Advances and Challenges in Neonatal Echocardiography and Hemodynamic Evaluation

Clinical evaluations and standard lab markers are indirect indicators of cardiovascular health, but their limitations in assessing neonatal circulatory function, especially in the early postnatal period, are well-documented. Echocardiography offers a direct assessment of cardiovascular function, enhancing diagnosis and management of cardiac issues in neonatal intensive care units (NICUs).

History and Development:

Functional echocardiography was introduced in NICUs in the 1990s, focusing on heart function rather than structure, distinguishing it from cardiologists' assessments. Initially aimed at evaluating systemic blood flow in very preterm infants, its use expanded in the 2000s, leading to terms like Point-of-Care (POC) echocardiography and Targeted Neonatal Echocardiography (TNE).

Clinical Applications:

Beyond physical exams, assessing hemodynamics is crucial for diagnosing and managing neonatal cardiovascular issues. The skills required for echocardiography vary based on clinical scenarios, with basic skills needed for pericardial effusion and advanced skills for complex cases.

TNE for Hemodynamic Evaluation:  

TNE is vital for managing cardiorespiratory failure in neonates. It may be needed daily in NICUs, with some infants requiring serial assessments. While pediatric cardiology addresses congenital heart diseases, neonatologists are often best positioned for immediate evaluations during acute decompensation. Two primary models exist for TNE: 

1. Primary Neonatologist Model: The primary neonatologist performs and interprets TNE, allowing timely assessments but facing variability in skills.

2. Neonatology Hemodynamic Consultation Team: A specialized team conducts TNE, providing expertise and consistency, but may create a disconnect with the primary caregiver.

Both models complement each other in improving neonatal care.

Cardiac POCUS:

Cardiac point-of-care ultrasound (POCUS) addresses urgent clinical questions and overlaps with TNE, focusing on immediate assessments like contractility and pericardial effusion. Guidelines for POCUS in emergencies highlight its role in identifying causes of acute cardiorespiratory failure.

Training for Echocardiography:

While TNE and cardiac POCUS are vital for respiratory management, standardized training and competency verification are lacking. Training typically requires 6–12 months of mentorship, ideally during neonatology fellowships, though challenges exist due to resource scarcity.

Economic and Policy Implications:

Implementing TNE training requires financial commitment from pediatric departments. Proposed reductions in pediatric fellowship duration may hinder TNE training opportunities, necessitating careful consideration.

In conclusion, advances in hemodynamic evaluation using TNE and echocardiography have improved neonatal care. A structured approach to training neonatologists in echocardiography is essential to meet the growing demands in NICUs.

Source: Noori S, Ramanathan R, Lakshminrusimha S. et al. Hemodynamic assessment by neonatologist using echocardiography: Primary provider versus consultation model. Pediatr Res.2024(96);1603–1608. https://doi.org/10.1038/s41390-024-03248-7