Critical Congenital Heart Disease screening in the newborn
Critical Congenital Heart Disease screening in the newborn in Thailand Thanarat Layangool, MD. QSNICH
Issues Backgrounds of Critical CHD Statistic of Cyanotic CHD in the newborn Critical CHD screening program in neonate Results from our pilot study Results of the 3 years implemented this program in Thailand
Background The prenatal screening (fetal echo) for CHD in Thailand is limited to the university hospitals and some tertiary care centers. Postnatal screening of critical CHD by using pulse oximeter is feasible with reasonable cost.
Vicious cycle of the patients with critically ill in Thailand Not available ICU bed Delayed Diagnosis Prolong Length of stay Delayed Transfer complications Delyed treatment - few CVT surgeon
Number of new cardiac patients at Queen Sirikit NICH (25, 615 cases)
Prevalence of Neonatal Heart Disease at Queen Sirikit NICH 1995 -10 (2, 259 cases) % total NB-CHD
1. Cyanotic CHD presented during Neonate 795/2, 259 cases(35%) % of NB-CCHD
1. Cyanotic CHD presented during Neonate 795/2, 259 cases(35%) % of NB-CCHD
2. Cyanotic CHD presented during neonate 795/2, 259 cases(35%) % of NB-CCHD
2. Cyanotic CHD presented during neonate 795/2, 259 cases(35%) % of NB-CCHD
Fetal and neonatal circulation
Background of O 2 sat screening in CCHD Author Year Criteria Postnatal age Detection/ Total Hoke TR, etal(8) 2002 >7% diff or< 92% 6 -24 hr 4 / 2, 908 Richmond S, et al(9). 2002 < 95% >2 hr 6 / 5, 626 FN 3 (Co. A) Reich JD, et al(10) 2003 < 95% *3 < 90%*1 >4% diff 2 / 2, 114 FN 1 (TAPVR) Koppel RI. et al(11) 2003 < 96% 3 / 11, 281 FN 2 (Co. A, hypo LPA) FP 1 >24 hr Result / comment
Background of O 2 sat screening in CCHD Author Year Bakr AF, et al(12) 2005 Criteria < 93 % Postnatal age Before D/C Detection/ Total 5, 211 Result / comment Sens. 77% Spec 100% PPV 66. 7% (PE + O 2 sat) Knowles R, et al(13) SR (HTA) 2005 Life threatening CHD 121/100, 000 CCHD 39% by PE 68% by PO Rosati E, et al(14) 2005 >24 hr 3 / 5, 292 Sens 66. 7% Spec 100% PPV 50% NPV 100% Before D/C 12 / 7, 962 Human factors (placement time, training, nursing degree) Reich JD, et al(15) 2008 < 96 FP 0. 5% by PE 1. 3% by PO
Background of O 2 sat screening in CCHD Author Year Criteria De-Wahl Granelli, < 95% *3 et al(16). 2009 < 90%*1 >4% diff Postnatal age > 24 hr Detection/ Total 29/39, 821 Result / comment Sens 82. 8%* Spec 97. 8%* Comparison with late detection cases, MR decrease in early diagnosed gr. from 18% to 0. 9% Riede FT, et al(17). 2010 < 96% (post fetal diagnosis) >24 hr 14 / 41, 445 Sens 77. 8% Spec 99. 9% PPV 25. 9% NPV 99. 9% Walsh W. (18) 2011 < 94 % (only foot) (post fetal diagnosis) >24 hr 1/ 14, 983 No echo confirm positive screening test
Anne De-Wahl Granelli
Background of O 2 sat screening in CCHD Author Year Criteria Ewer AK, et al. (19) 2011 Thangaratinum S, et al. (20) 2012 Metaanalysis 13 studies Postnatal age Detection/ Total Result / comment 24/ 20, 055 (2. 6/1000) Sens 75% Spec 99. 2% 229, 421 Sens 76. 5% Spec 99. 9% FP 0. 14% FN 0. 05% after, 0. 5% before 24 hr.
Positive screening criteria 1. Any O 2 saturation < 90% or 1. O 2 saturation < 95% in both RH and F or > 3% difference on 3 measurement , each separate by 1 hr.
Negative screening criteria 1. O 2 saturation at RH or F more than or equal to 95 % and 2. The difference of O 2 saturation between RH and F less than or equal to 3 %
Primary target diseases(critical CHD) Hypoplastic left heart syndrome. (2. 2%) Pulmonary atresia. (8%) Transposition of the great arteries. (4%) Tetralogy of Fallot. (4%) Total anomalous pulmonary venous return. (1. 2%) Tricuspid atresia. (0. 7%) Truncus arteriosus. (1. 2%) Others. Coarctation of the aorta (2%) Interrupted aortic arch (1%) Critical AS (0. 4%)
Hypoplastic left heart syndrome LA RA
Transposition of the great arteries
Coarctation of aorta
We started the pilot study in April 2012 12 general hospitals (6 provinces and Bangkok) Using AAP guideline plus peripheral perfusion index > 0. 7 Age > 24 hrs Pulse Oximeter: Masimo (Rad 6) Positive screening-> echo Negative screening-> advice Phone call at 1 -2 m of age
Funding NHSO Supported from the National Health Security Office of Thailand
Results From Apr 2012 - Oct 2014 50, 000 NB babies received screening True positive 21 cases False negative 11 cases
ICU stay > 2 m
False Negative Cases 1. Dextroposition, TA, PA, hypo LPA, small PDA รพ. นพรตน 2. PA, hypo RV (22 d) : BT shunt รพ. สพรรณ 3. TOF (8 m) : FU รพ. สพรรณ 4. TAPVR : FU รพ. ภมพล 5. Severe PS : loss FU 6. Single ventricle, PS : waiting for BT shunt 7. DORV : FU รพ. พยลฯ รพ. พยล 8. TOF รพ. อยธยา
False Positive 1. 2. 3. 4. 5. Pulmonary Hypertension Normal Pneumonia BMP hosp. (4) AYT hosp. (5) KJB hosp.
Diagnosis before 24 hrs (26 cases) PA, IVS PA, VSD TOF TGA Co. A Truncus TAPVR IAA AS TA Ebstein’s TV HLHS 3 2 7 5 2 1 1 cases cases case 1 1 1 case
Conclusions from our study Pulse Oximeter can be used as a screening CHD in NB Sensitivity 65. 5 % Specificity 99. 9% True Positive rate 0. 4: 1, 000 (with comparable to the previous reports) Higher false negative rate Asymptomatic critical CHD babies can be detected, received early management and may improve survival.
Comparison the results of screening > 24 hr Bakr Reich Koppel Rosati de Wahl Reide Kawalec number 5211 2114 11281 5292 39821 41442 27200 132361 average Thailand 1000 27290 TP 3 0 3 2 19 14 7 48 0. 362 645 11 FP 2 4 1 1 68 40 13 129 FN 0 0 2 1 10 4 1 18 0. 974607 0. 135992 5 10 TN 5206 2110 11275 5288 39724 41384 27179 132166 27264
2014 : Implementation of Critical CHD screening in the newborn program at secondary and tertiary care hospitals in 4 of 13 health service regions in Thailand.
2014 : (1, 8, 4, 7) 2015 : (2, 5, 9, 11) + Community base hospitals in 30/77 provinces 2016: (3, 6, 10, 12)
http: //pacs. lph. go. th: 8181/Screening. Heart/
Data until 6 -12 -15 88 hospitals: 104, 000 cases
Data until 17 -6 -16 107 hospitals: 159, 323 cases Positive screening 159 cases
http: //pacs. lph. go. th: 8181/cchd/ 89 93 89
Thank you for your attention
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