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

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.