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Does pulsatility index add value to newborn pulse oximetry screening for critical congenital heart disease?
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  • Published on:
    Cardiac Screening: Pulsatility Index, Population Studies and False-Positive Rates
    • Jonathan Searle, Paediatric Registrar Imperial College Healthcare NHS Trust, London, UK
    • Other Contributors:
      • Devangi Thakkar, Neonatal Registrar
      • Jayanta Banerjee, Neonatal Consultant, Honorary Senior Clinical Lecturer

    We thank Nitzan et al for their comments in relation to our article on use of pulsatility index (PI) in screening for critical congenital heart disease (Searle 2018). In particular, we are grateful that they draw further attention to the potential for current screening to miss critical lesions, such as coarctation of the aorta. Given the progressive nature of these pathologies, it is an extremely difficult challenge to design an acceptable screening tool, which highlights all affected babies in appropriate time. Despite strong biological plausibility, current evidence is unclear whether pulsatility index can translate into such a tool.

    We fully agree that the local quality of both antenatal and postnatal screening significantly affects the measured benefit of pulsatility index. Several articles draw the distinction here between ‘tertiary’ and ‘non-tertiary’ units, though it may be more accurate to distinguish ‘better resourced’ from ‘less resourced’ settings, particularly in relation to antenatal scanning. As described in our original article, the apparent potential of PI screening in ‘less resourced’ settings seems strong, especially since many pulse oximetry sensors already measure it. Both Schena et al (2017) and Granelli & Ostman-Smith (2007) highlight a small but important population of babies not detected by standard screening, but with abnormal pre-morbid pulsatility indices. It seems incongruous, however, to extrapolate a single extra case detected by th...

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    Conflict of Interest:
    None declared.
  • Published on:
    Perfusion index and undiagnosed critical left-sided obstructive heart defects.
    • Itamar Nitzan, neonatal fellow Monash medical center clayton, Victoria, Australia
    • Other Contributors:
      • Robbert Koppel, Neonatologist
      • Meir Nitzan, Professor of physics

    The review by Searle et al “Does pulsatility index add value to newborn pulse oximetry screening for critical congenital heart disease?" (Searle 2018), provides a comprehensive overview of the current evidence regarding the addition of perfusion index to the CCHD screening algorithm.
    The authors’ main concern is that adding pulsatility index (perfusion index, PI) will not significantly improve the current detection rate which is already quite high. As a proof, they cite the work of the large trial by Schena et al, (Schena 2017) that found one additional case of CCHD in 42,169 babies examined. The authors conclude that incorporating PI into current screening algorithms provides little additional benefit in detecting CCHD and confers a high false positive rate.
    We would like to voice several comments regarding this article:
    First, in the study of Schena et al, CCHD was suspected before screening in 36/38 cases in tertiary centers. This is the main reason that PI (and pulse oximetry screening) did not have any additional value in tertiary centers. In this study, only 23.6% of the neonates were born in non-tertiary center. We suggest that an alternative way to describe the results is that in non-tertiary centers, pulse oximetry detected 2 cases and PI detected an additional 1 case per approximately 10,000 screened neonates. Therefore, adding PI to the screening algorithm improved the detection rate by 50%. Moreover, the 2 cases detected by pulse oximetry...

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    Conflict of Interest:
    We are currently working on impruving PI measurements like we stated in the response.