Epidemiology and major subtypes of congenital heart defects in Hunan Province, China

Very young and advanced maternal age strongly elevates the occurrence of nonchromosomal congenital anomalies: a systematic review and meta-analysis of population-based studies

BACKGROUND

Nonchromosomal congenital anomalies (NCAs) are the most common cause of infant mortality and morbidity. The role of maternal age is well known, although the specifics are not thoroughly elucidated in the literature.

OBJECTIVE

To evaluate the role of maternal age in the incidence of NCAs and to pinpoint age groups at higher risk to refine screening protocols.

STUDY DESIGN

A systematic review and meta-analysis were conducted following the PRISMA 2020 guidelines and Cochrane Handbook. Searches were performed on October 19, 2021, across MEDLINE (via PubMed), Cochrane Library (CENTRAL), and Embase. Population-based studies assessing the impact of maternal age on the incidence of NCAs in pregnant women were included, without restrictions on age range, country, or comorbidities. A random-effects model was used for pooling effect sizes, considering the heterogeneity across studies.

RESULTS

From 15,547 studies, 72 were synthesized. Maternal age >35 showed an increased NCA risk (risk ratio [RR]: 1.31, confidence interval [CI]: 1.07 -1.61), rising notably after>40 (RR: 1.44, CI: 1.25 -1.66). The latter changes to 1.25 (CI: 1.08 -1.46) if the co-occurrence of chromosomal aberrations is excluded. Specific anomalies like cleft lip/palate (>40, RR: 1.57, CI: 1.11 -2.20) and circulatory system defects (>40, RR: 1.94, CI: 1.28 -2.93) were significantly associated with advanced maternal age. Conversely, gastroschisis was linked to mothers <20 (RR: 3.08, CI: 2.74 -3.47).

CONCLUSION

The study confirms that both very young and advanced maternal ages significantly increase the risk of NCAs. There is a pressing need for age-specific prenatal screening protocols to better detect these anomalies, especially considering the current trend of delayed childbearing. Further research is required to fully understand the impact of maternal age on the prevalence of rarer NCAs.

Multivariate logistic regression analysis of risk factors for birth defects: a study from population-based surveillance data

OBJECTIVE

To explore risk factors for birth defects (including a broad range of specific defects).

METHODS

Data were derived from the Population-based Birth Defects Surveillance System in Hunan Province, China, 2014-2020. The surveillance population included all live births, stillbirths, infant deaths, and legal termination of pregnancy between 28 weeks gestation and 42 days postpartum. The prevalence of birth defects (number of birth defects per 1000 infants) and its 95% confidence interval (CI) were calculated. Multivariate logistic regression analysis (method: Forward, Wald, α = 0.05) and adjusted odds ratios (ORs) were used to identify risk factors for birth defects. We used the presence or absence of birth defects (or specific defects) as the dependent variable, and eight variables (sex, residence, number of births, paternal age, maternal age, number of pregnancies, parity, and maternal household registration) were entered as independent variables in multivariate logistic regression analysis.

RESULTS

Our study included 143,118 infants, and 2984 birth defects were identified, with a prevalence of 20.85% (95%CI: 20.10-21.60). Multivariate logistic regression analyses showed that seven variables (except for parity) were associated with birth defects (or specific defects). There were five factors associated with the overall birth defects. The risk factors included males (OR = 1.49, 95%CI: 1.39-1.61), multiple births (OR = 1.44, 95%CI: 1.18-1.76), paternal age < 20 (OR = 2.20, 95%CI: 1.19-4.09) or 20-24 (OR = 1.66, 95%CI: 1.42-1.94), maternal age 30-34 (OR = 1.16, 95%CI: 1.04-1.29) or > = 35 (OR = 1.56, 95%CI: 1.33-1.81), and maternal non-local household registration (OR = 2.96, 95%CI: 2.39-3.67). Some factors were associated with the specific defects. Males were risk factors for congenital metabolic disorders (OR = 3.86, 95%CI: 3.15-4.72), congenital limb defects (OR = 1.34, 95%CI: 1.14-1.58), and congenital kidney and urinary defects (OR = 2.35, 95%CI: 1.65-3.34). Rural areas were risk factors for congenital metabolic disorders (OR = 1.21, 95%CI: 1.01-1.44). Multiple births were risk factors for congenital heart defects (OR = 2.09, 95%CI: 1.55-2.82), congenital kidney and urinary defects (OR = 2.14, 95%CI: 1.05-4.37), and cleft lip and/or palate (OR = 2.85, 95%CI: 1.32-6.15). Paternal age < 20 was the risk factor for congenital limb defects (OR = 3.27, 95%CI: 1.10-9.71), 20-24 was the risk factor for congenital heart defects (OR = 1.64, 95%CI: 1.24-2.17), congenital metabolic disorders (OR = 1.56, 95%CI: 1.11-2.21), congenital limb defects (OR = 1.61, 95%CI: 1.14-2.29), and congenital ear defects (OR = 2.13, 95%CI: 1.17-3.89). Maternal age < 20 was the risk factor for cleft lip and/or palate (OR = 3.14, 95%CI: 1.24-7.95), 30-34 was the risk factor for congenital limb defects (OR = 1.37, 95%CI: 1.09-1.73), >=35 was the risk factor for congenital heart defects (OR = 1.51, 95%CI: 1.14-1.99), congenital limb defects (OR = 1.98, 95%CI: 1.41-2.78), and congenital ear defects (OR = 1.82, 95%CI: 1.06-3.10). Number of pregnancies = 2 was the risk factor for congenital nervous system defects (OR = 2.27, 95%CI: 1.19-4.32), >=4 was the risk factor for chromosomal abnormalities (OR = 2.03, 95%CI: 1.06-3.88) and congenital nervous system defects (OR = 3.03, 95%CI: 1.23-7.47). Maternal non-local household registration was the risk factor for congenital heart defects (OR = 3.57, 95%CI: 2.54-5.03), congenital metabolic disorders (OR = 1.89, 95%CI: 1.06-3.37), congenital limb defects (OR = 2.94, 95%CI: 1.86-4.66), and congenital ear defects (OR = 3.26, 95%CI: 1.60-6.65).

CONCLUSION

In summary, several risk factors were associated with birth defects (including a broad range of specific defects). One risk factor may be associated with several defects, and one defect may be associated with several risk factors. Future studies should examine the mechanisms. Our findings have significant public health implications as some factors are modifiable or avoidable, such as promoting childbirths at the appropriate age, improving the medical and socio-economic conditions of non-local household registration residents, and devoting more resources to some specific defects in high-risk groups, which may help reducing birth defects in China.

Associations of maternal exposure to multiple plasma trace elements with the prevalence of fetal congenital heart defects: A nested case-control study

BACKGROUND

Scanty knowledge prevails regarding the combined impact of multiple plasma trace elements and main contributors on the prevalence of congenital heart defects (CHDs) in offspring. Thus, we performed a nested case-control analysis in a neonates cohort to investigate this important public health issue.

METHODS

We selected 164 pairs of cases and non-malformed controls from live births registered in the parent cohort (n = 11,578) at the same hospital. Plasma levels of 14 trace elements were determined by inductively coupled plasma-mass spectrometry. The odds ratios (ORs) of exposure were compared between cases and controls. Bayesian Kernel Machine Regression (BKMR) and Quantile g-Computation (QgC) models were employed to assess the cumulative effect of exposure to trace elements.

RESULTS

We found positive associations and linear dose-response relationships between plasma Pb and Sn and CHD. BKMR models indicated that the overall effect of the trace element mixture was associated with CHDs below the 45th percentile or above the 50th percentile, and the combined effect was primarily attributed to Sn and Pb. The QgC model indicated significantly increased odds of CHD with simultaneous exposure to all studied trace elements (OR: 2.19, 95%CI: 1.44-3.33).

CONCLUSIONS

This study is the first to report an association between elevated levels of mixed trace elements in maternal plasma with an increased prevalence of fetal CHDs, particularly in the case of Pb and Sn. Findings from this study provide further evidence of the important of heavy metal pollution to human health, and can help stakeholders prioritize policies and develop interventions to target the leading contributors to human exposure.

Clinical profile of congenital heart diseases detected in a tertiary hospital in China: a retrospective analysis

Background

Congenital heart diseases (CHDs) are conditions that involve structural problems to the heart's structure existing at birth, with an incidence of approximately 8 per 1,000 live births globally. CHD is one of the leading causes of maternal, fetal, and neonatal morbidity and mortality worldwide. The present study sought to examine the clinical profiles of CHD patients and provide important implications for therapeutic interventions.

Methods

This was a retrospective, observational, cohort study. The medical records of all CHDs patients aged between 0 and 18 years were collected from July 1, 2021 to June 30, 2022. Clinical profiles and demographic data were collected from cardiology and pediatric department registers for analysis.

Results

Of the 265 children with CHDs, 201 were diagnosed with acyanotic CHD (ACHD), while 64 children had cyanotic CHD (CCHD). Based on the eleventh revision of the International Classification of Diseases (ICD-11), "congenital anomaly of a ventricle or the ventricular septum" was the most common CHD. The most common symptom was failure to thrive, accounting for 18.5% of all CHD cases. The most frequent symptom in ACHD was murmur (93.53%) and sweating (80.60%), whereas the most common symptom in CCHD was sweating (95.31%) and cyanosis (84.38%).

Conclusions

This study retrospectively analyzed CHD clinical characteristics from children receiving care at the seventh center, which forms a proper basis for appropriate clinical treatments and further studies.

Prenatal diagnosis, management, and outcomes of fetuses with tetralogy of Fallot in China after prenatal counseling: a prospective cohort study

Objective

The study aimed to monitor fetuses with tetralogy of Fallot (TOF) after prenatal counseling and how it influenced the decision of parents to terminate the pregnancy.

Methods

Fetuses with isolated TOF diagnosed between January 2019 and December 2021 were prospectively enrolled. The follow-up period extended until termination or 6 months after the operation.

Results

Of the 1,026 fetuses diagnosed with cardiac defects, 129 were identified to have isolated TOF and completed the follow-up. A total of 55 (42.6%) fetuses were terminated, with larger maternal age (odds ratio: 0.893, 95% confidence interval: 0.806-0.989, P = 0.031) as the protective factor. The maternal anxiety score, gestational weeks, and pulmonary-to-aortic-diameter ratio lost significance in multivariate analysis. Subjectively, the two most common reasons for terminating the pregnancy were worries about the prognosis (41.8%) and concerns about the possible suffering of the unborn child (18.2%). The prenatal diagnosis was accurate in 73 of the 74 (98.6%) live births. Out of the 64 live births that underwent surgical repair in our center, 57 (89.1%) received primary repair, with a median age of 104 days, and 49 (76.6%) underwent valve-sparing repair. No perioperative death occurred.

Conclusions

Termination for fetuses with TOF remains common in China. Live births with TOF can be safely and effectively managed.

Effect of prostaglandin-E1 treatment on pyloric wall thickness in newborns with ductal-dependent critical congenital heart diseases

BACKGROUND

Prostaglandin E1 (PGE1) is used in the medical treatment of ductal-dependent critical congenital heart disease (CCHD) in neonates. Apnea/bradycardia, hypotension, hypokalemia, and fever are the most important side effects of PGE1. Moreover, gastric outlet obstruction has been reported in a few case reports. A prospective study was conducted to investigate the effect of PGE1 treatment on pyloric wall thickness in newborns with congenital heart diseases.

METHODS

A total of 22 newborns with ductal-dependent CCHD having PGE1 infusion longer than a week were included in this study. Ultrasonographic measurements were performed before and one week after the PGE1 infusion to evaluate the pyloric thickness and length. The protocol was registered with ClinicalTrials.govidentifier NCT04496050.

RESULTS

A total of 22 neonates with mean gestational age 38 ± 1.8 weeks and birth weight 3105 ± 611 gr were enrolled in the study. The median time of the second ultrasound was seven days. The median cumulative dose of PGE1 given during this period was 108 mcg/kg/min. There was a statistically significant increase in post-treatment pyloric thickness and length compared to pre-treatment measurements (p < 0.001, p < 0.001). None of the patients with increased thickness and pyloric muscle length presented any symptoms.

CONCLUSION

PGE1 treatment significantly increased the pyloric thickness and length after at least one-week treatment. PGE1 with its action mechanism is likely to cause gastric outlet obstruction, although not exactly pyloric stenosis on the condition used for a long time.

A novel stop-gain pathogenic variant in FLT4 and a nonsynonymous pathogenic variant in PTPN11 associated with congenital heart defects

BACKGROUND

Congenital heart defects (CHDs) are the most common congenital malformations, including structural malformations in the heart and great vessels. CHD complications such as low birth weight, prematurity, pregnancy termination, mortality, and morbidity depend on the type of defect.

METHODS

In the present research, genetic analyses via whole-exome sequencing (WES) was performed on 3 unrelated pedigrees with CHDs. The candidate variants were confirmed, segregated by PCR-based Sanger sequencing, and evaluated by bioinformatics analysis.

RESULTS

A novel stop-gain c.C244T:p.R82X variant in the FLT4 gene, as well as a nonsynonymous c.C1403T:p.T468M variant in the PTPN11 gene, was reported by WES. FLT4 encodes a receptor tyrosine kinase involved in lymphatic development and is known as vascular endothelial growth factor 3.

CONCLUSIONS

We are the first to report a novel c.C244T variant in the FLT4 gene associated with CHDs. Using WES, we also identified a nonsynonymous variant affecting protein-tyrosine phosphatase, the non-receptor type 11 (PTPN11) gene. The clinical implementation of WES can determine gene variants in diseases with high genetic and phenotypic heterogeneity like CHDs.

Psychological needs of parents of children with complicated congenital heart disease after admitting to pediatric intensive care unit: A questionnaire study

BACKGROUND

Parents of children with complicated congenital heart disease (CHD) have different needs after surgery. Little literature reports the impact factors for psychological needs of parents of children with complicated CHD.

AIM

To investigate the status quo of the needs of parents of children after surgery for complex CHD, and analyze the influencing factors, in order to provide a theoretical basis for formulating corresponding nursing countermeasures.

METHODS

A modified Chinese version of the Critical Care Family Needs Inventory (M-CCFNI) was used to select 200 parents of children with complex CHD after surgery within 72 h after admission to the intensive care unit in our hospital to conduct an online questionnaire survey. The aim was to understand the needs of parents in relation to the following five aspects: The support from medical staff, comfort of the parents themselves, the acquisition of information, their closeness to the children, and assurance of the child’s condition.

RESULTS

Parents of children with complex CHD had a higher degree of demand, especially in terms of condition assurance, acquisition of information, and closeness to the children. The age, education level, and residence of the parents were related to the five dimensions of the needs of parents of children with complex CHD who had undergone surgery.

CONCLUSION

In practice, nurses should formulate corresponding nursing strategies based on the different cultural and social backgrounds of parents of children after complex CHD surgery to meet their different needs, and improve satisfaction. These findings provide a theoretical basis for constructing a family participatory nursing model for children in the intensive care unit in the future.

Congenital heart diseases trends in São Paulo State, Brazil: a national live birth data bank analysis

BACKGROUND

Congenital heart diseases (CHD) are the most common type of birth defects, affecting millions of newborns every year; no prevalence data are available in São Paulo State, Brazil's most populous state. The objective is to identify trends in prevalence and risk factors for CHD in São Paulo State, Brazil.

METHODS

We developed a population-based study to estimate the CHD trend of prevalence in recent years, stratified by maternal age and geographical clusters, using all cases of CHD identified by the Live Births Information System (SINASC-Sistema de Informação Sobre Nascidos Vivos) from January 1, 2005, to December 31, 2018. We calculated the trends of prevalence, the regression coefficient (β), the annual percent change (APC), and 95% confidence interval using the Prais-Winsten regression model, with the Durbin-Watson test.

RESULTS

We found 10,594 cases of CHD among 8,536,101 live births (LB), a prevalence of 12.4/10,000 LB. There was no difference in the sex distribution; they are primarily Caucasian (60.2%), 75.2% born at term, and 74.4% weight > 2500 g, 66.9% of births were by cesarean section. São Paulo State presented an increasing CHD trend of prevalence (APC = 18.9%). The highest CHD prevalence rate was in mothers aged ≥ 35 years (22.2/10,000 LB). There were 12,271 specific congenital heart defects among 10,594 patients (1.16 CHD/patient). Atrial septal defect has the highest number of cases (3835), with a prevalence of 4.49/10,000 LB, corresponding to 31.3% of all CHD.

CONCLUSION

CHD had an increasing prevalence trend in recent years, being highest in São Paulo City and ≥ 35-year mothers.

Congenital anomalies and maternal age: A systematic review and meta-analysis of observational studies

INTRODUCTION

Several studies have reported on the maternal age-associated risks of congenital anomalies. However, there is a paucity of studies with comprehensive review of anomalies. We aimed to quantify the risk of birth defects in children born to middle-aged mothers compared with that in children born to young or older mothers.

MATERIAL AND METHODS

We classified maternal ages into three groups: young (<20 years old), middle (20-34 years old) and older age (≥35 years old). Observational studies that met our age criteria were eligible for inclusion. The articles searched using the Embase and MEDLINE databases were those published from 1989 to January 21, 2021. The Newcastle-Ottawa scale was used to assess the risk of bias. If heterogeneity exceeded 50%, the random effect method was used; otherwise, the fixed-effect method was used. Prospero registration number: CRD42021235229.

RESULTS

We included 15 cohort, 14 case-control and 36 cross-sectional studies. The pooled unadjusted odds ratio (95% CI) of any congenital anomaly was 1.64 (1.40-1.92) and 1.05 (0.95-1.15) in the older and young age groups, respectively (very low quality of evidence). The pooled unadjusted odds ratio of chromosomal anomaly was 5.64 (5.13-6.20) and 0.69 (0.54-0.88) in the older and young age groups, respectively. The pooled unadjusted odds ratio of non-chromosomal anomaly was 1.09 (1.01-1.17) and 1.10 (1.01-1.21) in the older and young age groups, respectively (very low quality of evidence). The incidence of abdominal wall defects was increased in children of women in the young maternal age group.

CONCLUSIONS

We identified that very low quality evidence suggests that women in the older maternal age group had increased odds of having children with congenital anomalies compared with those in the 20-34 year age group. There was no increase in odds of children with congenital anomalies in women of <20 year age group except for abdominal defects compared with those in the 20-34 year age group. The results stem from very low quality evidence with no adjustment of confounders.

Epidemiology of Congenital Heart Disease in Jinan, China From 2005 to 2020: A Time Trend Analysis

Background

Although congenital heart defect (CHD) was the dominating birth defect, the time trend analysis of CHD was largely unknown. In our study, the time trend analysis of CHD from 2005 to 2020 in Jinan was conducted, aimed to reveal the epidemiological characteristics in a city and provided the data basis for the government to make a policy intervention.

Methods

A multi-institutional and retrospective review of CHD for all births from January 1, 2005 to December 31, 2020 was performed. Proportioner prevalence was used to describe the distribution of CHD. Comparisons of CHD characteristics among different groups were assessed with Chi-squares tests. Cochran-Armitage tests (CAT) were used to track changes in CHD prevalence.

Results

About 322,374 births and 5,180 CHD in Jinan were included from 2005 to 2020, and the total CHD prevalence was 3.92 per 1,000 births. The CHD prevalence showed an upward trend, with a total increase of 227.66% from 2005 to 2020. The CHD prevalence in urban areas was 34.17% higher than that in rural areas, but the gap was narrowing. Atrial septal defect (3.07 per 1,000 births), patent ductus arteriosus (1.62 per 1,000 births), ventricular septal defect (1.18 per 1,000 births), tetralogy of Fallot (0.62 per 1,000 births), and atrioventricular septal defect (0.47 per 1,000 births) were the 5 most common subtypes.

Conclusion

The prevalence of CHD in Jinan was gradually on the rise, which needs to be highly focused on by the health management department. Older pregnant women and women in rural areas should be concerned, and targeted measures need to be introduced.

Epidemiological Aspects, Prenatal Screening and Diagnosis of Congenital Heart Defects in Beijing

Background: In China, congenital heart disease (CHD) is the most common birth defect type, with approximately 13,000 new cases annually. This study aimed to investigate high-risk factors, prenatal screening and prenatal diagnosis as a basis for clinical decisions. Methods: All CHD cases identified from 2018 to 2020 were obtained from the Beijing city birth defect surveillance system and prenatal diagnosis institutions. The prenatal CHD diagnosis was confirmed by fetal echocardiography and amniotic fluid or cord blood genetic examination. Chi-square, odds ratio (OR), 95% confidence interval (CI), and univariate and multivariate logistic analyses were used to explore the high-risk factors, prenatal screening and prenatal diagnosis of CHD. Results: In total, 6,786/594,860 fetuses with CHD were diagnosed by prenatal echocardiography. The average incidence of CHD was 11.4 per 1,000 births, with an increase of 30.7 per 1,000 births from 2018 to 2020 (P < 0.05); the average incidence of complex CHD (CCHD) was 2.02 per 1,000 births, with no significant change from 2018 to 2020 (P > 0.05). Women age ≥35 years (OR 1.06, 95% CI 0.77-1.46) was at higher risk of having babies with CHD than women aged 21-34 years. Overall, CHD incidence increased with maternal age (OR1.03, 95% CI 1.02-1.03). Additionally, women who had a non-local household registration (OR 1.16, 95% CI 1.10-1.22) or had diabetes mellitus (DM) (OR 1.16, 95% CI 0.96-1.25) were at higher risk of CHD. As an independent factor, CCHD was related to maternal age, DM, fetal gender, and maternal education level (all P < 0.05). The prenatal ultrasound screening detection rate of CCHD was 97.59%, which was far higher than that of total CHD (51.67%) (P < 0.001). The prenatal ultrasound diagnosis rate of CCHD was higher than that of simple CHD (P < 0.001), but the coincidence rate in the ultrasound diagnosis of CCHD was lower than that of simple CHD (P < 0.001). Prenatal genetic testing revealed chromosomal abnormalities in 25.62% (279/1089) of CHD cases with indications for a prenatal diagnosis. Conclusions: Maternal age, household registration and DM were related to CHD occurrence. Prenatal ultrasound screening is a highly effective method for CCHD diagnosis, and CHD fetuses should be closely evaluated to exclude chromosomal abnormalities.

Prevalence of Congenital Heart Disease in Chinese Children With Different Birth Weights and Its Relationship to the Neonatal Birth Weight

OBJECTIVE

This study aimed to examine the prevalence and the related risk factors of congenital heart disease (CHD) in children with different birth weights in China and the relationship between the subtypes of CHD and birth weight (BW).

METHODS

This study conducted a cross-sectional survey on the data collected in the children's congenital heart disease database (CHDD) established in China. This database contained data from one Grade A, Level III Children's Public Hospital in Zhengzhou, Henan. The study included all the children and their parents in the database from 2014 to 2020 as the study subjects, and the missing data were processed by means of imputation. Diagnoses of CHD were coded using the International Classification of Diseases version 10 (ICD-10), and subtypes were classified by the codes Q20 to Q26. We reported the prevalence of CHD based on birth weight and gestational age and analyzed the related risk factors for children with CHD in different birth weight groups and factors for children of the same birth weight groups between the CHD groups and the non-CHD groups. The generalized linear model was used to assess the association between the subtypes of CHD and BW by establishing three adjusting models, and the data were stratified for further analysis by urban-rural and infant gender.

RESULTS

A total of 42,814 children were identified as having CHD among 5,071,799 live children; the overall prevalence of CHD was 8.44 per 1,000 live births during 2014-2020; and the three subtypes with the highest prevalence of CHD were atrial septal defect (ASD) (2.75‰), ventricular septal defect (VSD) (2.57‰), and patent foramen ovale (PFO) (1.12‰). The prevalence of CHD was 18.87‰ in the group with BW <1,500 g, 12.84‰ in the group with BW 1,500-2,500 g, 8.24‰ in the group with BW 2,500-4,000 g, and 4.80‰ in the group with BW ≥4,000 g. The prevalence of CHD was 16.62‰ in the small for gestational age (SGA) group, 6.99‰ in the appropriate for gestational age (AGA) group, and 6.40‰ in the larger for gestational age (LGA) group. Parental factors such as drinking, smoking, viral infections, peri-pregnancy exposure to radioactive substances, low family monthly expenditure, and low Apgar scores at 1 and 5 min were related to the increased risk of CHD in the offspring. Parental supplementation of folic acid and exercise during the peri-pregnancy period could reduce the risk of CHD in the offspring. The results of Model 3 adjusting for confounding variables showed that infants with ASD had a birth weight 461 g lower (95% CI: -1,085, -128), infants with VSD had a birth weight 426 g lower (95% CI: -932, -120), infants with tetralogy of Fallot (TOF) had a birth weight 532 g lower (95% CI: -987, -168), and without classification, infants with CHD had a birth weight 973 g lower (95% CI: -1,502, -204).

CONCLUSION

In very low birth weight (VLBW) and low birth weight (LBW) infants, CHDs are more prevalent than in the general live-born population. Moreover, some peri-pregnancy factors of parents are closely related to the occurrence of CHD in offspring; different types of heart defects can lead to LBW. Therefore, if the fetus is found to have a heart defect during the prenatal examination, the mother should pay more attention to maintaining weight and ensuring that the fetus is within the normal weight range, thereby increasing the postpartum survival rate, reducing complications, and promoting children's health.

Spatio-Temporal Distribution and Demographic Characteristics of Congenital Heart Defects in Guangdong, China, 2016-2020

BACKGROUND

Congenital heart defects are the most common type of birth defects and bring a heavy disease burden in China. Examining the temporal and spatial trends of congenital heart defects epidemics can give some elementary knowledge for succeeding studies.

OBJECTIVE

To characterize the spatial-temporal patterns of the prevalence of congenital heart defects based on a substantial cohort of the perinatal fetus in south China in 2016-2020.

METHODS

This study was a retrospective population-based cohort study conducted in Guangdong, China from 2016 to 2020. Pregnant women and their infants received birth defect surveillance during pregnancy and seven days after delivery in more than 1,900 midwifery hospitals in 21 cities. Perinatal infants with congenital heart defects were identified and enrolled. The prevalence of congenital heart defects was calculated according to cities, years, urban and rural areas, regions of Guangdong, categories of maternal age at delivery, seasons of delivery, and infant's gender.

RESULTS

A total of 8,653,206 perinatal infants and 53,912 total congenital heart defects were monitored in Guangdong, including 46,716 (86.65%) without other defects and 7,736 (13.35%) with other defects. The average prevalence of total congenital heart defects was 62.30/10,000 (95% CI, 61.78/10,000-62.83/10,000), congenital heart defects without other defects was 53.36/10,000 (95% CI, 52.88/10,000-53.85/10,000), and congenital heart defects with other defects was 8.94/10,000 (95%CI, 8.74/10,000-9.14/10,000). From 2016 to 2020, the prevalence of total congenital heart defects was 54.92/10,000, 54.23/10,000, 63.79/10,000, 73.11/10,000, 68.20/10,000, respectively. We observed geographical variations within the prevalence of congenital heart defects. The prevalence of congenital heart defects was much higher in the Pearl River Delta region than in the non-Pearl River Delta region, as well as higher in urban areas than in rural areas.

CONCLUSION

The findings of this study are helpful to the understanding of the etiology and epidemiology characteristics of congenital heart defects in south China. Our data likely reflect a better estimate of the spatiotemporal trends in congenital heart defects prevalence than reported previously.

Model-based iterative reconstruction for 320-detector row CT angiography reduces radiation exposure in infants with complex congenital heart disease

PURPOSE

We investigated the impact of model-based iterative reconstruction (MBIR) on 320-detector row computed tomography angiography (CTA) in infants with complex congenital heart disease (CHD).

METHODS

Seventy infants with complex CHD who underwent 320-detector row CTA (40 boys and 30 girls; age range, 0-22 months; median age, 60 days) were retrospectively evaluated. First, the images were reconstructed by filtered back projection (FBP), hybrid iterative reconstruction (HIR), or MBIR in 20 cases, and variables were compared among the three iterative reconstruction methods (IR test). Second, the variables were compared between 25 cases scanned using HIR and 25 cases scanned using MBIR, with a 20 standard deviation noise level for both. Attenuation values and contrast-to-noise ratios (CNRs) of the great vessels and heart chambers were calculated. Total dose-length products were recorded for all patients (radiation dose: RD test).

RESULTS

In the IR test, the mean CNR values were 4.8±1.3 for FBP, 6.9±1.4 for HIR, and 8.2±1.7 for MBIR (P < 0.0001). The best subjective image qualities in the great vessels and heart chambers were obtained with MBIR. In RD testing, no significant differences between HIR and MBIR in image quality (CNR: HIR, 8.4±2.4; MBIR, 8.3±2.4) were observed. The effective dose was significantly lower for MBIR than for HIR (0.7±0.2 vs. 1.1±0.3 mSv; P < 0.001).

CONCLUSION

The MBIR algorithm significantly improved image quality and decreased radiation exposure in 320-row CTA of infants with complex CHD, providing an alternative to FBP or HIR that is both safer and produces better results.

Associations between weekly air pollution exposure and congenital heart disease

BACKGROUND

The topic of congenital heart diseases (CHDs) has attracted more and more attentions. Accumulating evidence suggests that exposure to air pollutants during pregnancy is associated with CHDs, yet the results are inconsistent and study about weekly exposure is few. Our study evaluated the association between weekly air pollution and CHDs in Hefei, China.

MATERIALS AND METHODS

Daily CHDs admission data were obtained from eight hospitals in Hefei from October 2015 to September 2017. Meteorological data and air quality were collected from China Meteorological Data Network. Distributed lag nonlinear model (DLNM) considering both the lag effect of exposure factors and the nonlinear relationship of exposure-reaction was used to assess the effect of weekly air pollutants exposure on CHDs admission.

RESULTS

During the study period, totally 47,046 cases of perinatal infants were recruited, and the incidence of CHDs was 9.71 per thousand. The findings showed PM_2.5, PM₁₀, SO₂ and NO₂ significantly increased the risk of CHDs. Each 10 μg/m³ increase in PM_2.5 during gestational weeks 20-26 increased the risk of CHDs. The susceptibility windows of PM₁₀ (weeks 0-2 and weeks 25-29 of pregnancy), SO₂ (weeks 8-16 and weeks 29-38) and NO₂ (week 40), while the strongest effects of these 4 pollutants on CHDs were observed in week 22 (RR = 1.034, 95% CI: 1.007-1.062), week 0 (RR = 1.081, 95% CI: 1.02-1.146), week 37 (RR = 1.528, 95% CI: 1.085-2.153) and week 40 (RR = 1.171, 95% CI: 1.006-1.364), respectively.

CONCLUSIONS

Air pollutants (SO₂, NO₂, PM₁₀, and PM_2.5) exposure could increase the risk of CHDs, while the most crucial susceptibility windows for the exposure were mainly in the second and third trimesters. Boys seemed to be more sensitive to air pollution. Our study contributes to the knowledge of the association between maternal exposure to air pollution and CHDs, but the associations need to be verified by further studies.

Transient increase in VEGF-A leads to cardiac tube anomalies and increased risk of congenital heart malformations

Vascular endothelial growth factor (VEGF) plays a critical role during early heart development. Clinical evidence shows that conditions associated with changes in VEGF signaling in utero are correlated with an increased risk of congenital heart defects (CHD) in newborns. However, how malformations develop after abnormal VEGF exposure is unknown. During embryogenesis, a primitive heart, consisting of an endocardial tube enveloped by a myocardial mantle, is the first organ to function. This tubular heart ultimately transforms into a four-chambered heart. To determine how a transient increase in VEGF prior to heart tube formation affects heart development leading to CHD, we applied exogenous VEGF or a control (vehicle) solution to quail embryos in ovo at Hamburger-Hamilton (HH) stage 8 (28-30 hr of incubation), right before heart tube formation. Light microscopy analysis of embryos re-incubated after treatment for 13 hrs (to approximately HH11/HH12) showed that increased VEGF leads to impaired heart tube elongation accompanied by diameter expansion. Micro-CT analysis of embryos re-incubated for 9 days (to approximately HH38), when the heart is fully formed, showed that VEGF treatment increased the rate of cardiac malformations in surviving embryos. Despite no sex differences in survival, female embryos were more likely to develop cardiac malformations. Our results further suggest that heart tube malformations after a transient increase in VEGF right before heart tube formation may be reversible, leading to normal hearts.

Prevalence of Congenital Heart Disease among Children in Khorramabad (West of Iran)

AIMS

Congenital heart disease is among the most common congenital anomalies in pediatrics. The aim of this study was to evaluate the prevalence of congenital heart disease in children in Khorramabad, Iran.

METHODS

This is a descriptive-cross sectional study where all the children diagnosed with congenital heart disease by echocardiography were enrolled to the Shahid Madani Hospital. Patient information was collected by means of a questionnaire. Of 1600 children who underwent cardiac counseling, 9.75% presented congenital heart disease. These were most prevalent among the children of 0-28 days of the age (14.7%) and least in children aged 1 month-1 year. According to this study, atrial (20.3%) and ventricular septal defect (10.5%) were the most common heart defects, respectively. Among signs and symptoms of cardiac disease, 49.1% of children had cyanosis, 89.7% with increased CT (cardiothoracic)-ratio, and 82.7% of had heart murmur. Congenital heart disease was more prevalent in male infants (58%) and 6.6% patients had heart failure and 1.4% had other congenital conditions, such as Down syndrome.

RESULTS

According to our findings, atrial and ventricular septal defects are the most common congenital heart anomalies, respectively, in pediatric patients in Khorramabad.

Chromosomal abnormality: Prevalence, prenatal diagnosis and associated anomalies based on a provincial-wide birth defects monitoring system

AIM

To investigate the epidemiology of chromosomal abnormalities (CA) in fetuses of all pregnancies based on a provincial-wide birth defects-monitoring system, which could provide scientific basis for making relatively policy and research.

METHODS

Chromosomal abnormalities cases were collected from all hospitals in Hunan Province, China, between 2016 and 2019. The prevalence of CAs was calculated to examine associations among infant sex, maternal age and region. The rates of prenatal diagnosis and termination of pregnancy (TOP) involving CA or associated anomalies were calculated as rates or proportions.

RESULTS

From 2016 to 2019, a total of 2 883 890 perinatal infants (28 weeks of gestation to postpartum 7 days) underwent prenatal screening and diagnostic tests, and 3181 fetuses were diagnosed as CA, with the prevalence of 11.03/10 000. The average prevalence of CAs was higher for male than female fetuses (11.33/10 000 vs 10.06/10 000) (OR = 1.13, 95% CI: 1.05-1.21), which was higher in urban areas than rural areas (23.03/10 000 vs 7.13/10 000) (OR = 3.23, 95% CI: 3.02-3.47), and the prevalence increased linearly with maternal age ( X trend 2 = 1821.844, P = 0.000). Among the fetuses with CAs, 3097 (97.36%) were diagnosed prenatally, and 3046 (98.35%) underwent TOP. The majority of CA were numerical abnormalities (90.18%). The main types of numerical autosomal abnormalities were trisomy 21 (6.69/10 000, 59.57%), trisomy 18 (1.13/10 000, 10.04%) and trisomy 13 (0.21/10 000, 1.88%). The main types of numerical gonosomal abnormalities were Klinefelter syndrome (0.68/10 000, 6.02%), Turner syndrome (0.49/10 000, 4.39%), Triple X syndrome (0.26/10 000, 2.29%) and 47,XYY syndrome (0.21/10 000, 1.91%). The three associated anomalies with the highest proportions were congenital heart defects (CHD) (41.06%), cleft palate or/and cleft lip (10.89%) and congenital talipes equinovarus (8.94%).

CONCLUSION

The prevalence of CA was lower than that reported. Chromosome detection should be further promoted including test contest and coverage, especially for urban areas, older mothers and fetuses with CHD, cleft palate or/and cleft lip or congenital talipes equinovarus.

Selective serotonin reuptake inhibitor or serotonin-norepinephrine reuptake inhibitors and epidemiological characteristics associated with prenatal diagnosis of congenital heart disease

OBJECTIVE

Identify early pregnancy associations of congenital heart disease (CHD) in a multiethnic cohort.

METHODS

This retrospective observational cohort study compared the general obstetric population to women who gave birth at a referral centre in Australia between 2012 and 2017, after 20 weeks' of gestation, with a pregnancy affected by CHD. We defined mood disorder and anxiety as a history of self-reported or medically diagnosed anxiety, depression, postpartum depression or bipolar disorder.

RESULTS

We compared epidemiological factors between 30 842 general obstetric patients and 470 obstetric patients with a foetus affected by CHD. Multivariate analysis showed independent associations between CHD and use of selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) in the first trimester (relative risk [RR] 4.14, 95% CI 2.58-6.65), history of anxiety or mood disorder with no SSRI/SNRI first trimester (RR 2.20, 95% CI 1.77-2.74), folate and/or pregnancy multivitamin use in the first trimester (RR 0.69, 95% CI 0.55-0.87) and increased risk with maternal age >40 years (RR 2.30, 95% CI 1.57-3.38).

CONCLUSIONS

Our data show maternal mood disorders with and without SSRI or SNRI use, maternal age >40 years and lack of multivitamin/folate use to be independently associated with CHD in pregnancy.

Epidemiology, prenatal diagnosis, and neonatal outcomes of congenital heart defects in eastern China: a hospital-based multicenter study

BACKGROUND

Congenital heart defect is the leading malformation in China. There may have been changes in congenital heart defect incidence because of birth policy shift in China over past years. This study aimed to investigate the epidemiology, prenatal diagnosis, and outcomes of congenital heart disease to improve medical and policy decisions.

METHODS

Data on cases of congenital heart disease identified during 2014-2018 were taken from the Zhejiang provincial birth defects surveillance system. Chi-square test, odds ratio (OR) and 95% confidence interval (CI) were used to explore epidemiology, prenatal diagnosis, and birth outcomes of congenital heart disease.

RESULTS

The average incidence of congenital heart disease was 16.0 per 1000 births, which increased by 62.2% during 2014-2018(χ2trend = 181.41, P < 0.001). However, the average critical congenital heart incidence was 1.6 per 1000 births, which remained stable over time. Women aged ≤20 years (OR2.1, 95% CI 1.9-2.3) or ≥ 35 years (OR 1.2, 95% CI 1.2-1.3) were at higher risk of having babies with congenital heart disease than women aged 21-34 years. Women who gave birth in urban areas (OR 1.2, 95% CI 1.2-1.3), had a son (OR 1.3, 95% CI 1.3-1.4), or had multiple births (OR 4.0, 95% CI 3.7-4.4) were also at higher risk than those giving birth in rural areas, to girls, or single births, respectively. The three major subtypes of congenital heart disease were atrial septal defect (67.9%), patent ductus arteriosus (34.7%), and ventricular septal defect (6.4%). The prenatal detection rate of critical congenital heart disease was 90.0%, which was far higher than total congenital heart disease, at 22.2% (χ2 = 1687.67, P < 0.001). There were 1457 (17.1%) stillbirths, 106 (1.2%) early neonatal deaths, and 6983 (81.7%) live births associated with congenital heart disease.

CONCLUSIONS

The high incidence of congenital heart disease in Zhejiang might be attributable to the large proportion of mild congenital heart disease. The incidence of critical congenital heart disease, the prenatal detection rate, and perinatal deaths from congenital heart disease are comparable to those in other studies.

Birth prevalence of congenital heart disease in China, 1980-2019: a systematic review and meta-analysis of 617 studies

To assess the birth prevalence and spatial distribution of congenital heart disease (CHD) in China by conducting a complete overview and using spatial epidemiological methods. Unrestricted searches were conducted on seven electronic databases, with an end-date parameter of May 2019. Data on the birth prevalence of CHD and its subtypes were collected and combined using either the random-effect model or fixed-effect model. Subgroup sensitivity analyses were performed to explore potential heterogeneity moderators. The three-dimensional trend analysis and a visualization of CHD birth prevalence among different provinces were performed to describe the spatial distribution characteristics. Total 617 studies involving 76,961,354 births and 201,934 CHD individuals were included. Overall, total CHD birth prevalence increased continuously over time, from 0.201‰ in 1980-1984 to 4.905‰ in 2015-2019. The study on the high-income provinces, population-based monitoring model, male births, and urban regions reported a significantly higher prevalence of total CHD compared with upper-middle-income provinces, hospital-based monitoring model, female births, and rural regions, respectively. National CHD birth prevalence increased gradually from western region to eastern region, but decreased gradually from southern to northern region. Relevant heterogeneity moderators including gender, geographic region, income levels, and monitoring models have been identified by subgroup analyses. Sensitivity analysis yielded consistent results. Total CHD birth prevalence in China increases continuously in the past 40 years. Significant differences in gender, geographical regions, income levels, and monitoring models were found. In the future, population wide prospective birth defect registries covering the entire Chinese population need to determine the exact birth prevalence.

Transthoracic closure of ventricular septal defects guided by transesophageal echocardiography

Background

This study aims to investigate the effectiveness and safety of transthoracic closure of ventricular septal defects totally guided by transesophageal echocardiography.

Methods

A total of 119 patients (62 males, 57 females; mean age 2.1±5.2 years; range, 11 months to 50 years) who underwent transthoracic closure of ventricular septal defects in our center between April 2017 and November 2018 were included. All patients were evaluated in terms of the diameter and morphological features of ventricular septal defects via transesophageal echocardiography. During the procedure, transthoracic echocardiography was used as the only guiding tool for occluder implantation.

Results

Of the patients, 116 underwent successful transthoracic device closure procedure. Two patients were switched to surgical repair due to new-onset aortic regurgitation in one patient and severe arrhythmias after device release in the other patient. One patient underwent a second operation for occluder migration during the hospital stay. In the first attempt, 106 ventricular septal defect occluders were correctly positioned. Transthoracic echocardiography revealed the insecure position or significant residual shunting in 10 patients. The original device was replaced with an asymmetric device or a more extensive occluder, and satisfactory results were finally obtained. No complications such as new-onset aortic regurgitation, residual shunt, complete heart block, or device dislodgement occurred during follow-up.

Conclusion

Transthoracic closure of ventricular septal defects under the total guidance of transthoracic echocardiography is a safe and effective method.

Association of maternal ethnicity and urbanicity on severe pediatric disease: a nationwide cohort study

BACKGROUND

A healthy migrant effect on birth outcomes has been reported, however, whether this protective effect persists throughout childhood is unknown. The effect of urbanicity on child health among an immigrant population is unclear. The objective of this study was to compare the incidence rate and cumulative incidence of severe diseases among urban children of Taiwan-born mothers, rural children of Taiwan-born mothers, urban children of foreign-born mothers, and rural children of foreign-born mothers.

METHODS

A nationwide cohort study was conducted for children born in Taiwan during 2004-2011 and follow-up till age 4 to 11 years old by linkage the Taiwan Birth Registry 2004-2011, Taiwan Death Registry 2004-2015, and National Health Insurance Research Database 2004-2015. Cox proportional hazards model (multivariable) was used to examine differences among the four study groups.

RESULTS

There were 682,982 urban children of Taiwan-born mothers, 662,818 rural children of Taiwan-born mothers, 61,570 urban children of foreign-born mothers, 87,473 rural children of foreign-born mothers. Children of foreign-born mothers had a lower incidence of vasculitis, mainly Kawasaki disease. The incidences of congenital disorders did not differ between children of foreign-born mothers and children of Taiwan-born mothers. The incidence of psychotic disorders was higher in urban children. However, children in rural areas had a higher incidence of major trauma/burn and a higher mortality rate.

CONCLUSIONS

A healthy migrant effect was only seen for Kawasaki disease. The mental health of urban children born to immigrant mothers warrants concern.

Associations between maternal social support and stressful life event with ventricular septal defect in offspring: a case-control study

Background

Previous studies suggested that maternal subjective feeling of stress seemed to be involved in the incidence of congenial heart disease in offspring. To better understand the findings, our study would discuss the relationships of maternal exposure to stressful life event and social support, which are more objective and comprehensive indicators of stress, around periconceptional period with the risk of ventricular septal defect (VSD), the most popular subtype of congenital heart disease.

Methods

A hospital-based case-control study was conducted through June, 2016 to December, 2017. We collected maternal self-reports of 8 social support questions in 3 aspects and 8 stressful life events among mothers of 202 VSD cases and 262 controls. Social support was categorized into low, medium high, and high (higher is better), and stressful life event was indexed into low, medium low, and high (higher is worse). Logistic regression models were applied to estimate adjusted odds ratios and 95% confidence intervals (95% CI).

Results

The adjusted odds ratio of high stressful life event was 2.342 (95% CI: 1.348, 4.819) compared with low stressful life event. After crossover analysis, compared with low event & high support, the adjusted odds ratio of low event & low support, high event & high support, and high event & low support were 2.059 (95% CI: 1.104, 3.841), 2.699 (95% CI: 1.042, 6.988) and 2.781 (95% CI: 1.033, 7.489), respectively.

Conclusions

In summary, we observed an increased risk of VSD when pregnant women exposed to stressful life events, however, social support could, to some extent, reduce the risk of stressful life event.

Association study of a functional variant of TNF-α gene and serum TNF-α level with the susceptibility of congenital heart disease in a Chinese population

BACKGROUND

Congenital heart disease (CHD) is among the leading causes of infant death worldwide. Although shortage of folate has been found potentially to contribute to CHD in the embryo, the aetiology of CHD was not completely understood. Inflammation and altered immune processes are involved in all forms of cardiac malformation, including CHD. Tumour necrosis factor-α (TNF-α), was involved in the pathogenesis of multiple kinds of heart diseases. However, no studies have systematically evaluated the associations of genetic variants of TNF-α with susceptibility of CHD.

METHODS

A case-control study was conducted to evaluate the associations between tagSNPs of TNF-α and CHD susceptibility. Serum level of TNF-α was assessed using ELISA. The dual luciferase reporter assay was used to evaluate the functional significance of variant rs1800629 on TNF-α transcriptional activity.

RESULTS

We found rs1800629 was significantly correlated with increased CHD susceptibility (OR: 1.72, 95% CI 1.26 to 2.36, p=0.001). Serum levels of TNF-α were significantly higher in CHD group (9.09±1.90 pg/mL) than that in control group (6.12±1.56 pg/mL, p<0.001). The AA genotype and AG genotype of rs1800629 was associated with higher serum TNF-α level, compared with GG genotype. The dual luciferase reporter assay showed that promoter activity was significantly increased by 57% and 76% for plasmids containing the minor A allele compared with the major G allele in H9c2 and HEK 293T, respectively.

CONCLUSION

These results indicate that higher level of serum TNF-α increases risk of CHD, while TNF-α rs1800629 A allele might contribute to higher risk for CHD due to the increase in TNF-α expression.

Risk Factors for Major Adverse Events after Surgical Closure of Ventricular Septal Defect in Patients Less than 1 Year of Age: A Single-Center Retrospective

OBJECTIVE

To reveal the risk factors that can lead to a complicated course and an increased morbidity in patients < 1 year old after surgical ventricular septal defect (VSD) closure.

METHODS

We reviewed a consecutive series of patients who were admitted to our institution for surgical VSD closure who were under one year of age, between 2015 and 2018. Mechanical ventilation (MV) time > 24 hours, intensive care unit (ICU) stay longer than three days, and hospital stay longer than seven days were defined as "prolonged". Unplanned reoperation, complete heart block requiring a permanent pacemaker implantation, sudden circulatory arrest, and death were considered as significant major adverse events (MAE).

RESULTS

VSD closure was performed in 185 patients. The median age was five (1-12) months. There was prolonged MV time in 54 (29.2%) patients. Four patients (2.2%) required permanent pacemaker implantation. Hemodynamically significant residual VSD was observed in six (3.2%) patients. Extracorporeal membrane oxygenation-cardiopulmonary resuscitation was performed in one (0.5%) patient. Small age (< 4 months) (P-value<0.001) and prolonged cardiopulmonary bypass time (P=0.03) were found to delay extubation and to prolong MV time. Low birth weight at the operation was associated with MAE (P=0.03).

CONCLUSION

Higher body weight during operation had a reducing effect on the MAE frequency and shortened the MV duration, ICU stay, and hospital stay. As a conclusion, for patients who are scheduled to undergo VSD closure, body weight should be taken into consideration.