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

Detection of congenital heart disease by neonatologist performed cardiac ultrasound in extreme preterm infants | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Detection of congenital heart disease by neonatologist performed cardiac ultrasound in extreme preterm infants Bradley MacDonald, Deane Yim, James Ramsay, Andrew Gill This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3984333/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose We aimed to assess the frequency and accuracy of neonatologist-performed cardiac ultrasound (NPCU) in detecting de novo congenital heart disease (CHD) in premature infants born at < 30 weeks of gestation. Methods This retrospective cross-sectional study was conducted on all NPCU studies performed at a tertiary-level neonatal department from January 2004 to June 2023. Clinicians completing the NPCU identified de novo suspected CHD at the time of the scan. All NPCUs were cross-checked with cardiology databases to confirm the final CHD diagnosis. Results A total of 3739 infants < 30 weeks’ gestation were admitted during the review period, 2088 (56%) of which received at least one NPCU; 294 (14%) were referred to pediatric cardiology and received an echocardiogram. CHD was confirmed in 109 of 2088 (5.2%) babies, 3 (3%) had critical disease, 8 (7%) had major cardiac anomalies, and 53 (49%) had non-major flagged CHD. No major or critical CHD was missed by the NPCU in the cohort. Conclusion De novo presentation of significant CHD still occurs in the preterm population and needs to be recognized by those performing NPCU. Ongoing training and collaboration with cardiology to optimize NPCU may provide benefits in the early referral and diagnosis of CHD. congenital heart disease echocardiography neonatologist performed ultrasound prematurity Figures Figure 1 What is known? Neonatologist performed cardiac ultrasound has potential to detect congenital heart disease with reliable anatomical concordance. What is new? Neonatologist-performed cardiac ultrasound reliably detects critical and major congenital heart disease, in premature infants, prompting early referral for ongoing management. With appropriate training, neonatologist-performed cardiac ultrasound may be an important adjunctive to already implemented screening methods for congenital heart disease. Introduction Congenital heart disease (CHD) is the most common birth defect, affecting 4–5 per 1000 live births worldwide[ 1 ]. The nature of CHD often has a profound influence on the lives of patients. In the first year, significant morbidity and mortality rates were associated with certain types of CHD. Delayed referral may increase the risk of death and serious lifelong morbidity[ 2 ]. Therefore, it is imperative for CHD that has not been prenatally diagnosed to be detected early by the treatment team and referred to cardiology for a timely formal diagnosis. The early detection of CHD has a measurable effect on CHD prevalence[ 3 ]. The use of neonatologist-performed cardiac ultrasound (NPCU) has increased over the past few decades[ 4 ]. In Australia and New Zealand, over 40% of neonatal intensive care units (NICU) perform NPCU, which is attributable to an improved advanced skill set of the performing clinician and readily available echocardiography machines and platforms[ 5 , 6 ]. This has been driven by the clinical need for echocardiography within a critical population and is utilized for prompt hemodynamic assessment, such as patent ductus arteriosus (PDA) assessment, systemic hypotension, and hypoxic respiratory failure[ 7 ]. The focus of NPCU on CHD is quite variable between centers, and the primary diagnosis of CHD by NPCU has only tangentially been addressed [ 8 ]. In addition, NPCU are largely completed in premature infants, where the risk of CHD may be higher and can significantly influence their clinical course. We aimed to assess the utility of NPCU in the detection of critical and major CHD in extreme prematurity. Our secondary objectives include a review of the nature of CHD not detected by the NPCU, as well as the assessment of CHD detection in the NPCU in infants of all gestations seen by our service. We have observed significant advances in fetal screening for CHD, including improved fetal echocardiography scanning and the addition of pulse oximetry screening. We aimed to assess the utility of NPCU in the detection of critical and major CHD in extreme prematurity. Our secondary objectives include a review of the nature of CHD not detected by the NPCU, as well as the assessment of CHD detection in the NPCU in infants of all gestations seen by our service. Material and methods Setting King Edward’s Memorial Hospital for Children is the primary tertiary perinatal center in Western Australia (WA) that cares for all extremely premature infants born in the state. Author AG introduced a formal training program in NPCU in 2003. This program was developed in conjunction with pediatric cardiologists and emphasizes the importance of defining anatomy in addition to hemodynamic assessment. The training program is affiliated with the Australian Society of Ultrasound in Medicine certificate in Clinician Performed Ultrasound. At the outset, a formal electronic reporting system was introduced. Infants with suspected cardiac anomalies were referred to the WA Pediatric Cardiology Team. The Perth Children’s Hospital Cardiology Centre is the only tertiary pediatric cardiology center in the state and care for most CHD patients in the jurisdiction. The center also provides quaternary fetal screening. Pediatric cardiology data were also recorded in an electronic database (Synapse™ Cardiovascular Client V4.0.4, Fujifilm Medical Systems USA) and a clinical cardiology database (Cardiobase™, Version 8.1.44.10, Derby, UK). Cases Patients with suspected CHD were identified from neonatal electronic records and cross-checked with a formal pediatric cardiology scan. As we sought to identify only those cases selected de novo by the NPCU, infants with antenatally expected CHD, those previously scanned and identified by cardiology, or with syndromes suggestive of CHD were excluded. We restricted the analysis to infants less than 30 weeks of gestational age, as these infants were most likely to receive NPCU. Infants greater than 30 weeks of gestation were more likely to be scanned for clinical symptoms suggestive of CHD, rather than hemodynamic assessment. In our center, patients with PDA at discharge are referred to cardiology, even though they do not meet the formal definition of CHD based on age (> 3 months corrected gestational age). As such, we excluded patients with PDA identified on the NPCU for cardiology referral, as few of them met the CHD criteria. Definitions CHD was defined in accordance with the International Pediatric Congenital Cardiac Code[ 9 ]. In this study, critical CHD was defined as requiring surgical or catheter-based intervention at less than 30 days of life (or death prior to surgery that would otherwise be critical), major as having intervention at less than 12 months of life, and non-major as having either no intervention or required intervention at 12 months of age or greater [ 10 ]. Extreme prematurity was defined as less than 30 weeks of gestation at birth. Patients were included if they had undergone NPCU and had a concurrent or formal echocardiogram at any point during childhood. Every patient with suspected CHD on the NPCU was referred to the cardiology department. To determine the accuracy of NPCU, the cohort was subdivided into a flagged group, defined as patients flagged for CHD by NPCU with diagnosis confirmed with a formal echocardiogram, and the other group, who were not referred to cardiology based on NPCU but by other means (clinical signs, follow-up review, etc.). In addition to the critical/major CHD requiring intervention, we audited the acquisition of the non-major CHD diagnosis on the NPCU. Statistical Analysis Demographic and clinical information are presented as proportions with percentages or medians with interquartile ranges. Odds ratios with confidence intervals were used to reflect the likelihood of NPCU in screening for CHD within the cohort. All statistical analyses were performed using R, Version 1.4.1717 (R Foundation for Statistical Computing, Vienna, Austria)[ 11 ]. Ethical approval Ethics approval for this study was obtained from the Child and Adolescent Health Service Human Research Ethics Council under the Medicine Division: Cardiology Committee with approval number 2023-000444. All research was conducted in accordance with the ethical standards of the institutional ethics committee with waiver of consent. Results Of the 3739 extremely preterm infants admitted to our service during this period, 2088 (56%) received an NPCU. In total, 2886 infants received NPCU between 2004 and 2023, of which 669 were excluded as they were 30 weeks of gestation or greater at birth and 129 with PDA alone. Sixteen patients with a syndromic diagnosis associated with CHD and 64 with suspected CHD on antenatal imaging were also excluded. Of these infants, 293 (14%) had a formal cardiology echocardiogram, of which 12 (<1%) had CHD requiring cardiac intervention. There were 3 patients had critical CHD, eight had major CHD, and one had non-major CHD that required cardiac intervention. The flow diagram of the study population is shown in Figure 1 . Of the preterm cohort, there were 293 patients referred to our cardiologists from the NPCU, and 109 (38%) had CHD. In total, 64 (58% of those with CHD) were flagged and referred after suspicion of CHD during NPCU, with 45 (42%) in the other group referred by other means. The patients’ baseline characteristics are listed in Table 1 . The NPCU flagged 183 cases that did not have CHD and reliably excluded 1794 cases (true negatives). Only one surgical procedure was detected in the other group, but occurred after one year of life and was non-major. Eleven patients in the flagged group had critical or major CHD undergoing cardiac surgery or procedures in the flagged group. Other demographic features were comparable between the groups, including location in a metropolitan area (35 patients in the other group and 35 in the flagged group), although 23 patients had no recorded postcodes. Gestational age and sex distributions were comparable ( Table 1 ). CHD flagged by NPCU included ASD (17%), PS (28%), and VSD (39%) ( Table 2 ). Most of the cardiac lesions not flagged by the NPCU included ASD (37%), PS (50%), and VSD (11%). All critical or major lesions that required immediate intervention were flagged by the NPCU. One patient in the false-negative group had CHD classified as non-major but did not require intervention within the first year of life for balloon pulmonary valvuloplasty in the context of pulmonary stenosis. Two patients with critical CHD died without surgical intervention due to factors such as CHD and prematurity. One patient was diagnosed with pulmonary atresia that did not receive intervention and the other had tetralogy of Fallot; however, both patients also had complications associated with prematurity contributing to the outcome. The odds ratio of CHD diagnosis if flagged during NPCU in prematurity (<30 weeks gestation) was 13.64 (9.07, 20.52), with a positive predictive value of 26% (sensitivity 58%, specificity 91%). At greater than 30 weeks gestation the odds ratio is 15.33 (7.71, 30.48) and for the whole cohort is 14.92 (10.71, 20.79). An overall incidence rate of 6.46 per 1000 live births was noted in our tertiary level center. In the 669 infants born at 30 weeks of gestation or greater, 71 were flagged correctly by NPCU, with 10 in the other group. Diagnoses included PS (50%), ASD (30%) or VSD (10%). In the other group, all CHD were non-major, with no cardiac interventions required to date. A further 354 patients were correctly excluded by the NPCU for CHD ( true negatives ) and 164 patients were flagged for cardiology review by the NPCU but did not have a diagnosis of CHD. Discussion Neonatologists perform cardiac ultrasound (NPCU) as an important assessment tool to assess cardiac hemodynamics in premature and unwell neonates. In extremely premature infants routinely receiving NPCU studies, we identified 109 (5%) with a de novo diagnosis of congenital heart disease (CHD) and 11 with critical or major CHD conditions requiring early cardiac intervention that may have otherwise been diagnosed later. All patients were appropriately referred to. The NPCU was able to facilitate prompt cardiac referral and inform early management in all cases. No major or critical CHD were missed on NPCU flagged cardiac scans. Our study suggests that NPCU still detects de novo CHD despite the implementation of modern antenatal imaging and pulse oximetry saturation screening techniques. As such, NPCU-trained clinicians should be adept at recognizing abnormalities in cardiac structures. In Australia, training for neonatologists in echocardiography is guided by the Asian Society for Ultrasound in Medicine, resulting in a Certificate of Clinician-Performed Ultrasound with significant hands-on training[12]. Although the NPCU is not used as a screening tool for CHD, it is important that neonatologists can exclude CHD to appropriately assess hemodynamics and that this is rigorously taught[13]. This is partly because appropriate hemodynamic assessment, for example, assessment of a PDA, is not necessarily possible in the presence of congenital heart disease. Effective NPCU services should be able to identify lesions using structured training and appropriate supervision. They should then closely collaborate with cardiology services to ensure optimal follow-up and care[12,14]. If a center is implementing an NPCU, adequate attention to training and support is paramount to the reliable detection of CHD and subsequent appropriate hemodynamic assessment. NPCU training must include the recognition of CHD with scans required to demonstrate normal cardiac chambers, connections, and valves. Currently, the degree to which this is practiced varies widely across countries and neonatology centers. CHD continues to be detected by the NPCU despite multiple advances in antenatal and postnatal screening for CHD. In Australia, obstetric ultrasonography has seen recent advances that have contributed to the detection of CHD[15]. NPCU may also be considered within the spectrum of tools available to detect CHD and are being increasingly used in Australia[5,6,8]. In particular, knowing that each of these measures can continue to miss critical CHD [16]. With appropriate training and close integration with pediatric cardiology services, the NPCU can potentially improve issues with current screening for CHD. Other Australian studies have shown de novo CHD diagnosis by NPCU in 14% of CHD cases, but a vast majority were still diagnosed antenatally [14]. Our overall rate of CHD detection remains like that of other studies but did not improve the detection of critical CHD with a high rate of false positives [17]. In our cohort, the odds of CHD were significantly higher if flagged by the NPCU early in life. The exact diagnosis is less important in our clinical environment than the prompt recognition of abnormal anatomy, leading to the need for referral. Decreased precision in recognizing more minor anomalies is expected in sonographers with varying experiences and in those with complex cardiac lesions [18]. Errors in detection continue to occur within other screening methods and may be related to the frequency of sonographer experience [19] as well as the weight of the baby being scanned [20]. Some of these lesions are not routinely determined on NPCU, and others, such as pulmonary stenosis, may not be obvious in the first few days of life when NPCU is routinely performed. Our data were obtained from a tertiary-level NICU with close collaborative ties with pediatric cardiology services. Cardiology-led echocardiography and reviews are readily available. Our perspective may not translate into other centers where NPCU are more integral to initial screening, especially if there are delays in accessing timely cardiology services or neonatal transfers are necessary. The accuracy of diagnosis by neonatologists needs to be further explored, and anatomic concordance data were not available for this study because of our referral process. Many NPCU scans were ceased upon the finding of suspected CHD and were referred for a formal scan once concerns were raised. The retrospective nature of the study design is a limitation. This means that the earlier scans may not have been performed in a structured stepwise approach, and the indications for NPCU were clinician-driven as opposed to guideline-driven, as they are now. We acknowledge that minor CHD may still exist but is undiagnosed in the true negative group, and that younger members of the cohort may also receive cardiac intervention in the future. Abbreviations *CHD congenital heart disease NPCU neonatologist performed cardiac ultrasound neonatal intensive care unit NICU PDA patent ductus arteriosus. Conclusion The NPCU has been shown to accurately identify CHD in patients without a prior prenatal diagnosis and can lead to earlier diagnosis, cardiology referral, and treatment. The success of the NPCU involves clear and structured guidelines for its performance, appropriate training, accreditation, and supervision, as well as strong collaboration between neonatal and cardiology services. Future directions for NPCU should be taken in the context of improvements to both prenatal diagnosis and postnatal screening. Declarations Author contributions: AG and JR conceptualised the paper. BM collected data, completed applications, analysed data, and produced the manuscript. Manuscript and analysis review was completed by AG and DY. Competing interests: BM received the Royal Australasian College of Physicians Eric Burnard Fellowship for funding. All other authors disclose no conflict of interest. Acknowledgements: BM would like to thank the RACP (Royal Australasian College of Physicians) Foundation for the Eric Burnard Fellowship for funding support with this research. References Hoffman JIE, Kaplan S. The incidence of congenital heart disease. J Am Coll Cardiol 2002; 39 :1890–900. Brown KL, Ridout DA, Hoskote A, et al. Delayed diagnosis of congenital heart disease worsens preoperative condition and outcome of surgery in neonates. Heart 2006; 92 :1298–302. van der Bom T, Zomer AC, Zwinderman AH, et al. The changing epidemiology of congenital heart disease. Nat Rev Cardiol 2011; 8 :50–60. Groves AM, Singh Y, Dempsey E, et al. Introduction to neonatologist-performed echocardiography. Pediatr Res 2018; 84 :1–12. Evans N. Echocardiography on neonatal intensive care units in Australia and New Zealand. J Paediatr Child Health 2000; 36 :169–71. Sehgal A, Mehta S, Evans N, et al. Cardiac sonography by the neonatologist: clinical usefulness and educational perspective. J Ultrasound Med 2014; 33 :1401–6. Groves AM, Kuschel CA, Skinner JR. International Perspectives The Neonatologist as an Echocardiographer. Neoreviews 2006; 7 :e391–9. Samson GR, Kumar SR. A study of congenital cardiac disease in a neonatal population--the validity of echocardiography undertaken by a neonatologist. Cardiol Young 2004; 14 :585–93. Jacobs JP, Franklin RCG, Béland MJ, et al. Nomenclature for Pediatric and Congenital Cardiac Care: Unification of Clinical and Administrative Nomenclature - The 2021 International Pediatric and Congenital Cardiac Code (IPCCC) and the Eleventh Revision of the International Classification of Diseases (ICD-11). Cardiol Young 2021; 31 :1057–188. Ewer AK, Middleton LJ, Furmston AT, et al. Pulse oximetry screening for congenital heart defects in newborn infants (PulseOx): a test accuracy study. Lancet 2011; 378 :785–94. R Core Team. R: A Language and Environment for Statistical Computing. R Foundation for Statistical Computing, Vienna, Austria Published Online First: 2021.https://www.R-project.org/ Evans N, Gournay V, Cabanas F, et al. Point-of-care ultrasound in the neonatal intensive care unit: international perspectives. Semin Fetal Neonatal Med 2011; 16 :61–8. Singh Y, Tissot C, Fraga MV, et al. International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC). Crit Care 2020; 24 :65. Priyadarshi A, Klimek J. Neonatal cardiac ultrasound: How accurate are we? Australas J Ultrasound Med 2017; 20 :66–71. Mogra R. Simplifying ultrasound assessment of the fetal heart: Incorporating the complete Three Vessel View into routine screening. Australas J Ultrasound Med 2013; 16 :168–75. Martin GR, Schwartz BN, Hom LA, et al. Lessons Learned from Infants with Late Detection of Critical Congenital Heart Disease. Pediatr Cardiol 2022; 43 :580–5. Kondo M, Ohishi A, Baba T, et al. Can echocardiographic screening in the early days of life detect critical congenital heart disease among apparently healthy newborns? BMC Pediatr 2018; 18 :359. Saraf RP, Suresh P, Maheshwari S, et al. Pediatric echocardiograms performed at primary centers: Diagnostic errors and missing links! Ann Pediatr Cardiol 2015; 8 :20–4. van Nisselrooij AEL, Teunissen AKK, Clur SA, et al. Why are congenital heart defects being missed? Ultrasound Obstet Gynecol 2020; 55 :747–57. Dorfman AL, Levine JC, Colan SD, et al. Accuracy of echocardiography in low birth weight infants with congenital heart disease. Pediatrics 2005; 115 :102–7. Tables Table 1: Baseline characteristics of patients undergoing NPCU with formal CHD diagnosis by referral from NPCU or referral by other means. Demographics Flagged by NPCU n = 64 Other referral n = 45 Gestational age (weeks) 26.3 (3.2) 26.3 (2.0) Sex, female 33 (51) 24 (52) Critical CHD 3 (5) 0 (0) Major CHD 8 (12) 0 (0) Non-Major CHD 53 (83) 45 (100) Cardiac surgery (initial) Coarctation repair 3 (5) 0 (0) Balloon Pulmonary Valvotomy 1 (2) 1 (2) Tetralogy of Fallot repair 2 (3) 0 (0) Ventricular septal defect repair 3 (5) 0 (0) Death prior to surgery 2 (3) 0 (0) *PDA not a primary diagnosis Table 2: Congenital heart disease (CHD) diagnosis in the flagged and other groups of patients undergoing neonatologist performed cardiac ultrasound. All CHD Critical/major CHD Non-major CHD Diagnosis Flagged Other Flagged* Other Flagged Other Total 64 45 11 0 53 45 Atrial septal defect 11 (17) 17 (37) 0 (0) 0 (0) 11 (21) 17 (37) Bicuspid aortic valve 0 (0) 1 (2) 0 (0) 0 (0) 0 1 (2) Coarctation/ hypoplastic aortic arch 4 (6) 0 (0) 3 (27) 0 (0) 1 (2) 0 (0) Left ventricular outflow tract obstruction 1 (1) 0 (0) 0 (0) 0 (0) 1 (2) 0 (0) Pulmonary atresia 1 (1) 0 (0) 1 (1) 0 (0) 0 (0) 0 (0) Pulmonary stenosis 18 (28) 22 (50) 1 (9) 0 (0) 17 (32) 22 (49) Tetralogy of Fallot 4 (6) 0 (0) 3 (27) 0 (0) 1 (2) 0 (0) Ventricular septal defect 25 (39) 5 (11) 3 (27) 0 (0) 22 (41) 5 (11) 1 n (%) *Includes two critical patients that passed away with no surgery Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3984333","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":275186090,"identity":"f403afd2-3f5b-4109-92ea-49207ba21788","order_by":0,"name":"Bradley MacDonald","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYBACNmbG9h8ffvzj4YfwmQlr4WdvPiA5s+eAnGQDsVoke44lSPOwHTA2OECsFoMbOQYGPDx3EjffyDH8wFBhndjAfsaAoJYECYtnidtu5BhLMJxJT2zgySGs5YABDzNQS+4GCca2w4kNDIS1GDYksDEnbp6Ru/kH4z+gFv43+LUAvZ/McIDtsLGBRO42CcYGoBYJArYAA/kYY2NPmpzEmfffLBKOpRu3STwrwKsFGJVtzH9+2PDwt6cl3/hQYy3bz5+8Aa8WVJAAMoQE9aNgFIyCUTAKcAAATURLDMEwZ+oAAAAASUVORK5CYII=","orcid":"","institution":"University of Western Australia","correspondingAuthor":true,"prefix":"","firstName":"Bradley","middleName":"","lastName":"MacDonald","suffix":""},{"id":275186091,"identity":"5511c42b-6f2c-4aa5-94fe-470f6c3705c8","order_by":1,"name":"Deane Yim","email":"","orcid":"","institution":"Perth Children's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Deane","middleName":"","lastName":"Yim","suffix":""},{"id":275186092,"identity":"81729390-88f4-4a73-a91d-c6306ad0a4ea","order_by":2,"name":"James Ramsay","email":"","orcid":"","institution":"Perth Children's Hospital","correspondingAuthor":false,"prefix":"","firstName":"James","middleName":"","lastName":"Ramsay","suffix":""},{"id":275186093,"identity":"7e4531a9-60df-4dd4-8cc5-867b57835c13","order_by":3,"name":"Andrew Gill","email":"","orcid":"","institution":"Perth Children's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Andrew","middleName":"","lastName":"Gill","suffix":""}],"badges":[],"createdAt":"2024-02-24 08:06:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3984333/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3984333/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":51825553,"identity":"f8325e9f-3937-4145-b55a-5d94a7195ac5","added_by":"auto","created_at":"2024-02-29 17:00:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":200513,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eNeonatologist-performed cardiac ultrasound (NPCU) patients with subsequent cardiology-led echocardiogram and formal diagnosis of congenital heart disease (CHD).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e*CHD = congenital heart disease; NPCU = neonatologist performed cardiac ultrasound; neonatal intensive care unit = NICU\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3984333/v1/20ce235ae5cf6ad182c201a9.png"},{"id":51896931,"identity":"2f073237-4de5-4109-9742-17386d59db6a","added_by":"auto","created_at":"2024-03-02 11:43:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":408704,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3984333/v1/2e62363b-0a18-40e1-a45c-d9f09eff9a3b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Detection of congenital heart disease by neonatologist performed cardiac ultrasound in extreme preterm infants","fulltext":[{"header":"What is known?","content":"\u003cul\u003e\n \u003cli\u003eNeonatologist performed cardiac ultrasound has potential to detect congenital heart disease with reliable anatomical concordance.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eWhat is new?\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eNeonatologist-performed cardiac ultrasound reliably detects critical and major congenital heart disease, in premature infants, prompting early referral for ongoing management.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWith appropriate training, neonatologist-performed cardiac ultrasound may be an important adjunctive to already implemented screening methods for congenital heart disease.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eCongenital heart disease (CHD) is the most common birth defect, affecting 4\u0026ndash;5 per 1000 live births worldwide[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The nature of CHD often has a profound influence on the lives of patients. In the first year, significant morbidity and mortality rates were associated with certain types of CHD. Delayed referral may increase the risk of death and serious lifelong morbidity[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Therefore, it is imperative for CHD that has not been prenatally diagnosed to be detected early by the treatment team and referred to cardiology for a timely formal diagnosis. The early detection of CHD has a measurable effect on CHD prevalence[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe use of neonatologist-performed cardiac ultrasound (NPCU) has increased over the past few decades[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In Australia and New Zealand, over 40% of neonatal intensive care units (NICU) perform NPCU, which is attributable to an improved advanced skill set of the performing clinician and readily available echocardiography machines and platforms[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This has been driven by the clinical need for echocardiography within a critical population and is utilized for prompt hemodynamic assessment, such as patent ductus arteriosus (PDA) assessment, systemic hypotension, and hypoxic respiratory failure[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The focus of NPCU on CHD is quite variable between centers, and the primary diagnosis of CHD by NPCU has only tangentially been addressed [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In addition, NPCU are largely completed in premature infants, where the risk of CHD may be higher and can significantly influence their clinical course. We aimed to assess the utility of NPCU in the detection of critical and major CHD in extreme prematurity. Our secondary objectives include a review of the nature of CHD not detected by the NPCU, as well as the assessment of CHD detection in the NPCU in infants of all gestations seen by our service.\u003c/p\u003e \u003cp\u003eWe have observed significant advances in fetal screening for CHD, including improved fetal echocardiography scanning and the addition of pulse oximetry screening. We aimed to assess the utility of NPCU in the detection of critical and major CHD in extreme prematurity. Our secondary objectives include a review of the nature of CHD not detected by the NPCU, as well as the assessment of CHD detection in the NPCU in infants of all gestations seen by our service.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003eKing Edward\u0026rsquo;s Memorial Hospital for Children is the primary tertiary perinatal center in Western Australia (WA) that cares for all extremely premature infants born in the state. Author AG introduced a formal training program in NPCU in 2003. This program was developed in conjunction with pediatric cardiologists and emphasizes the importance of defining anatomy in addition to hemodynamic assessment. The training program is affiliated with the Australian Society of Ultrasound in Medicine certificate in Clinician Performed Ultrasound. At the outset, a formal electronic reporting system was introduced. Infants with suspected cardiac anomalies were referred to the WA Pediatric Cardiology Team.\u003c/p\u003e \u003cp\u003eThe Perth Children\u0026rsquo;s Hospital Cardiology Centre is the only tertiary pediatric cardiology center in the state and care for most CHD patients in the jurisdiction. The center also provides quaternary fetal screening. Pediatric cardiology data were also recorded in an electronic database (Synapse\u0026trade; Cardiovascular Client V4.0.4, Fujifilm Medical Systems USA) and a clinical cardiology database (Cardiobase\u0026trade;, Version 8.1.44.10, Derby, UK).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eCases\u003c/h2\u003e \u003cp\u003ePatients with suspected CHD were identified from neonatal electronic records and cross-checked with a formal pediatric cardiology scan. As we sought to identify only those cases selected \u003cem\u003ede novo\u003c/em\u003e by the NPCU, infants with antenatally expected CHD, those previously scanned and identified by cardiology, or with syndromes suggestive of CHD were excluded. We restricted the analysis to infants less than 30 weeks of gestational age, as these infants were most likely to receive NPCU. Infants greater than 30 weeks of gestation were more likely to be scanned for clinical symptoms suggestive of CHD, rather than hemodynamic assessment. In our center, patients with PDA at discharge are referred to cardiology, even though they do not meet the formal definition of CHD based on age (\u0026gt;\u0026thinsp;3 months corrected gestational age). As such, we excluded patients with PDA identified on the NPCU for cardiology referral, as few of them met the CHD criteria.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eDefinitions\u003c/h2\u003e \u003cp\u003eCHD was defined in accordance with the International Pediatric Congenital Cardiac Code[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In this study, critical CHD was defined as requiring surgical or catheter-based intervention at less than 30 days of life (or death prior to surgery that would otherwise be critical), major as having intervention at less than 12 months of life, and non-major as having either no intervention or required intervention at 12 months of age or greater [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Extreme prematurity was defined as less than 30 weeks of gestation at birth.\u003c/p\u003e \u003cp\u003ePatients were included if they had undergone NPCU and had a concurrent or formal echocardiogram at any point during childhood. Every patient with suspected CHD on the NPCU was referred to the cardiology department. To determine the accuracy of NPCU, the cohort was subdivided into a \u003cem\u003eflagged\u003c/em\u003e group, defined as patients flagged for CHD by NPCU with diagnosis confirmed with a formal echocardiogram, and the \u003cem\u003eother\u003c/em\u003e group, who were not referred to cardiology based on NPCU but by other means (clinical signs, follow-up review, etc.). In addition to the critical/major CHD requiring intervention, we audited the acquisition of the non-major CHD diagnosis on the NPCU.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eDemographic and clinical information are presented as proportions with percentages or medians with interquartile ranges. Odds ratios with confidence intervals were used to reflect the likelihood of NPCU in screening for CHD within the cohort. All statistical analyses were performed using R, Version 1.4.1717 (R Foundation for Statistical Computing, Vienna, Austria)[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003cp\u003e\u003cem\u003eEthical approval\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval for this study was obtained from the Child and Adolescent Health Service Human Research Ethics Council under the Medicine Division: Cardiology Committee with approval number 2023-000444. All research was conducted in accordance with the ethical standards of the institutional ethics committee with waiver of consent.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 3739 extremely preterm infants admitted to our service during this period, 2088 (56%) received an NPCU. In total, 2886 infants received NPCU between 2004 and 2023, of which 669 were excluded as they were 30 weeks of gestation or greater at birth and 129 with PDA alone. Sixteen patients with a syndromic diagnosis associated with CHD and 64 with suspected CHD on antenatal imaging were also excluded.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOf these infants, 293 (14%) had a formal cardiology echocardiogram, of which 12 (\u0026lt;1%) had CHD requiring cardiac intervention. There were 3 patients had critical CHD, eight had major CHD, and one had non-major CHD that required cardiac intervention. The flow diagram of the study population is shown in \u003cem\u003eFigure 1\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eOf the preterm cohort, there were 293 patients referred to our cardiologists from the NPCU, and 109 (38%) had CHD. In total, 64 (58% of those with CHD) were \u003cem\u003eflagged\u0026nbsp;\u003c/em\u003eand referred after suspicion of CHD during NPCU, with 45 (42%) in the \u003cem\u003eother\u0026nbsp;\u003c/em\u003egroup referred by other means. The patients\u0026rsquo; baseline characteristics are listed in \u003cem\u003eTable 1\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eThe NPCU \u003cem\u003eflagged\u0026nbsp;\u003c/em\u003e183 cases that did not have CHD and reliably excluded 1794 cases (true negatives). Only one surgical procedure was detected in the \u003cem\u003eother\u003c/em\u003e group, but occurred after one year of life and was non-major. Eleven patients in the flagged group had critical or major CHD undergoing cardiac surgery or procedures in the \u003cem\u003eflagged\u0026nbsp;\u003c/em\u003egroup. Other demographic features were comparable between the groups, including location in a metropolitan area (35 patients in the \u003cem\u003eother\u0026nbsp;\u003c/em\u003egroup and 35 in the \u003cem\u003eflagged\u0026nbsp;\u003c/em\u003egroup), although 23 patients had no recorded postcodes. Gestational age and sex distributions were comparable (\u003cem\u003eTable 1\u003c/em\u003e).\u003c/p\u003e\n\u003cp\u003eCHD flagged by NPCU included ASD (17%), PS (28%), and VSD (39%) (\u003cem\u003eTable 2\u003c/em\u003e). Most of the cardiac lesions not flagged by the NPCU included ASD (37%), PS (50%), and VSD (11%). All critical or major lesions that required immediate intervention were flagged by the NPCU. One patient in the false-negative group had CHD classified as non-major but did not require intervention within the first year of life for balloon pulmonary valvuloplasty in the context of pulmonary stenosis. Two patients with critical CHD died without surgical intervention due to factors such as CHD and prematurity. One patient was diagnosed with pulmonary atresia that did not receive intervention and the other had tetralogy of Fallot; however, both patients also had complications associated with prematurity contributing to the outcome. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe odds ratio of CHD diagnosis if flagged during NPCU in prematurity (\u0026lt;30 weeks gestation) was 13.64 (9.07, 20.52), with a positive predictive value of 26% (sensitivity 58%, specificity 91%). At greater than 30 weeks gestation the odds ratio is 15.33 (7.71, 30.48) and for the whole cohort is 14.92 (10.71, 20.79).\u003c/p\u003e\n\u003cp\u003eAn overall incidence rate of 6.46 per 1000 live births was noted in our tertiary level center. In the 669 infants born at 30 weeks of gestation or greater, 71 were flagged correctly by NPCU, with 10 in the \u003cem\u003eother\u0026nbsp;\u003c/em\u003egroup. Diagnoses included PS (50%), ASD (30%) or VSD (10%). In the \u003cem\u003eother\u0026nbsp;\u003c/em\u003egroup, all CHD were non-major, with no cardiac interventions required to date. A further 354 patients were correctly excluded by the NPCU for CHD (\u003cem\u003etrue negatives\u003c/em\u003e) and 164 patients were flagged for cardiology review by the NPCU but did not have a diagnosis of CHD.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eNeonatologists perform cardiac ultrasound (NPCU) as an important assessment tool to assess cardiac hemodynamics in premature and unwell neonates. In extremely premature infants routinely receiving NPCU studies, we identified 109 (5%) with a \u003cem\u003ede novo \u003c/em\u003ediagnosis of congenital heart disease (CHD) and 11 with critical or major CHD conditions requiring early cardiac intervention that may have otherwise been diagnosed later. All patients were appropriately referred to. The NPCU was able to facilitate prompt cardiac referral and inform early management in all cases. No major or critical CHD were missed on NPCU \u003cem\u003eflagged \u003c/em\u003ecardiac scans. Our study suggests that NPCU still detects \u003cem\u003ede novo \u003c/em\u003eCHD despite the implementation of modern antenatal imaging and pulse oximetry saturation screening techniques. As such, NPCU-trained clinicians should be adept at recognizing abnormalities in cardiac structures. \u003c/p\u003e\n\u003cp\u003eIn Australia, training for neonatologists in echocardiography is guided by the Asian Society for Ultrasound in Medicine, resulting in a Certificate of Clinician-Performed Ultrasound with significant hands-on training[12]. Although the NPCU is not used as a screening tool for CHD, it is important that neonatologists can exclude CHD to appropriately assess hemodynamics and that this is rigorously taught[13]. This is partly because appropriate hemodynamic assessment, for example, assessment of a PDA, is not necessarily possible in the presence of congenital heart disease. Effective NPCU services should be able to identify lesions using structured training and appropriate supervision. They should then closely collaborate with cardiology services to ensure optimal follow-up and care[12,14]. If a center is implementing an NPCU, adequate attention to training and support is paramount to the reliable detection of CHD and subsequent appropriate hemodynamic assessment. NPCU training must include the recognition of CHD with scans required to demonstrate normal cardiac chambers, connections, and valves. Currently, the degree to which this is practiced varies widely across countries and neonatology centers. \u003c/p\u003e\n\u003cp\u003eCHD continues to be detected by the NPCU despite multiple advances in antenatal and postnatal screening for CHD. In Australia, obstetric ultrasonography has seen recent advances that have contributed to the detection of CHD[15]. NPCU may also be considered within the spectrum of tools available to detect CHD and are being increasingly used in Australia[5,6,8]. In particular, knowing that each of these measures can continue to miss critical CHD [16]. With appropriate training and close integration with pediatric cardiology services, the NPCU can potentially improve issues with current screening for CHD. Other Australian studies have shown \u003cem\u003ede novo \u003c/em\u003eCHD diagnosis by NPCU in 14% of CHD cases, but a vast majority were still diagnosed antenatally [14]. \u003c/p\u003e\n\u003cp\u003eOur overall rate of CHD detection remains like that of other studies but did not improve the detection of critical CHD with a high rate of false positives [17]. In our cohort, the odds of CHD were significantly higher if flagged by the NPCU early in life. The exact diagnosis is less important in our clinical environment than the prompt recognition of abnormal anatomy, leading to the need for referral. Decreased precision in recognizing more minor anomalies is expected in sonographers with varying experiences and in those with complex cardiac lesions [18]. Errors in detection continue to occur within other screening methods and may be related to the frequency of sonographer experience [19] as well as the weight of the baby being scanned [20]. Some of these lesions are not routinely determined on NPCU, and others, such as pulmonary stenosis, may not be obvious in the first few days of life when NPCU is routinely performed.\u003c/p\u003e\n\u003cp\u003eOur data were obtained from a tertiary-level NICU with close collaborative ties with pediatric cardiology services. Cardiology-led echocardiography and reviews are readily available. Our perspective may not translate into other centers where NPCU are more integral to initial screening, especially if there are delays in accessing timely cardiology services or neonatal transfers are necessary. The accuracy of diagnosis by neonatologists needs to be further explored, and anatomic concordance data were not available for this study because of our referral process. Many NPCU scans were ceased upon the finding of suspected CHD and were referred for a formal scan once concerns were raised. The retrospective nature of the study design is a limitation. This means that the earlier scans may not have been performed in a structured stepwise approach, and the indications for NPCU were clinician-driven as opposed to guideline-driven, as they are now. We acknowledge that minor CHD may still exist but is undiagnosed in the true negative group, and that younger members of the cohort may also receive cardiac intervention in the future.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cem\u003e*CHD\u003c/em\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003econgenital heart disease\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cem\u003eNPCU\u003c/em\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eneonatologist performed cardiac ultrasound\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cem\u003eneonatal intensive care unit\u003c/em\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eNICU\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cem\u003ePDA\u003c/em\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003epatent ductus arteriosus.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe NPCU has been shown to accurately identify CHD in patients without a prior prenatal diagnosis and can lead to earlier diagnosis, cardiology referral, and treatment. The success of the NPCU involves clear and structured guidelines for its performance, appropriate training, accreditation, and supervision, as well as strong collaboration between neonatal and cardiology services. Future directions for NPCU should be taken in the context of improvements to both prenatal diagnosis and postnatal screening.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u0026nbsp;\u003c/strong\u003eAG and JR conceptualised the paper. BM collected data, completed applications, analysed data, and produced the manuscript. Manuscript and analysis review was completed by AG and DY.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eBM received the Royal Australasian College of Physicians Eric Burnard Fellowship for funding. All other authors disclose no conflict of interest.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eBM would like to thank the RACP (Royal Australasian College of Physicians) Foundation for the Eric Burnard Fellowship for funding support with this research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHoffman JIE, Kaplan S. The incidence of congenital heart disease. \u003cem\u003eJ Am Coll Cardiol\u003c/em\u003e 2002;\u003cstrong\u003e39\u003c/strong\u003e:1890\u0026ndash;900.\u003c/li\u003e\n\u003cli\u003eBrown KL, Ridout DA, Hoskote A, \u003cem\u003eet al.\u003c/em\u003e Delayed diagnosis of congenital heart disease worsens preoperative condition and outcome of surgery in neonates. \u003cem\u003eHeart\u003c/em\u003e 2006;\u003cstrong\u003e92\u003c/strong\u003e:1298\u0026ndash;302.\u003c/li\u003e\n\u003cli\u003evan der Bom T, Zomer AC, Zwinderman AH, \u003cem\u003eet al.\u003c/em\u003e The changing epidemiology of congenital heart disease. \u003cem\u003eNat Rev Cardiol\u003c/em\u003e 2011;\u003cstrong\u003e8\u003c/strong\u003e:50\u0026ndash;60.\u003c/li\u003e\n\u003cli\u003eGroves AM, Singh Y, Dempsey E, \u003cem\u003eet al.\u003c/em\u003e Introduction to neonatologist-performed echocardiography. \u003cem\u003ePediatr Res\u003c/em\u003e 2018;\u003cstrong\u003e84\u003c/strong\u003e:1\u0026ndash;12.\u003c/li\u003e\n\u003cli\u003eEvans N. Echocardiography on neonatal intensive care units in Australia and New Zealand. \u003cem\u003eJ Paediatr Child Health\u003c/em\u003e 2000;\u003cstrong\u003e36\u003c/strong\u003e:169\u0026ndash;71.\u003c/li\u003e\n\u003cli\u003eSehgal A, Mehta S, Evans N, \u003cem\u003eet al.\u003c/em\u003e Cardiac sonography by the neonatologist: clinical usefulness and educational perspective. \u003cem\u003eJ Ultrasound Med\u003c/em\u003e 2014;\u003cstrong\u003e33\u003c/strong\u003e:1401\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eGroves AM, Kuschel CA, Skinner JR. International Perspectives The Neonatologist as an Echocardiographer. \u003cem\u003eNeoreviews\u003c/em\u003e 2006;\u003cstrong\u003e7\u003c/strong\u003e:e391\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eSamson GR, Kumar SR. A study of congenital cardiac disease in a neonatal population--the validity of echocardiography undertaken by a neonatologist. \u003cem\u003eCardiol Young\u003c/em\u003e 2004;\u003cstrong\u003e14\u003c/strong\u003e:585\u0026ndash;93.\u003c/li\u003e\n\u003cli\u003eJacobs JP, Franklin RCG, B\u0026eacute;land MJ, \u003cem\u003eet al.\u003c/em\u003e Nomenclature for Pediatric and Congenital Cardiac Care: Unification of Clinical and Administrative Nomenclature - The 2021 International Pediatric and Congenital Cardiac Code (IPCCC) and the Eleventh Revision of the International Classification of Diseases (ICD-11). \u003cem\u003eCardiol Young\u003c/em\u003e 2021;\u003cstrong\u003e31\u003c/strong\u003e:1057\u0026ndash;188.\u003c/li\u003e\n\u003cli\u003eEwer AK, Middleton LJ, Furmston AT, \u003cem\u003eet al.\u003c/em\u003e Pulse oximetry screening for congenital heart defects in newborn infants (PulseOx): a test accuracy study. \u003cem\u003eLancet\u003c/em\u003e 2011;\u003cstrong\u003e378\u003c/strong\u003e:785\u0026ndash;94.\u003c/li\u003e\n\u003cli\u003eR Core Team. R: A Language and Environment for Statistical Computing. \u003cem\u003eR Foundation for Statistical Computing, Vienna, Austria\u003c/em\u003e Published Online First: 2021.https://www.R-project.org/\u003c/li\u003e\n\u003cli\u003eEvans N, Gournay V, Cabanas F, \u003cem\u003eet al.\u003c/em\u003e Point-of-care ultrasound in the neonatal intensive care unit: international perspectives. \u003cem\u003eSemin Fetal Neonatal Med\u003c/em\u003e 2011;\u003cstrong\u003e16\u003c/strong\u003e:61\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eSingh Y, Tissot C, Fraga MV, \u003cem\u003eet al.\u003c/em\u003e International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC). \u003cem\u003eCrit Care\u003c/em\u003e 2020;\u003cstrong\u003e24\u003c/strong\u003e:65.\u003c/li\u003e\n\u003cli\u003ePriyadarshi A, Klimek J. Neonatal cardiac ultrasound: How accurate are we? \u003cem\u003eAustralas J Ultrasound Med\u003c/em\u003e 2017;\u003cstrong\u003e20\u003c/strong\u003e:66\u0026ndash;71.\u003c/li\u003e\n\u003cli\u003eMogra R. Simplifying ultrasound assessment of the fetal heart: Incorporating the complete Three Vessel View into routine screening. \u003cem\u003eAustralas J Ultrasound Med\u003c/em\u003e 2013;\u003cstrong\u003e16\u003c/strong\u003e:168\u0026ndash;75.\u003c/li\u003e\n\u003cli\u003eMartin GR, Schwartz BN, Hom LA, \u003cem\u003eet al.\u003c/em\u003e Lessons Learned from Infants with Late Detection of Critical Congenital Heart Disease. \u003cem\u003ePediatr Cardiol\u003c/em\u003e 2022;\u003cstrong\u003e43\u003c/strong\u003e:580\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eKondo M, Ohishi A, Baba T, \u003cem\u003eet al.\u003c/em\u003e Can echocardiographic screening in the early days of life detect critical congenital heart disease among apparently healthy newborns? \u003cem\u003eBMC Pediatr\u003c/em\u003e 2018;\u003cstrong\u003e18\u003c/strong\u003e:359.\u003c/li\u003e\n\u003cli\u003eSaraf RP, Suresh P, Maheshwari S, \u003cem\u003eet al.\u003c/em\u003e Pediatric echocardiograms performed at primary centers: Diagnostic errors and missing links! \u003cem\u003eAnn Pediatr Cardiol\u003c/em\u003e 2015;\u003cstrong\u003e8\u003c/strong\u003e:20\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003evan Nisselrooij AEL, Teunissen AKK, Clur SA, \u003cem\u003eet al.\u003c/em\u003e Why are congenital heart defects being missed? \u003cem\u003eUltrasound Obstet Gynecol\u003c/em\u003e 2020;\u003cstrong\u003e55\u003c/strong\u003e:747\u0026ndash;57.\u003c/li\u003e\n\u003cli\u003eDorfman AL, Levine JC, Colan SD, \u003cem\u003eet al.\u003c/em\u003e Accuracy of echocardiography in low birth weight infants with congenital heart disease. \u003cem\u003ePediatrics\u003c/em\u003e 2005;\u003cstrong\u003e115\u003c/strong\u003e:102\u0026ndash;7.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cem\u003eTable 1: Baseline characteristics of patients undergoing NPCU with formal CHD diagnosis by referral from NPCU or referral by other means.\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"594\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.67003367003367%\" valign=\"top\"\u003e\n \u003cp\u003eDemographics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.16498316498316%\" valign=\"top\"\u003e\n \u003cp\u003eFlagged by NPCU\u003c/p\u003e\n \u003cp\u003en = 64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.16498316498316%\" valign=\"top\"\u003e\n \u003cp\u003eOther referral\u0026nbsp;\u003c/p\u003e\n \u003cp\u003en = 45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.67003367003367%\" valign=\"top\"\u003e\n \u003cp\u003eGestational age (weeks)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.16498316498316%\" valign=\"top\"\u003e\n \u003cp\u003e26.3 (3.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.16498316498316%\" valign=\"top\"\u003e\n \u003cp\u003e26.3 (2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.67003367003367%\" valign=\"top\"\u003e\n \u003cp\u003eSex, female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.16498316498316%\" valign=\"top\"\u003e\n \u003cp\u003e33 (51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.16498316498316%\" valign=\"top\"\u003e\n \u003cp\u003e24 (52)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.67003367003367%\" valign=\"top\"\u003e\n \u003cp\u003eCritical CHD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.16498316498316%\" valign=\"top\"\u003e\n \u003cp\u003e3 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.16498316498316%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.67003367003367%\" valign=\"top\"\u003e\n \u003cp\u003eMajor CHD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.16498316498316%\" valign=\"top\"\u003e\n \u003cp\u003e8 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.16498316498316%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.67003367003367%\" valign=\"top\"\u003e\n \u003cp\u003eNon-Major CHD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.16498316498316%\" valign=\"top\"\u003e\n \u003cp\u003e53 (83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.16498316498316%\" valign=\"top\"\u003e\n \u003cp\u003e45 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.67003367003367%\" valign=\"top\"\u003e\n \u003cp\u003eCardiac surgery (initial)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.16498316498316%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.16498316498316%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.67003367003367%\" valign=\"top\"\u003e\n \u003cp\u003eCoarctation repair\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.16498316498316%\" valign=\"top\"\u003e\n \u003cp\u003e3 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.16498316498316%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.67003367003367%\" valign=\"top\"\u003e\n \u003cp\u003eBalloon Pulmonary Valvotomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.16498316498316%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.16498316498316%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.67003367003367%\" valign=\"top\"\u003e\n \u003cp\u003eTetralogy of Fallot repair\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.16498316498316%\" valign=\"top\"\u003e\n \u003cp\u003e2 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.16498316498316%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.67003367003367%\" valign=\"top\"\u003e\n \u003cp\u003eVentricular septal defect repair\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.16498316498316%\" valign=\"top\"\u003e\n \u003cp\u003e3 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.16498316498316%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.67003367003367%\" valign=\"top\"\u003e\n \u003cp\u003eDeath prior to surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.16498316498316%\" valign=\"top\"\u003e\n \u003cp\u003e2 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.16498316498316%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*PDA not a primary diagnosis\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 2: Congenital heart disease (CHD) diagnosis in the flagged and other groups of patients undergoing neonatologist performed cardiac ultrasound.\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"101%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.510204081632654%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.510204081632654%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eAll CHD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eCritical/major CHD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eNon-major\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.77319587628866%\" valign=\"top\"\u003e\n \u003cp\u003eCHD Diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003eFlagged\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003eFlagged*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003eFlagged\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.77319587628866%\" valign=\"top\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.77319587628866%\" valign=\"top\"\u003e\n \u003cp\u003eAtrial septal defect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e11 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e17 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e11 (21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e17 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.77319587628866%\" valign=\"top\"\u003e\n \u003cp\u003eBicuspid aortic valve\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.77319587628866%\" valign=\"top\"\u003e\n \u003cp\u003eCoarctation/ hypoplastic aortic arch\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e4 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e3 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.77319587628866%\" valign=\"top\"\u003e\n \u003cp\u003eLeft ventricular outflow tract obstruction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.77319587628866%\" valign=\"top\"\u003e\n \u003cp\u003ePulmonary atresia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.77319587628866%\" valign=\"top\"\u003e\n \u003cp\u003ePulmonary stenosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e18 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e22 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e17 (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e22 (49)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.77319587628866%\" valign=\"top\"\u003e\n \u003cp\u003eTetralogy of Fallot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e4 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e3 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.77319587628866%\" valign=\"top\"\u003e\n \u003cp\u003eVentricular septal defect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.463917525773196%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e25 (39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e5 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e3 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e22 (41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e5 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"76.53061224489795%\" colspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u003csup\u003e1\u003c/sup\u003en (%) \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e*Includes two \u003cem\u003ecritical\u0026nbsp;\u003c/em\u003epatients that passed away with no surgery\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.244897959183673%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.224489795918368%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"congenital heart disease, echocardiography, neonatologist performed ultrasound, prematurity","lastPublishedDoi":"10.21203/rs.3.rs-3984333/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3984333/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eWe aimed to assess the frequency and accuracy of neonatologist-performed cardiac ultrasound (NPCU) in detecting de novo congenital heart disease (CHD) in premature infants born at \u0026lt;\u0026thinsp;30 weeks of gestation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective cross-sectional study was conducted on all NPCU studies performed at a tertiary-level neonatal department from January 2004 to June 2023. Clinicians completing the NPCU identified \u003cem\u003ede novo\u003c/em\u003e suspected CHD at the time of the scan. All NPCUs were cross-checked with cardiology databases to confirm the final CHD diagnosis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 3739 infants\u0026thinsp;\u0026lt;\u0026thinsp;30 weeks\u0026rsquo; gestation were admitted during the review period, 2088 (56%) of which received at least one NPCU; 294 (14%) were referred to pediatric cardiology and received an echocardiogram. CHD was confirmed in 109 of 2088 (5.2%) babies, 3 (3%) had critical disease, 8 (7%) had major cardiac anomalies, and 53 (49%) had non-major flagged CHD. No major or critical CHD was missed by the NPCU in the cohort.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003e \u003cem\u003eDe novo\u003c/em\u003e presentation of significant CHD still occurs in the preterm population and needs to be recognized by those performing NPCU. Ongoing training and collaboration with cardiology to optimize NPCU may provide benefits in the early referral and diagnosis of CHD.\u003c/p\u003e","manuscriptTitle":"Detection of congenital heart disease by neonatologist performed cardiac ultrasound in extreme preterm infants","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-29 17:00:23","doi":"10.21203/rs.3.rs-3984333/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"75dff470-1660-4158-b946-0f1086cdbc25","owner":[],"postedDate":"February 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-02T11:35:13+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-29 17:00:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3984333","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3984333","identity":"rs-3984333","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}