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Application of Echocardiography to Non-Congenital Heart Problems in Tertiary Pediatric Referral Centres

Dr. Victor Grech
Paediatric Senior Registrar
Paediatric Department
St. Lukes Hospital

Ms. Rachel Danvers
Chief Echocardiography Technician
Cardiothoracic Unit
Great Ormond Street Hospital for Children NHS Trust
London WC1N 3JH

Corresponding Author
Dr. Victor Grech
Surface mail address - as above
e-mail: victor.e.grech@magnet.mt

Echocardiography has revolutionised the practice of paediatric cardiology by allowing non-invasive diagnosis and follow-up of a wide variety of conditions, particularly congenital heart disease (CHD) - allowing patients to be diagnosed, followed-up and even operated without invasive investigations (1,2). Echocardiography machines have become highly sophisticated and versatile pieces of equipment. This article illustrates non-CHD applications of echocardiography in the setting of a tertiary paediatric cardiac referral centre.

Images were obtained by Acuson XP-10, Acuson Sequoia and Toshiba SSH654 machines from patients referred to the Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS Trust. All graphics were downloaded to conventional photographic paper, and then converted to digital images using a Hewlett Packard Scanjet IICX. The images were annotated using Paint Shop Pro. Cropping and contrast adjustments were made using Adobe Photoshop.

Intracardiac masses

Right atrial thrombus (4).

Wilm's tumour with extension to right atrium (5).

Extracardiac intracirculatory masses

Thrombus formation in the innominate vein after bidirectional Glenn procedure for tricuspid atresia (6).


Pericardial effusion with fibrin formation (7).

Bilateral pleural effusions (8).

Localisation of central lines and associated thrombi/vegetations

Umbilical arterial line in descending aorta seen both in short axis and long axis aortic views (9).

Ventriculo-arterial shunt

Infected ventriculo-arterial shunt with vegetation formation at tip of shunt in right atrium (10).

Extra-corporeal life support cannulae

Extra-corporeal life support venous cannula in superior vena cava extending to the right atrium.

Arterial cannula in apex of aortic arch (11).

Arteriovenous malformations causing heart failure due to extracardiac left-to-right shunting (12)

Diagnosis of post-operative diaphragmatic paralysis.

Unilateral and even bilateral, partial or complete diaphragmatic paralysis due to trauma to the phrenic nerve, is an occasional complication of surgery for CHD. Upward and downward movement of the diaphragm in expiration and inspiration respectively, can be screened in real-time both ultrasonographically and fluoroscopically. The left and right components of the diaphragm can be viewed simultaneously from the subcostal window by US allowing paradoxical movement to be visualised in ventilated patients with unilateral diaphragmatic paralysis (13).

Cardiac applications of ultrasonography techniques have undergone tremendous strides since the inception of M-mode echocardiography. 2-dimensional echocardiography allows detailed intracardiac analysis of complex malformations, and the availability of pulse-wave Doppler and continuous-wave Doppler since the mid-1980s and colour Doppler since the late 1980s has allowed even more information to be gathered in the cardiac ultrasound examination (14). Full diagnosis, follow-up and even surgery of patients with CHD can be undertaken without resort to more invasive techniques in many individuals (1,2).

The images in this article illustrate how chocardiography has been utilized for the diagnosis and/or monitoring of non-congenital heart problems in a tertiary pediatric referral hospital (15).


  1. Marek J, Svovranek J, Hucin B, Chaloupeky V, Tax P, Reich O, Samanek M. Seven year experience of noninvasive preoperative diagnostics in children with congenital heart defects: comprehensive analysis of 2,788 consecutive patients. Cardiology 1995;86: 488-495

  2. Grech V. Trends in preoperative cardiac catheterisation in congenital heart disease. Maltese Journal of Family Doctors - in press

  3. Vogel S, Ho SY, Lincoln C, Yacoub MH, Anderson RH. Three-dimensional echocardiography can simulate intraoperative visualization of congenitally malformed hearts. Ann Thorac Surg 1995;60:1282-1288

  4. Marsh D, Wilkerson SA, Cook LN, Pietsch JB. Right atrial thrombus formation screening using two-dimensional echocardiograms in neonates with central venous catheters. Pediatrics 1988;81:284-286

  5. De Compo FJ. Ultrasound of Wilm's tumour. Pediatr Radiol 1986;16:21-24

  6. DeAngelis GA, McIlhenny J, Willson DF, Vittone S, Dwyer SJ 3rd, Gibson JC, Alford BA. Prevalence of deep venous thrombosis in the lower extremities of children in the intensive care unit. Pediatr Radiol 1996;26:821-824

  7. Walinsky P. Pitfalls in the diagnosis of pericardial effusion. Cardiovasc Clin 1978;9:111-112

  8. Lipscomb DJ, Flower CD. Ultrasound in the diagnosis and management of pleural disease. Br. J. Dis. Chest 1980;74:353-361

  9. Oppenheimer DA, Carroll BA. Ultrasonic localization of neonatal umbilical catheters. Radiology 1982;142:781-782

  10. Bricker JT, Latson LA, Huhta JC, Gutgesell H. Echocardiographic evaluation of infective endocarditis in children. Clin Pediatr 1985;24:312-317

  11. Riccabona M, Dacar D, Zobel G, Kuttnig-Haim M, Maurer U, Urlesberger B, Reiterer F. Sonographically guided cannula positioning for extracorporeal membrane oxygenation. Pediatr Radiol 1995;25:643-645

  12. Vaksmann G, Decoulx E, Mauran P, Jardin M, Rey C, Dupuis C. Evaluation of vein of Galen arteriovenous malformation in newborns by two dimensional ultrasound, pulsed and colour Doppler method. Eur J Pediatr 1989;148:510-512

  13. Balaji S, Kunovsky P, Sullivan I. Ultrasound in the diagnosis of diaphragmatic paralysis after operation for congenital heart disease. Br Heart J 1990;64:20-22

  14. Leung MP, Mok CK, Lau KC, Lo R, Yeung CY. The role of cross-sectional echocardiography and pulsed Doppler ultrasound in the management of neonates in whom congenital heart disease is suspected. A prospective study. Br Heart J 1986;56:73-82

  15. Fyler DC, Buckley CP, Hellebrand WE, Cohn HE. Report on the New England Regional Infant Cardiac Program. Pediatrics 1980;65:376-461

Abstract on the use of echocardiography in a Canadian level three neonatal intensive care unit.

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