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Pulse Oximetry and Auscultation for

Congenital Heart Disease Detection

Tugas Jurnal Stase Anak


Oleh: Nurullia Ulfah Ishedy
Perseptor: dr. Aspri Sulanto Sp.A
• Pulse oximetry (POX) has been confirmed as a
specific screening modality for critical congenital
heart disease (CCHD), with moderate sensitivity.
However, POX is not able to detect most serious
and critical cardiac lesions (major congenital heart
disease [CHD]) without hypoxemia. In this study,
we investigated the accuracy and feasibility of the
addition of cardiac auscultation to POX as a
screening method for asymptomatic major CHD.

Objektive
Methode
• A multicenter prospective observational screening
study.
• at 13 hospitals (hospitals 1–13 in Fig 1) between
July 1, 2012, and December 31, 2014, and at 2
hospitals between February 1, 2013, and
December 31, 2014, (hospitals 14 and 15 in Fig 1)
in Shanghai.
• All consecutive asymptomatic newborn infants
were included (irrespective of gestational age), but
newborn infants with prenatally diagnosed CHD
were excluded from the analysis of the current
study. Study Design and Participants
• Screening methodology, POX measurement
criteria, and the definition of CHD severity were
the same as our previous study, but in this study,
we only screened asymptomatic neonates, and
screening modalities included only POX and
cardiac auscultation.
• A positive screen result was defined as presence of
any abnormality in the 2 examinations as presented
in Fig 2.
• Neonates who screened positive for CHD were
referred for echocardiography within 24 hours of
screening.
Procedures
• For infants who had negative screening results,
clinical follow-up was done at 6 weeks of age, in
combination with feedback from parents about
cardiac symptoms such as cyanosis, tachypnea,
and feeding difficulty or CHD diagnosis by any
hospitals after the infant was discharged from the
delivery hospital.

Procedures
• Sensitivity, specificity, positive and negative
predictive values, and positive and negative
likelihood ratios were calculated for POX alone
and in combination with cardiac auscultation.
• 95% confidence interval of sensitivity and
specificity was computed by the Wilson method.
• McNemar’s test was used to compare differences
in sensitivity and specificity.

Statistical Analysis
• A logistic regression model was performed to test
the trend of FPRs across 7 time intervals during
which screening occurred.
• χ2 decomposition analysis was further performed
to identify the difference of the FPRs between
time intervals

Statistical Analysis
Results
• All 15 hospitals that participated in the study
were able to complete routine CHD screening
and complete
 Sensitivity, or refer
specificity, for echocardiography
positive and negative predictive in
values,and
a timely and positive
effectiveand negative
manner,likelihood
with aratios were
screening
ratecalculated
of 94.0% for to
POX alone and
99.8% as inshown
combination
in Figwith
1.
cardiac auscultation.
• There was no significant difference in positive
 95% confidence interval of sensitivity and specificity was
screening
computed results
by the Wilson between
method. these hospitals
(1.1%–1.8%, P > .05).
 McNemar’s test was used to compare differences in
sensitivity and specificity.
The Complete Compliance of POX
Plus Cardiac Auscultation Screening
• POX alone as a screening method detected 34 out
of 44 (77.3%) CCHD cases but only 90 out of
203 (44.3%) major CHD cases. POX plus cardiac
auscultation detected 42 out of 44 (95.5%) cases
of CCHD and 187 out of 203 (92.1%) cases of
major CHD. The addition of cardiac auscultation
to POX significantly improved the sensitivity of
screening for both CCHD and serious CHD
(Table 2).

The Sensitivity of Screening for Major CHD


by Using POX Plus Cardiac Auscultation
• χ2 decomposition analysis showed that the FPR in
the earliest 4 time intervals were significantly
higher than the others (P < .0001); however, the
FPR in the fifth, sixth, and seventh time intervals
did not differ from each other (P = .139 for 36–48
hours, P = .198 for 49–60 hours, and P =.907 for
61–72 hours).

The FPR of Screening for Major


CHD by Using POX Plus Cardiac
Auscultation
Discussion
• In the current study, which was conducted in 15
hospitals in Shanghai city, 44 infants with CCHD
and 159 infants
Sensitivity, with serious
specificity, CHD
positive and were
negative detected
predictive
fromvalues,
those asymptomatic
and positive neonates,
and negative likelihood ratioswhereas
were
another 34 infants
calculated withandCCHD
for POX alone and 58
in combination withinfants
with cardiac
serious CHD were identified from those
auscultation.
symptomatic
 95% confidenceneonates
interval who were and
of sensitivity transported
specificity wasto
the NICU
computedof CHFU without
by the Wilson method.screening in the birth
hospitals; theretestwere
 McNemar’s was used 28tocases of differences
compare CCHD and in 62
casessensitivity
of serious andCHD identified prenatally.
specificity.

Prevalence of Major CHDs


• In previous studies, researchers showed that ∼1% of
newborns had a heart murmur, and 31.0% to 86.0%
of these infants hastructural heart disease (even
potentially life-threatening
 Sensitivity, heart
specificity, positive and defects
negative may not be
predictive
associated with
values, and any initial
positive signs likelihood
and negative or symptoms other
ratios were
thancalculated
a heart murmur).
for POX alone and in combination with
• Thiscardiac
was further confirmed by our present study.
auscultation.
Hence, we wouldinterval
 95% confidence suggest that POX
of sensitivity and plus cardiac
specificity was
auscultation
computedshould be applied
by the Wilson method.to screen for all major
CHDs, including CCHD and serious defects.
 McNemar’s test was used to compare differences in
sensitivity and specificity.
All Major CHDs Should Be Set as a
Screening Target
• Moreover, among 1860 infants who had
positive test results for noncardiac conditions,
74 (4.3%) infants were referred to the NICU
for Sensitivity,
further specificity,
treatment. Most
positive of them
and negative had an
predictive
values, and
infection positive
such as and negative
sepsis or likelihood ratios were
pneumonia. The
calculated for
detection of POX alone and
these in combination
conditions with be
could
cardiac auscultation.
considered an added value of screening.
 95% confidence interval of sensitivity and specificity was
computed by the Wilson method.
 McNemar’s test was used to compare differences in
sensitivity and specificity.
The Current CHD Screening Strategy
Has High Accuracy
• Although the advantages of CCHD screening
are well recognized, when compared with
 Sensitivity,countries,
developed specificity, positive and negative
challenges to thepredictive
values, and positive
implementation of and negative likelihood
screening certainlyratios were
exist.
calculated for POX alone and in combination with
cardiac auscultation.
 95% confidence interval of sensitivity and specificity was
computed by the Wilson method.
 McNemar’s test was used to compare differences in
sensitivity and specificity.
The Current CHD Screening
Strategy Is Feasible
Conclusions
In our current study, we further displayed
that using POX plus cardiac auscultation
significantly improved the detection rate of
major CHD in the early neonatal stage, with
high sensitivity and reasonable FPR. It
provides strong evidence and a reliable
method for neonatal CHD screening.
Thank you