Adult-Trained Cardiac Sonographers: Essential Team Members in the Evaluation and Management of Unexpected Neonatal Critical Congenital Heart Disease

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Abstract
Early identification of critical congenital heart disease (CCHD) is essential in the management of neonates without a prenatal diagnosis. Adult-trained cardiac sonographers often perform initial neonatal transthoracic echocardiograms for outside interpretation. We sought to critically evaluate the accuracy and quality of these echocardiograms. Neonates treated at our center for postnatally diagnosed CCHD, who had an initial echocardiogram performed by an adult-trained sonographer at an outside birthing center were included. Each initial echocardiogram was evaluated using a 4-point Likert scale for diagnostic accuracy and quality, and a 3-point Likert scale assessing 5 standard echocardiogram views. Six paired graders independently assessed an equal distribution of echocardiograms. 52 echocardiograms from 4 states met all inclusion criteria. The most common diagnoses were aortic arch abnormalities (37%), followed by dTGA (19%), and TAPVR (17%). Ninety-eight percent of the original interpretations provided the correct primary diagnosis or high enough suspicion of the primary diagnosis to warrant appropriate escalation in care. Average scores of the echocardiograms were 3.13 ± 0.66 for diagnostic accuracy and 3.09 ± 0.54 for overall image quality. Average scores were highest for parasternal long-axis view (2.74 ± 0.31) and lowest for suprasternal notch (2.18 ± 0.46) and subcostal (2.07 ± 0.34) views. The average intraclass correlation between raters was > 0.9. Postnatal CCHD is discoverable by adult-trained sonographers with remote interpretation by pediatric cardiologists. Suprasternal notch and subcostal views are areas of educational opportunity. With appropriate support systems, adult-trained sonographers can be an invaluable asset in the early diagnosis and management of unexpected CCHD.

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