Clinical Investigations in Children
Normalizing Echocardiographic Measurements in Children and Neonates
Echocardiographic Nomograms for Chamber Diameters and Areas in Caucasian Children

https://doi.org/10.1016/j.echo.2014.08.005Get rights and content

Background

Although a quantitative evaluation of cardiac chamber dimensions in pediatric echocardiography is often important, nomograms for these structures are limited. The aim of this study was to establish reliable echocardiographic nomograms of cardiac chamber diameters and areas in a wide population of children.

Methods

A total of 1,091 Caucasian Italian healthy children (age range, 0 days to 17 years; 44.8% female) with body surface areas (BSAs) ranging from 0.12 to 1.8 m2 were prospectively enrolled. Twenty-two two-dimensional and M-mode measurements of atrial and ventricular chamber diameters and areas were performed. Models using linear, logarithmic, exponential, and square-root relationships were tested. Heteroscedasticity was tested by the White test and the Breusch-Pagan test. Age, weight, height, and BSA, calculated by the Haycock formula, were used as the independent variables in different analyses to predict the mean value of each echocardiographic measurement. The influence of various confounders, including gender, type of delivery, prematurity, and interobserver variability, was also evaluated. Structured Z scores were then computed.

Results

The Haycock formula provided the best fit and was used when presenting data as predicted values (mean ± 2 SDs) for a given BSA and within equations relating echocardiographic measurements to BSA. Confounders were not included in the final models, because they did not show significant effects for most of the measurements.

Conclusions

Echocardiographic reference values are presented for chamber area and diameters, derived from a large population of healthy children. These data partly cover a gap in actual pediatric echocardiographic nomograms. Further studies are required to reinforce these data, as well as to evaluate other parameters and ethnicities.

Section snippets

Inclusion Criteria

Healthy Caucasian children evaluated in the outpatient department of the Pediatric Cardiology Department for the screening of congenital heart disease at Fondazione G. Monasterio CNR–Regione Toscana of Massa eligible for inclusion into the study were prospectively enrolled.

The presence of innocent defects such as a patent ductus arteriosus with small or less left-to-right shunting seen in the first 3 days of life or a patent foramen ovale was considered to be normal.7, 9 Premature neonates were

Subjects

A total of 1,091 children (age range, 0 days to 17 years) were enrolled. The mean age of the study population was 53.3 months (median, 34.9 months; interquartile range, 2.2–95.1 months; range, 0–17 years). Body weight ranged from 1.3 to 88.0 kg (median, 13.7 kg; interquartile range, 4.9–28.0 kg) (Table 3). Height ranged from 41 to 181 cm (median, 93 cm; interquartile range, 57–127 cm). BSA calculated with the Haycock formula22 ranged from 0.12 to 1.8 m2 (median, 0.6 m2; interquartile range,

Discussion

The importance of accurate pediatric nomograms has recently been addressed by various authors,1, 2, 3, 4, 5, 6, 7, 8 with recommendations to use Z scores for quantification during the performance of pediatric echocardiography. Various numeric and methodologic limitations of actual pediatric nomograms have been underscored by multiple authors.1, 2, 3, 4, 5, 6, 7, 8

The nomograms we present offer the advantage of a rigorous statistical approach6 whose importance has been widely explained1, 2, 3, 4

Conclusions

The nomograms provided in the present report may be considered helpful tools for clinicians to perform quantitative measurements of cardiac chamber areas and diameters in children with various acquired and congenital heart defects.

In particular, this work substantially covers the gap of knowledge on chamber dimensions in children with the advantage of a rigorous statistical design.

Further studies, however, are required to reinforce these data, as well as to evaluate other parameters of clinical

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