Which neonates should have a pre-operative echocardiography? Findings from a national survey and a retrospective tertiary single-centre analysis in the United Kingdom

Which neonates should have a pre-operative echocardiography? 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Findings from a national survey and a retrospective tertiary single-centre analysis in the United Kingdom Joel WE Chin, Anthony WR Kelsall, Danny Jenkins, Abha Khushu, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4441088/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Purpose The detection of congenital heart disease (CHD) before neonatal surgery is crucial for anaesthetic and perioperative management. There are no established criteria for preoperative echocardiography in neonates. We aimed to survey current practice in the United Kingdom and evaluate the reliability of antenatal screening and postnatal clinical assessment in detecting CHD before surgery. Method A 9-point questionnaire was sent to all paediatric surgical centres in the United Kingdom to assess their practice. Subsequently, a single-centre retrospective review of all neonatal surgery over 5 years (2015–2020) was conducted in our tertiary paediatric/neonatal hospital. Data included preoperative clinical assessment, performance of chest radiograph and echocardiography. Indications for echocardiography were categorised and assessed using sensitivity, specificity, positive predictive value and negative predictive value. Results All 26 paediatric surgical centres responded to our survey. 23/26 (88.5%) did not have established criteria or guidelines for preoperative echocardiography. There was a large variation in which surgical conditions required a preoperative scan and whether a normal clinical examination was considered sufficient to not require one. For the retrospective review, 454 patients were identified. There were 40 cases with CHDs (8.8%), 13 were classed as major. Indications for echocardiography were categorised into abnormal fetal cardiac screening, medical/surgical conditions associated with CHD and an abnormal cardiorespiratory examination. Sensitivity, specificity, positive predictive value and negative predictive value for major CHD was 46%, 99%, 67%, 98% for abnormal fetal screening, 46%, 97%, 35%, 98% for associated medical conditions, 62%, 66%, 6%, 98% for associated surgical conditions, and 100%, 66%, 9%, 100% for abnormal clinical examination. Conclusion The use of preoperative echocardiography in neonates is not standardised across the UK.. The results from our cohort demonstrates that fetal echocardiography is not sufficient to capture all major CHDs, but the absence of abnormal clinical examination is highly reliable in ruling out major CHD. Specifying a list of medical/surgical of conditions associated with CHD warranting preoperative echocardiography may improve yield, but this depends on the availability of resources and expertise. Figures Figure 1 Figure 2 Introduction Preoperative echocardiography is used to identify congenital heart defects (CHD) in neonates which may impact on anaesthetic management and intraoperative care. This is especially important as there are well-recognised medical and surgical conditions associated with higher incidences of CHD. Tulloh first reported in 1994 that clinical and radiological evaluation were insufficient to detect CHD in the neonatal period, and therefore recommended routine echocardiography for neonates undergoing surgery for gastrointestinal malformations.[ 1 ] Similarly, earlier studies recommended echocardiography screening in neonates with suspected trisomy 21 (T21) due to perceived lower sensitivity of clinical evaluation alone.[ 2 ] However, these studies did not classify CHD according to clinical significance.[ 3 ] Advances in fetal cardiac imaging has increased the proportion of significant CHDs diagnosed in utero , potentially reducing the need for routine postnatal echocardiography prior to neonatal surgery. This is in keeping with a return to a more selective approach, relying on clinical history and examination to determine the need for preoperative echocardiography across a range of conditions including oesophageal atresia, exomphalos, anorectal malformation, duodenal atresia and myelomeningocele.[ 3 , 5 – 9 ] Despite this, there remains no consensus on which criteria should act as triggers to request echocardiography prior to neonatal surgery. This includes understanding which conditions are associated with the highest risk of significant CHD (especially those that may be missed on antenatal screening), or the sensitivity of clinical examination in sufficiently ruling out significant CHD in a heterogeneous cohort of neonates with various medical co-morbidities and surgical anomalies. Recognising these uncertainties and the potential resource implications of non-selective use of echocardiography prior to neonatal surgery, this study aimed to survey current practice in paediatric surgical centres across the United Kingdom (UK) before examining the additional diagnostic yield of neonatal echocardiography using a retrospective analysis of our centre’s electronic health records (EHR). Methods Survey All specialty paediatric surgical centres in the United Kingdom were identified through the British Association of Paediatric Surgeons.[ 10 ] The lead neonatologist for each unit was contacted by email. A 9-point questionnaire was posed (see supplemental material). Eight questions were closed ended (yes/no or multiple choice), with a final free text response used to understand which conditions would require preoperative echocardiography. Definition of CHD Cardiac defects were categorized into minor and major categories according to the classification systems devised by Nasr et al 3 : major if they were likely to impact on patient well-being or change the surgical course, including defects where the likelihood of cardiovascular surgical intervention was high, defects that required treatment with prostaglandins, or defects where the anaesthetic risk was greatly increased. Minor cardiac defects were those that were not likely to alter the surgical course, and no cardiovascular intervention was required. A paediatrician with expertise in cardiology (WK) who was blinded to data collection, independently reviewed all the available echocardiograms and categorised them accordingly. To understand the additional diagnostic benefit of echocardiography (see below), our primary outcome was a composite of major CHD identified on echocardiography or, in those without preoperative echocardiography, a documented cardiac intervention in the year following the initial general surgical intervention. Evaluating the additional diagnostic yield of neonatal echocardiography Cambridge University Hospitals (CUH) is an academic tertiary centre providing (non-cardiac) paediatric surgical services to patients across the East of England. Since October 2014 CUH has employed an integrated EHR (Epic – Epic Systems Verona) capturing all inpatient and outpatient activity including anaesthetic care. We identified all neonates (aged 28 days and under at the time of surgery) who had a surgical encounter from January 2015- October 2020 identified through the hospital’s electronic medical records. We defined “having a transthoracic echocardiogram” as one performed before the first surgical episode. If echocardiography was not performed, we reviewed hospital medical records for evidence of cardiology clinic appointments or cardiac surgery in the year following surgery. If there were no records over the next year, this patient was considered as lost to follow-up. Based on a review of our current practice and the medical literature, four broad categories of indication for neonatal echocardiography were considered to evaluate the additional diagnostic yield of echocardiography ( Table 1 ). These included the presence of a suspected cardiac defect on fetal echocardiography (F), suspicion of a medical condition associated with CHD (M), a surgical condition associated with significant CHD (S), or abnormal clinical evaluation (C). For the medical conditions criteria, only antenatally confirmed or postnatally suspected cases were included, as genetic testing results would usually not be obtained before neonatal surgery. Surgical diagnostic criteria, were conditions that have reported association with CHD in the literature were included.[ 3 , 6 , 8 ] Clinical assessment, this refers to abnormal cardiovascular, respiratory and radiological signs of CHD that were detected preoperatively, as cited in previous studies.[ 3 , 5 ] Table 1 Indications for neonatal preoperative echocardiography in use at our institution. ARM Anorectal malformation, CDH Congenital diaphragmatic hernia, OA oesophageal atresia Fetal echocardiography (F) Medical conditions (M) Surgical conditions (S) Clinical assessment (C) Cardiac defect detected Complex genetic abnormalities detected antenatally or suspected postnatally. Syndromes associated with CHD suspected at birth based on morphological features CDH Cyanosis OA Murmur ARM Abnormal pulses Exomphalos Tachycardia Duodenal atresia Intubation Choanal atresia Shock Myelomeningocele Tachypnoea Intercostal recessions Desaturations Cardiomegaly on chest radiograph Abnormal pulmonary vasculature on chest radiograph Statistical method Descriptive statistics were used for patient demographics, medical details and surgical information. Non-normally distributed (based on visual inspection) variables were summarised using median and interquartile range, with normally distributed variables summarised using mean and standard deviation. Data was analysed using R. Sensitivity and specificity testing was used for each of the indications for neonatal echocardiography ( Table 1 ) as well as sequential combinations of the criteria, such as F + M, F + M + S and F + M + S + C, in the order that information would be available to practicising clinicians. Association testing between categorical variables was performed using Fisher’s exact test. Two-tailed significance testing with an alpha of 0.05 was performed. Approvals Retrospective review of our hospital EHR was granted as an approved service evaluation (reference number: Project ID 2005524) Results Survey response 26 specialist children’s surgical centres in the UK were invited to participate in the survey via email. The lead clinician for neonatology for each unit was contacted on behalf of the multiprofessional team. The response rate was 100%. N = 10 (38.4%) of these hospitals have co-located paediatric cardiac surgical services. The majority (n = 23, 88.5%) of centres reported not having any local guidelines for mandatory cardiac assessment prior to neonatal surgery. N = 6 (23.1%) centres reported requiring routine preoperative echocardiography for a number of specific surgical conditions. All sites ( n = 26 ) listed specific conditions where preoperative echocardiography was always required prior to surgery. These included oesophageal atresia (n = 18, 69.2%), congenital diaphragmatic hernia (n = 12, 46.2%), chromosomal abnormality or syndromic/dysmorphic appearance (n = 12, 46.2%), exomphalos (n = 8, 30.8%), abnormal clinical examination (n = 8, 30.8%), abnormal fetal echocardiography (n = 6, 23.1%), duodenal atresia (n = 4, 15.4%), anorectal malformation/imperforate anus (n = 3, 11.5%) and gastroschisis (n = 1, 3.8%). When asked “ if the cardiovascular examination was normal, would an echocardiography be performed” , 11 (42.3%) answered yes. 11 (42.3%) centres reported having a 24/7 transthoracic echocardiography service. Echocardiograms were performed by a range of clinicians depending on availability: 19 (73.1%) centres had cardiologists performing echocardiography, 19 (73.1%) had paediatricians with cardiology expertise, and 10 (38.5%) had echocardiography technicians. Finally, for the question “ If an ECHO could not be performed in a child with a normal clinical exam who was haemodynamically stable would surgery be delayed?” , 7 (26.9%) centres answered yes. Evaluation of diagnostic benefit of echocardiography Cohort selection and patient characteristics A total of 454 (n = 264, 58% male) neonates were identified (Fig. 1). Median gestational age was 37.7 (interquartile range 34.6–39.7), birth weight was 2.73 (+/- 1.04) kg. 280 (70.3%) were emergency cases. Full cohort characteristics are summarized in Table 2 . 174 (38.3%) of neonates were preterm, of which 37 were extremely premature (< 28 weeks), 36 very preterm (28–32 weeks) and 101 moderate to late preterm (32–37 weeks). 37 (8.1%) were classed as extreme low birth weight (< 1000g) and 41 (9.0%) had very low birth weight (1000-1500g). There were 30 (6.6%) neonates with associated medical conditions, including 8 neonates with trisomy 21, 2 trisomy 18, 4 CHARGE syndrome, 2 VACTERL syndrome, 4 Beckwith Wiedemann syndrome, 6 chromosomal deletion/genetic abnormality, 1 Treacher Collins syndrome, 2 Pierre- Robin syndrome and 1 Crouzon syndrome. The surgical procedures was performed by: General Surgery (n = 346, 76.2%); ENT (n = 44, 9.7%); Neurosurgery (n = 36, 7.9%); Urology (n = 16, 3.5%); Orthopaedics (n = 4, 0.9%); Oral Surgery (n = 3, 0.7%); Plastic Surgery (n = 3, 0.7%); Ophthalmology (n = 1, 0.3%) and Respiratory medicine (n = 1, 0.3%). Of note, there were 58 (14.9%) oesophageal atresias, 49 (12.6%) anorectal malformations, 48 (12.3%) laparotomies for necrotising enterocolitis, 15 (3.9%) duodenal atresias, 13 (3.3%) congenital diaphragmatic hernias, 12 (3.1%) anorectal malformations and 5 (1.3%) exomphalos closures. A full list of procedures are detailed in Table 3 . Figure 1 Selection of a retrospective cohort of neonates undergoing surgery to evaluate the use of neonatal echocardiography. Table 2 Patient characteristics of a cohort of neonatal patients undergoing surgery (N = 454). Operative characteristics Patient characteristics Characteristics n % Gestational age: median (range) in weeks 37.7 (34.639.7) birth weight: mean (SD) in kg 2.7 (1.0) male 264 58.0% female 190 42.0% Medical conditions T21 8 1.8% Beckwith Wiedemann syndrome 4 0.9% chromosomal deletion 4 0.9% Charge syndrome 4 0.9% T18 2 0.4% VACTERL syndrome 2 0.4% undetermined chromosomal abnormality 2 0.4% Pierre Robin syndrome 2 0.4% Crouzon syndrome 1 0.2% Treacher Collins syndrome 1 0.2% Prematurity extremely preterm (< 28 weeks) 37 8.1% very preterm (28–32 weeks) 36 7.9% moderate to late preterm (32 − 27 weeks) 101 22.2% Low birth weight extremely low birth weight (< 1kg) 37 8.1% very low birth weight (1-1.5kg) 41 9.0% low birth weight (1.5-2.5kg) 80 17.6% Table 3 Operative characteristics of a cohort of neonatal patients undergoing surgery (N = 454). Characteristics n % Surgical specialties Paediatric Surgery 346 76.2% ENT 44 9.7% Neurosurgery 36 7.9% Paediatric Urology 16 3.5% Orthopaedics 4 0.9% Maxillofacial Surgery 3 0.7% Plastic Surgery 3 0.7% Paediatric Ophthalmology 1 0.2% Paediatric Respiratory Medicine 1 0.2% Operation details Oeseophageal atresia 58 14.9% anorectal malformation 49 12.6% nectrotising enterocolitis 48 12.3% laparotomy - malrotation 37 9.5% Microlaryngoscopy And Tracheoscopy 30 7.7% Gastroschisis Closure 29 7.5% Exploratory laparotomy 28 7.2% pyloromyotomy 26 6.7% ventricular shunt surgery 18 4.6% Insertion Central Line 17 4.4% duodenal atresia 15 3.9% Closure Spinal Myelomeningocele 15 3.9% Congenital Diaphragmatic Hernia Repair 13 3.3% Dilatation Choanal Atresia 11 2.8% Orchidectomy 11 2.8% Small bowel atresia 8 2.1% Hirschprung's 5 1.3% Exomphalos Closure 5 1.3% Prevalence of CHD diagnosed by echocardiography Of the 263 neonates who received perioperative echocardiography, 13 (4.9%) were classed as having major cardiac defects with 27 (10.3%) classed as having minor CHD circulation (Table 4 ). Table 4 Summary of cardiac defects on echocardiography Cardiac defect Total Major cardiac defects Tetralogy of Fallot (50% overriding aorta, large PDA and ASD) 1 Atrioventricular Septal Defect 2 Large PDA with haemodynamic instability 1 Large ASD 1 Non-restrictive VSD 7 Coarctation of aorta 1 Total 13 Minor cardiac defects Small ASD 6 Restrictive VSD 15 Bilateral superior vena cava 1 Pulmonary stenosis 2 Bicuspid aortic valve 2 Rhabdomyoma 1 Total 27 ASD atrial septal defect VSD ventricular septal defects PDA patent ductus arteriosus Evaluating additional diagnostic yield of preoperative neonatal echocardiography We examined the sequential application of our triaging criteria (Table 1 ) using sensitivity and negative predictive value ( Table 5 ). Clinical evaluation alone demonstrated a sensitivity of 100%, while the other three criteria had low to moderate sensitivity (F – 46%, M – 46%, S – 62%). However, when combined, the sensitivity improved to 85%. Fetal echocardiography and the medical criteria had high specificity, 99% and 97% respectively, but surgical association and clinical evaluation both had moderate specificity, 66% for both. Criteria Sensitivity Specificity PPV NPV fisher's exact test F 46% 99% 67% 98% < 0.00001 M 46% 97% 35% 98% < 0.00001 S 62% 66% 6% 98% 0.071 F + M + S 85% 64% 7% 99% 0.0007 C 100% 66% 9% 100% < 0.00001 PPV – Positive Predictive Value, NPV – Negative Predictive Value, F – fetal echocardiography suggestive of CHD, M – medical conditions associated with CHD, S – surgical conditions associated with CHD, C – clinical findings suggestive of CHD Table 5: sensitivity analysis of fetal echocardiography, pre-defined medical and surgical conditions, and clinical evaluation in detecting major cardiac defects Discussion This paper has sought to both document national practice in the use of routine neonatal echocardiography prior to surgery as well as to evaluate its diagnostic yield in a large, heterogeneous cohort of neonates undergoing surgery at a non-cardiac centre. National survey data suggests there is no consensus on which conditions are felt to ‘require’ an echocardiogram preoperatively, with most (n = 23, 88.5%) hospitals not having predetermined criteria. Broadly, indications described in the responses for echocardiography corresponded to the four triaging categories documented in Table 1 . Specific surgical conditions varied between institutions, with oesophageal atresia, congenital diaphragmatic hernia and exomphalos being the most commonly cited conditions. The difference of opinion regarding the utility of a normal clinical examination was also evident, with 42.3% of hospitals insisting on preoperative echocardiography in certain conditions despite a normal clinical examination, and 26.9% choosing to delay surgery if an echocardiography could not be obtained in time. This is an important observation as retrospective evaluation of our data suggested that normal clinical examination had a sensitivity and negative predictive value of 100% in excluding major CHD. However, this observation should be interpreted with caution given its single centre origin and small numbers of major cases of CHD (n = 13). Across the four categories that were compared, each of the individual criteria (F, M, S, C) had moderate to high specificity, which makes each one a reasonable “rule-in” decision. However, their individual sensitivity was lower. Only clinical evaluation alone achieved 100% sensitivity. For fetal echocardiography, the results revealed high specificity and moderate sensitivity, in keeping with a published meta-analysis.[ 11 ] Fetal echocardiography is operator-dependent and requires a high degree of expertise to provide an accurate diagnosis. Furthermore, some cardiac defects only manifest after undergoing the physiological transition after birth. A normal fetal echocardiogram does not reliably detect all major CHD postnatally. Of the 13 major CHD cases, 7 had “normal” antenatal scans. The addition of medical and surgical conditions associated with CHD improved the sensitivity for detecting major CHD to 85%. Associated elevated rates of CHD have been well documented in the literature for oesophageal atresia (13.2–42%),[ 12 ] congenital diaphragmatic hernia (12–25%),[ 13 ] exomphalos (14–58%),[ 14 ] anorectal malformation (12–15%),[ 1 ] duodenal atresia (31–39%)[ 8 ] and myelomeningocele (4.7–40.5%).[ 6 ] However, the inclusion criteria vary widely, and the definition of CHD and its severity are not standardised in these reports. Our survey results suggest that decisions on which conditions to include vary and may be influenced by individual hospital’s experience and resources available for echocardiography. However, using a pre-determined criteria can improve the detection rate of severe CHD, albeit with moderate sensitivity and specificity. With a sensitivity of 100% for capturing CHD for clinical evaluation as a criterion, our results match other recent studies in reinforcing the message that clinically significant CHD is highly unlikely if the clinical evaluation is normal preoperatively. Our data goes one step further in providing validation in a mixed population of neonates with medical and surgical co-morbidities. The main limitation to our study is that it is performed in a single tertiary centre without cardiac surgical services. Some neonates with major cases cardiac defects like transposition of the great arteries or hypoplastic left heart syndrome that are detected antenatally may be born in an obstetric unit co-located with a specialist cardiac surgical centre. This may explain the low numbers of major forms of CHD in our cohort. If these cases were included in our dataset, it may improve the sensitivity of fetal echocardiography in detecting major CHD, which is higher for more severe defects according to a previous study. Currently across the UK the fetal anomaly screening programme aims to detect 50% of cases of severe CHD before birth.[ 16 ] It is important to note that detecting missed cases of major CHDs on fetal echocardiography may be more crucial in non-cardiac paediatric surgical centres, which represent the majority of UK paediatric surgical centres (16, 61.5%), to guide perioperative management. Due to the retrospective nature of the study, the assessment of clinical evaluation as documented in the medical records was subject to bias. There was no standardisation of how it was performed, in what order, or by whom. All infants with congenital anomalies will have been examined by a senior member of the neonatal medical team. There is also a risk of confirmation bias, in that clinicians are more likely to detect signs if they are examining a neonate with a known medically or surgically associated condition. In addition, our mixed cohort included emergency cases some with diagnosed sepsis such as necrotising enterocolitis where some of the clinical signs may mimic CHD. Our database contains a mixed population of neonates that represents a real-world context to test criteria for preoperative echocardiography screening (Fig. 2 ). While previous studies have focused on specific conditions, our study is the first to evaluate the use of a multi-pronged approach in a heterogenous cohort, that also considers the impact of fetal screening for CHD. In conclusion, our study demonstrates that fetal and postnatal echocardiography alone are not sufficient to capture all significant CHDs postnatally. A normal clinical evaluation is highly reliable in ruling out major CHD. The addition of medical and surgical conditions associated with CHD as criteria for echocardiography will help improve the sensitivity of detecting significant CHD. Institutions may disagree on the list of surgical conditions that warrant a preoperative echocardiogram, as this is influenced by the availability of local resources to perform echocardiography and urgency of surgery. However, what is critical is to carry out a thorough clinical evaluation to help decide if echocardiography will improve the yield of detecting major CHD before proceeding with surgery. A successful surgical outcome depends on good communication between the paediatricians, surgeons and anaesthetic colleagues. Declarations Author Contribution J.C. W.K. and J.L. conceived and designed the study.D.J., A.K., J.C., W.K. and J.L. collected the data.D.S., A.K., W.K. and J.C. analysed the data.D.J. and J.C. wrote the main manuscript text. All authors reviewed the manuscript. References Tulloh RM, Tansey SP, Parashar K, De Giovanni JV, Wright C, Silove JG (1994) Echocardiographic screening in neonates undergoing surgery for selected gastrointestinal malformations. Arch Dis Child Fetal Neonatal Ed 70(3):F206–F208 Bogarapu S, Pinto NM, Etheridge SP, Sheng X, Liesemer KN, Young PC et al (2016) Screening for Congenital Heart Disease in Infants with Down Syndrome: Is Universal Echocardiography Necessary? Pediatr Cardiol 37(7):1222–1227 Nasr A, McNamara PJ, Mertens L, Levin D, James A, Holtby H et al (2010) Is routine preoperative 2-dimensional echocardiography necessary for infants with esophageal atresia, omphalocele, or anorectal malformations? J Pediatr Surg 45(5):876–879 Sun HY (2021) Prenatal diagnosis of congenital heart defects: Echocardiography. Vol. 10, Translational Pediatrics. AME Publishing Company, pp 2210–2224 Tanny SPT, King SK, Comella A, Hawley A, Brooks JA, Hunt RW et al (2021) Selective approach to preoperative echocardiography in esophageal atresia. Pediatr Surg Int 37(4):503–509 Vernon MM, Powell D, Schultz AH, Simon TD, Doherty D (2015) Is routine preoperative transthoracic echocardiography necessary in newborns with myelomeningocele? J Perinatol 35(10):842–845 Ritter S, Tani LY, Shaddy RE, Minich (1999) L Luann. Are Screening Echocardiograms Warranted for Neonates With Meningomyelocele? Arch Pediatr Adolesc Med 153(12):1264–1266 Short SS, Pierce JR, Burke RV, Papillon S, Frykman PK, Nguyen N (2014) Is routine preoperative screening echocardiogram indicated in all children with congenital duodenal obstruction? Pediatr Surg Int 30(6):609–614 Khan A, Tanny ST, Perkins EJ, Hunt RW, Hutson JM, King SK et al (2017) Is selective echocardiography in duodenal atresia the future standard of care? J Pediatr Surg 52(12):1952–1955 https://. (accessed 15 May 2024) Zhang YF, Zeng XL, Zhao EF, Lu HW (2015) Diagnostic value of fetal echocardiography for congenital heart disease, vol 94. Lippincott Williams and Wilkins, p e1759. (United States) Encinas JL, Luis AL, Avila LF, Martinez L, Guereta L, Lassaletta L et al (2006) Impact of preoperative diagnosis of congenital heart disease on the treatment of esophageal atresia. Pediatr Surg Int 22(2):150–153 Hautala J, Karstunen E, Ritvanen A, Rintala R, Mattila IP, Räsänen J et al (2018) Congenital diaphragmatic hernia with heart defect has a high risk for hypoplastic left heart syndrome and major extra-cardiac malformations: 10-year national cohort from Finland. Acta Obstet Gynecol Scand 97(2):204–211 Stoll C, Alembik Y, Dott B, Roth MP (2008) Omphalocele and gastroschisis and associated malformations. Am J Med Genet A 146A(10):1280–1285 Chu C, Yan Y, Ren Y, Li X, Gui Y (2017) Prenatal diagnosis of congenital heart diseases by fetal echocardiography in second trimester: a Chinese multicenter study. Acta Obstet Gynecol Scand 96(4):454–463 Fetal anomaly screening programme handbook NHS England. Published 9 July 2015. Last updated 19 February 2024. https://www.gov.uk/government/publications/fetal-anomaly-screening-programme-handbook/data . (accessed 15 May 2024). Additional Declarations No competing interests reported. Supplementary Files neonatalechosuppmaterial.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 09 Jun, 2024 Reviews received at journal 28 May, 2024 Reviewers agreed at journal 28 May, 2024 Reviewers invited by journal 27 May, 2024 Editor assigned by journal 21 May, 2024 Submission checks completed at journal 20 May, 2024 First submitted to journal 18 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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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-4441088","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":308374982,"identity":"6dd92a4f-c68c-4074-8998-dc993a819d57","order_by":0,"name":"Joel WE 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Trust","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Stubbs","suffix":""},{"id":308374987,"identity":"852a6d2a-2b10-4d91-b9cf-3772409322d9","order_by":5,"name":"Johanne Lynch","email":"","orcid":"","institution":"Cambridge University Hospitals NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Johanne","middleName":"","lastName":"Lynch","suffix":""}],"badges":[],"createdAt":"2024-05-18 12:53:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4441088/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4441088/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57722715,"identity":"fcee313a-9091-47f1-b1ee-e4fe79db4e49","added_by":"auto","created_at":"2024-06-04 19:10:10","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":25723,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSelection of a retrospective cohort of neonates undergoing surgery to evaluate the use of neonatal echocardiography.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"F1.png","url":"https://assets-eu.researchsquare.com/files/rs-4441088/v1/eddbccbc6a5c2eac7c48fc94.png"},{"id":57722717,"identity":"3a7be6e2-8bb6-4fbc-a2a1-8a04d929feff","added_by":"auto","created_at":"2024-06-04 19:10:10","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":44394,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA schematic representation of a selective criteria in detecting major CHD (n=13) preoperatively based on our cohort of 464 patients\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"f2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4441088/v1/dc1a08727c82a74b25d19c1b.jpg"},{"id":57722729,"identity":"4ade2790-d8aa-4adb-ad39-19e9466c8a98","added_by":"auto","created_at":"2024-06-04 19:10:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":791728,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4441088/v1/c2ada05c-f3bb-4375-b24e-a26354ad84d5.pdf"},{"id":57722721,"identity":"b8e2d0e9-93e4-4006-9a83-24d2156c9b82","added_by":"auto","created_at":"2024-06-04 19:10:12","extension":"docx","order_by":9,"title":"","display":"","copyAsset":false,"role":"supplement","size":16590,"visible":true,"origin":"","legend":"","description":"","filename":"neonatalechosuppmaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-4441088/v1/a401130b4237e6e2f74a9baf.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Which neonates should have a pre-operative echocardiography? Findings from a national survey and a retrospective tertiary single-centre analysis in the United Kingdom","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePreoperative echocardiography is used to identify congenital heart defects (CHD) in neonates which may impact on anaesthetic management and intraoperative care. This is especially important as there are well-recognised medical and surgical conditions associated with higher incidences of CHD.\u003c/p\u003e \u003cp\u003eTulloh first reported in 1994 that clinical and radiological evaluation were insufficient to detect CHD in the neonatal period, and therefore recommended routine echocardiography for neonates undergoing surgery for gastrointestinal malformations.[\u003csup\u003e1\u003c/sup\u003e] Similarly, earlier studies recommended echocardiography screening in neonates with suspected trisomy 21 (T21) due to perceived lower sensitivity of clinical evaluation alone.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] However, these studies did not classify CHD according to clinical significance.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Advances in fetal cardiac imaging has increased the proportion of significant CHDs diagnosed \u003cem\u003ein utero\u003c/em\u003e, potentially reducing the need for routine postnatal echocardiography prior to neonatal surgery.\u003c/p\u003e \u003cp\u003eThis is in keeping with a return to a more selective approach, relying on clinical history and examination to determine the need for preoperative echocardiography across a range of conditions including oesophageal atresia, exomphalos, anorectal malformation, duodenal atresia and myelomeningocele.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR6 CR7 CR8\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Despite this, there remains no consensus on which criteria should act as triggers to request echocardiography prior to neonatal surgery. This includes understanding which conditions are associated with the highest risk of significant CHD (especially those that may be missed on antenatal screening), or the sensitivity of clinical examination in sufficiently ruling out significant CHD in a heterogeneous cohort of neonates with various medical co-morbidities and surgical anomalies.\u003c/p\u003e \u003cp\u003eRecognising these uncertainties and the potential resource implications of non-selective use of echocardiography prior to neonatal surgery, this study aimed to survey current practice in paediatric surgical centres across the United Kingdom (UK) before examining the additional diagnostic yield of neonatal echocardiography using a retrospective analysis of our centre\u0026rsquo;s electronic health records (EHR).\u003c/p\u003e "},{"header":"Methods","content":" \u003cp\u003eSurvey\u003c/p\u003e \u003cp\u003eAll specialty paediatric surgical centres in the United Kingdom were identified through the British Association of Paediatric Surgeons.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] The lead neonatologist for each unit was contacted by email. A 9-point questionnaire was posed (see supplemental material). Eight questions were closed ended (yes/no or multiple choice), with a final free text response used to understand which conditions would require preoperative echocardiography.\u003c/p\u003e \u003cp\u003eDefinition of CHD\u003c/p\u003e \u003cp\u003eCardiac defects were categorized into minor and major categories according to the classification systems devised by Nasr \u003cem\u003eet al\u003c/em\u003e\u003csup\u003e3\u003c/sup\u003e: major if they were likely to impact on patient well-being or change the surgical course, including defects where the likelihood of cardiovascular surgical intervention was high, defects that required treatment with prostaglandins, or defects where the anaesthetic risk was greatly increased. Minor cardiac defects were those that were not likely to alter the surgical course, and no cardiovascular intervention was required. A paediatrician with expertise in cardiology (WK) who was blinded to data collection, independently reviewed all the available echocardiograms and categorised them accordingly.\u003c/p\u003e \u003cp\u003eTo understand the additional diagnostic benefit of echocardiography (see below), our primary outcome was a composite of major CHD identified on echocardiography or, in those without preoperative echocardiography, a documented cardiac intervention in the year following the initial general surgical intervention.\u003c/p\u003e \u003cp\u003eEvaluating the additional diagnostic yield of neonatal echocardiography\u003c/p\u003e \u003cp\u003eCambridge University Hospitals (CUH) is an academic tertiary centre providing (non-cardiac) paediatric surgical services to patients across the East of England. Since October 2014 CUH has employed an integrated EHR (Epic \u0026ndash; Epic Systems Verona) capturing all inpatient and outpatient activity including anaesthetic care. We identified all neonates (aged 28 days and under at the time of surgery) who had a surgical encounter from January 2015- October 2020 identified through the hospital\u0026rsquo;s electronic medical records. We defined \u0026ldquo;having a transthoracic echocardiogram\u0026rdquo; as one performed before the first surgical episode. If echocardiography was not performed, we reviewed hospital medical records for evidence of cardiology clinic appointments or cardiac surgery in the year following surgery. If there were no records over the next year, this patient was considered as lost to follow-up.\u003c/p\u003e \u003cp\u003eBased on a review of our current practice and the medical literature, four broad categories of indication for neonatal echocardiography were considered to evaluate the additional diagnostic yield of echocardiography \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e These included the presence of a suspected cardiac defect on fetal echocardiography (F), suspicion of a medical condition associated with CHD (M), a surgical condition associated with significant CHD (S), or abnormal clinical evaluation (C). For the medical conditions criteria, only antenatally confirmed or postnatally suspected cases were included, as genetic testing results would usually not be obtained before neonatal surgery. Surgical diagnostic criteria, were conditions that have reported association with CHD in the literature were included.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] Clinical assessment, this refers to abnormal cardiovascular, respiratory and radiological signs of CHD that were detected preoperatively, as cited in previous studies.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eIndications for neonatal preoperative echocardiography in use at our institution.\u003c/b\u003e \u003cem\u003eARM\u003c/em\u003e Anorectal malformation, \u003cem\u003eCDH\u003c/em\u003e Congenital diaphragmatic hernia, \u003cem\u003eOA\u003c/em\u003e oesophageal atresia\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFetal echocardiography (F)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedical conditions (M)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurgical conditions (S)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinical assessment (C)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiac defect detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003eComplex genetic abnormalities detected antenatally or suspected postnatally.\u003c/p\u003e \u003cp\u003eSyndromes associated with CHD suspected at birth based on morphological features\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCDH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCyanosis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMurmur\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eARM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAbnormal pulses\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExomphalos\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTachycardia\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDuodenal atresia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntubation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChoanal atresia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eShock\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMyelomeningocele\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTachypnoea\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntercostal recessions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDesaturations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCardiomegaly on chest radiograph\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAbnormal pulmonary vasculature on chest radiograph\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eStatistical method\u003c/h3\u003e\n\u003cp\u003eDescriptive statistics were used for patient demographics, medical details and surgical information. Non-normally distributed (based on visual inspection) variables were summarised using median and interquartile range, with normally distributed variables summarised using mean and standard deviation. Data was analysed using R. Sensitivity and specificity testing was used for each of the indications for neonatal echocardiography \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e as well as sequential combinations of the criteria, such as F\u0026thinsp;+\u0026thinsp;M, F\u0026thinsp;+\u0026thinsp;M\u0026thinsp;+\u0026thinsp;S and F\u0026thinsp;+\u0026thinsp;M\u0026thinsp;+\u0026thinsp;S\u0026thinsp;+\u0026thinsp;C, in the order that information would be available to practicising clinicians. Association testing between categorical variables was performed using Fisher\u0026rsquo;s exact test. Two-tailed significance testing with an alpha of 0.05 was performed.\u003c/p\u003e \u003cp\u003eApprovals\u003c/p\u003e \u003cp\u003e Retrospective review of our hospital EHR was granted as an approved service evaluation (reference number: Project ID 2005524)\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eSurvey response\u003c/p\u003e \u003cp\u003e26 specialist children\u0026rsquo;s surgical centres in the UK were invited to participate in the survey via email. The lead clinician for neonatology for each unit was contacted on behalf of the multiprofessional team. The response rate was 100%. N\u0026thinsp;=\u0026thinsp;10 (38.4%) of these hospitals have co-located paediatric cardiac surgical services.\u003c/p\u003e \u003cp\u003e The majority (n\u0026thinsp;=\u0026thinsp;23, 88.5%) of centres reported not having any local guidelines for mandatory cardiac assessment prior to neonatal surgery. N\u0026thinsp;=\u0026thinsp;6 (23.1%) centres reported requiring routine preoperative echocardiography for a number of specific surgical conditions. All sites (\u003cem\u003en\u0026thinsp;=\u0026thinsp;26\u003c/em\u003e) listed specific conditions where preoperative echocardiography was always required prior to surgery. These included oesophageal atresia (n\u0026thinsp;=\u0026thinsp;18, 69.2%), congenital diaphragmatic hernia (n\u0026thinsp;=\u0026thinsp;12, 46.2%), chromosomal abnormality or syndromic/dysmorphic appearance (n\u0026thinsp;=\u0026thinsp;12, 46.2%), exomphalos (n\u0026thinsp;=\u0026thinsp;8, 30.8%), abnormal clinical examination (n\u0026thinsp;=\u0026thinsp;8, 30.8%), abnormal fetal echocardiography (n\u0026thinsp;=\u0026thinsp;6, 23.1%), duodenal atresia (n\u0026thinsp;=\u0026thinsp;4, 15.4%), anorectal malformation/imperforate anus (n\u0026thinsp;=\u0026thinsp;3, 11.5%) and gastroschisis (n\u0026thinsp;=\u0026thinsp;1, 3.8%).\u003c/p\u003e \u003cp\u003eWhen asked \u0026ldquo;\u003cem\u003eif the cardiovascular examination was normal, would an echocardiography be performed\u0026rdquo;\u003c/em\u003e, 11 (42.3%) answered yes.\u003c/p\u003e \u003cp\u003e11 (42.3%) centres reported having a 24/7 transthoracic echocardiography service. Echocardiograms were performed by a range of clinicians depending on availability: 19 (73.1%) centres had cardiologists performing echocardiography, 19 (73.1%) had paediatricians with cardiology expertise, and 10 (38.5%) had echocardiography technicians.\u003c/p\u003e \u003cp\u003eFinally, for the question \u0026ldquo;\u003cem\u003eIf an ECHO could not be performed in a child with a normal clinical exam who was haemodynamically stable would surgery be delayed?\u0026rdquo;\u003c/em\u003e, 7 (26.9%) centres answered yes.\u003c/p\u003e \u003cp\u003eEvaluation of diagnostic benefit of echocardiography\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eCohort selection and patient characteristics\u003c/h2\u003e \u003cp\u003eA total of 454 \u003cem\u003e(n\u0026thinsp;=\u0026thinsp;264, 58% male)\u003c/em\u003e neonates were identified (Fig.\u0026nbsp;1). Median gestational age was 37.7 (interquartile range 34.6\u0026ndash;39.7), birth weight was 2.73 (+/- 1.04) kg. 280 (70.3%) were emergency cases. Full cohort characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e174 (38.3%) of neonates were preterm, of which 37 were extremely premature (\u0026lt;\u0026thinsp;28 weeks), 36 very preterm (28\u0026ndash;32 weeks) and 101 moderate to late preterm (32\u0026ndash;37 weeks). 37 (8.1%) were classed as extreme low birth weight (\u0026lt;\u0026thinsp;1000g) and 41 (9.0%) had very low birth weight (1000-1500g).\u003c/p\u003e \u003cp\u003eThere were 30 (6.6%) neonates with associated medical conditions, including 8 neonates with trisomy 21, 2 trisomy 18, 4 CHARGE syndrome, 2 VACTERL syndrome, 4 Beckwith Wiedemann syndrome, 6 chromosomal deletion/genetic abnormality, 1 Treacher Collins syndrome, 2 Pierre- Robin syndrome and 1 Crouzon syndrome.\u003c/p\u003e \u003cp\u003eThe surgical procedures was performed by: General Surgery (n\u0026thinsp;=\u0026thinsp;346, 76.2%); ENT (n\u0026thinsp;=\u0026thinsp;44, 9.7%); Neurosurgery (n\u0026thinsp;=\u0026thinsp;36, 7.9%); Urology (n\u0026thinsp;=\u0026thinsp;16, 3.5%); Orthopaedics (n\u0026thinsp;=\u0026thinsp;4, 0.9%); Oral Surgery (n\u0026thinsp;=\u0026thinsp;3, 0.7%); Plastic Surgery (n\u0026thinsp;=\u0026thinsp;3, 0.7%); Ophthalmology (n\u0026thinsp;=\u0026thinsp;1, 0.3%) and Respiratory medicine (n\u0026thinsp;=\u0026thinsp;1, 0.3%).\u003c/p\u003e \u003cp\u003eOf note, there were 58 (14.9%) oesophageal atresias, 49 (12.6%) anorectal malformations, 48 (12.3%) laparotomies for necrotising enterocolitis, 15 (3.9%) duodenal atresias, 13 (3.3%) congenital diaphragmatic hernias, 12 (3.1%) anorectal malformations and 5 (1.3%) exomphalos closures. A full list of procedures are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure\u0026nbsp;1 Selection of a retrospective cohort of neonates undergoing surgery to evaluate the use of neonatal echocardiography.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003ePatient characteristics of a cohort of neonatal patients undergoing surgery (N\u0026thinsp;=\u0026thinsp;454).\u003c/b\u003e Operative characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGestational age: median (range) in weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e37.7\u003c/p\u003e \u003cp\u003e(34.639.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ebirth weight: mean (SD) in kg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.7 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e264\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e190\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical conditions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBeckwith Wiedemann syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003echromosomal deletion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCharge syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVACTERL syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eundetermined chromosomal abnormality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePierre Robin syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCrouzon syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTreacher Collins syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrematurity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eextremely preterm (\u0026lt;\u0026thinsp;28 weeks)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003every preterm (28\u0026ndash;32 weeks)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emoderate to late preterm (32\u0026thinsp;\u0026minus;\u0026thinsp;27 weeks)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow birth weight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eextremely low birth weight (\u0026lt;\u0026thinsp;1kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003every low birth weight (1-1.5kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003elow birth weight (1.5-2.5kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOperative characteristics of a cohort of neonatal patients undergoing surgery (N\u0026thinsp;=\u0026thinsp;454).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical specialties\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePaediatric Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e346\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e76.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eENT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeurosurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePaediatric Urology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOrthopaedics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMaxillofacial Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePlastic Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePaediatric Ophthalmology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePaediatric Respiratory Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation details\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOeseophageal atresia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eanorectal malformation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003enectrotising enterocolitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003elaparotomy - malrotation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMicrolaryngoscopy And Tracheoscopy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGastroschisis Closure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExploratory laparotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003epyloromyotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eventricular shunt surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInsertion Central Line\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eduodenal atresia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClosure Spinal Myelomeningocele\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCongenital Diaphragmatic Hernia Repair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDilatation Choanal Atresia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOrchidectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSmall bowel atresia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHirschprung's\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExomphalos Closure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePrevalence of CHD diagnosed by echocardiography\u003c/p\u003e \u003cp\u003eOf the 263 neonates who received perioperative echocardiography, 13 (4.9%) were classed as having major cardiac defects with 27 (10.3%) classed as having minor CHD circulation (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of cardiac defects on echocardiography\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCardiac defect\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMajor cardiac defects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTetralogy of Fallot (50% overriding aorta, large PDA and ASD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAtrioventricular Septal Defect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLarge PDA with haemodynamic instability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLarge ASD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-restrictive VSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCoarctation of aorta\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e13\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMinor cardiac defects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSmall ASD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRestrictive VSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBilateral superior vena cava\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePulmonary stenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBicuspid aortic valve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRhabdomyoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e27\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eASD\u003c/em\u003e atrial septal defect \u003cem\u003eVSD\u003c/em\u003e ventricular septal defects \u003cem\u003ePDA\u003c/em\u003e patent ductus arteriosus\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eEvaluating additional diagnostic yield of preoperative neonatal echocardiography\u003c/p\u003e \u003cp\u003eWe examined the sequential application of our triaging criteria (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) using sensitivity and negative predictive value (\u003cb\u003eTable\u0026nbsp;5\u003c/b\u003e). Clinical evaluation alone demonstrated a sensitivity of 100%, while the other three criteria had low to moderate sensitivity (F \u0026ndash; 46%, M \u0026ndash; 46%, S \u0026ndash; 62%). However, when combined, the sensitivity improved to 85%. Fetal echocardiography and the medical criteria had high specificity, 99% and 97% respectively, but surgical association and clinical evaluation both had moderate specificity, 66% for both.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriteria\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSensitivity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSpecificity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePPV\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNPV\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003efisher's exact test\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e98%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.00001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e98%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.00001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e98%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.071\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eF\u0026thinsp;+\u0026thinsp;M\u0026thinsp;+\u0026thinsp;S\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e99%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.0007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.00001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003ePPV \u0026ndash;\u003c/em\u003e Positive Predictive Value, \u003cem\u003eNPV \u0026ndash;\u003c/em\u003e Negative Predictive Value, \u003cem\u003eF \u0026ndash;\u003c/em\u003e fetal echocardiography suggestive of CHD, \u003cem\u003eM\u003c/em\u003e \u0026ndash; medical conditions associated with CHD, \u003cem\u003eS\u003c/em\u003e \u0026ndash; surgical conditions associated with CHD, \u003cem\u003eC\u003c/em\u003e \u0026ndash; clinical findings suggestive of CHD\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;5: sensitivity analysis of fetal echocardiography, pre-defined medical and surgical conditions, and clinical evaluation in detecting major cardiac defects\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis paper has sought to both document national practice in the use of routine neonatal echocardiography prior to surgery as well as to evaluate its diagnostic yield in a large, heterogeneous cohort of neonates undergoing surgery at a non-cardiac centre. National survey data suggests there is no consensus on which conditions are felt to \u0026lsquo;require\u0026rsquo; an echocardiogram preoperatively, with most (n\u0026thinsp;=\u0026thinsp;23, 88.5%) hospitals not having predetermined criteria.\u003c/p\u003e \u003cp\u003eBroadly, indications described in the responses for echocardiography corresponded to the four triaging categories documented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Specific surgical conditions varied between institutions, with oesophageal atresia, congenital diaphragmatic hernia and exomphalos being the most commonly cited conditions. The difference of opinion regarding the utility of a normal clinical examination was also evident, with 42.3% of hospitals insisting on preoperative echocardiography in certain conditions despite a normal clinical examination, and 26.9% choosing to delay surgery if an echocardiography could not be obtained in time. This is an important observation as retrospective evaluation of our data suggested that normal clinical examination had a sensitivity and negative predictive value of 100% in excluding major CHD. However, this observation should be interpreted with caution given its single centre origin and small numbers of major cases of CHD (n\u0026thinsp;=\u0026thinsp;13).\u003c/p\u003e \u003cp\u003eAcross the four categories that were compared, each of the individual criteria (F, M, S, C) had moderate to high specificity, which makes each one a reasonable \u0026ldquo;rule-in\u0026rdquo; decision. However, their individual sensitivity was lower. Only clinical evaluation alone achieved 100% sensitivity.\u003c/p\u003e \u003cp\u003eFor fetal echocardiography, the results revealed high specificity and moderate sensitivity, in keeping with a published meta-analysis.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Fetal echocardiography is operator-dependent and requires a high degree of expertise to provide an accurate diagnosis. Furthermore, some cardiac defects only manifest after undergoing the physiological transition after birth. A normal fetal echocardiogram does not reliably detect all major CHD postnatally. Of the 13 major CHD cases, 7 had \u0026ldquo;normal\u0026rdquo; antenatal scans.\u003c/p\u003e \u003cp\u003eThe addition of medical and surgical conditions associated with CHD improved the sensitivity for detecting major CHD to 85%. Associated elevated rates of CHD have been well documented in the literature for oesophageal atresia (13.2\u0026ndash;42%),[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] congenital diaphragmatic hernia (12\u0026ndash;25%),[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] exomphalos (14\u0026ndash;58%),[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] anorectal malformation (12\u0026ndash;15%),[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] duodenal atresia (31\u0026ndash;39%)[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and myelomeningocele (4.7\u0026ndash;40.5%).[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] However, the inclusion criteria vary widely, and the definition of CHD and its severity are not standardised in these reports. Our survey results suggest that decisions on which conditions to include vary and may be influenced by individual hospital\u0026rsquo;s experience and resources available for echocardiography. However, using a pre-determined criteria can improve the detection rate of severe CHD, albeit with moderate sensitivity and specificity.\u003c/p\u003e \u003cp\u003eWith a sensitivity of 100% for capturing CHD for clinical evaluation as a criterion, our results match other recent studies in reinforcing the message that clinically significant CHD is highly unlikely if the clinical evaluation is normal preoperatively. Our data goes one step further in providing validation in a mixed population of neonates with medical and surgical co-morbidities.\u003c/p\u003e \u003cp\u003eThe main limitation to our study is that it is performed in a single tertiary centre without cardiac surgical services. Some neonates with major cases cardiac defects like transposition of the great arteries or hypoplastic left heart syndrome that are detected antenatally may be born in an obstetric unit co-located with a specialist cardiac surgical centre. This may explain the low numbers of major forms of CHD in our cohort. If these cases were included in our dataset, it may improve the sensitivity of fetal echocardiography in detecting major CHD, which is higher for more severe defects according to a previous study. Currently across the UK the fetal anomaly screening programme aims to detect 50% of cases of severe CHD before birth.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] It is important to note that detecting missed cases of major CHDs on fetal echocardiography may be more crucial in non-cardiac paediatric surgical centres, which represent the majority of UK paediatric surgical centres (16, 61.5%), to guide perioperative management.\u003c/p\u003e \u003cp\u003eDue to the retrospective nature of the study, the assessment of clinical evaluation as documented in the medical records was subject to bias. There was no standardisation of how it was performed, in what order, or by whom. All infants with congenital anomalies will have been examined by a senior member of the neonatal medical team. There is also a risk of confirmation bias, in that clinicians are more likely to detect signs if they are examining a neonate with a known medically or surgically associated condition. In addition, our mixed cohort included emergency cases some with diagnosed sepsis such as necrotising enterocolitis where some of the clinical signs may mimic CHD.\u003c/p\u003e \u003cp\u003eOur database contains a mixed population of neonates that represents a real-world context to test criteria for preoperative echocardiography screening (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). While previous studies have focused on specific conditions, our study is the first to evaluate the use of a multi-pronged approach in a heterogenous cohort, that also considers the impact of fetal screening for CHD.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn conclusion, our study demonstrates that fetal and postnatal echocardiography alone are not sufficient to capture all significant CHDs postnatally. A normal clinical evaluation is highly reliable in ruling out major CHD. The addition of medical and surgical conditions associated with CHD as criteria for echocardiography will help improve the sensitivity of detecting significant CHD. Institutions may disagree on the list of surgical conditions that warrant a preoperative echocardiogram, as this is influenced by the availability of local resources to perform echocardiography and urgency of surgery. However, what is critical is to carry out a thorough clinical evaluation to help decide if echocardiography will improve the yield of detecting major CHD before proceeding with surgery. A successful surgical outcome depends on good communication between the paediatricians, surgeons and anaesthetic colleagues.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJ.C. W.K. and J.L. conceived and designed the study.D.J., A.K., J.C., W.K. and J.L. collected the data.D.S., A.K., W.K. and J.C. analysed the data.D.J. and J.C. wrote the main manuscript text. All authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eTulloh RM, Tansey SP, Parashar K, De Giovanni JV, Wright C, Silove JG (1994) Echocardiographic screening in neonates undergoing surgery for selected gastrointestinal malformations. Arch Dis Child Fetal Neonatal Ed 70(3):F206\u0026ndash;F208\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBogarapu S, Pinto NM, Etheridge SP, Sheng X, Liesemer KN, Young PC et al (2016) Screening for Congenital Heart Disease in Infants with Down Syndrome: Is Universal Echocardiography Necessary? Pediatr Cardiol 37(7):1222\u0026ndash;1227\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eNasr A, McNamara PJ, Mertens L, Levin D, James A, Holtby H et al (2010) Is routine preoperative 2-dimensional echocardiography necessary for infants with esophageal atresia, omphalocele, or anorectal malformations? J Pediatr Surg 45(5):876\u0026ndash;879\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSun HY (2021) Prenatal diagnosis of congenital heart defects: Echocardiography. Vol. 10, Translational Pediatrics. AME Publishing Company, pp 2210\u0026ndash;2224\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eTanny SPT, King SK, Comella A, Hawley A, Brooks JA, Hunt RW et al (2021) Selective approach to preoperative echocardiography in esophageal atresia. Pediatr Surg Int 37(4):503\u0026ndash;509\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eVernon MM, Powell D, Schultz AH, Simon TD, Doherty D (2015) Is routine preoperative transthoracic echocardiography necessary in newborns with myelomeningocele? J Perinatol 35(10):842\u0026ndash;845\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eRitter S, Tani LY, Shaddy RE, Minich (1999) L Luann. Are Screening Echocardiograms Warranted for Neonates With Meningomyelocele? Arch Pediatr Adolesc Med 153(12):1264\u0026ndash;1266\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eShort SS, Pierce JR, Burke RV, Papillon S, Frykman PK, Nguyen N (2014) Is routine preoperative screening echocardiogram indicated in all children with congenital duodenal obstruction? Pediatr Surg Int 30(6):609\u0026ndash;614\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKhan A, Tanny ST, Perkins EJ, Hunt RW, Hutson JM, King SK et al (2017) Is selective echocardiography in duodenal atresia the future standard of care? J Pediatr Surg 52(12):1952\u0026ndash;1955\u0026nbsp;\u003c/span\u003e\u003cspan\u003ehttps://. (accessed 15 May 2024)\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eZhang YF, Zeng XL, Zhao EF, Lu HW (2015) Diagnostic value of fetal echocardiography for congenital heart disease, vol 94. Lippincott Williams and Wilkins, p e1759. (United States)\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eEncinas JL, Luis AL, Avila LF, Martinez L, Guereta L, Lassaletta L et al (2006) Impact of preoperative diagnosis of congenital heart disease on the treatment of esophageal atresia. Pediatr Surg Int 22(2):150\u0026ndash;153\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHautala J, Karstunen E, Ritvanen A, Rintala R, Mattila IP, R\u0026auml;s\u0026auml;nen J et al (2018) Congenital diaphragmatic hernia with heart defect has a high risk for hypoplastic left heart syndrome and major extra-cardiac malformations: 10-year national cohort from Finland. Acta Obstet Gynecol Scand 97(2):204\u0026ndash;211\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eStoll C, Alembik Y, Dott B, Roth MP (2008) Omphalocele and gastroschisis and associated malformations. Am J Med Genet A 146A(10):1280\u0026ndash;1285\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eChu C, Yan Y, Ren Y, Li X, Gui Y (2017) Prenatal diagnosis of congenital heart diseases by fetal echocardiography in second trimester: a Chinese multicenter study. Acta Obstet Gynecol Scand 96(4):454\u0026ndash;463\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eFetal anomaly screening programme handbook NHS England. Published 9 July 2015. Last updated 19 February 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.gov.uk/government/publications/fetal-anomaly-screening-programme-handbook/data\u003c/span\u003e\u003c/span\u003e. (accessed 15 May 2024).\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-surgery-international","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pesi","sideBox":"Learn more about [Pediatric Surgery International](http://link.springer.com/journal/383)","snPcode":"383","submissionUrl":"https://submission.nature.com/new-submission/383/3","title":"Pediatric Surgery International","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4441088/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4441088/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThe detection of congenital heart disease (CHD) before neonatal surgery is crucial for anaesthetic and perioperative management. There are no established criteria for preoperative echocardiography in neonates. We aimed to survey current practice in the United Kingdom and evaluate the reliability of antenatal screening and postnatal clinical assessment in detecting CHD before surgery.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eA 9-point questionnaire was sent to all paediatric surgical centres in the United Kingdom to assess their practice. Subsequently, a single-centre retrospective review of all neonatal surgery over 5 years (2015\u0026ndash;2020) was conducted in our tertiary paediatric/neonatal hospital. Data included preoperative clinical assessment, performance of chest radiograph and echocardiography. Indications for echocardiography were categorised and assessed using sensitivity, specificity, positive predictive value and negative predictive value.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAll 26 paediatric surgical centres responded to our survey. 23/26 (88.5%) did not have established criteria or guidelines for preoperative echocardiography. There was a large variation in which surgical conditions required a preoperative scan and whether a normal clinical examination was considered sufficient to not require one. For the retrospective review, 454 patients were identified. There were 40 cases with CHDs (8.8%), 13 were classed as major. Indications for echocardiography were categorised into abnormal fetal cardiac screening, medical/surgical conditions associated with CHD and an abnormal cardiorespiratory examination. Sensitivity, specificity, positive predictive value and negative predictive value for major CHD was 46%, 99%, 67%, 98% for abnormal fetal screening, 46%, 97%, 35%, 98% for associated medical conditions, 62%, 66%, 6%, 98% for associated surgical conditions, and 100%, 66%, 9%, 100% for abnormal clinical examination.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe use of preoperative echocardiography in neonates is not standardised across the UK.. The results from our cohort demonstrates that fetal echocardiography is not sufficient to capture all major CHDs, but the absence of abnormal clinical examination is highly reliable in ruling out major CHD. Specifying a list of medical/surgical of conditions associated with CHD warranting preoperative echocardiography may improve yield, but this depends on the availability of resources and expertise.\u003c/p\u003e","manuscriptTitle":"Which neonates should have a pre-operative echocardiography? Findings from a national survey and a retrospective tertiary single-centre analysis in the United Kingdom","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-04 19:10:01","doi":"10.21203/rs.3.rs-4441088/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-09T08:45:06+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-28T15:51:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"281654630401665889357192136775013305309","date":"2024-05-28T07:47:54+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-27T16:41:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-21T09:30:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-20T07:17:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Surgery International","date":"2024-05-18T12:40:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-surgery-international","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pesi","sideBox":"Learn more about [Pediatric Surgery International](http://link.springer.com/journal/383)","snPcode":"383","submissionUrl":"https://submission.nature.com/new-submission/383/3","title":"Pediatric Surgery International","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"88700fb8-371b-45d8-b238-ec10d249d2ae","owner":[],"postedDate":"June 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-06-25T16:42:38+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-04 19:10:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4441088","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4441088","identity":"rs-4441088","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}