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1. TTE in Pediatric Lia

2. Terms Echocardiography Make sure the   Ultrasound Image Indicator Marker   is on the   RIGHT side   of the ultrasound screen . 3. Place the ultrasound machine on the patient’s right side , so you can scan with your right hand and manipulate ultrasound buttons with your left hand . 2. Make sure the   Ultrasound Probe Marker is on the   Left side   of patient or right hand operator.

3. Indication for TTE in Children

4. View Echo Subcostae Apical − four chamber Subxiphoid − short axis Intercostal − long axis Suprasternal − arcus aorta

5. Probe positioning 1. Subcostae 2. Apical − four chamber dan Subxiphoid − short axis 3. Intercostal − long axis 4. Suprasternal − arcus aorta

6. View Echo 1. Subcostae UTILITY : Determine abdominal visceral situs Evaluate relative locations of IVC, DAo , spine , liver , and stomach Probe indicator direction : 3 o’clock

7. View Echo 2. Four chamber Probe indicator direction : 3 o’clock UTILITY : Evaluate atrium and ventricular septum Estimate RV systolic pressure from the tricuspid regurgitation and evaluate LV size Evaluate LV size , systolic and diastolic function Measure LA and RA size Evaluate TV and MV morphology , function and flow Evaluate at least one right and / or one left pulmonary vein entering the left atrium

8. FOUR CHAMBERS

9. FOUR CHAMBERS

10. View Echo 3. Apical − short axis Probe indicator direction : 3 o’clock UTILITY : Evaluate AoV and MV morphology Evaluate ventricular septum M easure LV size , e valuate LV systolic function Estimate RV systolicpressure from the tricuspid regurgitation gradient Evaluate PV morphology , function , and flow Measure PV and MPA gradient if elevated

11. SHORT AXIS

12. View Echo 4. Intercostal − long axis Probe indicator direction : 10-11 o’clock UTILITY : Evaluate mitral-to-AoV fibrous continuity Evaluate MV and AoV morphology and function Measure diameters of AoV annulus , aortic root , sinotubular junction , and AAo Display origin of RCA from aortic root by 2D and color mapping Evaluate TV morphology , function,and flow Estimate RV systolic pressure from the tricuspid regurgitation gradient Evaluate PV morphology , function , and flow Measure diameters of PV annulus and MPA Measure PV and MPA gradient if elevated

13. LONG AXIS

14. LONG AXIS

15. View Echo 5. Suprasternal − arcus aorta Probe indicator direction : 12-13 o’clock UTILITY : Evaluate aortic arch and origin of right innominate , left common carotid , and left subclavian arteries Measure diameters of proximal and distal transverse aortic arch and aortic isthmus Evaluate flow along aortic arch and proximal DAo

16. OTHER VIEWS

17. FIVE CHAMBERS Ti lted too much towards the patient’s head

18. SUBCOSTAE - IVC Evaluate for IVC Collapsibility with Respirations

19. SUBCOSTAE - IVC Small and Collapsible IVC

20. SUBCOSTAE - IVC Dilated and Non- collapsible IVC and hepatic vein

21. CARDIAC TAMPONADE Parasternal Long Axis : Cardiac Tamponade – RV Diastolic Collapse Apical View : Cardiac Tamponade – RA Systolic Collapse

22. SUBCOSTAE VIEW

23. MEASUREMENT

24. EJECTION FRACTION Ejection fraction (EF) is basically a percentage , of how much blood the left ventricle pumps out with each contraction . One of the most commonly used surrogates in assessing systolic function in these patients is done by measuring the   Left Ventricular Ejection   Measuring   Ejection Fraction   on ultrasound can be approached either qualitatively or quantitatively . Long axis  Measurement  General  LV study

25. EJECTION FRACTION Quantitative Qualitative

26. EJECTION FRACTION Hyperdynamic Ejection Fraction

27. EJECTION FRACTION Normal Ejection Fraction

28. EJECTION FRACTION Mildly Reduced Ejection Fraction

29. EJECTION FRACTION Moderately Reduced Ejection Fraction

30. EJECTION FRACTION Severely Reduced Ejection Fraction

31. E / A Ratio Long axis / Four Chambers  Measurement  General  E / A ratio

32. La/ Ao Ratio Long axis  Measurement  General  La/ Ao

33. TERIMA KASIH