Chest X-Rays for Early Detection of Congenital Heart Disease in Newborns

Congenital heart disease (CHD) represents a significant global health burden, and while chest radiography (CXR) is traditionally utilized as an accessible imaging modality, its sensitivity and overall accuracy can vary significantly, particularly for structural anomalies or in preterm neonates. This prospective observational cross-sectional study is designed to systematically evaluate the specific radiographic patterns and limitations of CXR in detecting CHD.

Upon enrollment, each neonate will undergo a comprehensive clinical evaluation by an attending neonatologist or pediatric cardiologist. This assessment includes documenting demographic data, maternal and neonatal history, presenting clinical signs (such as cyanosis type, murmur characteristics, respiratory pattern, and perfusion), and detailed vital signs.

Standardized digital anteroposterior (AP) chest X-rays will be obtained within 24 hours of clinical suspicion. To ensure rigorous and unbiased evaluation, all chest radiographs will be independently interpreted by two experienced pediatric radiologists who are blinded to the clinical and echocardiographic findings. In cases of disagreement, a third senior radiologist will provide a final interpretation. The imaging review will systematically evaluate:

• Cardiac size (defined by a cardiothoracic ratio >0.6) and configuration (e.g., boot-shaped, egg-on-side, snowman configurations).
• Specific chamber enlargement (atrial and ventricular).
• Pulmonary vascularity patterns (normal, plethora, oligemia, or venous congestion).
• Aortic arch sidedness and abnormalities. Within 72 hours of the chest radiograph, transthoracic echocardiography will be performed by a pediatric cardiologist to serve as the gold standard diagnostic reference. Diagnoses will be classified according to the International Pediatric and Congenital Cardiac Code (IPCCC) system into four main categories: acyanotic CHD with left-to-right shunt, acyanotic CHD with obstruction, cyanotic CHD, and complex CHD involving multiple defects.

Inclusion criteria

• Neonates aged 0-28 days admitted to the NICU with X-ray findings suspecting CHD during the study period.
• Neonates presenting with clinical signs suggestive of congenital heart disease, including: cyanosis (central or peripheral), heart murmur detected on auscultation, tachypnea, or respiratory distress.
• Neonates with abnormal pulse oximetry findings (oxygen saturation <95% in room air).
• Neonates with abnormal antenatal ultrasound findings suggesting cardiac anomalies.

Exclusion criteria

• Infants aged more than 28 days.
• Infants with no clinical or radiological evidence of CHD.