplastic, moderate regurgitation

• Poor LV function, EFE

• Small, thickened and immobile aortic or pulmonary valve

• VSD with overriding aorta or single outflow tract

• Parallel great arteries

• Marked discrepancy between the aorta and pulmonary artery size

• Hypoplastic arch or coarctation (or failed to delineate normal aortic arch)

• Reversal flow into the aortic arch

Easily pick upon 4CH view

Newborn with cyanosis

Hypoplastic RVAtretic pulmonary valveReversal flow into MPA PDA right to left shunt

DIAGNOSIS: PAIVSTREATMENT: START PROSTAGLANDIN REFER TO PAEDIATRIC CARDIAC CENTER – RF VALVOTOMY +/- PDA STENTING

RV

oa

Baby severe cyanosis

VSD OVERRIDING AOA

SMALL PA DIAGNOSIS: PAVSD WITH RESTRICTIVE PDA

TREATMENT: • PROSTAGLANDIN

INFUSION• PDA STENTING OR BTS

D5 baby present with shock

MV annulus 3.8mm (Z score <2.5)EFE +

Ascending AO 2.8mm

Reversal flow into the ascending aorta Restrictive PFO

PDA restrictive

Diagnosis: HLHSTreatment: Resuscitation, prostaglandin, stabilize & refer to Paed cardiac centerOption: Norwood or conservative treatment, counselling

Newborn, respiratory distress, cyanosis SaO2 80%

RDSCONGENITAL PNEUMONIAPPHN??

PPHN like lesions

• Pulmonary hypertension in newborn

• CARDIAC: obstructed TAPVD, mitral stenosis, PV stenosis, obstructed cortriatriatum

• NON CARDIAC: Meconium aspiration, PPHN, lung pathology (diaphragmatic hernia) etc

• ECHO features of PHT:

• Dilated RA, RV

• Tricuspid regurgitation

• Bidirectional or right to left shunt across PDA/VSD/PFO

• Severity of PHT: Estimation of PA pressure using CW Doppler

Role of ECHO in ICU

2 weeks old, respiratory distress D2 of life, ventilator dependent and cyanosis. RX as PPHN

AO

IVC

AO

Dilated portal veins

Ascending vein

PV CONFLUENCE

R TO L SHUNT ACROSS PFO

OBSTRUCTED INFRACARDIAC TAPVDNEED URGENT REPAIR OR URGENT BAS

Suprasternal

Estimated PAP =50mmHg

Abnormal flow into innom v

R to L shunt across restrictive PFO Pulmonary veins to CS

Severe TR

ECHO assessment of PHT

CW

• TR PEAK GRADIENT + RA PRESSURE (+10) = PA SYSTOLIC PRESSURE (IN THE ABSENCE OF PULMONARY STENOSIS)

• PA DIASTOLIC PRESSURE CAN BE MEASURED IF THERE IS PULMONARY REGURGITATION (DIFFICULT TO OBTAIN GOOD TRACING)

• ESTIMATED RA PRESSURE ABOUT 10-15MMHG

10

PA diastolic pressure

ECHO assessment of PHT : PDA • Estimated PAP = systolic BP – PG across PDA• Bidrectional flow = systemic PAP• Right to left shunt = suprasystemic PAP

MANAGEMENT:• OBSTRUCTED PV FLOW –URGENT REFERRAL, SURGICAL

INTERVENTION• PPHN: NO2 ETC..SERIAL ECHO TO ASSESS RESPONSE TO

TREATMENT

Bidirectional PDA flow

Colour MMode across PDA

CW across PDA

Neonate with heart failureRole of ECHO in ICU

Dilated cardiomyopathy• Aetiology:

• CARDIAC: ALCAPA, critical AS and coarctation of aorta, arrhythmias

• NON CARDIAC: infection (myocarditis), hypoxic insult, metabolic and genetic

• Cardiac cause – correctable with potential improvement in cardiac function

• ECHO assessment:

• Dilated LA, LV, EFE

• Poor LV contractility (FS,EF), MR

• Coronary origin

• Aortic valve and aortic arch (size, flow)

Role of ECHO in ICU

Anomalous LCA from pulmonary artery

AO

PA

Endocardial fibroelastosis (EFE)Look for thrombus

GENERAL MANAGEMENT: FLUID RESTRICTION, INOTROPES, EARLY REFERRAL TO PAED CARDIOLOGIST

B/O V, ill at birth, ventilated at birth, IV prostin started. Took over D1 of life, sick on arrival, requiring HFOV and urgent procedure in PICU.

Poor LV function, moderate MR, EFE Small, thick aortic valve, minimal flow across the valve

PG across AV =19mmHg

Critical AS – PDA dependentRx: Prostaglandin infusion, urgent referral for aortic valvuloplasty

AS jet up to lower ascending AO Reversal flow from PDA into upper Asc Ao

LA

AOLV

Discrete Coarctation: ECHO diagnosis

In the presence of large PDA or poor LC function will not get diastolic run off

Balloon dilation discrete coarctation

ECHO guided intervention

• Advantage of echo: portable, easily available, non invasive

• Bedside procedures:

• balloon atrial septostomy (BAS)

• pericardial tapping

• intravenous line position

Role of echo in ICU

TGA – 3 days old presented in collapse state

Diagnosis?What is the important echo assessment?What is the immediate Rx required?

PAAO

PA

LV

PA

AO

Restrictive PFO

Balloon atrial septostomy

Non restrictive PFO post BASImmediate increase in SaO2

Arterial switch operation within 1/12 of life

Involuted LV

Bedside BAS under ECHO guidance in PICU

Assess response to treatment

• Serial assessment of LV and RV function

• Severity of PHT

• Complication of treatment: Blocked BTS/stent, pericardial effusion, infection (endocarditis), pleural effusions, diaphragmatic paralysis, ventricular dysfunction etc.

Role of echo in ICU

Newborn with antenatal diagnosis small VSDHypoplastic aortic archLarge PDAStarted IV Prostaglandin after birth

Reviewed on D2 – large PDA, no significant coarc.PG stopped – monitored clinically – no different in UL and LL BP

Reviewed on D5Coactation after PDA closes

Restarted IVIG, PDA reopened

Underwent coarctation repair via sternotomy approach

Importance of serial echo

Post op complicationsCCTGA, VSD, PA, PDA, hypoplastic LPALBTS – worse after BTS

SaO2 improved after revision of BTS

Role of ECHO in ICU

Other cause of ill neonate: cardiac tamponadePost op complications

Infective endocarditis –vegetations

Large pericardial effusion requiring drainage

• 241 sick neonates admitted to NICU had ECHO

• Indications: mumur, extracardiac anomaly, cardiopulmonary symptoms, including shock

• Change clinical management in 66% of newborn (incl. emergency surgical intervention 22%, medical treatment 22%)

Limitations of echo

• Non continuous monitoring

• Echo window

• HIGHLY OPERATOR DEPENDENT

Neonatologist/Paediatrician ECHO

• Basic 2DEcho views and Doppler

• Familiarize with normal echo features

• Recognize critical echo features

• Basic hemodynamic assessment

Summary

• ECHO plays important roles in diagnosing the critical cardiac lesion, guides the management and assess the response of treatment

• It has become an important tool in the neonatal ICU

• Neonatologists and paediatricians should acquire the skill for basic echo to be able to diagnose critical cardiac lesions – safe patient’s life

THANK YOU