(BQ) Part 1 book Pediatric ultrasound presents the following contents: Theory and basics, ultrasound guided interventions, neurosonography in neonates, infants and children, ultrasound of the neck, basics of paediatric echocardiography.
Michael Riccabona Pediatric Ultrasound Requisites and Applications With contributions by Brian Coley Andreas Gamillscheg Bernd Heinzl Gerolf Schweintzger 123 Pediatric Ultrasound Michael Riccabona Pediatric Ultrasound Requisites and Applications With Contributions by Brian Coley, Andreas Gamillscheg, Bernd Heinzl, and Gerolf Schweintzger Michael Riccabona Division of Pediatric Radiology Department of Radiology University Hospital Graz Graz Austria First edition originally published by © Georg Thieme Verlag, 2000 ISBN 978-3-642-39155-2 ISBN 978-3-642-39156-9 DOI 10.1007/978-3-642-39156-9 Springer Heidelberg New York Dordrecht London (eBook) Library of Congress Control Number: 2014931858 © Springer Berlin Heidelberg 2014 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher's location, in its current version, and permission for use must always be obtained from Springer Permissions for use may be obtained through RightsLink at the Copyright Clearance Center Violations are liable to prosecution under the respective Copyright Law The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made The publisher makes no warranty, express or implied, with respect to the material contained herein Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) Preface Ultrasound (US) has become the mainstay of paediatric radiology, particularly as neonates, infants and children offer ideal scanning conditions Furthermore, with growing concern about radiation risks imposed to children for medical imaging, it has become even more important to exploit all options US may offer Numerous papers have been written on this topic focusing on the child’s increased radiation sensitivity Many campaigns have been initiated to promote radiation protection awareness throughout the world, such as the Image Gently campaign in the United States However, children will continue to need medical imaging, and when trying to avoid irradiating methods such as CT and fluoroscopy, alternative non-invasive imaging must be available Ultrasound is a relatively inexpensive, non-invasive and non-radiating imaging modality that promises to comply with all this requirements and must be promoted as the major initial modality As a consequence of this paradigm, high standard paediatric US must become available to all children in need throughout the world, 24 h a day, days a week, throughout the year When trying to support and educate people to properly perform high level paediatric US I was often asked by participants of various courses and lectures, if I know a reasonably priced comprehensive booklet that covers all main aspects of paediatric US It shouldn’t be too big, and should address not only all relevant aspects and diseases but also modern methods and must offer image examples This request came particularly from colleagues from less wealthy countries such as the Third World and Asia, but also from sonographers and technicians, students, young colleagues and residents in training, as well as paediatricians, paediatric surgeons, and radiologists who are not full time paediatric radiologists So I set out to try and create such booklet In order to achieve these goals the text had to be short - thus this book is written in a checklist like style The text is less extensive, and the legends are compact Some less important conditions and aspects are only briefly mentioned or omitted, and image examples are focused on either very common important entities or on rare but still essential conditions that should not be overlooked or mistaken (i.e., relevant for differential diagnosis) Particular emphasis has been given to new approaches that widen US potential such as perineal US, contrast-enhanced US or filling techniques, using modern equipment and routinely encompassing Doppler sonography However, basic features and rules also remain valid and important, particularly as they need to be respected and be addressed with any standard equipment; the description of those should enable the v vi Preface reader to make an US diagnosis provided careful and proper selection of adequate transducers and correct device settings is available Further and more detailed information must, however, be retrieved from respective established textbooks This project could only be realized by the help and support of Springer company, my colleagues at work, the input (and images) from my co-authors, and the patience of my partner Barbara And the enterprise was further spurred by the motivation and inspiration I got from all the children and parents I encountered during daily work, their needs and suffering, but also their gratitude or their rewarding smile I can only hope that you will find this booklet helpful for your daily needs and that it will achieve its goal, to contribute and improve access to dedicated paediatric US for all children in need, inspiring sonographers and physicians to outmost exploit US potential, to use creative approaches and apply US whenever there is an option that this might offer a diagnostic or therapeutic solution to the child’s condition Even if US is financially not as rewarding as other imaging methods, it will hopefully be rewarding in terms of diagnostic success at reduced invasiveness and without radiation burden - an aspect I particularly learned to pursue and value from my four children to whom I want to dedicate this work Graz, Austria January 2013 Prof Michael Riccabona Acknowledgements I thank my co-authors for also providing many images for the various chapters of the book, and I am furthermore particular thankful to Prof Coley for all the hard work he must have had with English editing, as well as Mrs Einspieler for typing the scripts vii Contents Theory and Basics 1.1 Ultrasound (US) Physics 1.1.1 US Waves 1.1.2 Propagation and Modulation of US 1.2 Practical Application in US Device 1.2.1 Emission, Transmission, Reception and Amplification 1.2.2 Signal Processing 1.2.3 Components of US Device 1.3 US Methods 1.3.1 A (Amplitude)-Mode 1.3.2 (T)M-Mode (Time-Motion-Mode) 1.3.3 B (Brightness)-Mode 1.3.4 Doppler Sonography 1.4 Artefacts 1.4.1 General Remarks 1.4.2 Common Artefacts 1.5 Biologic Effects 1.5.1 General Remarks 1.5.2 Thermal Effects 1.5.3 Mechanical Effects and Resonance 1.5.4 Potential Risks of Diagnostic US 1.5.5 Various Methods and Indices That Allow Estimation of Biological Risks 1.6 How to Perform Paediatric US 1.6.1 Requisites 1.6.2 Positioning 1.6.3 Device Handling 1.6.4 Transducer Selection 1.6.5 Course of Investigation and Measurements 1.7 Documentation and Interpretation 1.7.1 Image Documentation 1.7.2 Report 2 4 9 10 11 11 11 12 15 15 16 16 17 18 19 19 20 21 22 23 25 25 26 ix 174 Fig 5.8 Atrium septum defect of secundum type (ASD II) – apical four- chamber view CDS demonstrates interatrial left-to-right shunt by red colour signals crossing interatrial septum Enlarged right atrium (RA) and right ventricle (RV) with straight course of interventricular septum indicating volume overload LA left atrium 5 Basics of Paediatric Echocardiography RV RA LA level in ventricles (normally insertion of tricuspid valve more apical than of mitral valve) If AV-valve attached to crest of interventricular septum (IVS), shunting only between RA and LA possible (partial AVSD or ostium primum ASD) AV-valve regurgitation of different degrees at commissures between leaflets (“clefts”) of common AV-valve always present Size of interatrial and interventricular communications and ventricles as well as morphology of common AV-valve best evaluated in subcostal and apical four- chamber views and in parasternal short axis view Degree of AV-valve regurgitation and shunting assessed by CDS and CW-Doppler Partial AVSD (Ostium Primum ASD): • Defect only in lowest part of IAS near AV-valve in subcostal and apical four- chamber view • Left-to-right shunt only at atrial level • Variable degree of mitral valve regurgitation Complete AVSD (Fig. 5.9): • Ostium primum ASD and Inlet-VSD in the apical and subcostal four-chamber views • Interatrial, interventricular and LV-RA shunt • Common AV-valve with mitral and tricuspidal valve regurgitation 5.8.1.3 Ventricular Septal Defects (VSD) VSD – most common congenital heart defect Interventricular septum (IVS) divided into small upper membranous septum and larger muscular septum Muscular septum consists of inlet, trabecular and outlet-(infundibular) portion Most VSD located in membranous part, often adjacent muscular septum involved (“perimembranous” VSD) Muscular and subarterial (infundibular) VSD (below great arteries) less common 5.8 Pathologic Findings 175 Fig 5.9 Atrioventricular (AV) septal defect – apical four-chamber view Defects at ventricular and atrial level (→), common AV-valve LV left ventricle, LA left atrium, RA right atrium, RV right ventricle RV LV RA LA Because IVS visible not in single plane entirely, different views necessary to provide detailed information about localisation and size of defect and its relation to adjacent structures CDS improves detection of small or multiple VSDs, shows direction of shunt across defect CW-Doppler allows indirect estimation of RV systolic pressure using Bernoulli equation (systolic blood pressure minus peak pressure gradient between LV and RV = systolic RV pressure) when blood pressure measured simultaneously; the larger the defect, the lower the gradient between ventricles Hemodynamic relevance of leftto-right shunt demonstrated by degree of enlargement of LA, LV and RV and dilatation of PA due to increased pulmonary blood flow and pulmonary venous return Perimembranous VSD (Fig. 5.10): • Parasternal long and short axis views, in modified four-chamber view: defect beneath aortic valve • Sometimes associated with ventricular septal pseudoaneurysm Muscular VSD: • Parasternal long axis view: in middle third of IVS (mid muscular) or inferiorly (apical) • Parasternal short axis views: at different levels • Apical four-chamber view: inlet VSD in upper third, mid muscular VSD in middle of IVS and apical VSD in most distal part of IVS Subarterial (infundibular) VSD: • Standard long axis view: beneath aortic valve • Parasternal short axis view: beneath pulmonary valve • Often associated with aortic valve regurgitation due to prolapse of aortic valve 176 5 Basics of Paediatric Echocardiography Fig 5.10 Perimembranous ventricular septal defect (VSD) – parasternal long axis view CDS demonstrates left-to-right shunt beneath aortic valve through VSD (→) LV left ventricle, LA left atrium, Ao Aorta, RV right ventricle RV LV Ao LA a b PA PDA RPA LPA Fig 5.11 Persistent ductus arteriosus (PDA) – parasternal short axis at heart base: (a) Left-to- right shunt demonstrated by CDS (b) Shunt confirmed/further assessed by CW-Doppler spectral analysis (right image) CW-Doppler measurements: gradient of 129 mmHg indicating normal pulmonary artery (PA) pressure (peak flow velocity 568 cm/s) RPA right pulmonary artery, LPA left pulmonary artery 5.8.1.4 Patent Ductus Arteriosus of Botalli (PDA) Persistent patency of ductus arteriosus occurs in preterm infants as an isolated defect or associated with other congenital heart defects: • PDA best visualised in parasternal short axis or high left parasternal views (“ductus view”) – three vessels arise from main PA: right and left PA and PDA connecting to descending aorta (Fig. 5.11) 5.8 Pathologic Findings 177 • In pulmonary atresia: atypical course of PDA arising from aortic arch, best detected on suprasternal long axis view • Large PDA: LA and LV enlarged due to increased pulmonary blood flow CDS and CW-Doppler demonstrate direction of shunt: • Normal systolic pulmonary pressure – left-to-right shunt, continuous flow from aorta to PA (towards transducer) • Pulmonary hypertension – bidirectional shunt • Severe left heart obstructions – right-to-left shunt Systolic PA pressure calculated by Bernoulli equation (systolic blood pressure minus peak Doppler pressure gradient = systolic pulmonary artery pressure) when simultaneously measuring blood pressure 5.8.1.5 Persistent Truncus Arteriosus (Truncus Arteriosus Communis) Parasternal long axis view: single artery (truncus) overriding a large VSD The single truncal valve (occasionally with four cusps) and type of origin of PA from truncus best demonstrated in parasternal short axis view at base of the heart 5.8.2 Obstructions of Left Ventricular Outflow 5.8.2.1 Aortic Valve Stenosis (AS) Morphology of aortic valve including number of cusps best evaluated in parasternal short axis view - at base of the heart (Fig. 5.12) Stenotic aortic valve often consists only of two cusps (occasional only one cusp) creating “fish-mouth shape” of valve in systole Parasternal long axis view enables measurement of valve diameter, shows restricted opening of thickened cusps resulting in dome shape of valve in systole Poststenotic dilatation of ascending aorta frequently seen Depending on severity of AS hypertrophy of LV demonstrated CDS in parasternal long axis, subcostal and suprasternal views demonstrate highvelocity jet into ascending aorta – occasionally associated with aortic regurgitation • Measurements of peak and mean Doppler pressure gradients using different views (suprasternal, subcostal) allow estimation of severity –– Critical AS of newborn: LV cavity and aortic annulus small with echogenic thickened endocardium presenting endocardial fibroelastosis If LV dilated and contractility reduced: low-pressure gradient measured – low cardiac output 5.8.2.2 Subaortic Stenosis (Sub AS) Parasternal long axis, apical and subcostal views: fibrous membrane just below aortic valve or tunnel-like narrowing of left ventricular outflow tract detected (DDx asymmetric hypertrophic cardiomyopathy) Aortic valve regurgitation often seen • Sub AS may be associated with multiple left heart obstructions (“Shone complex”) 178 5 Basics of Paediatric Echocardiography Fig 5.12 Valvular aortic stenosis – parasternal long axis view Aortic valve leaflets thickened (→), hypertrophy of left ventricle (LV) Ao aorta Ao LV 5.8.2.3 Supravalvular Aortic Stenosis Circumscribed stenosis or long hypoplastic segment of ascending aorta visualised in parasternal, apical and subcostal long axis and suprasternal views Rare anomaly, associated frequently with Williams-Beuren syndrome 5.8.2.4 Aortic Coarctation (CoA) CoA best evaluated from suprasternal notch in supine position with hyperextended neck Suprasternal long axis view (Fig. 5.13): entire aortic arch must be imaged, because occasionally aortic arch may be hypoplastic – particularly in neonates Short stenosis or longer hypoplastic segment demonstrated near origin of left subclavian artery CDS shows high-velocity jet distal to CoA CW-Doppler measurements reveal increased flow extended into diastole and distal to CoA allows calculation of pressure gradient LV may be hypertrophied • In neonates LV function may be severely depressed – PDA-dependent systemic perfusion 5.8.2.5 Interrupted Aortic Arch Exact site of interruption, origin of aortic arch vessels from proximal and distal segments of aorta - best demonstrated in suprasternal long axis view PDA with right-to-left shunt provides systemic perfusion distal to interruption Additional congenital heart defects common (e.g VSD or persistent truncus arteriosus) 5.8 Pathologic Findings 179 a b CoA Fig 5.13 Coarctation of aorta (CoA) – suprasternal view (a) Hypoplastic isthmus with turbulent blood flow (→) on CDS (b) CW-Doppler measurement: increased flow velocity with characteristic flow pattern extended into diastole 5.8.3 Obstructions of the Right Ventricular Outflow 5.8.3.1 Isolated Pulmonary Valve Stenosis (PS) Pulmonary valve best evaluated in parasternal short axis (Fig. 5.14), parasternal long axis through right ventricular outflow tract, and subcostal views Commonly pulmonary valve diameter normal, valvular cusps thickened with restricted opening and systolic doming, usually poststenotic dilatation of main PA RV usually normal, may be hypertrophic – in particular at infundibulum • Patients with Noonan syndrome and PS: pulmonary valve often dysplastic, with myxomatous changes of leaflets • Neonates with critical PS: pulmonary valve annulus hypoplastic with reduced RV cavity; pulmonary blood supply may be dependent on PDA –– CDS: high-velocity jet distal to pulmonary valve –– CW-Doppler: estimates pressure gradient 5.8.3.2 Subvalvular Pulmonary Stenosis Fibromuscular stenosis at infundibulum or anomalous muscle band below infundibulum dividing RV into two chambers (“double-chambered right ventricle”) Seen on subcostal four-chamber view or subcostal long axis view of RV Associated congenital heart defects common 5.8.3.3 Supravalvular Pulmonary Stenosis Circumscribed stenosis or longer hypoplastic segments in main PA or pulmonary branches Best visualised on parasternal short axis and subcostal views • Associated with other congenital heart defects, rubella or Williams-Beuren syndrome 180 5 Basics of Paediatric Echocardiography Fig 5.14 Pulmonary valve stenosis – parasternal short axis view High-velocity mosaic jet on CDS distal to pulmonary valve Ao Aorta, PA main pulmonary artery PA Ao 5.8.3.4 Tetralogy of Fallot (TOF) and Pulmonary Atresia (PA) with VSD • TOF – most common cyanotic congenital heart defect • Characterised by large VSD with overriding aorta, RV outflow tract obstruction, RV hypertrophy Pulmonary valve annulus, main PA and PA branches usually hypoplastic to different degrees (Fig. 5.15) Pulmonary valve leaflets may be thickened with systolic doming • PA with VSD – most extreme type of TOF Pulmonary blood supply provided via PDA or multiple aortopulmonary collateral arteries arising from aorta or arch arteries • Large subaortic VSD with overriding aorta – best imaged in parasternal long axis view • Parasternal and subcostal short axis views, long axis view through RV outflow tract: evaluate degree of subpulmonic stenosis, morphology, and size of pulmonary valve, size of the main PA • Parasternal short axis and suprasternal views: demonstrate PA bifurcation, size of PA branches and PDA, occasionally right aortic arch • CDS: high-velocity jet in RV outflow tract – usually beginning below pulmonary valve (infundibulum), predominant right-to-left shunt via VSD • CW-Doppler: estimates pressure gradient across RV outflow tract –– PA with VSD: no pulmonary valve seen, blind end of RV outflow tract, no antegrade flow into main PA 5.8 Pathologic Findings 181 Fig 5.15 Tetralogy of fallot – parasternal long axis view Large ventricular septal defect (→) with overriding aorta (Ao) RV right ventricle, LV left ventricle RV LV Ao 5.8.4 Miscellaneous Congenital Heart Defects 5.8.4.1 Transposition of Great Arteries (TGA) Simple TGA - ventriculoarterial discordance: aorta arises anteriorly from RV, PA posteriorly from LV In contrast to normal heart (crossing of great arteries) great arteries exit from heart in parallel course Systemic and pulmonary circulation connected in parallel (instead of normal serial connection); survival depends on communications between circulations (commonly PDA, PFO/ASD in patients with an intact IVS or VSD) Parallel course of the great arteries demonstrated in parasternal short and long axis and in suprasternal long axis views (Fig. 5.16) Parasternal long axis and suprasternal views: both arteries seen in longitudinal section The aorta and aortic arch branches lay anteriorly to PA In parasternal short axis view, great arteries seen in cross section as double circles; posterior artery – pulmonary artery (identified by demonstrating bifurcation into left and right PA) Subcostal four-chamber view: connection of LV to PA with its bifurcation seen, whereas aorta with aortic arch arises from RV (Fig. 5.17) Coronary artery origin from aortic sinuses best evaluated in parasternal short axis view CDS reveals information about amount of mixing via PDA, PFO/ASD or both Associated anomalies common: VSD, CoA, LV outflow obstruction (i.e pulmonary stenosis) 5.8.4.2 Total Anomalous Pulmonary Venous Return (TAPVR) Different Forms: • Cardiac type: all PV drain directly (or via coronary sinus) into RA 182 5 Basics of Paediatric Echocardiography Fig 5.16 Transposition of great arteries (TGA) – suprasternal view Parallel alignment of great arteries with Aorta (Ao) anteriorly and main pulmonary artery (PA) posteriorly Aa PA Fig 5.17 Transposition of great arteries (TGA) – subcostal view Main pulmonary artery (PA) with its bifurcation arising from left ventricle (LV) RV right ventricle RV LV PA • Supracardiac type: all PV form pulmonary venous confluence draining into SVC via left innominate vein; pulmonary venous confluence may be visualised posteriorly to LA without direct communication • Infracardiac or subdiaphragmatic type: all PV drain into IVC, portal vein, hepatic vein or ductus venosus – large vessel passing below diaphragm with venous flow away from heart/chest ASD or PFO with right-to-left shunt mandatory for survival RV, RA and main PA enlarged, whereas LA and LV normal or small • In cases with small PFO: IAS bulged to left Dependent on site of pulmonary venous drainage: dilated coronary sinus, innominate vein/SVC, or IVC CDS: exclude obstruction of pulmonary venous return 5.8 Pathologic Findings 183 5.8.4.3 Univentricular Heart (UVH) UVH summarises wide spectrum of complex congenital heart defects with one large dominant ventricle and a small rudimentary ventricular chamber Various congenital heart defects often associated (e.g VSD, ASD, PDA, TGA, PS or PA, CoA, systemic and pulmonary venous anomalies, situs anomalies) Echocardiographic evaluation of UVH: • Include morphology and site of dominant and rudimentary ventricle/ventricular chamber • Assess type and size of communication between atria and ventricles, interventricular and interatrial communications and ventriculoarterial connecxions • Assess presence of obstructions of ventricular outflow • Assess other associated anomalies Many Different forms – Most Common Examples: Double Inlet Left Ventricle: • Both AV-valves drain into large morphological LV • Rudimentary (right) chamber communicates with LV via VSD • Usually PA arises from LV, aorta from rudimentary ventricle (TGA) Tricuspid Atresia: • No tricuspid valve • Systemic venous blood flows from RA via ASD/PFO to LA which drains into large LV • Hypoplastic RV communicates via VSD with LV • Great arteries may be transposed – aorta arising from hypoplastic RV, PA from LV Hypoplastic Left Heart Syndrome: • LA and LV hypoplastic – with small or even atretic mitral and aortic valves • Hypoplastic ascending aorta • Large RV acts as systemic ventricle • LA drains into RA via ASD or PFO • Systemic perfusion dependent on PDA – retrograde flow into hypoplastic ascending aorta 5.8.4.4 Double Outlet Right Ventricle (DORV) Aorta and PA arise completely or predominantly from RV The usually normal sized LV empties via VSD into RV Wide anatomic variability of DORV regarding site of VSD and relationship of great arteries (normal or side-by-side position, TGA), PS frequently associated 5.8.4.5 Ebstein Anomaly Inferior displacement of proximal attachments of septal and posterior tricuspid valve leaflets • Best demonstrated in four-chamber views • Depending on degree of inferior displacement: large RA, small functioning RV (“atrialisation of RV”) 184 5 Basics of Paediatric Echocardiography CDS, CW/PW-Doppler: evaluate severity of tricuspid valve regurgitation, rightto-left shunt via ASD or PFO nearly always present 5.8.4.6 Cor Triatriatum Fibromuscular membrane with small hole divides LA in posterior and anterior chamber Imaged in apical and subcostal four-chamber view and parasternal long axis views Due to higher pressure in posterior chamber which receives pulmonary venous return, membrane bulged toward mitral valve during diastole 5.9 Acquired Paediatric Heart Diseases 5.9.1 Cardiomyopathies (CMP) 5.9.1.1 Hypertrophic CMP US feature: commonly impressive thickening in particular of IVS and – to a lesser degree – of LV posterior wall End-diastolic LV diameter usually normal, but end-systolic LV diameter reduced Shortening and ejection fraction of LV usually normal or increased 5.9.1.2 Hypertrophic Obstructive CMP (HOCMP) Subaortic obstruction caused by hypertrophy of IVS and systolic anterior motion of anterior mitral leaflet (Fig. 5.18) 5.9.1.3 Dilated (Congestive) CMP LV and LA dilated – with significantly decreased systolic LV function Mitral regurgitation common – due to dilatation of mitral valve annulus Occasionally thrombus visible in LV and/or LA Sometimes endocardial fibroelastosis – particularly in infants 5.9.1.4 Restrictive CMP Rare; ventricles usually show normal size with normal systolic function Atria excessively dilated due to severely impaired diastolic ventricular filling 5.9.2 Acute Myocarditis US findings: ventricles and atria may be enlarged, with reduced contractility particularly of LV 5.9.3 Acute (Infective) Endocarditis Intracardiac vegetations may be demonstrated (Fig. 5.19) • TEE increases sensitivity in detecting vegetations not seen transthoracically Occasionally paravalvular abscess can be detected Valve disruption may lead to valve insufficiency 5.9 Acquired Paediatric Heart Diseases Fig 5.18 Hypertrophic obstructive cardiomyopathy – parasternal long axis view Massive hypertrophy (↔) of interventricular septum (IVS) and left ventricular posterior wall (LVPW) LA left atrium, Ao Aorta 185 IVS AO LVPW LA Fig 5.19 Endocarditis – apical fourchamber view Endocarditic vegetation attached to mitral valve (→) LA left atrium, LV left ventricle LV LA 5.9.4 Pericarditis/Pericardial Effusion US findings: anechoic space surrounding (and compressing) heart (Fig. 5.20) Compression of RA and RV wall indicates beginning tamponade 5.9.5 Kawasaki Disease Associated with coronary artery aneurysms or ectatic coronary arteries: • From second week of illness • Best seen in parasternal short axis view at base of heart • Pericardial effusion, valve regurgitations and LV dysfunction common • Follow-up studies mandatory – particularly in patients with coronary artery involvement 186 5 Basics of Paediatric Echocardiography Fig 5.20 Pericardial effusion with tamponade – apical four-chamber view Significant compression of heart by anechoic surrounding pericardial fluid (—) LV left ventricle, LA left atrium, RV right ventricle, RA right atrium LV RV RA LA 5.9.6 Intracardiac Thrombi In children, intracardiac thrombi mainly associated with intravascular catheters, dilated CMP, atrial dilatation (atrial flutter or fibrillation) and prosthetic valves 5.9.7 Cardiac Tumours Primary tumours of heart – rare in infants and children, most of them benign: • Rhabdomyoma: homogenous, echo-bright mass(es) in both ventricles and highly associated with tuberous sclerosis • Fibroma: predominantly single intramuscular tumour of left ventricle • Myxoma: globular and heterogenous tumours, usually attached to atrial septum When tumour found: • Exact evaluation of entire heart - to rule out multiple lesions • Evaluation of hemodynamic consequences (e.g congestive heart failure or valve obstruction) • Evaluate for systemic condition; sometimes additional imaging needed 5.10 Complementing Investigations 5.10.1 Cardiac Catherisation and Angiography Diagnostic cardiac catheter angiography necessary if: • Exact hemodynamic evaluation essential (shunt volume, pulmonary pressure/ resistance…) 5.11 When to Do What 187 • Echocardiographic assessment of morphology (e.g lung perfusion, coronary anatomy) not satisfying • In most cases of congenital heart disease, preoperative echo sufficient – diagnostic catheterisation not needed • Today role has changed: Over 50 % of cardiac catheterisations in children are therapeutic interventional procedures 5.10.2 Cardiac MRI and CT • • • • • Have become more important during the last two decades Can provide additional morphologic and functional information Can provide more detailed topographic relation to other intrathoracic structures 3D reconstruction helpful in preoperative evaluation of complex anatomy Carefully select indications 5.11 When to Do What 5.11.1 Imaging in Typical Clinical Scenarios 5.11.1.1 Typical Orientating Examination Particularly in newborns and infants in emergency situation or in (N)ICU e.g echocardiographic differential diagnosis of a cyanotic newborn, echocardiographic evaluation of critically ill child • Most relevant malformations easily depictable • Always include apical four-chamber view and view at IVC entrance to RA in every US of upper abdomen • Include transabdominal/apical heart view during FAST in ER (e.g pericardial effusion, poor contractility) • Typical course of basic orienting investigation and minimal requirements for orienting assessment –– Start with apical and/or subcostal four-chamber view –– Continue through parasternal long and short axis –– End with suprasternal view of the aorta 5.11.1.2 Typical Clinical Queries • Child with murmur: clinical examination and echocardiography • Child with cyanosis: clinical examination and echocardiography • Child with syncope: clinical examination, exact history; echocardiography only necessary in case of pathologic ECG or murmur • Child with chest/heart pain and sensations: clinical examination, ECG and echocardiography NOTE: Cardiac reasons for chest pain rare in children 188 5 Basics of Paediatric Echocardiography 5.11.2 Trauma and Emergency In chest trauma – orientating four-chamber view often sufficient: • Assess global function • Rule out pericardial effusion • Severe traume = indication for ce-CT(A) ... 19 5 19 6 19 6 19 8 19 8 19 8 19 8 200 200 2 01 2 01 202 202 203 203 203 204 205 206 207 208 208 210 210 210 211 211 213 214 214 214 214 215 215 216 216 217 217 217 218 218 218 Contents xv... 84 87 92 92 94 98 98 10 0 10 5 10 7 11 4 11 9 12 2 12 2 12 2 12 2 12 3 12 3 12 3 12 3 12 3 12 4 12 4 12 4 12 4 12 4 12 4 12 5 12 7 12 7 12 7 12 7 xii Contents 3.7.4 3.7.5 3.7.6 3.7.7 3.7.8 3.7.9 3.7 .10 Normal Findings... 5 .11 .1 Imaging in Typical Clinical Scenarios 5 .11 .2 Trauma and Emergency 17 2 17 2 17 2 17 2 17 2 17 2 17 3 17 3 17 7 17 9 18 1 18 4 18 4 18 4 18 4 18 5 18 5 18 6 18 6 18 6