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Chambers HN, Caris E, Conwell J, Edwards LA, Hulse JE, Lewin M, Pinto NM, Wolfe E, Arya B. Suboptimal Imaging on Obstetric Ultrasound Should Prompt Early Referral for Fetal Echocardiography. Pediatr Cardiol 2024:10.1007/s00246-024-03495-9. [PMID: 38831151 DOI: 10.1007/s00246-024-03495-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 04/08/2024] [Indexed: 06/05/2024]
Abstract
Recent studies suggest that suboptimal cardiac imaging on routine obstetric anatomy ultrasound (OB-scan) is not associated with a higher risk for congenital heart disease (CHD) and, therefore, should not be an indication for fetal echocardiography (F-echo). We aim to determine the incidence of CHD in patients referred for suboptimal imaging in a large catchment area, including regions that are geographically distant from a tertiary care center. We conducted a retrospective chart review of patients referred to Seattle Children's Hospital (SCH) and SCH Regional Cardiology sites (SCH-RC) from 2011 to 2021 for F-echo with the indication of suboptimal cardiac imaging by OB-scan. Of 454 patients referred for suboptimal imaging, 21 (5%) of patients were diagnosed with CHD confirmed on postnatal echo. 10 patients (2%) required intervention by age one. Mean GA at F-echo was significantly later for suboptimal imaging compared to all other referral indications (27.5 ± 3.9 vs 25.2 ± 5.2 weeks, p < 0.01). Mean GA at F-echo was also significantly later at SCH-RC compared to SCH (29.2 ± 4.6 vs 24.2 ± 2.9 weeks; p < 0.01). In our experience, CHD in patients referred for suboptimal imaging is higher (5%) than previously described, suggesting that routine referral for is warranted. Furthermore, while suboptimal imaging was associated with a delayed F-echo compared to other indications, this delay was most striking for those seen at regional sites. This demonstrates a potential disparity for these patients and highlights opportunities for targeted education in cardiac assessment for primary providers in these regions.
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Affiliation(s)
- Hailey N Chambers
- Seattle Children's Hospital, University of Washington Medical Center, OC.7.830, 4800 Sandpoint Way NE, Seattle, WA, 98105, USA.
| | | | - Jeffrey Conwell
- Seattle Children's Hospital, University of Washington Medical Center, Seattle, WA, USA
| | | | - J Eddie Hulse
- Seattle Children's Hospital, University of Washington Medical Center, Seattle, WA, USA
| | - Mark Lewin
- Seattle Children's Hospital, University of Washington Medical Center, Seattle, WA, USA
| | - Nelangi M Pinto
- Seattle Children's Hospital, University of Washington Medical Center, Seattle, WA, USA
| | - Elana Wolfe
- Seattle Children's Hospital, University of Washington Medical Center, Seattle, WA, USA
| | - Bhawna Arya
- Seattle Children's Hospital, University of Washington Medical Center, Seattle, WA, USA
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2
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Janzing P, Nourkami-Tutdibi N, Tutdibi E, Freundt P, von Ostrowski T, Langer M, Zemlin M, Steinhard J. Controlled prospective study on ultrasound simulation training in fetal echocardiography: FESIM II. Arch Gynecol Obstet 2024; 309:2505-2513. [PMID: 37454353 PMCID: PMC11147821 DOI: 10.1007/s00404-023-07133-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/27/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE To analyze the learning curves of ultrasound novices in fetal echocardiography during structured simulation-based ultrasound training (SIM-UT) including a virtual, randomly moving fetus. METHODS 11 medical students with minimal (< 10 h) prior obstetric ultrasound experience underwent 12 h of structured fetal echocardiography SIM-UT in individual hands-on sessions during a 6-week training program. Their learning progress was assessed with standardized tests after 2, 4, and 6 weeks of SIM-UT. Participants were asked to obtain 11 fetal echocardiography standard planes (in accordance with ISUOG and AHA guidelines) as quickly as possible. All tests were carried out under real life, examination-like conditions on a healthy, randomly moving fetus. Subsequently, we analyzed the rate of correctly obtained images and the total time to completion (TTC). As reference groups, 10 Ob/Gyn physicians (median of 750 previously performed Ob/Gyn scans) and 10 fetal echocardiography experts (median of 15,000 previously performed Ob/Gyn scans) were examined with the same standardized tests. RESULTS The students showed a consistent and steady improvement of their ultrasound performance during the training program. After 2 weeks, they were able to obtain > 95% of the standard planes correctly. After 6 weeks, they were significantly faster than the physician group (p < 0.001) and no longer significantly slower than the expert group (p = 0.944). CONCLUSION SIM-UT is highly effective to learn fetal echocardiography. Regarding the acquisition of the AHA/ISUOG fetal echocardiography standard planes, the students were able to reach the same skill level as the expert group within 6 weeks.
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Affiliation(s)
- Paul Janzing
- Hospital for General Pediatrics and Neonatology, Saarland University Medical Center, 66421, Homburg/Saar, Germany.
| | - Nasenien Nourkami-Tutdibi
- Hospital for General Pediatrics and Neonatology, Saarland University Medical Center, 66421, Homburg/Saar, Germany
| | - Erol Tutdibi
- Hospital for General Pediatrics and Neonatology, Saarland University Medical Center, 66421, Homburg/Saar, Germany
| | - Paula Freundt
- Hospital for General Pediatrics and Neonatology, Saarland University Medical Center, 66421, Homburg/Saar, Germany
| | | | - Martin Langer
- LARA-Praxis für Frauengesundheit, Bocholt, NRW, Germany
| | - Michael Zemlin
- Hospital for General Pediatrics and Neonatology, Saarland University Medical Center, 66421, Homburg/Saar, Germany
| | - Johannes Steinhard
- Fetal Cardiology, Heart and Diabetes Center NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
- Prenatal Medicine Center Münster, Münster, NRW, Germany
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3
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Rosamilia MB, Williams J, Bair CA, Mulder H, Chiswell KE, D'Ottavio AA, Hartman RJ, Sang CJ, Welke KF, Walsh MJ, Hoffman TM, Landstrom AP, Li JS, Sarno LA. Risk Factors and Outcomes Associated with Gaps in Care in Children with Congenital Heart Disease. Pediatr Cardiol 2024; 45:976-985. [PMID: 38485760 PMCID: PMC11056317 DOI: 10.1007/s00246-024-03414-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 01/09/2024] [Indexed: 04/29/2024]
Abstract
Adults with congenital heart disease (CHD) benefit from cardiology follow-up at recommended intervals of ≤ 2 years. However, benefit for children is less clear given limited studies and unclear current guidelines. We hypothesize there are identifiable risks for gaps in cardiology follow-up in children with CHD and that gaps in follow-up are associated with differences in healthcare utilization. Our cohort included children < 10 years old with CHD and a healthcare encounter from 2008 to 2013 at one of four North Carolina (NC) hospitals. We assessed associations between cardiology follow-up and demographics, lesion severity, healthcare access, and educational isolation (EI). We compared healthcare utilization based on follow-up. Overall, 60.4% of 6,969 children received cardiology follow-up within 2 years of initial encounter, including 53.1%, 58.1%, and 79.0% of those with valve, shunt, and severe lesions, respectively. Factors associated with gaps in care included increased drive time to a cardiology clinic (Hazard Ratio (HR) 0.92/15-min increase), EI (HR 0.94/0.2-unit increase), lesion severity (HR 0.48 for shunt/valve vs severe), and older age (HR 0.95/month if < 1 year old and 0.94/year if > 1 year old; p < 0.05). Children with a care gap subsequently had more emergency department (ED) visits (Rate Ratio (RR) 1.59) and fewer inpatient encounters and procedures (RR 0.51, 0.35; p < 0.05). We found novel factors associated with gaps in care for cardiology follow-up in children with CHD and altered health care utilization with a gap. Our findings demonstrate a need to mitigate healthcare barriers and generate clear cardiology follow-up guidelines for children with CHD.
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Affiliation(s)
| | - Jason Williams
- Department of Pediatrics, Division of Pediatric Cardiology, Duke School of Medicine, Durham, NC, USA
| | | | - Hillary Mulder
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Karen E Chiswell
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Alfred A D'Ottavio
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Robert J Hartman
- Department of Pediatrics, Division of Pediatric Cardiology, University of North Carolina at Chapel Hill Medical Center, Chapel Hill, NC, USA
| | - Charlie J Sang
- Department of Pediatrics, Division of Pediatric Cardiology, East Carolina University, Greenville, NC, USA
| | - Karl F Welke
- Department of Surgery, Division of Pediatric Cardiothoracic Surgery, Atrium Health Levine Children's Hospital, Charlotte, NC, USA
| | - Michael J Walsh
- Department of Pediatrics, Division of Pediatric Cardiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Timothy M Hoffman
- Department of Pediatrics, Division of Pediatric Cardiology, University of North Carolina at Chapel Hill Medical Center, Chapel Hill, NC, USA
| | - Andrew P Landstrom
- Department of Pediatrics, Division of Pediatric Cardiology, Duke School of Medicine, Durham, NC, USA
- Department of Cell Biology, Duke School of Medicine, Durham, NC, USA
| | - Jennifer S Li
- Department of Pediatrics, Division of Pediatric Cardiology, Duke School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Lauren A Sarno
- Department of Pediatrics, Division of Pediatric Cardiology, East Carolina University, Greenville, NC, USA.
- Brody School of Medicine, East Carolina University, 115 Heart Drive, Greenville, NC, 27834, USA.
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Klein JH, Donofrio MT. Untangling the Complex Associations between Socioeconomic and Demographic Characteristics and Prenatal Detection and Outcomes in Congenital Heart Disease. J Cardiovasc Dev Dis 2024; 11:155. [PMID: 38786977 PMCID: PMC11122600 DOI: 10.3390/jcdd11050155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/02/2024] [Accepted: 05/12/2024] [Indexed: 05/25/2024] Open
Abstract
Recent literature has established a strong foundation examining the associations between socioeconomic/demographic characteristics and outcomes for congenital heart disease. These associations are found beginning in fetal life and influence rates of prenatal detection, access to timely and appropriate delivery room and neonatal interventions, and surgical and other early childhood outcomes. This review takes a broad look at the existing literature and identifies gaps in the current body of research, particularly as it pertains to disparities in the prenatal detection of congenital heart disease within the United States. It also proposes further research and interventions to address these health disparities.
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Moise KJ, Bebbington MW, Nix M, Thomas H, Kosko A. The Special Delivery Unit: A Novel Concept for Mother-Baby Continuity for Major Fetal Abnormalities. Am J Perinatol 2024; 41:e2216-e2224. [PMID: 37286183 DOI: 10.1055/a-2107-1923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE This article describes the experience in the planning and development of a special delivery unit (SDU) at our free-standing children's hospital in Austin, Texas. STUDY DESIGN Description of various aspects of the development of the SDU. In addition, telephone surveys were obtained from five other institutions regarding the planning and current status of their SDUs. RESULTS Since the advent of the SDU at Children's Hospital of Philadelphia in 2008, several free-standing children's hospitals have opened similar units at their institutions. Developing an obstetrical unit in a children's hospital can be a daunting task on many fronts. The costs of providing 24-hour obstetrical, nursing, and anesthesiology coverage must be considered. Although most SDUs are associated with a fetal center and fetal surgery/interventions, some units function exclusively for the delivery of pregnancies complicated by major fetal conditions where the neonate will require immediate surgical care or other interventions. CONCLUSION Research on the cost-effectiveness and the effect of SDUs on clinical outcome, teaching, and patient satisfaction is warranted. KEY POINTS · Specialized delivery units are becoming more common at free-standing children's hospitals.. · The primary aim of the SDU is to maintain mother-baby continuity in cases of congenital anomalies.. · Developing an obstetrical unit at a pediatric hospital is a daunting task..
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Affiliation(s)
- Kenneth J Moise
- Department of Women's Health, Dell Medical School-University of Texas at Austin, Austin, Texas
- Comprehensive Fetal Care Center, Dell Children's Medical Center, Austin, Texas
| | - Michael W Bebbington
- Department of Women's Health, Dell Medical School-University of Texas at Austin, Austin, Texas
- Comprehensive Fetal Care Center, Dell Children's Medical Center, Austin, Texas
| | - Michael Nix
- Department of Women's Health, Dell Medical School-University of Texas at Austin, Austin, Texas
- Ascension Medical Group, Austin, Texas
| | | | - Andrew Kosko
- Ascension Dell Children's Medical Center, Austin, Texas
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Freud LR, Simpson LL. Fetal cardiac screening: 1st trimester and beyond. Prenat Diagn 2024. [PMID: 38613152 DOI: 10.1002/pd.6571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/29/2024] [Accepted: 03/30/2024] [Indexed: 04/14/2024]
Abstract
Congenital heart defects (CHD) are the most common birth defect and a leading cause of infant morbidity and mortality. CHD often occurs in low-risk pregnant patients, which underscores the importance of routine fetal cardiac screening at the time of the 2nd trimester ultrasound. Prenatal diagnosis of CHD is important for counseling and decision-making, focused diagnostic testing, and optimal perinatal and delivery management. As a result, prenatal diagnosis has led to improved neonatal and infant outcomes. Updated fetal cardiac screening guidelines, coupled with technological advancements and educational efforts, have resulted in increased prenatal detection of CHD in both low- and high-risk populations. However, room for improvement remains. In recent years, fetal cardiac screening for specific high-risk populations has started in the 1st trimester, which is a trend that is likely to expand over time. This review discusses fetal cardiac screening throughout pregnancy.
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Affiliation(s)
- Lindsay R Freud
- Paediatrics, Fetal Cardiology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Lynn L Simpson
- Hillary Rodham Clinton Professor of Women's Health, Department of Obstetrics & Gynecology, Columbia University Irving Medical Center, New York, New York, USA
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Patel SR, Michelfelder E. Prenatal Diagnosis of Congenital Heart Disease: The Crucial Role of Perinatal and Delivery Planning. J Cardiovasc Dev Dis 2024; 11:108. [PMID: 38667726 PMCID: PMC11050606 DOI: 10.3390/jcdd11040108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 03/29/2024] [Accepted: 03/29/2024] [Indexed: 04/28/2024] Open
Abstract
Although most congenital heart defects (CHDs) are asymptomatic at birth, certain CHD lesions are at significant risk of severe hemodynamic instability and death if emergent cardiac interventions are not performed in a timely fashion. Therefore, accurate identification of at-risk fetuses and appropriate delivery resource planning according to the degree of anticipated hemodynamic instability is crucial. Fetal echocardiography has increased prenatal CHD detection in recent years due to advancements in ultrasound techniques and improved obstetrical cardiac screening protocols, enabling the prediction of newborns' hemodynamic status. This assessment can guide multidisciplinary resource planning for postnatal care, including selection of delivery site, delivery room management, and transport to a cardiac center based on CHD risk severity. This review will discuss fetal cardiovascular physiology and the circulatory changes that occur at the time of and immediately following birth, outline fetal echocardiographic findings used to risk-stratify newborns with CHDs, and outline principles for neonatal resuscitation and initial transitional care in neonates with these complex CHD lesions.
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Affiliation(s)
- Sheetal R. Patel
- Ann & Robert H Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Erik Michelfelder
- Children’s Healthcare of Atlanta, Emory School of Medicine, Emory University, Atlanta, GA 30265, USA
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8
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Verma SK, Kuyumcu-Martinez MN. RNA binding proteins in cardiovascular development and disease. Curr Top Dev Biol 2024; 156:51-119. [PMID: 38556427 DOI: 10.1016/bs.ctdb.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Congenital heart disease (CHD) is the most common birth defect affecting>1.35 million newborn babies worldwide. CHD can lead to prenatal, neonatal, postnatal lethality or life-long cardiac complications. RNA binding protein (RBP) mutations or variants are emerging as contributors to CHDs. RBPs are wizards of gene regulation and are major contributors to mRNA and protein landscape. However, not much is known about RBPs in the developing heart and their contributions to CHD. In this chapter, we will discuss our current knowledge about specific RBPs implicated in CHDs. We are in an exciting era to study RBPs using the currently available and highly successful RNA-based therapies and methodologies. Understanding how RBPs shape the developing heart will unveil their contributions to CHD. Identifying their target RNAs in the embryonic heart will ultimately lead to RNA-based treatments for congenital heart disease.
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Affiliation(s)
- Sunil K Verma
- Department of Molecular Physiology and Biological Physics, University of Virginia School of Medicine Charlottesville, VA, United States.
| | - Muge N Kuyumcu-Martinez
- Department of Molecular Physiology and Biological Physics, University of Virginia School of Medicine Charlottesville, VA, United States; Robert M. Berne Cardiovascular Research Center, University of Virginia School of Medicine, Charlottesville, VA, United States; University of Virginia Cancer Center, Charlottesville, VA, United States.
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9
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Freud LR, Galloway S, Crowley TB, Moldenhauer J, Swillen A, Breckpot J, Borrell A, Vora NL, Cuneo B, Hoffman H, Gilbert L, Nowakowska B, Geremek M, Kutkowska-Kaźmierczak A, Vermeesch JR, Devriendt K, Busa T, Sigaudy S, Vigneswaran T, Simpson JM, Dungan J, Gotteiner N, Gloning KP, Digilio MC, Unolt M, Putotto C, Marino B, Repetto G, Fadic M, Garcia-Minaur S, Achón Buil A, Thomas MA, Fruitman D, Beecroft T, Hui PW, Oskarsdottir S, Bradshaw R, Criebaum A, Norton ME, Lee T, Geiger M, Dunnington L, Isaac J, Wilkins-Haug L, Hunter L, Izzi C, Toscano M, Ghi T, McGlynn J, Romana Grati F, Emanuel BS, Gaiser K, Gaynor JW, Goldmuntz E, McGinn DE, Schindewolf E, Tran O, Zackai EH, Yan Q, Bassett AS, Wapner R, McDonald-McGinn DM. Prenatal vs postnatal diagnosis of 22q11.2 deletion syndrome: cardiac and noncardiac outcomes through 1 year of age. Am J Obstet Gynecol 2024; 230:368.e1-368.e12. [PMID: 37717890 DOI: 10.1016/j.ajog.2023.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/24/2023] [Accepted: 09/07/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND The 22q11.2 deletion syndrome is the most common microdeletion syndrome and is frequently associated with congenital heart disease. Prenatal diagnosis of 22q11.2 deletion syndrome is increasingly offered. It is unknown whether there is a clinical benefit to prenatal detection as compared with postnatal diagnosis. OBJECTIVE This study aimed to determine differences in perinatal and infant outcomes between patients with prenatal and postnatal diagnosis of 22q11.2 deletion syndrome. STUDY DESIGN This was a retrospective cohort study across multiple international centers (30 sites, 4 continents) from 2006 to 2019. Participants were fetuses, neonates, or infants with a genetic diagnosis of 22q11.2 deletion syndrome by 1 year of age with or without congenital heart disease; those with prenatal diagnosis or suspicion (suggestive ultrasound findings and/or high-risk cell-free fetal DNA screen for 22q11.2 deletion syndrome with postnatal confirmation) were compared with those with postnatal diagnosis. Perinatal management, cardiac and noncardiac morbidity, and mortality by 1 year were assessed. Outcomes were adjusted for presence of critical congenital heart disease, gestational age at birth, and site. RESULTS A total of 625 fetuses, neonates, or infants with 22q11.2 deletion syndrome (53.4% male) were included: 259 fetuses were prenatally diagnosed (156 [60.2%] were live-born) and 122 neonates were prenatally suspected with postnatal confirmation, whereas 244 infants were postnatally diagnosed. In the live-born cohort (n=522), 1-year mortality was 5.9%, which did not differ between groups but differed by the presence of critical congenital heart disease (hazard ratio, 4.18; 95% confidence interval, 1.56-11.18; P<.001) and gestational age at birth (hazard ratio, 0.78 per week; 95% confidence interval, 0.69-0.89; P<.001). Adjusting for critical congenital heart disease and gestational age at birth, the prenatal cohort was less likely to deliver at a local community hospital (5.1% vs 38.2%; odds ratio, 0.11; 95% confidence interval, 0.06-0.23; P<.001), experience neonatal cardiac decompensation (1.3% vs 5.0%; odds ratio, 0.11; 95% confidence interval, 0.03-0.49; P=.004), or have failure to thrive by 1 year (43.4% vs 50.3%; odds ratio, 0.58; 95% confidence interval, 0.36-0.91; P=.019). CONCLUSION Prenatal detection of 22q11.2 deletion syndrome was associated with improved delivery management and less cardiac and noncardiac morbidity, but not mortality, compared with postnatal detection.
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Affiliation(s)
- Lindsay R Freud
- Hospital for Sick Children, University of Toronto, Toronto, Canada.
| | - Stephanie Galloway
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY
| | | | - Julie Moldenhauer
- Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ann Swillen
- University Hospitals Leuven, Department of Human Genetics, Catholic University of Leuven, Leuven, Belgium
| | - Jeroen Breckpot
- University Hospitals Leuven, Department of Human Genetics, Catholic University of Leuven, Leuven, Belgium
| | - Antoni Borrell
- Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Neeta L Vora
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Bettina Cuneo
- Children's Hospital Colorado, University of Colorado, Denver, CO
| | - Hilary Hoffman
- Children's Hospital Colorado, University of Colorado, Denver, CO
| | - Lisa Gilbert
- Children's Hospital Colorado, University of Colorado, Denver, CO
| | | | | | | | - Joris R Vermeesch
- University Hospitals Leuven, Department of Human Genetics, Catholic University of Leuven, Leuven, Belgium
| | - Koen Devriendt
- University Hospitals Leuven, Department of Human Genetics, Catholic University of Leuven, Leuven, Belgium
| | - Tiffany Busa
- Hôpital de la Timone, Marseille University, Marseille, France
| | - Sabine Sigaudy
- Hôpital de la Timone, Marseille University, Marseille, France
| | - Trisha Vigneswaran
- Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust and Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, United Kingdom
| | - John M Simpson
- Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust and Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, United Kingdom
| | - Jeffrey Dungan
- Prentice Women's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Nina Gotteiner
- Prentice Women's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | | | - Marta Unolt
- Children's Hospital of Philadelphia, Philadelphia, PA; Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | | | | | - Gabriela Repetto
- Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Magdalena Fadic
- Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
| | | | | | - Mary Ann Thomas
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Deborah Fruitman
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Taylor Beecroft
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Pui Wah Hui
- Queen Mary Hospital, Tsan Yuk Hospital, University of Hong Kong, Hong Kong, China
| | | | - Rachael Bradshaw
- SSM Health Cardinal Glennon St. Louis Fetal Care Institute, Saint Louis University, St. Louis, MO
| | - Amanda Criebaum
- SSM Health Cardinal Glennon St. Louis Fetal Care Institute, Saint Louis University, St. Louis, MO
| | - Mary E Norton
- University of California, San Francisco, San Francisco, CA
| | - Tiffany Lee
- University of California, San Francisco, San Francisco, CA
| | - Miwa Geiger
- Kravis Children's Hospital, Mount Sinai Medical Center, New York City, NY
| | - Leslie Dunnington
- Memorial Hermann-Texas Medical Center, University of Texas Health Science Center at Houston, Houston, TX
| | | | | | - Lindsey Hunter
- Royal Hospital for Children, University of Glasgow, Glasgow, United Kingdom
| | - Claudia Izzi
- Children's Hospital of Philadelphia, Philadelphia, PA; Azienda Socio Sanitaria Territoriale (ASST) degli Spedali Civili di Brescia, Brescia, Italy
| | | | - Tullio Ghi
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | | | | | - Beverly S Emanuel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kimberly Gaiser
- Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - J William Gaynor
- Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Elizabeth Goldmuntz
- Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Daniel E McGinn
- Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Erica Schindewolf
- Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Oanh Tran
- Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Elaine H Zackai
- Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Qi Yan
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY
| | - Anne S Bassett
- Centre for Addiction and Mental Health and Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Ronald Wapner
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY
| | - Donna M McDonald-McGinn
- Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Savitsky LM, Hamilton C, Sterrett M, Olerich K, Ma K, Albright CM. Universal Fetal Echocardiography for Pregestational Diabetes Mellitus: A Cost-Effectiveness Analysis. Obstet Gynecol 2024:00006250-990000000-01035. [PMID: 38422504 DOI: 10.1097/aog.0000000000005538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 01/18/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVE To evaluate the cost effectiveness of universal fetal echocardiogram for patients with pregestational diabetes mellitus by first-trimester hemoglobin A1c (Hb A1c) level. METHODS We developed a cost-effectiveness model comparing two strategies of screening for critical fetal congenital heart disease among patients with diabetes: universal fetal echocardiogram and fetal echocardiogram only after abnormal findings on detailed anatomy ultrasonogram. We excluded ventricular septal defect, atrial septal defects, and bicuspid aortic valve from the definition of critical fetal congenital heart disease. Probabilities and costs were derived from the literature. We used individual models to evaluate different scenarios: first-trimester Hb A1c lower than 6.5%, Hb A1c 6.5-9.0%, and Hb A1c higher than 9.0%. Primary outcomes included fetal death, neonatal death, and false-positive and false-negative results. A cost-effectiveness threshold was set at $100,000 per quality-adjusted life-year. Univariable sensitivity analyses were performed to investigate the drivers of the model. RESULTS Universal fetal echocardiogram is not cost effective except for when first-trimester Hb A1c level is higher than 9.0% (incremental cost-effectiveness ratio $638,100, $223,693, and $67,697 for Hb A1c lower than 6.5%, 6.5-9.0%, and higher than 9.0%, respectively). The models are sensitive to changes in the probability of congenital heart disease at a given Hb A1c level, as well as the cost of neonatal transfer to a higher level of care. Universal fetal echocardiogram became both cost saving and more effective when the probability of congenital heart disease reached 14.48% (15.4 times the baseline risk). In the Monte Carlo simulation, universal fetal echocardiogram is cost effective in 22.7%, 48.6%, and 62.3% of scenarios for each of the three models, respectively. CONCLUSION For pregnant patients with first-trimester Hb A1c levels lower than 6.5%, universal fetal echocardiogram was not cost effective, whereas, for those with first-trimester Hb A1c levels higher than 9.0%, universal fetal echocardiogram was cost effective. For those with intermediate Hb A1c levels, universal fetal echocardiogram was cost effective in about 50% of cases; therefore, clinical judgment based on individual patient values, willingness to pay to detect congenital heart disease, and resource availability needs to be considered.
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Affiliation(s)
- Leah M Savitsky
- Department of Obstetrics and Gynecology, University of Washington, and the Department of Maternal-Fetal Medicine, Providence Swedish Hospital, Seattle, Washington; and the Department of Maternal-Fetal Medicine, Kaiser San Diego, San Diego, California
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11
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Martin SS, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Barone Gibbs B, Beaton AZ, Boehme AK, Commodore-Mensah Y, Currie ME, Elkind MSV, Evenson KR, Generoso G, Heard DG, Hiremath S, Johansen MC, Kalani R, Kazi DS, Ko D, Liu J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Perman SM, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Tsao CW, Urbut SM, Van Spall HGC, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Palaniappan LP. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. Circulation 2024; 149:e347-e913. [PMID: 38264914 DOI: 10.1161/cir.0000000000001209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
BACKGROUND The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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12
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Robinson J, Sahai S, Pennacchio C, Sharew B, Chen L, Karamlou T. Effects of Sociodemographic Factors on Access to and Outcomes in Congenital Heart Disease in the United States. J Cardiovasc Dev Dis 2024; 11:67. [PMID: 38392282 PMCID: PMC10889660 DOI: 10.3390/jcdd11020067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 02/24/2024] Open
Abstract
Congenital heart defects (CHDs) are complex conditions affecting the heart and/or great vessels that are present at birth. These defects occur in approximately 9 in every 1000 live births. From diagnosis to intervention, care has dramatically improved over the last several decades. Patients with CHDs are now living well into adulthood. However, there are factors that have been associated with poor outcomes across the lifespan of these patients. These factors include sociodemographic and socioeconomic positions. This commentary examined the disparities and solutions within the evolution of CHD care in the United States.
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Affiliation(s)
- Justin Robinson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Siddhartha Sahai
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Caroline Pennacchio
- Case Western Reserve University School of Medicine, Cleveland, OH 44195, USA
| | - Betemariam Sharew
- Cleveland Clinic Learner College of Medicine, Cleveland, OH 44195, USA
| | - Lin Chen
- Case Western Reserve University School of Medicine, Cleveland, OH 44195, USA
| | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
- Division of Pediatric Cardiac Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic Children's Hospital, 9500 Euclid Avenue, Desk M41, Cleveland, OH 44195, USA
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13
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Chen J, Huang S, Zhang Y, Chang Q, Zhang Y, Li D, Qiu J, Hu L, Peng X, Du Y, Gao Y, Chen DZ, Bellou A, Wu J, Liang H. Congenital heart disease detection by pediatric electrocardiogram based deep learning integrated with human concepts. Nat Commun 2024; 15:976. [PMID: 38302502 PMCID: PMC10834950 DOI: 10.1038/s41467-024-44930-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/10/2024] [Indexed: 02/03/2024] Open
Abstract
Early detection is critical to achieving improved treatment outcomes for child patients with congenital heart diseases (CHDs). Therefore, developing effective CHD detection techniques using low-cost and non-invasive pediatric electrocardiogram are highly desirable. We propose a deep learning approach for CHD detection, CHDdECG, which automatically extracts features from pediatric electrocardiogram and wavelet transformation characteristics, and integrates them with key human-concept features. Developed on 65,869 cases, CHDdECG achieved ROC-AUC of 0.915 and specificity of 0.881 on a real-world test set covering 12,000 cases. Additionally, on two external test sets with 7137 and 8121 cases, the overall ROC-AUC were 0.917 and 0.907 while specificities were 0.937 and 0.907. Notably, CHDdECG surpassed cardiologists in CHD detection performance comparison, and feature importance scores suggested greater influence of automatically extracted electrocardiogram features on CHD detection compared with human-concept features, implying that CHDdECG may grasp some knowledge beyond human cognition. Our study directly impacts CHD detection with pediatric electrocardiogram and demonstrates the potential of pediatric electrocardiogram for broader benefits.
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Affiliation(s)
- Jintai Chen
- State Key Laboratory of Transvascular Implantation Devices of the Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, 310009, Hangzhou, China
| | - Shuai Huang
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 510080, Guangzhou, Guangdong Province, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080, Guangzhou, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), 510080, Guangzhou, Guangdong Province, China
| | - Ying Zhang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080, Guangzhou, Guangdong Province, China
- Department of Cardiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 510080, Guangzhou, Guangdong Province, China
| | - Qing Chang
- Liaoning Engineering Research Center of Intelligent Diagnosis and Treatment Ecosystem, 110004, Shenyang, Liaoning Province, China
- Clinical Research Center of Shengjing Hospital of China Medical University, 110004, Shenyang, Liaoning Province, China
| | - Yixiao Zhang
- Liaoning Engineering Research Center of Intelligent Diagnosis and Treatment Ecosystem, 110004, Shenyang, Liaoning Province, China
- Department of Urology Surgery, Shengjing Hospital of China Medical University, 110004, Shenyang, Liaoning Province, China
| | - Dantong Li
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 510080, Guangzhou, Guangdong Province, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080, Guangzhou, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), 510080, Guangzhou, Guangdong Province, China
| | - Jia Qiu
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080, Guangzhou, Guangdong Province, China
- Department of Cardiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 510080, Guangzhou, Guangdong Province, China
| | - Lianting Hu
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 510080, Guangzhou, Guangdong Province, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080, Guangzhou, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), 510080, Guangzhou, Guangdong Province, China
| | - Xiaoting Peng
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 510080, Guangzhou, Guangdong Province, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080, Guangzhou, Guangdong Province, China
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), 510080, Guangzhou, Guangdong Province, China
| | - Yunmei Du
- College of Information Technology and Engineering, Guangzhou College of Commerce, 510363, Guangzhou, Guangdong Province, China
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 510623, Guangzhou, Guangdong Province, China
| | - Yunfei Gao
- Zhuhai Precision Medical Center, Zhuhai People's Hospital/ Zhuhai Hospital Affiliated with Jinan University, Jinan University, 519000, Zhuhai, Guangdong Province, China
- The Biomedical Translational Research Institute, Jinan University Faculty of Medical Science, Jinan University, 510632, Guangzhou, Guangdong Province, China
| | - Danny Z Chen
- Department of Computer Science and Engineering, University of Notre Dame, Notre Dame, IN, 46556, USA
| | - Abdelouahab Bellou
- Institute of Sciences in Emergency Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080, Guangzhou, China.
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI, 48201, USA.
| | - Jian Wu
- State Key Laboratory of Transvascular Implantation Devices of the Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, 310009, Hangzhou, China.
- School of Public Health, Zhejiang University, 310058, Hangzhou, China.
| | - Huiying Liang
- Medical Big Data Center, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, 510080, Guangzhou, Guangdong Province, China.
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 510080, Guangzhou, Guangdong Province, China.
- Guangdong Provincial Key Laboratory of Artificial Intelligence in Medical Image Analysis and Application, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), 510080, Guangzhou, Guangdong Province, China.
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Woo JL, Burton S, Iyengar T, Sivakumar A, Spiewak S, Wakulski R, Grobman WA, Davis MM, Yee LM, Patel A, Johnson JT, Patel S, Gandhi R. Patient-reported barriers to prenatal diagnosis of congenital heart defects: A mixed-methods study. Prenat Diagn 2024; 44:57-67. [PMID: 38108462 DOI: 10.1002/pd.6481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/20/2023] [Accepted: 11/24/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVE To ascertain patient-reported, modifiable barriers to prenatal diagnosis of congenital heart defects (CHDs). METHODS This was a mixed-methods study among caretakers of infants who received congenital heart surgery from 2019 to 2020 in the Chicagoland area. Quantitative variables measuring sociodemographic characteristics and prenatal care utilization, and qualitative data pertaining to patient-reported barriers to prenatal diagnosis were collected from electronic health records and semi-structured phone surveys. Thematic analysis was performed using a convergent parallel approach. RESULTS In total, 160 caretakers completed the survey, 438 were eligible for survey, and 49 (31%) received prenatal care during the COVID-19 pandemic. When comparing respondents and non-respondents, there was a lower prevalence of maternal Hispanic ethnicity and a higher prevalence of non-English/Spanish-speaking households. Of all respondents, 34% reported an undetected CHD on ultrasound or echocardiogram, while 79% reported at least one barrier to prenatal diagnosis related to social determinants of health. Among those social barriers, the most common were difficulty with appointment scheduling (n = 12, 9.5%), far distance to care/lack of access to transportation (n = 12, 9.5%) and difficulty getting time off work to attend appointments (n = 6, 4.8%). The latter two barriers were correlated. CONCLUSION While technical improvements in the detection of CHDs remain an important area of research, it is equally critical to produce evidence for interventions that mitigate barriers to prenatal diagnosis due to social determinants of health.
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Affiliation(s)
- Joyce L Woo
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Shelvonne Burton
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children's Health Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- University of Maryland Baltimore County, Baltimore, Maryland, USA
| | - Tara Iyengar
- Division of Cardiology, Department of Pediatrics, Advocate Christ Children's Hospital, Chicago, Illinois, USA
| | - Adithya Sivakumar
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Rush Medical College, Chicago, Illinois, USA
| | - Sarah Spiewak
- Division of Cardiology, Department of Pediatrics, Advocate Christ Children's Hospital, Chicago, Illinois, USA
| | - Renee Wakulski
- Division of Cardiology, Department of Pediatrics, Advocate Christ Children's Hospital, Chicago, Illinois, USA
| | - William A Grobman
- Division of Maternal-Fetal-Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Matthew M Davis
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children's Health Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Advanced General Pediatrics & Primary Care, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Departments of Medicine and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lynn M Yee
- Division of Maternal-Fetal-Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Angira Patel
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Joyce T Johnson
- Division of Cardiology, Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Sheetal Patel
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rupali Gandhi
- Division of Cardiology, Department of Pediatrics, Advocate Christ Children's Hospital, Chicago, Illinois, USA
- Section of Cardiology, Department of Pediatrics, University of Chicago Comer Children's Hospital, Chicago, Illinois, USA
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15
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Schwartz BN, Evans FJ, Burns KM, Kaltman JR. Social inequities impact infant mortality due to congenital heart disease. Public Health 2023; 224:66-73. [PMID: 37738879 PMCID: PMC10950838 DOI: 10.1016/j.puhe.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 08/12/2023] [Accepted: 08/15/2023] [Indexed: 09/24/2023]
Abstract
OBJECTIVES To evaluate how educational, economic, and racial residential segregation may impact congenital heart disease infant mortality (CHD-IM). STUDY DESIGN This is a population-based US ecological study. METHODS This study evaluated linked live birth-infant death files from the National Center for Health Statistics for live births from 2006 to 2018 with cause of death attributed to CHD. Maternal race and education data were obtained from the live birth-infant death files, and income data were obtained from the American Community Survey. A spatial social polarization measure termed the Index of Concentration at the Extremes (ICE) was calculated and split by quintiles for maternal education, household income, and race for all US counties (n = 3142). The lowest quintile represents counties with highest concentration of disadvantaged groups (income < $25K, non-Hispanic Black, no high school degree). Proximity to a pediatric cardiac center (PCC) was also analyzed in a categorical manner based on whether each county was in a metropolitan area with a US News and World Report top 50 ranked PCC, a lower ranked PCC, or not proximal to any PCC. RESULTS Between 2006 and 2018, 17,489 infant deaths were due to CHD, an unadjusted CHD-IM of 0.33 deaths per 1000 live births. The risk of CHD-IM was 1.5 times greater among those in the lowest ICE-education quintile (0.41 [0.39-0.44] vs 0.28 deaths/1000 live births [0.27-0.29], P < 0.0001) and the lowest ICE-income quintile (0.44 [0.41-0.47] vs 0.29 [0.28-0.30], P < 0.0001) in comparison to those in the highest quintiles. CHD-IM increases with higher ICE-race value (counties with a higher concentration of non-Hispanic White mothers). However, after adjusting for proximity to a US News and World Report top 50 ranked PCC in the multivariable models, CHD-IM decreases with higher ICE-race value. CONCLUSIONS Counties with the highest concentration of lower-educated mothers and the highest concentration of low-income households were associated with higher rates of CHD-IM. Mortality as a function of race is more complicated and requires further investigation.
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Affiliation(s)
- B N Schwartz
- Division of Cardiology, Children's National Hospital, Washington, DC, USA; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
| | - F J Evans
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - K M Burns
- Division of Cardiology, Children's National Hospital, Washington, DC, USA; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - J R Kaltman
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
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16
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Dischinger AN, Li JS, Mulder H, Spears T, Chiswell KE, Hoffman TM, Hartman RJ, Walsh MJ, Sang CJ, Sarno LA, Paolillo JA, Welke K, D'Ottavio A, Sethi NJ. Impact of Prenatal Diagnosis of Critical Congenital Heart Disease on Preoperative and Postoperative Outcomes. Pediatr Cardiol 2023; 44:1520-1528. [PMID: 37289278 DOI: 10.1007/s00246-023-03197-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/23/2023] [Indexed: 06/09/2023]
Abstract
The objective of this study was to assess the relationship of prenatal diagnosis of critical congenital heart disease (CHD) to preoperative and postoperative patient findings. Retrospective analysis of neonates with critical CHD who underwent cardiothoracic surgery at one of four centers in North Carolina between 2008 and 2013. Surgical data collected by sites for submission to the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) and the North Carolina CHD Lifespan Database were queried. There were 715 patients with STS records; 558 linked to the NC-CHD database. Patients with prenatal diagnosis had a lower incidence of preoperative risk factors, including need for mechanical ventilation and presence of shock. However, prenatally diagnosed patients had worse short-term outcomes, including higher operative mortality, higher incidence of select postoperative complications, and longer LOS. There was no difference in one-year mortality. Our findings are consistent with current literature which suggests that prenatal diagnosis of critical CHD is associated with a more optimized preoperative clinical status. However, we found that patients with prenatal diagnoses had less favorable postoperative outcomes. This needs to be investigated further, but may be secondary to patient-specific factors, such as CHD disease severity.
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Affiliation(s)
- Ashley N Dischinger
- Department of Pediatrics, Division of Pediatric Cardiology, Duke University School of Medicine, 2301 Erwin Road, #7506, Durham, NC, USA.
| | - Jennifer S Li
- Department of Pediatrics, Division of Pediatric Cardiology, Duke University School of Medicine, 2301 Erwin Road, #7506, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Hillary Mulder
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Tracy Spears
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Karen E Chiswell
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Timothy M Hoffman
- Department of Pediatrics, Division of Pediatric Cardiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Robert J Hartman
- Department of Pediatrics, Division of Pediatric Cardiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Michael J Walsh
- Department of Pediatrics, Division of Pediatric Cardiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Charlie J Sang
- Departmart of Pediatrics, Division of Pediatric Cardiology, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Lauren A Sarno
- Departmart of Pediatrics, Division of Pediatric Cardiology, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Joseph A Paolillo
- Atrium Health Levine Children's Congenital Heart Center, Charlotte, NC, USA
| | - Karl Welke
- Atrium Health Levine Children's Congenital Heart Center, Charlotte, NC, USA
| | - Alfred D'Ottavio
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Neeta J Sethi
- Department of Pediatrics, Division of Pediatric Cardiology, Duke University School of Medicine, 2301 Erwin Road, #7506, Durham, NC, USA
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Valencia E, Staffa SJ, Kuntz MT, Zaleski KL, Kaza AK, Maschietto N, Nasr VG. Transcatheter Ductal Stents Versus Surgical Systemic-Pulmonary Artery Shunts in Neonates With Congenital Heart Disease With Ductal-Dependent Pulmonary Blood Flow: Trends and Associated Outcomes From the Pediatric Health Information System Database. J Am Heart Assoc 2023; 12:e030528. [PMID: 37589149 PMCID: PMC10547312 DOI: 10.1161/jaha.123.030528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/24/2023] [Indexed: 08/18/2023]
Abstract
Background Surgical systemic-to-pulmonary artery shunts have been the standard approach to establish stable pulmonary blood flow in neonates with congenital heart disease with ductal-dependent pulmonary blood flow. More recently, transcatheter ductal stents have been performed as an alternative, less invasive intervention. We aimed to characterize trends in the utilization of surgical shunts versus ductal stents and compare associated outcomes. Methods and Results Using data from the Pediatric Health Information System, we retrospectively analyzed neonates with congenital heart disease with ductal-dependent pulmonary blood flow who underwent surgical shunt or ductal stent placement between January 2016 and December 2021. Patients were identified by International Classification of Diseases, Tenth Revision (ICD-10) diagnosis and procedure codes. The primary outcome was length of hospital stay. Secondary outcomes were reintervention risk and adjusted hospital costs. Of 936 patients included, 65.2% underwent a surgical shunt over the 6-year period. The proportion who underwent ductal stenting increased from 19% to 53.4% from 2016 to 2021. The median adjusted difference in postintervention length of hospital stay was 11 days greater for the surgical shunt cohort (95% CI, 7.2-14.8; P<0.001). The adjusted reintervention risks within 3 (odds ratio [OR], 3.37 [95% CI, 1.91-5.95], P<0.001) and 6 months (OR, 2.43 [95% CI, 1.62-3.64], P<0.001) were significantly greater in the ductal stent group. Median adjusted index hospital costs were $198 300 ($11 6400-$340 000) versus $120 400 ($81 800-$192 400) for the surgical shunt and ductal stent cohorts, respectively (P<0.001). Conclusions Ductal stenting has become an increasingly utilized palliative approach to secure pulmonary blood flow in neonates with congenital heart disease with ductal-dependent pulmonary blood flow in the United States. Ductal stenting is associated with decreased length of hospital stay and reduced overall cost for the index hospitalization but with a greater reintervention risk than surgical shunting.
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Affiliation(s)
- Eleonore Valencia
- Department of Cardiology, Boston Children’s HospitalHarvard Medical SchoolBostonMA
| | - Steven J. Staffa
- Department of Anesthesiology, Critical Care and Pain MedicineBoston Children’s Hospital, Harvard Medical SchoolBostonMA
| | - Michael T. Kuntz
- Department of AnesthesiologyVanderbilt University Medical CenterNashvilleTN
| | - Katherine L. Zaleski
- Department of Anesthesiology, Critical Care and Pain MedicineBoston Children’s Hospital, Harvard Medical SchoolBostonMA
| | - Aditya K. Kaza
- Department of Cardiac SurgeryBoston Children’s Hospital, Harvard Medical SchoolBostonMA
| | - Nicola Maschietto
- Department of Cardiology, Boston Children’s HospitalHarvard Medical SchoolBostonMA
| | - Viviane G. Nasr
- Department of Anesthesiology, Critical Care and Pain MedicineBoston Children’s Hospital, Harvard Medical SchoolBostonMA
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18
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Ross FJ, Latham G, Tjoeng L, Everhart K, Jimenez N. Racial and Ethnic Disparities in U.S Children Undergoing Surgery for Congenital Heart Disease: A Narrative Literature Review. Semin Cardiothorac Vasc Anesth 2023; 27:224-234. [PMID: 36514942 DOI: 10.1177/10892532221145229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Congenital Heart Disease (CHD) is a significant source of pediatric morbidity and mortality. As in other fields of medicine, studies have demonstrated racial and ethnic disparities in congenital heart disease outcomes. The cause of these outcome disparities is multifactorial, involving biological, behavioral, environmental, sociocultural, and systemic medical factors. Potential contributors include differences in preoperative illness severity secondary to coexisting medical conditions, differences in the rate of prenatal and early postnatal detection of CHD, and delayed access to care, as well as discrepancies in socioeconomic and insurance status, and systemic disparities in hospital care. Understanding the factors that contribute to these disparities is an essential step towards developing strategies to address them. As stewards of the perioperative surgical home, anesthesiologists have an important role in developing institutional policies that mitigate racial disparities. Here, we provide a thorough narrative review of recent research concerning perioperative factors contributing to surgical outcomes disparities for children of all ages with CHD, examine potentially modifiable contributing factors, discuss avenues for future research, and suggest strategies to address disparities both locally and nationally.
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Affiliation(s)
- Faith J Ross
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | - Gregory Latham
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | - Lie Tjoeng
- Department of Critical Care Medicine/Department of Cardiology, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | - Kelly Everhart
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | - Nathalia Jimenez
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
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19
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Miles KG, Liu J, Tseng SY, DeFranco EA, Divanovic AA, Jones HN, Ollberding NJ, Cnota JF. Neonatal Depression Is Associated With 1-Year Mortality in Critical Congenital Heart Disease. J Am Heart Assoc 2023; 12:e028774. [PMID: 37260029 PMCID: PMC10381992 DOI: 10.1161/jaha.122.028774] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 05/03/2023] [Indexed: 06/02/2023]
Abstract
Background Low 5-minute Apgar scores (AS) are predictive of term and preterm neonatal mortality but have not been well studied in the critical congenital heart disease (CCHD) population. We analyzed US national vital statistics data to evaluate the association between neonatal depression (AS 0-3) and 1-year mortality in CCHD. Methods and Results We performed a retrospective cohort study using 2014 to 2018 Centers for Disease Control and Prevention cohort-linked birth certificate and infant death records. Five-minute AS were categorized as ≤3, 4 to 6, or ≥7. We calculated birth rates and associated mortality rates by AS group in infants with and without CCHD. Multivariable logistic regression analyzed neonatal, maternal, and pregnancy-related risk factors for neonatal depression and 1-year mortality. Of 11 642 neonates with CCHD (0.06% of all births), the 5.8% with AS 0 to 3 accounted for 23.3% of all 1-year CCHD mortality, with 69.9% of deaths occurring within 1 month of life. Gestational age at birth, growth restriction, extracardiac defects, race, and low maternal education were associated with an increased odds of AS 0 to 3 in neonates with CCHD relative to those with AS 7 to 10 on multivariable analysis. AS 0 to 3 was associated with 1-year CCHD mortality after adjusting for these factors, prenatal care, and delivery location (adjusted odds ratio, 14.57 [95% CI, 11.73-18.10]). Conclusions The AS is a routine clinical measure providing important prognostic information in CCHD. These findings suggest that prenatal and perinatal factors, beyond those included in current risk stratification tools, are important for CCHD outcomes. Multidisciplinary collaboration to understand the pathophysiology underlying neonatal depression may help identify interventions to improve CCHD mortality rates.
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Affiliation(s)
| | - James Liu
- Division of Maternal‐Fetal Medicine, Department of Obstetrics and GynecologyUniversity of CincinnatiCincinnatiOH
| | | | - Emily A. DeFranco
- Division of Maternal‐Fetal Medicine, Department of Obstetrics and GynecologyUniversity of CincinnatiCincinnatiOH
| | | | - Helen N. Jones
- Department of Physiology and AgingUniversity of FloridaGainesvilleFL
| | - Nicholas J. Ollberding
- Division of Biostatistics and EpidemiologyCincinnati Children’s Hospital Medical CenterCincinnatiOH
| | - James F. Cnota
- The Heart InstituteCincinnati Children’s HospitalCincinnatiOH
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20
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Soszyn N, Cloete E, Sadler L, de Laat MWM, Crengle S, Bloomfield F, Finucane K, Gentles TL. Factors influencing the choice-of-care pathway and survival in the fetus with hypoplastic left heart syndrome in New Zealand: a population-based cohort study. BMJ Open 2023; 13:e069848. [PMID: 37055204 PMCID: PMC10106067 DOI: 10.1136/bmjopen-2022-069848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2023] Open
Abstract
OBJECTIVES To better understand the relative influence of fetal and maternal factors in determining the choice-of-care pathway (CCP) and outcome in the fetus with hypoplastic left heart syndrome (HLHS). DESIGN A retrospective, population-based study of fetuses with HLHS from a national dataset with near-complete case ascertainment from 20 weeks' gestation. Fetal cardiac and non-cardiac factors were recorded from the patient record and maternal factors from the national maternity dataset. The primary endpoint was a prenatal decision for active treatment after birth (intention-to-treat). Factors associated with a delayed diagnosis (≥24 weeks' gestation) were also reviewed. Secondary endpoints included proceeding to surgical treatment, and 30-day postoperative mortality in liveborns with an intention-to-treat. SETTING New Zealand population-wide. PARTICIPANTS Fetuses with a prenatal diagnosis of HLHS between 2006 and 2015. RESULTS Of 105 fetuses, the CCP was intention-to-treat in 43 (41%), and pregnancy termination or comfort care in 62 (59%). Factors associated with intention-to-treat by multivariable analysis included a delay in diagnosis (OR: 7.8, 95% CI: 3.0 to 20.6, p<0.001) and domicile in the maternal fetal medicine (MFM) region with the most widely dispersed population (OR: 5.3, 95% CI: 1.4 to 20.3, p=0.02). Delay in diagnosis was associated with Māori maternal ethnicity compared with European (OR: 12.9, 95% CI: 3.1 to 54, p<0.001) and greater distance from the MFM centre (OR: 3.1, 95% CI: 1.2 to 8.2, p=0.02). In those with a prenatal intention-to-treat, a decision not to proceed to surgery was associated with maternal ethnicity other than European (p=0.005) and the presence of major non-cardiac anomalies (p=0.01). Thirty-day postoperative mortality occurred in 5/32 (16%) and was more frequent when there were major non-cardiac anomalies (p=0.02). CONCLUSIONS Factors associated with the prenatal CCP relate to healthcare access. Anatomic characteristics impact treatment decisions after birth and early postoperative mortality. The association of ethnicity with delayed prenatal diagnosis and postnatal decision-making suggests systemic inequity and requires further investigation.
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Affiliation(s)
- Natalie Soszyn
- Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Te Whatu Ora - Health New Zealand, Te Toka Tumai Auckland, Auckland, New Zealand
| | - Elza Cloete
- The University of Auckland Liggins Institute, Auckland, New Zealand
- Neonatal Unit, Christchurch Women's Hospital, Te Whatu Ora - Health New Zealand, Waitaha Canterbury, Christchurch, New Zealand
| | - Lynn Sadler
- Women's Health, Auckland City Hospital, Te Whatu Ora - Health New Zealand, Te Toka Tumai Auckland, Auckland, New Zealand
- The University of Auckland Department of Obstetrics and Gynaecology, Auckland, New Zealand
| | - Monique W M de Laat
- Women's Health, Auckland City Hospital, Te Whatu Ora - Health New Zealand, Te Toka Tumai Auckland, Auckland, New Zealand
| | - Sue Crengle
- Otago Medical School Department of Preventive and Social Medicine, Dunedin, New Zealand
| | - Frank Bloomfield
- The University of Auckland Liggins Institute, Auckland, New Zealand
| | - Kirsten Finucane
- Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Te Whatu Ora - Health New Zealand, Te Toka Tumai Auckland, Auckland, New Zealand
| | - Thomas L Gentles
- Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Te Whatu Ora - Health New Zealand, Te Toka Tumai Auckland, Auckland, New Zealand
- Faculty of Medical and Health Sciences, The University of Auckland Department of Paediatrics Child and Youth Health, Auckland, New Zealand
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21
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Erickson LA, Ricketts A, Swanson T, Weiner J, Hasnie UA, Bonessa K, Noel-Macdonnell J, Russell CL. Determinants of Length of Stay after Neonatal Cardiac Surgery Using Path Analysis. West J Nurs Res 2023; 45:306-315. [PMID: 36217759 DOI: 10.1177/01939459221129037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
After neonatal cardiac surgery, families, and the health care team strive for exclusive oral feedings before hospital discharge. With the hypothesis that exclusive oral feedings would reduce the length of stay (LOS), a multidimensional path analysis was used to examine a cross-section of 280 neonates from 2009 to 2013. Buttigieg, Abela, and Pace's theoretical framework of structural and process-related determinants of LOS was modeled with hypothesis-driven correlation and directionality. The recursive path model had a good global and local fit with outcome variances of 26% for exclusive oral feeding and LOS. In the full cohort and model groups (single and biventricular), when controlling for covariances: sepsis, birth distance, necrotizing enterocolitis, genetic differences, specialty consults, the age at which neonatal cardiac surgery occurred (β = .23, p ≤ .001) and the duration of postoperative intubation (β = .47, p ≤ .001) more significantly influenced the LOS than intermediate mediation of exclusive oral feedings at discharge.
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Affiliation(s)
- Lori A Erickson
- Children's Mercy Kansas City, Kansas City, MO, USA.,University of Missouri-Kansas City, Kansas City, MO, USA
| | - Amy Ricketts
- Children's Mercy Kansas City, Kansas City, MO, USA.,University of Missouri-Kansas City, Kansas City, MO, USA
| | - Tara Swanson
- University of Missouri-Kansas City, Kansas City, MO, USA
| | - Julie Weiner
- Children's Mercy Kansas City, Kansas City, MO, USA.,University of Missouri-Kansas City, Kansas City, MO, USA
| | - Usman A Hasnie
- University of Missouri-Kansas City, Kansas City, MO, USA.,Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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22
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Zaleski KL, Valencia E, Matte GS, Kaza AK, Nasr VG. How We Would Treat Our Own Hypoplastic Left Heart Syndrome Neonate for Stage 1 Surgery. J Cardiothorac Vasc Anesth 2023; 37:504-512. [PMID: 36717315 DOI: 10.1053/j.jvca.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/26/2022] [Accepted: 01/02/2023] [Indexed: 01/09/2023]
Affiliation(s)
- Katherine L Zaleski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Eleonore Valencia
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Gregory S Matte
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Aditya K Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA.
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23
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Millen SM, Olsen CH, Flanagan RP, Scott JS, Dobson CP. The effect of geographic origin and destination on congenital heart disease outcomes: a retrospective cohort study. BMC Cardiovasc Disord 2023; 23:99. [PMID: 36814200 PMCID: PMC9945673 DOI: 10.1186/s12872-023-03037-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 01/02/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Congenital heart disease (CHD) is a common and significant birth defect, frequently requiring surgical intervention. For beneficiaries of the Department of Defense, a new diagnosis of CHD may occur while living at rural duty stations. Choice of tertiary care center becomes a function of geography, referring provider recommendations, and patient preference. METHODS Using billing data from the Military Health System over a 5-year period, outcomes for beneficiaries age < 10 years undergoing CHD surgery were compared by patient origin (rural versus urban residence) and the distance to treatment (patient's home and the treating tertiary care center). These beneficiaries include children of active duty, activated reserves, and federally activated National Guard service members. Analysis of the outcomes were adjusted for procedure complexity risk. Treatment centers were further stratified by annual case volume and whether they publicly reported results in the society of thoracic surgery (STS) outcomes database. RESULTS While increasing distance was associated with the cost of admission, there was no associated risk of inpatient mortality, one year mortality, or increased length of stay. Likewise, rural origination was not significantly associated with target outcomes. Patients traveled farther for STS-reporting centers (STS-pr), particularly high-volume centers. Such high-volume centers (> 50 high complexity cases annually) demonstrated decreased one year mortality, but increased cost and length of stay. CONCLUSIONS Together, these findings contribute to the national conversation of rural community medicine versus regionalized subspecialty care; separation of patients between rural areas and more urban locations for initial CHD surgical care does not increase their mortality risk. In fact, traveling to high volume centers may have an associated mortality benefit.
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Affiliation(s)
- Spencer M Millen
- Walter Reed National Military Medical Center, Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
| | - Cara H Olsen
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | - John S Scott
- Veterans' Health Administration, Washington, DC, USA
| | - Craig P Dobson
- Walter Reed National Military Medical Center, Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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24
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Tsao CW, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Beaton AZ, Boehme AK, Buxton AE, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Fugar S, Generoso G, Heard DG, Hiremath S, Ho JE, Kalani R, Kazi DS, Ko D, Levine DA, Liu J, Ma J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Virani SS, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association. Circulation 2023; 147:e93-e621. [PMID: 36695182 DOI: 10.1161/cir.0000000000001123] [Citation(s) in RCA: 1047] [Impact Index Per Article: 1047.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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25
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Hypoplastic Left Heart Syndrome: About a Postnatal Death. Diagnostics (Basel) 2023; 13:diagnostics13050821. [PMID: 36899964 PMCID: PMC10000365 DOI: 10.3390/diagnostics13050821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/14/2023] [Accepted: 02/20/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Hypoplastic left heart syndrome (HLHS) is a congenital heart disease that is associated with high mortality rates in the early neonatal period and during surgical treatments. This is mainly due to missed prenatal diagnosis, delayed diagnostic suspicion, and consequent unsuccessful therapeutic intervention. CASE REPORT twenty-six hours after birth, a female newborn died of severe respiratory failure. No cardiac abnormalities and no genetic diseases had been evidenced or documented during intrauterine life. The case became of medico-legal concern for the assessment of alleged medical malpractice. Therefore, a forensic autopsy was performed. RESULTS the macroscopic study of the heart revealed the hypoplasia of the left cardiac cavities with the left ventricle (LV) reduced to a slot and a right ventricular cavity that simulated the presence of a single and unique ventricular chamber. The predominance of the left heart was evident. CONCLUSIONS HLHS is a rare condition that is incompatible with life, with very high mortality from cardiorespiratory insufficiency that occurs soon after birth. The prompt diagnosis of HLHS during pregnancy is crucial in managing the disease with surgery.
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26
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Structural Racism, Social Determinants of Health, and Provider Bias: Impact on Brain Development in Critical Congenital Heart Disease. Can J Cardiol 2023; 39:133-143. [PMID: 36368561 DOI: 10.1016/j.cjca.2022.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 10/17/2022] [Accepted: 11/03/2022] [Indexed: 11/11/2022] Open
Abstract
Critical congenital heart disease (cCHD) has neurodevelopmental sequelae that can carry into adulthood, which may be due to aberrant brain development or brain injury in the prenatal and perinatal/neonatal periods and beyond. Health disparities based on the intersection of sex, geography, race, and ethnicity have been identified for poorer pre- and postnatal outcomes in the general population, as well as those with cCHD. These disparities are likely driven by structural racism, disparities in social determinants of health, and provider bias, which further compound negative brain development outcomes. This review discusses how aberrant brain development in cCHD early in life is affected by reduced access to quality care (ie, prenatal care and testing, postnatal care) due to divestment in non-White neighbourhoods (eg, redlining) and food insecurity, differences in insurance status, location of residence, and perceived interpersonal racism and bias that disproportionately affects pregnant people of colour who have fewer economic resources. Suggestions are discussed for moving forward with implementing strategies in medical education, clinical care, research, and gaining insight into the communities served to combat disparities and bias while promoting cultural humility.
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27
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Olutoye OO, Joyeux L, King A, Belfort MA, Lee TC, Keswani SG. Minimally Invasive Fetal Surgery and the Next Frontier. Neoreviews 2023; 24:e67-e83. [PMID: 36720693 DOI: 10.1542/neo.24-2-e67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Most patients with congenital anomalies do not require prenatal intervention. Furthermore, many congenital anomalies requiring surgical intervention are treated adequately after birth. However, there is a subset of patients with congenital anomalies who will die before birth, shortly after birth, or experience severe postnatal complications without fetal surgery. Fetal surgery is unique in that an operation is performed on the fetus as well as the pregnant woman who does not receive any direct benefit from the surgery but rather lends herself to risks, such as hemorrhage, abruption, and preterm labor. The maternal risks involved with fetal surgery have limited the extent to which fetal interventions may be performed but have, in turn, led to technical innovations that have significantly advanced the field. This review will examine congenital abnormalities that can be treated with minimally invasive fetal surgery and introduce the next frontier of prenatal management of fetal surgical pathology.
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Affiliation(s)
- Oluyinka O Olutoye
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Luc Joyeux
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Michael A Belfort
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Timothy C Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Sundeep G Keswani
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
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28
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Mehta Z, Touma M. Post-Transcriptional Modification by Alternative Splicing and Pathogenic Splicing Variants in Cardiovascular Development and Congenital Heart Defects. Int J Mol Sci 2023; 24:ijms24021555. [PMID: 36675070 PMCID: PMC9862068 DOI: 10.3390/ijms24021555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/08/2023] [Accepted: 01/09/2023] [Indexed: 01/15/2023] Open
Abstract
Advancements in genomics, bioinformatics, and genome editing have uncovered new dimensions in gene regulation. Post-transcriptional modifications by the alternative splicing of mRNA transcripts are critical regulatory mechanisms of mammalian gene expression. In the heart, there is an expanding interest in elucidating the role of alternative splicing in transcriptome regulation. Substantial efforts were directed toward investigating this process in heart development and failure. However, few studies shed light on alternative splicing products and their dysregulation in congenital heart defects (CHDs). While elegant reports showed the crucial roles of RNA binding proteins (RBPs) in orchestrating splicing transitions during heart development and failure, the impact of RBPs dysregulation or genetic variation on CHDs has not been fully addressed. Herein, we review the current understanding of alternative splicing and RBPs' roles in heart development and CHDs. Wediscuss the impact of perinatal splicing transition and its dysregulation in CHDs. We further summarize the discoveries made of causal splicing variants in key transcription factors that are implicated in CHDs. An improved understanding of the roles of alternative splicing in heart development and CHDs may potentially inform novel preventive and therapeutic advancements for newborn infants with CHDs.
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Affiliation(s)
- Zubin Mehta
- Neonatal/Congenital Heart Laboratory, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
- Department of Pediatrics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
- Children’s Discovery and Innovation Institute, Department of Pediatrics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
- Eli and Edythe Broad Stem Cell Research Center, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Marlin Touma
- Neonatal/Congenital Heart Laboratory, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
- Department of Pediatrics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
- Children’s Discovery and Innovation Institute, Department of Pediatrics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
- Eli and Edythe Broad Stem Cell Research Center, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
- Correspondence:
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29
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Liang YJ, Fang JX, Sun YX, Feng ZC, Liu CS, Zhang XH, Jian MQ, Zhong J, Wang XM, Liu YM, He SR. The implications of an integrated management model of prenatal diagnosis/postnatal treatment for premature infants with critical congenital heart disease-a case-control study. Cardiovasc Diagn Ther 2022; 12:868-879. [PMID: 36605076 PMCID: PMC9808112 DOI: 10.21037/cdt-22-74] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 09/14/2022] [Indexed: 11/18/2022]
Abstract
Background The high death rate and medical costs of critical congenital heart disease (CCHD) in preterm infants has resulted in significant burdens on both countries and individuals. It is unclear how this affects the mortality of the integrated management model of prenatal diagnosis/postnatal treatment. This study explored the effects of the delivery classification scale for fetal heart and postnatal infants' CCHD on prenatal and postnatal integrated treatment strategies to improve the effectiveness of disease management in CCHD. Methods This study was a case-control study, which retrospectively analyzed the clinical data of 79 preterm infants (<37 weeks) who underwent prenatal diagnosis and postpartum treatment in Guangdong Provincial People' s Hospital (China) from June 2017 to June 2019. According to the diagnostic and exclusion criteria, the subjects were divided into prenatal and postpartum diagnostic groups. The clinical characteristics and survival outcomes of patients were collected and compared. The delivery classification scale was used for risk stratification and patient management. Results Among the 79 patients included in this study, 48 (60.76%) were diagnosed prenatally, and 31 (39.24%) were diagnosed postpartum. The prenatal diagnosis group was born slightly earlier during the gestation period [35.00 (33.29-35.86) vs. 35.57 (34.14-36.71) weeks, P<0.05], and their mothers were older (33.23±5.22 vs. 30.43±6.37 years, P<0.05). The difference in the admission age between the groups was statistically significant [0 (0-5.5) vs. 7 (5-16) days, P<0.001]. The median survival time of the prenatal diagnosis group was higher than the postnatal diagnosis group [48 months (95% CI: 40.78-57.29) vs. 39 months (95% CI: 34.41-44.32), P<0.05]. The 3-year survival rates of the classes I, II, and III were 92.31% (12/13), 59.09% (13/22), and 38.46% (5/13), respectively. The survival of class I as denoted in the delivery classification scale was better than classes II or III (class I vs. II, P<0.05; class I vs. III, P<0.05). Unexpectedly, the hospitalisation costs were lower and total in-hospital days were shorter in the postnatal diagnosis group. Conclusions The results indicated that the integrated management of a prenatal diagnosis/postnatal treatment approach in premature infants may be effective. Furthermore, the delivery classification scale has a particular prognostic value for CCHD. The authors anticipate that their management model will be able to contribute to the shift from a reactive monodisciplinary system to a proactive, multidisciplinary and dynamic management paradigm in premature infants with CCHD in the near future.
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Affiliation(s)
- Yi-Jing Liang
- Department of NICU, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China;,Department of Child Healthcare, Affiliated Foshan Maternity and Child Healthcare Hospital, Southern Medical University, Foshan, China
| | - Jing-Xuan Fang
- Department of NICU, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yun-Xia Sun
- Department of NICU, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangzhou, China
| | - Zhi-Chun Feng
- Department of Neonatology, Senior Department of Pediatrics, the Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Cai-Sheng Liu
- Department of NICU, Guangdong Provincial People’s Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Xiao-Hui Zhang
- Department of NICU, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Min-Qiao Jian
- Department of NICU, Guangdong Provincial People’s Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Jin Zhong
- Department of NICU, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangzhou, China
| | - Xi-Meng Wang
- Prevention and Treatment Research Office for Cardiovascular Diseases and Epidemiological Research Office, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yu-Mei Liu
- Department of NICU, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangzhou, China
| | - Shao-Ru He
- Department of NICU, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China;,Department of NICU, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangzhou, China
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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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Baldini L, Librandi K, D’Eusebio C, Lezo A. Nutritional Management of Patients with Fontan Circulation: A Potential for Improved Outcomes from Birth to Adulthood. Nutrients 2022; 14:nu14194055. [PMID: 36235705 PMCID: PMC9572747 DOI: 10.3390/nu14194055] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/23/2022] [Accepted: 09/24/2022] [Indexed: 11/30/2022] Open
Abstract
Fontan circulation (FC) is a surgically achieved palliation state offered to patients affected by a wide variety of congenital heart defects (CHDs) that are grouped under the name of univentricular heart. The procedure includes three different surgical stages. Malnutrition is a matter of concern in any phase of life for these children, often leading to longer hospital stays, higher mortality rates, and a higher risk of adverse neurodevelopmental and growth outcomes. Notwithstanding the relevance of proper nutrition for this subset of patients, specific guidelines on the matter are lacking. In this review, we aim to analyze the role of an adequate form of nutritional support in patients with FC throughout the different stages of their lives, in order to provide a practical approach to appropriate nutritional management. Firstly, the burden of faltering growth in patients with univentricular heart is analyzed, focusing on the pathogenesis of malnutrition, its detection and evaluation. Secondly, we summarize the nutritional issues of each life phase of a Fontan patient from birth to adulthood. Finally, we highlight the challenges of nutritional management in patients with failing Fontan.
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Affiliation(s)
- Letizia Baldini
- Postgraduate School of Pediatrics, University of Turin, 10126 Turin, Italy
- Pediatria Specialistica, Ospedale Infantile Regina Margherita, Piazza Polonia 94, 10126 Torino, Italy
- Correspondence:
| | - Katia Librandi
- Postgraduate School of Pediatrics, University of Turin, 10126 Turin, Italy
| | - Chiara D’Eusebio
- Dietetic and Clinical Nutrition Unit, Pediatric Hospital Regina Margherita, University of Turin, 10126 Turin, Italy
| | - Antonella Lezo
- Dietetic and Clinical Nutrition Unit, Pediatric Hospital Regina Margherita, University of Turin, 10126 Turin, Italy
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Perez MT, Bucholz E, Asimacopoulos E, Ferraro AM, Salem SM, Schauer J, Holleman C, Sekhavat S, Tworetzky W, Powell AJ, Sleeper LA, Beroukhim RS. Impact of maternal social vulnerability and timing of prenatal care on outcome of prenatally detected congenital heart disease. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:346-358. [PMID: 35061294 DOI: 10.1002/uog.24863] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 12/30/2021] [Accepted: 01/07/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Early prenatal detection of congenital heart disease (CHD) allows mothers to plan for their pregnancy and delivery; however, the effect of certain sociodemographic and fetal factors on prenatal care has not been investigated thoroughly. This study evaluated the impact of maternal and fetal characteristics on the timing of prenatal diagnosis of CHD and fetal and postnatal outcomes. METHODS This retrospective multicenter cohort study included women with a fetal echocardiographic diagnosis of CHD between 2010 and 2019. Women were grouped into quartiles of social vulnerability (quartiles 1-4; low-high) using the 2014 social vulnerability index (SVI) provided by the Centers for Disease Control and Prevention. A fetal disease severity score (range, 1-7) was calculated based on a combination of CHD severity (mild = 1; moderate = 2; severe, two ventricles = 3; severe, single ventricle = 4 points) and prenatally diagnosed genetic abnormality, non-cardiac abnormality and fetal hydrops (1 point each). Late diagnosis was defined as a fetal echocardiographic diagnosis of CHD after 24 weeks' gestation. Univariate and multivariable regression analyses were used to identify factors associated with late diagnosis, termination of pregnancy (TOP), postnatal death, prenatal-postnatal discordance in CHD diagnosis and severity and, for liveborn infants, to identify which prenatal variables were associated with postnatal death or heart transplant. RESULTS Among 441 pregnancies included, 94 (21%) had a late diagnosis of CHD. Late diagnosis was more common in the most socially vulnerable quartile, 38% of women in this group having diagnosis > 24 weeks, compared with 14-18% in the other three quartile groups. Late diagnosis was also associated with Catholic or other Christian religion vs non-denominational or other religion and with a lower fetal disease severity score. There were 93 (21%) TOP and 26 (6%) in-utero fetal demises. Factors associated with TOP included early diagnosis and greater fetal disease severity. Compared with the other quartiles, the most socially vulnerable quartile had a higher incidence of in-utero fetal demise and a lower incidence of TOP. Among the 322 liveborn infants, 49 (15%) died or underwent heart transplant during the follow-up period (range, 0-16 months). Factors associated with postnatal death or heart transplant included longer delay between obstetric ultrasound examination at which CHD was first suspected and fetal echocardiogram at which CHD was confirmed and greater fetal disease severity. CONCLUSIONS High social vulnerability, Catholic or other Christian religion and low fetal disease severity are associated with late prenatal CHD diagnosis. Delays in CHD diagnosis are associated with fewer TOPs and worse postnatal outcome. Therefore, efforts to expedite fetal echocardiography following abnormal obstetric screening, particularly for at-risk women (e.g. those with high SVI), have the potential to impact pregnancy and postnatal outcome among the prenatally diagnosed CHD population. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- M T Perez
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - E Bucholz
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - E Asimacopoulos
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - A M Ferraro
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, Rome, Italy
| | - S M Salem
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - J Schauer
- Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA
| | | | - S Sekhavat
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Pediatrics, Boston Medical Center, Boston, MA, USA
| | - W Tworetzky
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - A J Powell
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - L A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - R S Beroukhim
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Buss R, SenthilKumar G, Bouchard M, Bowder A, Marquart J, Cooke-Barber J, Vore E, Beals D, Raval M, Rich BS, Goldstein S, Van Arendonk K. Geographic barriers to children's surgical care: A systematic review of existing evidence. J Pediatr Surg 2022; 57:107-117. [PMID: 34963510 DOI: 10.1016/j.jpedsurg.2021.11.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Ensuring that children have access to timely and appropriate surgical care is a vital component of comprehensive pediatric care. This study systematically reviews the existing evidence related to geographic barriers in children's surgery. METHODS Medline and Scopus databases were searched for any English language studies that examined associations between geographic burden (rural residence or distance to care) and a quantifiable outcome within pediatric surgical subspecialties. Two independent reviewers extracted data from each study. RESULTS From 6331 studies screened, 22 studies met inclusion criteria. Most studies were retrospective analyses and conducted in the U.S. or Canada (14 and three studies, respectively); five were conducted outside North America. In transplant surgery (seven studies), greater distance from a transplant center was associated with higher waitlist mortality prior to kidney and liver transplantation, although graft outcomes were generally similar. In congenital cardiac surgery (five studies), greater travel was associated with higher neonatal mortality and older age at surgery but not with post-operative outcomes. In general surgery (eight studies), rural residence was associated with increased rates of perforated appendicitis, higher frequency of negative appendectomy, and increased length of stay after appendectomy. In orthopedic surgery (one study), rurality was associated with decreased post-operative satisfaction. No evidence for disparate outcomes based upon distance or rurality was identified in neurosurgery (one study). CONCLUSIONS Substantial evidence suggests that geographic barriers impact the receipt of surgical care among children, particularly with regard to transplantation, congenital cardiac surgery, and appendicitis.
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Affiliation(s)
- Radek Buss
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, 999 North 92nd Street, Suite CCC 320, Milwaukee, WI 53226, United States
| | - Gopika SenthilKumar
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, 999 North 92nd Street, Suite CCC 320, Milwaukee, WI 53226, United States
| | - Megan Bouchard
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave. Chicago, IL 60611, United States
| | - Alexis Bowder
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, 999 North 92nd Street, Suite CCC 320, Milwaukee, WI 53226, United States
| | - John Marquart
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, 999 North 92nd Street, Suite CCC 320, Milwaukee, WI 53226, United States
| | - Jo Cooke-Barber
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital, 3333 Burnet Ave. ML 2023, Cincinnati, OH 45229, United States
| | - Emily Vore
- Department of Surgery, Marshall University Medical Center, 1600 Medical Center Drive, Suite 2500, Huntington, WV 25701, United States
| | - Daniel Beals
- Department of Surgery, Marshall University Medical Center, 1600 Medical Center Drive, Suite 2500, Huntington, WV 25701, United States
| | - Mehul Raval
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave. Chicago, IL 60611, United States
| | - Barrie S Rich
- Division of Pediatric Surgery, Cohen Children's Medical Center, 450 Lakeville Rd, North New Hyde Park, NY 11042, United States
| | - Seth Goldstein
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave. Chicago, IL 60611, United States
| | - Kyle Van Arendonk
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, 999 North 92nd Street, Suite CCC 320, Milwaukee, WI 53226, United States.
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Edwin F, Edwin AK, Palacios-Macedo A, Mamorare H, Yao NA. Management of Hypoplastic Left Heart Syndrome in Low-Resource Settings and the Ethics of Decision-Making. World J Pediatr Congenit Heart Surg 2022; 13:609-614. [PMID: 36053092 DOI: 10.1177/21501351221103511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Hypoplastic left heart syndrome (HLHS) is possibly the most challenging congenital heart defect to confront in any setting. The highly specialized infrastructure and resources needed to treat HLHS is not available in many low-resource settings. However, low-resource settings must not be assumed to be synonymous with low- and middle-income countries as national income is not necessarily indicative of a country's prioritization of healthcare resources. Besides, a low-resource setting may be institution-specific as well as country-specific. We have stratified institutional capabilities for addressing the requirements of treatment for HLHS into five levels based on the capacity for diagnosis, intervention, and post-discharge monitoring. Depending on institutional capabilities, children born with HLHS in low-resource settings experience a spectrum of outcomes ranging from death without diagnosis to the hybrid or Norwood stage 1 palliation. The decision-making is ethically challenging when resources are scarce and economic efficiency must be considered in the context of distributive justice. Even in settings that would be classified as resource-rich where survival after surgery and quality of life afterward keep improving, not every parent would choose surgical intervention for their hypothetical child with HLHS.
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Affiliation(s)
- Frank Edwin
- Ho Cardiothoracic Centre, School of Medicine, University of Health & Allied Sciences, Ho, Ghana
- National Cardiothoracic Centre, Accra, Ghana
| | - Ama K Edwin
- Department of Psychological Medicine and Mental Health, School of Medicine, University of Health and Allied Sciences, Ho, Ghana
- Department of Bioethics and Palliative Care, University of Ghana Medical Centre, Accra, Ghana
| | - Alexis Palacios-Macedo
- Division de Cirugıa Cardiovasclar, 37759Instituto Nacional de Pediatria, Mexico City, Mexico
- Centro Pediatrico del Corazon ABC-Kardias, Mexico City, Mexico
| | | | - Nana Akyaa Yao
- National Cardiothoracic Centre, Accra, Ghana
- Department of Pediatric Cardiology, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana
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Reddy CD, Van den Eynde J, Kutty S. Artificial intelligence in perinatal diagnosis and management of congenital heart disease. Semin Perinatol 2022; 46:151588. [PMID: 35396036 DOI: 10.1016/j.semperi.2022.151588] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Prenatal diagnosis and management of congenital heart disease (CHD) has progressed substantially in the past few decades. Fetal echocardiography can accurately detect and diagnose approximately 85% of cardiac anomalies. The prenatal diagnosis of CHD results in improved care, with improved risk stratification, perioperative status and survival. However, there is much work to be done. A minority of CHD is actually identified prenatally. This seemingly incongruous gap is due, in part, to diminished recognition of an anomaly even when present in the images and the need for increased training to obtain specialized cardiac views. Artificial intelligence (AI) is a field within computer science that focuses on the development of algorithms that "learn, reason, and self-correct" in a human-like fashion. When applied to fetal echocardiography, AI has the potential to improve image acquisition, image optimization, automated measurements, identification of outliers, classification of diagnoses, and prediction of outcomes. Adoption of AI in the field has been thus far limited by a paucity of data, limited resources to implement new technologies, and legal and ethical concerns. Despite these barriers, recognition of the potential benefits will push us to a future in which AI will become a routine part of clinical practice.
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Affiliation(s)
- Charitha D Reddy
- Division of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA.
| | - Jef Van den Eynde
- Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, Baltimore, MD, USA; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Shelby Kutty
- Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, Baltimore, MD, 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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37
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Purkey NJ, Ma C, Lee HC, Hintz SR, Shaw GM, McElhinney DB, Carmichael SL. Distance from home to birth hospital, transfer, and mortality in neonates with hypoplastic left heart syndrome in California. Birth Defects Res 2022; 114:662-673. [PMID: 35488460 DOI: 10.1002/bdr2.2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 04/04/2022] [Accepted: 04/11/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Prior studies report a lower risk of mortality among neonates with hypoplastic left heart syndrome (HLHS) who are born at a cardiac surgical center, but many neonates with HLHS are born elsewhere and transferred for repair. We investigated the associations between the distance from maternal home to birth hospital, the need for transfer after birth, sociodemographic factors, and mortality in infants with HLHS in California from 2006 to 2011. METHODS We used linked data from two statewide databases to identify neonates for this study. Three groups were included in the analysis: "lived close/not transferred," "lived close/transferred," and "lived far/not transferred." We defined "lived close" versus "lived far" as 11 miles, the median distance from maternal residence to birth hospital. Log-binomial regression models were used to identify the association between sociodemographic variables, distance to birth hospital and transfer. Cox proportional hazards models were used to identify the association between mortality and distance to birth hospital and transfer. Models were adjusted for sociodemographic variables. RESULTS Infants in the lived close/not transferred and the lived close/transferred groups (vs. the lived far/not transferred group) were more likely to live in census tracts above the 75th percentile for poverty with relative risks 1.94 (95% confidence interval [CI] 1.41-2.68) and 1.21 (95% CI 1.05-1.40), respectively. Neonatal mortality was higher among the lived close/not transferred group compared with the lived far/not transferred group (hazard ratio 1.77, 95% CI 1.17-2.67). CONCLUSIONS Infants born to mothers experiencing poverty were more likely to be born close to home. Infants with HLHS who were born close to home and not transferred to a cardiac center had a higher risk of neonatal mortality than infants who were delivered far from home and not transferred. Future studies should identify the barriers to delivery at a cardiac center for mothers experiencing poverty.
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Affiliation(s)
- Neha J Purkey
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Chen Ma
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Henry C Lee
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Susan R Hintz
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Gary M Shaw
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Doff B McElhinney
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA.,Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Suzan L Carmichael
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA.,Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California, USA
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Lopez KN, Baker-Smith C, Flores G, Gurvitz M, Karamlou T, Nunez Gallegos F, Pasquali S, Patel A, Peterson JK, Salemi JL, Yancy C, Peyvandi S. Addressing Social Determinants of Health and Mitigating Health Disparities Across the Lifespan in Congenital Heart Disease: A Scientific Statement From the American Heart Association. J Am Heart Assoc 2022; 11:e025358. [PMID: 35389228 PMCID: PMC9238447 DOI: 10.1161/jaha.122.025358] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite the overall improvement in life expectancy of patients living with congenital heart disease (congenital HD), disparities in morbidity and mortality remain throughout the lifespan. Longstanding systemic inequities, disparities in the social determinants of health, and the inability to obtain quality lifelong care contribute to poorer outcomes. To work toward health equity in populations with congenital HD, we must recognize the existence and strategize the elimination of inequities in overall congenital HD morbidity and mortality, disparate health care access, and overall quality of health services in the context of varying social determinants of health, systemic inequities, and structural racism. This requires critically examining multilevel contributions that continue to facilitate health inequities in the natural history and consequences of congenital HD. In this scientific statement, we focus on population, systemic, institutional, and individual‐level contributions to health inequities from prenatal to adult congenital HD care. We review opportunities and strategies for improvement in lifelong congenital HD care based on current public health and scientific evidence, surgical data, experiences from other patient populations, and recognition of implicit bias and microaggressions. Furthermore, we review directions and goals for both quantitative and qualitative research approaches to understanding and mitigating health inequities in congenital HD care. Finally, we assess ways to improve the diversity of the congenital HD workforce as well as ethical guidance on addressing social determinants of health in the context of clinical care and research.
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Freud LR, Seed M. Prenatal Diagnosis and Management of Single Ventricle Heart Disease. Can J Cardiol 2022; 38:897-908. [DOI: 10.1016/j.cjca.2022.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 03/27/2022] [Accepted: 04/04/2022] [Indexed: 12/18/2022] Open
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Tran R, Forman R, Mossialos E, Nasir K, Kulkarni A. Social Determinants of Disparities in Mortality Outcomes in Congenital Heart Disease: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 9:829902. [PMID: 35369346 PMCID: PMC8970097 DOI: 10.3389/fcvm.2022.829902] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundSocial determinants of health (SDoH) affect congenital heart disease (CHD) mortality across all forms and age groups. We sought to evaluate risk of mortality from specific SDoH stratified across CHD to guide interventions to alleviate this risk.MethodsWe searched electronic databases between January 1980 and June 2019 and included studies that evaluated occurrence of CHD deaths and SDoH in English articles. Meta-analysis was performed if SDoH data were available in >3 studies. We included race/ethnicity, deprivation, insurance status, maternal age, maternal education, single/multiple pregnancy, hospital volume, and geographic location of patients as SDoH. Data were pooled using random-effects model and outcome was reported as odds ratio (OR) with 95% confidence interval (CI).ResultsOf 17,716 citations reviewed, 65 met inclusion criteria. Sixty-three were observational retrospective studies and two prospective. Of 546,981 patients, 34,080 died. Black patients with non-critical CHD in the first year of life (Odds Ratio 1.62 [95% confidence interval 1.47–1.79], I2 = 7.1%), with critical CHD as neonates (OR 1.27 [CI 1.05-1.55], I2 = 0%) and in the first year (OR 1.68, [1.45-1.95], I2 = 0.3%) had increased mortality. Deprived patients, multiple pregnancies, patients born to mothers <18 years and with education <12 years, and patients on public insurance with critical CHD have greater likelihood of death after the neonatal period.ConclusionThis systematic review and meta-analysis found that Black patients with CHD are particularly vulnerable for mortality. Numerous SDoH that affect mortality were identified for specific time points in CHD course that may guide interventions, future research and policy.Systematic Review Registration[https://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42019139466&ID=CRD42019139466], identifier [CRD42019139466].
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Affiliation(s)
- Richard Tran
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
- *Correspondence: Richard Tran,
| | - Rebecca Forman
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
| | - Elias Mossialos
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
| | - Khurram Nasir
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Institute, Houston Methodist Hospital, Houston, TX, United States
| | - Aparna Kulkarni
- Cohen Children’s Medical Center, Donald and Barbara Zucker School of Medicine, New Hyde Park, NY, United States
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Verma SK, Deshmukh V, Thatcher K, Belanger KK, Rhyner A, Meng S, Holcomb R, Bressan M, Martin J, Cooke J, Wythe J, Widen S, Lincoln J, Kuyumcu-Martinez M. RBFOX2 is required for establishing RNA regulatory networks essential for heart development. Nucleic Acids Res 2022; 50:2270-2286. [PMID: 35137168 PMCID: PMC8881802 DOI: 10.1093/nar/gkac055] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/14/2022] [Accepted: 01/25/2022] [Indexed: 12/14/2022] Open
Abstract
Human genetic studies identified a strong association between loss of function mutations in RBFOX2 and hypoplastic left heart syndrome (HLHS). There are currently no Rbfox2 mouse models that recapitulate HLHS. Therefore, it is still unknown how RBFOX2 as an RNA binding protein contributes to heart development. To address this, we conditionally deleted Rbfox2 in embryonic mouse hearts and found profound defects in cardiac chamber and yolk sac vasculature formation. Importantly, our Rbfox2 conditional knockout mouse model recapitulated several molecular and phenotypic features of HLHS. To determine the molecular drivers of these cardiac defects, we performed RNA-sequencing in Rbfox2 mutant hearts and identified dysregulated alternative splicing (AS) networks that affect cell adhesion to extracellular matrix (ECM) mediated by Rho GTPases. We identified two Rho GTPase cycling genes as targets of RBFOX2. Modulating AS of these two genes using antisense oligos led to cell cycle and cell-ECM adhesion defects. Consistently, Rbfox2 mutant hearts displayed cell cycle defects and inability to undergo endocardial-mesenchymal transition, processes dependent on cell-ECM adhesion and that are seen in HLHS. Overall, our work not only revealed that loss of Rbfox2 leads to heart development defects resembling HLHS, but also identified RBFOX2-regulated AS networks that influence cell-ECM communication vital for heart development.
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Affiliation(s)
- Sunil K Verma
- Department of Biochemistry and Molecular Biology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Vaibhav Deshmukh
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, TX 77030, USA
| | - Kaitlyn Thatcher
- Department of Pediatrics, Medical College of Wisconsin, Division of Pediatric Cardiology, The Herma Heart Institute, Children's WI, Milwaukee, WI 53226, USA
| | - KarryAnne K Belanger
- Department of Biochemistry and Molecular Biology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Alexander M Rhyner
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, TX 77030, USA
- Center for Organ Repair and Renewal, Baylor College of Medicine, Houston, TX 77030, USA
| | - Shu Meng
- Houston Methodist Research Institute, Department of Cardiovascular Sciences, Houston, TX 77030, USA
| | - Richard Joshua Holcomb
- Department of Biochemistry and Molecular Biology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Michael Bressan
- Department of Cell Biology and Physiology, McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC27599, USA
| | - James F Martin
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, TX 77030, USA
- Center for Organ Repair and Renewal, Baylor College of Medicine, Houston, TX 77030, USA
- Cardiomyocyte Renewal Lab;Texas Heart Institute, Houston, TX77030, USA
| | - John P Cooke
- Houston Methodist Research Institute, Department of Cardiovascular Sciences, Houston, TX 77030, USA
| | - Joshua D Wythe
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, TX 77030, USA
- Center for Organ Repair and Renewal, Baylor College of Medicine, Houston, TX 77030, USA
- Cardiomyocyte Renewal Lab;Texas Heart Institute, Houston, TX77030, USA
| | - Steven G Widen
- Department of Biochemistry and Molecular Biology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Joy Lincoln
- Department of Pediatrics, Medical College of Wisconsin, Division of Pediatric Cardiology, The Herma Heart Institute, Children's WI, Milwaukee, WI 53226, USA
| | - Muge N Kuyumcu-Martinez
- Department of Biochemistry and Molecular Biology, University of Texas Medical Branch, Galveston, TX 77555, USA
- Department of Neuroscience, Cell Biology and Anatomy, Institute for Translational Sciences, University of Texas Medical Branch, 301 University Blvd. Galveston, TX 77555, USA
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42
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Birth Location in Infants with Prenatally Diagnosed Hypoplastic Left Heart Syndrome. Pediatr Cardiol 2022; 43:301-307. [PMID: 34668072 DOI: 10.1007/s00246-021-02721-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
There are conflicting data on how delivery location impacts outcomes in neonates with ductal-dependent heart disease. Our goal was to evaluate the impact of delivery location on hospital length of stay and survival in infants with prenatally diagnosed hypoplastic left heart syndrome (HLHS) after stage 1 palliation (S1P). A multicenter cohort study was performed utilizing the National Pediatric Cardiology Quality Improvement Collaborative dataset for infants with prenatally diagnosed HLHS who underwent S1P from August 2016 to December 2018. Univariate comparisons of demographics, clinical, and outcome data were made and multivariable logistic regression was performed between groups stratified by distance from surgical center. A total of 790 patients from 33 centers were analyzed: 85% were born < 5 miles from the surgical center with 72% of those (486/673) born at the surgical center. Infants born < 5 miles from the surgical center were significantly (p < 0.05) more likely to be male, white, full term, have no non-cardiac anomaly, and have commercial health insurance; they were significantly more likely to breastfeed pre-operatively, and less likely to have pre-operative cardiac catheterizations, pre-operative mechanical ventilation, or delayed surgery. There was no significant difference between groups in hospital length of stay, 30-day survival, or survival to hospital discharge. In this multicenter dataset, hospital length of stay and survival after S1P did not differ based on distance from birth location to surgical center. However, neonates born < 5 miles from the surgical center had lower rates of potentially modifiable pre-operative risk factors including mechanical ventilation and delays to surgery.
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Madazlı R, Alıcı Davutoglu E, Alpay V, Kaymak D, Erenel H, Oztunc F. Perinatal outcomes of pregnancies with prenatally diagnosed foetal congenital heart disease. J OBSTET GYNAECOL 2022; 42:1079-1084. [PMID: 35023813 DOI: 10.1080/01443615.2021.2000944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
We aimed to assess the types of prenatally diagnosed congenital heart disease (CHD) and their association with structural and chromosomal abnormalities and to evaluate the perinatal outcomes according to the type of the heart defect. We retrospectively reviewed 377 pregnancies with prenatally diagnosed CHD. The main outcome measure was to evaluate the pregnancy outcomes of CHD according to the type of the heart defect and associated structural or chromosomal abnormalities. Of 377 foetuses with major structural CHD, 214 (56.8%) were isolated, 49 (13%) had additional cardiac anomalies, 58 (15.4%) had extracardiac malformations with normal karyotype and 56 (14.9%) had chromosomal abnormalities. The most common chromosomal abnormality was trisomy 21 (55.4%). Prenatal detection of CHD allows early workup to identify chromosomal abnormalities and detailed anatomic evaluation of extracardiac malformations. Prognostication of each heart defect at diagnosis and facilitating patients with isolated surgically correctable CHD for targeted postnatal care is essential.IMPACT STATEMENTWhat is already known on this subject? CHD is the most common structural anomaly and is strongly associated with chromosomal anomalies and genetic syndromes.What do the results of this study add? Survival of the prenatally diagnosed CHD depends on the type and severity of the condition and coexisting extracardiac structural or chromosomal abnormalities.What are the implications of these findings for clinical practice and/or further research? Prenatal detection of CHD allows early workup to identify chromosomal abnormalities, detailed anatomic evaluation of extracardiac malformations and time to refer the parents to tertiary cardiac care centres and prepare for planned delivery, as well as to establish an appropriate perinatal and postnatal therapeutic plan.
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Affiliation(s)
- Riza Madazlı
- Department of Obstetrics and Gynecology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ebru Alıcı Davutoglu
- Department of Obstetrics and Gynecology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Verda Alpay
- Department of Obstetrics and Gynecology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Didem Kaymak
- Department of Obstetrics and Gynecology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Hakan Erenel
- Department of Obstetrics and Gynecology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Funda Oztunc
- Pediatric Cardiology Division, Department of Pediatrics, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Klein J, Dwyer G, Donofrio MT, Krishnan A. Geographic Distribution of Congenital Heart Disease: A Single Surgical Center Experience. J Pediatr 2022; 240:117-121. [PMID: 34480916 DOI: 10.1016/j.jpeds.2021.08.080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/25/2021] [Accepted: 08/27/2021] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To determine presence of spatial clustering or dispersion of pre and postnatally detected hypoplastic left heart syndrome (HLHS) and d-transposition of the great arteries (TGA) cases. STUDY DESIGN This retrospective study examined all patients with a prenatal or postnatal diagnosis of HLHS or TGA who had an initial visit or hospitalization at our tertiary care center over a 5-year period from 2012 to 2016 (n = 105). Using geographic information systems software, the nearest neighbor ratio (NNR) tool was used to determine whether statistically significant clustering or dispersion occurred. RESULTS Geographic clustering was observed among prenatally diagnosed pooled cases of HLHS and TGA and all total cases (NNR = 0.73 and 0.66, respectively), but not postnatally detected cases (NNR = 1.08). Notably, there was significant dispersion of postnatally detected TGA cases (NNR = 1.22) There was no pattern for prenatally detected TGA or HLHS when analyzed individually. CONCLUSIONS The spatial distribution of HLHS and TGA is not random; these conditions occur in geographic clusters. Clustering of all patients in the study population and dispersion of postnatal diagnosis of TGA represent opportunities for improved delivery of fetal cardiac care.
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Affiliation(s)
- Jennifer Klein
- Division of Cardiology, Children's National Hospital, Washington, DC.
| | - Gina Dwyer
- Child Health Advocacy Institute, Children's National Hospital, Washington, DC
| | - Mary T Donofrio
- Division of Cardiology, Children's National Hospital, Washington, DC
| | - Anita Krishnan
- Division of Cardiology, Children's National Hospital, Washington, DC
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Abstract
BACKGROUND/INTRODUCTION One way the goal of establishing a partnership with families is accomplished, specific to the pediatric intensive care units, is 24-hour visitation and presence/participation during medical rounds and procedures. Despite the breadth of literature on the positive effect of parent presence, as well as the nearly nationwide adoption of 24-hour pediatric intensive care unit visitation, there is little to no research about how these changes have affected parents' perception of their role in the pediatric cardiac intensive care unit (PCICU). OBJECTIVES/AIMS The purpose of this study was to explore and better understand the experience of parents in the PCICU within a patient/family-centered care model. METHODS Using a qualitative descriptive approach, interviews were conducted with parents of children currently admitted as inpatients in the PCICU. Participants were asked broad, open-ended questions and probes to attain qualitative descriptions of their experiences and perceptions of their parental role in the PCICU. The research design for this study was based on naturalistic inquiry and was used to describe rather than interpret parental experiences in their own words. RESULTS Eleven parents from 7 families were interviewed; parents described their role in terms of 2 main categories, as one who is an advocate and decision maker and one who provides emotional and physical support. Parents valued the expertise of the PCICU team but also shared the significance of the team recognizing their role as parents. Incorporating parents as an integral member of the health care team is a fundamental component to PCICU care. DISCUSSION/CONCLUSION The role of parents is irreplaceable, particularly in the PCICU. The medical complexity of the intensive care can be a barrier to act as parents resulting in a disruption of family-centered care. Nursing staff avert this disruption through modeling parenting to their child's present circumstances and involvement in normal parenting tasks.
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46
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Al-Fahham MM, Gad NA, Ramy ARM, Habeeb NM. Clinical utility of fetal echocardiography: an Egyptian center experience. Egypt Heart J 2021; 73:71. [PMID: 34410524 PMCID: PMC8377121 DOI: 10.1186/s43044-021-00196-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 08/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The impact of early diagnosis of fetal cardiac abnormalities on the postnatal outcome has been controversial in literature. We aimed to evaluate the role of fetal echocardiography (FE) as a diagnostic tool for early detection and proper management of fetal cardiac abnormalities, study the indications of referral and detect the perinatal outcome in our institution. RESULTS This is a cross-sectional observational and descriptive study that included one hundred and one singleton pregnant women (101 fetuses) who were referred for FE over a period of one year. Indications for referral and perinatal risk factors were documented. FE and postnatal transthoracic echocardiography were done. Fetal cardiac abnormalities were detected in 46.5% of cases. Congenital heart defects (CHDs) in 34.6%, fetal arrythmias in 9.9%, cardiomyopathy in 2.9% and cardiac mass (Rhabdomyoma) in 1% (combined structural and rhythm abnormalities were observed in two fetuses). Of the CHDs, complex heart lesions were diagnosed in 57.1%, common atrioventricular canal in 28.6% and conotrunchal anomalies in 14.3%. Of the ten cases with fetal arrythmias, five fetuses had tachyarrhythmias, four had ectopics and one fetus had congenital heart block in association with maternal lupus. The indications for referral were abnormal obstetric ultrasound (52.5%), maternal medical illnesses (23.8%), multiple neonatal deaths (13.9%) and positive family history of CHD (10.9%). The number of fetuses with cardiac abnormalities was significantly higher than those without cardiac abnormalities in mothers not exposed to perinatal risk factors (p = 0.009) and was statistically lower in mothers exposed to perinatal risk factors (p = 0.005). FE showed 100% accuracy in diagnosing complex lesions, common atrio-ventricular canals, cono-truncal anomalies, cardiac masses and fetal arrhythmias. It missed two cases of tiny muscular ventricular septal defects and one case of aortic coarctation. Cases of fetal supraventricular tachycardia were successfully treated in-utero. CONCLUSIONS CHDs exist in fetuses with no underlying perinatal risk factors. FE can accurately diagnose most of the cardiac anomalies though few errors remain challenging (aortic coarctation). It also offers a good chance for successful early life-saving management of some types of fetal arrhythmia.
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Affiliation(s)
- Marwa Moustapha Al-Fahham
- Pediatric Department, Pediatric Cardiology Unit, Faculty of Medicine, Ain Shams University, Ramsis Street, Abbasia, Cairo, 11566, Egypt. .,Al-Salam International Hospital, Bneid Al Gar, Kuwait City, Kuwait.
| | - Nada Ayman Gad
- Pediatric Department, Pediatric Cardiology Unit, Faculty of Medicine, Ain Shams University, Ramsis Street, Abbasia, Cairo, 11566, Egypt
| | - Ahmed Ramy Mohamed Ramy
- Ultrasound Special Care Unit for the Fetus, Faculty of Medicine, Ain Shams University, Ramsis Street, Abbasia, Cairo, 11566, Egypt
| | - Nevin Mamdouh Habeeb
- Pediatric Department, Pediatric Cardiology Unit, Faculty of Medicine, Ain Shams University, Ramsis Street, Abbasia, Cairo, 11566, Egypt
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47
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Krishnan A, Jacobs MB, Morris SA, Peyvandi S, Bhat AH, Chelliah A, Chiu JS, Cuneo BF, Freire G, Hornberger LK, Howley L, Husain N, Ikemba C, Kavanaugh-McHugh A, Kutty S, Lee C, Lopez KN, McBrien A, Michelfelder EC, Pinto NM, Schwartz R, Stern KWD, Taylor C, Thakur V, Tworetzky W, Wittlieb-Weber C, Woldu K, Donofrio MT. Impact of Socioeconomic Status, Race and Ethnicity, and Geography on Prenatal Detection of Hypoplastic Left Heart Syndrome and Transposition of the Great Arteries. Circulation 2021; 143:2049-2060. [PMID: 33993718 DOI: 10.1161/circulationaha.120.053062] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Prenatal detection (PND) has benefits for infants with hypoplastic left heart syndrome (HLHS) and transposition of the great arteries (TGA), but associations between sociodemographic and geographic factors with PND have not been sufficiently explored. This study evaluated whether socioeconomic quartile (SEQ), public insurance, race and ethnicity, rural residence, and distance of residence (distance and driving time from a cardiac surgical center) are associated with the PND or timing of PND, with a secondary aim to analyze differences between the United States and Canada. METHODS In this retrospective cohort study, fetuses and infants <2 months of age with HLHS or TGA admitted between 2012 and 2016 to participating Fetal Heart Society Research Collaborative institutions in the United States and Canada were included. SEQ, rural residence, and distance of residence were derived using maternal census tract from the maternal address at first visit. Subjects were assigned a SEQ z score using the neighborhood summary score or Canadian Chan index and separated into quartiles. Insurance type and self-reported race and ethnicity were obtained from medical charts. We evaluated associations among SEQ, insurance type, race and ethnicity, rural residence, and distance of residence with PND of HLHS and TGA (aggregate and individually) using bivariate analysis with adjusted associations for confounding variables and cluster analysis for centers. RESULTS Data on 1862 subjects (HLHS: n=1171, 92% PND; TGA: n=691, 58% PND) were submitted by 21 centers (19 in the United States). In the United States, lower SEQ was associated with lower PND in HLHS and TGA, with the strongest association in the lower SEQ of pregnancies with fetal TGA (quartile 1, 0.78 [95% CI, 0.64-0.85], quartile 2, 0.77 [95% CI, 0.64-0.93], quartile 3, 0.83 [95% CI, 0.69-1.00], quartile 4, reference). Hispanic ethnicity (relative risk, 0.85 [95% CI, 0.72-0.99]) and rural residence (relative risk, 0.78 [95% CI, 0.64-0.95]) were also associated with lower PND in TGA. Lower SEQ was associated with later PND overall; in the United States, rural residence and public insurance were also associated with later PND. CONCLUSIONS We demonstrate that lower SEQ, Hispanic ethnicity, and rural residence are associated with decreased PND for TGA, with lower SEQ also being associated with decreased PND for HLHS. Future work to increase PND should be considered in these specific populations.
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Affiliation(s)
- Anita Krishnan
- Divisions of Cardiology (A.K., M.T.D.), Children's National Hospital, Washington, DC
| | - Marni B Jacobs
- Biostatistics (M.B.J.), Children's National Hospital, Washington, DC.,Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Diego (M.B.J.)
| | - Shaine A Morris
- Division of Pediatric Cardiology, Baylor College of Medicine, Houston, TX (S.A.M., K.N.L.)
| | - Shabnam Peyvandi
- Division of Cardiology, Department of Pediatrics, University of California, San Francisco (S.P.)
| | - Aarti H Bhat
- Division of Cardiology, Seattle Children's Hospital, University of Washington (A.H.B.)
| | - Anjali Chelliah
- Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York (A.C.)
| | - Joanne S Chiu
- Division of Pediatric Cardiology, Johns Hopkins University, Baltimore, MD (J.S.C., S.K.).,Division of Cardiology, Department of Pediatrics, Massachusetts General Hospital, Boston (J.S.C.)
| | - Bettina F Cuneo
- Division of Cardiology, Children's Hospital of Colorado/University of Colorado, Aurora (B.F.C., L.H.)
| | - Grace Freire
- Division of Cardiology, Johns Hopkins University All Children's Hospital, St. Petersburg, FL (G.F.)
| | - Lisa K Hornberger
- Division of Pediatric Cardiology, University of Alberta, Edmonton, Canada (L.K.H., A.M.)
| | - Lisa Howley
- Division of Cardiology, Children's Hospital of Colorado/University of Colorado, Aurora (B.F.C., L.H.).,Division of Cardiology, The Children's Heart Clinic/Children's Minnesota, Minneapolis (L.H.)
| | - Nazia Husain
- Division of Cardiology, Ann and Robert H. Lurie Children's Hospital of Chicago, IL (N.H.)
| | - Catherine Ikemba
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (C.I., K.W.)
| | - Ann Kavanaugh-McHugh
- Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN (A.K.-M.)
| | - Shelby Kutty
- Division of Pediatric Cardiology, Johns Hopkins University, Baltimore, MD (J.S.C., S.K.).,University of Nebraska Medical Center, Omaha (S.K.)
| | - Caroline Lee
- Division of Cardiology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO (C.L.)
| | - Keila N Lopez
- Division of Pediatric Cardiology, Baylor College of Medicine, Houston, TX (S.A.M., K.N.L.)
| | - Angela McBrien
- Division of Pediatric Cardiology, University of Alberta, Edmonton, Canada (L.K.H., A.M.)
| | - Erik C Michelfelder
- Emory University School of Medicine, Children's Healthcare of Atlanta/Sibley Heart Center, GA (E.C.M.)
| | - Nelangi M Pinto
- Division of Pediatric Cardiology, University of Utah, Salt Lake City (N.M.P.)
| | - Rachel Schwartz
- Division of Cardiology, Boston Children's Hospital, MA (R.S., W.T.).,The George Washington School of Medicine, Washington, DC (R.S.)
| | - Kenan W D Stern
- Division of Pediatric Cardiology, Icahn School of Medicine at Mount Sinai, Kravis Children's Hospital, New York (K.W.D.S.)
| | - Carolyn Taylor
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston (C.T.)
| | - Varsha Thakur
- Division of Cardiology, University of Toronto, Ontario, Canada (V.T.)
| | - Wayne Tworetzky
- Division of Cardiology, Boston Children's Hospital, MA (R.S., W.T.)
| | - Carol Wittlieb-Weber
- Division of Pediatric Cardiology, University of Rochester, NY (C.W.-W.).,Division of Cardiology, Children's Hospital of Philadelphia, PA (C.W.-W.)
| | - Kris Woldu
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas (C.I., K.W.).,Division of Cardiology, Cook Children's Heart Center, Ft. Worth, TX (K.W.)
| | - Mary T Donofrio
- Divisions of Cardiology (A.K., M.T.D.), Children's National Hospital, Washington, DC
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Karamlou T, Hawke JL, Zafar F, Kafle M, Tweddell JS, Najm HK, Frebis JR, Bryant RG. Widening our Focus: Characterizing Socioeconomic and Racial Disparities in Congenital Heart Disease. Ann Thorac Surg 2021; 113:157-165. [PMID: 33872577 DOI: 10.1016/j.athoracsur.2021.04.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 03/26/2021] [Accepted: 04/05/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Socioeconomic and racial (SER) disparities among congenital heart disease (CHD) patients may limit access to high-quality care. We characterized national SER landscape, its relationship to early outcomes, and identified interactions among determinants mitigating adverse outcome. METHODS The Pediatric Health Information System (PHIS) database queried patients (age < 26 years) with CHD between 2016-2018. ICD-10 codes were mapped to diagnostic categories for complexity adjustment. Correlational and hierarchical regression analyses identified risk-factors and characterized interactions. RESULTS N=166,599 unique admissions from 52 hospitals were identified, 58,395 having interventions. Median age was 0 years (IQR=4 years). Race/Ethnicity was predominantly White (59%), Hispanic (20%), and Black (16%). Median neighborhood household income (NHI) was $41,082, and varied among hospitals. Patient NHI had a parabolic relationship with mortality, with both higher and lower values having increased risk. Black patients had significantly higher mortality, and this relationship was potentiated by lower NHI and complexity. Length of hospital stay (LOS) was longer among Black neonates (median 51 days; IQR 93) compared to neonates of other ethnic groups (median 32 days; IQR 71), P<0.0001. Care pathways including permanent feeding tubes were also more prevalent among Black neonates (17.8%) compared to White neonates (15%), P=0.02. CONCLUSIONS Interactions among SER disparities modify CHD outcomes. Specific hospitals have more SER fragile patients, but may have developed care pathways that prolong LOS to mitigate risk among Black neonates. Adverse outcomes among SER disadvantaged patients are magnified in complex CHD, suggesting tangible benefits to targeted resource allocation and population health initiatives.
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Affiliation(s)
- Tara Karamlou
- Division of Pediatric Cardiac Surgery, Cleveland Clinic Children's and the Heart Vascular Institute, Cleveland, OH.
| | - Jesse L Hawke
- James A. Anderson Center for Clinical Systems Excellence, Cincinnati Children's Hospital, Cincinnati, OH
| | - Farhan Zafar
- Division of Pediatric Cardiothoracic Surgery, Cincinnati Children's Hospital
| | - Mahendra Kafle
- James A. Anderson Center for Clinical Systems Excellence, Cincinnati Children's Hospital, Cincinnati, OH
| | - James S Tweddell
- Division of Pediatric Cardiothoracic Surgery, Cincinnati Children's Hospital
| | - Hani K Najm
- Division of Pediatric Cardiac Surgery, Cleveland Clinic Children's and the Heart Vascular Institute, Cleveland, OH
| | - James R Frebis
- James A. Anderson Center for Clinical Systems Excellence, Cincinnati Children's Hospital, Cincinnati, OH
| | - Roosevelt G Bryant
- Division of Pediatric Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ
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49
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Bolin EH, Nembhard WN, Collins RT. Regionalization of Congenital Heart Surgery: Can We Make it Reality? Ann Thorac Surg 2021; 112:685. [PMID: 33422483 DOI: 10.1016/j.athoracsur.2020.10.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 10/01/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Elijah H Bolin
- Department of Pediatrics, Section of Pediatric Cardiology, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 512-3, Little Rock, AR 72202-3591.
| | - Wendy N Nembhard
- Department of Epidemiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - R Thomas Collins
- Department of Pediatrics, Section of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
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50
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Su Z, Xiang L, Liu Z, Wu H, Li S, Chen H, Zhang H. The Current Landscape of Congenital Heart Surgery in Northern China: A Geographic and Population-Based Analysis. Front Pediatr 2021; 9:555141. [PMID: 34026679 PMCID: PMC8138451 DOI: 10.3389/fped.2021.555141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 03/23/2021] [Indexed: 11/29/2022] Open
Abstract
Background: Congenital heart disease (CHD) is the leading birth defect in China, and many patients require congenital heart surgery (CHS) to achieve optimal outcomes. However, the current landscape and population accessibility to specialist resources for CHS in China are unclear. Methods: Care facilities performing CHS were identified from the 2018 white book of Chinese cardiovascular surgery and were categorized as full or limited facilities based on specialist capacity. Census-based population data and road data were obtained from administrative sources. Service area analysis of all facilities was performed to estimate geographic accessibility. Results: Of 93 facilities in 14 provinces and municipalities in northern China, only 30.1% had full specialist capacity. The shortage of pediatric cardiologists and mechanical circulatory support was the primary limiting factor. In 2018, 61.3% of facilities performed <200 CHS cases, and 31.6% of all CHS cases (N = 30,921) were performed in limited facilities with substantially lower volume than full-capacity facilities (median value: 85.0 vs. 368.0). Beijing had a disproportionately higher CHS volume (367 cases per million population) than other provinces. Of all children under 5 in northern China, only 12.9% live within 30 km (a typical half-day visit) of the service areas of all facilities. Compared to children from the eastern region (31.4%), 71.8% of children from the central region and 70.2% of children from the western region needed to travel >180 km (a typical overnight visit) to receive care in full-capacity facilities. Conclusions: Many facilities for CHS in northern China had limited specialist capacity, and many CHD patients received suboptimal surgical care. Policy measures should address the significant geographic disparities to receive high-quality surgical care among disadvantaged patients.
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Affiliation(s)
- Zhanhao Su
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Li Xiang
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Zeye Liu
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Hao Wu
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Shoujun Li
- Center for Pediatric Cardiac Surgery, National Center for Cardiovascular Diseases, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Huiwen Chen
- Shanghai Children's Medical Center, National Children's Medical Center, Heart Center and Shanghai Institution of Pediatric Congenital Heart Diseases, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hao Zhang
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Shanghai Children's Medical Center, National Children's Medical Center, Heart Center and Shanghai Institution of Pediatric Congenital Heart Diseases, Shanghai Jiaotong University School of Medicine, Shanghai, China
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