There were 19,198 births at Unity Point Meriter from 9-1-17 to 9-1-21. 1091 babies (5.7%) had at least one echocardiogram during their birth hospitalization during that time period. After the inclusion and exclusion criteria were applied, 95 babies remained to form the final study population. Patients in this cohort were generally seen in close outpatient follow-up with a mean age at first outpatient echocardiogram of two months and a maximum age at first outpatient echocardiogram of six months. The study cohort included only those babies with an ASD, muscular VSD or PDA where follow-up was recommended, which is presumably a subset of babies at the highest risk for long term consequences of an ASD, VSD or PDA. The demographics of the study population is shown in Table 1.
Table 1. Demographics and Clinical Information (N=95)
Sex, N (%)
|
|
Male
|
44 (46.3)
|
Female
|
51 (53.7)
|
Newborn hospital echoes per baby, mean (SD), Range
|
1.3 (1.0) Range 1-7
|
Babies with more than one newborn hospital echo, N (%)
|
19 (20.0)
|
Gestational age at last newborn hospital echo (weeks), mean (SD), Range
|
39.0 (1.5), Range 34.6-42.3
|
Weight on last newborn hospital echo (kilograms), mean (SD), Range
|
3.1 (0.6), Range 1.1-4.8
|
Age on last newborn hospital echo (days), mean (SD), Range
|
6.2 (14.9), Range 0-70
|
Indication for Newborn hospital echo, N (%)
|
|
Murmur
|
33 (34.7)
|
Follow-up after fetal echo
|
30 (31.6)
|
Trisomy 21
|
6 (6.3)
|
Pulmonary Hypertension
|
5 (5.3)
|
Family history
|
4 (4.2)
|
Postnatal arrhythmia
|
3 (3.2)
|
Failed CCHD screening
|
2 (2.1)
|
Prenatal arrhythmia
|
2 (2.1)
|
Other
|
10 (10.5)
|
Diagnosis at Last Birth Hospital Echocardiogram
|
|
Secundum ASD only
|
19
|
Secundum ASD with muscular VSD
|
7
|
Secundum ASD with muscular VSD and PDA
|
4
|
Secundum ASD with PDA
|
13
|
Muscular VSD only
|
15
|
Muscular VSD with PDA
|
15
|
PDA only
|
22
|
Outpatient echoes per baby, mean (SD), Range
|
1.6 (0.9), Range 1-7
|
Patients with more than one outpatient echo, N (%)
|
39 (41.0)
|
Age at first outpatient echo (days), mean (SD), Range
|
61.5 (32.6), Range 5-182
|
Weight at first outpatient echo (kilograms), mean (SD), Range
|
4.8 (1.2), Range 2.7-8.0
|
Age at last outpatient echo (days), mean (SD), Range
|
263.1 (376.6), Range 31-1398
|
Clinical Status
|
|
Discharged from follow-up
|
56
|
Not discharged from follow-up
|
26
|
Lost to follow-up
|
13
|
The indication for the initial echocardiogram at the birth hospitalization did not have a statistically significant impact on the number of echocardiograms performed or the final clinical disposition of the patient as shown in Supplemental Table 1.
A total of 274 echocardiograms were reviewed (124 in the newborn hospitalization and 150 during outpatient follow-up). 56 patients were discharged from follow-up cardiology evaluation, 26 were still in ongoing follow-up and 13 were lost to the follow-up that was recommended at their first outpatient pediatric cardiology visit (Supplemental Table 2). Patients with secundum ASD were over-represented in the group lost to follow-up with 6/19 (31.6%) of those with a diagnosis limited to a secundum ASD having been lost to scheduled follow-up (Table 2).
Ongoing follow-up was recommended for 39/95 (41.5%). The diagnosis at the final birth hospital echocardiogram did not influence the chance of discharge from follow-up, the mean number of outpatient echocardiograms performed or the age at last outpatient follow-up (Supplemental Table 3).
At birth hospital discharge, 43 babies had a secundum ASD, 41 babies had a muscular VSD, and 54 babies had a PDA. 39/95 babies (41.1%) had more than one intracardiac shunt on their last birth hospital echocardiogram.
No infants required medical, catheter, or surgical intervention in follow-up ranging from 2 to 6 years. Echocardiography was performed at all outpatient cardiology visits with a mean of 1.5 echoes per patient in follow-up and with 38/95 patients (41%) having two or more outpatient echocardiograms. None of the patients still in follow-up have a VSD or PDA that is likely to require intervention. None of the six patients still in follow-up for a PDA had a heart murmur on physical examination at the last pediatric cardiology clinic visit.
Additional attention was directed to the 43 infants diagnosed with a secundum ASD on their last newborn hospitalization echocardiogram (Table 2). 3/43 (7.0%) had a secundum ASD with a maximum diameter greater than 5 mm on their last outpatient echocardiogram (6.2 mm at 26 months, 8.6 mm at 1 month and 11 mm at 3 months). All three had normal physical examinations on their last cardiology visit with a normal second heart sound and no audible murmur. Their maximum ASD diameters on their last newborn hospitalization echocardiograms were 7.7, 8.3 and 10.9 mm respectively.
Of those 43 with a secundum ASD on their last newborn hospitalization echocardiogram, 16 (37.2%) had an outpatient echocardiogram with no evidence of an atrial level shunt. 13 (32.6%) were discharged from care despite a residual atrial shunt (mean maximum diameter 2.6, range 1.1- 3.4 mm). 9 (20.9%) were lost to follow-up before resolution of their ASD was demonstrated (mean maximum diameter 3.6 mm, range 1.4-8.6 mm). 4 (9.3%) were in ongoing follow-up (mean maximum diameter 5.4 mm, range 1.7-11 mm).
Of those 22 babies with a secundum ASD diameter of => 6 mm at their last newborn hospitalization echocardiogram, 3 (13.6%) had an ASD diameter of => 6 mm at last follow-up. None of the 21 babies with a secundum ASD diameter of < 6 mm at their last newborn hospitalization echocardiogram had a significant increase in their ASD size, with the maximum diameter reported at 4.1 mm at last follow-up.
Table 2: Outcome of Patients with Neonatal Diagnosis of a Secundum Atrial Septal Defect
Shunts Present
|
ASD Diameter on Last Newborn Echo (mm)
|
Age at Last Newborn Echo (days)
|
ASD Diameter on Last Outpatient Echo (mm)
|
Age Last Outpatient Echo (days)
|
Status
|
A
|
9.8
|
69
|
3.1
|
182
|
DC
|
A
|
8.9
|
1
|
4.1
|
1133
|
LTFU
|
A
|
8.3
|
1
|
8.6
|
34
|
LTFU
|
A
|
8
|
3
|
0
|
455
|
FU
|
A
|
7.7
|
3
|
6.1
|
791
|
FU
|
A
|
7.4
|
2
|
1.7
|
102
|
FU
|
A
|
7.1
|
1
|
0
|
81
|
DC
|
A
|
7
|
0
|
3.2
|
40
|
DC
|
A
|
6.9
|
6
|
0
|
783
|
FU
|
A
|
6.9
|
44
|
0
|
886
|
DC
|
A
|
6.5
|
5
|
2.9
|
105
|
LTFU
|
A
|
6.4
|
2
|
2.8
|
282
|
DC
|
A
|
5.9
|
2
|
4.1
|
74
|
LTFU
|
A
|
5.7
|
2
|
1.4
|
78
|
LTFU
|
A
|
5.1
|
2
|
3.4
|
69
|
DC
|
A
|
5
|
2
|
0
|
1860
|
DC
|
A
|
4.1
|
3
|
2.6
|
41
|
LTFU
|
A
|
3.7
|
13
|
2.8
|
110
|
DC
|
A
|
3.1
|
3
|
0
|
94
|
DC
|
A P
|
10.9
|
49
|
11
|
89
|
FU
|
A P
|
8.4
|
70
|
3.5
|
212
|
LTFU
|
A P
|
6.5
|
1
|
0
|
1100
|
DC
|
A P
|
6.4
|
0
|
2.4
|
90
|
DC
|
A P
|
5.2
|
3
|
0
|
788
|
DC
|
A P
|
4.8
|
1
|
2.2
|
56
|
DC
|
A P
|
4.5
|
2
|
0
|
69
|
DC
|
A P
|
3.9
|
3
|
2.4
|
58
|
DC
|
A P
|
3.8
|
1
|
3.4
|
69
|
DC
|
A P
|
2.9
|
1
|
0
|
120
|
DC
|
A P
|
2
|
2
|
2.6
|
84
|
LTFU
|
A P
|
1.8
|
1
|
1.1
|
32
|
DC
|
A V
|
8.7
|
4
|
0
|
236
|
LTFU
|
A V
|
8
|
1
|
2.5
|
69
|
LTFU
|
A V
|
7.3
|
2
|
2.7
|
32
|
FU
|
A V
|
6
|
2
|
2.2
|
43
|
DC
|
A V
|
5.5
|
2
|
0
|
223
|
FU
|
A V
|
4.2
|
2
|
3.1
|
46
|
DC
|
A V
|
2.2
|
2
|
0
|
93
|
DC
|
A V P
|
9.1
|
2
|
0
|
211
|
DC
|
A V P
|
6.8
|
1
|
2.6
|
46
|
DC
|
A V P
|
4.2
|
2
|
0
|
815
|
DC
|
A V P
|
4
|
2
|
1.4
|
212
|
DC
|
A V P
|
3.6
|
2
|
0
|
175
|
DC
|
|
|
|
|
|
|
Mean
|
5.9 mm
|
7.5 days
|
2.1 mm
|
283 days
|
|
Range
|
1.8 to 10.9 mm
|
1 to 70 days
|
0 to 11 mm
|
32 to 1860 days
|
|
A = Secundum ASD only, AP = Secundum ASD and PDA, AV = Secundum ASD and muscular VSD, AVP = Secundum ASD, muscular VSD and PDA, DC = Discharged from Care, FU = Still in Cardiology Follow-up, LTFU = Lost to Follow-up