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FOCUS ON NEONATOLOGY
March 2016 Affiliated with Columbia University College of Physicians and Surgeons and Weill Cornell Medical College
Functional Echocardiography a ‘Game Changer’ for Neonatal Care

“The bottom line is, heart function is vital. Babies need good heart function to perfuse all of their other organs, so that they get the blood flow that they need in order to survive,” said Alan Groves, MD, a specialist in neonatal and perinatal medicine at NewYork-Presbyterian Hospital/Phyllis and David Komansky Center for Children’s Health at Weill Cornell Medical Center in New York City.

“Historically it has been difficult to measure tissue perfusion accurately. We’d been left using other markers for that, such as blood pressure, and none of them was terribly effective.”

For babies born prematurely, such as those placed in Dr. Groves’ care, measuring tissue perfusion is often a matter of life and death. That’s why, as far as he is concerned, functional echocardiography ought to be the standard of care for neonatal management in the United States.

Functional Echo Should Be Standard

“We now have high-quality images available at the bedside, with really quite portable, small machines that can fit into the tight spaces of a neonatal unit, and provide us with very detailed assessments,” said Dr. Groves, who is the Friedman Family Foundation Clinical Scholar in Newborn Medicine and Associate Professor of Pediatrics at Weill Cornell Medical College. “And we can use that equipment to determine whether a child needs extra help with their heart function and then reassess them as often as we need to track their response to that therapy.”

Dr. Groves added that doctors must be careful when using functional echocardiography on preterm babies. “We have to try not to handle the small babies more than we need to,” he said, but emphasized that it carries few downsides compared with its many upsides.

As technology improves, so too does the ability of doctors to measure circulating volume and the rate at which babies’ hearts are contracting. Taken together, Dr. Groves said, these two measures reveal how much blood is being pumped into the tissues. He added that new measures are also being developed that can indicate how much blood the brain is receiving.

As a result of improvements in the technology, an increasing number of neonatal technicians are embracing functional echocardiography to improve patient care—a development that drives progress even further, as neonatal research groups are able to collect data and compare notes on their findings.

“Our group and a number of other groups have described the normal ranges for cardiac filling, for cardiac contractility, for tissue perfusion—all of those things are well described, in entirely healthy newborns, in healthy preterm babies, as well as in babies who are unwell due to infection or lung disease,” Dr. Groves said. “So it’s very easy to compare those together, or to compare an individual baby to the group norms.”

Dr. Groves, who has used functional echocardiography in his bedside assessments for 15 years, dating back to his time practicing in New Zealand, said the data supporting its use to improve neonatal decision making and outcomes is “robust.” The time has come, he added, for the practice to be incorporated as standard of care in managing sick neonates in the United States—a development that he called a “game changer.”

Three Developments

Dr. Groves cited three developments in recent years that will pave the way for functional echocardiography to become standard practice:

  1. First, the American Society of Echocardiography released a set of guidelines for training in and practicing functional echocardiography in the neonatal intensive care unit, which he said provides a roadmap that can be used across institutions.
  2. Second, echocardiogram images can now be stored and transmitted digitally, making it easy for neonatal specialists to consult with one another and, when necessary, consult a cardiologist, providing “a huge level of reassurance,” Dr. Groves said.
  3. The third game-changing development is improved training, which Dr. Groves said is “particularly exciting” at NYP/Komansky Center, where technicians unfamiliar with the technology can practice using a functional echocardiogram machine with preloaded data profiles on a mannequin. “Rather than practicing on a live baby, trainees can spend as many hours as they need on the trainer, with a description on the screen of what they should be doing,” Dr. Groves said, adding that past difficulties in training people is one of the main reasons that the use of functional echocardiography isn’t more widespread.
“I feel very strongly that we have to roll this out,” Dr. Groves said, adding that he has seen the use of functional echocardiography change the course of a neonate’s care for the better. “There are children who are alive and well,” he noted, “in part because of echocardiography performed by the neonatologist."

Dr. Groves added that in addition to helping with the management of preterm babies, functional echocardiography helps with a myriad of other issues that can arise around the time of delivery, including stress, infection, guiding the use of drugs such as adrenaline, and helping doctors determine how hard to drive the heart of a baby who needs cardiac support.

“In that first crucial 24 hours of life, to be able to turn a sick baby into a healthy baby—it’s a wonderful thing to be able to do with your day at work,” Dr. Groves said. “And using the echo to make sure we get that balance just right is really extremely rewarding.”

 
 
   
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