Accuracy of echocardiography in low birth weight infants with congenital heart disease

Detection of congenital heart disease by neonatologist performed cardiac ultrasound in preterm infants

OBJECTIVE

We aimed to assess the frequency of de novo congenital heart disease (CHD) detection via neonatologist-performed cardiac ultrasounds (NPCU) in premature infants born at <30 weeks of gestation.

STUDY DESIGN

In this cross-sectional study (2004-2023) clinicians completing NPCU flagged de novo suspected CHD. All flagged NPCUs were cross-checked with cardiologists to confirm CHD diagnosis.

RESULTS

There were 2088 out of 3739 infants (56%) with at least one NPCU; 294 (14%) with cardiology referral. CHD diagnosis was confirmed in 109 of the 2088 (5.2%) infants. All major and critical CHD on NPCU imaging were suspected during NPCU and had prompt referral to the cardiology department.

CONCLUSION

De novo presentation of significant CHD continues to occur in the preterm population, emphasizing the need for recognizing CHD during NPCU. Optimizing NPCU training may benefit patients with early cardiology referral and review.

Ambulatory sedation for children under 6 years with CHD in MRI and CT

INTRODUCTION

In infants and young children, good image quality in MRI and CT requires sedation or general anesthesia to prevent motion artefacts. This study aims to determine the safety of ambulatory sedation for children with CHD in an outpatient setting as a feasible alternative to in-hospital management.

METHODS

We recorded 91 consecutive MRI and CT examinations of patients with CHD younger than 6 years with ambulatory sedation. CHD diagnoses, vital signs, applied sedatives, and adverse events during or after ambulatory sedation were investigated.

RESULTS

We analysed 91 patients under 72 months (6 years) of age (median 26.0, range 1-70 months; 36% female). Sixty-eight per cent were classified as ASA IV, 25% as ASA III, and 7% as ASA II (American Society of Anesthesiologists Physical Status Classification). Ambulatory sedation was performed by using midazolam, propofol, and/or S-ketamine. The median sedation time for MRI was 90 minutes (range 35-235 minutes) and 65 minutes for CT (range 40-280 minutes). Two male patients (age 1.5 months, ASA II, and age 17 months, ASA IV) were admitted for in-hospital observation due to unexpected severe airway obstruction. The patients were discharged without sequelae after 1 and 3 days, respectively. All other patients were sent home on the day of examination.

CONCLUSION

In infants and young children with CHD, MRI or CT imaging can be performed under sedation in an outpatient setting by a well-experienced team. In-hospital backup should be available for unexpected events.

The Future of Cardiac Ultrasound in the Neonatal Intensive Care Unit

Cardiac ultrasound is increasingly used to guide hemodynamic decision making in the neonatal intensive care unit (NICU). This article focuses on likely future progress in training, accreditation, digital connectivity, miniaturization, and modality development. Many documents have been published internationally to guide cardiac ultrasound training, accreditation, and implementation in the NICU, but challenges remain in providing assessments of hemodynamic status without risking missed structural diagnoses. Advances in simulation training and digital connectivity provide an opportunity to standardize approaches across institutions and continents. Development of machine learning and ultrasound modalities in turn provide huge scope for improving robustness and completeness of assessment.

Noninvasive Imaging in Adult Congenital Heart Disease

Multimodality cardiovascular imaging plays a central role in caring for patients with congenital heart disease (CHD). CHD clinicians and scientists are interested not only in cardiac morphology but also in the maladaptive ventricular responses and extracellular changes predisposing to adverse outcomes in this population. Expertise in the applications, strengths, and pitfalls of these cardiovascular imaging techniques as they relate to CHD is essential. The purpose of this article is to provide an overview of cardiovascular imaging in CHD. We focus on the role of 3 widely used noninvasive imaging techniques in CHD—echocardiography, cardiac magnetic resonance imaging, and cardiac computed tomography. Consideration is given to the common goals of cardiac imaging in CHD, including assessment of structural and residual heart disease before and after surgery, quantification of ventricular volume and function, stress imaging, shunt quantification, and tissue characterization. Extracardiac imaging is highlighted as an increasingly important aspect of CHD care.

Unplanned Repeat Echocardiography with Sedation in Children: Patient Risk Factors

Patient selection criteria for echocardiography with sedation in children are not well defined. We attempted to identify predictors of unplanned repeat echocardiography with sedation. This was a single-center, case-control study of echocardiograms performed in children aged 1-36 months. Cases underwent unplanned repeat examinations with sedation, while controls did not. Patient variables and study indications were compared. Logistic regression identified the most significant predictors. Cases (n = 104, median time to repeat echocardiogram 17 days, median age 12.9 months) were older than controls (n = 212, median age 5.0 months, P < 0.001). Significantly more cases than controls had structural cardiac disease (64 vs. 23 %) and anatomic complexity ≥moderate (38 vs. 5 %, P < 0.001 for both). Cases more often had Kawasaki disease (11 vs. 2 %), and controls more often had murmur (56 vs. 11 %, P < 0.001 for both). Logistic regression identified age 6 months to <2 years (OR 3.26, 95 % CI 1.70-6.28, P < 0.001), Kawasaki disease (OR 5.20, 95 % CI 1.46-18.50, P = 0.01), and known pre-echocardiogram anatomic complexity ≥moderate (OR 3.99, 95 % CI 1.64-9.66, P = 0.002) as significant risk factors. An indication for murmur was protective (OR 0.32, 95 % CI 0.13-0.76, P = 0.01). We identified several risk factors for unplanned repeat echocardiography with sedation in children, including age 6 months to <2 years, higher anatomic complexity, and Kawasaki disease. Murmur was a protective factor. These results may help pediatric echocardiography laboratories establish criteria for sedation.

Pediatric echocardiograms performed at primary centers: Diagnostic errors and missing links!

Aim:

The present study was undertaken to assess the accuracy of pediatric echocardiograms done at non-tertiary centers and to evaluate the relationship of inaccurate interpretations with age, echocardiogram performer and complexity of congenital heart disease (CHD).

Materials and Methods:

The echocardiogram reports of 182 consecutive children with CHD (5 days-16 years) who were evaluated at a non-tertiary center and subsequently referred to our center were reviewed. Age of the child at echocardiogram, echocardiogram performer and complexity of CHD were noted. These reports were compared with echocardiogram done at our center. Discrepancies were noted and categorized. To assess our own error rate, we compared our echocardiogram reports with the findings obtained during surgery (n = 172), CT scan (n = 9) or cardiac catheterization reports (n = 1).

Results:

Most of the children at the non-tertiary center (92%) underwent echocardiogram by personnel other than a pediatric cardiologist. Overall, diagnostic errors were found in 69/182 (38%) children. Moderate and major discrepancies affecting the final management were found in 42/182 (23%) children. Discrepancies were higher when the echocardiogram was done by personnel other than pediatric cardiologist (P < 0.01) and with moderate and high complexity lesions (P = 0.0001). There was no significant difference in proportion of these discrepancies in children ≤ 1 year vs. >1 year of age.

Conclusions:

A significant number of pediatric echocardiograms done at non-tertiary centers had discrepancies that affected the management of these children. More discrepancies were seen when the echocardiogram performer was not a pediatric cardiologist and with complex CHD.

Congenital heart disease in low-birth-weight infants: effects of small for gestational age (SGA) status and maturity on postoperative outcomes

Few studies have examined the role that small for gestational age (SGA) status plays in postoperative outcomes for low-birth-weight (LBW) infants with congenital heart disease (CHD). This study aimed to examine the effect of SGA status, gestational and chronologic age, and weight on differences in morbidities and mortalities during the immediate postoperative hospitalization period. The charts of infants with CHD weighing less than 2.5 kg who underwent operative repair during the neonatal period between 2004 and 2011 were reviewed. Infants with an isolated patent ductus arteriosus were excluded from the study. Data on hospital morbidities and mortality before discharge were collected. The study identified 136 LBW infants with a diagnosis of CHD. Among the 74 infants who underwent surgery and had complete chart records, the SGA infants had a higher gestational age at birth (36.8 vs. 32.3 weeks; p < 0.0001). The SGA and non-SGA infants did not differ in terms of survival to discharge or immediate postoperative outcomes. A lower weight at surgery was significantly associated with an increased risk of postoperative infection. In contradistinction, an older postnatal age at surgery was associated with an increased risk of preoperative infection (p < 0.0001). Additionally, lower gestational age at birth was associated with home oxygen use, higher tracheostomy rates, and discharge with a gastrostomy tube. Small for gestational age status played no protective role in the outcome for LBW infants after primary surgery for CHD. A weight of 2.4 kg or greater at the time of surgery was associated with lower rates of postoperative infections. Greater duration of time between birth and surgery was associated with a greater risk of preoperative infection. A gestational age of 32 weeks or more at birth was associated with decreased morbidities, which could influence obstetric management.

The impact of procedural sedation on diagnostic errors in pediatric echocardiography

BACKGROUND

Infants and young children frequently have difficulty remaining still for an echocardiographic examination, potentially leading to poor study quality, increasing the likelihood of diagnostic errors. Sedation is believed to improve echocardiographic quality, but its effectiveness has not been demonstrated. The aim of this study was to test the hypothesis that sedation would improve study quality and reduce diagnostic errors.

METHODS

Outpatient echocardiograms from children aged ≤36 months obtained from January 2008 to June 2009 were examined. Variables related to image quality, report completeness, and sedation use were collected. Diagnostic errors were identified and categorized. Multivariate analysis identified the odds ratios (OR) and 95% confidence intervals (CI) for risk factors for potentially preventable diagnostic errors and the impact of sedation on these errors.

RESULTS

Among 2,003 echocardiographic examinations, sedation was used in 498 (25%). The overall diagnostic error rate was 6.5%. Most errors (66%) were potentially preventable. Multivariate analysis identified the following risk factors for potentially preventable errors: precardiac procedure (OR, 2.19; 95% CI, 1.05-4.59; P = .04), moderate anatomic complexity (OR, 3.91; 95% CI, 2.25-6.81; P < .001), and high anatomic complexity (OR, 8.36; 95% CI, 3.57-19.6; P < .001). Sedation was independently associated with lower odds of potentially preventable diagnostic errors (OR, 0.47; 95% CI, 0.27-0.80; P = .006). Echocardiographic examinations with sedation had fewer image quality concerns (22% vs 60%) and fewer incomplete reports (3% vs 20%) (P < .001).

CONCLUSIONS

Most echocardiographic diagnostic errors among infants and young children are potentially preventable. Sedation is associated with a lower likelihood of these diagnostic errors, fewer imaging quality concerns, and fewer incomplete reports.

Prematurity and congenital heart disease

Significant advances in technology and therapy have led to dramatic improvements in the survival of preterm babies over the last 2 decades. Similarly, improvements in surgical and cardiac intensive care techniques have increased the feasibility of supporting even very small babies to the point of surgical repair, leading some to adopt an approach of early and complete surgical repair in preterm infants, with the aim of minimizing potential preoperative morbidity associated with extended medical management or surgical palliation. (1,2) However, multiple diagnostic and therapeutic challenges complicate the care of premature infants. Major errors in echocardiography are more common in neonates weighing less than 2.5 kg, (3) and the ideal timing and type of surgical intervention in premature infants remains unknown. These problems are compounded by the need for critical care practices that optimize management of immature cardiopulmonary, gastrointestinal, and neurological systems. This review will summarize some of the recent advances in neonatal and perinatal medicine, which have the potential to contribute to improved management of preterm infants with critical cardiac disease.

Unplanned reinterventions are associated with postoperative mortality in neonates with critical congenital heart disease

OBJECTIVE

Neonates with critical congenital heart disease remain at risk of adverse outcomes after cardiac surgery. Residual or undiagnosed anatomic lesions might be contributory. The present study aimed to describe the incidence and type of cardiac lesions that lead to early, unplanned cardiac reintervention, identify the risk factors for unplanned reintervention, and explore the associations between unplanned reinterventions and hospital mortality.

METHODS

The present single-center retrospective cohort study included 943 consecutive neonates with critical congenital heart disease who underwent cardiac surgery from 2002 to 2008. An unplanned cardiac reintervention was defined as a cardiac reoperation or interventional cardiac catheterization performed during the same hospitalization as the initial operation. Multivariate logistic regression analyses were used to identify the risk factors for unplanned cardiac reintervention and hospital mortality.

RESULTS

Of the 943 neonates, 104 (11%) underwent an unplanned cardiac reintervention. The independent predictors of unplanned reintervention included prenatal diagnosis, lower birth weight, need for mechanical ventilation before the initial cardiac operation, lower attending surgeon experience, and greater Risk Adjustment in Congenital Heart Surgery, version 1, category. Those who underwent reintervention had increased hospital mortality (n = 33/104, 32%) relative to those who did not (n = 31/839, 4%; adjusted odds ratio, 8.6; 95% confidence interval, 4.7 to 15.6; P < .001). The mortality rates among patients undergoing surgical reintervention (23/66, 35%) or transcatheter reintervention (4/16, 25%), or both (6/22, 27%) were similar (P = .66).

CONCLUSIONS

The need for unplanned cardiac reintervention in neonates with critical congenital heart disease is strongly associated with increased mortality. Early unplanned reinterventions might be an important covariate in outcomes studies and useful as a quality improvement measure.

Various modalities for evaluation of a fused heart in conjoined twins

Conjoined twins are a rare congenital anomaly with an estimated incidence of 1/50,000 to 1/100,000. Among thoracopagus conjoined twins, 75% have a fused heart. We compare the usefulness of various modalities for evaluating cardiovascular structure in fused-heart conjoined twins. We report a series of 20 sets of thoracopagus conjoined twins as well as the results of a PubMed database literature review literature from 1982 to 2009. Twenty sets of fused-heart thoracopagus conjoined twins were evaluated by echocardiography, cardiac catheterization, magnetic resonance image (MRI), and three-dimensional computed tomography angiography (3D-CTA). Imaging results were compared to findings at surgery or autopsy. All sets of conjoined twins underwent postnatal echocardiography; 11 sets (55%) underwent cardiac catheterization; 4 sets (20%) underwent MRI; and 1 set (5%) underwent 3D-CTA. All intracardiac anatomy (ICA) was identified by echocardiography. Cardiac catheterization, MRI, and 3D-CTA were able to identify extracardiac vascular structures as well as the ICA. 3D-CTA, which can be performed as early as the first week of life, is a noninvasive, less expensive, and the safe examination with minimal risk due to its short procedural time. Three-dimensional CTA is an effective and safe modality for evaluating the cardiovascular anatomy of fused-heart conjoined twins before surgery.

Right aortic arch with anomalous left subclavian artery and left-sided patent ductus arteriosus (vascular ring) in an extremely low-birth-weight infant

We present three-dimensional reconstructed images of the vascular ring of a 4-day-old extremely premature neonate which were obtained utilizing multidetector computer tomography. This is a unique case of early detection of Kommerell's diverticulum and vascular ring in an extremely low-birth-weight infant using this noninvasive technology.

Echocardiography and the neonatologist

Pediatric echocardiography as performed and interpreted by pediatric cardiologists provides details of cardiac structure and function as well as hemodynamic data. Functional echocardiography, in contrast to echocardiography as performed by the cardiologist, is the bedside use of cardiac ultrasound to follow functional and hemodynamic changes longitudinally. Data reflecting cardiac function and systemic and pulmonary blood flow in critically ill preterm and term neonates can be monitored using this method. Functional echocardiography is being developed and driven by neonatologists as an extension of their clinical skills. A wealth of hemodynamic information can be derived from functional echocardiography used for the sick neonate, which provides clinical information different from the assumed underlying physiology. Lack of access to appropriate training programs and interdisciplinary politics is limiting the use of this potentially valuable clinical information. Without the use of functional echocardiography, clinicians are left to speculate as to the underlying pathophysiology of circulatory compromise, and the assumptions they make often are incorrect. For functional echocardiography to fulfill its clinical potential, it needs to be available at any time and at short notice in the neonatal intensive care unit (NICU). Because most NICUs do not have external diagnostic services to provide longitudinal hemodynamic follow-up assessment at the bedside, neonatologists should be able to develop appropriate echocardiographic skills in close collaboration with their cardiologist colleagues.

Diagnostic errors in pediatric echocardiography: development of taxonomy and identification of risk factors

BACKGROUND

Despite increased interest in complications within pediatric cardiology, the domain of imaging-related diagnostic errors has received little attention. We developed a new taxonomy for diagnostic errors within pediatric echocardiography that categorizes errors by severity, preventability, and primary contributor. Our objectives were to examine its findings when applied to diagnostic error cases and to identify risk factors for preventable or possibly preventable diagnostic errors.

METHODS AND RESULTS

Diagnostic errors were identified at a high-volume academic pediatric cardiac center from December 2004 to August 2007. Demographic, clinical, and situational variables were collected from these cases and controls. During the study period, approximately 50,660 echocardiograms were performed. Among the 87 diagnostic error cases identified, 70% affected clinical management or the patient was at risk of or experienced an adverse event. One third of the errors were preventable and 46% were possibly preventable; 69% of preventable errors were of moderate severity or greater. Univariate analysis demonstrated that preventable or possibly preventable errors were more likely to involve younger patients, lower body weight, study location, sedated/anesthetized patients, studies performed and interpreted at night, uncommon diagnoses, and greater anatomic complexity than controls. Multivariate analysis identified the following risk factors: rare or very rare diagnoses (adjusted odds ratio [AOR], 9.2; P<0.001), study location in the recovery room (AOR, 7.9; P<0.001), moderate anatomic complexity (AOR, 3.5; P=0.004), and patient weight <5 kg (AOR, 3.5; P=0.031).

CONCLUSIONS

A diagnostic error taxonomy and knowledge of risk factors can assist in identification of targets for quality improvement initiatives that aim to decrease diagnostic error in pediatric echocardiography.

Clinical feasibility of free-breathing, gadolinium-enhanced magnetic resonance angiography for assessing extracardiac thoracic vascular abnormalities in young children with congenital heart diseases

OBJECTIVE

Congenital heart diseases in pediatric patients are associated with a wide variety of extracardiac thoracic vascular abnormalities. This study analyzed the value of gadolinium-enhanced magnetic resonance angiography during quiet free breathing for assessing extracardiac thoracic vascular abnormalities in young children with congenital heart diseases.

METHODS

Fifty-three children with congenital heart diseases (age range, 1 day-40 months; mean, 10.9 months) associated with extracardiac thoracic vascular abnormalities who had undergone both free-breathing, gadolinium-enhanced magnetic resonance angiography and cardiac catheterization, surgical intervention, or both within 2 weeks were reviewed. Diagnostic findings on gadolinium-enhanced magnetic resonance angiography among patients grouped according to 3 major conditions of conotruncal abnormalities (n = 33), aortic or venous abnormalities (n = 11), and pulmonary vascular abnormalities (n = 9), as well as associated extracardiac thoracic vascular abnormality findings, were compared with findings made by using cardiac catheterization, surgical intervention, or both.

RESULTS

Extracardiac thoracic vascular abnormality findings on gadolinium-enhanced magnetic resonance angiography were similar to those on catheterization, surgical intervention, or both in patients with conotruncal abnormalities (124 vs 127, P = .083), aortic or venous abnormalities (36 vs 33, P = .083), and pulmonary vascular abnormalities (24 vs 25, P = .317). The overall sensitivity of gadolinium-enhanced magnetic resonance angiography for detection of these lesions identified by means of catheterization, surgical intervention, or both was 97.9%. However, gadolinium-enhanced magnetic resonance angiography revealed 11 additional extracardiac thoracic vascular abnormalities that were not found on cardiac catheterization. The kappa coefficient for the correlation of image quality and diagnostic value of gadolinium-enhanced magnetic resonance angiography by using a 4-point-scale (1 = nondiagnostic to 4 = excellent) assessed by 2 independent reviewers was excellent (mean score = 3.66), with superb interobserver agreement (kappa = 0.727-0.874).

CONCLUSIONS

Free-breathing, gadolinium-enhanced magnetic resonance angiography is clinically feasible for detailed anatomic delineation and treatment planning of various extracardiac thoracic vascular abnormalities in young children with congenital heart diseases.

Management of the neonate with patent ductus arteriosus

Care of the preterm infant with a suspected or confirmed diagnosis of patent ductus arteriosus (PDA) is a frequent challenge for the neonatal nurse. Management of term infants with cardiac lesions dependent upon a PDA can be even more challenging. It is vital for neonatal nurses to understand the normal cardiovascular and pulmonary changes that occur at birth so they can anticipate pathological processes influencing the clinical course of an infant with a PDA. In addition, knowledge of current and effective treatment approaches is essential to providing optimal care for these vulnerable infants, as well as in guiding their parents. The purpose of this article is to review current information about PDA, including physiology, pathophysiology, pharmacological approaches, surgical considerations, complications and outcomes, parental support, and areas for future research.

Cardiac computed tomography compared to transthoracic echocardiography in the management of congenital heart disease

OBJECTIVES

To compare cardiac CT and transthoracic echocardiography (TTE) as diagnostic utilities in congenital heart disease (CHD) and to determine their advantages and limitations.

BACKGROUND

TTE is widely used in the evaluation of CHD. Recent reports suggested an increasing role of CT. However, there are few quantitative data on its diagnostic accuracy.

METHODS

We investigated a total of 162 patients (51.24% male; mean age: 16.06 +/-+/- 17.92) with congenital heart defects, who underwent electron beam CT (EBCT) and TTE between March 2002 and June 2005. We retrospectively analyzed a total of 667 findings, stratified for age and anatomic categories.

RESULTS

EBCT and TTE findings are concordant in patients below 1 year of age (85.43% agreement). EBCT had poor sensitivity and specificity in detecting anomalies of cardiac chambers (0.68, 0.58), but was useful for great arteries (0.91, 0.85). Furthermore, sensitivity and specificity were remarkably different in systemic venous return (0.93, 0.3) and coronary vessels (0.8, 0.33) because of "false positive" findings, which were later found to be most likely real findings not detectable by reference standard. The opposite was true for cardiac valves (0.66, 0.89) and septa (0.76, 0.91).

CONCLUSIONS

EBCT delineates findings related to systemic venous return and coronary vessels well due to simultaneous visualization of complex anatomy. This advantage does not seem to apply in patients below 1 year of age with better acoustic windows. TTE was found more suitable for cardiac valves and septal defects because of the availability of flow imaging.

Management of low birth weight infants with congenital heart disease

Low birth weight infants with congenital heart disease (CHD) have a higher mortality risk and likely a higher morbidity risk than their preterm or appropriate for gestational age counterparts without CHD and term counterparts with CHD. As our understanding of the pathophysiology and treatment of the diseases associated with prematurity and growth restriction improves, the outcomes for these infants should continue to improve. In addition, as more of these infants survive and are referred for surgery, operative techniques and strategies are likely to continue to improve. At this time, there is no adequate evidence that mortality is improved by delaying surgery for weight gain or performing palliative operations initially. Given the challenging physiology in this population, optimal management includes early referral to a tertiary or quaternary facility and a multidisciplinary team approach consisting of cardiologists, neonatologists, surgeons, nurses, perfusionists, and anesthesiologists.