European Journal of Cardiovascular Medicine

Echocardiography had remained the most noninvasive ,effective, reproducible tool  & gold standard  for detecting not only structural heart disease but also in hemodynamic assessment in real time.¹ Its use as a bedside tool as a part of point of care ultrasound (POCUS) in neonatal intensive care unit (NICU) is growing rapidly all over the world.² It provides the neonatologist the in-depth information on the hemodynamics not available by blood pressure, pulse oximetry, capillary refill time and various blood tests.³ Its role had remained complementary to CXR and ECG.⁴ Its use is priceless specially in decision making situations like with the presence of cyanosis, respiratory distress and shock , where many differential diagnosis like  congenital heart defect (CHD), myocarditis, pulmonary, central nervous system , infectious, metabolic and hematologic causes comes in to account. Its use is indispensable in management of shock, pulmonary hypertension, patent ductus arteriosus, pericardial effusion and cardiac tamponade. It helps in timely & accurate diagnosis by which specific treatment can be provided to the sick neonates.^1,2,5 Recently conducted survey in India for PPHN in NICUs had showed that echocardiography facility was available in 90% of the units. Out of which 22% were govt institutions and 78% were privately run hospitals. Echocardiography was performed by neonatologist/paediatrician (49%), pediatric cardiologist (22%),13% adult cardiologist, 13% neonatal trainee & 3% by echocardiography technician.⁶ However a performer doing echo on a neonate should have clear and thorough understanding of fetal circulation, the circulatory changes in the form of transitional circulation to establishment of post-natal circulation. Also, the physiological hemodynamic change the baby has to pass through, otherwise erroneous interpretation of such things as pathological condition will not only bring unnecessary trauma to the family but also misguide the therapy as well.

Majority of the studies were focused on CHD and on NICUs. Not much studies found in the majority health care facility actually we are having for the neonates.Our hospital is the prime tertiary care hospital in southern Odisha, It  receives newborn referrals from neighboring districts of Andhra Pradesh also . Neonatal POCUS had not been started in our department during the study period. So, We wanted to do this study at to know the baseline status of CHD and other functional problem of the newborns requiring echocardiography and the geographical trend if any in this locality may increase awareness for early medical or surgical intervention in CHD and for other functional problem also. Which may help us to establish neopocus in our institute in near future.

The aim of the study was to

1. To describe the indication for echocardiography in the neonates.
2. To find the positive findings in echocardiography resulting change in clinical management.

The study was conducted in special newborn care unit (SNCU) & Newborn intensive care unit (NICU), Dept of Paediatrics, MKCG MCH, Berhampur, Odisha, from Nov’2020 – Oct ‘2021.It was prospective & hospital-based study. Institutional ethical committee approval was done for the study.

Inclusion criteria :  Newborn babies admitted  in newborn care unit having suspicion of the structural heart disease or functional problem with presence of cyanosis, heart failure, shock, murmur, decrease in O2 saturation, discrepancy in upper limb and lower limb O2 saturation or pulse or blood pressure , hypertension, presence of congenital anomaly having high association of structural anomaly of heart, antenatal scan detection of cardiac abnormality, infants of diabetic mother, family history or previous sibling history of structural heart disease, presence of tachyarrythmia or bradyarrhythmia, radiological presence of cardiomegaly or having situs abnormality or any other abnormality suspected cardiac problem were subjected for echocardiography.

Exclusion criteria :1. Newborn babies suspected structural cardiac problem or hemodynamic issues who were intubated or very sick but not intubated were not send for echo.2.who had high degree suspicion congenital heart disease but expired before the test. 3.Cases could not be sent for echocardiography for some reason other than above mentioned cause were also excluded from the study.

The newborn babies who were subjected for echocardiography, the demographic data of the babies in the form of age, gender, birthweight, birth order details were collected. Maternal details in the form of age, consanguinity of marriage, type of delivery, place of delivery, type of conception, presence of maternal risk factors in the form of DM, HTN, SLE, drug intake, radiation, infection, heart disease, family h/o heart disease data were collected. Indication for echocardiography was noted down. After echocardiography information regarding the findings of the scan and any change in clinical management following the scan were also collected.

Inview of nonavailability of POCUS (point of care ultrasound services) in the paediatric department echocardiography was done in the echo room in the department of Cardiology, which was in the super specialty block in 3^rd floor not to the vicinity of paediatric department. The newborn babies were brought by the hospital attendant and family members with or without on oxygen whenever required. They were also accompanied by post graduate resident or interns for the test with resuscitation kit stand by. All case echo was done without use of any sedation and with breastfeeding whenever possible. The days for echocardiography were weekly twice on tuesday and thursday. Other days like cardiology OPD days, holidays used to remain closed. No emergency neonatal echo done during emergency hrs. Has to depend absolutely on cardiology department. As per departmental policy none of the babies were allowed to be taken outside the institute for the test done some other place.

PHILLIPS echo machine with s4 transducer was used for the procedure. The echocardiogram was done by trained paediatric cardiologist from the department of paediatrics . Standard views were taken.2DE, M-MODE, COLOR Doppler, PW doppler, CW doppler were various modes used for the diagnosis.

The echocardiographic findings were classified as 1. Normal - when no abnormality was found, 2. Minor - when the structural abnormality is normal for the age like patent foramen ovale, hemodynamically insignificant PDA, mild left pulmonary stenosis. 3.Congenital heart defect (CHD) by presence of congenital anomalies and 4. Functional- abnormality in the form of PPHN and LVdysfunction.⁷ After echocardiography information regarding the findings of the scan and any change in clinical management following the scan were also collected.

Statical analysis:

Collected data was entered in to the excel sheet for further analysis. Statistical analysis was done by using the SPSS V.25 software. Qualitative data analysis was done by frequencies and percentages. Quantitative data was presented as mean, standard deviation, median and range.

The total no of babies included in the study period who were referred for echocardiography were 146. The demographic details of the neonate are shown in (Table -1). Maximum admission took place with in 1^st week of the postnatal age 124 (87%), among which 74(58.2%) were admitted with in 1^st 24hrs of the age, followed by 15-21days 6.1%, 8-14 days 14 (4.2%), 22-28days 4(2.7%). The birth order of the babies was G1 -74 (50.68%), G2 -53(36.32%), G3 – 16 (10.95%), and G4 – 3 (2.05%).

Table 1: Demographic details of the neonates

Maternal age was from 18-32yrs, maximum was between 18-25 yr age group. Various maternal issues and illnesses were present in 42(28.7%) mothers. Which were DM 19, hypothyroid 4, hypertension 4, polyhydramnion 4, HBsAg positive 2, oligo 1, eclampsia 1, CHD 1, VDRL positive 1, toxo 1, Tuberous sclerosis 1, on antipsychotic medication 1. All babies were conceived by normal conception other than 1 baby, who was by IVF. Consanguinity of the marriage was found in 1 case.

 The median age at which first echocardiogram was done was at Day 7 post-natal age (D3-D29). 19 (13%) babies were electively sent to R/O structural heart disease due to presence of extra cardiac anomalies. However, most of the other babies were sick babies having newborn issues like prematurity, respiratory distress, HIE, convulsion, hypoglycaemia, sepsis, NNHB etc. Among which the most common clinical problem for admission was HIE followed by respiratory distress,

Table 2: Indication for Echocardiography

The most common indication for echo referral was due presence of cardiac murmur 63(43.15%), followed by desaturation 17(11.64%), extracardiac anomaly 16(10.95%), infant of diabetic mother IDM 16(10.95%) (Table -2).In the echocardiographic findings 26(17.80%) cases were normal, minor 29(19.86%),structural abnormality 73(50%),functional 18(12.34%).The type of structural  heart disease found were shown in ( Table -3).

Table 3: Echocardiographic Findings (n= 73)

The birth prevalence of CHD we got was 1.44%. Which is slightly higher as in other studies in India, described the birth prevalence 0.9% (range 0.8- 1.2%). ^{8,9,10 The} mean gestational age was 38wks, mean birth weight (BW) was 2545gms and prematurity was found in 34% of cases. Similarity in gestataional age was found in other study but the mean birth weight and prematurity was found 2812gms and 16.9% respectively.¹¹The male preponderance was significant in our study with M: F being 63% vs 37%. The inborn and outborn figure were almost similar likely it being the only tertiary care center in that locality.The CS 42% and normal delivery 58%.However the study done at Bangladesh showed M:F being 52% vs 47%, inborn 62% and outborn37.8%,CS 73.9% and normal delivery26.1%.¹²

The median age at which first echocardiogram was done was D7 postnatal age which was absolutely depended on the availability of the service though the requirement was much earlier in many cases. However, the earlier scan done was as early as D2 in other study.⁷

 The most common indication for echo referral was due presence of cardiac murmur 63(43.15%), followed by desaturation 17(11.64%), extracardiac anomaly/dysmorphic features 16(10.95%). The retrospective study done by Kadivar et al found 2 most common indication was similarly being murmur (45%) and extracardiac anomalies/dysmorphic features (45%).¹¹ In the murmur group 47(74.60%) had CHD,9(14.29%) cases had minor abnormalities, 7(11.11%) case were having normal echo study. Murmur was present in 47(73.43%) of CHD and absent in 17(26.56%). Which is similar to study done by Roguin &Barak.¹³. Other studies done at India & Iran found CHD  62% and 51.6% respectively with murmur.^14,15Syndromic neonates present in 7(4.79%) case (5 Down syndrome,1Turner Syndrome,1Tuberous Sclerosis). Other study showed slightly higher chromosomal anomalies in 15% of cases.¹²

In the ECHO we have 73(50%)  have structural abnormality, minor abnormality 29(19.86%),functional abnormality 18(12.34%) and normal 26 (17.80%) .The study done earlier showed 53.65% structural abnormality, minor abnormality19.54%, functional abnormality 15.85% and normal 9.75% almost similar.⁷ However study done at Pakistan on cardiac evaluation of neonates in a paediatric cardiology center had found 55.8% normal, 31.7% CHD,2.5% duct dependent lesions,9.1%PPHN and 0.8% LV dysfunction in structurally normal heart which is very much different from the neonatal units of the paediatric department.¹⁶

In the structural abnormality group, we had CHD in 64(87.67%) and others 9(12.33%). ACHD was found in53(82.82%) and CCHD in 11(17.18%).VSD followed by ASD & ASD +PDA were the common ACHD where as in CCHD complex heart disease 6 (54.5%) followed by TOF with absent pulmonary valve were common. Almost similar findings were found in other study.¹²

The multiple cardiac rhabdomyoma with obstructing RVOT case was genetically confirmed of tuberous sclerosis both in mother and child. was referred to CTVS. The suspected metabolic case in echo had confirmed carnitine cycle defect presented with apnea and bradycardia, responded to carnitine supplementation.¹⁷

PPHN was found in 17(10.27%) of cases. Similar 9.1% found in Pakistan study whereas Bangladesh study showed 27% which was higher.^12,1614 cases were suspected clinically of PPHN.The underlying conditions were RDS, HIE, MAS, IDM. Sildenafil was started with moderate and severe PA pressure. Weekly follow up ECHO was done in all these cases to look for the response till the PA pressure became normal.1 case who presented with supraventricular tachycardia (SVT) with failure was found to have PPHN. On evaluation was found to have thyrotoxicosis whose mother was known case of hypothyroidism on thyroxine supplementation. Along with antithyroid drugs sildenafil was given. Other studies also show echocardiography plays important role in in diagnosis and management of PPHN.^5,18

Maternal DM was present in16(10.95%) of cases 7(43.4%) cases were having cardiac anomalies. Which was similar to studies done in India (42.2%) as well as abroad (46.9%).^19,20

 In the PDA group 10 cases were send for echocardiography after starting 1^st course of ibuprofen in NICU with clinically suspicion of PDA in preterm babies. Among which 7 got closed on follow up echo.2 cases were having large PDA and 1 was associated with VSD.

Echocardiography helped for selecting cases for repeat echo for the management purpose depending upon the type of case. It required 2-3 times in PDA to look for duct closure those required 2^nd and 3^rd course of ibuprofen.^21.22 PPHN cases till normalization of pressure. LV dysfunction in tachycardiomyopathy till normalization of LV function.²³

The outcome of the neonates in hospital was, 17(11.64%) cases of structurally abnormal heart referred for early cardiac surgery, 64(43.84%) cases required both routine paediatric and echo cardiography follow up,63(43.16%) cases required only paediatric follow up and 2  (1.36%)1 TGA & 1 PPHN succumbed during their stay.

Limitation of the study

The total number of echoes done is not likely the true real requirement of echocardiography in the neonate,

1. As very sick babies for functional or structural cardiac assessment not included.
2. Many babies who had high degree of suspicion of structural heart lesion from clinical exam and CXR had succumbed before echo during the waiting period are not included.
3. The study was done in covid pandemic period with restriction of the echocardiography test time to time.

The most common indication for echo referral  in our study was presence of a murmur. However in 26.5% of significant cardiac lesion cases cardiac murmur was absent. Increased number of CHD in maternal diabetic group points towards early detection and glucose control. Beside the CHD other structural abnormality was found in 10.97% of cases pointing to keeping the mind open for other things also.The antenatal scanning for detection of CHD was very less, which points towards improvement in antenatal screening for detection of CHD so that early intervention can be taken.  Increase number of sick babies requiring echocardiogram indicates it is an essential tool as point of care ultrasound and necessitates it as bed side availability.Word of caution too, to know when to refer the case to the paediatric cardiologist.

I am very much thankful to the Dean and Principal , MKCGMCH, Prof Diptimayee Tripathy,Prof Narendra Behera, HOD Paediatrics, Prof Trinath Mishra,HOD Cardiology for their support in making this piece of work.

Funding: Nil

Conflict of interest: None declared

Ethical approval: Ethical approval taken

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