international perspectives
The Neonatologist as an
Author Disclosure
Drs Groves, Kuschel, and Skinner did
not disclose any financial
relationships relevant to this article.
Echocardiographer
Alan M. Groves, MBChB, MRCPCH,*
Carl A. Kuschel, MBChB, FRACP,†
Jonathan R. Skinner, MD, FRACP‡
Introduction
When echocardiography is necessary
in the newborn period, it often is
needed urgently. (1) However, staff-
ing, organizational, and geographic
limitations make it unlikely for pedi-
atric cardiologists to provide 24-
hour coverage for echocardiographic
assessment of sick newborns in most
centers. (2) Pediatric cardiology ser-
vices also could be overwhelmed
with requests for assessments of duc-
tal shunting in preterm infants who
have yet to develop clinical signs. (3)
In many parts of the world, litera-
ture on the value of early hemody-
namic assessment and increased ac-
cess to ultrasonography equipment
with improving image quality has
motivated neonatologists to develop
echocardiographic skills. As a result,
echocardiography is increasingly
considered an integral component of
the assessment of the critically ill new-
born. (2)(4)(5) An increasing number
of neonatologists are undertaking as-
sessments of functional hemody-
namic status by echocardiography,
with particular interest in volume of
ductal shunt, (3) severity of persis-
tent pulmonary hypertension, (6)
and detection of low systemic blood
flow. (7) In addition, some neonatol-
ogists have assumed the responsibil-
ity of excluding structural congenital
*Neonatal Specialist Registrar, Queen Charlotte’s
and Chelsea Hospital, London, United Kingdom.
†
Neonatologist, Newborn Services, Auckland District
Health Board, Auckland, New Zealand.
‡
Paediatric Cardiologist, Paediatric Congenital and
Cardiac Services, Starship Children’s Health,
Auckland District Health Board, Park Road,
Auckland, New Zealand.
heart disease in newborns presenting
with cyanosis or a cardiac murmur.
This review describes the principal
applications of echocardiography by
the neonatologist, with some practi-
cal guidance on method of assess-
ment and interpretation of findings.
Limitations on Practice
Echocardiography is highly user-
dependent. (8) The primary concern
about neonatologists performing
echocardiography has been the po-
tential for misdiagnosis, particularly
failure to recognize cardiac disease.
There is scope for error in the diag-
nosis of both structural and func-
tional cardiac pathology. Although
errors in assessment of structural car-
diac disease usually become evident
over time, cardiac function changes
dramatically during the neonatal pe-
riod, so it is more difficult to assess
whether interoperator discrepancies
in functional assessment are due to
observer error or true functional
change.
Some reports have suggested an
unacceptably high error rate in the
diagnosis of structural cardiac disease
when scans are performed by person-
nel other than pediatric cardiologists.
(8)(9) However, these assessed diag-
noses were made by radiologists and
echocardiographers of adults rather
than neonatologists. (10)
Others have supported the prac-
tice of neonatologists performing
echocardiography with appropriate
cardiology support. (1)(2)(11) These
opinions are supported by the results
of a prospective analysis in which
echocardiography performed by
neonatologists showed minimal dis-
crepancies from that carried out by a
pediatric cardiologist. (4)
NeoReviews Vol.7 No.8 August 2006 e391
international perspectives
However, there is no excuse for
complacency. Errors can exact a high
cost from the patient. For any neona-
tologist performing echocardiogra-
phy, a few guidelines for safe practice
are shown in Table 1.
Another concern for neonatolo-
gists performing echocardiography is
the handling involved, which poten-
tially conflicts with the principles of
minimal handling of preterm infants.
(12) When performed carefully, echo-
cardiography can be undertaken in the
preterm infant without significantly
disturbing cardiorespiratory status.
(13) However, the number and du-
ration of scans should be minimized
and directed by clinical necessity.
Training/Teaching
As demand for the technique in-
creases, familiarity with echocardiog-
raphy may become a recommended
part of the training for neonatolo-
gists, at least in Europe. However, at
present we are not aware of any for-
malized training process or accredita-
tion, despite suggestions that such
guidelines are required. (2)(4)(5)
A number of courses on pediatric
and neonatal echocardiography are
available and serve as a useful intro-
duction to the technique. A textbook
aimed exclusively at the neonatal echo-
cardiographer is available. (14) Inter-
active DVDs that provide a compre-
hensive guide to assessment of the
normal as well as the structurally or
functionally abnormal heart also have
been produced and are extremely valu-
able. (15) For neonatologists who an-
ticipate echocardiography becoming a
significant component of their prac-
tices, a detailed pediatric cardiology
text is another worthwhile investment.
However, there is no substitute
for performing scans under the su-
pervision of a pediatric cardiologist
or experienced neonatal echocardi-
ographer. Every opportunity should
be taken to observe and perform scans
e392 NeoReviews Vol.7 No.8 August 2006
Guidelines for Safe Practice for
Table 1.
Neonatologists Performing
Echocardiography
Training and Audit
● Consider whether you will perform this procedure often enough to acquire
and maintain a basic set of skills.
● Attend a formal course in echocardiography and decide on the level of
expertise you wish to acquire.
● If you wish to diagnose heart disease accurately, seek a training fellowship
or placement within a pediatric cardiac center.
● When you begin practice, keep a log of your scans, and ask a mentor to
discuss and audit your progress.
Examination
● Perform a clinical examination prior to echocardiography. If the
echocardiographic findings do not fit the clinical picture, request a
cardiology review. Always check the femoral or foot pulses.
● Refer any child who has suspected or confirmed structural congenital heart
disease for expert cardiology review.
● It may be safer to initiate prostaglandin therapy on the basis of clinical
suspicion rather than delaying treatment while a noncardiologist performs
echocardiography.
● Do not hesitate to rescan with an open mind if an infant’s clinical signs
unexpectedly persist or change.
● Record all scans, audit your performance, and reassess any diagnostic
inaccuracies.
● Know your limits: If you are not certain of the diagnosis, obtain a second
opinion before altering management on the basis of the scan.
Reporting Scans
● Establish a standard pro forma (if you forget to check something, go back
and check!). Title the report “Neonatal Cardiac or Hemodynamic
Assessment” or similar to avoid the impression that pediatric cardiologist
echocardiography has been performed, which could delay referral later for
clinical signs of cardiac disease.
● Always write a full report and be careful to state if you consider heart
disease has been excluded.
with supervision, especially while train- provides scope for cardiologists to re-
ing. This experience may be obtained view scan findings without either the
on the neonatal unit and in outpatient infant or the specialist having to travel.
clinics. Because the recognition of nor- Those who wish to exclude congenital
mal anatomy rather than the delinea- heart disease confidently should seek a
tion of precise abnormality is a priority training fellowship or placement
in neonatal scanning, it is helpful to within a pediatric cardiology unit.
perform most early scans on infants
who have normal anatomy. Routine Structural
Throughout a neonatologist’s Echocardiographic Views
scanning career, it is vitally important It is beyond the scope of this review
to maintain close contact with pediat- to offer comprehensive instruction
ric cardiologists. The use of recorded on the technique of echocardiogra-
scans or teleechocardiography also phy. Rather, we examine standard

views obtained in neonatal echocar-
diography to aid understanding.
In all cases, it is essential to follow
a structured approach to echocardi-
ography. At every scan, standard
views (Table 2) should be obtained
in sequence, with at least a minimum
“checklist” of normal anatomic fea-
tures confirmed. The echocardio-
gram should be performed in a logi-
cal sequence, taking care to delineate
the venous drainage, all four cardiac
chambers, the septae, and all four
valves. (14)
Assessment of Structural
Congenital Heart Disease
The diagnosis and management of
structural congenital heart disease al-
ways will be the role of the pediatric
cardiologist. In some cases, an ur-
gent assessment of cardiac structure
may be carried out by a neonatolo-
gist, when the primary goal is to con-
firm or exclude normal anatomy,
rather than delineate a precise struc-
tural diagnosis. This can be of great
value, particularly in centers remote
from pediatric cardiology. In practi-
cal terms, the neonatologist is likely
to have to exclude structural pathol-
ogy in two primary scenarios.
The first example involves an in-
fant who has cyanosis in which the
task is to differentiate cyanotic con-
genital heart disease (eg, transposi-
tion of the great arteries, pulmonary
atresia, tricuspid atresia, tetralogy
of Fallot) from persistent pulmo-
nary hypertension of the newborn
(PPHN). Exclusion of total or partial
anomalous pulmonary venous con-
nection (TAPVC) can be particularly
difficult, especially in infants who
have evidence of PPHN and reduced
pulmonary blood flow.
The second example involves an
infant who has collapsed or has hy-
potension in whom an obstructive
cardiac pathology (eg, critical aortic
stenosis, hypoplastic left heart syn-
international perspectives
Standard Views in Neonatal
Table 2.
Echocardiography
View Demonstrates
Transverse subcostal view ● Normal situs
Subcostal atrial and four- ● Superior vena cava drains into right atrium,
chamber views pulmonary veins into left
● Intact intra-atrial septum
● Intact ventricular septum
Apical four-chamber view ● Normal mitral and tricuspid valves, with
tricuspid positioned closer to the apex of
the heart. Establish atrioventricular
concordance
● Intact ventricular septum
● Rotate to “five-chamber view” to identify
normal aortic valve from the left ventricle
● Pulmonary artery from the right ventricle
crossing over aorta, excluding transposition
(ie, establishing ventriculo-arterial
concordance)
Parasternal long axis view ● Normal motion of mitral and aortic valves
● Intact ventricular septum
● Normal pulmonary valve
Parasternal short axis view ● Intact ventricular septum
● Normal pulmonary valve
● Drainage of pulmonary veins into left
atrium
Ductal view ● Ductal patency and direction of flow
Arch view ● Exclusion of coarctation
drome, coarctation of the aorta) This rapid circulatory adaptation
must be differentiated from other can fail in both term and preterm
causes of collapse such as sepsis or infants. Echocardiography allows de-
metabolic disease. termination of the functional status
of the transitional circulation and
Assessment of Functional permits exclusion of a structural
Cardiovascular Status cause for any failure in transition.
The central features of the transi- Because the transitional circulation
tional circulation are: evolves rapidly, repeated echocardio-
● An abrupt decrease in pulmo- graphic assessments may be required.
nary vascular resistance leading Echocardiographic assessment may
to an increase in pulmonary be warranted when one or more of
blood flow the principal components of the tran-
● Removal of the low-resistance sitional circulation is failing. Failure
placental circulation by clamp- of pulmonary vascular resistance to
ing of the umbilical cord, lead- decrease presents as PPHN, with cy-
ing to a sudden increase in pe- anosis resistant to adequate ventila-
ripheral vascular resistance tion and right-to-left shunting at
● Functional closure of the arte- atrial or ductal levels. Failure of the
rial duct and foramen ovale, myocardium to pump adequately
generally within 24 hours of may result in impaired systemic per-
birth in the healthy term infant fusion.
NeoReviews Vol.7 No.8 August 2006 e393
international perspectives

tent, ventilation-refractory hypoxia

requires a pediatric cardiology re-
view. Tricuspid and pulmonary atre-
sia, Ebstein anomaly, and tetralogy
of Fallot can be excluded by the dem-
onstration of four normally function-
ing cardiac valves. Transposition of
the great vessels can be excluded by
demonstrating normal ventriculo-
arterial connection of the two great
arteries. The primary difficulty echo-
cardiographically in the infant who
has persistent cyanosis is excluding
the relatively rare – but treatable –
TAPVC (Fig. 1), which can be ex-
cluded only by seeing the pulmonary
veins draining into the left atrium.
Another trap is isolated valvar pul-
monary atresia. Because ductal flow
can swirl in the main pulmonary ar-
tery, suggesting that the pulmonary
valve is competent, it is important to
Figure 1. Subcostal view of TAPVC, with pulmonary veins failing to drain into the left
see that the valve opens well.
atrium (LA). Note that the flap of the foramen ovale (labeled ASD) bulges to the left,
consistent with pure right-to-left flow from right atrium (RA) to LA.
Signs of PPHN on echocardiogra-
phy include:
1. Distention of the right heart
Persistent Pulmonary Echocardiographic confirmation of chambers, with flattening of the
Hypertension of the Newborn the diagnosis allows exclusion of a interventricular septum (Fig. 2)
PPHN is a relatively common cause primary cardiac cause, focused ther- 2. Indirect evidence of raised
of morbidity and mortality in term apy, and assessment of response to right ventricular pressure from
infants. (16) The final common path- therapy. high-velocity tricuspid regur-
way in PPHN is failure of the pulmo- An essential step in echocardio- gitation. Most infants who
nary vascular resistance to decrease graphic assessment is exclusion of have PPHN have tricuspid re-
from intrauterine levels, leading to structural cardiac abnormality, which gurgitation, (6) and use of the
pulmonary-to-systemic shunting of can be more than can be expected Bernoulli equation (pressure⫽
blood, reduced pulmonary blood from the level of expertise of many 4⫻velocity2) allows calcula-
flow, and ventricular dysfunction. (6) neonatal echocardiographers. Persis- tion of the peak systolic pres-
sure gradient between the
right ventricle and the right
atrium (Fig. 3). This is the
most repeatable method of es-
timating pulmonary arterial
pressure. (17) The pulmonary
arterial pressure can be esti-
mated by adding a nominal
pressure value for the right
atrial pressure (usually taken as
5 to 10 mm Hg).
Figure 2. Parasternal short axis view. In healthy infants (A) the left ventricle is 3. Right-to-left shunting through
circular; in PPHN (or TAPVC) (B) the raised right ventricular pressure flattens the fetal channels. Although the
interventricular septum and displaces it into the left ventricle. arterial duct is not universally

e394 NeoReviews Vol.7 No.8 August 2006

 international perspectives

patent in PPHN, (6) clear vi-

sualization of pure right-to-
left ductal flow (Fig. 4) in the
presence of normal cardiac
anatomy confirms the diagno-
sis of PPHN, if left-heart ob-
struction (especially aortic co-
arctation) is ruled out. In some
cases, the shunt is bidirectional
or even pure left-to-right, al-
though with low velocity, again
demonstrating that the pul-
monary pressures are abnor-
mally high. (14) Shunt from
the right to the left atrium
through a patent foramen
ovale is also usual in infants
who have PPHN.
4. Low left ventricular output
(LVO) and right ventricular
Figure 3. Assessment of velocity of tricuspid regurgitation from the apical four- output (RVO) indicate a
chamber view. Application of the modified Bernoulli equation (Pⴝ4v2) allows poorer prognosis. (6)
estimation of the right ventricular/pulmonary arterial pressure. 5. Notching of the pulmonary ar-
tery waveform (due to a back-
ward traveling compression
wave “bouncing” back off the
constricted pulmonary vascu-
lar bed). (18)
In all cases, response to treatment,
particularly changes in cardiac out-
put and direction of ductal shunting,
can be assessed by repeated echocar-
diographic assessments. (6) If there is
any uncertainty about the cardiac
anatomy or if the pattern of PPHN is
not consistent with the clinical con-
dition of the infant, urgent referral to
a pediatric cardiologist should be
made. PPHN can coexist with struc-
tural congenital heart disease.

Assessment of Systemic
Perfusion
Episodes of inadequate systemic per-
fusion in the newborn period may
occur in preterm infants due to im-
maturity (19) and in term infants due
Figure 4. A high parasternal view shows the characteristic “three-legged stool” to systemic illness. (7) Adequacy of
appearance of the duct (PDA) and left (LPA) and right pulmonary arteries (RPA). Color the circulation in most clinical set-
Doppler demonstrates blue flow in the duct (away from the transducer) from the tings is assessed using surrogate
pulmonary artery to the aorta. markers, which are imperfect predic-

NeoReviews Vol.7 No.8 August 2006 e395

international perspectives
Figure 5. Subcostal view of color Doppler assessment of SVC flow velocity (note that
the flow velocity varies with respiration). Flow can be estimated by multiplying the
area under the curve by the cross-sectional area of the SVC.
tors of flow. (20) Blood pressure has
an unreliable relationship with sys-
temic (21) and cerebral (22) perfu-
sion. Prolonged capillary refill time is
associated with poor perfusion, (20)
although the sensitivity is poor. Lac-
tate concentration (23) and urine
output (24) are generally markers of
prior, rather than current, perfusion.
Doppler echocardiography pro-
vides a noninvasive method of assess-
ing cardiac output. (25) In the ab-
sence of shunting through fetal
pathways, LVO and RVO are both
equivalent to systemic perfusion.
Doppler echocardiographic estima-
tion of LVO has been shown to cor-
relate well with invasive estimates of
flow in neonates. (26) Because aortic
diameter changes little in the new-
born period, (27) change in left ven-
tricular stroke volume over time may
be assessed by monitoring aortic
stroke distance (the area under the
Doppler profile). In the first postna-
tal week, the intraobserver repeat-
ability of aortic stroke distance ap-
e396 NeoReviews Vol.7 No.8 August 2006
proximates 20%. (28) Therefore, a
20% change is likely to represent a
genuine change in flow volume.
Doppler echocardiographic estima-
tion of RVO has been shown to have
similar repeatability to LVO. (29)
However, in the presence of per-
sistent shunting through a patent ar-
terial duct or foramen ovale, neither
LVO nor RVO represents true sys-
temic perfusion; both can overesti-
mate systemic perfusion by at least
50%. (30)(31) Superior vena cava
(SVC) flow (Fig. 5) is unaffected by
shunting through fetal pathways and
has been shown to be a repeatable
marker of systemic perfusion. (32)
Low flow in the neonatal period is
associated with subsequent periven-
tricular hemorrhage (33) and adverse
long-term neurodevelopmental out-
come. (34) Work by our own group
has confirmed that measurement of
SVC flow volume is feasible in more
than 95% of scans in preterm infants
and suggested similar repeatability
and reference ranges to those pro-
duced by Kluckow and associates
(unpublished observations).
Echocardiographic assessment of
cardiac filling as a guide to adequacy
of preload has not yet been shown to
be reliable. (35) However, multiple
sites of assessment (SVC, inferior
vena cava, atrial and ventricular di-
ameters) that are showing potential
in adult patients (36)(37) need to be
considered. An echocardiographic
assessment of cardiac filling in the
sick neonate is likely to be better than
no assessment at all, but in the sick
term infant, central venous pressure
should be measured. (38)
Echocardiographic assessment of
systemic perfusion clearly has limita-
tions, particularly in repeatability and
inaccuracies from shunt through fe-
tal channels. Nevertheless, using
multiple hemodynamic measure-
ments at each scan enables a single
clinician to gain a global assessment
of cardiac function and minimizes
the impact of measurement error.
(39) A global circulatory assessment,
including estimation of LVO, RVO,
and SVC flow, fetal shunt patterns,
and ventricular filling, can be
achieved in only 10 minutes. (13)
Assessment of Ductal Shunt
Volume
Patency of the arterial duct is normal
in the first 48 hours of postnatal life
in healthy term and preterm infants.
(3) Patency tends to be prolonged in
preterm infants who have respiratory
disease, leading to significant volume
of systemic-to-pulmonary shunting.
Potentially this may lead to worsen-
ing of respiratory status (40) and per-
haps systemic hypoperfusion. (41)
However, trials of intervention have
failed to show significant benefit in
long-term outcomes from therapy
aimed at ductal closure, (42) leaving
the possibility that the association
between prolonged ductal patency
and adverse outcomes in preterm ne-

Figure 6. High parasternal view of patent arterial duct with left-to-right shunting.
The duct is demonstrated by the red flow seen on color Doppler imaging. A duct
diameter less than 1.5 mm at the point of maximal constriction is unlikely to be
associated with high shunt volume.
onates is not causative, but due to
confounders such as the severity of
respiratory disease. (43) Some au-
thors have recommended that phar-
maceutical closure not be considered
standard care in the neonate. (43)
Further discussion of the scenarios in
which treatment may be indicated is
outside the scope of this review.
Nevertheless, attempts at thera-
peutic ductal closure remain com-
mon, particularly in infants who re-
main ventilator-dependent. The
significance of an individual’s duct
remains a common clinical debate,
and this cannot be assessed reliably
without echocardiographic examina-
tion. However echocardiography
does not replace clinical examination
for evidence of ductal shunt (eg,
bounding pulses, hyperactive precor-
dium), to exclude signs of structural
congenital heart disease (cyanosis,
lower limb pulses), and perhaps most
importantly, to assess the infant’s
overall clinical status. An echocardio-
graphic examination cannot deter-
mine whether a duct merits treatment;
it merely can diagnose patency, ex-
clude coexisting structural heart dis-
ease, and establish whether the shunt
volume through the duct is high,
moderate, or low. (3)(14)
Echocardiographic assessment in
ductal patency can be used for a
number of conditions:
1. Exclude structural congenital
heart disease, particularly co-
arctation of the aorta and pul-
monary atresia. If this cannot
be done with confidence, no
treatment aimed at ductal clo-
sure should be initiated until
the infant has been reviewed
by a cardiologist.
2. Ductal diameter from the high
parasternal (“ductal”) view
(Fig. 6). With appropriate
color Doppler scale and gain
settings, a duct diameter less
than 1.5 mm at the point of
maximal constriction is un-
international perspectives
likely to be associated with
high shunt volume. (44)
3. Ductal flow pattern, using
continuous wave Doppler, to
confirm direction of flow and
assess maximum and mini-
mum flow velocities. A mini-
mum flow velocity that is more
than 50% of the maximum ve-
locity is associated with a con-
stricting duct and suggests
lower shunt volume. (45)
4. Left atrial and ventricular dila-
tation. Increased left-to-right
ductal shunt creates a volume-
loaded appearance of both the
left atrium and ventricle. The
ratio of the left atrial to the
aortic diameter can be assessed,
using M-mode echocardiogra-
phy from the parasternal long
axis view. A ratio or more than
1.5:1 suggests a higher-volume
shunt.
5. Descending aortic flow pat-
tern, which can be visualized
using pulsed wave Doppler
from a high parasternal view.
In healthy infants, there is con-
tinuous forward flow in the de-
scending aorta, which is high
velocity during cardiac systole
and low velocity during dias-
tole (Fig. 7A). However, in in-
fants who have high-volume
ductal shunt, flow in the de-
scending aorta is reversed dur-
ing diastole, as blood is
“sucked” back up the descend-
ing aorta and into the pulmo-
nary circulation (Fig. 7B). (46)
6. Persistent forward flow in pe-
ripheral pulmonary arteries.
Blood traveling through the
ductus creates persistent for-
ward flow through the periph-
eral pulmonary arteries, sug-
gesting high shunt volume.
(47)
NeoReviews Vol.7 No.8 August 2006 e397
international perspectives
Figure 7. High parasternal views of (A) a healthy infant who has forward diastolic flow and (B) an infant who has reversed diastolic
flow that is associated with high-volume left-to-right ductal shunt.
Line Placements/Tamponade
Echocardiography also may have a
role in selected infants who do not
need the services of a pediatric cardi-
ologist in determining normal car-
diac anatomy. Such situations in-
clude infants in whom a sudden
clinical deterioration could be due to
cardiac tamponade from extravasa-
tion of fluid through a central line.
There also may be a role for echocar-
diography, with color Doppler, to
visualize percutaneous central line
tips when radiographs cannot deter-
mine line position. (48)
Summary
Echocardiograpy can be performed
by neonatologists who have appro-
priate training and support from pe-
diatric cardiology services. The inci-
dence of congenital heart disease is
not high among preterm infants.
Echocardiography should supple-
ment—not replace— clinical assess-
ment and acumen. Fear of missing co-
vert congenital heart disease should
not deny sick preterm infants the ben-
efit of a detailed echocardiographic as-
sessment. Extreme caution is needed
with the infant who exhibits persistent
cyanosis, and in general, a pediatric
cardiologist should be consulted.
e398 NeoReviews Vol.7 No.8 August 2006
Increasing use of echocardiogra-
phy on the neonatal unit has led to a
greater awareness of cardiovascular
function in the neonate. Minute-to-
minute management can be greatly
improved and interventions targeted
to improve function, increase vascu-
lar volume, or close the arterial duct.
References
1. Wren C. Commentary on Moss S, Kitch-
iner DJ, Yoxall CW, Subhedar NV. Evalua-
tion of echocardiography on the neonatal
unit. Arch Dis Child Fetal Neonatal Ed.
2003;88:F290 –F291
2. Skinner JR. Echocardiography on the
neonatal unit: a job for the neonatologist or
the cardiologist? Arch Dis Child. 1998;78:
401– 402
3. Skinner J. Diagnosis of patent ductus
arteriosus. Semin Neonatol. 2001;6:49 – 61
4. Moss S, Kitchiner DJ, Yoxall CW, Sub-
hedar NV. Evaluation of echocardiography
on the neonatal unit. Arch Dis Child Fetal
Neonatal Ed. 2003;88:F287–F291
5. Evans N. Echocardiography on neonatal
intensive care units in Australia and New
Zealand. J Paediatr Child Health. 2000;36:
169 –171
6. Skinner JR, Hunter S, Hey EN. Haemo-
dynamic features at presentation in persis-
tent pulmonary hypertension of the new-
born and outcome. Arch Dis Child Fetal
Neonatal Ed. 1996;74:F26 –F32
7. Osborn DA. Diagnosis and treatment of
preterm transitional circulatory compro-
mise. Early Hum Dev. 2005;81:413– 422
8. Ward CJ, Purdie J. Diagnostic accuracy
of paediatric echocardiograms interpreted
by individuals other than paediatric cardiol-
ogists. J Paediatr Child Health. 2001;37:
331–336
9. Stanger P, Silverman NH, Foster E. Di-
agnostic accuracy of pediatric echocardio-
grams performed in adult laboratories. Am J
Cardiol. 1999;83:908 –914
10. Evans N. Echocardiographic misdiag-
nosis and ultrasound skills. J Paediatr Child
Health. 2002;38:107–110
11. Katumba-Lunyenya JL. Neonatal/
infant echocardiography by the non-cardi-
ologist: a personal practice, past, present,
and future. Arch Dis Child Fetal Neonatal
Ed. 2002;86:F55–F57
12. Murdoch DR, Darlow BA. Handling
during neonatal intensive care. Arch Dis
Child. 1984;59:957–961
13. Groves AM, Kuschel CA, Knight DB,
Skinner JR. Cardiorespiratory stability dur-
ing echocardiography in preterm infants.
Arch Dis Child. 2005;90:86 – 87
14. Skinner JR, Alverson D, Hunter S.
Echocardiography for the Neonatologist.
London, England: Churchill Livingstone;
2000
15. Evans N, Malcolm G. Practical Echo-
cardiography for the Neonatologist [CD-
COM]. Sydney, Australia: Royal Prince Al-
fred Hospital; 2000
16. Walsh-Sukys MC, Tyson JE, Wright
LL, et al. Persistent pulmonary hyperten-
sion of the newborn in the era before nitric
oxide: practice variation and outcomes.
Pediatrics. 2000;105:14 –20

17. Skinner JR, Boys RJ, Heads A, Hey
EN, Hunter S. Estimation of pulmonary
arterial pressure in the newborn: study of
the repeatability of four Doppler echocar-
diographic techniques. Pediatr Cardiol.
1996;17:360 –369
18. Grant DA, Hollander E, Skuza EM,
Fauchere JC. Interactions between the right
ventricle and pulmonary vasculature in the
fetus. J Appl Physiol. 1999;87:1637–1643
19. Kluckow M. Low systemic blood flow
and pathophysiology of the preterm transi-
tional circulation. Early Hum Dev. 2005;
81:429 – 437
20. Osborn DA, Evans N, Kluckow M.
Clinical detection of low upper body blood
flow in very premature infants using blood
pressure, capillary refill time, and central-
peripheral temperature difference. Arch Dis
Child Fetal Neonatal Ed. 2004;89:
F168 –F173
21. Kluckow M, Evans N. Relationship be-
tween blood pressure and cardiac output in
preterm infants requiring mechanical venti-
lation. J Pediatr. 1996;129:506 –512
22. Tyszczuk L, Meek J, Elwell C, Wyatt
JS. Cerebral blood flow is independent of
mean arterial blood pressure in preterm in-
fants undergoing intensive care. Pediatrics.
1998;102:337–341
23. Tibby SM, Murdoch IA. Monitoring
cardiac function in intensive care. Arch Dis
Child. 2003;88:46 –52
24. Kluckow M, Evans N. Low systemic
blood flow and hyperkalemia in preterm
infants. J Pediatr. 2001;139:227–232
25. Murase M, Ishida A, Momota T. Serial
pulsed Doppler assessment of early left ven-
tricular output in critically ill very low-birth-
weight infants. Pediatr Cardiol. 2002;23:
442– 448
26. Alverson DC, Eldridge M, Dillon T,
Yabek SM, Berman W Jr. Noninvasive
pulsed Doppler determination of cardiac
output in neonates and children. J Pediatr.
1982;101:46 –50
27. Skelton R, Gill AB, Parsons JM. Refer-
ence ranges for cardiac dimensions and
blood flow velocity in preterm infants.
Heart. 1998;80:281–285
28. Hudson I, Houston A, Aitchison T,
Holland B, Turner T. Reproducibility of
measurements of cardiac output in newborn
infants by Doppler ultrasound. Arch Dis
Child. 1990;65:15–19
29. Tsai-Goodman B, Martin RP, Marlow
N, Skinner JR. The repeatability of echocar-
diographic determination of right ventricu-
lar output in the newborn. Cardiol Young.
2001;11:188 –194
30. Evans N. Current controversies in the
diagnosis and treatment of patent ductus
arteriosus in preterm infants. Adv Neonatal
Care. 2003;3:168 –177
31. Evans N, Iyer P. Incompetence of the
foramen ovale in preterm infants supported
by mechanical ventilation. J Pediatr. 1994;
125:786 –792
32. Kluckow M, Evans N. Superior vena
cava flow in newborn infants: a novel marker
of systemic blood flow. Arch Dis Child Fetal
Neonatal Ed. 2000;82:F182–F187
33. Kluckow M, Evans N. Low superior
vena cava flow and intraventricular haemor-
rhage in preterm infants. Arch Dis Child
Fetal Neonatal Ed. 2000;82:F188 –F194
34. Hunt RW, Evans N, Rieger I, Kluckow
M. Low superior vena cava flow and neuro-
development at 3 years in very preterm in-
fants. J Pediatr. 2004;145:588 –592
35. Hruda J, Rothuis EG, van Elburg RM,
Sobotka-Plojhar MA, Fetter WP. Echocar-
diographic assessment of preload conditions
does not help at the neonatal intensive care
unit. Am J Perinatol. 2003;20:297–303
36. Vieillard-Baron A, Chergui K, Rabiller
A, et al. Superior vena caval collapsibility as a
gauge of volume status in ventilated septic
patients. Intensive Care Med. 2004;30:
1734 –1739
37. Bendjelid K, Romand JA, Walder B,
Suter PM, Fournier G. Correlation between
measured inferior vena cava diameter and
right atrial pressure depends on the echocar-
diographic method used in patients who are
mechanically ventilated. J Am Soc Echocar-
diogr. 2002;15:944 –949
international perspectives
38. Skinner JR, Milligan DW, Hunter S,
Hey EN. Central venous pressure in the
ventilated neonate. Arch Dis Child. 1992;
67:374 –377
39. Evans N, Kluckow M. Early determi-
nants of right and left ventricular output in
ventilated preterm infants. Arch Dis Child
Fetal Neonatal Ed. 1996;74:F88 –F94
40. Kluckow M, Evans N. Ductal shunting,
high pulmonary blood flow, and pulmonary
hemorrhage. J Pediatr. 2000;137:68 –72
41. Martin CG, Snider AR, Katz SM, Pea-
body JL, Brady JP. Abnormal cerebral
blood flow patterns in preterm infants with a
large patent ductus arteriosus. J Pediatr.
1982;101:587–593
42. Knight DB. The treatment of patent
ductus arteriosus in preterm infants. A re-
view and overview of randomized trials.
Semin Neonatol. 2001;6:63–73
43. Laughon MM, Simmons MA, Bose
CL. Patency of the ductus arteriosus in the
premature infant: is it pathologic? Should it
be treated? Curr Opin Pediatr. 2004;16:
146 –151
44. Evans N, Iyer P. Longitudinal changes
in the diameter of the ductus arteriosus in
ventilated preterm infants: correlation with
respiratory outcomes. Arch Dis Child Fetal
Neonatal Ed. 1995;72:F156 –F161
45. Su BH, Watanabe T, Shimizu M,
Yanagisawa M. Echocardiographic assess-
ment of patent ductus arteriosus shunt flow
pattern in premature infants. Arch Dis Child
Fetal Neonatal Ed. 1997;77:F36 –F40
46. Evans N, Iyer P. Assessment of ductus
arteriosus shunt in preterm infants supported
by mechanical ventilation: effect of interatrial
shunting. J Pediatr. 1994;125:778 –785
47. Suzumura H, Nitta A, Tanaka G, Arisaka
O. Diastolic flow velocity of the left pulmo-
nary artery of patent ductus arteriosus in pre-
term infants. Pediatr Int. 2001;43:146 –151
48. Groves AM, Kuschel CA, Battin MR.
Neonatal long lines: localisation with colour
Doppler ultrasonography. Arch Dis Child
Fetal Neonatal Ed. 2005;90:F5
NeoReviews Vol.7 No.8 August 2006 e399