Temporal variability in birth prevalence of cardiovascular malformations

Modelling survival and mortality risk to 15 years of age for a national cohort of children with serious congenital heart defects diagnosed in infancy

BACKGROUND

Congenital heart defects (CHDs) are a significant cause of death in infancy. Although contemporary management ensures that 80% of affected children reach adulthood, post-infant mortality and factors associated with death during childhood are not well-characterised. Using data from a UK-wide multicentre birth cohort of children with serious CHDs, we observed survival and investigated independent predictors of mortality up to age 15 years.

METHODS

Data were extracted retrospectively from hospital records and death certificates of 3,897 children (57% boys) in a prospectively identified cohort, born 1992-1995 with CHDs requiring intervention or resulting in death before age one year. A discrete-time survival model accounted for time-varying predictors; hazards ratios were estimated for mortality. Incomplete data were addressed through multilevel multiple imputation.

FINDINGS

By age 15 years, 932 children had died; 144 died without any procedure. Survival to one year was 79.8% (95% confidence intervals [CI] 78.5, 81.1%) and to 15 years was 71.7% (63.9, 73.4%), with variation by cardiac diagnosis. Importantly, 20% of cohort deaths occurred after age one year. Models using imputed data (including all children from birth) demonstrated higher mortality risk as independently associated with cardiac diagnosis, female sex, preterm birth, having additional cardiac defects or non-cardiac malformations. In models excluding children who had no procedure, additional predictors of higher mortality were younger age at first procedure, lower weight or height, longer cardiopulmonary bypass or circulatory arrest duration, and peri-procedural complications; non-cardiac malformations were no longer significant.

INTERPRETATION

We confirm the high mortality risk associated with CHDs in the first year of life and demonstrate an important persisting risk of death throughout childhood. Late mortality may be underestimated by procedure-based audit focusing on shorter-term surgical outcomes. National monitoring systems should emphasise the importance of routinely capturing longer-term survival and exploring the mechanisms of mortality risk in children with serious CHDs.

Patient-reported quality of life outcomes for children with serious congenital heart defects

OBJECTIVE

To compare patient-reported, health-related quality of life (QoL) for children with serious congenital heart defects (CHDs) and unaffected classmates and to investigate the demographic and clinical factors influencing QoL.

DESIGN

Retrospective cohort study.

SETTING

UK National Health Service.

PATIENTS

UK-wide cohort of children with serious CHDs aged 10-14 years requiring cardiac intervention in the first year of life in one of 17 UK paediatric cardiac surgical centres operating during 1992-1995. A comparison group of classmates of similar age and sex was recruited.

MAIN OUTCOME MEASURES

Child self-report of health-related QoL scores (Pediatric Quality of Life Inventory, PedsQL) and parental report of schooling and social activities.

RESULTS

Questionnaires were completed by 477 children with CHDs (56% boys; mean age 12.1 (SD 1.0) years) and 464 classmates (55%; 12.0 (SD 1.1) years). Children with CHDs rated QoL significantly lower than classmates (CHDs: median 78.3 (IQR 65.0-88.6); classmates: 88.0 (80.2-94.6)) and scored lower on physical (CHDs: 84.4; classmates: 93.8; difference 9.4 (7.8 to 10.9)) and psychosocial functioning subscales (CHDs: 76.7, classmates: 85.0; difference 8.3 (6.0 to 10.6)). Cardiac interventions, school absence, regular medications and non-cardiac comorbidities were independently associated with reduced QoL. Participation in sport positively influenced QoL and was associated with higher psychosocial functioning scores.

CONCLUSIONS

Children with serious CHDs experience lower QoL than unaffected classmates. This appears related to the burden of clinical intervention rather than underlying cardiac diagnosis. Participation in sports activities is positively associated with increased emotional well-being. Child self-report measures of QoL would be a valuable addition to clinical outcome audit in this age group.

Diagnosis and treatment of fetal cardiac disease: a scientific statement from the American Heart Association

BACKGROUND

The goal of this statement is to review available literature and to put forth a scientific statement on the current practice of fetal cardiac medicine, including the diagnosis and management of fetal cardiovascular disease.

METHODS AND RESULTS

A writing group appointed by the American Heart Association reviewed the available literature pertaining to topics relevant to fetal cardiac medicine, including the diagnosis of congenital heart disease and arrhythmias, assessment of cardiac function and the cardiovascular system, and available treatment options. The American College of Cardiology/American Heart Association classification of recommendations and level of evidence for practice guidelines were applied to the current practice of fetal cardiac medicine. Recommendations relating to the specifics of fetal diagnosis, including the timing of referral for study, indications for referral, and experience suggested for performance and interpretation of studies, are presented. The components of a fetal echocardiogram are described in detail, including descriptions of the assessment of cardiac anatomy, cardiac function, and rhythm. Complementary modalities for fetal cardiac assessment are reviewed, including the use of advanced ultrasound techniques, fetal magnetic resonance imaging, and fetal magnetocardiography and electrocardiography for rhythm assessment. Models for parental counseling and a discussion of parental stress and depression assessments are reviewed. Available fetal therapies, including medical management for arrhythmias or heart failure and closed or open intervention for diseases affecting the cardiovascular system such as twin-twin transfusion syndrome, lung masses, and vascular tumors, are highlighted. Catheter-based intervention strategies to prevent the progression of disease in utero are also discussed. Recommendations for delivery planning strategies for fetuses with congenital heart disease including models based on classification of disease severity and delivery room treatment will be highlighted. Outcome assessment is reviewed to show the benefit of prenatal diagnosis and management as they affect outcome for babies with congenital heart disease.

CONCLUSIONS

Fetal cardiac medicine has evolved considerably over the past 2 decades, predominantly in response to advances in imaging technology and innovations in therapies. The diagnosis of cardiac disease in the fetus is mostly made with ultrasound; however, new technologies, including 3- and 4-dimensional echocardiography, magnetic resonance imaging, and fetal electrocardiography and magnetocardiography, are available. Medical and interventional treatments for select diseases and strategies for delivery room care enable stabilization of high-risk fetuses and contribute to improved outcomes. This statement highlights what is currently known and recommended on the basis of evidence and experience in the rapidly advancing and highly specialized field of fetal cardiac care.

Risk factors for hospital admission with RSV bronchiolitis in England: a population-based birth cohort study

Objective

To examine the timing and duration of RSV bronchiolitis hospital admission among term and preterm infants in England and to identify risk factors for bronchiolitis admission.

Design

A population-based birth cohort with follow-up to age 1 year, using the Hospital Episode Statistics database.

Setting

71 hospitals across England.

Participants

We identified 296618 individual birth records from 2007/08 and linked to subsequent hospital admission records during the first year of life.

Results

In our cohort there were 7189 hospital admissions with a diagnosis of bronchiolitis, 24.2 admissions per 1000 infants under 1 year (95%CI 23.7–24.8), of which 15% (1050/7189) were born preterm (47.3 bronchiolitis admissions per 1000 preterm infants (95% CI 44.4–50.2)). The peak age group for bronchiolitis admissions was infants aged 1 month and the median was age 120 days (IQR = 61–209 days). The median length of stay was 1 day (IQR = 0–3). The relative risk (RR) of a bronchiolitis admission was higher among infants with known risk factors for severe RSV infection, including those born preterm (RR = 1.9, 95% CI 1.8–2.0) compared with infants born at term. Other conditions also significantly increased risk of bronchiolitis admission, including Down's syndrome (RR = 2.5, 95% CI 1.7–3.7) and cerebral palsy (RR = 2.4, 95% CI 1.5–4.0).

Conclusions

Most (85%) of the infants who are admitted to hospital with bronchiolitis in England are born at term, with no known predisposing risk factors for severe RSV infection, although risk of admission is higher in known risk groups. The early age of bronchiolitis admissions has important implications for the potential impact and timing of future active and passive immunisations. More research is needed to explain why babies born with Down's syndrome and cerebral palsy are also at higher risk of hospital admission with RSV bronchiolitis.

Prenatal detection of congenital heart diseases: one-year survey performing a screening protocol in a single reference center in Brazil

Objective. To describe the experience of a tertiary center in Brazil to which patients are referred whose fetuses are at increased risk for congenital heart diseases (CHDs). Methods. This was a cross-sectional observational study. The data was collected prospectively, during the year 2012, through a screening protocol of the fetal heart adapted from the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) guideline. We performed a fetal echocardiogram screening for all pregnant women who were referred to the fetal cardiology outpatient obstetrics clinic of a university hospital. The exams were classified as normal or abnormal. The cases considered abnormal were undergone to a postnatal echocardiogram. We categorized the abnormal fetal heart according to severity in “complex,” “significant,” “minor,” and “others.” Results. We performed 271 fetal heart screening. The incidence of abnormal screenings was 9.96% (27 fetuses). The structural CHD when categorized due to severity showed 48.1% (n = 13) of “complex” cases, 18.5% (n = 5) “significant” cases, and 7.4% (n = 2) “minor” cases. The most common referral reason was by maternal causes (67%) followed by fetal causes (33%). The main referral indication was maternal metabolic disease (30%), but there was just one fetus with CHD in such cases (1.2%). CHDs were found in 19/29 fetuses with suspicion of some cardiac abnormality by obstetrician (65.5%). Conclusion. We observed a high rate of CHD in our population. We also found that there was higher incidence of complex cases.

Modelling survival and mortality risk to 15 years of age for a national cohort of children with serious congenital heart defects diagnosed in infancy

BACKGROUND

Congenital heart defects (CHDs) are a significant cause of death in infancy. Although contemporary management ensures that 80% of affected children reach adulthood, post-infant mortality and factors associated with death during childhood are not well-characterised. Using data from a UK-wide multicentre birth cohort of children with serious CHDs, we observed survival and investigated independent predictors of mortality up to age 15 years.

METHODS

Data were extracted retrospectively from hospital records and death certificates of 3,897 children (57% boys) in a prospectively identified cohort, born 1992-1995 with CHDs requiring intervention or resulting in death before age one year. A discrete-time survival model accounted for time-varying predictors; hazards ratios were estimated for mortality. Incomplete data were addressed through multilevel multiple imputation.

FINDINGS

By age 15 years, 932 children had died; 144 died without any procedure. Survival to one year was 79.8% (95% confidence intervals [CI] 78.5, 81.1%) and to 15 years was 71.7% (63.9, 73.4%), with variation by cardiac diagnosis. Importantly, 20% of cohort deaths occurred after age one year. Models using imputed data (including all children from birth) demonstrated higher mortality risk as independently associated with cardiac diagnosis, female sex, preterm birth, having additional cardiac defects or non-cardiac malformations. In models excluding children who had no procedure, additional predictors of higher mortality were younger age at first procedure, lower weight or height, longer cardiopulmonary bypass or circulatory arrest duration, and peri-procedural complications; non-cardiac malformations were no longer significant.

INTERPRETATION

We confirm the high mortality risk associated with CHDs in the first year of life and demonstrate an important persisting risk of death throughout childhood. Late mortality may be underestimated by procedure-based audit focusing on shorter-term surgical outcomes. National monitoring systems should emphasise the importance of routinely capturing longer-term survival and exploring the mechanisms of mortality risk in children with serious CHDs.

Newborns with congenital heart diseases: epidemiological data from a single reference center in Brazil

OBJECTIVE

to describe the epidemiological data of the population born with the diagnosis of Congenital Heart Disease (CHD); to compare diagnoses made using fetal echocardiography with the findings from postnatal echocardiography or anatomopathological examination of the heart; and to evaluate mortality among newborns that underwent surgical treatment.

METHODS

this was a cohort study with information gathered from the medical records of the pregnant women and their newborns diagnosed with CHD during the fetal or postnatal periods, between January 2008 and December 2012. Means, standard deviations and maximum and minimum values were calculated for the quantitative variables. Relative and absolute values were calculated for the qualitative variables. The heart malformations were categorized in four groups: complex lesions, significant lesions, minor lesions and others.

RESULTS

we detected postnatal incidence of CHD of 1.9% at our service. The mean maternal age was 28.3 years and 10 (21.3%) of the pregnant women were ≥ 35 years old. The mean gestational age at the time of performing the fetal echocardiogram was 27.8 weeks. Mean gestational age at delivery was 38 weeks, and the mean weight of the newborns was 2,644.5 grams. Regarding the diagnosis of CHD, there were: 23 complex lesions (39%); 15 significant lesions (26%); 10 minor lesions (17%); 4 other lesions (7%) and 6 normal anatomies (10%). The diagnosis of CHD made on the fetus and postnatally coincided in 77.6% of the cases. A total of 27 patients (60%) underwent surgery, and the outcome was neonatal death in five cases.

CONCLUSION

we detected postnatal incidence of CHD of 1.9%, and it was more common among older pregnant women and with late detection in the intrauterine period. Complex heart diseases predominated, thus making it difficult to have a good result regarding neonatal mortality rates.

Use of diagnostic information submitted to the United Kingdom Central Cardiac Audit Database: development of categorisation and allocation algorithms

OBJECTIVE

To categorise records according to primary cardiac diagnosis in the United Kingdom Central Cardiac Audit Database in order to add this information to a risk adjustment model for paediatric cardiac surgery.

DESIGN

Codes from the International Paediatric Congenital Cardiac Code were mapped to recognisable primary cardiac diagnosis groupings, allocated using a hierarchy and less refined diagnosis groups, based on the number of functional ventricles and presence of aortic obstruction.

SETTING

A National Clinical Audit Database. Patients Children undergoing cardiac interventions: the proportions for each diagnosis scheme are presented for 13,551 first patient surgical episodes since 2004.

RESULTS

In Scheme 1, the most prevalent diagnoses nationally were ventricular septal defect (13%), patent ductus arteriosus (10.4%), and tetralogy of Fallot (9.5%). In Scheme 2, the prevalence of a biventricular heart without aortic obstruction was 64.2% and with aortic obstruction was 14.1%; the prevalence of a functionally univentricular heart without aortic obstruction was 4.3% and with aortic obstruction was 4.7%; the prevalence of unknown (ambiguous) number of ventricles was 8.4%; and the prevalence of acquired heart disease only was 2.2%. Diagnostic groups added to procedural information: of the 17% of all operations classed as "not a specific procedure", 97.1% had a diagnosis identified in Scheme 1 and 97.2% in Scheme 2.

CONCLUSIONS

Diagnostic information adds to surgical procedural data when the complexity of case mix is analysed in a national database. These diagnostic categorisation schemes may be used for future investigation of the frequency of conditions and evaluation of long-term outcome over a series of procedures.

Neonatal screening for critical cardiovascular anomalies using pulse oximetry

INTRODUCTION

Babies with cardiac anomalies are often asymptomatic at birth, and many remain undetected despite routine newborn examination. We retrospectively assessed the effect of routine pulse oximetry in detection of such anomalies from a hospital birth population of 31 946 babies born between 1 April 1999 and 31 March 2009.

METHOD

29 925 babies who were not admitted to the neonatal unit at birth underwent postductal oxygen saturation measurement before discharge. If saturation was below 95% an examination was performed. If this was abnormal or saturation remained low, an echocardiogram was performed. All babies with cardiac anomaly diagnosed before 1-year were identified from the region's fetal abnormality database.

RESULTS

Critical anomalies affected 27 infants (1 in 1180); 10 identified prenatally, 2 after echocardiogram was performed because of other anomalies, 2 in preterm infants, 2 when symptomatic before screening, 5 by oximetry screening, 1 when symptomatic in hospital after a normal screen and 5 after discharge home. Serious anomalies affected 50 infants (1 in 640); 8 identified antenatally, 7 because of other anomalies, 3 in the neonatal unit, 5 by pulse oximetry screening, 11 by routine newborn examination, and 16 after discharge home.

CONCLUSIONS

Routine pulse oximetry aided detection of 5/27 of critical and 5/50 of serious anomalies in this sample, but did not prevent five babies with critical and 15 with serious anomalies being discharged undiagnosed. Results from screening over 250 000 babies have now been published, but this total includes only 49 babies with transposition, and even smaller numbers of rarer anomalies.

Congenital heart defects in a large, unselected cohort of monochorionic twins

OBJECTIVE

To determine the prevalence of congenital heart defects (CHDs) in a large, unselected cohort of monochorionic (MC) twins.

STUDY DESIGN

We completed a chart review of all MC twin pregnancies in the Kaiser Permanente Northern California population from 1996 to 2003. CHDs were identified by diagnostic codes and confirmed by postnatal echocardiograms. Follow-up was obtained through one year of age.

RESULT

A total of 926 liveborn MC twins met inclusion criteria. The prevalence of CHDs was 7.5%, 11.6 times the general population rate (CI 9.2 to 14.5). Septal defects were most common. 20% of infants with heart defects had twin-to-twin transfusion syndrome (TTTS) versus 8% of infants without defects (P<0.01); this association remained significant when controlling for potential confounders.

CONCLUSION

The prevalence of CHDs in this large cohort of MC twins was significantly higher than the general population rate, with TTTS an added risk factor.

A mortality risk model to adjust for case mix in UK paediatric cardiac surgery

Background

Congenital heart disease (CHD) is a relatively common disorder in childhood, affecting approximately 8–9 per 1000 live-born infants annually in the UK. CHD often involves serious abnormalities and is an important cause of childhood mortality, morbidity and disability. It is generally recognised that it is important and valuable to monitor outcomes in cardiac surgery and that, to do so fairly and effectively, one needs to risk stratify the case load of each unit. There is evidence that, since outcome monitoring in adult cardiac surgery became mandatory and routine, outcomes have improved. At present, no process for routinely monitoring risk-adjusted outcomes in paediatric cardiac surgery exists.

Objectives

To establish whether or not a risk model can be developed that is fit for the purpose of adjusting for case mix severity to facilitate routine monitoring of outcomes for paediatric cardiac surgery in the UK and to assess whether or not and how diagnostic information can augment procedural information in risk adjustment.

Methods

Data from the Central Cardiac Audit Database (CCAD) for all cardiac surgery procedures, excluding reoperations within 30 days, performed in the UK for patients < 16 years between 2000 and 2010 (38,597 patient episodes) were included: 70% for model development and 30% quarantined for validation. The outcome was 30-day survival, as supplied to CCAD through the Central Register of NHS patients (now the Medical Research Information Service). The CCAD defines 36 ‘specific procedures’. Nine of these were merged as a ‘low-volume specific procedure’ group (< 90 cases each in the entire development set). Unassigned cases were grouped as ‘not a specific procedure’. Twenty-four ‘primary’ cardiac diagnoses and separately a categorisation of ‘univentricular’ status were defined using a hierarchical algorithm developed by the study team based on International Paediatric and Congenital Cardiac codes. Comorbidities considered included prematurity (< 37 weeks' gestation), Down syndrome, constellations of features that constitute a recognised syndrome, congenital structural defects of organs other than the heart and acquired conditions. Other candidate variables included use of bypass and patient age, weight and sex. Data were analysed using logistic regression.

Results

In the development set, there were 25,665 episodes that resulted in survival to 30 days, 693 episodes for which the vital status at 30 days was unknown and 854 episodes that resulted in death within 30 days in the development set (mortality 3.2% overall). The risk model developed includes the following factors: specific procedure, primary cardiac diagnosis grouped into low-, medium- and high-risk categories, univentricular heart status, age band (neonate, infant, child), continuous age, continuous weight, presence of a comorbidity other than Down syndrome and use of bypass. To account for decreasing mortality over time in the development set, a binary indicator for operations performed after 1 January 2007 is also included in the model. We were able to calculate a risk score for 95% of cases in the test set: weight was missing in 5% of cases. Data completeness improved over time. The proposed model discriminated well: the area under the receiver operating characteristic curve (AUC) for the test set was 0.77 (0.81 for post-2007 data). Removal of all but procedural information gave a reduced AUC of 0.72. The model performed well across the spectrum of predicted risk in the entire data set, but there was underestimation of mortality risk in the test set among neonates operated from 2007.

Limitations

An important limitation is that the model pertains to short-term 30-day outcomes (not long-term outcomes) and is designed for the purpose of routine monitoring for quality assurance rather than bedside-type predictions for individual patients. Over the recent period in the validation set (since 2007), the model was found to underestimate risk at the very high-risk end (> 10% risk), in particular among neonates. This indicates that risk adjustment based on the current parameterisation of the model will potentially give an unduly negative impression of outcomes at those centres with a high proportion of high-risk cases. Finally, any risk model used for ongoing quality improvement initiatives needs to be regularly updated as data quality improves and clinical practice evolves.

Conclusions

For the first time diagnostic information has been successfully incorporated into risk adjustment for short-term outcomes in this patient group, which added discriminatory power. The risk model is fit for purpose, although the underestimation of risk in recent neonates is an important caveat. Several centres have expressed an interest in piloting the risk model and the accompanying monitoring tool. Future work includes developing software to generate variable life-adjusted display charts within units using the risk model; using the risk model to explore trends in case mix over time; and informing future work in evaluating long-term outcomes for children with CHD.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Lifetime costs and outcomes of repair of Tetralogy of Fallot compared to natural progression of the disease: Great Ormond Street Hospital cohort

Background

Tetralogy of Fallot is a congenital heart disease that requires surgical repair without which survival through childhood is extremely rare. The aim of this paper is to use data from the mandatory follow-up of patients with Tetralogy of Fallot to model the health-related costs and outcomes over the first 55-years of life.

Method

A decision analytical model was developed to establish costs and outcomes for patients up to 55 years after diagnosis and first repair of Tetralogy of Fallot compared to natural progression. Data from Adult Congenital Heart Disease (ACHD) centres that follow up Tetralogy of Fallot patients and Great Ormond Street Hospital (GOSH), London, United Kingdom (UK) medical records was used to establish the cost and effectiveness of current interventions. Data from a Czech cohort was used for the natural, no intervention condition.

Results

The average cost per patient of a repair for Tetralogy of Fallot was £26,938 (SE = £4,140). The full life time cost per patient, with no discount rate, was £65,310 (95% CI £64,981–£65,729); £56,559 discounted (95% CI £56,159–£56,960). Patients with a repair had an average of 35 Quality Adjusted Life Years (QALYs) per patient over 55 years undiscounted and 20.16 QALYs discounted. If the disorder was left to take its natural course, patients on average had a total of 3 QALYs per patient with no discount rate and 2.30 QALYs discounted.

Conclusion

A model has been developed that provides an estimate of the value for money of an expensive repair of a congenital heart disease. The model could be used to test the cost-effectiveness of making amendments to the care pathway.

The impact of patent ductus arteriosus in neonates with late onset sepsis: a retrospective matched-case control study

BACKGROUND

Late-onset sepsis (LOS) in neonates with patent ductus arteriosus (PDA) may predispose them to more complicated hospital courses. The objective of this study was to determine the incidence, the distribution of pathogens, and the clinical features of LOS in neonates with PDA and analyze their outcomes.

METHODS

The medical records were reviewed retrospectively of infants with PDA and LOS who were hospitalized in NICUs of Chang Gung Children's Hospital between January 2003 and December 2009. The clinical features of these infants were compared with a group of gestational age and birth body weight-matched neonates with LOS during the same period.

RESULTS

During this period, 224 neonates were found to have at least one event of blood-culture proven LOS and 79 (35.3%) were documented to have PDA. Although most LOS episodes (85/104, 81.7%) in neonates with PDA occurred after closure of PDA, neonates with PDA had a significantly higher rate of bronchopulmonary dysplasia (81.0% vs. 61.0%, p = 0.002) and a relatively higher rate of recurrent sepsis (25.3% vs. 15.2%, p = 0.079) than those without PDA. Longer durations of ventilator support and hospital stay were also noted in neonates with PDA as compared to those without (p = 0.001 and 0.005, respectively).

CONCLUSION

In neonates with LOS, the presence of PDA, even though it is aggressively treated with indomethacin or surgical intervention, may still contribute to the complexity of hospitalization. Close monitoring and aggressive treatments are warranted in these neonates with PDA.

Preterm birth and congenital heart defects: a population-based study

BACKGROUND AND OBJECTIVES

Preterm birth (PTB) and congenital heart defect (CHD) are 2 major causes of mortality and disability of perinatal origin. There are limited data on the relation between CHD and PTB. Our objective was to use population-based data to estimate the risk of PTB in newborns with CHD and to study specific associations between categories of CHD and PTB.

METHODS

We used data from a population-based cohort study of CHD (EPIdémiologique sur le devenir des enfants porteurs de CARDiopathies congénitales study), including 2189 live births with CHD (excluding isolated atrial septal defects) born between 2005 and 2008. We categorized CHD by using an anatomic and clinical classification. Data from the French National Perinatal Survey of 2003 were used to compare PTB in the EPIdémiologique sur le devenir des enfants porteurs de CARDiopathies congénitales study to that of the general population.

RESULTS

Of the newborns with CHD, 13.5% were preterm. The odds of PTB were twofold higher than for the general population (odds ratio 2.0, 95% confidence interval 1.6-2.5), essentially due to an increase in spontaneous PTB for newborns with CHD. The risk of PTB associated with CHD persisted after exclusion of chromosomal or other anomalies. There were significant variations in risk of PTB across the categories of CHD after adjustment for known risk factors of PTB and factors related to medical management of pregnancy and delivery.

CONCLUSIONS

We found a higher risk of PTB in newborns with CHD, which was essentially due to spontaneous PTB. Risk of PTB varied for categories of CHD. Our finding may be helpful for generating hypotheses about the developmental links between CHD and PTB.

Mortality in infants with cardiovascular malformations

Cardiovascular malformations are an important cause of infant death and the major cause of death due to malformation. Our aims were to analyse and categorise all deaths in infants with cardiovascular malformations, and to analyse trends in mortality over time and influences on mortality. We obtained details of infant deaths and cardiovascular malformations from the population of one health region for 1987-2006. We categorised deaths by cause and by presence of additional chromosomal or genetic abnormalities or non-cardiac malformations. In 676,927 live births the total infant mortality was 4,402 (6.5 per 1,000). A total of 4,437 infants had cardiovascular malformations (6.6 per 1000) of whom 458 (10.3%) died before 1 year of age. Of this number, 151 (33%) deaths had non-cardiac causes, 128 (28%) were cardiac without surgery and 179 (39%) occurred from cardiac causes after surgery. Death was unrelated to the cardiovascular malformation in 57% of infants with an additional chromosomal or genetic abnormality, in 76% of infants with a major non-cardiac malformation and in 16% of infants with an isolated cardiovascular malformation. Terminations of pregnancies affected by cardiovascular malformations increased from 20 per 100,000 registered births in the first 5 years to 78 per 100,000 in the last 5 years. A total of 2,067 infants (47%) underwent surgery and of these 216 (10%) died before 1 year of age.

CONCLUSIONS

A total of 10.4% of infants who died had a cardiovascular malformation and two-thirds of deaths were due to the malformation or its treatment. Mortality declined due to increasing termination of pregnancy and improved survival after operation.

Socioeconomic status and prevalence of congenital heart defects: does universal access to health care system eliminate the gap?

BACKGROUND

A twofold increase in the prevalence of congenital heart defects (CHDs) has been reported since the early 1970s with higher rates among children from low socioeconomic status (SES). This increase and the observed SES gap are postulated to be reflective of higher ascertainment, especially increased use of ultrasound and echography. The purpose of this study was to examine if trends over time in the prevalence of CHD were the same for high and low SES groups.

METHODS

Using the child's health number as a unique identifier and through record linkage, children born in Ontario between 1994 and 2007 were followed for the diagnosis of CHD. Using postal codes and census information, SES quintiles were assigned to each child. We used adjusted rates and used multivariate models to compare trends in the prevalence rate among children born in different SES groups.

RESULTS

Children born in low SES areas (23% of all births) had significantly higher rates of CHDs (rate ratio = 1.20; 95% confidence interval [CI] = 1.15-1.24). While prevalence of nonsevere CHDs declined in all SES groups since 2000, severe CHDs, especially atrial septal defects were on the rise during the study period.

DISCUSSION

It is assumed that increased ascertainment is responsible for observed increase in the prevalence of CHD, especially minor defects. While the trend and pattern over time changed for severe and nonsevere CHDs, the SES gap remained consistent during the study period. Our results indicate that even free and universal access to a health care system does not eliminate the SES gap observed in the prevalence of CHD.

The changing occurrences of tetralogy of Fallot and simple transposition of the great arteries in Southern Nevada

We analysed the occurrence of tetralogy of Fallot and simple transposition in the Hispanic and non-Hispanic populations of Clark County, Nevada, in the United States of America over a 30-year period from 1980 to 2009. We found a downward trend in the incidence of simple transposition of the great arteries in the non-Hispanic population but an upward trend in the incidence in the Hispanic population. For tetralogy of Fallot, we found an upward trend in the incidence in both populations; the trend, however, was more dramatic in the Hispanic population. We also noted differences in the male to female ratios in the different groups. Even though we make no definitive conclusions regarding the causes of these incidence curves or the differences in occurrence between males or females, the data suggest an interplay of genetics and the environment.

The registry and follow-up of complex pediatric therapies program of Western Canada: a mechanism for service, audit, and research after life-saving therapies for young children

Newly emerging health technologies are being developed to care for children with complex cardiac defects. Neurodevelopmental and childhood school-related outcomes are of great interest to parents of children receiving this care, care providers, and healthcare administrators. Since the 1970s, neonatal follow-up clinics have provided service, audit, and research for preterm infants as care for these at-risk children evolved. We have chosen to present for this issue the mechanism for longitudinal follow-up of survivors that we have developed for western Canada patterned after neonatal follow-up. Our program provides registration for young children receiving complex cardiac surgery, heart transplantation, ventricular assist device support, and extracorporeal life support among others. The program includes multidisciplinary assessments with appropriate neurodevelopmental intervention, active quality improvement evaluations, and outcomes research. Through this mechanism, consistently high (96%) follow-up over two years is maintained.

Early diagnosis and screening of congenital cardiac anomalies

Considerable numbers of congenital cardiac anomalies are missed at the time of delivery. Study reports show that congenital cardiac anomalies are the second most common birth defect in many countries. Despite this fact, our previous study showed that the prevalence of congenital cardiac anomalies is the fifth most common one, indicating that many of these defects might not be properly diagnosed at the time of delivery and birth. The aim of this study was to estimate the missing frequency of congenital cardiac anomalies at the time of delivery and birth. The population of the study was 185,650 births in the Northwest region of Iran covered by the Tabriz Registry of Congenital Anomalies. A total of 451 children with congenital cardiac anomalies were studied in the region from 2000 to 2009. The expected prevalence of congenital cardiac anomalies at birth was estimated to be 24.2 per 10,000 births while a prevalence of 9.2 per 10,000 births was observed at the same time and place. This indicated that 59.1% of children with congenital cardiac anomalies were not identified at birth (p-value less than 0.05). This proportion increased by 13% over the study period from 2000 to 2009 (p-value greater than 0.1). Our findings indicated that a remarkable frequency of congenital cardiac anomalies was not diagnosed at birth because there was no paediatric cardiologist available at the time of birth in the gynaecology and obstetrics wards.

Post-operative cardiac lesions after cardiac surgery in childhood

A new population of patients in cardiology has been growing steadily so that the number of grown-ups with congenital heart disease (GUCH) is almost equal to those under paediatric care. The dramatic improvement in survival should lead to a larger number of GUCH patients than children with CHD in the new millennium. Although echocardiography remains the imaging modality of choice, cross-sectional imaging techniques have a decision-aiding function for the postoperative evaluation of surgical reconstructions as well as in the preparation of complex interventional procedures. Cardiovascular CT and MRI are often complementary in providing comprehensive complex anatomical evaluation, haemodynamic assessment of residual postoperative lesions and complications of surgery. A thorough understanding of postsurgical corrections is a prerequisite for choosing the optimal imaging techniques and achieving an accurate evaluation.

Is the rate of congenital heart defects detected by fetal echocardiography among pregnancies conceived by in vitro fertilization really increased?: a case-historical control study

OBJECTIVE

We investigated the prenatal prevalence of congenital heart defects (CHDs) among in vitro fertilization (IVF) pregnancies at a referral program in the United States.

METHODS

Study patients were referred for fetal echocardiography between April 1, 2006, and May 1, 2009, due to IVF. An IVF pregnancy was defined as a patient who conceived with IVF with or without intracytoplasmic sperm injection. Congenital heart defect odds relative to historical data were calculated by standard methods. P < .05 was considered statistically significant.

RESULTS

During the study period, we performed fetal echocardiography on 749 consecutive IVF pregnancies. Overall, the frequency of CHDs was 1.1% (95% confidence interval, 0.3%-1.8%) per pregnancy. Compared to earlier historical population data, IVF pregnancies had a significantly higher risk of CHDs (odds ratios, 7.3 [3.6-14.7] and 2.9 [1.4-5.9], respectively). However, compared to more contemporary population data, there was no difference in the CHD risk between IVF gestations and naturally conceived pregnancies. Further analysis indicated that IVF twin pregnancies were as much as 12.5 (4.6-33.5) times as likely to have CHDs compared to a general population.

CONCLUSIONS

In this study population, the frequency of CHDs in IVF pregnancies was higher than early historical population data; however, it was similar to that of a more contemporary general population. Further analysis showed that this increase was mainly driven by IVF twin gestations. Previous reports of increased CHD risk in pregnancies conceived via IVF may have been due, in part, to an increased frequency of higher-order pregnancies seen among these patients.

Prevalence and clinical significance of heart murmurs detected in routine neonatal examination

OBJECTIVE

To determine the prevalence and clinical impact of murmurs detected during routine physical examination in neonates.

METHODS

In a 4 years retrospective study, 6333 healthy newborn babies were screened for the presence of a heart murmur during routine neonatal physical examination. Prematures or those who were admitted to neonatal intensive care unit or any neonate with a risk factor that is known to be associated with increased incidence of congenital heart disease were excluded from the study. All those with murmurs underwent echocardiography examination and color Doppler study.

RESULTS

Murmurs were detected in 87 neonate (1.37%) of whom 37 (42.5%) had a structural cardiac malformation. Ventricular septal defect (62%) was the most common diagnosis, followed by atrial septal defect, pulmonary stenosis and patent ductus arteriosus.

CONCLUSION

The prevalence of heart murmur was 13.7 per 1000 neonate. If a murmur is heard there is a (42.5%) chance of their being underlying structural defects. Therefore, detection of a murmur should prompt early referral for investigation and diagnosis or appropriate family reassurance.

20-year survival of children born with congenital anomalies: a population-based study

BACKGROUND

Congenital anomalies are a leading cause of perinatal and infant mortality. Advances in care have improved the prognosis for some congenital anomaly groups and subtypes, but there remains a paucity of knowledge about survival for many others, especially beyond the first year of life. We estimated survival up to 20 years of age for a range of congenital anomaly groups and subtypes.

METHODS

Information about children with at least one congenital anomaly, delivered between 1985 and 2003, was obtained from the UK Northern Congenital Abnormality Survey (NorCAS). Anomalies were categorised by group (the system affected), subtype (the individual disorder), and syndrome according to European Surveillance of Congenital Anomalies (EUROCAT) guidelines. Local hospital and national mortality records were used to identify the survival status of liveborn children. Survival up to 20 years of age was estimated by use of Kaplan-Meier methods. Cox proportional hazards regression was used to examine factors that affected survival.

FINDINGS

13,758 cases of congenital anomaly were notified to NorCAS between 1985 and 2003. Survival status was available for 10 850 (99.0%) of 10 964 livebirths. 20-year survival was 85.5% (95% CI 84.8-86.3) in individuals born with at least one congenital anomaly, 89.5% (88.4-90.6) for cardiovascular system anomalies, 79.1% (76.7-81.3) for chromosomal anomalies, 93.2% (91.6-94.5) for urinary system anomalies, 83.2% (79.8-86.0) for digestive system anomalies, 97.6% (95.9-98.6) for orofacial clefts, and 66.2% (61.5-70.5) for nervous system anomalies. Survival varied between subtypes within the same congenital anomaly group. The proportion of terminations for fetal anomaly increased throughout the study period (from 12.4%, 9.8-15.5, in 1985 to 18.3%, 15.6-21.2, in 2003; p<0.0001) and, together with year of birth, was an independent predictor of survival (adjusted hazard ratio [HR] for proportion of terminations 0.95, 95% CI 0.91-0.99, p=0.023; adjusted HR for year of birth 0.94, 0.92-0.96, p<0.0001).

INTERPRETATION

Estimates of survival for congenital anomaly groups and subtypes will be valuable for families and health professionals when a congenital anomaly is detected, and will assist in planning for the future care needs of affected individuals.

FUNDING

BDF Newlife.

Effect of pathoanatomic diagnosis on the quality of birth defects surveillance in China

OBJECTIVE

To provide evidence for more accurate diagnosis of birth defects based on the pathoanatomy of congenital malformations.

METHODS

Data used in this study were obtained from Luliang City Hospital and three county hospitals of Shanxi province between February 2004 and March 2006. Autopsy and pathological examination of 160 dead fetuses and stillbirths were performed. Photos of dead fetuses and stillbirths were taken, tissues were cut into sections for pathological examination under microscope, all pathological information was recorded, and percentage of birth defects was calculated.

RESULTS

The proportion of dead fetuses and stillbirths with or without congenital malformations was 84.4% (135/160) and 15.6% (25/160), respectively. There were 16 categories of major external and internal birth defects in 135 cases of such defects. Congenital heart defects, anencephaly and spina bifida had a higher prevalence rate in the study period. The prevalence rate of non-malformation death and birth defects < 28 gestational weeks and internal anomalies > or = 28 gestational weeks was 14.61% (61/4175) and 17.25% (72/4175), respectively. A total of 413 in situ anomalies were found in 135 cases of autopsy. Spina bifida, anencephaly, congenital heart defects, aplasia or accessory lobe of lung, renal agenesis and dysplasis and congenital hydrocephaly were more closely associated with severe malformations than with mitis malformations. The cases of dead fetuses and stillbirths with multiple malformations (> or = 2 in situ anomalies) had a higher proportion (74.1%), whereas those with isolated malformations had a lower proportion (25.93%).

CONCLUSION

The occurrence of congenital malformations in different embryonic developmental stages affects multiple organs. Postmortem examination of internal and multiple malformations of fetal deaths and stillbirths can provide more accurate diagnostic information for birth defects.

Urban versus rural residence and occurrence of septal heart defects in Texas

BACKGROUND

There is conflicting information on the association between urban/rural residence of mothers and atrial septal defect (ASD) or ventricular septal defect (VSD) in their offspring. Few studies have compared multiple measures of urban/rural residence.

METHODS

Data were taken from the Texas Birth Defects Registry, 1999-2003. Poisson regression was used to compare crude and adjusted birth prevalence.

RESULTS

Three broad urban/rural measures, namely, the rural urban continuum code (RUCC), urban influence code (UIC), and rural urban commuting area (RUCA), were correlated with each other, but much less correlated with percentage of land in crops. ASD showed few consistent patterns with RUCC, UIC, and RUCA but was more prevalent in counties with higher cropland percentage. For example, counties with > or =50% cropland had a prevalence ratio (PR) for isolated ASD of 3.49 (95% confidence interval [CI]: 2.85-4.24) compared to counties with <15% cropland. VSD was less prevalent in rural areas using RUCC, UIC, and RUCA. For example, for isolated VSD, small towns/rural areas had a PR of 0.64 (95% CI: 0.51-0.78) compared to urban core areas using RUCA. The pattern was seen among mild cases of VSD but not among severe cases. VSD was not associated with percentage cropland.

CONCLUSIONS

The measure of urban/rural status can greatly affect associations with certain birth defects. More prevalent ASD in areas with greater percentage cropland suggests that agricultural chemicals may be relevant. Mild cases of VSD but not severe cases were less prevalent in rural areas, suggesting that variation in detection may be largely responsible.

Real-time three-dimensional echocardiography using a matrix probe with live xPlane imaging of the interventricular septum

OBJECTIVE

To describe a technique to rapidly visualize the in-plane view of the fetal interventricular septum (IVS) to enable the identification of a ventricular septal defect (VSD).

METHODS

One hundred and fifty-one women were invited to participate after their routine fetal morphology scan, including four suspected to have congenital cardiac defects which were confirmed postnatally. A standard examination protocol using real-time three-dimensional (3D) echocardiography with live xPlane imaging was developed. The ability of this new technology to examine the ventricular septum was investigated.

RESULTS

The in-plane view of the fetal IVS was visualized successfully in 150 (99.3%) cases by real-time 3D echocardiography with live xPlane imaging, including 82 (54.3%) cases with the spine posterior and 68 (45.7%) cases with the spine anterior. The in-plane view of the IVS successfully visualized the VSDs in three fetuses with VSD and displayed the intact IVS in one fetus with transposition of the great arteries without VSD.

CONCLUSION

We describe live xPlane imaging, a simple method for the real-time assessment of the in-plane view of the IVS that has the potential to enhance the diagnostic accuracy of fetal cardiac examination.

Coarctation of the aorta: a case presentation

Coarctation is a constriction or narrowing of the aorta and presents most commonly within the first two weeks of life. This article reviews a case study of an infant diagnosed with coarctation of the aorta on day 8 of life. It includes an overview of the etiology, clinical presentation, and management plus an account of the infant's transport to a regional pediatric intensive care unit (PICU).

National time trends in congenital heart defects, Denmark, 1977-2005

BACKGROUND

Time trends in congenital heart defects (CHD) by specific phenotype and with long follow-up time are rarely available for an entire population. We present trends in national CHD prevalences over the past 3 decades.

METHODS

We linked information from the National Patient Register, the Causes of Death Register, and the Danish Cytogenetic Central Register for all persons born in Denmark, 1977 to 2005, and registered in the Civil Registration System, yielding a cohort of 1,763,591 persons-18,207 with CHD. Individuals with CHDs were classified by phenotype (heterotaxia, conotruncal defect, atrioventricular septal defect, anomalous pulmonary venous return, left and right ventricular outflow tract obstructions, septal defects, complex defects, associations, patent ductus arteriosus, unspecified, and other specified) by combining International Classification of Diseases codes using a hierarchical approach.

RESULTS

From 1977 to 2005, the overall CHD birth prevalence increased from 73 to 113 per 10,000 live births. Generally, prevalence increased for defects diagnosed in infancy, until 1996-1997, and then stabilized. For each 5-year interval, isolated septal defects and severe defects increased by 22% (95% CI, 20%-25%) and 5% (95% CI, 4%-7%), respectively. Among the severe defects, conotruncal defects and atrioventricular septal defect showed the largest prevalence increases. Women had a lower prevalence of severe defects during the 1980s. The CHD prevalence increase was unchanged when persons with extracardiac defects or chromosomal aberrations were excluded.

CONCLUSIONS

CHD birth prevalence increased from the beginning of the 1980s but stabilized in the late 1990s.

Congenital heart disease in 111 225 births in Belgium: birth prevalence, treatment and survival in the 21st century

AIM

To investigate the birth prevalence, treatment modalities and short-term survival of children with congenital heart disease who were born in 2002.

METHODS

We undertook a retrospective review of medical records of all patients who were born in 2002, and were diagnosed, treated and/or followed-up in one of the seven-paediatric cardiology programmes in Belgium.

RESULTS

In 111 225 births, 921 children with congenital heart disease were detected, yielding a birth prevalence of 8.3 per 1000. The most frequently occurring conditions were ventricular septal defects (VSDs) (33%), ostium secundum atrial septal defects (18%) and pulmonary valve abnormalities (10%). Thirty-nine percent of the children either had a cardiosurgical operation or catheter intervention. In this study, 4% of the children died. The actuarial survival at 6 months and 1 year of age was 97% and 96%, respectively and remained stable after then. Compared to other heart defects, mortality was higher in univentricular physiology, pulmonary atresia with VSD, left ventricle outflow obstruction and tetralogy of Fallot.

CONCLUSION

Survival of congenital heart disease is excellent and continued to improve in the early 21st century. New therapeutic options are increasingly used. This study provides baseline data for the longitudinal follow-up of this cohort.

Proteomic-based detection of a protein cluster dysregulated during cardiovascular development identifies biomarkers of congenital heart defects

Background

Cardiovascular development is vital for embryonic survival and growth. Early gestation embryo loss or malformation has been linked to yolk sac vasculopathy and congenital heart defects (CHDs). However, the molecular pathways that underlie these structural defects in humans remain largely unknown hindering the development of molecular-based diagnostic tools and novel therapies.

Methodology/Principal Findings

Murine embryos were exposed to high glucose, a condition known to induce cardiovascular defects in both animal models and humans. We further employed a mass spectrometry-based proteomics approach to identify proteins differentially expressed in embryos with defects from those with normal cardiovascular development. The proteins detected by mass spectrometry (WNT16, ST14, Pcsk1, Jumonji, Morca2a, TRPC5, and others) were validated by Western blotting and immunoflorescent staining of the yolk sac and heart. The proteins within the proteomic dataset clustered to adhesion/migration, differentiation, transport, and insulin signaling pathways. A functional role for several proteins (WNT16, ADAM15 and NOGO-A/B) was demonstrated in an ex vivo model of heart development. Additionally, a successful application of a cluster of protein biomarkers (WNT16, ST14 and Pcsk1) as a prenatal screen for CHDs was confirmed in a study of human amniotic fluid (AF) samples from women carrying normal fetuses and those with CHDs.

Conclusions/Significance

The novel finding that WNT16, ST14 and Pcsk1 protein levels increase in fetuses with CHDs suggests that these proteins may play a role in the etiology of human CHDs. The information gained through this bed-side to bench translational approach contributes to a more complete understanding of the protein pathways dysregulated during cardiovascular development and provides novel avenues for diagnostic and therapeutic interventions, beneficial to fetuses at risk for CHDs.

Descriptive epidemiology of congenital heart disease in Northern England

Congenital heart disease (CHD) is the most prevalent group of congenital anomalies. There is considerable variation in the reported epidemiology of CHD, mainly attributable to methodological differences. Using register-based data, the current study describes the epidemiology of CHD in a geographically well-defined population of the North of England during 1985-2003. The total prevalence of CHD was 85.9 per 10 000 births and terminations of pregnancy for fetal anomaly. Livebirth prevalence was 79.7 per 10 000 livebirths. Both total and livebirth prevalence increased during the study period. Ninety-two per cent of affected pregnancies resulted in a livebirth, 5% were terminated, 2% resulted in a stillbirth, and 1% in a late miscarriage. Almost a quarter (23%) of cases had one or more coincident anomalies of other organs, with chromosomal abnormalities the most frequent group. A total of 89.2% of cases survived to 1 year and the survival improved during the study period. This population-based study has demonstrated an increasing trend in both prevalence and survival among children with CHD.

Fetal cardiac output in monochorionic twins

OBJECTIVES

To compare fetal cardiac output (CO) in donor and recipient twins of twin-twin transfusion syndrome (TTTS) pregnancies after laser therapy with that of monochorionic twins without TTTS and normal singletons.

METHODS

In a longitudinal, prospective study, we sonographically assessed fetal CO in donors (n = 10) and recipients (n = 10) with TTTS after fetoscopic laser therapy, in monochorionic twins without TTTS (n = 20) and in normal singleton pregnancies (n = 20). The fetal CO of TTTS twins was determined 1 day and 1 week after laser treatment, and from then on every 2-4 weeks until birth. Twins without TTTS were examined biweekly until birth. Singletons were examined twice, with an 8-week interval, at different gestational ages between 17 and 35 weeks.

RESULTS

Absolute CO increased exponentially with advancing gestational age (P < 0.0001), and was significantly related to fetal weight in all groups (P < 0.0001). The median CO/kg in donors after laser therapy, recipients after laser therapy and non-TTTS monochorionic twins was significantly higher than that in singletons (all P < 0.001). Median CO/kg in donors after laser therapy, recipients after laser therapy, and non-TTTS monochorionic twins was not significantly different between groups.

CONCLUSIONS

Monochorionic twins with TTTS have higher CO after laser therapy than normal singletons.

Congenital heart disease in twin-to-twin transfusion syndrome treated with fetoscopic laser surgery

OBJECTIVE

To determine the incidence of congenital heart disease (CHD) and right ventricular outflow tract obstruction (RVOTO) in twin-to-twin transfusion syndrome (TTTS) treated with fetoscopic laser surgery and evaluate the role of increased afterload by determining the difference in blood pressure and endothelin-1 at birth between donor and recipient twins.

DESIGN

Prospective study.

SETTING

Tertiary medical center, serving as the national referral center for fetoscopic laser surgery for TTTS in The Netherlands.

PATIENTS

All consecutive cases of monochorionic twins with TTTS treated with laser (n = 46 twin pairs) and monochorionic twins without TTTS (n = 55 twin pairs) delivered at our center between June 2002 and June 2005 were included in the study.

INTERVENTIONS

Echocardiography was performed within 1 week after delivery. At birth, blood pressure was measured in all survivors and endothelin-1 was determined in umbilical cord blood. Data on RVOTO in TTTS treated with laser surgery at our center but delivered elsewhere were reviewed retrospectively from medical records.

RESULTS

The incidence of CHD in the TTTS group and non-TTTS group was 5.4% (4/74) and 2.3% (2/87) (P = .42), respectively. RVOTO was diagnosed in 1 recipient twin delivered at our center and 2 recipient twins delivered elsewhere. The incidence of RVOTO in recipients was 4% (3/75). Mean systolic blood pressure at birth was similar in donor and recipient twins, respectively, 53 mm Hg vs. 56 mm Hg (P = .42). Mean endothelin-1 level at birth was also similar between donors and recipients, respectively, 14.3 ng/L and 13.2 ng/L (P = .64).

CONCLUSION

The incidence of CHD in TTTS treated with fetoscopic laser surgery is higher than in the general population (5.4% vs. 0.5%). We found no difference in afterload parameters between donors and recipients after laser treatment.

Prenatal course of isolated muscular ventricular septal defects diagnosed only by color Doppler sonography: single-institution experience

OBJECTIVE

Counseling patients with an isolated ventricular septal defect (i-VSD) is clinically important because with high-resolution ultrasound equipment, more small muscular VSDs are now being diagnosed. The prevalence of these lesions is not yet completely described, and the frequency with which muscular VSDs resolve in utero has also not been extensively reported.

METHODS

We investigated the perinatal course of isolated muscular VSDs diagnosed only on color Doppler examinations and followed between January 1, 2005, and December 31, 2006. A complete evaluation of the fetal heart was performed by gray scale, spectral Doppler, and color Doppler examinations.

RESULTS

We performed a total of 2583 fetal echocardiographic examinations on 2410 fetuses during 2318 pregnancies. The study group included 78 twin gestations (3.4%) and 7 triplet gestations (0.3%). There were 16 fetuses with an i-VSD (6.6/1000 fetuses) within the study group. The mean gestational age +/- SD at diagnosis was 23.5 +/- 4.3 weeks. Two of the i-VSDs (12.5%) spontaneously resolved prenatally. One fetus with an i-VSD had trisomy 21 and also had increased nuchal translucency in the first trimester. One i-VSD was diagnosed among 22 fetuses with trisomy 21 examined during the study period.

CONCLUSIONS

An i-VSD is a common congenital heart defect. Prenatal resolution of i-VSDs is less frequent than reported in the literature. A larger cohort is needed to provide a better risk estimate for aneuploidy in the presence of an i-VSD.

Improving the quality of surveillance data on congenital heart defects in the metropolitan Atlanta congenital defects program

BACKGROUND

One of the challenges in epidemiologic studies of congenital heart defects (CHDs) has been the lack of a current, standard nomenclature and classification system. Recently such a standard nomenclature became available from the Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database. This study reports the classification of cases of CHDs in a birth defects surveillance database using modified STS nomenclature.

METHODS

Records of infants and fetuses in the Metropolitan Atlanta Congenital Defects Program delivered during 1968-2003 with CHD diagnoses were reviewed by a team of pediatric cardiologists. The cases were assigned one or more STS codes and subsequently grouped into successively broader levels of aggregation. Aggregation was based on presumed morphogenetically similar developmental mechanisms.

RESULTS

There were 12,639 cases reviewed, of which 89% had a single, primary STS code. Structural CHDs were found in 7,749 infants, while 4,890 were considered to have structurally normal hearts. Application of clinical CHD nomenclature improved the clinical accuracy of surveillance data by eliminating normal physiologic variants and obligatory shunt lesions. Classification also aggregated specific CHDs into groups appropriate for research and surveillance.

CONCLUSIONS

Application of a current, standard CHD nomenclature and classification system to cases in a birth defects surveillance database improves the specificity of cardiac diagnoses and allows for the development of a flexible case aggregation system for monitoring of CHD prevalence.

Twenty-year trends in diagnosis of life-threatening neonatal cardiovascular malformations

BACKGROUND

Infants with cardiovascular malformations are usually asymptomatic at birth. Earlier diagnosis is likely to improve outcome.

OBJECTIVE

To examine trends in the diagnosis of potentially life-threatening cardiovascular malformations.

METHODS

Ascertainment of all cardiovascular malformations diagnosed in infancy in the resident population of one English health region between 1985 and 2004. Infants with life-threatening cardiovascular malformations were all with hypoplastic left heart, pulmonary atresia with intact ventricular septum, transposition of the great arteries or interruption of the aortic arch; and those dying or undergoing operation within 28 days with coarctation of the aorta, aortic stenosis, pulmonary stenosis, tetralogy of Fallot, pulmonary atresia with ventricular septal defect or total anomalous pulmonary venous connection.

RESULTS

Cardiovascular malformations were diagnosed in infancy in 4444 of 690,215 live births (6.4 per 1000) and were potentially life threatening in 669 (15%). Overall, 55 (8%) were recognised prenatally, 416 (62%) postnatally before discharge from hospital, 168 (25%) in living infants after discharge and 30 (5%) after death. Antenatal diagnoses increased from 0 to around 20% and no case was first diagnosed after death in the past 6 years. However, the proportion going home without a diagnosis remains around 25%. Malformations most likely to remain undiagnosed at discharge were coarctation of the aorta (54%), interruption of the aortic arch (44%), aortic valve stenosis (40%) and total anomalous pulmonary venous connection (37%).

CONCLUSIONS

One in three infants with a potentially life-threatening cardiovascular malformation left hospital undiagnosed. Better early diagnosis is likely to be achieved by further improvements in antenatal diagnosis and more widespread use of routine pulse oximetry.