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ORIGINAL ARTICLE
Year : 2022  |  Volume : 25  |  Issue : 4  |  Page : 478-482

Pre-operative 2-D transthoracic echocardiographic diagnosis with intra-operative findings of children with structural heart diseases: A comparative analysis


1 Department of Paediatrics/Paediatric Cardiology Unit, University of Nigeria, Ituku Ozalla, Enugu, Nigeria
2 Department of Surgery/Cardio-thoracic Centre of Excellence, University of Nigeria, Ituku Ozalla, Enugu, Nigeria

Date of Submission30-Jul-2021
Date of Acceptance31-Jan-2022
Date of Web Publication19-Apr-2022

Correspondence Address:
Prof. J M Chinawa
Department of Paediatrics, College of Medicine, University of Nigeria Enugu Campus, PMB 40001, Enugu
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_1714_21

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   Abstract 


Background: Structural heart disease is a major cause of morbidity and mortality in children. Echocardiography is accepted as the first line cost-effective diagnostic modality for pre-operative assessment of children with structural heart diseases. Two-dimensional transthoracic echocardiography (2-D TTE) may be the only diagnostic tool in a resource-poor environment where further investigations may be very expensive and not readily available. Aim: The aim of the study is to determine the degree of accuracy of pre-operative 2-D echocardiographic diagnosis with eventual surgical (intra-operative) findings among children with structural heart diseases with a view to audit the echocardiographic diagnoses and final surgical diagnoses among the patients in the University of Nigeria Teaching Hospital Ituku-Ozalla Enugu, a tertiary cardiothoracic center in Enugu, South-east Nigeria. Patients and Methods: 2-D TEE (GE Model) diagnosis of all the children that had cardiac surgery at University of Nigeria Teaching Hospital (UNTH) Ituku/Ozalla Enugu over a 3-year period was studied. All the patients had at least two echocardiographic sessions and results were recorded in a proforma. Surgical findings were obtained from post-operative surgical notes. Intra-operative findings were compared with 2-D TTE findings. Data were analyzed using SPSS version 20. The degree of accuracy was expressed as percentages. The relationship between the sensitivity of 2-D TTE and intra-operative findings as ascertained using sensitivities and positive predictive values. Results: There were 55 pediatric cardiac operations performed within the period under review. There were 22 males and 23 females, the age range was from 8 months to 17 years. Fifty-two (94.5%) were due to congenital heart diseases, whereas three (5.5%) were due to acquired heart diseases. Echocardiographic findings were the same as surgical findings in all isolated PDAs (100%), Isolated ASDs (100%), Mitral valve regurgitation three (100%), but missed out PDA as an associated finding in a case of sub-aortic VSD (7.7%) and an ASD in a case of TOF (5.9%), congenital absence of tricuspid valve was also missed as a component of complex cardiac anomaly one (1.1%). These omissions however did not change the surgical approach and outcome. Pre-operative echocardiographic diagnoses and eventual surgical diagnoses were largely concordant. The sensitivity of 2-D TTE and intra-operative findings is 94.5%, positive predictive value is 94.5%, and the false negative rate is 5.5%. Conclusion: Echocardiography is a veritable diagnostic tool in the pre-operative evaluation of children with structural heart diseases. Continuous training and re-training are key in skill development and capacity building in resource-poor countries.

Keywords: Cardiac defects, pediatric echocardiography, surgery


How to cite this article:
Ujunwa F A, Chinawa J M, Okwulehie V, Obidike E K. Pre-operative 2-D transthoracic echocardiographic diagnosis with intra-operative findings of children with structural heart diseases: A comparative analysis. Niger J Clin Pract 2022;25:478-82

How to cite this URL:
Ujunwa F A, Chinawa J M, Okwulehie V, Obidike E K. Pre-operative 2-D transthoracic echocardiographic diagnosis with intra-operative findings of children with structural heart diseases: A comparative analysis. Niger J Clin Pract [serial online] 2022 [cited 2022 May 18];25:478-82. Available from: https://www.njcponline.com/text.asp?2022/25/4/478/343454




   Introduction Top


Congenital heart defects (CHDs) are the leading cause of mortality in children worldwide.[1],[2],[3] These defects include cyanotic and acyanotic CHDs. In Nigeria, a multi-center study had shown a variable prevalence of CHDs. The commonest CHD was ventricular septal defect (VSD) (46.6%), patent ductus arteriosus (PDA) (12.1%), atrial septal defect (ASD) (8.7%), and atrioventricular septal defect (AVSD) (8.2%). Tetralogy of Fallot (TOF) (7.8%) was noted as the commonest cyanotic CHD.[4]

The need for accurate clinical diagnosis of congenital heart disease without recourse to very expensive equipment such as 3D and 4D Echocardiography cannot be overemphasized especially in resource-poor countries like ours. Nevertheless, a certain complex cardiac anomaly is often missed during physical examination; this has led to diagnostic innovations such as 2D Echocardiography and angiocardiography.[5],[6]

Echocardiography is accepted as the first line cost-effective diagnostic modality for pre-operative assessment of children with structural heart diseases.[7] It usually provides adequate information on cardiac structure and anatomical/functional appraisal with a high diagnostic yield using ultrasound-acquired images.[7] Echocardiography is of immense diagnostic importance globally but even more so in resource-poor environments where the cost, availability, and accessibility of other investigations such as cardiac CT, cardiac catheterization, magnetic resonance imaging (MRI), and so on may be unattainable for the majority of the patients with structural heart diseases that require cardiac surgery.[7],[8],[9] Adequate or comprehensive clinical and echocardiographic diagnosis need to be made before embarking on any form of cardiac surgery. This enables the surgeon to plan the procedure, decide on the operative approach, and prepare for any possible or potential complications. It also helps in the prognostication of cardiac lesions and in planning staged surgery in certain complex congenital heart diseases.[9],[10]

These goals of making prompt diagnosis and managing children with congenital heart disease are usually thought-provoking especially in resource-poor environment where other investigative modalities such as cardiac catheterization, cardiac CT, and MRI are not readily available and when available the cost of the investigations are usually not affordable for the patients or the household, as a good number of them do “pay-out-of-pocket payment.”[5]

Echocardiography is a non-invasive and cost-effective diagnostic modality that helps in the diagnosis and prognostication of cardiac lesions.[7],[11] Thus, the need for improved echocardiographic diagnosis in a functional cardiac surgery program cannot be overemphasized, considering the cost and the dearth of advanced cardiac investigations in a budding open heart surgery program in a resource-poor country.


   Aims and Objectives Top


The study aims to determine the degree of accuracy of preoperative 2-dimensional echocardiographic diagnosis with eventual surgical (intra-operative) findings among children with structural heart diseases to auditing the echocardiocardiographic diagnoses and final surgical diagnoses among the patients in the University of Nigeria Teaching Hospital Ituku-Ozalla Enugu, a tertiary cardiothoracic center in Enugu, South-east Nigeria.


   Methodology Top


Study area and study design

This was a retrospective study carried out in the University of Nigeria Teaching Hospital over a 3 -year period from 2018 to 2020.

Study population

Children aged 8 months–17 years who attended the University of Nigeria Teaching Hospital and who had surgery for congenital heart disease were recruited retrospectively into the study.

Study materials

A two-dimensional transthoracic echocardiographic (2-D TTE) diagnosis of all the children that had cardiac surgery in UNTH Ituku Ozalla over 3 years was reviewed. All the patients had complete evaluation including a complete history, physical examination, chest X-ray, electrocardiogram, and comprehensive blood workup. Pre-operative transthoracic echocardiographic diagnosis of each patient was noted. The echocardiography was done according to American Echocardiography Society guidelines.[8] This was done by at least two pediatric cardiologists independently and using the segmental sequential approach. Patients with complex cyanotic congenital heart disease were referred for a cardiac angiogram. All the patients had at least two echo sessions with at least two pediatric cardiologists to reduce bias. The echocardiographic results were recorded in a proforma. Surgical findings were obtained from post-operative surgical notes of the patient. Diagnostic accuracy was obtained by comparing intra-operative diagnoses with pre-operative 2-D TTE findings. We categorized the errors into minor and major errors; in minor errors the surgical outcome and approach were not affected, whereas in major errors the surgical outcome and approach were affected.

Data analysis

Data were analyzed using SPSS version 20. The degree of accuracy was expressed as percentages. Findings from pre-operative 2-D TTE diagnosis were compared with that of the intra-operative findings of children with structural heart diseases using Chi-square, whereas errors emanating from pre-operative 2-D TTE diagnosis from that of intra-operative findings of children with structural heart diseases were ascertained using sensitivity, specificity, and predictive values. The metrics were kept at 95% confidence intervals. P values of 0.05 were taken as statistical significance.


   Results Top


There were 55 pediatric cardiac operations performed within the period under review. There were 22 males and 23 females, the age range was from 8 months to 17 years. Fifty-two (94.5%) were due to congenital heart diseases, whereas three (5.5%) were due to acquired heart diseases (Rheumatic heart disease). TOF (classic with pulmonary stenosis (PS)) constituted 17 (30.9%), Isolated Ventricular Septal Defect 13 (23.6%), Isolated PDA seven (12.37%), Isolated ASD six (10.9%), congenital mitral valve prolapse three (5.5%), complex CHDs including (Truncus arteriosus, atrioventricular canal defects with pulmonary stenosis and double outlet right ventricles univentricular heart defects) nine (16.4%) [Table 1]. [Table 2] shows the frequency of surgically diagnosed complex cardiac anomaly.
Table 1: Distribution of Congenital Heart Surgery done over the Review Period

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Table 2: Frequency of Surgically Diagnosed Complex Cardiac Anomaly

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Echocardiographic correlates

Echocardiographic findings were the same as surgical findings in all isolated PDAs seven (100%), Isolated ASDs six (100%), Rheumatic mitral valves three (100%). Patent ductus arteriosus (PDA) was missed out as an associated finding in a case of sub-aortic VSD coexisting with PDA (7.7%) and an ASD in a case of TOF (5.9%). Congenital absence of tricuspid valve was also missed as a component of complex cardiac anomaly one (1.1%). TOF with PDA was seen in four females, whereas ASD was observed with TOF in three males. Congenital absence of posterior cusps and anterior cusps of tricuspid valve in a patient with severe Tricuspid regurgitation for which a pre-operative echo diagnosis of tricuspid rupture secondary to infective endocarditis was missed on echocardiography. These omissions however did not change the surgical approach and outcome. There is no significant difference between the 2-D TTE diagnosis of structural heart diseases and final surgical diagnosis of structural heart diseases in children.(χ2 = 0.084, P = 0.77; [Table 3]).
Table 3: Pre-operational echocardiographic diagnosis and intra-operational findings among the patients

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   Discussion Top


Our audit shows that 2-D TTE, though operator-dependent, is a veritable diagnostic tool in the management of congenital heart diseases in children. Frequent echocardiographic reviews help in the improvement of the diagnostic yield in the pre-operative assessment of patients undergoing cardiac surgery. Single structural lesions were easily identified by echocardiography; missed diagnoses were noted among multiple lesions. This has been identified by previous authors.[12] Thus, it is important to check for multiple lesions even when the echocardiographic diagnosis looks obvious. Common missed diagnoses in our series include ASD and PDA. Chinawa et al.[13] reported a positive correlation between clinical diagnosis and echocardiography in children. In our study, pre-operative echocardiography findings were consistent with surgical findings in more than 90% of the cases, though seems a good percentage, similar reports have been noted by previous authors.[8],[9] However, more echocardiographic reviews may be advised to improve the diagnostic accuracy, though the cost of echocardiography may mitigate against this.[14] However, it is recommended that more complex congenital anomalies such as transposition of great vessels and PS as well as double outlet right ventricle with critical PS usually require further investigations such as cardiac catheterization to properly delineate the structures. Fortunately, these constitute a small percentage of the congenital cardiac anomalies that require definitive surgery.[15],[16],[17]

This study also showed some errors where echocardiography does not correlate with intra-operative diagnosis. For instance, echocardiography missed rare abnormalities such as the congenital absence of posterior cusp and the anterior cusp of the tricuspid valve (seen in the theater), which hitherto was diagnosed as ruptured valve due to infective endocarditis. The audit showed that pre-operative echocardiography correctly predicted the surgical diagnosis of cardiac patients in more than 90% of the cases, thereby buttressing the fact that TTE is a veritable investigation for children with structural heart diseases that require cardiac surgery in a resource-poor environment. This has been corroborated in recent studies.[7],[14],[18],[19]

In addition, the study also showed that the VSD is the commonest acyanotic CHD, whereas TOF is the commonest cyanotic defect. These defects constitute more than 50% of structural heart defects in children and has been noted by previous authors.[12] Furthermore, they can easily be detected by echocardiography with very high sensitivity. Thus, in a resource-poor setting echocardiography can be used to diagnose these abnormalities without the use of high-end investigations.

In our study, all the omissions found were minor errors, which did not affect the approach and outcome of the surgery; the low frequency of minor errors was due to repeated echocardiographic screening before surgery. Our findings are comparable to the study of Sohn et al.[20]

Certain factors may contribute to the mismatch between pre-operative TTE and intra-operative findings. For instance, in a long-standing Tetralogy, echocardiographic images may be sub-optimal and severe pulmonary artery hypertension may occasionally obscure ease of delineating a PDA. Furthermore, in echocardiographic images of long-standing Tetralogy, increased right-sided pressures may obscure ASD, which may be seen intra-operatively. This might then be left as an intentional ASD, which becomes important as a vent for post-operative right ventricular decompression.


   Conclusions Top


Echocardiography is a veritable diagnostic tool in the pre-operative evaluation of children with structural heart diseases. Continuous training and re-training are keys for skill development in resource-poor countries.

Limitation

The study was limited by a small sample size; this was due to the number of children that were able to afford surgery in our facility.

Recommendation

Multiple echocardiographic sessions should be encouraged before any cardiac surgery to limit missed diagnoses. A systematic approach (segmental sequential method) should be the practice. Pediatric echocardiography and higher resolution machines should be used in order to improve image quality, whereas further evaluation is advised in very complex congenital heart diseases on merit.

What is already known on this topic

Echocardiography is accepted as the first line cost-effective diagnostic modality for pre-operative assessment of children with structural heart diseases. It usually provides adequate information on cardiac structure and function using images recorded as ultrasound.

What this study adds

This study is relevant because it is coming from a developing country with nascent cardiac surgery. Much is not documented if there is any agreement between findings from echocardiographic studies of children with congenital heart disease and that seen intra-operatively. Thus, the need for improved echocardiographic diagnosis in a functional cardiac surgery program cannot be overemphasized, considering the cost and the dearth of advanced cardiac investigations of a budding open-heart surgery program in a resource-poor country. There is no study anywhere in south-east Nigeria to ascertain the link between pre-operative 2-D echocardiographic diagnosis with intra-operative findings of children with structural heart diseases.

Authors' contribution

JMC and FAU contributed in the conception, writing, and proof reading of this manuscript. JMC, FAU, EO, and OV contributed in proofreading the manuscript. FAU did data analysis.

Acknowledgments

We acknowledge the resident doctors and ward secretary for helping in retrieving the data used in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3]



 

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