Are we Adhering to Guidelines for Follow-up Imaging in Neonates with Simple Congenital Heart Defects? What are the Healthcare Costs of Non-adherence?

Simple congenital heart defects (CHDs) are frequently identified via neonatal echocardiograms (“echos”). In 2020, the American Heart Association/American College of Cardiology issued guidelines for follow-up imaging of CHDs. In this retrospective study, we evaluated adherence to these guidelines at an academic health center in Southeastern Ontario. The cohort included neonates who had one or more simple CHDs diagnosed in the first 30 days of life between April 1, 2020, and March 31, 2024. We reviewed electronic medical records up to September 30, 2025 to examine a) rates of non-adherence to guideline-recommended follow-up imaging; b) factors that may contribute to non-adherence; and the costs of excessive imaging. Among 248 patients, 376 echos were performed over the study period; adherence status could be determined for 320. Follow-up for 39.7% of echos did not adhere to the guidelines, primarily because repeat echos were performed earlier than recommended. Non-adherence was substantially higher for lesions requiring surveillance imaging, as per guidelines, compared with lesions where follow-up imaging is not recommended or findings were normal (91.9% vs. 12.0%; OR = 83.4, 95% CI: 37.5-185.5). Pediatric cardiologist’s recommendation was documented for 74.5% of echos, but only 48.9% of recommendations aligned with the guidelines. Non-adherence was higher when recommendations were not documented or deviated from the guidelines. Sixty-two echos were deemed excessive, corresponding to $13,339 in extra imaging costs. The high rate of non-adherence to guideline-recommended follow-up imaging for simple CHDs highlights an opportunity to reduce unnecessary healthcare costs though consistent documentation of guideline-aligned follow-up recommendations by pediatric cardiologists.