Retrospective cohort study of prenatally and postnatally diagnosed coarctation of the aorta (CoA): prenatal diagnosis improve neonatal outcome in severe CoA

Congenitally Corrected Transposition of the Great Arteries in Utero: Morphological Spectrum, Outcomes and Pitfalls in Fetal Diagnosis

Congenitally corrected transposition of the great arteries (ccTGA) is a rare malformation with diverse morphology. We assessed features of fetuses with ccTGA and evaluated neonatal and pediatric outcomes. This was a retrospective review of fetuses with ccTGA at Birmingham Women's and Children's Hospital born from 2005 to 2019. Of thirty-six fetuses identified, six had unavailable prenatal data, one was postnatally diagnosed with isomerism and 29 fetuses were evaluated. ccTGA without associated cardiac lesions was found in 28% (8/29), ccTGA with significant VSD in 31% (9/29), ccTGA with pulmonary obstruction in 24% (7/29) and ccTGA with complex anomalies in 17% (5/29). Tricuspid regurgitation (TR) was observed in 17% (5/29) and heart block (HB) in 10% (3/29) prenatally. Six, that is 21% underwent genetic testing of which one was abnormal. Five extra-cardiac anomalies were reported prenatally and postnatally. Pregnancy was discontinued in five, of which two had moderate TR. There were thirty-one liveborn. Coarctation of the aorta was found in five postnatally but not suspected prenatally. In one, pulmonary stenosis was underestimated; otherwise, prenatal morphology was confirmed. Cardiac interventions were performed in 77% (24/31) liveborn with 39% (12/31) undergoing neonatal intervention. Overall, 6/31 liveborn died including all three with prenatal heart block and one with TR. Estimated survival for all liveborn at 1, 5 and 10 years was 87% (95% CI 76-100%), 83% (95% CI 72-98%) and 80% (95% CI 66-96%) respectively. Accurate prenatal diagnosis of ccTGA is critical for counseling. Early outcomes are favorable with 77% of liveborn undergoing surgery. Fetuses with prenatal diagnosis of complex associated abnormalities, HB and TR appear to do less well.

Diagnostic accuracy of prenatal ultrasound in coarctation of aorta: systematic review and individual participant data meta-analysis

OBJECTIVE

To determine the diagnostic accuracy of prenatal ultrasound in detecting coarctation of the aorta (CoA).

METHODS

An individual participant data meta-analysis was performed to report on the strength of association and diagnostic accuracy of different ultrasound signs in detecting CoA prenatally. MEDLINE, EMBASE and CINAHL were searched for studies published between January 2000 and November 2021. Inclusion criteria were fetuses with suspected isolated CoA, defined as ventricular and/or great vessel disproportion with right dominance on ultrasound assessment. Individual participant-level data were obtained by two leading teams. PRISMA-IPD and PRISMA-DTA guidelines were used for extracting data, and the QUADAS-2 tool was used for assessing quality and applicability. The reference standard was CoA, defined as narrowing of the aortic arch, diagnosed after birth. The most commonly evaluated parameters on ultrasound, both in B-mode and on Doppler, constituted the index test. Summary estimates of sensitivity, specificity, diagnostic odds ratio (DOR) and likelihood ratios were computed using the hierarchical summary receiver-operating-characteristics model.

RESULTS

The initial search yielded 72 studies, of which 25 met the inclusion criteria. Seventeen studies (640 fetuses) were included. On random-effects logistic regression analysis, tricuspid valve/mitral valve diameter ratio > 1.4 and > 1.6, aortic isthmus/arterial duct diameter ratio < 0.7, hypoplastic aortic arch (all P < 0.001), aortic isthmus diameter Z-score of < -2 in the sagittal (P = 0.003) and three-vessel-and-trachea (P < 0.001) views, pulmonary artery/ascending aorta diameter ratio > 1.4 (P = 0.048) and bidirectional flow at the foramen ovale (P = 0.012) were independently associated with CoA. Redundant foramen ovale was inversely associated with CoA (P = 0.037). Regarding diagnostic accuracy, tricuspid valve/mitral valve diameter ratio > 1.4 had a sensitivity of 72.6% (95% CI, 48.2-88.3%), specificity of 65.4% (95% CI, 46.9-80.2%) and DOR of 5.02 (95% CI, 1.82-13.9). The sensitivity and specificity values were, respectively, 75.0% (95% CI, 61.1-86.0%) and 39.7% (95% CI, 27.0-53.4%) for pulmonary artery/ascending aorta diameter ratio > 1.4, 47.8% (95% CI, 14.6-83.0%) and 87.6% (95% CI, 27.3-99.3%) for aortic isthmus diameter Z-score of < -2 in the sagittal view and 74.1% (95% CI, 58.0-85.6%) and 62.0% (95% CI, 41.6-78.9%) for aortic isthmus diameter Z-score of < -2 in the three-vessel-and-trachea view. Hypoplastic aortic arch had a sensitivity of 70.0% (95% CI, 42.0-88.6%), specificity of 91.3% (95% CI, 78.6-96.8%) and DOR of 24.9 (95% CI, 6.18-100). The diagnostic yield of prenatal ultrasound in detecting CoA did not change significantly when considering multiple categorical parameters. Five of the 11 evaluated continuous parameters were independently associated with CoA (all P < 0.001) but all had low-to-moderate diagnostic yield.

CONCLUSIONS

Several prenatal ultrasound parameters are associated with an increased risk for postnatal CoA. However, diagnostic accuracy is only moderate, even when combinations of parameters are considered. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Prenatal diagnosis of coarctation: Impact on early and late cardiovascular outcome

BACKGROUND

Prenatal diagnosis (PND) of aortic coarctation (AoCo) has been associated with a significant improvement in early results, but there is limited information on the long-term cardiovascular outcome.

METHODS

We studied 103 patients with simple AoCo, operated in the neonatal period, with a median follow-up of 8,5 years (2 to 23,7 years), with 47% followed for over 10 years. PND was made in 35%. The primary aim was to determine the short and long-term cardiovascular impact of PND of AoCo.

RESULTS

Neonates with PND had less preoperative neonatal complications, with only 2,8% incidence of a composite preoperative severe morbidity course, compared to 28% in the postnatal group. PND patients underwent surgery 8 days earlier and had a shorter length of stay in ICU. PND did not impact the incidence of post-operative complications. On the long-term, prevalence of hypertension, left ventricular hypertrophy and rate of recoarctation were not influenced by PND. The PND group had mean 24 h diastolic BP 9 mmHg lower and mean daytime diastolic BP 11 mmHg lower. In the final multivariable model, PND was the single independent variable correlating with daytime diastolic BP.

CONCLUSION

PND of AoCo effectively leads to a better pre-operative course with less pre-operative morbidity. We found no significant differences in immediate post-operative cardiovascular outcomes. A better initial course of patients with PND does not have a major long-term impact on cardiovascular outcomes, nevertheless, at late follow-up PND patients had lower diastolic BP values on ambulatory monitoring, which may have an impact on long-term cardiovascular risk.

Using computed tomography angiography and computational fluid dynamics to study aortic coarctation in different arch morphologies

Objective

To study the differences in computed tomography angiography (CTA) imaging of gothic arches, crenel arches, and romanesque arches in children with Aortic Coarctation (CoA), and to apply computational fluid dynamics (CFD) to study hemodynamic changes in CoA children with gothic arch aorta.

Methods

The case data and CTA data of children diagnosed with CoA (95 cases) in our hospital were retrospectively collected, and the morphology of the aortic arch in the children was defined as gothic arch (n = 27), crenel arch (n = 25) and romanesque arch (n = 43). The three groups were compared with D1/AOA, D2/AOA, D3/AOA, D4/AOA, D5/AOA, and AAO-DAO angle, TAO-DAO angle, and aortic arch height to width ratio (A/T). Computational fluid dynamics was applied to assess hemodynamic changes in children with gothic arches.

Results

There were no significant differences between D1/AOA and D2/AOA among gothic arch, crenel arch, and romanesque arch (P > 0.05). The differences in D3/AOA, D4/AOA, and D5/AOA among the three groups were statistically significant (P < 0.05), D4/AOA, D5/AOA of the gothic arch group were smaller than the crenel arch group, and the D3/AOA and D5/AOA of the gothic arch group were smaller than the romanesque arch group (P < 0.05). The difference in AAO-DAO angle among the three groups was statistically significant (P < 0.05), and the AAO-DAO angle of gothic arch was smaller than that of romanesque arch and crenel arch group (P < 0.05). There was no significant difference in the TAO-DAO angle between the three groups (P > 0.05). The difference in A/T values among the three groups was statistically significant (P < 0.05), and the A/T values: gothic arch > romanesque arch > crenel arch (P < 0.05). The CFD calculation of children with gothic arch showed that the pressure drop between the distal stenosis and the descending aorta was 58 mmHg, and the flow rate at the isthmus and descending aorta was high and turbulent.

Conclusion

Gothic aortic arch is common in CoA, it may put adverse effects on the development of the aortic isthmus and descending aorta, and its A/T value and AAO-DAO angle are high. CFD could assess hemodynamic changes in CoA.

Impact of prenatal diagnosis on outcomes of surgical correction in newborns with transposition of the great arteries comparing to other critical congenital heart defects

A review of the literature data describing the influence of prenatal diagnosis of critical congenital heart defects on perioperative and long-term results is presented, with a focus on the features of prenatal detection of transposition of the great arteries. This heart defect is a convenient object of studying due to the relative anatomical homogeneity of the nosological form; the birth of patients, as a rule, at full term; the rarity of the combination of this pathology with multiple congenital malformations and chromosomal abnormalities that can potentially worsen the results of treatment; the similarity of the principles of preoperative management in this category of patients in different clinics; the performing of arterial switch surgery in a strictly defined time frame (usually during the first month of life); the relative similarity of surgical techniques used. The relevance of this study is to identify patterns that make it possible to improve existing protocols for the treatment of newborns with transposition of the great arteries and create new algorithms for interaction between gynecologists, neonatologists, resuscitators, and cardiac surgeons.

The potential of 1.5 T magnetic resonance imaging for the evaluation of fetal anomalies of the great vessels

Purpose

To determine the efficacy of 1.5 T magnetic resonance imaging (MRI) for the diagnosis of anomalies of the fetal great arteries with comparison to fetal ultrasound, and to compare image quality between 1.5 T and 3.0 T MRI in fetal imaging of the great arteries.

Methods

We compared the results of postnatal exam or surgery and evaluated the application value of prenatal 1.5 T MRI in the assessment of fetal great-vessel anomalies. To further determine the diagnostic potential of 1.5 T MRI, 23 pregnant women with suspected fetal cardiovascular abnormalities who had undergone ultrasound and 3.0 T MRI were enrolled and compared, respectively.

Results

Prenatal MRI was superior to ultrasound in demonstrating aortic arch and branch abnormalities (sensitivity, 92.86% vs. 83.33%; specificity, 66.67% vs. 20%). The mean quality ratings for fetal MRI at 1.5 T was higher than 3.0 T (P < 0.001). Other than the fast scan speed afforded by 3.0 T MRI, the signal noise ratio (SNR) of 1.5 T MRI were higher than those of 3.0 T MRI; however, the difference in contrast to noise ratio (CNR) between the two imaging modalities was not statistically significant.

Conclusions

1.5 T MRI can achieve an overall assessment of fetal great-vessel anomalies, especially aortic arch and branch abnormalities. Therefore, 1.5 T MRI can be considered a supplementary imaging modality for the prenatal assessment of extracardiac great vessels malformations.

PHACE(S) SYNDROME - EARLY DIAGNOSTICS IN THE MAXILLOFACIAL AREA

OBJECTIVE

The aim: To determine the minimum criteria for early diagnosing PHACE(S) syndrome in neonates and infants with infantile hemangioma (IH) in the max¬illofacial area.

PATIENTS AND METHODS

Materials and methods: A total of 26 asymptomatic children from 20 days to six months of aged with IH of more than 5 cm² in the maxillofacial area were included in this study. A medical record of patients clinical examination, Holter monitoring, echocardiographic ultrasound and magnetic resonance imaging (MRI) were analysed. The IH treatment with β-blockers was carried out.

RESULTS

Results: IH localization was diagnosed: 62% with a lesion of a part facial segment, 23% in one segment, 15% in several segments (p=0.018), and 12% with other parts of the body lesion (p=1.000). The patent foramen ovale was diagnosed in 35% of children. Central nervous system disorders were observed in 12% over two years of age. The indices of Holter monitoring and blood glucose changed in age norm range during treatment. Cardiovascular (the aortic coarctation (p=0.003) and brain (the Dandy-Walker malformation) (p=0.031) abnormalities were determined in two cases (8%) according to the MRI only. We diagnosed PHACE(S) syndrome in both these cases of children, only aged 12 months and 2.5 years old.

CONCLUSION

Conclusions: Early diagnosis of PHACE(S) syndrome is possible on a contrast-enhanced MRI performed in asymptomatic neonates and infants with the facial several segmental IH with / without ulceration (p=0.018, p=0.046; p < 0.05) for recognition of presymptomatic cardiovascular and brain abnormalities.

Prenatal prediction of Shone's complex. The role of the degree of ventricular disproportion and speckle-tracking analysis

OBJECTIVES

Shone's complex (SC) is characterized by sequential obstructions of left ventricular (LV) inflow and outflow. It can be associated with poor long-term prognosis when compared to Simple-Aortic Coarctation (S-CoA). We aimed to assess whether the degree of ventricular disproportion and 2D-speckle-tracking echocardiography (2D-STE) could improve the accuracy of prenatal prediction of SC.

METHODS

75 consecutive fetuses were retrospectively enrolled from January 2010 to June 2021. Fetuses were divided into 4 groups (Group 1: SC; Group 2: S-CoA; Group 3: False Positive-Coarctation of the Aorta [FP-CoA]; group 4: controls). Comparisons for echocardiographic measures and myocardial deformation indices were performed. A receiver operating characteristic (ROC) analysis was performed on the MV/TV (mitral valve/tricuspid valve ratio) and LV GLS (global longitudinal strain) values to identify cut-offs to separate group 1 and 2 fetuses.

RESULTS

SC fetuses showed a significant reduction in MV/TV when compared to S-CoA and FP-CoA fetuses (p<0.001). LV GLS in SC fetuses was significantly reduced compared to S-CoA fetuses (-13.3 ± 2.1% vs. -17.0 ± 2.2%, p=0.001). A cut-off value of 0.59 for MV/TV and -15.35% for LV GLS yielded a sensitivity of 76 and 82% and a specificity of 71 and 83% respectively in separating SC vs. S-CoA fetuses.

CONCLUSIONS

SC fetuses showed a more severe degree of ventricular disproportion and a lower LV GLS compared to S-CoA, FP-CoA and control fetuses. MV/TV and GLS are both predictors of SC. These findings may improve the quality of prenatal parental counselling.

Fetal Echocardiographic Findings to Predict Early Surgical Repair and Neonatal Outcomes in Fetuses with Isolated Coarctation of the Aorta

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..

Challenges of prenatal diagnosis of fetal hypoplastic aortic arch and predication of the need for intervention

Prenatal diagnosis of hypoplastic aortic arch and coarctation of aorta is still challenging and remains one of the most difficult cardiac defects to diagnose. The results reveal a significant improvement of prenatal diagnosis of hypoplastic arch and coarctation of aorta. The data also shows the significant overlapping of fetal aortic isthmus z score between the infants who need the arch procedure and those who do not.

Incremental value of myocardial deformation in predicting postnatal coarctation of the aorta: establishment of a novel diagnostic model

BACKGROUND

Prenatal detection of coarctation of the aorta (CoA) still suffers from high false-positive and false-negative rates. The objective of this study was to develop a novel model to improve the diagnostic accuracy of fetal CoA.

METHODS

A retrospective study was conducted in 122 fetuses with suspected CoA who also had postnatal follow-ups. Fetuses with confirmed diagnosis of CoA after birth were defined as CoA group, and Non-CoA group were those false-positives. Conventional fetal echocardiographic measurements, including great arterial dimensions and flow characteristics were obtained. Left ventricular (LV) functional parameters were determined using two-dimensional speckle tracking echocardiography. A novel multi-parametric diagnostic model, including gestational age (GA) at diagnosis, aortic isthmus (AOI) Z-score and LV longitudinal strain (LVLS), was developed by univariate and multivariate logistic regression analyses. The model was validated prospectively by a validation cohort of 48 fetuses.

RESULTS

CoA was confirmed in 62/122 (50.8%) cases after birth. Fetuses with postnatal CoA were diagnosed significantly earlier than false-positives (median (interquartile range), 24.5 (23.3-26.4) vs 27.8 (24.5-30.4) weeks; P < .001). The Z-scores of aortic dimensions (aortic valve annulus, ascending aorta, transverse aortic arch and AOI) were significantly smaller (all P < .001), while the Z-scores of pulmonary dimensions (pulmonary valve annulus and main pulmonary artery) were significantly greater (all P < .05), in cases of confirmed CoA than false-positives. Compared with Non-CoA group, CoA group displayed lower LV ejection fraction (P = .005), LV fractional area change (P < .001) and LVLS (P < .001). A multivariate logistic regression model incorporating GA (odds ratio (OR): 0.74, 95% confidence interval (CI): 0.60-0.88; P = .001), AOI Z-score (OR: 0.20, 95% CI: 0.08-0.41; P < .001) and LVLS (OR: 1.79, 95% CI: 1.41-2.42; P < .001) was established to diagnose CoA more accurately (Akaike information criterion: 81.77, C-statistics: 0.945). The performance of this model was confirmed prospectively in the validation cohort.

CONCLUSIONS

In fetuses with suspected CoA, speckle tracking analysis of LVLS may have an incremental value in predicting postnatal CoA. Our diagnostic model, including GA, AOI Z-score and LVLS, may provide a good tool for the stratification of the risk in fetal CoA and contribute to patient-specific perinatal management.

Challenges in diagnosis and management of coarctation of the aorta

PURPOSE OF REVIEW

Coarctation of the aorta remains a controversial topic with uncertainties in long-term outcomes.

RECENT FINDINGS

Recent advances in fetal imaging including echocardiography and MRI offer novel opportunities for better detection and prediction of the need for neonatal intervention.New imaging techniques are providing novel insights about the impact of arch geometry and size on flow dynamics and pressure gradients. The importance of arch size rather than shape for optimal hemodynamics has been identified. Long-term outcome data suggest a significant increase in mortality risk in coarctation patients beyond the third decade when compared with the general population. Hypertension is highly prevalent not only in adult patients following repair of coarctation but also in normotensive patients presenting with LV diastolic dysfunction and adverse remodelling, indicating that abnormal vascular properties are important. Patients with coarctation undergoing neonatal repair are at risk for adverse neurodevelopmental outcomes and patients could benefit from timely neurocognitive evaluation and intervention.

SUMMARY

Optimizing aortic arch size, prevention and aggressive treatment of hypertension and vascular stiffening are important to improve long-term outcomes.

Fetal Diagnosis is Associated with Improved Perioperative Condition of Neonates Requiring Surgical Intervention for Coarctation

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.

Prenatal diagnosis of aortic arch anomalies: Echocardiography, 3D-ultrasonography, and computed tomography angiogram findings. A case-report

We report the case of a fetus presenting aortic arch anomalies associated with a ventricular septal defect (VSD). This fetus, which was referred at 25 weeks of gestation, was suspected to have coarctation of aorta (CoA) evidenced by enlarged right chambers at the four-chamber view during a routine obstetric ultrasonographic scan. The prenatal diagnosis of CoA remains a challenge. Here, we review the ultrasonographic findings that could contribute to this diagnosis.

Prenatal diagnosis of coarctation of the aorta with a long and angled isthmus by two- and three-dimensional echocardiography: a case report

Background

Prenatal diagnosis of coarctation of the aorta (CoA) is challenging for most examiners. The malformation often occurs at the aortic isthmus, which is a short segment between the origin of the left subclavian artery and the insertion of the ductus. We report herein a rare case of CoA with a long, angled, and hypoplastic isthmus. The echocardiographic characteristics and postmortem findings are presented to approach the skill of fetal diagnosis.

Case presentation

A pregnant women undergone fetal echocardiography at 26 + 3 gestational weeks in our center. Conventional two-dimensional echocardiography (2DE) showed that ascending aorta went straight upward branching three brachiocephalic arteries without the appearance of the arch, suggesting the possibility of an interrupted aortic arch. Three-dimensional echocardiography (3DE) using spatiotemporal image correlation (STIC) and high-definition flow imaging technique was performed to obtain the 3D rendered images, which clearly showed the arch and its angled junction with the slim isthmus in space. Intra-uterine fetal death occurred and an autopsy was performed. The gross findings showed the angled hypoplastic aortic isthmus in detail and thus confirmed the prenatal diagnosis.

Conclusions

Traditional 2DE may be limited in showing the angled hypoplastic aortic isthmus, while the 3DE STIC technique can provide additional spatial information to show great arteries in detail, help to find tiny vessels, and thus benefit the examiners to make an accurate diagnosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-01987-7.

Improved detection of coarctation of the aorta using speckle-tracking analysis of fetal heart on last examination prior to delivery

OBJECTIVE

The false-positive rate for prenatal diagnosis of coarctation of the aorta (FP-CoA) commonly exceeds 50%, with an accurate detection rate of < 50%. This study was conducted to determine if the sensitivity for prenatal detection of true CoA and the FP-CoA rate could be improved by evaluating the fetal epicardial size and shape in the four-chamber view (4CV) and the endocardial right (RV) and left (LV) ventricular size, shape and contractility.

METHODS

We analyzed retrospectively Digital Imaging and Communications in Medicine (DICOM) clips of the 4CV from the last examination prior to delivery in a series of 108 fetuses with CoA suspected prenatally by pediatric cardiologists using traditional diagnostic criteria. Postnatal evaluation distinguished those fetuses which subsequently required CoA surgery (true positives; true CoA) from those that were FP-CoA. Postnatal cardiac abnormalities were identified for each group. For the prenatal evaluation, we measured the 4CV end-diastolic epicardial area, circumference, length, width and global sphericity index. Speckle-tracking analysis was used to compute the endocardial RV and LV end-diastolic area, length, 24-segment sphericity index, 24-segment transverse width and the following functional parameters: fractional area change; global longitudinal, free-wall and septal-wall strain; basal-apical-length, basal free-wall and basal septal-wall fractional shortening; septal-wall annular plane systolic excursion; 24-segment transverse-width fractional shortening; and LV end-diastolic and end-systolic volumes, stroke volume, cardiac output and ejection fraction. In addition, the RV/LV end-diastolic area ratio was computed. Using a control group of 200 normal fetuses, the mean and SD for each of the above cardiac measurements was used to compute the Z-scores for each measurement in each of the 108 study fetuses. Logistic regression analysis was then performed on the Z-score values to identify variables that separated the true CoA group from the FP-CoA group.

RESULTS

Of the 108 study fetuses, 54 were confirmed postnatally to have true CoA and 54 were FP-CoA. Right/left area disproportion > 90^th  centile was present in 80% (n = 43) of the true-CoA fetuses and 76% (n = 41) of the FP-CoA fetuses. Fetuses with true CoA had a significantly greater number of associated cardiac abnormalities (93%, n = 50) compared with the FP-CoA fetuses (61%, n = 33) (P < 0.001). The most common associated malformations were bicuspid aortic valve (true CoA, 46% (n = 25) vs FP-CoA, 22% (n = 12); P < 0.01), aortic arch hypoplasia (true CoA, 31% (n = 17) vs FP-CoA, 11% (n = 6); P < 0.01), ventricular septal defect (true CoA, 33% (n = 18) vs FP-CoA, 11% (n = 6); P < 0.05) and mitral valve abnormality (true CoA, 30% (n = 16) vs FP-CoA, 4% (n = 2); P < 0.01). Logistic regression analysis identified 28 variables that correctly identified 96% (52/54) of the fetuses with true CoA, with a false-positive rate of 4% (2/54) and a false-negative rate of 4% (2/54). These variables included the epicardial size in the 4CV, size and shape of RV and LV, and abnormal contractility of RV and LV. The area under the receiver-operating-characteristics curve was 0.98 (SE, 0.023; 95% CI, 0.84-1). There was no significant difference in the percent of fetuses with RV/LV area disproportion between those with CoA and those that were FP-CoA.

CONCLUSIONS

Speckle-tracking analysis of multiple ventricular measurements may be helpful to refine the diagnosis in fetuses that are suspected to have CoA prenatally. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Comparison of the 1-year survival rate in infants with congenital heart disease diagnosed by prenatal and postnatal ultrasound: A retrospective study

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.

Risk Factors for Recoarctation and Mortality in Infants Submitted to Aortic Coarctation Repair: A Systematic Review

Aortic coarctation is a common congenital heart defect that often requires correction at a young age. Currently, success is defined by the achievement of a durable repair with low morbidity and mortality. We sought to systematically review the literature on risk factors for recoarctation and mortality in infants submitted to aortic arch coarctation repair under 1 year of age. PubMed and Scopus were searched for studies reporting risk factors for recoarctation and mortality from January 1989 to August 2019. Among the 1038 retrieved articles, 18 met the inclusion criteria, with a total of 2891 patients. The extracted risk factors for recoarctation were comprehensively summarized in the following categories: demographic variables, associated anomalies, clinical and repair variables, and morphometric variables. Younger age and lower weight were weak determinants of need for reintervention, while smaller aortic arch was a strong predictor of recoarctation. While balloon angioplasty is a clear risk factor for arch restenosis, the chosen surgical technique is not a strong risk factor. Associated minor cardiac anomalies and lower weight at surgery were important risk factors for death. Younger and smaller infants are at increased risk for adverse outcomes when submitted to aortic arch coarctation repair. This is particularly important when associated with smaller arch morphology. Strategies to improve the management of these patients may play a key role in improving their outcomes. Notably, surgical technique was not a strong predictor of recoarctation and mortality, suggesting that the choice of one over the other should be tailored.