Functional echocardiography in neonatal intensive care: 1-Year experience in a unit in Spain

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Corredera, M.J. Rodríguez, P. Arévalo, B. Llorente, M. Moro, L. Arruza" "autores" => array:6 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Corredera" ] 1 => array:2 [ "nombre" => "M.J." "apellidos" => "Rodríguez" ] 2 => array:2 [ "nombre" => "P." "apellidos" => "Arévalo" ] 3 => array:2 [ "nombre" => "B." "apellidos" => "Llorente" ] 4 => array:2 [ "nombre" => "M." "apellidos" => "Moro" ] 5 => array:4 [ "nombre" => "L." "apellidos" => "Arruza" "email" => array:1 [ 0 => "luisarruza@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Neonatología, Hospital Clínico San Carlos, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ecocardiografía funcional en cuidados intensivos neonatales: experiencia en una unidad española a lo largo de un año" ] ] "textoCompleto" => "IntroductionThe newborn may have a variety of haemodynamic problems with a variable and complex pathophysiology, that at times have limited clinical manifestations. This cardiovascular vulnerability stems from particular features of the newborn, such as incomplete myocardial development, the presence of foetal shunts, changes in systemic and pulmonary vascular resistance, and more generally the complex haemodynamic changes that take place during transition to extrauterine life.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Despite progressive technological advances in neonatal intensive care, in most cases haemodynamic monitoring in newborns is still based on assessment of continuous heart rate, blood pressure (BP), acid–base status, urine output, or poorly validated clinical signs such as capillary refill time.<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a> While these measures provide important and useful information to the clinician, they are just variables associated in varying degrees to tissue perfusion, which is the key haemodynamic parameter, and for which an adequate monitoring method has yet to be developed.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> One potentially interesting option would be measurement of regional oxygen saturation by means of near-infrared spectroscopy, although further research is required to confirm this.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> Many publications have demonstrated that the correlation between BP and cardiac output is weak.<a class="elsevierStyleCrossRefs" href="#bib0015">3,6</a> It is not uncommon to find situations in which BP is normal and peripheral blood flow is below normal range. This can have important implications, as low peripheral blood flow in the first hours of life has been associated with the development of brain damage and neurodevelopmental abnormalities in premature infants.<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a> On the other hand, there is no clear definition of what constitutes a normal BP in newborns.<a class="elsevierStyleCrossRefs" href="#bib0045">9,10</a> The use of clinical assessment and the classic parameters mentioned before to elucidate the underlying pathophysiology in haemodynamic disturbances can lead to incorrect assumptions and therapeutic decisions, which may even cause harm.<a class="elsevierStyleCrossRef" href="#bib0055">11</a>In the neonate, echocardiography is commonly performed by a cardiologist to assess structure and function of the heart. Usually, a single study is done to rule out congenital heart disease or global myocardial dysfunction, and the time at which it is performed often depends on the availability of a cardiologist. This can be an important factor in units that have limited access to a cardiologist, or in situations in which serial assessment is needed to evaluate response to treatment or the haemodynamic changes that take place during transition from foetal to postnatal circulation. It is important to consider that these changes can be very different from what might be assumed clinically based on conventional assessment.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Functional echocardiography, or neonatologist-performed cardiac ultrasound, depending on the terminology suggested by different authors,<a class="elsevierStyleCrossRefs" href="#bib0010">2,12</a> is being introduced progressively in neonatal intensive care units (NICU) as a tool to help guide treatment choices. Functional echocardiography (FnECHO) adds to the assessment of classic clinical parameters in an attempt to provide individualised treatment based on the specific pathophysiology at hand. It must be used as an adjunct to clinical assessment and not as a substitute for assessment by a cardiologist, as their purposes are different and complementary. The neonatologist can use FnECHO to obtain information about haemodynamic function in real time and to make longitudinal assessments as needed.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> The aims of FnECHO are assessment of myocardial function, systemic and pulmonary blood flow, intracardiac and extracardiac shunts, and tissue perfusion.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> Functional echocardiography is commonly used to assess haemodynamic status during the transition from foetal to postnatal circulation in the extremely premature neonate, to assess for the presence and significance of PDA, to determine the underlying pathophysiology in patients with haemodynamic instability, and in neonates with high oxygen requirements.<a class="elsevierStyleCrossRefs" href="#bib0010">2,13–15</a> It has shown a positive impact on the management of adult patients.<a class="elsevierStyleCrossRefs" href="#bib0080">16–18</a> However, there is no clear evidence associating the use of FnECHO with improved outcomes of neonates admitted to the NICU, although some publications show a positive effect in this regard.<a class="elsevierStyleCrossRefs" href="#bib0055">11,19,20</a> As far as we know, there are no publications on the use of FnECHO in Spanish NICUs. We present the results of a retrospective study on the use of FnECHO in a Spanish NICU during a 1-year period, in which we analysed frequency of FnECHO use, type of patient receiving it, indications for FnECHO, and effects on the management of patients.MethodsWe performed a retrospective study of every FnECHO done in newborns admitted to the NICU of the Hospital Clínico San Carlos of Madrid between January 2012 and January 2013. This 11-bed unit provides treatment for all types of neonatal disease except for heart surgery and ECMO (Level IIIB). All the studies were performed at the request of the physicians in charge by 2 NICU neonatologists (AC and LA) that have more than 5-year experience in FnECHO. The ultrasound assessments and measurements were performed according to a standardised procedure that has been previously described and is presented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<a class="elsevierStyleCrossRefs" href="#bib0065">13,21</a> The indications for the ultrasound scans and their results were documented in the medical record of each patient. When an ultrasound was done, the results were discussed with the physicians in charge to decide on the therapeutic approach.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>We collected the following general data on patients: gestational age (GA), birth weight, and principal diagnosis. The following clinical data were recorded from the ultrasound tests: heart rate, presence of a murmur, presence of a gradient between preductal and postductal haemoglobin oxygen saturation >10%, mean BP (MBP; mmHg), lactate levels (mmol/L) and presence of oliguria (diuresis <1ml/kg/h).The data about the echocardiographic examinations included: days of life at the time of examination, number of ultrasound studies per patient, and indication for examination. We documented whether the results of FnECHO led to treatment modification, and if so, what changes were made. Our analysis excluded ultrasound examinations performed in newborns with a suspected or confirmed structural congenital cardiopathy (CC). Although neonatologist-performed FnECHO, our unit is also used to localise catheters, assess for the presence of pleural effusion and its evacuation, the study of brain blood flow, or screening for gross brain injury, our study only took into account echocardiographic examinations.Analysed ultrasound parameters: all echocardiograms were done with a portable ultrasound machine with a neonatal probe (Titan, SonoSite Inc., Bothell, USA, probe C11/5–8MHz): (1) assessment of ductus presence/consequences: presence, diameter in colour or 2D Doppler; shunt direction, ratio of left atrium to aorta, ductal Doppler pattern; (2) assessment of myocardial function and systemic blood flow: ejection fraction (EF), shortening fraction (SF), left ventricle (LV) and right ventricle (RV) cardiac output, superior vena cava blood flow and (3) assessment of pulmonary hypertension: calculation of pulmonary artery pressure in the presence of tricuspid regurgitation, interventricular septal shape, shunt direction.Qualitative variables are expressed as absolute and relative frequencies, and quantitative variables as mean±standard deviation or median and interquartile range in case of asymmetrical distribution or high dispersion of the data. We used the statistical package STATA 12 to do the analysis.ResultsA total of 168 ultrasound examinations were performed in 50 patients during the period under study, with a mean of 3.4±2.83 examinations per patient. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the general characteristics of the patients. The mean GA of the patients was 31.3 weeks, with a range of 24.1–40.2 weeks, and the mean birth weight was 1549g (590–4160g). Seventy percent of patients were born before 32 weeks of gestation. The most frequent admission diagnosis was extreme prematurity and/or extremely low weight at birth (38%). Very low birth weight occurred in 34% of the patients (1000–1500g). Other principal diagnoses (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>) at the time of admission were hypoxic ischaemic encephalopathy to be treated with hypothermia (10%), respiratory distress syndrome (8%), transient tachypnoea (6%) and other (4%). The median days of life at the time of ultrasound examination was 6 days (2–19 days). The most frequent indication for echocardiography was assessment of the presence and significance of PDA, accounting for 58.3% of examinations (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>). Other indications included haemodynamic instability (22.2%), presence of heart murmur (8.3%), assessment of transition from foetal to postnatal circulation in extremely preterm neonates (5.4%), pulmonary hypertension screening (1.2%), and other (4.8%). As for the impact of FnECHO on patient management, the echocardiography results led to treatment modification in 62 patients (36.9%). The most common modifications involved the management of PDA. Thus, treatment with ibuprofen was initiated in 17.4% of patients following the ultrasound test, while in 1.2% of patients treatment with this drug was discontinued early. As for haemodynamic support, ultrasound results led to changes in the management of 10.8% of the patients. The changes involved volume expansion therapy (0.6%), initiation or modification of inotropic therapy (9.6%) or initiation of hydrocortisone therapy (0.6%). Out of all ultrasound scans, 36.3% were done in patients who had no murmur, arterial hypotension, oliguria, increased lactate levels, tachycardia, or presence of an oxygen saturation gradient. Of all these examinations, 21.7% corresponded to routine studies in the early days of life. Another 78.3% were follow-up studies in patients who had been previously assessed. In 14 of these ultrasounds (22.9%) the results led to a modification of treatment. Twelve corresponded to PDA. The analysis of echocardiography parameters included the assessment of the presence and significance of PDA in 100% of the patients. Myocardial function was assessed by means of the EF/FA ratio in 23.8%, LV output in 24.4% and RV output in 21.4% of patients. Systemic blood flow in the superior vena cava was measured in 42% of the examinations. The presence of pulmonary hypertension was assessed in 7.7% of patients.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia>DiscussionThis study is the first to describe the use of FnECHO in a Spanish NICU. The results suggest that this technique is used frequently and that it leads to treatment modification in a significant percentage of cases. A similar study published recently describes the performance of 512 FnECHOs in a Canadian unit over a period of 3.5 years, which works out at an average of 142 examinations a year, a figure that is very close to the one described in this work of 168 examinations in 12 months.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> That study also observed an increasing use of this technique during the period under analysis, which confirms the interest in FnECHO and its progressive implantation in neonatology units. A survey-based study shows that as early as 10 years ago 41% of the level 3 neonatology units in Australia and New Zealand had at least 1 neonatologist with FnECHO skills.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> This figure had increased by more than 90% in 2010.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> The neonatologist in our unit started to use FnECHO 10 years ago and used it mostly as a diagnostic tool and to monitor response to treatment of PDA. Since then, the range of indications has increased to the point that it has nearly turned into an additional part of the clinical assessment of haemodynamic disturbances. According to our study, the most frequent indication for FnECHO is diagnosis or monitoring of PDA (58.3% of patients), followed by assessment of pathophysiology underlying haemodynamic instability (22.2%). This is consistent with the data of the study by El-Kuffash et al., in which PDA assessment amounted for 51% of FnECHO indications.<a class="elsevierStyleCrossRef" href="#bib0110">22</a>In our study, the results of 36.9% of FnECHO examinations led to changes in the management of the patient, a figure that is very close to the one reported by El-Kuffash, with a 41% rate of management changes following the ultrasound examination.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> Studies in adults suggest that FnECHO results in treatment changes in up to 51.4% of patients.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> This supports the definition of FnECHO as a tool that guides therapeutic decision making. In the study presented here, 36.3% of the ultrasounds were performed in patients with no other abnormal haemodynamic parameters or heart murmur, despite which the management of 22.9% of them changed after the examination. Almost all of these patients had PDA. We already mentioned that FnECHO findings are not always predictable based on traditional clinical assessment.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Thus, El-Kuffash et al. found 6% of unexpected diagnosis.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> In fact, in FnECHO study performed in adult intensive care units, previously undetected severe abnormalities were found in up to 7.5% of patients.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> In our study, an average of 3.4 ultrasounds were made per patient, with some patients receiving up to 16 ultrasounds. This shows how FnECHO can be used for patient follow-up or to monitor response to treatment.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>While it is clear that this technique is useful in practise, strong evidence of the positive impact of the use of FnECHO in the NICU on patient outcomes is still lacking. But several retrospective studies<a class="elsevierStyleCrossRefs" href="#bib0055">11,19,20</a> and a few clinical trials<a class="elsevierStyleCrossRef" href="#bib0130">26</a> suggest that FnECHO is beneficial in this way. In any case, randomised studies need to be performed to see whether the FnECHO has an effect on patient outcomes.The main controversy surrounding performance of echocardiography by a neonatologist is based on the potential danger of missing a CC or making an incorrect diagnosis and starting the wrong treatment in a patient with CC. However, while this is a real danger, in most cases an existing structural cardiopathy is detected by FnECHO, even if a complete diagnostic assessment is not made.<a class="elsevierStyleCrossRefs" href="#bib0135">27,28</a> Either way, cardiologists and neonatologists must work in close collaboration, and a cardiology consult must be requested whenever there are doubts. Adequate training in FnECHO is essential to minimise these risks.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Yet, despite the increasingly widespread use of this technique worldwide, many countries, including Spain, do not have a standardised training programme. In this case, training depends on personal interest, is performed at the same time as the working routine and relies on the collaboration of the cardiologists and/or the availability of specific materials like text books or CDs.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> This has been how training in FnECHO has been done in our unit, and it would not have been possible without the collaboration of paediatric cardiologists who understood that this technique is used by the neonatologist as an adjunct in clinical assessment, and not an intrusion in their field. Other countries like Australia, New Zealand, the United States, Canada, and some European countries have accredited training programmes.<a class="elsevierStyleCrossRefs" href="#bib0065">13,29,30</a> The American Society of Echocardiography, in collaboration with the European Association of Echocardiography and the Association for European Pediatric Cardiologists, has recently published specific recommendations for the training of neonatologists in FnECHO, which explain in detail what the training and accrediting process should entail,<a class="elsevierStyleCrossRef" href="#bib0065">13</a> recommendations that have been modified by other authors.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> Given the growing interest in this technique and its widespread use, training and accreditation programmes should be developed in Spain with the support of the Sociedad Española de Neonatología (Spanish Society of Neonatologists).There are several limitations to this study, most of which derive from its retrospective nature. For instance, treatment modification following FnECHO ultimately depended on the decision of the physician in charge of the patient, and not only on the data obtained from the ultrasound, which may have affected the perceived influence of this technique on the management of neonates, making it smaller or greater than it is. On the other hand, this study cannot determine whether therapeutic choices would have been different if FnECHO had not been available, nor whether those choices were the correct ones. Furthermore, the very decision of performing the ultrasound test, or not, also rested with the physician in charge rather than being determined by a study protocol, which could have a considerable effect on the observed frequency of use. Also, the echocardiographic view may constitute an important limitation in some patients.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> Although this study did not collect information on this variable in a systematic manner, technical limitations associated to the view and the use of a 5–8MHz probe rather than a probe with a higher frequency (8–12MHz), which would be ideal, may have affected the quality of some of these ultrasound studies.<a class="elsevierStyleCrossRef" href="#bib0065">13</a>ConclusionsFunctional echocardiography is a useful tool employed widely in the NICU. It provides complementary information that aids in making therapeutic decisions. Its use is spreading in neonatology units, although clinical trials need to be done to assess its impact on patient outcomes. Structured training and accreditation programmes based on existing recommendations need to be developed to ensure the correct and safe use of this technique.Conflicts of interestThe authors have no conflicts of interests to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres369686" "titulo" => array:6 [ 0 => "Abstract" 1 => "Introduction" 2 => "Objectives" 3 => "Methods" 4 => "Results" 5 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec348846" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres369685" "titulo" => array:6 [ 0 => "Resumen" 1 => "Introducción" 2 => "Objetivo" 3 => "Métodos" 4 => "Resultados" 5 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec348845" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-09-10" "fechaAceptado" => "2013-11-25" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec348846" "palabras" => array:4 [ 0 => "Functional echocardiography" 1 => "Newborn" 2 => "Intensive care unit" 3 => "Point-of-care ultrasound" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec348845" "palabras" => array:4 [ 0 => "Ecocardiografía funcional" 1 => "Recién nacido" 2 => "Cuidados intensivos neonatales" 3 => "Ecografía en el punto de la asistencia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "IntroductionSeveral publications highlight the usefulness of functional echocardiography (FnECHO) in neonatal intensive care. Data are lacking on its use in neonatal units in Spain. ObjectivesTo evaluate frequency of use, patient characteristics, indications, measurements, and impact on patient management of FnECHO in a neonatal intensive care unit (NICU) in Spain over a 1-year period. MethodsA retrospective study conducted in NICU patients during 1 year. Variables: gestational age, birthweight, admission criteria, days of life at examination, indication for FnECHO, parameters assessed, and treatment modifications. Results168 echocardiographic studies were performed in 50 patients (mean 3.4; SD 2.83). The most frequent indication was patent ductus (PDA) assessment (58.3%), followed by haemodynamic instability (22.2%). The results of FnECHO modified treatment in 62 cases (36.9%). In 17.4% of them treatment with ibuprofen was initiated, and in 1.2% it was discontinued. In 10.8% of the cases, the results of FnECHO modified haemodynamic support. Echocardiographic evaluation included: assessment of presence/haemodynamic significance of PDA (100%); myocardiac function: ejection fraction/shortening fraction (EF/SF) 23.8%, left ventricular output 24.4%, right ventricular output 21.4%, systemic blood flow 42.3%; and signs of pulmonary hypertension 7.7%. ConclusionsFnECHO is frequently used in the NICU, and in many cases it guides treatment. PDA assessment and haemodynamic instability are the most frequent indications. It still needs to be elucidated if the use of FnECHO modifies patient outcomes." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "IntroducciónNumerosas publicaciones destacan la utilidad de la ecocardiografía funcional (EcoFn) en neonatología. No existen datos sobre su uso en unidades españolas. ObjetivoEvaluar la frecuencia de uso, pacientes, indicaciones, mediciones y repercusión sobre el tratamiento de la EcoFn en un año en una unidad de cuidados intensivos neonatales (UCIN) española. MétodosEstudio descriptivo retrospectivo en pacientes ingresados en UCIN en un año. Variables: edad gestacional, peso, diagnóstico principal, días de vida en el momento del estudio, indicación, parámetros medidos y modificaciones del tratamiento. ResultadosSe realizaron 168 ecografías en 50 pacientes, con una media ± desviación estándar de 3,4 ± 2,83 por paciente. Las indicaciones más frecuentes fueron la valoración del ductus (58,3%) seguida de la inestabilidad hemodinámica (22,2%). El resultado de la ecografía modificó el tratamiento en 62 casos (36,9%). En un 17,4% se inició tratamiento con ibuprofeno y en un 1,2% de los casos se adelantó el fin de este. En un 10,8% de los casos, la ecografía modificó el soporte hemodinámico. Los parámetros principales valorados fueron: valoración de presencia/repercusión del ductus 100%; función miocárdica: fracción de eyección/acortamiento 23,8%, gasto ventrículo del izquierdo 24,4%, gasto del ventrículo derecho 21,4%; flujo sistémico 42,3%; signos de hipertensión pulmonar 7,7%. ConclusionesLa EcoFn es utilizada frecuentemente en UCIN y en muchos casos guía el tratamiento de los pacientes. La valoración del ductus y de la inestabilidad hemodinámica son las indicaciones más frecuentes. Queda por determinar si el uso de la EcoFn modifica la evolución de los pacientes de UCIN." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Corredera A, Rodríguez MJ, Arévalo P, Llorente B, Moro M, Arruza L. Ecocardiografía funcional en cuidados intensivos neonatales: experiencia en una unidad española a lo largo de un año. An Pediatr (Barc). 2014;81:167–173." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "CW: continuous wave; EF: ejection fraction; PW: pulsed wave; LV: left ventricle; MV: mitral valve; RV: right ventricle; SF: shortening fraction; SVC: superior vena cava." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Component \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Mode \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">View \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Assessment of ductus arteriosus</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diameter (narrowest dimension of duct) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2D or colour Doppler \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ductal/suprasternal \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Shunt directionality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Colour/CW/PW Doppler \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ductal/suprasternal \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Systolic and diastolic flow velocity through ductus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CW/PW Doppler \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ductal/suprasternal \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LV systolic function</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SF/EF: LV end-diastolic and end-systolic diameter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M mode \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Parasternal long axis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Assessment of overall myocardial function</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LV Tei index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Time interval between end and onset of transmitral flow \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PW Doppler \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Apical four-chamber \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LV ejection time \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Apical five-chamber \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RV Tei index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Time interval between end and onset of transtricuspid flow \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PW Doppler \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Apical four-chamber \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RV ejection time \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Parasternal long axis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Assessment of pulmonary hypertension</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Peak tricuspid regurgitation velocity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Colour Doppler \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Apical four-chamber \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Interventricular septum morphology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Parasternal short axis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Assessment of atrial-level shunt</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Directionality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Colour/PW Doppler \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Subxiphoid \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LV cardiac index</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LV outflow tract diameter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2D/M mode \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Parasternal long axis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Velocity–time integral of PW in LV outflow tract \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PW Doppler \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Apical five-chamber \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RV cardiac index</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RV outflow tract diameter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Parasternal long axis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Velocity–time integral of PW in RV outflow tract \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PW Doppler \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Parasternal long axis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SVC flow</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SVC diameter (mean of systolic and diastolic diameter) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M mode \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High parasternal \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Velocity–time integral of SVC (mean of 5 cycles) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PW Doppler \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Subxiphoid \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Assessment of RV function</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tricuspid annular plane systolic excursion (TAPSE) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M mode \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Apical four-chamber \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab556671.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Components of functional echocardiography and techniques used for their assessment." ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Characteristic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">n=50 \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gestational age</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><32 weeks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35 (70%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32–37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (12%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (18%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weight</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><1500g \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36 (72%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1500–2499g \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (14%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥2500g \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (14%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab556668.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Gestational age and weight of the patients." ] ] 2 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Principal diagnosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">n=50 \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Extreme prematurity/extreme low weight \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 (38%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Respiratory distress syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypoxic ischaemic encephalopathy/therapeutic hypothermia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (10%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate prematurity/very low weight \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 (34%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transient tachypnoea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab556670.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Principal diagnoses of studied patients." ] ] 3 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Results are expressed as mean±standard deviation, percentage, or median with interquartile range.Ao: aorta; LA: left atrium; PDA: patent ductus arteriosus." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Patients who underwent assessment for PDA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">n=98 \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gestational age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28.2 (2.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weight \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1196.5 (410) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Median days of life at first ultrasound \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (1–6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Murmur \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">53.6% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Treatment modification \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42.5% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Start of ibuprofen treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42.5% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ductus diameter, mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.7 (0.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LA:Ao ratio \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.8 (0.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab556669.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of patients who underwent assessment for patent ductus arteriosus." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Systemic and cerebral hemodynamics during the transitional period after premature birth" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. 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Functional echocardiography in neonatal intensive care: 1-Year experience in a unit in Spain

Ecocardiografía funcional en cuidados intensivos neonatales: experiencia en una unidad española a lo largo de un año

A. Corredera, M.J. Rodríguez, P. Arévalo, B. Llorente, M. Moro, L. Arruza

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luisarruza@yahoo.es

Corresponding author.

Servicio de Neonatología, Hospital Clínico San Carlos, Madrid, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The newborn may have a variety of haemodynamic problems with a variable and complex pathophysiology&#44; that at times have limited clinical manifestations&#46; This cardiovascular vulnerability stems from particular features of the newborn&#44; such as incomplete myocardial development&#44; the presence of foetal shunts&#44; changes in systemic and pulmonary vascular resistance&#44; and more generally the complex haemodynamic changes that take place during transition to extrauterine life&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Despite progressive technological advances in neonatal intensive care&#44; in most cases haemodynamic monitoring in newborns is still based on assessment of continuous heart rate&#44; blood pressure &#40;BP&#41;&#44; acid&#8211;base status&#44; urine output&#44; or poorly validated clinical signs such as capillary refill time&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> While these measures provide important and useful information to the clinician&#44; they are just variables associated in varying degrees to tissue perfusion&#44; which is the key haemodynamic parameter&#44; and for which an adequate monitoring method has yet to be developed&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> One potentially interesting option would be measurement of regional oxygen saturation by means of near-infrared spectroscopy&#44; although further research is required to confirm this&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Many publications have demonstrated that the correlation between BP and cardiac output is weak&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;6</span></a> It is not uncommon to find situations in which BP is normal and peripheral blood flow is below normal range&#46; This can have important implications&#44; as low peripheral blood flow in the first hours of life has been associated with the development of brain damage and neurodevelopmental abnormalities in premature infants&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> On the other hand&#44; there is no clear definition of what constitutes a normal BP in newborns&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> The use of clinical assessment and the classic parameters mentioned before to elucidate the underlying pathophysiology in haemodynamic disturbances can lead to incorrect assumptions and therapeutic decisions&#44; which may even cause harm&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In the neonate&#44; echocardiography is commonly performed by a cardiologist to assess structure and function of the heart&#46; Usually&#44; a single study is done to rule out congenital heart disease or global myocardial dysfunction&#44; and the time at which it is performed often depends on the availability of a cardiologist&#46; This can be an important factor in units that have limited access to a cardiologist&#44; or in situations in which serial assessment is needed to evaluate response to treatment or the haemodynamic changes that take place during transition from foetal to postnatal circulation&#46; It is important to consider that these changes can be very different from what might be assumed clinically based on conventional assessment&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Functional echocardiography&#44; or neonatologist-performed cardiac ultrasound&#44; depending on the terminology suggested by different authors&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;12</span></a> is being introduced progressively in neonatal intensive care units &#40;NICU&#41; as a tool to help guide treatment choices&#46; Functional echocardiography &#40;FnECHO&#41; adds to the assessment of classic clinical parameters in an attempt to provide individualised treatment based on the specific pathophysiology at hand&#46; It must be used as an adjunct to clinical assessment and not as a substitute for assessment by a cardiologist&#44; as their purposes are different and complementary&#46; The neonatologist can use FnECHO to obtain information about haemodynamic function in real time and to make longitudinal assessments as needed&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The aims of FnECHO are assessment of myocardial function&#44; systemic and pulmonary blood flow&#44; intracardiac and extracardiac shunts&#44; and tissue perfusion&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Functional echocardiography is commonly used to assess haemodynamic status during the transition from foetal to postnatal circulation in the extremely premature neonate&#44; to assess for the presence and significance of PDA&#44; to determine the underlying pathophysiology in patients with haemodynamic instability&#44; and in neonates with high oxygen requirements&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;13&#8211;15</span></a> It has shown a positive impact on the management of adult patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#8211;18</span></a> However&#44; there is no clear evidence associating the use of FnECHO with improved outcomes of neonates admitted to the NICU&#44; although some publications show a positive effect in this regard&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;19&#44;20</span></a> As far as we know&#44; there are no publications on the use of FnECHO in Spanish NICUs&#46; We present the results of a retrospective study on the use of FnECHO in a Spanish NICU during a 1-year period&#44; in which we analysed frequency of FnECHO use&#44; type of patient receiving it&#44; indications for FnECHO&#44; and effects on the management of patients&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">We performed a retrospective study of every FnECHO done in newborns admitted to the NICU of the Hospital Cl&#237;nico San Carlos of Madrid between January 2012 and January 2013&#46; This 11-bed unit provides treatment for all types of neonatal disease except for heart surgery and ECMO &#40;Level <span class="elsevierStyleSmallCaps">IIIB</span>&#41;&#46; All the studies were performed at the request of the physicians in charge by 2 NICU neonatologists &#40;AC and LA&#41; that have more than 5-year experience in FnECHO&#46; The ultrasound assessments and measurements were performed according to a standardised procedure that has been previously described and is presented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;21</span></a> The indications for the ultrasound scans and their results were documented in the medical record of each patient&#46; When an ultrasound was done&#44; the results were discussed with the physicians in charge to decide on the therapeutic approach&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">We collected the following general data on patients&#58; gestational age &#40;GA&#41;&#44; birth weight&#44; and principal diagnosis&#46; The following clinical data were recorded from the ultrasound tests&#58; heart rate&#44; presence of a murmur&#44; presence of a gradient between preductal and postductal haemoglobin oxygen saturation &#62;10&#37;&#44; mean BP &#40;MBP&#59; mmHg&#41;&#44; lactate levels &#40;mmol&#47;L&#41; and presence of oliguria &#40;diuresis &#60;1<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;h&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The data about the echocardiographic examinations included&#58; days of life at the time of examination&#44; number of ultrasound studies per patient&#44; and indication for examination&#46; We documented whether the results of FnECHO led to treatment modification&#44; and if so&#44; what changes were made&#46; Our analysis excluded ultrasound examinations performed in newborns with a suspected or confirmed structural congenital cardiopathy &#40;CC&#41;&#46; Although neonatologist-performed FnECHO&#44; our unit is also used to localise catheters&#44; assess for the presence of pleural effusion and its evacuation&#44; the study of brain blood flow&#44; or screening for gross brain injury&#44; our study only took into account echocardiographic examinations&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Analysed ultrasound parameters&#58; all echocardiograms were done with a portable ultrasound machine with a neonatal probe &#40;Titan&#44; SonoSite Inc&#46;&#44; Bothell&#44; USA&#44; probe C11&#47;5&#8211;8<span class="elsevierStyleHsp" style=""></span>MHz&#41;&#58; &#40;1&#41; assessment of ductus presence&#47;consequences&#58; presence&#44; diameter in colour or 2D Doppler&#59; shunt direction&#44; ratio of left atrium to aorta&#44; ductal Doppler pattern&#59; &#40;2&#41; assessment of myocardial function and systemic blood flow&#58; ejection fraction &#40;EF&#41;&#44; shortening fraction &#40;SF&#41;&#44; left ventricle &#40;LV&#41; and right ventricle &#40;RV&#41; cardiac output&#44; superior vena cava blood flow and &#40;3&#41; assessment of pulmonary hypertension&#58; calculation of pulmonary artery pressure in the presence of tricuspid regurgitation&#44; interventricular septal shape&#44; shunt direction&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Qualitative variables are expressed as absolute and relative frequencies&#44; and quantitative variables as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation or median and interquartile range in case of asymmetrical distribution or high dispersion of the data&#46; We used the statistical package STATA 12 to do the analysis&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">A total of 168 ultrasound examinations were performed in 50 patients during the period under study&#44; with a mean of 3&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;83 examinations per patient&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the general characteristics of the patients&#46; The mean GA of the patients was 31&#46;3 weeks&#44; with a range of 24&#46;1&#8211;40&#46;2 weeks&#44; and the mean birth weight was 1549<span class="elsevierStyleHsp" style=""></span>g &#40;590&#8211;4160<span class="elsevierStyleHsp" style=""></span>g&#41;&#46; Seventy percent of patients were born before 32 weeks of gestation&#46; The most frequent admission diagnosis was extreme prematurity and&#47;or extremely low weight at birth &#40;38&#37;&#41;&#46; Very low birth weight occurred in 34&#37; of the patients &#40;1000&#8211;1500<span class="elsevierStyleHsp" style=""></span>g&#41;&#46; Other principal diagnoses &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41; at the time of admission were hypoxic ischaemic encephalopathy to be treated with hypothermia &#40;10&#37;&#41;&#44; respiratory distress syndrome &#40;8&#37;&#41;&#44; transient tachypnoea &#40;6&#37;&#41; and other &#40;4&#37;&#41;&#46; The median days of life at the time of ultrasound examination was 6 days &#40;2&#8211;19 days&#41;&#46; The most frequent indication for echocardiography was assessment of the presence and significance of PDA&#44; accounting for 58&#46;3&#37; of examinations &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; Other indications included haemodynamic instability &#40;22&#46;2&#37;&#41;&#44; presence of heart murmur &#40;8&#46;3&#37;&#41;&#44; assessment of transition from foetal to postnatal circulation in extremely preterm neonates &#40;5&#46;4&#37;&#41;&#44; pulmonary hypertension screening &#40;1&#46;2&#37;&#41;&#44; and other &#40;4&#46;8&#37;&#41;&#46; As for the impact of FnECHO on patient management&#44; the echocardiography results led to treatment modification in 62 patients &#40;36&#46;9&#37;&#41;&#46; The most common modifications involved the management of PDA&#46; Thus&#44; treatment with ibuprofen was initiated in 17&#46;4&#37; of patients following the ultrasound test&#44; while in 1&#46;2&#37; of patients treatment with this drug was discontinued early&#46; As for haemodynamic support&#44; ultrasound results led to changes in the management of 10&#46;8&#37; of the patients&#46; The changes involved volume expansion therapy &#40;0&#46;6&#37;&#41;&#44; initiation or modification of inotropic therapy &#40;9&#46;6&#37;&#41; or initiation of hydrocortisone therapy &#40;0&#46;6&#37;&#41;&#46; Out of all ultrasound scans&#44; 36&#46;3&#37; were done in patients who had no murmur&#44; arterial hypotension&#44; oliguria&#44; increased lactate levels&#44; tachycardia&#44; or presence of an oxygen saturation gradient&#46; Of all these examinations&#44; 21&#46;7&#37; corresponded to routine studies in the early days of life&#46; Another 78&#46;3&#37; were follow-up studies in patients who had been previously assessed&#46; In 14 of these ultrasounds &#40;22&#46;9&#37;&#41; the results led to a modification of treatment&#46; Twelve corresponded to PDA&#46; The analysis of echocardiography parameters included the assessment of the presence and significance of PDA in 100&#37; of the patients&#46; Myocardial function was assessed by means of the EF&#47;FA ratio in 23&#46;8&#37;&#44; LV output in 24&#46;4&#37; and RV output in 21&#46;4&#37; of patients&#46; Systemic blood flow in the superior vena cava was measured in 42&#37; of the examinations&#46; The presence of pulmonary hypertension was assessed in 7&#46;7&#37; of patients&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">This study is the first to describe the use of FnECHO in a Spanish NICU&#46; The results suggest that this technique is used frequently and that it leads to treatment modification in a significant percentage of cases&#46; A similar study published recently describes the performance of 512 FnECHOs in a Canadian unit over a period of 3&#46;5 years&#44; which works out at an average of 142 examinations a year&#44; a figure that is very close to the one described in this work of 168 examinations in 12 months&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> That study also observed an increasing use of this technique during the period under analysis&#44; which confirms the interest in FnECHO and its progressive implantation in neonatology units&#46; A survey-based study shows that as early as 10 years ago 41&#37; of the level 3 neonatology units in Australia and New Zealand had at least 1 neonatologist with FnECHO skills&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> This figure had increased by more than 90&#37; in 2010&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> The neonatologist in our unit started to use FnECHO 10 years ago and used it mostly as a diagnostic tool and to monitor response to treatment of PDA&#46; Since then&#44; the range of indications has increased to the point that it has nearly turned into an additional part of the clinical assessment of haemodynamic disturbances&#46; According to our study&#44; the most frequent indication for FnECHO is diagnosis or monitoring of PDA &#40;58&#46;3&#37; of patients&#41;&#44; followed by assessment of pathophysiology underlying haemodynamic instability &#40;22&#46;2&#37;&#41;&#46; This is consistent with the data of the study by El-Kuffash et al&#46;&#44; in which PDA assessment amounted for 51&#37; of FnECHO indications&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In our study&#44; the results of 36&#46;9&#37; of FnECHO examinations led to changes in the management of the patient&#44; a figure that is very close to the one reported by El-Kuffash&#44; with a 41&#37; rate of management changes following the ultrasound examination&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Studies in adults suggest that FnECHO results in treatment changes in up to 51&#46;4&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> This supports the definition of FnECHO as a tool that guides therapeutic decision making&#46; In the study presented here&#44; 36&#46;3&#37; of the ultrasounds were performed in patients with no other abnormal haemodynamic parameters or heart murmur&#44; despite which the management of 22&#46;9&#37; of them changed after the examination&#46; Almost all of these patients had PDA&#46; We already mentioned that FnECHO findings are not always predictable based on traditional clinical assessment&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Thus&#44; El-Kuffash et al&#46; found 6&#37; of unexpected diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> In fact&#44; in FnECHO study performed in adult intensive care units&#44; previously undetected severe abnormalities were found in up to 7&#46;5&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> In our study&#44; an average of 3&#46;4 ultrasounds were made per patient&#44; with some patients receiving up to 16 ultrasounds&#46; This shows how FnECHO can be used for patient follow-up or to monitor response to treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">While it is clear that this technique is useful in practise&#44; strong evidence of the positive impact of the use of FnECHO in the NICU on patient outcomes is still lacking&#46; But several retrospective studies<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;19&#44;20</span></a> and a few clinical trials<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> suggest that FnECHO is beneficial in this way&#46; In any case&#44; randomised studies need to be performed to see whether the FnECHO has an effect on patient outcomes&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The main controversy surrounding performance of echocardiography by a neonatologist is based on the potential danger of missing a CC or making an incorrect diagnosis and starting the wrong treatment in a patient with CC&#46; However&#44; while this is a real danger&#44; in most cases an existing structural cardiopathy is detected by FnECHO&#44; even if a complete diagnostic assessment is not made&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;28</span></a> Either way&#44; cardiologists and neonatologists must work in close collaboration&#44; and a cardiology consult must be requested whenever there are doubts&#46; Adequate training in FnECHO is essential to minimise these risks&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Yet&#44; despite the increasingly widespread use of this technique worldwide&#44; many countries&#44; including Spain&#44; do not have a standardised training programme&#46; In this case&#44; training depends on personal interest&#44; is performed at the same time as the working routine and relies on the collaboration of the cardiologists and&#47;or the availability of specific materials like text books or CDs&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> This has been how training in FnECHO has been done in our unit&#44; and it would not have been possible without the collaboration of paediatric cardiologists who understood that this technique is used by the neonatologist as an adjunct in clinical assessment&#44; and not an intrusion in their field&#46; Other countries like Australia&#44; New Zealand&#44; the United States&#44; Canada&#44; and some European countries have accredited training programmes&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;29&#44;30</span></a> The American Society of Echocardiography&#44; in collaboration with the European Association of Echocardiography and the Association for European Pediatric Cardiologists&#44; has recently published specific recommendations for the training of neonatologists in FnECHO&#44; which explain in detail what the training and accrediting process should entail&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> recommendations that have been modified by other authors&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Given the growing interest in this technique and its widespread use&#44; training and accreditation programmes should be developed in Spain with the support of the Sociedad Espa&#241;ola de Neonatolog&#237;a &#40;Spanish Society of Neonatologists&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">There are several limitations to this study&#44; most of which derive from its retrospective nature&#46; For instance&#44; treatment modification following FnECHO ultimately depended on the decision of the physician in charge of the patient&#44; and not only on the data obtained from the ultrasound&#44; which may have affected the perceived influence of this technique on the management of neonates&#44; making it smaller or greater than it is&#46; On the other hand&#44; this study cannot determine whether therapeutic choices would have been different if FnECHO had not been available&#44; nor whether those choices were the correct ones&#46; Furthermore&#44; the very decision of performing the ultrasound test&#44; or not&#44; also rested with the physician in charge rather than being determined by a study protocol&#44; which could have a considerable effect on the observed frequency of use&#46; Also&#44; the echocardiographic view may constitute an important limitation in some patients&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Although this study did not collect information on this variable in a systematic manner&#44; technical limitations associated to the view and the use of a 5&#8211;8<span class="elsevierStyleHsp" style=""></span>MHz probe rather than a probe with a higher frequency &#40;8&#8211;12<span class="elsevierStyleHsp" style=""></span>MHz&#41;&#44; which would be ideal&#44; may have affected the quality of some of these ultrasound studies&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0070" class="elsevierStylePara elsevierViewall">Functional echocardiography is a useful tool employed widely in the NICU&#46; It provides complementary information that aids in making therapeutic decisions&#46; Its use is spreading in neonatology units&#44; although clinical trials need to be done to assess its impact on patient outcomes&#46; Structured training and accreditation programmes based on existing recommendations need to be developed to ensure the correct and safe use of this technique&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interests to declare&#46;</p></span></span>"
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    "fechaRecibido" => "2013-09-10"
    "fechaAceptado" => "2013-11-25"
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          "clase" => "keyword"
          "titulo" => "Keywords"
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            0 => "Functional echocardiography"
            1 => "Newborn"
            2 => "Intensive care unit"
            3 => "Point-of-care ultrasound"
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:4 [
            0 => "Ecocardiograf&#237;a funcional"
            1 => "Reci&#233;n nacido"
            2 => "Cuidados intensivos neonatales"
            3 => "Ecograf&#237;a en el punto de la asistencia"
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Several publications highlight the usefulness of functional echocardiography &#40;FnECHO&#41; in neonatal intensive care&#46; Data are lacking on its use in neonatal units in Spain&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Objectives</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">To evaluate frequency of use&#44; patient characteristics&#44; indications&#44; measurements&#44; and impact on patient management of FnECHO in a neonatal intensive care unit &#40;NICU&#41; in Spain over a 1-year period&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A retrospective study conducted in NICU patients during 1 year&#46; Variables&#58; gestational age&#44; birthweight&#44; admission criteria&#44; days of life at examination&#44; indication for FnECHO&#44; parameters assessed&#44; and treatment modifications&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">168 echocardiographic studies were performed in 50 patients &#40;mean 3&#46;4&#59; SD 2&#46;83&#41;&#46; The most frequent indication was patent ductus &#40;PDA&#41; assessment &#40;58&#46;3&#37;&#41;&#44; followed by haemodynamic instability &#40;22&#46;2&#37;&#41;&#46; The results of FnECHO modified treatment in 62 cases &#40;36&#46;9&#37;&#41;&#46; In 17&#46;4&#37; of them treatment with ibuprofen was initiated&#44; and in 1&#46;2&#37; it was discontinued&#46; In 10&#46;8&#37; of the cases&#44; the results of FnECHO modified haemodynamic support&#46; Echocardiographic evaluation included&#58; assessment of presence&#47;haemodynamic significance of PDA &#40;100&#37;&#41;&#59; myocardiac function&#58; ejection fraction&#47;shortening fraction &#40;EF&#47;SF&#41; 23&#46;8&#37;&#44; left ventricular output 24&#46;4&#37;&#44; right ventricular output 21&#46;4&#37;&#44; systemic blood flow 42&#46;3&#37;&#59; and signs of pulmonary hypertension 7&#46;7&#37;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">FnECHO is frequently used in the NICU&#44; and in many cases it guides treatment&#46; PDA assessment and haemodynamic instability are the most frequent indications&#46; It still needs to be elucidated if the use of FnECHO modifies patient outcomes&#46;</p>"
      ]
      "es" => array:2 [
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Numerosas publicaciones destacan la utilidad de la ecocardiograf&#237;a funcional &#40;EcoFn&#41; en neonatolog&#237;a&#46; No existen datos sobre su uso en unidades espa&#241;olas&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Evaluar la frecuencia de uso&#44; pacientes&#44; indicaciones&#44; mediciones y repercusi&#243;n sobre el tratamiento de la EcoFn en un a&#241;o en una unidad de cuidados intensivos neonatales &#40;UCIN&#41; espa&#241;ola&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Estudio descriptivo retrospectivo en pacientes ingresados en UCIN en un a&#241;o&#46; Variables&#58; edad gestacional&#44; peso&#44; diagn&#243;stico principal&#44; d&#237;as de vida en el momento del estudio&#44; indicaci&#243;n&#44; par&#225;metros medidos y modificaciones del tratamiento&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Se realizaron 168 ecograf&#237;as en 50 pacientes&#44; con una media &#177; desviaci&#243;n est&#225;ndar de 3&#44;4 &#177; 2&#44;83 por paciente&#46; Las indicaciones m&#225;s frecuentes fueron la valoraci&#243;n del ductus &#40;58&#44;3&#37;&#41; seguida de la inestabilidad hemodin&#225;mica &#40;22&#44;2&#37;&#41;&#46; El resultado de la ecograf&#237;a modific&#243; el tratamiento en 62 casos &#40;36&#44;9&#37;&#41;&#46; En un 17&#44;4&#37; se inici&#243; tratamiento con ibuprofeno y en un 1&#44;2&#37; de los casos se adelant&#243; el fin de este&#46; En un 10&#44;8&#37; de los casos&#44; la ecograf&#237;a modific&#243; el soporte hemodin&#225;mico&#46; Los par&#225;metros principales valorados fueron&#58; valoraci&#243;n de presencia&#47;repercusi&#243;n del ductus 100&#37;&#59; funci&#243;n mioc&#225;rdica&#58; fracci&#243;n de eyecci&#243;n&#47;acortamiento 23&#44;8&#37;&#44; gasto ventr&#237;culo del izquierdo 24&#44;4&#37;&#44; gasto del ventr&#237;culo derecho 21&#44;4&#37;&#59; flujo sist&#233;mico 42&#44;3&#37;&#59; signos de hipertensi&#243;n pulmonar 7&#44;7&#37;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La EcoFn es utilizada frecuentemente en UCIN y en muchos casos gu&#237;a el tratamiento de los pacientes&#46; La valoraci&#243;n del ductus y de la inestabilidad hemodin&#225;mica son las indicaciones m&#225;s frecuentes&#46; Queda por determinar si el uso de la EcoFn modifica la evoluci&#243;n de los pacientes de UCIN&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Corredera A&#44; Rodr&#237;guez MJ&#44; Ar&#233;valo P&#44; Llorente B&#44; Moro M&#44; Arruza L&#46; Ecocardiograf&#237;a funcional en cuidados intensivos neonatales&#58; experiencia en una unidad espa&#241;ola a lo largo de un a&#241;o&#46; An Pediatr &#40;Barc&#41;&#46; 2014&#59;81&#58;167&#8211;173&#46;</p>"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">CW&#58; continuous wave&#59; EF&#58; ejection fraction&#59; PW&#58; pulsed wave&#59; LV&#58; left ventricle&#59; MV&#58; mitral valve&#59; RV&#58; right ventricle&#59; SF&#58; shortening fraction&#59; SVC&#58; superior vena cava&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Component&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Mode&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">View&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Assessment of ductus arteriosus</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Diameter &#40;narrowest dimension of duct&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2D or colour Doppler&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ductal&#47;suprasternal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Shunt directionality</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Colour&#47;CW&#47;PW Doppler&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ductal&#47;suprasternal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Systolic and diastolic flow velocity through ductus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CW&#47;PW Doppler&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ductal&#47;suprasternal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">LV systolic function</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SF&#47;EF&#58; LV end-diastolic and end-systolic diameter</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M mode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Parasternal long axis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Assessment of overall myocardial function</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">LV Tei index</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Time interval between end and onset of transmitral flow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PW Doppler&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Apical four-chamber&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>LV ejection time&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Apical five-chamber&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">RV Tei index</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Time interval between end and onset of transtricuspid flow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PW Doppler&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Apical four-chamber&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>RV ejection time&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Parasternal long axis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Assessment of pulmonary hypertension</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Peak tricuspid regurgitation velocity</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Colour Doppler&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Apical four-chamber&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Interventricular septum morphology</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Parasternal short axis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Assessment of atrial-level shunt</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Directionality</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Colour&#47;PW Doppler&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Subxiphoid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">LV cardiac index</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">LV outflow tract diameter</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2D&#47;M mode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Parasternal long axis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Velocity&#8211;time integral of PW in LV outflow tract</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PW Doppler&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Apical five-chamber&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">RV cardiac index</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">RV outflow tract diameter</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Parasternal long axis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Velocity&#8211;time integral of PW in RV outflow tract</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PW Doppler&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Parasternal long axis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">SVC flow</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SVC diameter &#40;mean of systolic and diastolic diameter&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M mode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High parasternal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Velocity&#8211;time integral of SVC &#40;mean of 5 cycles&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PW Doppler&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Subxiphoid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Assessment of RV function</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Tricuspid annular plane systolic excursion &#40;TAPSE&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M mode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Apical four-chamber&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Characteristic&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>50&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Gestational age</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#60;32 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35 &#40;70&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>32&#8211;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;12&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;18&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Weight</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#60;1500<span class="elsevierStyleHsp" style=""></span>g&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">36 &#40;72&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1500&#8211;2499<span class="elsevierStyleHsp" style=""></span>g&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;14&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8805;2500<span class="elsevierStyleHsp" style=""></span>g&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;14&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                0 => "xTab556668.png"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Gestational age and weight of the patients&#46;</p>"
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        "identificador" => "tbl0015"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Principal diagnosis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>50&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Extreme prematurity&#47;extreme low weight&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">19 &#40;38&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Respiratory distress syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">4 &#40;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Hypoxic ischaemic encephalopathy&#47;therapeutic hypothermia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">5 &#40;10&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moderate prematurity&#47;very low weight&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">17 &#40;34&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Other&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2 &#40;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Results are expressed as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#44; percentage&#44; or median with interquartile range&#46;</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Ao&#58; aorta&#59; LA&#58; left atrium&#59; PDA&#58; patent ductus arteriosus&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>98&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">28&#46;2 &#40;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">1196&#46;5 &#40;410&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;1&#8211;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">42&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">1&#46;8 &#40;0&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Characteristics of patients who underwent assessment for patent ductus arteriosus&#46;</p>"
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    ]
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      "titulo" => "References"
      "seccion" => array:1 [
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          "bibliografiaReferencia" => array:30 [
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                  "host" => array:1 [
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            1 => array:3 [
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                  "host" => array:1 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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                            0 => "S&#46; Victor"
                            1 => "R&#46;E&#46; Appleton"
                            2 => "M&#46; Beirne"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                          "etal" => false
                          "autores" => array:2 [
                            0 => "M&#46; Kluckow"
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
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                        "fecha" => "2000"
                        "volumen" => "82"
                        "paginaInicial" => "F188"
                        "paginaFinal" => "F194"
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Article information

ISSN: 23412879
Original language: English

DOI:10.1016/j.anpede.2013.11.004

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Year/Month	Html	Pdf	Total

2024 November	6	11	17
2024 October	42	47	89
2024 September	54	25	79
2024 August	54	62	116
2024 July	57	41	98
2024 June	56	20	76
2024 May	54	44	98
2024 April	44	37	81
2024 March	33	33	66
2024 February	72	39	111
2024 January	29	29	58
2023 December	41	30	71
2023 November	26	19	45
2023 October	49	28	77
2023 September	30	33	63
2023 August	36	18	54
2023 July	32	49	81
2023 June	31	41	72
2023 May	49	40	89
2023 April	27	34	61
2023 March	68	28	96
2023 February	40	18	58
2023 January	34	34	68
2022 December	57	32	89
2022 November	46	36	82
2022 October	54	39	93
2022 September	59	40	99
2022 August	91	56	147
2022 July	87	51	138
2022 June	37	42	79
2022 May	68	50	118
2022 April	63	38	101
2022 March	64	49	113
2022 February	72	31	103
2022 January	56	41	97
2021 December	53	45	98
2021 November	56	53	109
2021 October	107	65	172
2021 September	62	58	120
2021 August	47	42	89
2021 July	91	36	127
2021 June	66	33	99
2021 May	78	34	112
2021 April	122	79	201
2021 March	119	40	159
2021 February	34	17	51
2021 January	58	22	80
2020 December	64	25	89
2020 November	61	25	86
2020 October	95	15	110
2020 September	99	13	112
2020 August	102	15	117
2020 July	66	20	86
2020 June	94	25	119
2020 May	77	30	107
2020 April	34	21	55
2020 March	44	18	62
2020 February	48	21	69
2020 January	28	11	39
2019 December	48	26	74
2019 November	51	15	66
2019 October	72	11	83
2019 September	58	10	68
2019 August	36	32	68
2019 July	59	30	89
2019 June	33	29	62
2019 May	84	30	114
2019 April	106	29	135
2019 March	67	20	87
2019 February	62	26	88
2019 January	45	26	71
2018 December	61	30	91
2018 November	153	28	181
2018 October	101	17	118
2018 September	50	14	64
2018 August	14	0	14
2018 July	4	0	4
2018 June	4	0	4
2018 May	5	0	5
2018 April	34	0	34
2018 March	25	0	25
2018 February	18	0	18
2018 January	13	0	13
2017 December	23	0	23
2017 November	15	0	15
2017 October	22	0	22
2017 September	20	0	20
2017 August	25	0	25
2017 July	16	2	18
2017 June	30	24	54
2017 May	32	34	66
2017 April	25	27	52
2017 March	19	16	35
2017 February	17	16	33
2017 January	37	8	45
2016 December	39	13	52
2016 November	52	13	65
2016 October	62	25	87
2016 September	51	17	68
2016 August	35	16	51
2016 July	24	28	52

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