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Raza S, Aggarwal S, Jenkins P, Kharabish A, Anwer S, Cullington D, Jones J, Dua J, Papaioannou V, Ashrafi R, Moharem-Elgamal S. Coarctation of the Aorta: Diagnosis and Management. Diagnostics (Basel) 2023; 13:2189. [PMID: 37443581 DOI: 10.3390/diagnostics13132189] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 07/15/2023] Open
Abstract
Coarctation of the aorta (CoA) accounts for approximately 5-8% of all congenital heart defects. Depending on the severity of the CoA and the presence of associated cardiac lesions, the clinical presentation and age vary. Developments in diagnosis and management have improved outcomes in this patient population. Even after timely repair, it is important to regularly screen for hypertension. Patients with CoA require lifelong follow-up with a congenital heart disease specialist as these patients may develop recoarctation and complications at the repair site and remain at enhanced cardiovascular risk throughout their lifetime.
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Affiliation(s)
- Sadaf Raza
- Adult Congenital Heart Disease Centre, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
| | - Suneil Aggarwal
- Adult Congenital Heart Disease Centre, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
| | - Petra Jenkins
- Adult Congenital Heart Disease Centre, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
| | - Ahmed Kharabish
- Radiology Department, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
- Radiology Department, Al Kasr Al Aini, Old Cairo, Cairo 11562, Egypt
| | - Shehab Anwer
- Cardiology Department, University of Zurich, 8006 Zurich, Switzerland
| | - Damien Cullington
- Adult Congenital Heart Disease Centre, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
| | - Julia Jones
- Adult Congenital Heart Disease Centre, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
| | - Jaspal Dua
- Adult Congenital Heart Disease Centre, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
| | - Vasileios Papaioannou
- Adult Congenital Heart Disease Centre, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
| | - Reza Ashrafi
- Adult Congenital Heart Disease Centre, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
| | - Sarah Moharem-Elgamal
- Adult Congenital Heart Disease Centre, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
- Cardiology Department, National Heart Institute, Giza 11111, Egypt
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Haxel CS, Johnson JN, Hintz S, Renno MS, Ruano R, Zyblewski SC, Glickstein J, Donofrio MT. Care of the Fetus With Congenital Cardiovascular Disease: From Diagnosis to Delivery. Pediatrics 2022; 150:189887. [PMID: 36317976 DOI: 10.1542/peds.2022-056415c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The majority of congenital cardiovascular disease including structural cardiac defects, abnormalities in cardiac function, and rhythm disturbances can be identified prenatally using screening obstetrical ultrasound with referral for fetal echocardiogram when indicated. METHODS Diagnosis of congenital heart disease in the fetus should prompt assessment for extracardiac abnormalities and associated genetic abnormalities once maternal consent is obtained. Pediatric cardiologists, in conjunction with maternal-fetal medicine, neonatology, and cardiothoracic surgery subspecialists, should counsel families about the details of the congenital heart defect as well as prenatal and postnatal management. RESULTS Prenatal diagnosis often leads to increased maternal depression and anxiety; however, it decreases morbidity and mortality for many congenital heart defects by allowing clinicians the opportunity to optimize prenatal care and plan delivery based on the specific lesion. Changes in prenatal care can include more frequent assessments through the remainder of the pregnancy, maternal medication administration, or, in selected cases, in utero cardiac catheter intervention or surgical procedures to optimize postnatal outcomes. Delivery planning may include changing the location, timing or mode of delivery to ensure that the neonate is delivered in the most appropriate hospital setting with the required level of hospital staff for immediate postnatal stabilization. CONCLUSIONS Based on the specific congenital heart defect, prenatal echocardiogram assessment in late gestation can often aid in predicting the severity of postnatal instability and guide the medical or interventional level of care needed for immediate postnatal intervention to optimize the transition to postnatal circulation.
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Affiliation(s)
- Caitlin S Haxel
- The University of Vermont Children's Hospital, Burlington, Vermont
| | | | - Susan Hintz
- Stanford University, Lucille Salter Packard Children's Hospital, Palo Alto, California
| | - Markus S Renno
- University Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | | | - Julie Glickstein
- Columbia University Vagelos School of Medicine, Morgan Stanley Children's Hospital, New York, New York
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Akalın M, Demirci O, Yücel İK, Erol N. Fetal Echocardiographic Findings to Predict Early Surgical Repair and Neonatal Outcomes in Fetuses with Isolated Coarctation of the Aorta. Am J Perinatol 2022. [PMID: 35858644 DOI: 10.1055/a-1904-9519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE The aim of this study was to investigate fetal echocardiographic findings in predicting the need for surgical repair in fetuses with coarctation of the aorta (CoA) and to evaluate perinatal outcomes. STUDY DESIGN In this retrospective study, fetuses diagnosed with CoA in a tertiary center between January 2015 and June 2021 were analyzed. Fetal echocardiographic measurements and quantitative findings, middle cerebral artery (MCA) and umbilical artery (UA) Doppler indices, and perinatal outcomes were recorded. RESULTS A total of 57 fetuses with CoA were included in the study. In total, 51 (89.5%) pregnancies resulted in live births and 32 (62.8%) of the neonates underwent surgical repair. The left ventricle/right ventricle width ratio and aortic isthmus z-score were significantly lower in fetuses who underwent surgical repair (p = 0.004 0.001, respectively). Retrograde flow in the aortic isthmus (odds ratio [OR]:7.43; 95% confidence interval [CI]: 1.98-27.76), left-to-right foramen ovale shunt (OR: 8.50; 95% CI: 1.68-42.98), and ventricular septal defect (OR: 9.63; 95% CI: 1.90-48.74) were associated with the need for surgical repair. A new scoring system integrating these echocardiographic findings had 89% specificity and 54% sensitivity in predicting surgical repair. Fetal growth restriction rates, preterm birth rates, mean MCA pulsatility index (PI), and mean UA PI were similar in fetuses with and without surgical repair. CONCLUSION A scoring system integrating echocardiographic findings in fetuses with CoA may improve the prediction of surgical repair need. There is no evidence of an increased risk of FGR, preterm birth, and brain sparing effect in fetuses with CoA who require surgical repair. KEY POINTS · Coarctation of the aorta is one of the most difficult congenital heart defects to diagnose.. · A new scoring system may improve the prediction of surgical repair need.. · There is no increased risk of fetal growth restriction in fetuses requiring early surgical repair..
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Affiliation(s)
- Münip Akalın
- Department of Perinatology, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Oya Demirci
- Department of Perinatology, University of Health Sciences Zeynep Kamil Women's and Children's Disease Training and Research Hospital, Istanbul, Turkey
| | - İlker K Yücel
- Department of Pediatric Cardiology, University of Health Sciences Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Nurdan Erol
- Department of Pediatric Cardiology, University of Health Sciences Zeynep Kamil Women's and Children's Disease Training and Research Hospital, Istanbul, Turkey
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Wong J, Kohari K, Bahtiyar MO, Copel J. Impact of prenatally diagnosed congenital heart defects on outcomes and management. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:646-654. [PMID: 35543387 DOI: 10.1002/jcu.23219] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/13/2022] [Accepted: 04/26/2022] [Indexed: 06/14/2023]
Abstract
Fetal echocardiogram aids in prenatal identification of neonates at high risk for congenital heart defects (CHD). Prenatal detection rates for CHD have increased with improved ultrasound technology, the use of the early fetal echocardiography, and standardization of the performance of the fetal echocardiogram. Accurate prenatal detection of CHD, particularly complex CHD, is an important contributor to improved survival rates for patients with CHD. Early detection allows for families to choose whether or not to continue with pregnancy, referral to pediatric cardiology specialists for patient education, and delivery planning. Better psychosocial supports are needed for families with CHD.
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Affiliation(s)
- Jennifer Wong
- Section of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Katherine Kohari
- Section of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Mert Ozan Bahtiyar
- Section of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Joshua Copel
- Section of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut, USA
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Sethi N, Carpenter JL, Donofrio MT. Impact of perinatal management on neurodevelopmental outcomes in congenital heart disease. Semin Perinatol 2022; 46:151582. [PMID: 35418321 DOI: 10.1016/j.semperi.2022.151582] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
With advancements in cardiopulmonary bypass technique and perioperative care, there has been a progressive decline in mortality associated with neonatal surgical correction of congenital heart disease (CHD). Thus, there is now increased focus on improving neurodevelopmental outcomes in CHD survivors. While the cause of these neurodevelopmental impairments is multifactorial, there is increasing evidence that structural and functional cerebral abnormalities are present before cardiac corrective repair. This suggests that in addition to patient specific risk factors, underlying cardiac physiology and clinical hemodynamics are critical to brain health and development. Prenatal diagnosis of CHD and subsequent optimization of perinatal care may therefore be important modifiable factors for long-term neurodevelopmental outcome. This article reviews the impact that prenatal diagnosis of CHD has on perinatal care and the preoperative clinical status of a neonate, as well as the potential influence this may have on lessening the degree of cerebral injury and long-term neurodevelopmental impairments.
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Affiliation(s)
- Neeta Sethi
- Duke Children's Pediatric and Congenital Heart Center, Duke University Medical Center, Durham, NC, USA
| | - Jessica L Carpenter
- Division of Pediatric Neurology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Mary T Donofrio
- Division of Cardiology, Children's National Hospital, Washington, DC, USA.
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Houshmandi MM, Eckersley L, Fruitman D, Mills L, Power A, Hornberger LK. Fetal Diagnosis is Associated with Improved Perioperative Condition of Neonates Requiring Surgical Intervention for Coarctation. Pediatr Cardiol 2021; 42:1504-1511. [PMID: 33988733 DOI: 10.1007/s00246-021-02634-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 05/05/2021] [Indexed: 11/28/2022]
Abstract
To define the relative importance of fetal diagnosis and comorbidities in severity of preoperative compromise, outcomes and hospitalization in neonatal coarctation of the aorta (CoA). Retrospective comparison of preoperative condition and postoperative course of neonates prenatally (PreDx n = 48) or postnatally diagnosed (PostDx n = 67) with CoA. Congenital and non-congenital comorbidities were adjusted for. Postnatal diagnosis was associated with preoperative mortality (n = 2), and severe acidosis (lactate > 5 mM or pH < 7.20) on multivariate analysis (OR 4.2 (1.3-14.4, p = 0.02), with extracardiac congenital anomalies also a risk factor (OR 3.2 (1.03-10, p = 0.044). Median age at operation was delayed in the PostDx group (PreDx 6.5 days (IQR 4-9) vs PostDx 10 days (IQR 6-17)). Only comorbid left heart disease and extracardiac congenital anomalies were associated with prolonged total length of hospital stay. Prenatal diagnosis is the major adjustable risk factor affecting preoperative condition in critical CoA but does not reduce length of stay.
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Affiliation(s)
- Mohammad Mehdi Houshmandi
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Luke Eckersley
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada. .,Pediatric Cardiology 4C2, Stollery Children's Hospital, 8440 112th Street, Edmonton, AB, T6G2B7, Canada.
| | - Deborah Fruitman
- Division of Cardiology, Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Lindsay Mills
- Division of Cardiology, Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Alyssa Power
- Division of Cardiology, Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Lisa K Hornberger
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Department of Obstetrics & Gynecology, Women's & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada.,Pediatric Cardiology 4C2, Stollery Children's Hospital, 8440 112th Street, Edmonton, AB, T6G2B7, Canada
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Lloyd DF, van Poppel MP, Pushparajah K, Vigneswaran TV, Zidere V, Steinweg J, van Amerom JF, Roberts TA, Schulz A, Charakida M, Miller O, Sharland G, Rutherford M, Hajnal JV, Simpson JM, Razavi R. Analysis of 3-Dimensional Arch Anatomy, Vascular Flow, and Postnatal Outcome in Cases of Suspected Coarctation of the Aorta Using Fetal Cardiac Magnetic Resonance Imaging. Circ Cardiovasc Imaging 2021; 14:e012411. [PMID: 34187165 PMCID: PMC8300852 DOI: 10.1161/circimaging.121.012411] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/14/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Identifying fetuses at risk of severe neonatal coarctation of the aorta (CoA) can be lifesaving but is notoriously challenging in clinical practice with a high rate of false positives. Novel fetal 3-dimensional and phase-contrast magnetic resonance imaging (MRI) offers an unprecedented means of assessing the human fetal cardiovascular system before birth. We performed detailed MRI assessment of fetal vascular morphology and flows in a cohort of fetuses with suspected CoA, correlated with the need for postnatal intervention. METHODS Women carrying a fetus with suspected CoA on echocardiography were referred for MRI assessment between 26 and 36 weeks of gestation, including high-resolution motion-corrected 3-dimensional volumes of the fetal heart and phase-contrast flow sequences gated with metric optimized gating. The relationship between aortic geometry and vascular flows was then analyzed and compared with postnatal outcome. RESULTS Seventy-two patients (51 with suspected fetal CoA and 21 healthy controls) underwent fetal MRI with motion-corrected 3-dimensional vascular reconstructions. Vascular flow measurements from phase-contrast sequences were available in 53 patients. In the CoA group, 25 of 51 (49%) required surgical repair of coarctation after birth; the remaining 26 of 51 (51%) were discharged without neonatal intervention. Reduced blood flow in the fetal ascending aorta and at the aortic isthmus was associated with increasing angulation (P=0.005) and proximal displacement (P=0.006) of the isthmus and was seen in both true positive and false positive cases. A multivariate logistic regression model including aortic flow and isthmal displacement explained 78% of the variation in outcome and correctly predicted the need for intervention in 93% of cases. CONCLUSIONS Reduced blood flow though the left heart is associated with important configurational changes at the aortic isthmus in fetal life, predisposing to CoA when the arterial duct closes after birth. Novel fetal MRI techniques may have a role in both understanding and accurately predicting severe neonatal CoA.
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Affiliation(s)
- David F.A. Lloyd
- School of Imaging Sciences and Biomedical Engineering, King’s College London, United Kingdom (D.F.A.L., M.P.M.v.P., K.P., J.S., J.F.P.v.A., T.R., A.S., M.R., J.H., R.R.)
- Department of Congenital Heart Disease, Evelina London Children’s Hospital, United Kingdom (D.F.A.L., K.P., T.V.V., V.Z., M.C., O.M., G.S., J.M.S., R.R.)
| | - Milou P.M. van Poppel
- School of Imaging Sciences and Biomedical Engineering, King’s College London, United Kingdom (D.F.A.L., M.P.M.v.P., K.P., J.S., J.F.P.v.A., T.R., A.S., M.R., J.H., R.R.)
| | - Kuberan Pushparajah
- School of Imaging Sciences and Biomedical Engineering, King’s College London, United Kingdom (D.F.A.L., M.P.M.v.P., K.P., J.S., J.F.P.v.A., T.R., A.S., M.R., J.H., R.R.)
- Department of Congenital Heart Disease, Evelina London Children’s Hospital, United Kingdom (D.F.A.L., K.P., T.V.V., V.Z., M.C., O.M., G.S., J.M.S., R.R.)
| | - Trisha V. Vigneswaran
- Department of Congenital Heart Disease, Evelina London Children’s Hospital, United Kingdom (D.F.A.L., K.P., T.V.V., V.Z., M.C., O.M., G.S., J.M.S., R.R.)
| | - Vita Zidere
- Department of Congenital Heart Disease, Evelina London Children’s Hospital, United Kingdom (D.F.A.L., K.P., T.V.V., V.Z., M.C., O.M., G.S., J.M.S., R.R.)
| | - Johannes Steinweg
- School of Imaging Sciences and Biomedical Engineering, King’s College London, United Kingdom (D.F.A.L., M.P.M.v.P., K.P., J.S., J.F.P.v.A., T.R., A.S., M.R., J.H., R.R.)
| | - Joshua F.P. van Amerom
- School of Imaging Sciences and Biomedical Engineering, King’s College London, United Kingdom (D.F.A.L., M.P.M.v.P., K.P., J.S., J.F.P.v.A., T.R., A.S., M.R., J.H., R.R.)
| | - Thomas A. Roberts
- School of Imaging Sciences and Biomedical Engineering, King’s College London, United Kingdom (D.F.A.L., M.P.M.v.P., K.P., J.S., J.F.P.v.A., T.R., A.S., M.R., J.H., R.R.)
| | - Alexander Schulz
- School of Imaging Sciences and Biomedical Engineering, King’s College London, United Kingdom (D.F.A.L., M.P.M.v.P., K.P., J.S., J.F.P.v.A., T.R., A.S., M.R., J.H., R.R.)
| | - Marietta Charakida
- Department of Congenital Heart Disease, Evelina London Children’s Hospital, United Kingdom (D.F.A.L., K.P., T.V.V., V.Z., M.C., O.M., G.S., J.M.S., R.R.)
| | - Owen Miller
- Department of Congenital Heart Disease, Evelina London Children’s Hospital, United Kingdom (D.F.A.L., K.P., T.V.V., V.Z., M.C., O.M., G.S., J.M.S., R.R.)
| | - Gurleen Sharland
- Department of Congenital Heart Disease, Evelina London Children’s Hospital, United Kingdom (D.F.A.L., K.P., T.V.V., V.Z., M.C., O.M., G.S., J.M.S., R.R.)
| | - Mary Rutherford
- School of Imaging Sciences and Biomedical Engineering, King’s College London, United Kingdom (D.F.A.L., M.P.M.v.P., K.P., J.S., J.F.P.v.A., T.R., A.S., M.R., J.H., R.R.)
| | - Joseph V. Hajnal
- School of Imaging Sciences and Biomedical Engineering, King’s College London, United Kingdom (D.F.A.L., M.P.M.v.P., K.P., J.S., J.F.P.v.A., T.R., A.S., M.R., J.H., R.R.)
| | - John M. Simpson
- Department of Congenital Heart Disease, Evelina London Children’s Hospital, United Kingdom (D.F.A.L., K.P., T.V.V., V.Z., M.C., O.M., G.S., J.M.S., R.R.)
| | - Reza Razavi
- School of Imaging Sciences and Biomedical Engineering, King’s College London, United Kingdom (D.F.A.L., M.P.M.v.P., K.P., J.S., J.F.P.v.A., T.R., A.S., M.R., J.H., R.R.)
- Department of Congenital Heart Disease, Evelina London Children’s Hospital, United Kingdom (D.F.A.L., K.P., T.V.V., V.Z., M.C., O.M., G.S., J.M.S., R.R.)
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Zhang X, He S, Liu Y, Zhong J, Sun Y, Zheng M, Gui J, Wang R, Feng B, Mo J, Jian M, Liu C, Liang Y. The significance of an integrated management mode of prenatal diagnosis-postnatal treatment for critical congenital heart disease in newborns. Cardiovasc Diagn Ther 2021; 11:447-456. [PMID: 33968622 DOI: 10.21037/cdt-20-892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Congenital heart disease (CHD) is the most common congenital defect in human beings. The purpose of this article is to investigate impact of an integrated management mode of 'prenatal diagnosis-postnatal treatment' on birth, surgery, prognosis and complications associated with critical CHD (CCHD) in newborns. Methods A retrospective analysis of the medical records of newborns diagnosed with CCHD were divided into two groups: prenatal diagnosis and postnatal diagnosis. The demographics, clinical characteristics, surgical status, prognosis and complications of the two groups were compared and the differences identified. Results Among the 290 newborns with CCHD, 97 (33.4%) were prenatally diagnosed and 193 (66.6%) were postnatally diagnosed. Newborns in the prenatal diagnostic group were hospitalized immediately after birth, whereas the median age of admission was 6.00 (3.00-12.00) days in postnatal diagnostic group, P=0.000. In terms of postnatal symptoms and signs, the incidence of anhelation, cyanosis and cardiac murmur was higher in the postnatal diagnostic group. The rates of preoperative intubation, postoperative open chest exploration and treatment abandonment were higher in the postnatal diagnostic group. The postnatal diagnostic group was more prone to postoperative complications, such as pneumonia and hypoxic-ischemic brain damage. The preoperative mortality [0 (0.0%) vs. 12 (6.2%), P=0.028] in the prenatal diagnostic group was lower than that in the postnatal diagnostic group. And the one-year survival rate of the prenatal diagnostic group was higher (log-rank test P=0.034). Conclusions The integrated management mode of prenatal diagnosis-postnatal treatment can improve postnatal symptoms, reduces complications, reduces preoperative mortality and increases one-year survival rates in newborns with CCHD.
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Affiliation(s)
- Xiaohui Zhang
- Department of NICU, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shaoru He
- Department of NICU, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangzhou, China
| | - Yumei Liu
- Department of NICU, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jing Zhong
- Department of NICU, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yunxia Sun
- Department of NICU, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Manli Zheng
- Department of NICU, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Juan Gui
- Department of NICU, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ruixi Wang
- Department of NICU, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Bowen Feng
- Department of NICU, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jianling Mo
- Department of NICU, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Minqiao Jian
- Department of NICU, Guangdong Provincial People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Caisheng Liu
- Department of NICU, Guangdong Provincial People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Yijing Liang
- Department of NICU, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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9
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Han B, Tang Y, Qu X, Deng C, Wang X, Li J. Comparison of the 1-year survival rate in infants with congenital heart disease diagnosed by prenatal and postnatal ultrasound: A retrospective study. Medicine (Baltimore) 2021; 100:e23325. [PMID: 33530157 PMCID: PMC7850709 DOI: 10.1097/md.0000000000023325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 10/21/2020] [Indexed: 01/05/2023] Open
Abstract
The impact of prenatal diagnosis on the survival outcome of infants with congenital heart disease (CHD) is still unclear. This study aimed to compare the 1-year survival rate between the prenatally and postnatally diagnosed infants with CHDs.A single-center population-based retrospective cohort study was performed on data from all infants diagnosed with CHD born between January 1998 and December 2017. Among infants with isolated CHDs, the 1-year Kaplan-Meier survival probabilities for prenatal and postnatal diagnosis were estimated. Cox proportional hazard ratios were adjusted for critical CHD (CCHD) status and gestational age.A total of 424 (40 prenatally and 384 postnatally) diagnosed infants with CHDs were analyzed. Compared with non-CCHDs, infants with CCHDs were more likely to be prenatally diagnosed (55.0% vs 18.0%; P < .001). Among the 312 infants with isolated CHDs, the 1-year survival rate for the prenatally diagnosed was significantly lower than postnatally diagnosed (77.1% vs 96.1%; P < .001). For isolated CCHDs, the 1-year survival rate for the prenatally diagnosed was significantly lower than postnatally diagnosed (73.4% vs 90.0%; P < .001). The 1-year survival rate was increased with the increase of age at diagnosis. Among infants with isolated CHDs and CCHDs, the adjusted hazard ratios for 1-year mortality rates for the prenatally versus postnatally diagnosed were 2.554 (95% confidence interval [CI], 1.790, 3.654; P < .001) and 2.538 (95% CI: 1.796, 3.699; P < .001), respectively.Prenatal diagnosis is associated with lower 1-year survival rate for infants with isolated CCHDs. This could probably due to variation in the disease severity among the CCHD subtypes.
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Affiliation(s)
- Bing Han
- Department of Ultrasound, Qilu Hospital of Shandong University, Jinan
- Department of Ultrasound, Shandong Weihai Municipal Hospital
| | - Yi Tang
- Department of Ultrasound, The Affiliated Weihai Second Municipal Hospital of Qingdao University, Weihai, Shandong, China
| | - Xueling Qu
- Department of Ultrasound, Shandong Weihai Municipal Hospital
| | - Chuanjun Deng
- Department of Ultrasound, Shandong Weihai Municipal Hospital
| | - Xing Wang
- Department of Ultrasound, Shandong Weihai Municipal Hospital
| | - Jie Li
- Department of Ultrasound, Qilu Hospital of Shandong University, Jinan
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10
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Bak GS, Shaffer BL, Madriago E, Allen A, Kelly B, Caughey AB, Pereira L. Detection of fetal cardiac anomalies: cost-effectiveness of increased number of cardiac views. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:758-767. [PMID: 31945242 DOI: 10.1002/uog.21977] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 12/22/2019] [Accepted: 12/31/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To compare the recommended three-view fetal heart screening method to detect major congenital heart disease (CHD) with more elaborate screening strategies to determine the cost-effective strategy in unselected (low-risk) pregnancies. METHODS A decision-analytic model was designed to compare four screening strategies to identify fetuses with major CHD in a theoretical cohort of 4 000 000 births in the USA. The four strategies were: (1) three views: four-chamber view (4CV) and views of the left (LVOT) and right (RVOT) ventricular outflow tracts; (2) five views: 4CV, LVOT, RVOT and longitudinal views of the ductal arch and aortic arch; (3) five axial views: 4CV, LVOT, RVOT, three-vessel (3V) view and three-vessels-and-trachea view; and (4) six views: 4CV, LVOT, RVOT and 3V views and longitudinal views of the ductal arch and aortic arch. Outcomes related to neonatal mortality and neurodevelopmental disability were evaluated. The analysis was performed from a healthcare-system perspective, with a cost-effectiveness willingness-to-pay threshold set at $100 000 per quality-adjusted life year (QALY). Baseline analysis, one-way sensitivity analysis and Monte-Carlo simulation were performed. RESULTS In our baseline model, screening with five axial views was the optimal strategy, detecting 3520 more CHDs, and resulting in 259 fewer children with neurodevelopmental disability, 40 fewer neonatal deaths and only slightly higher costs, compared with screening with the currently recommended three views. Screening with six views was more effective, but also cost considerably more, compared with screening with five axial views, and had an incremental cost of $490 023/QALY, which was over the willingness-to-pay threshold. The five-view strategy was dominated by the other three strategies, i.e. it was more costly and less effective in comparison. The data were robust when tested with Monte-Carlo and one-way sensitivity analysis. CONCLUSION Although current guidelines recommend a minimum of three views for detecting CHD during the mid-trimester anatomy scan, screening with five axial views is a cost-effective strategy that may lead to improved outcome compared with three-view screening. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- G S Bak
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
| | - B L Shaffer
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Oregon Health & Science University, Portland, OR, USA
| | - E Madriago
- Department of Pediatrics, Division of Pediatric Cardiology, Oregon Health & Science University, Portland, OR, USA
| | - A Allen
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Oregon Health & Science University, Portland, OR, USA
| | - B Kelly
- Department of Pediatrics, Division of Pediatric Cardiology, Oregon Health & Science University, Portland, OR, USA
| | - A B Caughey
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Oregon Health & Science University, Portland, OR, USA
| | - L Pereira
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Oregon Health & Science University, Portland, OR, USA
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11
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Qiu X, Weng Z, Liu M, Chen X, Wu Q, Ling W, Ma H, Huang H, Lin Y. Prenatal diagnosis and pregnancy outcomes of 1492 fetuses with congenital heart disease: role of multidisciplinary-joint consultation in prenatal diagnosis. Sci Rep 2020; 10:7564. [PMID: 32371943 PMCID: PMC7200674 DOI: 10.1038/s41598-020-64591-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 04/20/2020] [Indexed: 01/26/2023] Open
Abstract
Early diagnosis of congenital heart disease (CHD) can improve the prognosis of neonates with CHD. We retrospectively evaluated the value of prenatal diagnosis of CHD by comparing the pregnancy outcomes. Prenatal diagnosis of CHD was established by echocardiographic evaluation of fetal heart. Amniotic fluid and/or cord blood genetic examination, pathological anatomy, casting specimen, and/or multidisciplinary-joint consultation (MDJC) were performed. A total of 1492 fetuses with CHD were diagnosed by prenatal echocardiography from 67834 pregnant women. There were 445, 236, 583, and 228 cases in groups A (simple CHD), B (simple CHD plus extra-cardiac abnormality), C (complex CHD), and D (complex CHD plus extra-cardiac abnormality), respectively. The pregnancy continuation rate in the four groups was 98.67%, 85.71%, 67.65%, and 36.84%, respectively (P < 0.001). The pregnancy termination rate for fetal CHD with extra-cardiac abnormalities was significantly higher than that for fetuses with only CHD (81.24% vs. 53.6%, P < 0.05). Prenatal genetic test revealed chromosomal abnormalities in 20.43% of fetuses with CHD. MDJC significantly decreased the pregnancy termination rate. In 88 cases, the original decision to terminate the pregnancy was changed after consultation and the pregnancy was continued. Of these, 87 cases culminated in live births; 65 of these children had better prognosis. Nine-segment sequential segment analysis method for prenatal fetal echocardiography was compared with the results of pathological anatomy, cast specimen, postoperative diagnosis, and postnatal ultrasound. The accuracy of prenatal ultrasound for diagnosis of fetal complex CHD and fetal simple CHD was 90.5–91.66% and 98.6%, respectively. Prenatal ultrasound is still the most effective method for fetal CHD diagnosis.
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Affiliation(s)
- Xiuqing Qiu
- Department of obstetrics and gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, 18 Daoshan Road, Gulou District, Fuzhou, Fujian, 350001, People's Republic of China
| | - Zongjie Weng
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, 18 Daoshan Road, Gulou District, Fuzhou, Fujian, 350001, People's Republic of China
| | - Min Liu
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, 18 Daoshan Road, Gulou District, Fuzhou, Fujian, 350001, People's Republic of China
| | - Xiujuan Chen
- Department of obstetrics and gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, 18 Daoshan Road, Gulou District, Fuzhou, Fujian, 350001, People's Republic of China
| | - Qiumei Wu
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, 18 Daoshan Road, Gulou District, Fuzhou, Fujian, 350001, People's Republic of China
| | - Wen Ling
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, 18 Daoshan Road, Gulou District, Fuzhou, Fujian, 350001, People's Republic of China
| | - Hong Ma
- Department of pathology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, 18 Daoshan Road, Gulou District, Fuzhou, Fujian, 350001, People's Republic of China
| | - Hailong Huang
- Department of prenatal diagnosis center, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, 18 Daoshan Road, Gulou District, Fuzhou, Fujian, 350001, People's Republic of China
| | - Yuan Lin
- Department of obstetrics and gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, 18 Daoshan Road, Gulou District, Fuzhou, Fujian, 350001, People's Republic of China.
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12
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Ngeow AJH, Tan MG, Choo JTL, Tan TH, Tan WC, Chan DKL. Screening for congenital heart disease in a Singapore neonatal unit. Singapore Med J 2019; 62:341-346. [PMID: 31820009 DOI: 10.11622/smedj.2019167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Congenital heart disease (CHD) is a leading cause of infant mortality. The aim of this study was to evaluate the efficacy of a neonatal screening programme for CHD before the introduction of pulse oximetry. METHODS This was a retrospective review of live births in the period 2003-2012. Cases of CHD were detected through prenatal ultrasonography and/or postnatal examination, and confirmed using two-dimensional echocardiography. Data was rigorously checked against multiple sources. The antenatal detection rate, sensitivity, specificity, predictive values and likelihood ratios of the screening programme were analysed for all cases of CHD and critical CHD. RESULTS The incidence of CHD was 9.7 per 1,000 live births. The commonest CHD was ventricular septal defect (54.8%). The antenatal detection rate was three times higher in the critical CHD group (64.0%) compared to the group as a whole (21.1%). The sensitivity and specificity of screening was 64.5% and 99.7% for all CHD, and 92.9% and 99.1% for the critical CHD group, respectively. The positive likelihood ratio was 215 and 103, while the negative likelihood ratio was 0.36 and 0.07 for all CHD and critical CHD, respectively. CONCLUSION The CHD screening programme had excellent specificity but limited sensitivity. The high positive likelihood ratios indicate that where sufficient risk factors for CHD are present, a positive result effectively confirms the presence of CHD. The low negative likelihood ratio for critical CHD indicates that, where prior suspicion for critical CHD is low, a negative result is reassuring.
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Affiliation(s)
- Alvin Jia-Hao Ngeow
- Department of Neonatal and Developmental Medicine, Singapore General Hospital, Singapore
| | - Mary Grace Tan
- Department of Neonatal and Developmental Medicine, Singapore General Hospital, Singapore
| | - Jonathan Tze-Liang Choo
- Cardiology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore
| | - Teng-Hong Tan
- Cardiology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore
| | - Wei Ching Tan
- Department of Obstetrics and Gynaecology, Singapore General Hospital, Singapore
| | - Daisy Kwai-Lin Chan
- Department of Neonatal and Developmental Medicine, Singapore General Hospital, Singapore
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13
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Janicki MB, Fernandez CG, Wakefield D, Shepherd JP, Figueroa R. Improving fetal congenital heart disease screening using a checklist-based approach. Prenat Diagn 2019; 40:223-231. [PMID: 31652332 DOI: 10.1002/pd.5581] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/19/2019] [Accepted: 09/20/2019] [Indexed: 11/07/2022]
Abstract
To determine if using a checklist of specific ultrasound image criteria to screen the fetal heart improves the cardiac exam completion rate, defined as the ability to classify the heart as normal or abnormal. This is a retrospective cohort study of patients with singleton pregnancies who underwent a fetal anatomy survey between 18 and 28 weeks' gestation. A checklist was used from 1 September 2015 to 31 March 2016 to categorize exams as complete-normal, complete-abnormal, or incomplete. Performance was compared with a 7-month period prior to checklist introduction (1 December 2014 to 30 June 2015). Checklist utilization improved the cardiac exam completion rate by 8.9%. With the checklist, 1083 of 1202 exams (90.1%) were completed compared to 987 of 1193 (82.7%) pre-checklist, P < .001. We did not detect a change in cases classified as abnormal and referred for echocardiography: 25 (2.1%) with the checklist and 16 (1.3%) pre-checklist, P = .16. We did not detect more congenital heart disease (CHD), 12 (1.0%) with checklist screening, 5 (0.4%) pre-checklist, P = .14. Critical CHD was not missed in either group. Using the checklist improved the cardiac exam completion rate. There was no change in congenital heart disease detection.
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Affiliation(s)
- Mary B Janicki
- Department of Obstetrics and Gynecology, Saint Francis Hospital and Medical Center/Trinity Health of New England, Hartford, Connecticut
| | - Christopher G Fernandez
- Department of Obstetrics and Gynecology, Saint Francis Hospital and Medical Center/Trinity Health of New England, Hartford, Connecticut
| | - Dorothy Wakefield
- Department of Obstetrics and Gynecology, Saint Francis Hospital and Medical Center/Trinity Health of New England, Hartford, Connecticut.,UConn Center on Aging, UCONN Health Center, Farmington, Connecticut
| | - Jonathan P Shepherd
- Department of Obstetrics and Gynecology, Saint Francis Hospital and Medical Center/Trinity Health of New England, Hartford, Connecticut
| | - Reinaldo Figueroa
- Department of Obstetrics and Gynecology, Saint Francis Hospital and Medical Center/Trinity Health of New England, Hartford, Connecticut
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14
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Richards B, Freel L, Stiver C, Texter K, Cua CL. Serial fetal echocardiograms in hypoplastic left heart syndrome fetuses: Does it affect immediate post-natal care? Int J Cardiol 2019; 301:80-84. [PMID: 31785958 DOI: 10.1016/j.ijcard.2019.11.119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 09/16/2019] [Accepted: 11/15/2019] [Indexed: 02/04/2023]
Abstract
Guidelines recommend serial fetal echocardiograms when congenital heart disease is diagnosed. Necessity, timing, and frequency of serial echocardiograms are based on clinical judgment. Fetuses with hypoplastic left heart syndrome (fHLHS) may undergo multiple studies prior to birth. Goal of this study was to determine if the need for unexpected, emergent cardiac interventions were required immediately post-natally, if there were no concerns on initial fetal echocardiogram. METHODS Fetal echocardiograms performed between 2006 and 2018 on fHLHS were reviewed. fHLHS were excluded if initial fetal scan documented any other concerns. Unexpected, emergent catheterization or surgical procedures, intubation, or inotropic support within the first 72 h of life were recorded. RESULTS Total of 80 fHLHS were reviewed. Thirty-two fHLHS were excluded because of concerns on the initial fetal echocardiogram. Sixteen fHLHS had one scan, 14 had two scans, 13 had three scans, and 5 had four scans. No patient underwent an unexpected, emergent catheterization or surgical procedure within the first 72 h of life. Seven patients required intubation and 1 patient received inotropic support within the first 72 h of life. CONCLUSION No fHLHS underwent an unexpected, emergent catheterization or surgical procedure within the first 72 h of life if the initial fetal echocardiogram had no significant concerns. Medical interventions did occur immediately post-natally, but could not be directly attributed to a missed fetal cardiac diagnosis. Frequent serial fetal echocardiograms may not necessarily be needed to predict the need for an unexpected, emergent procedure.
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Affiliation(s)
- Bernadette Richards
- Heart Center, Nationwide Children's Hospital, Columbus, OH, United States of America
| | - Lesley Freel
- Heart Center, Nationwide Children's Hospital, Columbus, OH, United States of America
| | - Corey Stiver
- Heart Center, Nationwide Children's Hospital, Columbus, OH, United States of America
| | - Karen Texter
- Heart Center, Nationwide Children's Hospital, Columbus, OH, United States of America
| | - Clifford L Cua
- Heart Center, Nationwide Children's Hospital, Columbus, OH, United States of America.
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15
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Parental reactions, distress, and sense of coherence after prenatal versus postnatal diagnosis of complex congenital heart disease. Cardiol Young 2019; 29:1328-1334. [PMID: 31522698 DOI: 10.1017/s1047951119001781] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION A diagnosis of congenital heart disease (CHD) in offspring triggers psychological distress in parents. Results of previous studies have been inconsistent regarding the psychological impact of a prenatal versus a postnatal diagnosis. The aim of this study was to evaluate the influence of the time of diagnosis on levels of parental distress. METHODS Pregnant women and their partners with a fetus diagnosed with complex CHD, parents of children with postnatally diagnosed CHD, and pregnant women and their partners with uncomplicated pregnancies were invited to participate. Data were collected during pregnancy and 2-6 months after delivery using the Hospital Anxiety and Depression Scale, sense of coherence, life satisfaction, and Dyadic Adjustment Scale. RESULTS During pregnancy, the prenatal group scored lower sense of coherence compared to controls (p=0.044). Postnatally the prenatal group scored lower on sense of coherence compared to the postnatal group and controls (p=0.001; p=0.001). Postnatally, the prenatal and postnatal groups had higher levels of anxiety compared to controls (p=0.025; p=0.0003). Life satisfaction was lower in the prenatal group compared to that in the postnatal group and in controls (p=0.000; p=0.0004). CONCLUSION Parents with a prenatal diagnosis of CHD in offspring report a low sense of coherence already during pregnancy which decreased further at follow-up. The same group reported a lower satisfaction with life compared to parents of a child with postnatal diagnosis of CHD and parents of a healthy child. This motivates further efforts to improve counselling and support during pregnancy and for parents after a prenatal diagnosis.
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16
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Cloete E, Bloomfield FH, Sadler L, de Laat MWM, Finucane AK, Gentles TL. Antenatal Detection of Treatable Critical Congenital Heart Disease Is Associated with Lower Morbidity and Mortality. J Pediatr 2019; 204:66-70. [PMID: 30292491 DOI: 10.1016/j.jpeds.2018.08.056] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 08/06/2018] [Accepted: 08/22/2018] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To establish the impact that timing of diagnosis and place of birth have on neonatal outcomes in those with readily treatable critical congenital heart disease. STUDY DESIGN This was a population-based study with a complete national cohort of live-born infants with transposition of the great arteries and aortic arch obstruction in New Zealand between 2006 and 2014. Timing of diagnosis, place of birth, survival to surgery, in-hospital events, and neonatal mortality were reviewed. Live births with a gestation of ≥35 weeks and without associated major extracardiac anomalies were included for analysis. RESULTS A total of 166 live-born infants with transposition of the great arteries and 87 with aortic arch obstruction were included. Antenatal detection increased from 32% in the first 3 years to 47% in the last 3 years (P = .05). During the same period, neonatal mortality decreased from 9% to 1% (P = .02). No deaths occurred after surgical intervention. An antenatal diagnosis was associated with decreased mortality (1/97 [1%] vs 11/156 [7%]; P = .03) and birth outside the surgical center was associated with increased risk of mortality (11/147 [7%] vs 1/106 [1%]; P = .02). Those with an antenatal diagnosis required fewer hours of mechanical ventilation (P = .02) and had shorter durations of hospital stay (P = .05) compared with those diagnosed >48 hours after birth. CONCLUSIONS The mortality risk for transposition of the great arteries and critical aortic arch obstruction is greatest before cardiac surgery. Improved antenatal detection allowing delivery at a surgical center is associated with reduced mortality.
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Affiliation(s)
- Elza Cloete
- Liggins Institute, University of Auckland, Auckland, New Zealand.
| | | | - Lynn Sadler
- Women's Health, Auckland City Hospital, Auckland, New Zealand
| | | | - A Kirsten Finucane
- Pediatric and Congenital Cardiac Services, Starship Children's Hospital, Auckland, New Zealand
| | - Thomas L Gentles
- Pediatric and Congenital Cardiac Services, Starship Children's Hospital, Auckland, New Zealand
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17
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Chakraborty A, Gorla SR, Swaminathan S. Impact of prenatal diagnosis of complex congenital heart disease on neonatal and infant morbidity and mortality. Prenat Diagn 2018; 38:958-963. [DOI: 10.1002/pd.5351] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 08/22/2018] [Accepted: 08/24/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Abhishek Chakraborty
- Division of Pediatric Cardiology, Department of Pediatrics; Jackson Memorial Hospital/University of Miami, Miller School of Medicine; Miami Florida
| | - Sudheer R. Gorla
- Division of Pediatric Cardiology, Department of Pediatrics; Jackson Memorial Hospital/University of Miami, Miller School of Medicine; Miami Florida
| | - Sethuraman Swaminathan
- Division of Pediatric Cardiology, Department of Pediatrics; Jackson Memorial Hospital/University of Miami, Miller School of Medicine; Miami Florida
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18
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Power A, Nettel-Aguirre A, Fruitman D. Fetal Right Ventricular Prominence: Associated Postnatal Abnormalities and Coarctation Clinical Prediction Tool. Pediatr Cardiol 2017; 38:1471-1477. [PMID: 28741093 DOI: 10.1007/s00246-017-1686-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 07/11/2017] [Indexed: 11/26/2022]
Abstract
Fetal right ventricular (RV) prominence is a known indicator of possible left-sided structural heart disease with a low positive predictive value for aortic coarctation. There is a paucity of data on identifying which fetuses with RV prominence will have postnatal arch obstruction. Our study objectives were to create a clinical prediction tool for coarctation and to describe the diagnostic outcomes of our cohort with fetal RV prominence. We performed a retrospective review of patients referred with fetal RV prominence from January 2009 to October 2015. Recorded fetal echocardiographic variables included gestational age, semilunar and atrioventricular valve dimensions, left and right ventricular mid-cavitary dimensions, foramen ovale and aortic arch flow direction, and isthmal diameter. Postnatal cardiac and non-cardiac diagnoses were documented. We performed descriptive analysis for postnatal outcomes and classification tree analysis to create a clinical prediction tool. Eighty-eight patients were reviewed; 58 (66%) had abnormal postnatal echocardiograms, 45 (51%) had left-sided lesions, including 26 (30%) with coarctation, and 6 (7%) had pulmonary hypertension. Our clinical prediction tool employs gestational age, RV mid-cavitary dimension z-score, and isthmal diameter z-score to predict coarctation with 85% accuracy, 95% confidence interval [75.3, 92.4%]. Our model correctly classified 45/54 non-coarctation and 19/21 coarctation cases, with 90% sensitivity and 83% specificity. Developing an accurate prediction tool for coarctation in cases of fetal RV prominence is an important first step in improving our management of these challenging cases.
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Affiliation(s)
- Alyssa Power
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, 2500 University Drive NW, Calgary, AB, T2N 1N4, Canada
| | - Alberto Nettel-Aguirre
- Alberta Children's Hospital, 2888 Shaganappi Trail NW, Calgary, AB, T3B 6A8, Canada
- Department of Pediatrics and Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 2500 University Drive NW, Calgary, AB, T2N 1N4, Canada
- Faculty of Kinesiology, University of Calgary, 2500 University Drive NW, Calgary, AB, T2N 1N4, Canada
- Alberta Children's Hospital Research Institute, Alberta Children's Hospital, 2888 Shaganappi Trail NW, Calgary, AB, T3B 6A8, Canada
| | - Deborah Fruitman
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, 2500 University Drive NW, Calgary, AB, T2N 1N4, Canada.
- Department of Pediatrics, Section of Cardiology, Alberta Children's Hospital, 2888 Shaganappi Trail NW, Calgary, AB, T3B 6A8, Canada.
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19
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Thakur V, Munk N, Mertens L, Nield LE. Does prenatal diagnosis of hypoplastic left heart syndrome make a difference? - A systematic review. Prenat Diagn 2016; 36:854-63. [DOI: 10.1002/pd.4873] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 06/27/2016] [Accepted: 07/04/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Varsha Thakur
- Labatt Family Heart Centre, Department of Paediatrics, The Hospital for Sick Children; University of Toronto; Toronto Canada
| | - Nadia Munk
- Labatt Family Heart Centre, Department of Paediatrics, The Hospital for Sick Children; University of Toronto; Toronto Canada
| | - Luc Mertens
- Labatt Family Heart Centre, Department of Paediatrics, The Hospital for Sick Children; University of Toronto; Toronto Canada
| | - Lynne E. Nield
- Labatt Family Heart Centre, Department of Paediatrics, The Hospital for Sick Children; University of Toronto; Toronto Canada
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20
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Li YF, Zhou KY, Fang J, Wang C, Hua YM, Mu DZ. Efficacy of prenatal diagnosis of major congenital heart disease on perinatal management and perioperative mortality: a meta-analysis. World J Pediatr 2016; 12:298-307. [PMID: 27059744 DOI: 10.1007/s12519-016-0016-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 10/15/2014] [Indexed: 01/09/2023]
Abstract
BACKGROUND There is no consensus on the effectiveness of prenatal diagnosis except for hospitalized outcomes. Hence, a meta-analysis of published literature was conducted to assess the effect of prenatal diagnosis. METHODS Literature review has identified relevant studies up to December 2013. A meta-analysis was performed according to the guidelines from the Cochrane review group and the PRISMA statement. Studies were identified by searching PubMed, Embase, the Cochrane Central Register of Controlled Trials and World Health Orgnization clinical trials registry center. Meta-analysis was performed in a fixed/random-effect model using Revman 5.1.1 according to the guidelines from the Cochrane review group and the PRISMA guidelines. RESULTS The results from 13 cohort studies in 12 articles were analyzed to determine the optimal treatment with the lower rate of perioperative mortality in prenatal diagnosis. The superiority of a prenatal diagnosis has been proven because the surgical procedure could be done in the early neonatal period (95% CI, -0.76, -0.40). The prenatal diagnosis has also remarkably reduced the preoperative and postoperative mortality rates in cases of transposition of the great arteries (95% CI=0.06, 0.80; 95% CI=0.01, 0.82, respectively), as well as the overall results with all subtypes (95% CI=0.18, 0.94; 95% CI=0.46, 0.94, respectively). CONCLUSIONS Prenatal diagnosis is effective in perinatal management with an earlier intervention for major congenital heart disease, but only results in a reduced perioperative mortality in cases of transposition of the great arteries. Further investigations are required to evaluate the effect of prenatal diagnosis on life quality during a long-term follow-up.
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Affiliation(s)
- Yi-Fei Li
- Department of Pediatrics, Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, Chengdu, China.,West China Medical School, Chengdu, China
| | - Kai-Yu Zhou
- Department of Pediatrics, Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, Chengdu, China.,Program for Yangtze River Scholars and Innovative Research Team in University, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Jie Fang
- West China Stomatology School, Sichuan University, Chengdu, China
| | - Chuan Wang
- Department of Pediatrics, Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, Chengdu, China.,West China Medical School, Chengdu, China
| | - Yi-Min Hua
- Department of Pediatrics, Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, Chengdu, China.,Program for Yangtze River Scholars and Innovative Research Team in University, West China Second University Hospital, Sichuan University, Chengdu, China
| | - De-Zhi Mu
- Department of Pediatrics, Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, Chengdu, China. .,Program for Yangtze River Scholars and Innovative Research Team in University, West China Second University Hospital, Sichuan University, Chengdu, China.
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21
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Sanapo L, Moon-Grady AJ, Donofrio MT. Perinatal and Delivery Management of Infants with Congenital Heart Disease. Clin Perinatol 2016; 43:55-71. [PMID: 26876121 DOI: 10.1016/j.clp.2015.11.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Advances in fetal echocardiography have improved prenatal diagnosis of congenital heart disease (CHD) and allowed better delivery and perinatal management. Some newborns with CHD require urgent intervention after delivery. In these cases, delivery close to a pediatric cardiac center may be considered, and the presence of a specialized cardiac team in the delivery room or urgent transport of the infant should be planned in advance. Delivery planning, monitoring in labor, rapid intervention at birth if needed, and avoidance of iatrogenic preterm delivery have the potential to improve outcomes for infants with prenatally diagnosed CHD.
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Affiliation(s)
- Laura Sanapo
- Division of Fetal and Transitional Medicine, Children's National Health System, 111 Michigan Avenue, Northwest, Suite M3-118, Washington, DC 20010, USA
| | - Anita J Moon-Grady
- Fetal Cardiovascular Program, UCSF Benioff Children's Hospitals, University of California San Francisco, 550 16th Street, 5th Floor, Box 0544, San Francisco, CA 94158, USA
| | - Mary T Donofrio
- Division of Fetal and Transitional Medicine, Children's National Health System, 111 Michigan Avenue, Northwest, Suite M3-118, Washington, DC 20010, USA; Fetal Heart Program, Division of Cardiology, Children's National Health System, 111 Michigan Avenue, Northwest, Washington, DC 20010, USA.
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Mogra R. Simplifying ultrasound assessment of the fetal heart: Incorporating the complete Three Vessel View into routine screening. Australas J Ultrasound Med 2015; 16:168-175. [PMID: 28191193 PMCID: PMC5030054 DOI: 10.1002/j.2205-0140.2013.tb00243.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction: As our experience and ultrasound resolution have improved significantly in last 30 years it is possible to detect most of the major cardiac abnormalities prenatally with high degree of accuracy. Method: Current screening techniques have poor detection rate for congenital heart diseases (CHD) and nearly half of the major cardiac abnormalities mainly of Great Arteries goes unrecognised. A high detection rate for major CHDs can be achieved in a screening setting by improving techniques of routine screening in the low risk population. Conclusion: This article summarises the alternative strategies to examine the outflow tracts and Great Arteries, its correct interpretation and examples of abnormal views.
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Affiliation(s)
- Ritu Mogra
- RPA Women and Babies Royal Prince Alfred Hospital Sydney Ultrasound for Women Sydney New South Wales Australia
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Arya B, Bhat A, Vernon M, Conwell J, Lewin M. Utility of novel fetal echocardiographic morphometric measures of the aortic arch in the diagnosis of neonatal coarctation of the aorta. Prenat Diagn 2015; 36:127-34. [PMID: 26630206 DOI: 10.1002/pd.4753] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 11/17/2015] [Accepted: 11/25/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Prenatal diagnosis of neonatal coarctation of the aorta (CoA) is challenging; there is a high false-positive rate, yet 60-80% are not identified prenatally. We aimed to identify novel fetal echocardiographic measures to improve prenatal identification of CoA. METHODS A retrospective review was conducted of subjects seen from 1/2007-1/2014 with prenatal suspicion for CoA and postnatal follow-up. The last fetal echocardiogram prior to delivery was evaluated for right/left ventricular dimensions, ascending (AAo), transverse (TAo), descending aorta (DAo), aortic isthmus (AoI), ductus arteriosus (DA), and main pulmonary artery diameters, and AoI and DA spectral Doppler. Three novel fetal measurements were performed: left common carotid-to-left subclavian artery distance (LCSA), AAo-DAo angle, and TAo-DAo angle. Postnatal data included diagnosis, surgical approach, and timing. RESULTS Forty subjects were identified (mean gestational age at fetal echo 32.8 ± 4.2 weeks) with prenatal suspicion for CoA. Comparing subjects with (n = 20) and without CoA (n = 20), significant differences were detected for LCSA, AAo-DAo angle, and TAo-DAo angle (p < 0.0001). An LCSA >4.5 mm (sensitivity 80%,specificity 95%), AAo-DAo angle ≤20.31° (sensitivity 95%,specificity 100%) and TAo-DAo angle ≥96.15°(sensitivity 90%,specificity 100%) identified CoA. CONCLUSIONS Fetal LCSA, AAo-DAo angle, and TAo-DAo angles are novel measures that can differentiate between subjects with and without CoA.
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Affiliation(s)
- Bhawna Arya
- Division of Pediatric Cardiology, Seattle Children's Hospital and the University of Washington School of Medicine, Seattle, WA, USA
| | - Aarti Bhat
- Division of Pediatric Cardiology, Seattle Children's Hospital and the University of Washington School of Medicine, Seattle, WA, USA
| | - Margaret Vernon
- Division of Pediatric Cardiology, Seattle Children's Hospital and the University of Washington School of Medicine, Seattle, WA, USA
| | - Jeffrey Conwell
- Division of Pediatric Cardiology, Seattle Children's Hospital and the University of Washington School of Medicine, Seattle, WA, USA
| | - Mark Lewin
- Division of Pediatric Cardiology, Seattle Children's Hospital and the University of Washington School of Medicine, Seattle, WA, USA
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Toole BJ, Schlosser B, McCracken CE, Stauffer N, Border WL, Sachdeva R. Importance of Relationship between Ductus and Isthmus in Fetal Diagnosis of Coarctation of Aorta. Echocardiography 2015; 33:771-7. [PMID: 26667892 DOI: 10.1111/echo.13140] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The prenatal diagnosis of coarctation of aorta (CoA) can prove problematic, with relatively high false-positive and false-negative rates. This significantly impacts both prenatal counseling and postnatal management. We sought to evaluate a variety of prenatal echo indices to determine which would best predict neonatal CoA. METHODS Fetal echocardiograms of those with prenatal diagnosis of COA were analyzed for the following: diameter of cardiac valves, ascending aorta, distal transverse arch, aortic isthmus, and ductus; right (RV) and left ventricular (LV) length and end-diastolic area and isthmus-ductal angle (IDA). Ratios of RV: LV area, aortic: pulmonary valve diameter, mitral: tricuspid valve ratio (MV:TV ratio), and isthmus: ductal diameter (IDD) were calculated. These measures were compared between those with CoA after birth (CoA group) and those without (no CoA group). RESULTS Of the 62 subjects, 27 were in CoA and 35 in no CoA group. CoA group had a significantly smaller mitral valve, MV:TV ratio, IDD, and IDA compared to no CoA group. The ROC curves for each of these significant measures showed that mitral valve, IDD, and IDA had an AUC of 0.72, 0.80, and 0.83, respectively. Multiple variable model using at least two of these measures had 85% sensitivity and 60% specificity. CONCLUSIONS A smaller mitral valve, MV:TV ratio, IDD, and IDA are associated with development of neonatal coarctation. In cases with suspected prenatal diagnosis of CoA, careful evaluation of the relation between the isthmus and the ductus arteriosus using IDD and IDA may enhance the diagnostic accuracy of fetal echocardiograms.
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Affiliation(s)
- Benjamin J Toole
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Healthcare of Atlanta and Sibley Heart Center Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Brian Schlosser
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Healthcare of Atlanta and Sibley Heart Center Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Courtney E McCracken
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Healthcare of Atlanta and Sibley Heart Center Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Nanci Stauffer
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Healthcare of Atlanta and Sibley Heart Center Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - William L Border
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Healthcare of Atlanta and Sibley Heart Center Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Ritu Sachdeva
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Healthcare of Atlanta and Sibley Heart Center Cardiology, Emory University School of Medicine, Atlanta, Georgia
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Bratt EL, Järvholm S, Ekman-Joelsson BM, Mattson LÅ, Mellander M. Parent's experiences of counselling and their need for support following a prenatal diagnosis of congenital heart disease--a qualitative study in a Swedish context. BMC Pregnancy Childbirth 2015; 15:171. [PMID: 26276642 PMCID: PMC4537590 DOI: 10.1186/s12884-015-0610-4] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 08/07/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prenatal screening for foetal cardiac abnormalities has been increasingly practiced in Sweden during the last 25 years. A prenatal diagnosis may have medical benefits but may also cause sustained parental psychological distress. The aim of this study was to explore pregnant women's, and their partner's, experiences of counselling and need for support during continued pregnancy following a prenatal diagnosis of a cardiac defect. A second aim was to use this information to propose a structured follow-up programme for continued support after the first counselling. METHOD DESIGN Qualitative study, using interviews performed 5-9 weeks after a prenatal diagnosis of congenital heart disease. SETTING A tertiary foetal cardiology unit in Sweden Sample: Six pregnant women and their 6 partners, consecutively recruited after a prenatal diagnosis of an isolated and significant cardiac defect. DATA ANALYSIS Qualitative content analysis. RESULTS The analysis resulted in three themes. 1/ Counselling and making a decision--the importance of knowledge and understanding: Short waiting time for specialist evaluation together with clear and straightforward information was essential. Parents called for written information together with a high-quality website with relevant information about congenital heart disease. 2/ Continued support during pregnancy: Continued and easy access to health care professionals, including a paediatric specialist nurse, throughout pregnancy, was important. Contact with couples with similar experiences and social media were also considered valuable sources of support. 3/ Next step--the near future: Practical and economical issues during the postnatal hospital stay and the initial period following the hospital stay were common concerns. CONCLUSIONS The following aspects should be considered in a structured follow up program during pregnancy after a prenatal diagnosis of CHD; written information, access to a safe web-site with information of high quality in their native language, support from parents with similar experiences and continued contact with a specialist liaison nurse with experience of paediatric cardiology.
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Affiliation(s)
- Ewa-Lena Bratt
- Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Arvid Wallgrens Backe, Box 457, , 405 30, Gothenburg, Sweden. .,Department of Paediatric Cardiology, The Queen Silvia Childréns hospital, Rondvägen 10, 416 50, Gothenburg, Sweden.
| | - Stina Järvholm
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Blå Stråket 6, 413 45, Gothenburg, Sweden.
| | - Britt-Marie Ekman-Joelsson
- Department of Paediatric Cardiology, The Queen Silvia Childréns hospital, Rondvägen 10, 416 50, Gothenburg, Sweden.
| | - Lars-Åke Mattson
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Blå Stråket 6, 413 45, Gothenburg, Sweden.
| | - Mats Mellander
- Department of Paediatric Cardiology, The Queen Silvia Childréns hospital, Rondvägen 10, 416 50, Gothenburg, Sweden.
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Holland BJ, Myers JA, Woods CR. Prenatal diagnosis of critical congenital heart disease reduces risk of death from cardiovascular compromise prior to planned neonatal cardiac surgery: a meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:631-8. [PMID: 25904437 DOI: 10.1002/uog.14882] [Citation(s) in RCA: 149] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 04/17/2015] [Accepted: 04/19/2015] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To determine if prenatal diagnosis improves the chance that a newborn with critical congenital heart disease will survive to undergo planned cardiac surgery. METHODS A systematic review of the medical literature identified eight studies which met the following criteria: compared outcomes between newborns with prenatal and those with postnatal diagnosis of critical congenital heart disease; compared groups of patients with the same anatomical diagnosis; provided detailed information on cardiac anatomy; included detailed information on preoperative cause of death. A meta-analysis was performed to assess differences in preoperative mortality rates between newborns with prenatal diagnosis and those with postnatal diagnosis. Patients with established risk factors for increased mortality (high risk) and those whose families chose comfort care rather than cardiac surgery were excluded. RESULTS In patients with comparable anatomy, standard risk, a parental desire to treat and optimal care, newborns with a prenatal diagnosis of critical congenital heart disease were significantly less likely to die prior to planned cardiac surgery than were those with a comparable postnatal diagnosis (pooled odds ratio, 0.26; 95% CI, 0.08-0.84). CONCLUSIONS For newborns most likely to benefit from treatment for their critical congenital heart disease, because they did not have additional risk factors and their families pursued treatment, prenatal diagnosis reduced the risk of death prior to planned cardiac surgery relative to patients with a comparable postnatal diagnosis. Further study and efforts to improve prenatal diagnosis of congenital heart disease should therefore be considered.
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Affiliation(s)
- B J Holland
- Division of Pediatric Cardiology, Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY, USA
| | - J A Myers
- Child and Adolescent Health Research and Design Support Unit, Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY, USA
| | - C R Woods
- Child and Adolescent Health Research and Design Support Unit, Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY, USA
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Prenatal screening of congenital heart defects in population at low risk of congenital defects. A reality today. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.anpede.2013.10.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
PURPOSE OF REVIEW Fetal cardiology is a rapidly evolving field. Imaging technology continues to advance as do approaches to in-utero interventions and care of the critically ill neonate, with even greater demand for improvement in prenatal diagnosis of congenital heart disease (CHD) and arrhythmias. RECENT FINDINGS Reviewing the advances in prenatal diagnosis of CHD in such a rapidly developing field is a broad topic. Therefore, we have chosen to focus this review of recent literature on challenges in prenatal detection of CHD, challenges in prenatal counseling, advances in fetal arrhythmia diagnosis, and potential benefits to patients with CHD who are identified prenatally. SUMMARY As methods and tools to diagnose and manage CHD and arrhythmias in utero continue to improve, future generations will hopefully see a reduction in both prenatal and neonatal morbidity and mortality. Prenatal diagnosis can and should be used to optimize location and timing of delivery and postnatal interventions.
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Pike JI, Krishnan A, Donofrio MT. Early fetal echocardiography: congenital heart disease detection and diagnostic accuracy in the hands of an experienced fetal cardiology program. Prenat Diagn 2014; 34:790-6. [DOI: 10.1002/pd.4372] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 03/26/2014] [Accepted: 03/26/2014] [Indexed: 11/10/2022]
Affiliation(s)
- Jodi I. Pike
- Children's National Heart Institute; Children's National Medical Center; Washington DC 20010 USA
| | - Anita Krishnan
- Children's National Heart Institute; Children's National Medical Center; Washington DC 20010 USA
| | - Mary T. Donofrio
- Children's National Heart Institute; Children's National Medical Center; Washington DC 20010 USA
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30
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Donofrio MT, Moon-Grady AJ, Hornberger LK, Copel JA, Sklansky MS, Abuhamad A, Cuneo BF, Huhta JC, Jonas RA, Krishnan A, Lacey S, Lee W, Michelfelder EC, Rempel GR, Silverman NH, Spray TL, Strasburger JF, Tworetzky W, Rychik J. Diagnosis and treatment of fetal cardiac disease: a scientific statement from the American Heart Association. Circulation 2014; 129:2183-242. [PMID: 24763516 DOI: 10.1161/01.cir.0000437597.44550.5d] [Citation(s) in RCA: 696] [Impact Index Per Article: 69.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
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.
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31
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Oster ME, Kim CH, Kusano AS, Cragan JD, Dressler P, Hales AR, Mahle WT, Correa A. A population-based study of the association of prenatal diagnosis with survival rate for infants with congenital heart defects. Am J Cardiol 2014; 113:1036-40. [PMID: 24472597 DOI: 10.1016/j.amjcard.2013.11.066] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 11/18/2013] [Accepted: 11/18/2013] [Indexed: 02/07/2023]
Abstract
Prenatal diagnosis has been shown to improve preoperative morbidity in newborns with congenital heart defects (CHDs), but there are conflicting data as to the association with mortality. We performed a population-based, retrospective, cohort study of infants with prenatally versus postnatally diagnosed CHDs from 1994 to 2005 as ascertained by the Metropolitan Atlanta Congenital Defects Program. Among infants with isolated CHDs, we estimated 1-year Kaplan-Meier survival probabilities for prenatal versus postnatal diagnosis and estimated Cox proportional hazard ratios adjusted for critical CHD status, gestational age, and maternal race/ethnicity. Of 539,519 live births, 4,348 infants had CHDs (411 prenatally diagnosed). Compared with those with noncritical defects, those with critical defects were more likely to be prenatally diagnosed (58% vs 20%, respectively, p <0.001). Of the 3,146 infants with isolated CHDs, 1-year survival rate was 77% for those prenatally diagnosed (n = 207) versus 96% for those postnatally diagnosed (n = 2,939, p <0.001). Comparing 1-year survival rate among those with noncritical CHDs alone (n = 2,455) showed no difference between prenatal and postnatal diagnoses (96% vs 98%, respectively, p = 0.26), whereas among those with critical CHDs (n = 691), prenatally diagnosed infants had significantly lower survival rate (71% vs 86%, respectively, p <0.001). Among infants with critical CHDs, the adjusted hazard ratio for 1-year mortality rate for those prenatally versus postnatally (reference) diagnosed was 2.51 (95% confidence interval 1.72 to 3.66). In conclusion, prenatal diagnosis is associated with lower 1-year survival rate for infants with isolated critical CHDs but shows no change for those with isolated noncritical CHDs. More severe disease among the critical CHD subtypes diagnosed prenatally might explain these findings.
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Sainz JA, Zurita MJ, Guillen I, Borrero C, García-Mejido J, Almeida C, Turmo E, Garrido R. [Prenatal screening of congenital heart defects in population at low risk of congenital defects. A reality today]. An Pediatr (Barc) 2014; 82:27-34. [PMID: 24635979 DOI: 10.1016/j.anpedi.2013.10.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Revised: 07/15/2013] [Accepted: 10/22/2013] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION We propose to demonstrate that it is possible to implement a valid (diagnostic sensitivity for major cardiac malformations 90%), and universal (applied to over 90% of pregnant women), prenatal screening method for congenital heart defects. MATERIALS AND METHODS Prospective study. A total of 12478 pregnant women were evaluated between January 2008 and December 2010. Congenital heart diseases were screened using fetal extended basic echocardiography (cardiac ultrasound). RESULTS The prevalence of birth defects in general and congenital heart disease was 2.5% (2.2-2.7%) and 0.9% (0.7-1%) respectively. Congenital heart disease had a higher rate of association with other structural abnormalities with 11.5% (5.6-17.4%), 21% for major congenital heart disease (9.9-32%), and chromosomal abnormalities of 15.9% (9.1-22.7%), with 32.6% for major congenital heart disease (19.8-45.3%). A fetal cardiac ultrasound assessment was performed on 99.2% of pregnant women. The fetal echocardiography is useful for the diagnosis of congenital heart disease in general, and major congenital heart disease, with a sensitivity of 42.8% (33.5-52.5%) and 90.4% (78.9-96.8%), respectively, and a specificity for both of 99.9% (99.8-99.9%). CONCLUSIONS It is possible to perform a valid prenatal and universal screening of major congenital heart disease.
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Affiliation(s)
- J A Sainz
- Servicio de Obstetricia y Ginecología, Hospital Universitario Valme, Sevilla, España.
| | - M J Zurita
- Servicio de Obstetricia y Ginecología, Hospital Universitario Valme, Sevilla, España
| | - I Guillen
- Servicio de Pediatría, Unidad de Cardiología Infantil, Hospital Universitario Valme, Sevilla, España
| | - C Borrero
- Servicio de Obstetricia y Ginecología, Hospital Universitario Valme, Sevilla, España
| | - J García-Mejido
- Servicio de Obstetricia y Ginecología, Hospital Universitario Valme, Sevilla, España
| | - C Almeida
- Sección de Estadística de la Unidad de Investigación, Hospital Universitario Valme, Sevilla, España
| | - E Turmo
- Servicio de Obstetricia y Ginecología, Hospital Universitario Valme, Sevilla, España
| | - R Garrido
- Servicio de Obstetricia y Ginecología, Hospital Universitario Valme, Sevilla, España
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Matsui H, Gardiner H. Coarctation of the aorta: fetal and postnatal diagnosis and outcome. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.4.2.191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Effectiveness of prenatal screening for congenital heart disease: assessment in a jurisdiction with universal access to health care. Can J Cardiol 2013; 29:879-85. [PMID: 23725863 DOI: 10.1016/j.cjca.2013.04.028] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 04/23/2013] [Accepted: 04/23/2013] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Neonates with certain forms of severe congenital heart disease (CHD) diagnosed prenatally might have better outcomes in comparison with those diagnosed after birth. The proportion of prenatally detected neonates with severe CHD and the effect of prenatal diagnosis on clinical outcomes have not been previously investigated in Canada. METHODS We retrospectively studied infants in Alberta, Canada, who required surgical or catheter intervention for CHD at younger than 1 year of age, between January 2007 and December 2010, and pregnancy terminations affected by CHD. RESULTS Of the 374 subjects identified (327 infants, 47 pregnancies with termination), 188 (50%) were detected prenatally. Failure of prenatal diagnosis was associated with anomalies not involving the 4-chamber view on ultrasound (odds ratio, 1.86; 95% confidence interval, 1.48-2.35; P < 0.001) and region of residence (P = 0.04). Prenatal detection was associated with fewer days to hospital admission (P < 0.001), fewer days to surgery (P = 0.003), and greater use of prostaglandins (P = 0.001). Infants diagnosed prenatally who underwent surgery within 15 days of age had higher preductal O2 saturations (P = 0.04), fewer days to admission (P = 0.03), and less frequently required preoperative intubation (P = 0.004), and inotropes (P = 0.001). Pregnancy termination occurred among 49% of fetuses detected before 24 weeks' gestation. CONCLUSIONS Only 50% of fetuses and/or neonates with severe CHD managed in Alberta have a prenatal diagnosis. The likelihood of prenatal detection is influenced by the status of the 4-chamber view on ultrasound and the region of maternal residence indicating heterogeneous access to fetal echocardiography within Alberta. Prenatal detection might improve clinical outcomes for neonates with severe CHD.
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Abstract
BACKGROUND Fetal echocardiography plays a critical role in the diagnosis and management of structural, functional and rhythm-related fetal cardiovascular disease. OBJECTIVES/METHODS This article reviews the history of fetal echocardiography and the prenatal diagnosis of fetal cardiovascular disease as well as the evolution of the field of fetal cardiology. The clinical application of fetal echocardiography, including indications for referral, timing of referral and considerations in the diagnosis and serial assessment of fetal cardiovascular disease, is presented. CONCLUSIONS Newer directions in the field of fetal cardiology, including first trimester diagnoses and fetal intervention, will continue to expand its role in the evaluation and treatment of affected pregnancies in the future; however, equally as important are efforts to continue to improve prenatal detection rates.
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Affiliation(s)
- Lisa K Hornberger
- Professor of Pediatrics University of Alberta William C McKenzie Health Centre, Director of the Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics & Obstetrics, 4C2.23, 8440 112th Street, Edmonton, Alberta T6G2B7, Canada +1 780 407 3952 ; +1 780 407 3954 ;
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Landis BJ, Levey A, Levasseur SM, Glickstein JS, Kleinman CS, Simpson LL, Williams IA. Prenatal diagnosis of congenital heart disease and birth outcomes. Pediatr Cardiol 2013; 34:597-605. [PMID: 23052660 PMCID: PMC3647457 DOI: 10.1007/s00246-012-0504-4] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 08/26/2012] [Indexed: 11/26/2022]
Abstract
This study was undertaken to examine the impact that prenatal diagnosis of congenital heart disease (CHD) has on birth and early neonatal outcomes. The prevalence of prenatally diagnosed CHD has risen over the past decade, but the effect that prenatal diagnosis of CHD has on peripartum decisions remains unclear. No consensus exists on the effect of prenatal diagnosis on neonatal outcomes. Between January 2004 and July 2009, a retrospective chart review of all neonates with CHD admitted to our institution's neonatal intensive care unit was conducted. Obstetric and postnatal variables were collected. Among the 993 subjects, 678 (68.3%) had a prenatal diagnosis. A prenatal diagnosis increased the odds of a scheduled delivery [odds ratio (OR) 4.1, 95% confidence interval (CI) 3.0-5.6] and induction of labor (OR 11.5, 95% CI 6.6-20.1). Prenatal diagnosis was not significantly associated with cesarean delivery when control was used for maternal age, multiple gestation, and presence of extracardiac anomaly. Mean gestational age had no impact on prenatal diagnosis, but prenatal diagnosis was associated with increased odds of delivery before a gestational age of 39 weeks (OR 1.5, 95% CI 1.1-1.9) and decreased odds of preoperative intubation (OR 0.5, 95% CI 0.3-0.6). Prenatal diagnosis did not have an impact on preoperative or predischarge mortality. Prenatal diagnosis was associated with increased odds of a scheduled delivery, birth before a gestational age of 39 weeks, and a decreased need for invasive respiratory support. Prenatal diagnosis of CHD was not associated with preoperative or predischarge mortality.
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Affiliation(s)
- Benjamin J Landis
- Division of Pediatric Cardiology, Department of Pediatrics, Morgan Stanley Children's Hospital of New York-Presbyterian, Columbia University Medical Center, New York, NY, USA.
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Frank LH, Bradshaw E, Beekman R, Mahle WT, Martin GR. Critical congenital heart disease screening using pulse oximetry. J Pediatr 2013; 162:445-53. [PMID: 23266220 DOI: 10.1016/j.jpeds.2012.11.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 10/12/2012] [Accepted: 11/02/2012] [Indexed: 11/17/2022]
Affiliation(s)
- Lowell H Frank
- Division of Pediatric Cardiology, Children's National Medical Center, Washington, DC 20010, USA.
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Chock VY, Chang IJ, Reddy VM. Short-term neurodevelopmental outcomes in neonates with congenital heart disease: the era of newer surgical strategies. CONGENIT HEART DIS 2012; 7:544-50. [PMID: 22676547 DOI: 10.1111/j.1747-0803.2012.00678.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to determine neurodevelopmental outcomes up to 30 months of age in a cohort of neonates requiring surgical intervention without circulatory arrest for congenital heart disease and to correlate these outcomes with characteristics detected prior to hospital discharge. DESIGN AND SETTING An observational cohort of surviving neonates who underwent surgical intervention without circulatory arrest for congenital heart disease between 2002 and 2003 was studied at a single tertiary care institution. PATIENTS Thirty-five patients were followed from 4 to 6 months of age until 24-30 months of age. OUTCOME MEASURES Neuromotor abnormalities, use of special services, and degree of developmental delay at set intervals between 4 and 30 months of age were retrospectively obtained from clinical reports. The relationship between these outcomes and clinical characteristics prior to hospital discharge was analyzed. RESULTS Those with neuromotor abnormalities prior to discharge were likely to have persistent abnormalities in muscle strength, tone, and symmetry until 4-6 months of age, odds ratio 6 (1.3-29). By 24-30 months of age, motor abnormalities or developmental delay occurred in 10 of 20 infants (50%), but were no longer significantly associated with predischarge findings. CONCLUSIONS Infants undergoing surgical intervention for congenital heart disease are at risk for neurodevelopmental abnormalities, which may not become apparent until months after hospital discharge. Early impairment may also resolve over time. Close developmental follow-up in this high-risk cohort of patients is warranted.
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Affiliation(s)
- Valerie Y Chock
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, Calif, USA.
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Pádua LMS, Garcia LC, Rubira CJ, de Oliveira Carvalho PE. Stent placement versus surgery for coarctation of the thoracic aorta. Cochrane Database Syst Rev 2012:CD008204. [PMID: 22592728 DOI: 10.1002/14651858.cd008204.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Coarctation of the aorta (CoA) accounts for 5% to 7% of congenital heart disease, with an incidence of 0.3 to 0.4 per 1000 live births. Surgery was the only choice of therapy for CoA until 1982 when balloon angioplasty became an available alternative for its treatment. Re-coarctation, aneurysm and aortic dissection remain the disadvantages of both treatments. To avoid those disadvantages, in 1990 endovascular stents were introduced for native coarctation and re-coarctation and since then they have become an alternative approach to surgical repair. The best approach to treat the CoA, whether open surgery or by stent placement, is not clear. OBJECTIVES To analyze the effectiveness and safety of stent placement compared with open surgery in patients with coarctation of the thoracic aorta. SEARCH METHODS The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (last searched September 2011) and CENTRAL (2011, Issue 3). We also searched MEDLINE, EMBASE, CINAHL, AMED, Web of Science and LILACS (last searched in September 2011). We evaluated the located references and applied the inclusion criteria to selected studies. There was no restriction on language. SELECTION CRITERIA Randomized or quasi-randomized controlled clinical trials that compared patients with CoA undergoing open surgery or stent placement. DATA COLLECTION AND ANALYSIS The review authors independently assessed the studies identified for eligibility for inclusion. We excluded studies after a consensus meeting. MAIN RESULTS All identified studies were screened and had the selection criteria applied to the title and abstract. In total, we selected five studies for full-text analysis. After detailed evaluation, we excluded all studies because there was no comparison between stent placement and open surgery. AUTHORS' CONCLUSIONS There is insufficient evidence with regards to the best treatment for coarctation of the thoracic aorta. This review suggests a need to perform a randomized controlled clinical trial with emphasis on the allocation method, evaluation of primary outcomes, size and quality of the sample, and long-term follow-up.
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Galindo A, Gutiérrez-Larraya F, de la Fuente P. Congenital heart defects in fetal life: an overview. ACTA ACUST UNITED AC 2011. [DOI: 10.3109/14722240400023578] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Präoperative Azidose und Entwicklung von Säuglingen nach Operation angeborener Herzfehler. Herz 2010; 35:358-63. [DOI: 10.1007/s00059-010-3356-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2009] [Accepted: 03/18/2010] [Indexed: 11/25/2022]
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Abstract
Advances in surgical techniques and perioperative management have led to dramatic improvements in outcomes for children with complex congenital heart disease (CHD). As the number of survivors continues to grow, clinicians are becoming increasingly aware that adverse neurodevelopmental outcomes after surgical repair of CHD represent a significant cause of morbidity, with widespread neuropsychologic deficits in as many as 50% of these children by the time they reach school age. Modifications of intraoperative management have yet to measurably impact long-term neurologic outcomes. However, exciting advances in our understanding of the underlying mechanisms of cellular injury and of the events that mediate endogenous cellular protection have provided a variety of new potential targets for the assessment, prevention, and treatment of neurologic injury in patients with CHD. In this review, we will discuss the unique challenges to developing neuroprotective strategies in children with CHD and consider how multisystem approaches to neuroprotection, such as ischemic preconditioning, will be the focus of ongoing efforts to develop new diagnostic tools and therapies. Although significant challenges remain, tremendous opportunity exists for the development of diagnostic and therapeutic interventions that can serve to limit neurologic injury and ultimately improve outcomes for infants and children with CHD.
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Affiliation(s)
- Erin L Albers
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee 37323, USA
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The impact of prenatal diagnosis of complex congenital heart disease on neonatal outcomes. Pediatr Cardiol 2010; 31:587-97. [PMID: 20165844 PMCID: PMC2889000 DOI: 10.1007/s00246-010-9648-2] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Accepted: 01/19/2010] [Indexed: 10/19/2022]
Abstract
Prenatal diagnosis of congenital heart disease (CHD) is increasingly common. However, the current impact of prenatal diagnosis on neonatal outcomes is unclear. Between January 2004 and January 2008, a retrospective chart review of infants who underwent surgical repair of CHD before discharge at our institution was conducted. Obstetric and perioperative variables were recorded. Of 439 neonates, 294 (67%) were diagnosed prenatally (PREdx). Infants with PREdx had a lower mean birth weight (3.0 +/- 0.6 vs. 3.1 +/- 0.6 kg, p = 0.002) and gestational age (37.9 +/- 2.1 vs. 38.6 +/- 2.4 wk, p < 0.001) than those with postnatal diagnosis (POSTdx). Severe lesions were more likely to be PREdx: Neonates with single-ventricle (SV) physiology (n = 130 patients [31.2%]) had increased odds of PREdx (n = 113/130, odds ratio [OR] 4.7; 95% confidence interval [CI] 2.7-8.2, p < 0.001). PREdx was associated with decreased preoperative intubation (OR 0.62; 95% CI 0.42-0.95, p = 0.033), administration of antibiotics (OR 0.23; 95% CI 0.15-0.36, p < 0.001), cardiac catheterization (OR 0.54; 95% CI 0.34-0.85, p = 0.01), and emergency surgery (OR 0.18; 95% CI 0.06-0.5, p < 0.001) compared with POSTdx infants. There was no difference in APGAR scores, preoperative pH, day of life of surgery, operative complications, hospital length of stay, or overall mortality in the PREdx versus POSTdx groups, even when controlling for lesion severity. PREdx was not independently associated with neonatal mortality, despite having included more severe cardiac lesions. PREdx was significantly associated with decreased neonatal morbidity in terms of decreased use of preoperative ventilator, administration of antibiotics, cardiac catheterization, and emergency surgery.
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Romosan G, Henriksson E, Rylander A, Valentin L. Diagnostic performance of routine ultrasound screening for fetal abnormalities in an unselected Swedish population in 2000-2005. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2009; 34:526-533. [PMID: 19688769 DOI: 10.1002/uog.6446] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVES To determine the detection rate of fetal malformations and chromosomal abnormalities and the rate of false-positive ultrasound diagnoses at routine ultrasound examinations carried out by specially trained midwives in an unselected pregnant population from 2000 to 2005, and to describe the consequences of true-positive and false-positive ultrasound diagnoses of fetal malformations. METHODS A retrospective analysis was undertaken of all babies born in Malmö, Sweden, between January 2000 and December 2005 by mothers residing in Malmö and of all fetuses with an ultrasound diagnosis of malformation made in the same time interval at the two units performing all routine pregnancy scans in Malmö. All women underwent two routine scans, at 18 and 32 weeks, including scrutiny of the fetal anatomy. Detection rates and false-positive rates were calculated per fetus. RESULTS The prevalence of chromosomally abnormal fetuses was 0.31% (52/16 775); that of chromosomally normal fetuses with major and minor malformations was 1.80% (302/16 775) and 1.32% (222/16 775), respectively. The detection rate of fetuses with major malformations but normal chromosomes was 68% (205/302), with a detection rate at < 22 weeks of 37% (112/302). In addition, 46% (24/52) of all chromosomally abnormal fetuses were diagnosed before birth because a malformation was detected at ultrasound imaging, 33% (17/52) being detected at < 22 gestational weeks. In all, 68 pregnancies were terminated because of an ultrasound diagnosis of fetal malformation (0.4% of all pregnancies and 47% of the pregnancies in which a fetal malformation was detected by ultrasound examination before 22 weeks). A false-positive ultrasound diagnosis of malformation was made in 0.19% (31/16 180) of the normally formed fetuses and in 20 (0.12%) fetuses the abnormal finding persisted during pregnancy. No fetus assigned a false-positive diagnosis was lost by termination of pregnancy, but most were subjected to one or more unnecessary interventions before birth (e.g. amniocentesis), at birth (e.g. Cesarean section) or after birth (e.g. electrocardiogram, X-ray, ultrasound examination or treatment with antibiotics). CONCLUSIONS In a screening program consisting of one fetal anomaly scan at 18 weeks and another at 32 weeks the detection rate of major malformations in chromosomally normal fetuses was 68% with a detection rate of 37% at < 22 weeks. The corresponding detection rates of chromosomally abnormal fetuses were 46% and 33%. Fewer than one in 500 screened fetuses had an ultrasound diagnosis of an anomaly that was not confirmed after birth.
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Affiliation(s)
- G Romosan
- Department of Obstetrics and Gynecology I, 'Victor Babes' University of Medicine and Pharmacy, Timisoara, Romania
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Michelfelder EC, Cnota JF. Prenatal diagnosis of congenital heart disease in an era of near-universal ultrasound screening: room for improvement. J Pediatr 2009; 155:9-11. [PMID: 19559289 DOI: 10.1016/j.jpeds.2009.02.057] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2009] [Accepted: 02/27/2009] [Indexed: 11/30/2022]
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Bernard LS, Ramos GA, Fines V, Hull AD. Reducing the cost of detection of congenital heart disease in fetuses of women with pregestational diabetes mellitus. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2009; 33:676-682. [PMID: 19479684 DOI: 10.1002/uog.6302] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To provide a cost minimization analysis to support a paradigm shift in the use of comprehensive ultrasound and echocardiography in the prenatal diagnosis of congenital heart disease (CHD) in fetuses of women with diabetes mellitus (DM). METHODS In this retrospective cohort study, the diabetic clinic service database of the University of California San Diego was searched from January 2001 to June 2004 for pregnant women with Type I or II DM and HbA1c >6.3%. Subjects underwent comprehensive ultrasound examination (with four-chamber views and outflow tracts) and fetal echocardiography according to a standard protocol. Newborns were examined for cardiac defects and underwent postnatal echocardiography as indicated. The cost of screening was evaluated. RESULTS Of 115 neonates and two terminations of pregnancy there were 20 (17%) cases of CHD. Six of these CHD were major and all six were detected prenatally by both ultrasound and echocardiography. Three additional clinically insignificant cases of CHD were identified by fetal echocardiography. Eleven cases of CHD were identified by postnatal echocardiography only, all of which were clinically insignificant lesions. The prenatal detection rate of major CHD was 100% (6/6) for both ultrasound and echocardiography. The sensitivites of ultrasound (30% (95% CI, 13-54%)) and echocardiography (45% (95% CI, 24-68%)) were similar (P = 0.32). A cost minimization analysis was done using the published Medicaid (California) system's relative value unit and conversion factors. Accordingly, our current protocol costs $6503.43 per case of major CHD detected. If echocardiography had been performed only as indicated and postnatal echocardiography had been performed on all neonates, the cost would have been $7056.83 per case of major CHD detected. Alternatively, combined targeted ultrasound with indicated prenatal and postnatal echocardiography would have been associated with a cost of $4996.05 per case of major CHD detected. CONCLUSION Detection of major CHD was excellent with both comprehensive prenatal ultrasound and echocardiography. Echocardiography added little to the prenatal diagnosis of CHD if the comprehensive ultrasound examination was normal. The highest cost-benefit ratio and most efficacious protocol for screening based on our data would be comprehensive ultrasound with prenatal and postnatal echocardiography only as indicated. Further prospective studies are warranted.
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Affiliation(s)
- L S Bernard
- Oregon Health and Sciences University, Department of Obstetrics and Gynecology, Maternal-Fetal Medicine, Portland, OR 97239, USA.
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Raeside L. Coarctation of the aorta: a case presentation. Neonatal Netw 2009; 28:103-13. [PMID: 19332408 DOI: 10.1891/0730-0832.28.2.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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).
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Affiliation(s)
- Lavinia Raeside
- Queen Mothers Hospital, Royal Hospital for Sick Children, Yorkhill, Glasgow, UK.
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Matsui H, Mellander M, Roughton M, Jicinska H, Gardiner HM. Morphological and Physiological Predictors of Fetal Aortic Coarctation. Circulation 2008; 118:1793-801. [DOI: 10.1161/circulationaha.108.787598] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Prenatal diagnosis of aortic coarctation suffers from high false-negative rates at screening and poor specificity.
Methods and Results—
This retrospective study tested the applicability of published aortic arch and ductal Z scores (measured just before the descending aorta in the 3-vessel and tracheal view) and their ratio on 200 consecutive normal controls at a median of 22±0 gestational weeks (range, 15±4 to 38±4 weeks). Second, this study tested the ability of serial Z scores to distinguish fetuses with coarctation within a cohort with ventricular and/or great arterial disproportion detected at screening or fetal echocardiography. Third, it evaluated the diagnostic significance of associated cardiac lesions, coarctation shelf, and isthmal flow disturbance. We studied 44 fetuses with suspected coarctation at 24±0 weeks (range, 17±3 to 37±4 weeks). Receiver-operating characteristic curves were created. Logistic regression tested the association between
z
scores, additional cardiac diagnoses, and coarctation. Good separation was found of isthmal Z scores for cases requiring surgery from controls and false-positive cases, and receiver-operating characteristic curves showed an excellent area under the curve for isthmal Z score (0.963) and isthmal-to-ductal ratio (0.969). Serial isthmal Z scores improved to >−2 in suspected cases with normal outcomes; those requiring surveillance or surgery remained <−2. Minor lesions did not increase the diagnostic specificity of coarctation, but isthmal flow disturbance increased the odds ratio of true coarctation versus arch hypoplasia 16-fold.
Conclusions—
Isthmal Z scores and isthmal-to-ductal ratio are sensitive indicators of fetal coarctation. Serial measurements and abnormal isthmal flow patterns improve diagnostic specificity and may reduce false positives.
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Affiliation(s)
- Hikoro Matsui
- From the Faculty of Medicine, Imperial College at Queen Charlotte’s and Chelsea Hospital (H.M., H.M.G.); Brompton Fetal Cardiology, Royal Brompton Hospital (H.M., M.M., H.J., H.M.G.); and Royal Brompton Hospital NHS Trust (M.R.), London, UK. Dr Mellander is now at the Department of Paediatric Cardiology, The Queen Silvia Children’s Hospital, Gothenburg, Sweden
| | - Mats Mellander
- From the Faculty of Medicine, Imperial College at Queen Charlotte’s and Chelsea Hospital (H.M., H.M.G.); Brompton Fetal Cardiology, Royal Brompton Hospital (H.M., M.M., H.J., H.M.G.); and Royal Brompton Hospital NHS Trust (M.R.), London, UK. Dr Mellander is now at the Department of Paediatric Cardiology, The Queen Silvia Children’s Hospital, Gothenburg, Sweden
| | - Michael Roughton
- From the Faculty of Medicine, Imperial College at Queen Charlotte’s and Chelsea Hospital (H.M., H.M.G.); Brompton Fetal Cardiology, Royal Brompton Hospital (H.M., M.M., H.J., H.M.G.); and Royal Brompton Hospital NHS Trust (M.R.), London, UK. Dr Mellander is now at the Department of Paediatric Cardiology, The Queen Silvia Children’s Hospital, Gothenburg, Sweden
| | - Hana Jicinska
- From the Faculty of Medicine, Imperial College at Queen Charlotte’s and Chelsea Hospital (H.M., H.M.G.); Brompton Fetal Cardiology, Royal Brompton Hospital (H.M., M.M., H.J., H.M.G.); and Royal Brompton Hospital NHS Trust (M.R.), London, UK. Dr Mellander is now at the Department of Paediatric Cardiology, The Queen Silvia Children’s Hospital, Gothenburg, Sweden
| | - Helena M. Gardiner
- From the Faculty of Medicine, Imperial College at Queen Charlotte’s and Chelsea Hospital (H.M., H.M.G.); Brompton Fetal Cardiology, Royal Brompton Hospital (H.M., M.M., H.J., H.M.G.); and Royal Brompton Hospital NHS Trust (M.R.), London, UK. Dr Mellander is now at the Department of Paediatric Cardiology, The Queen Silvia Children’s Hospital, Gothenburg, Sweden
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Jelliffe-Pawlowski LL, Walton-Haynes L, Currier RJ. Using second trimester ultrasound and maternal serum biomarker data to help detect congenital heart defects in pregnancies with positive triple-marker screening results. Am J Med Genet A 2008; 146A:2455-67. [DOI: 10.1002/ajmg.a.32513] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Nelson DP, Andropoulos DB, Fraser CD. Perioperative neuroprotective strategies. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2008; 11:49-56. [PMID: 18396225 DOI: 10.1053/j.pcsu.2008.01.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Long-term neurodevelopmental impairment is common in newborns and infants undergoing corrective or palliative congenital heart surgery. The etiologies of neurodevelopmental morbidity in these children are multifactorial and include prenatal, preoperative, intraoperative, and postoperative factors. Perioperative neurologic monitoring is thought to be integral to prevention or rescue from adverse neurologic events. Recent advances in perfusion techniques for congenital heart surgery now ensure adequate cerebral O(2) delivery during all phases of cardiopulmonary bypass. Periventricular leukomalacia and other serious neurologic injury can be minimized by an optimized perfusion strategy of continuous high-flow, high hematocrit cardiopulmonary bypass, minimal use of deep hypothermic circulatory arrest, antegrade cerebral perfusion during aortic arch reconstruction, pH-stat blood gas strategy, and cerebral monitoring with NIRS and trans-cranial Doppler. Because there is evidence that brain injury can also occur in the prenatal, preoperative, and postoperative periods, improved strategies to prevent injury in these arenas are much needed. Extensive further clinical investigation is warranted to identify neuroprotective management strategies for the operating room and intensive care unit to preserve neurologic function and optimize long-term neurodevelopmental outcomes in children with congenital heart disease.
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Affiliation(s)
- David P Nelson
- Section of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX 77030-2399, USA.
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