Which neonates should have a pre-operative echocardiography? Findings from a national survey and a retrospective tertiary single-centre analysis in the United Kingdom
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In brief
In brief
This UK study reveals lack of standardized criteria for pre-operative echocardiography in neonates undergoing surgery. Analysis of 454 cases shows that while antenatal screening misses significant CHD, normal postnatal clinical examination reliably excludes major cardiac defects, suggesting targeted echo protocols may optimize detection.
- 88.5% of UK paediatric surgical centres lack established criteria for pre-operative neonatal echocardiography, showing significant practice variation.
- 8.8% of neonates undergoing surgery had CHD; abnormal foetal screening missed 54% of major/moderate cases (46% sensitivity).
- Normal postnatal clinical examination has 100% sensitivity and 100% NPV for ruling out major/moderate CHD before neonatal surgery.
- Medical/surgical conditions associated with CHD had low PPV (35%, 6%) but high NPV (98%) for detecting significant cardiac anomalies.
- Standardized pre-operative echo criteria based on clinical exam and high-risk conditions could improve CHD detection in neonatal surgery.
Written by the GCMD Library team from the article.
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 pre-operative 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 pre-operative 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 pre-operative echocardiography. There was a large variation in which surgical conditions required a pre-operative 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 or moderate. Indications for echocardiography were categorised into abnormal foetal cardiac screening, medical/surgical conditions associated with CHD and an abnormal cardiorespiratory examination. Sensitivity, specificity, positive predictive value and negative predictive value for major and moderate CHD were 46%, 99%, 67%, 98% for abnormal foetal 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 pre-operative echocardiography in neonates is not standardised across the UK. The results from our cohort demonstrate that foetal echocardiography is not sufficient to capture all major and moderate CHDs, but the absence of abnormal clinical examination is highly reliable in ruling out them out. Specifying a list of medical/surgical of conditions associated with CHD warranting pre-operative echocardiography may improve yield, but this depends on the availability of resources and expertise.