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. 2025 Feb;4(2):101558.
doi: 10.1016/j.jacadv.2024.101558.

Diagnostic Accuracy Prior to Congenital Heart Defect Surgery: A Multicenter Collaboration

Shobha S Natarajan  1 , Kasey Chaszczewski  2 , Chris Penney  3 , Steve Ampah  3 , Douglas Ryba  3 , Andrea T Kennedy  3 , Robert Olsen  3 , Shubhika Srivastava  4 , Matthew J Campbell  4 , Mya Carney  4 , Carol Prospero  4 , Lisa Elliott  4 , Carlie Brewer  5 , Michael DiMaria  5 , Nitin Madan  6 , Seda Tierney  7 , Meaghan Beattie  7 , Ritu Sachdeva  8 , Joan Lipinski  9 , Kenan W D Stern  10 , Grace Kong  10 , Preeta Dhanantwari  11 , Elena N Kwon  11 , Hari Rajagopal  11 , Carolyn Taylor  12 , Tammy Churchill  12 , Aura A Sanchez Mejia  13 , Deidra Abenlah Ansah  13 , Anitha Parthiban  13 , Hasti Sanandajifar  13 , Sowmya Balasubramanian  14 , David A Parra  15 , Kimberly Crum  15 , Corey Stiver  16 , Aarti H Bhat  17 , Pei-Ni Jone  18 , Stefani Samples  18 , Kathleen Van't Hof  18 , Curt DeGroff  19 , Dalia Lopez-Colon  19 , Meryl S Cohen  3
Affiliations

Diagnostic Accuracy Prior to Congenital Heart Defect Surgery: A Multicenter Collaboration

Shobha S Natarajan et al. JACC Adv. 2025 Feb.

Abstract

Background: Echocardiography is the mainstay for diagnosing congenital heart disease (CHD). Diagnostic errors can lead to suboptimal surgical outcomes.

Objectives: This multicenter pediatric echocardiography collaborative learning initiative explores reasons for diagnostic errors, investigates associations between patient- and center-specific factors and errors, and relays the benefits of a multicenter approach to decrease these errors as a first step to improve CHD surgical outcomes.

Methods: Participating centers submitted diagnostic evaluations on patients prior to 2-ventricle repair into a central database. We held virtual meetings to revise variables and discuss cases to learn from each other.

Results: Fourteen pediatric echocardiography laboratories entered data on 1,476 consecutive patients with specific cardiac diagnoses who underwent a two-ventricle repair over 11 months. The mean error rate across centers was 7.1% (103 errors, 17/126-6/125). Seventy-six (74%) errors were preventable or possibly preventable. Cognitive (43%) and imaging factors (47%) commonly contributed to these errors. Moderate to severe impact on postoperative outcomes occurred in 19 (25%) preventable or possibly preventable errors. There were no statistically significant associations between patient- or center-specific factors and errors.

Conclusions: This work represents the feasibility and advantages of a multicenter approach to preoperative diagnostic errors. Variability existed in sedated protocols, number of echos needed, use of other modalities, and in other processes. Common anatomic areas were found. Rather than undertaking isolated, single-center projects, this collaborative is poised to learn about novel changes that would improve diagnostic accuracy across centers as a first step to advancing surgical outcomes for patients with CHD.

Keywords: echocardiography (echo) laboratory (lab); pediatric diagnostic errors; quality improvement (QI).

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Conflict of interest statement

Funding support and author disclosures This work was supported by the Cardiac Center at the Children's Hospital of Philadelphia. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

None
Graphical abstract
Figure 1
Figure 1
Preoperative Diagnostic Error Rate This figure is a run chart. The higher center line shows errors/total surgeries in the cohort per month (7.1%) over the study period (May 1, 2021 to March 31, 2022). The lower center line shows the mean error rate per month of those errors that had moderate or severe clinical impact on postoperative outcomes (1.8%) during the same study period. This run chart shows a stable system over time prior to any interventions from this collaborative.
Figure 2
Figure 2
Preoperative Diagnostic Errors by Participating Center This chart demonstrates the total number of preoperative diagnostic errors at each center. The X-axis are the centers are represented by letters and are anonymous. the individual bars represent total surgeries (black), total errors (dark gray), preventable errors (medium gray), nonpreventable errors (light gray). the percentage above each center on the X-axis is the (total errors/total surgeries) x 100 in that center. The chart shows the variability of errors at different centers and potential for centers to learn from each other about practical interventions that can be implemented at their own center to potentially improve diagnostic accuracy prior to surgery for congenital heart disease.
Figure 3
Figure 3
Pareto Chart for Anatomic Areas of Errors This figure demonstrates the most common anatomical areas of preventable or possibly preventable preoperative diagnostic errors specifically with moderate or severe clinical impact on postoperative outcomes. The bars are the anatomic areas of error, and the line is the cumulative percentage. Eighty percent of anatomic areas of error include atrioventricular and Aortic valves, ventricular septum, and coronary arteries. These areas are the “Vital Few” that have potential for improvement. The other 20%, or “Trivial many,” do not have as high a priority.
Central Illustration
Central Illustration
Diagnostic Accuracy Prior to Congenital Heart Defect Surgery: A Multicenter Collaboration The purpose of the study is to understand pathway to a preoperative diagnostic error and relay the benefits of a multicenter approach for collaborative learning and implementing innovative interventions to increase diagnostic accuracy prior to undergoing surgery for congenital heart disease.
See this image and copyright information in PMC

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