Critical Congenital Heart Disease
Diagnosis Coding
Q20.0, common arterial trunk
Q20.3, discordant ventriculoarterial connection
Q21.3, tetralogy of Fallot
Q22.0, pulmonary valve atresia
Q22.4, congenital tricuspid stenosis
Q23.4, hypoplastic left heart syndrome
Q26.2, total anomalous pulmonary venous connection
Overview
Critical congenital heart disease (CCHD) refers to a group of heart defects that are life threatening and require catheter-based intervention or heart surgery during the neonatal period. Newborns with CCHD may be missed because of minimal signs and symptoms early on, but can quickly decompensate when the ductus arteriosus, which may have been providing significant blood flow to the lungs or body, closes. Some of these newborns will have hypoxemia, which may be difficult to detect clinically in babies. Pulse oximetry can accurately identify many apparently asymptomatic cases of CCHD by detecting lower oxygen saturations. Early detection allows for timely treatment. Delayed diagnosis of CCHD may result in poorer preoperative condition, worse cardiopulmonary and neurological outcomes after treatment, or death.The 7 primary targets for CCHD newborn screening are:
- Truncus arteriosus
- Transposition of the great arteries
- Tetralogy of Fallot
- Pulmonary atresia with intact ventricular septum
- Tricuspid atresia
- Hypoplastic left heart syndrome
- Total anomalous pulmonary venous return
Incidence
Congenital heart defects occur in about 1:110 live births; CCHD occurs in 15-25% of these births. [Hugh: 2016]Inheritance
CCHD is an etiologically heterogeneous group of diseases. Known genetic causes may account for 20-25% of all CHDs. Genomic imbalances (chromosomal abnormalities and microdeletions/duplications) seem to account for approximately 10–15% of CCHDs. [Hugh: 2016] [Hartman: 2011] Single gene disorders (e.g., Noonan, Alagille, and CHARGE syndromes) probably account for a fraction of cases; however, recent findings using more advanced technology suggest that de novo mutations and novel copy number variants may account for additional 10-15% of incident cases. [Hugh: 2016] [Zaidi: 2013] [Al: 2014] Environmental factors, such as uncontrolled diabetes, certain viral illness, exposure to toxic agents (alcohol, drugs, chemicals) during pregnancy, and insufficient intake of folic acid may also increase the risk of the infant developing a CCHD.Maternal & Family History
Although recurrence risk varies among types of CCHD, approximately 1:9 cases are familial. [McSweeney: 2013] Generally, the recurrence risk increases if a parent rather than a sibling is affected, particularly when the affected parent is the mother. Individualized recurrence risks can be generated for members of families affected by CHD after obtaining a detailed family history, including accurate cardiac diagnoses for all affected members, and diagnostic genetic testing where indicated.Prenatal Testing
Expanded recommendations for prenatal screening of fetal hearts and evolution in fetal echocardiography have helped increase early detection of CCHD, but the prenatal rate of detection is still under 50%. [Quartermain: 2015] [Liberman: 2014]Other Testing
Testing for noncardiac causes of hypoxemia (e.g., infectious or pulmonary disease) are appropriate.Clinical Characteristics
Presentation of CCHD can be sudden and catastrophic. Timing often corresponds with the closing of the ductus arteriosus and physiologic changes in the heart after birth. Signs and symptoms of CCHD in infants can be varied and may include:- Cyanosis (a bluish tint to the skin, lips, and fingernails)
- Shock
- Severe hypoxemia
- Absent pulses
- Tachypnea
- Pulmonary edema
- Shortness of breath or troubled breathing
- Sweating around the head
- Poor weight gain
- Tiring easily during feedings
Follow-up Testing after Positive Screen
In most states, if either the preductal or postductal pulse oximetry reading is <90%, the result is considered a fail. [Matthew: 2016] If either reading is ≥95% and the difference between the 2 readings is ≤3%, the result is considered a pass. [Matthew: 2016] Results outside of these 2 ranges require repeat testing in 1 hour for up to 2 additional tests. A child who has not passed the screening by the third testing is considered to have failed. [Matthew: 2016]Primary Care Management
Upon Notification of the + Screen
- Examine the infant to make sure the baby is hemodynamically stable. Any signs or symptoms of compromise or cardiac failure should prompt rapid evaluation and care including potential urgent transfer to a center with advanced care capabilities.
- Evaluate the infant for cardiac and non-cardiac causes of hypoxemia. A positive screen does not always mean the baby has CCHD, and further testing may be needed if other clinical problems are obvious.
- If no other cause for hypoxemia is obvious, a cardiologist or neonatologist should be consulted and an echocardiogram should be performed as indicated clinically or by local protocol.
- Depending on timing and the nursery/hospital, the family of the newborn may be aware of the screening result and pediatric cardiology may already be involved. Contact the family to provide support and coordination of care as needed.
Specialty Care Collaboration
Refer to a pediatric cardiologist, if not already initiated, and a pediatric geneticist for initial consultation and ongoing collaboration. The pediatric geneticist can help with genetic counseling for the family and ruling out inherited disorders associated with CCHD (Pediatric Cardiology (see UT providers [7]) and Pediatric Genetics (see UT providers [6])).Resources
Information & Support
For Professionals
Newborn Screening for CCHD: Information & Resources for Clinicians (AAP)
Clinical guidance provided in a question and answer format; American Academy of Pediatrics.
Heart Defects - Information for Clinicians (CDC)
Contains a screening algorithm, current research summaries, and information about specific heart defects; Centers for Disease
Control and Prevention.
Utah Newborn Screening Program (UDOH)
Provides information about the program, related legislation, training for practices, and newborn conditions; Utah Department
of Health.
Genetics in Primary Care Institute (AAP)
Contains health supervision guidelines and other useful resources for the care of children with genetic disorders; American
Academy of Pediatrics.
Pulse Oximetry Screening for CCHD (University of Wisconsin) (
19.3 MB)
Focuses on helpful information for screening programs that includes screening recommendations, types of CCHD identified by
pulse oximetry, an algorithm for response to positive screen, and a sample screening form.
For Parents and Patients
Support
Mended Little Hearts
Support for children with congenital heart defects and their families. There are 80 chapters in the US and Mexico.
Intermountain Healing Hearts
A non-profit, volunteer-run organization providing support for children with cardiac disease and their families throughout
the Intermountain West; also offers events, information.
Kids with Heart
Provides surgical care packages, local support group meetings, parent matching, and other support services for families affected
by congenital heart defects.
Little Hearts
Emotional support, education, resources, and parent networking for families affected by congenital heart defects.
General
Baby's First Test: Critical Congenital Heart Disease (Genetic Alliance)
Information about early signs, follow-up testing, treatment, causes, accessing care, and expected outcomes. Provides links
to support services; supported by the U.S. Department of Health and Human Services.
Critical Congenital Heart Disease - Information for Parents (STAR-G)
A fact sheet, written by a genetic counselor and reviewed by metabolic and genetic specialists, for families who have received
an initial diagnosis of this newborn disorder; Screening, Technology and Research in Genetics.
Critical Congenital Heart Disease (Genetics Home Reference)
Excellent, detailed review of condition for patients and families; sponsored by the U.S. National Library of Medicine.
Newborn Screening for CCHD: Fact Sheet for Families (UDOH) ( 111 KB)
Family education about pulse oximetry screening and warning signs of CCHD.
Congenital Heart Defects (AHA)
Diagnosis and care information, printable information sheets, and resources for specific congenital heart defects; American
Heart Association.
Tools
ACT Sheet for Critical Congenital Heart Disease (ACMG) ( 881 KB)
Contains short-term recommendations for clinical follow-up of the newborn who has screened positive; American College of Medical
Genetics.
Services in Utah
For other services related to this condition, browse our Services categories or search our database.
Helpful Articles
PubMed search for CCHD, last 3 years.
Mahle WT, Newburger JW, Matherne GP, Smith FC, Hoke TR, Koppel R, Gidding SS, Beekman RH 3rd, Grosse SD.
Role of pulse oximetry in examining newborns for congenital heart disease: a scientific statement from the American Heart
Association and American Academy of Pediatrics.
Circulation.
2009;120(5):447-58.
PubMed abstract
Matthew E. Oster, Susan W. Aucott, Jill Glidewell, Jesse Hackell, Lazaros Kochilas, Gerard R. Martin, Julia Phillippi, Nelangi
M. Pinto, Annamarie Saarinen, Marci Sontag, Alex R. Kemper.
Lessons Learned From Newborn Screening for Critical Congenital Heart Defects.
Pediatrics.
2016;137(5).
/ Full Text
Garg LF, Van Naarden Braun K, Knapp MM, Anderson TM, Koppel RI, Hirsch D, Beres LM, Sweatlock J, Olney RS, Glidewell J, Hinton
CF, Kemper AR.
Results from the New Jersey statewide critical congenital heart defects screening program.
Pediatrics.
2013;132(2):e314-23.
PubMed abstract / Full Text
Kemper AR, Mahle WT, Martin GR, Cooley WC, Kumar P, Morrow WR, Kelm K, Pearson GD, Glidewell J, Grosse SD, Howell RR.
Strategies for implementing screening for critical congenital heart disease.
Pediatrics.
2011;128(5):e1259-67.
PubMed abstract / Full Text
Page Bibliography
Al Turki S, Manickaraj AK, Mercer CL, Gerety SS, Hitz MP, et al.
Rare variants in NR2F2 cause congenital heart defects in humans.
Am J Hum Genet.
2014;94(4):574-85.
PubMed abstract / Full Text
Hartman RJ, Rasmussen SA, Botto LD, Riehle-Colarusso T, Martin CL, Cragan JD, Shin M, Correa A.
The contribution of chromosomal abnormalities to congenital heart defects: a population-based study.
Pediatr Cardiol.
2011;32(8):1147-57.
PubMed abstract
Hugh A.
Moss & Adams’ Heart Disease in Infants, Children, and Adolescents, Including the Fetus and Young Adult.
9 ed. Philadelphia, PA: Lippincott Williams & Wilkins, a Wolters Kluwer business;
2016.
9781496300249 http://www.lww.com/Product/9781496300249
Lannering K, Bartos M, Mellander M.
Late Diagnosis of Coarctation Despite Prenatal Ultrasound and Postnatal Pulse Oximetry.
Pediatrics.
2015;136(2):e406-12.
PubMed abstract
Liberman RF, Getz KD, Lin AE, Higgins CA, Sekhavat S, Markenson GR, Anderka M.
Delayed diagnosis of critical congenital heart defects: trends and associated factors.
Pediatrics.
2014;134(2):e373-81.
PubMed abstract
Matthew E. Oster, Susan W. Aucott, Jill Glidewell, Jesse Hackell, Lazaros Kochilas, Gerard R. Martin, Julia Phillippi, Nelangi
M. Pinto, Annamarie Saarinen, Marci Sontag, Alex R. Kemper.
Lessons Learned From Newborn Screening for Critical Congenital Heart Defects.
Pediatrics.
2016;137(5).
/ Full Text
McSweeney ME, Jiang H, Deutsch AJ, Atmadja M, Lightdale JR.
Long-term outcomes of infants and children undergoing percutaneous endoscopy gastrostomy tube placement.
J Pediatr Gastroenterol Nutr.
2013;57(5):663-7.
PubMed abstract
Quartermain MD, Pasquali SK, Hill KD, Goldberg DJ, Huhta JC, Jacobs JP, Jacobs ML, Kim S, Ungerleider RM.
Variation in Prenatal Diagnosis of Congenital Heart Disease in Infants.
Pediatrics.
2015;136(2):e378-85.
PubMed abstract / Full Text
Zaidi S, Choi M, Wakimoto H, Ma L, Jiang J, Overton JD, et al.
De novo mutations in histone-modifying genes in congenital heart disease.
Nature.
2013;498(7453):220-3.
PubMed abstract / Full Text