PEDIATRICS Vol. 122 No. 2 August 2008, pp. 472 (doi:10.1542/peds.2008-1078)
LETTER TO THE EDITOR |
What Is the Effective Diagnostic Role of Pediatric Cardiac Assessment in the Offspring of Women With Congenital Heart Disease?
Arianna Bocelli, MDSilvia Favilli, MD
Iva Pollini, MD
Roberta Margherita Bini, MD
Division of Pediatric Cardiology,
Anna Meyer Children's Hospital,
University of Florence,
50100 Florence, Italy
To the Editor.—
Thangaroopan et al1 recently reported that pediatric cardiac assessment (CA) provided incremental diagnostic yield in comparison with fetal echocardiography (FE) in the offspring of women with congenital heart disease (CHD). We agree with the important role of CA in managing these patients. However, 2 aspects should be considered in interpreting these findings. First, caution is required when considering as effectively incremental the diagnostic information provided by a test in comparison with another when the 2 tests are not performed independently and in a blinded fashion. In particular, both in research and clinical practice, the risk that interpretation of CA findings may be affected by knowledge of FE results should be taken into account. In the presence of positive FE findings, physicians may be encouraged to assess CA features with particular attention and emphasize borderline findings; in contrast, because of the well-known low sensitivity of FE in detecting noncomplex lesions,2 a negative FE finding usually does not affect interpretation of CA findings significantly. In this study, this concept is highlighted by the very low prevalence of children with positive FE and negative CA findings (2.2%) compared with those with negative FE and positive CA findings (12.7%). As a result of this bias, the number of children with CHD missed by CA is reduced, thus leading to a spurious increase in sensitivity.
Second, Thangaroopan et al stressed that CA allowed correct detection of CHD in 18 (6.5%) infants in whom diagnosis had been missed by FE. However, the presence of 17 (6.2%) normal infants without CHD correctly identified by FE (as confirmed by subsequent pediatric echocardiography) and in whom CA findings were erroneously positive should also be pointed out. Unfortunately, because pediatric echocardiography was not performed on all patients, the sensitivity and specificity of FE and CA cannot be calculated. Nonetheless, assuming that infants with concordant positive results between FE and CA were effectively affected by CHD, and those with concordant negative results were normal, it could be estimated that specificity of FE alone was 97.6% (248 of 254 normal patients correctly identified), whereas specificity of the approach combining FE and postnatal CA, as proposed by the authors, was 90.9% (231 of 254 normal patients correctly identified).
On the basis of these considerations, and taking into account that additional lesions detected by CA and missed by FE were all minor or noncomplex CHD, the opportunity to routinely perform FE followed by postnatal CA in the offspring of women with CHD should be critically considered.
REFERENCES
1. Thangaroopan M, Wald RM, Silversides CK, et al. Incremental diagnostic yield of pediatric cardiac assessment after fetal echocardiography in the offspring of women with congenital heart disease: a prospective study. Pediatrics. 2008;121 (3). Available at: www.pediatrics.org/cgi/content/full/121/3/e660
2. Acherman RJ, Evans WN, Luna CF, et al. Prenatal detection of congenital heart disease in southern Nevada: the need for universal fetal cardiac evaluation.
J Ultrasound Med. 2007;26
:1715
–1719; quiz 1720–1721
PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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