Tissue-Tracking Mitral Annular Displacement in Neonates: A Novel Index of Left Ventricular Systolic Function.

OBJECTIVES: To assess the feasibility, accuracy, and reproducibility of tissue-tracking mitral annular displacement (TMAD) compared with other measures of left ventricular systolic function in healthy preterm and term neonates in the transitional period. METHODS: This was a prospective observational study. Two echocardiograms were performed at 24 and 48 hours of life. TMAD, shortening fraction (SF), ejection fraction (EF), s', and global longitudinal strain (GLS) were measured offline. Accuracy to detect impaired GLS was tested by ROC curve analysis. DeLong test was used to compare AUCs. Intra and interobserver reproducibility of the off-line analysis was calculated. RESULTS: Mean ± SD gestational age and weight were 34.2 ± 3.8 weeks and 2162 ± 833 g, respectively. TMAD was feasible in 168/180 scans (93%). At 24 hours the AUC (95% CI) of SF, EF, s', and TMAD (%) was 0.51 (0.36-0.67), 0.68 (0.54-0.82), 0.63 (0.49-0.77), and 0.89 (0.79-0.99) respectively. At 48 hours the AUC (95% CI) of SF, EF, s', and TMAD (%) was 0.64 (0.51-0.77), 0.59 (0.37-0.80), 0.70 (0.54-0.86), and 0.96 (0.91-1.00), respectively. The AUC of TMAD was superior to the AUC of SF, EF, s', at both timepoints (P < .02). Intraclass correlation coefficients (95% CI) of intra and interobserver reproducibility of TMAD were 0.97 (0.95-0.99) and 0.94 (0.88-0.97), respectively. CONCLUSION: TMAD showed improved accuracy and optimal reproducibility in neonates in the first 48 hours of life.

Cor Triatriatum Dexter: Contrast Echocardiography Is Key to the Diagnosis of a Rare but Treatable Cause of Neonatal Persistent Cyanosis.

Cor triatriatum dexter (CTD) is an extremely uncommon and underreported congenital cardiac anomaly in which the persistence of the embryonic right venous valve separates the right atrium into two chambers with varying degrees of obstruction to antegrade flow and variable degree of right to left shunt at atrial level. Depending on the size of the valves, clinical manifestations vary from absence of symptoms to severe hypoxia, requiring urgent surgical correction. We herein describe the diagnostic difficulties in a case of neonatal CTD, who developed increasingly severe and unresponsive cyanosis, first interpreted as postnatal maladjustment with pulmonary hypertension. The failure to respond to oxygen and pulmonary vasodilators led us to reconsider a different diagnosis. The use of contrast echocardiography improved the diagnostic performance of transthoracic echocardiogram (TTE) and revealed a massive right-to-left shunt secondary to the presence of an atrial membrane that required urgent surgery.

Feasibility, Reproducibility and Reference Ranges of Left Atrial Strain in Preterm and Term Neonates in the First 48 h of Life.

Left atrial strain (LAS) is the most promising technique for assessment of diastolic dysfunction but few data are available in neonates. Our aim was to assess feasibility and reproducibility, and to provide reference ranges of LAS in healthy neonates in the first 48 h of life. We performed one echocardiography in 30 neonates to assess feasibility and develop a standard protocol for image acquisition and analysis. LAS reservoir (LASr), conduit (LAScd) and contraction (LASct) were measured. We performed echocardiography at 24 and 48 h of life in an unrelated cohort of 90 neonates. Median (range) gestational age and weight of the first cohort were 34.4 (26.4-40.2) weeks and 2075 (660-3680) g. LAS feasibility was 96.7%. Mean (SD) gestational age and weight of the second cohort were 34.2 (3.8) weeks and 2162 (833) g. Mean (SD) LASr significantly increased from 24 to 48 h: 32.9 (3.2) to 36.8 (4.6). Mean (SD) LAScd and LASct were stable: -20.6 (8.0) and -20.8 (9.9), -11.6 (4.9) and -13.5 (6.4). Intra and interobserver intraclass correlation coefficient for LASr, LAScd and LASct were 0.992, 0.993, 0.986 and 0.936, 0.938 and 0.871, respectively. We showed high feasibility and reproducibility of LAS in neonates and provided reference ranges.

Impact of Aortic Diameter Measurements at Three Anatomical Landmarks on Left Ventricular Output Calculation in Neonates.

OBJECTIVES: To assess reproducibility and accuracy of left ventricular output (LVO) quantifications in neonates, when left ventricular outflow tract diameter (LVOTD) was measured at the hinges of the aortic valve (AV), at the aortic sinus (AS), and at the sinotubular junction (STJ). METHODS: This was an observational study. In the first cohort of very preterm neonates, we assessed intraobserver and interobserver repeatability of LVOTD measured at the AV, AS, and STJ and of the corresponding LVO. In the second cohort of older neonates, we compared paired LVO measurements by echo and magnetic resonance imaging (MRI). RESULTS: In the first cohort of 48 neonates, mean (standard deviation) weight and age at scan were 1046 (302) g and 28.1 (2.7) weeks. Interobserver bias (95% limits of agreement [LOA]) for LVOTD at the AV, AS, and STJ was 0 (-0.3 to 0.3) mm, 0 (-0.7 to 0.7) mm, and 0 (-0.8 to 0.7) mm, respectively. Interobserver bias (95% LOA) for the corresponding LVO was -1.3 (-31 to 33) ml/kg/min, -0.5 (-88 to 87) ml/kg/min, and -7.2 (-83 to 69) ml/kg/min, respectively. In the second cohort of 10 neonates, median (range) weight and age at scan were 1942 (970-3640) g and 37.2 (31.7-39.8) weeks. LVO measured at the AV showed stronger agreement with MRI: bias (LOA) -10.6 (-74 to 52) ml/kg/min, compared to LVO measured at AS and STJ: 194 (-0.5 to 388) ml/kg/min and 43 (-72 to 159) ml/kg/min respectively. CONCLUSIONS: Reproducibility and accuracy of LVO quantification by echo were better when aortic diameter was measured at AV.

Myocardial function in late preterm infants during the transitional period: comprehensive appraisal with deformation mechanics and non-invasive cardiac output monitoring.

BACKGROUND: There is a paucity of functional data on mid-to-late preterm infants between 30+0 and 34+6 weeks gestation. We aimed to characterise transitional cardiopulmonary and haemodynamic changes during the first 48 hours in asymptomatic mid-to-late preterm infants. METHODS: Forty-five healthy preterm newborns (mean ± standard deviation) gestation of 32.7 ± 1.2 weeks) underwent echocardiography on Days 1 and 2. Ventricular mechanics were assessed by speckle tracking-derived deformation, rotational mechanics, tissue Doppler imaging, and right ventricle-focused measures (tricuspid annular plane systolic excursion, fractional area change). Continuous haemodynamics were assessed using the NICOM™ system to obtain left ventricular output, stroke volume, heart rate, and total peripheral resistance by non-invasive cardiac output monitoring. RESULTS: Right ventricular function increased (all measures p < 0.005) with mostly stable left ventricular performance between Day 1 and Day 2. NICOM-derived left ventricular output [mean 34%, 95% confidence interval 21-47%] and stroke volume [29%, 16-42%] increased with no change in heart rate [5%, -2 to 12%]. There was a rise in mean blood pressure [11%, 1-21%], but a decline in total peripheral resistance [-14%, -25 to -3%]. CONCLUSION: Left ventricular mechanics remained persevered in mid-to-late premature infants, but right ventricular function increased. Non-invasive cardiac output monitoring is feasible in preterm infants with an increase in left ventricular output driven by an improvement in stroke volume during the transitional period.

Circumferential and radial deformation assessment in premature infants: Ready for primetime?

BACKGROUND: Speckle tracking echocardiography (STE) is a validated method to measure longitudinal deformation in premature infants, but there is a paucity of data on STE-derived circumferential and radial strain in this population. We assessed the feasibility and reproducibility of circumferential and radial deformation measurements in premature infants. METHODS: In a prospective study of 40 premature infants (<29 weeks of gestation at birth), STE-derived circumferential and radial strain, systolic strain rate (SRs), early diastolic strain rate (SRe), and late diastolic strain rate (SRa) were measured on day 2 and day 8. Intra- and inter-observer reproducibility analysis were performed using Bland-Altman analysis, coefficient of variation (COV), and intra-class correlation coefficient (ICC). The impact of a persistent patent ductus arteriosus (PDA) was analyzed. RESULTS: Deformation analysis was feasible in 98% of the acquisitions. Circumferential parameters demonstrated excellent intra- and inter-observer reproducibility with an ICC between 0.89 and 0.99 (all P < 0.001) and a COV between 4% and 13%. Radial parameters demonstrated acceptable intra- and inter-observer reproducibility with an ICC between 0.73 and 0.96 (all P < 0.001) and a COV between 14% and 27%. Infants with a PDA on day 8 (n = 21, 53%) demonstrated higher radial strain, SRs and SRe. There were no differences in circumferential parameters with a PDA at either time point. CONCLUSION: This study demonstrates clinical feasibility and reproducibility of circumferential and radial strain by STE in premature infants. A PDA elevates radial deformation measures, suggesting that the increased LV preload from a PDA may augment intrinsic contractility in the radial but not circumferential plane.

Association between Hemodynamically Significant Patent Ductus Arteriosus and Bronchopulmonary Dysplasia.

OBJECTIVE: To assess whether the duration and magnitude of the shunt with patent ductus arteriosus (PDA) are related to a higher incidence of bronchopulmonary dysplasia (BPD) or death. STUDY DESIGN: A total of 242 infants ≤ 28 weeks gestational age were evaluated retrospectively between 2007 and 2012; 105 (43.3%) developed BPD or died (group 1) and 137 (56.6%) did not (group 2). A review of all echocardiographic evaluations performed from birth up to 36 weeks of postconceptional age or final ductal closure was carried out, to detect the presence of PDA, and estimate the severity of ductal shunt through the "PDA staging system" proposed by McNamara and Sehgal. RESULTS: Group 1 presented with a hemodynamically significant ductus arteriosus (DA) (E3 and/or E4-PDA) for a longer period of time vs group 2: 4.8 vs 2.3 days, respectively (P < .001). Persistence of a nonsignificant DA (E2) was not associated with development of BPD (P = .16). Each week of a hemodynamically significant DA represented an added risk for BPD (OR 1.7), and the duration of a small, nonsignificant DA (E2) did not. Surgical ligation of PDA itself was not found to be an independent risk factor for BPD. In the subgroup of patients who received ligation, a later ligation (33 vs 23 days) and a prolonged PDA were the only factors associated to BPD or death. CONCLUSIONS: A shared scoring system of the severity of ductal shunt is helpful to correctly evaluate the association between PDA morbidities, to compare scientific studies, and to guide treatment.

A case report of aorto-pulmonary window in an infant born to a diabetic mother.

Several studies have described the association between pre-gestational maternal diabetes and cardiac disease in the newborn. Infants of diabetic mothers have an increased incidence of congenital heart disease, reported between 3% and 6% compared to 0.8% of the general population. A particularly high prevalence of conotruncal defects has been recently described among congenital heart diseases. This group of malformations affects ventricular outflows, aorta, and pulmonary artery and shares a common embryogenic origin. They include persistence of the truncus arteriosus, transposition of great arteries, tetralogy of Fallot, interruption of the aortic arch, and double outlet right ventricle. Aorto-pulmonary window, a rare congenital heart disease belonging to conotruncal malformations, has never been previously described in association with maternal diabetes. We describe the case of a male infant born to a mother suffering from a poorly controlled type 1 diabetes during pregnancy. In the early postnatal life the infant showed respiratory distress, tachycardia, and failure to thrive. He was found to be affected by aorto-pulmonary window that required corrective surgical intervention. .