The impact of prenatal diagnosis of congenital heart disease on pediatric cardiology and cardiac surgery

Associated factors with parental pregnancy decision-making and use of consultation after a prenatal congenital heart disease diagnosis

BACKGROUND

Prenatal diagnosis of congenital heart disease (CHD) often leads affected families to experience psychological stress. Pediatric cardiology consultation is important in providing parents with sufficient information and reducing their anxiety to make an informed pregnancy decision. Involving a fetal nurse coordinator may optimize fetal anomaly care. Our study aimed to identify factors associated with parental decision-making for choosing to use pediatric cardiology consultations and pregnancy termination.

METHODS

From September 2017 to December 2018, all fetal CHD cases diagnosed in the second trimester from a primary screening clinic in Taiwan were included (n = 145). Univariate and multivariate logistic regression were performed to analyze maternal, fetal, and medical factors for predictors of parental decisions for consultation use and pregnancy termination.

RESULTS

Acceptance for fetal nurse coordinator care and pediatric cardiology consultation were 84.8% (n = 123) and 83.4% (n = 121), respectively. Predictors for termination of pregnancy included the following: multiple anomalies (OR: 10.6; 95% CI: 3.6-35.7), chromosomal/genetic abnormalities (OR: 20.2; 95% CI: 3.1-395.8), severe CHDs (OR: 9.8; 95% CI: 4.3-23.4), CHDs that required surgery (OR: 32.4; 95% CI: 11.4-117.8), and physiological single-ventricle (OR: 47.3; 95% CI: 12.4-312.5). Parents who had pediatric cardiology counseling were less likely to terminate the pregnancy (OR: 0.1; 95% CI: 0.0-0.7). Parents with fetal diagnosis having multiple anomalies (OR: 0.2; 95% CI: 0.1-0.7) or chromosomal/genetic abnormalities (OR: 0.1; 95% CI: 0.03-0.9) were less likely to make use of cardiology consultation. Parents who accepted fetal nurse coordinator care were more likely to have pediatric cardiology consultation before pregnancy decision (OR: 149.5, 95% CI: 37.8-821.5).

CONCLUSIONS

Anomaly complexity appeared to be a strong predictor for termination of pregnancy beyond non-acceptability of prenatal cardiology consultation. Prenatal cardiology counseling may help support the parental decision to continue with the pregnancy. Incorporation of a fetal nurse coordinator care into the multidisciplinary fetal medicine team improved the acceptability of prenatal consultation.

Prevalence of congenital heart disease according to the echocardiography findings in 8145 neonates, multicenter study in southern Iran

Introduction

Congenital heart disease (CHD), the lethal congenital anomaly in newborns, is multifactorial, with environmental and genetic factors contributing to its occurrence. Although some studies on the prevalence of CHD have been conducted throughout the country, this large‐scale study aims to provide information on the prevalence of various types of CHDs in newborns according to the echocardiography findings.

Patients and Methods

Over 3 years, 8145 neonates with suspected CHD who underwent echocardiography by a trained pediatric cardiologist were included in this multicenter, cross‐sectional observational study. CHD was categorized into two major groups; cyanotic and acyanotic heart disease. The SPSS version 22 software was used to analyze the data with a significance level set at 0.05.

Results

Of 8145 neonates who were referred to our centers with CHD symptoms, 6307 were indicated for echocardiography. The mean age of the studied population was 8.5 ± 9.3 days and the male‐to‐female ratio was 2.6, especially in the arterial septal defect (ASD), ventricular septal defect (VSD), and patent ductus arteriosus (PDA) groups. 77.2% of patients had acyanotic heart disease (100 in 1000 neonates) with ASD as the most common one and 9% were diagnosed with cyanotic heart disease (11 in 1000 neonates) with transposition of the great arteries as the most common form and the aortopulmonary window was the rarest form.

Conclusion

This large prospective, multicenter screening study reported arterial septal defect (85%) and patents with ductus arteriosus (32%) as the most frequent type of CHD. Moreover, the prevalence of male patients was significantly higher. This information would be helpful for health policy makers, stakeholders, and general practitioners in regions where there are no trained pediatric cardiologist fellowships and limited access to echocardiography devices for better management of CHD.

Isolated Balanced Complete Atrioventricular Septal Defects: Prenatal Detection and Outcome in Nevada

We analyzed patients with isolated, balanced complete atrioventricular septal defects. We identified 71 patients born in Nevada, between January 2008 and December 2020. We also analyzed prenatal detection rates. Of the 71, 61 (85%) had trisomy 21, 1 (1%) had CHARGE syndrome and 22q.11 deletion, and 10 (14%) had no chromosomal abnormalities. Of the 71, 67 had prenatal care, and 43/67 (64%) were prenatally diagnosed. Prenatal detection rate for 2008-2012 was 9/20 (45%) and 18/21 (86%) for 2018-2020, P = .03. Of the 71, 67 underwent surgical repair with 1 current postpulmonary artery banding and 0 surgical deaths. Of the 67, 3 (4%) had heart block. Only 1 (1.5%) patient had reoperation for a mitral valve replacement. Of the 71, 67 (94%) are alive during a 6-year average (range = 0-12 years) follow-up. In conclusion, surgical and long-term outcomes were excellent. Also, high state-wide, general population prenatal detection rates were achieved.

Prenatal diagnosis in Nevada for patients undergoing cardiovascular surgery in the first six months

OBJECTIVE

We reviewed our center's experience with prenatal detection in Nevada's general population for young infants undergoing cardiovascular surgery.

METHODS

We identified patients born in Nevada that underwent an initial cardiovascular surgery between 0 and 6 months old with birth dates between August 2012 and July 2021. Additionally, we calculated prenatal congenital cardiovascular malformation detection rates for each of the 9 years.

RESULTS

We identified 660 patients. For the 660 patients, 649 (98%) mothers underwent prenatal care, which included at least one anatomical-survey obstetric ultrasound. Of the 649 with prenatal care, 395 (61%) had a prenatal diagnosis overall. However, prenatal diagnosis improved over the 9 years from 44% in 2012 to 79% in 2021 (correlation coefficient of 0.93, p = .00024).

CONCLUSIONS

Our results demonstrated a progressive rise in prenatal detection rates for young infants undergoing cardiovascular surgery in Nevada.

Prenatal diagnosis of isolated perimembranous ventricular septal defects undergoing primary surgical repair in infancy

OBJECTIVE

We retrospectively analyzed our center's experience with the prenatal diagnosis of isolated perimembranous ventricular septal defects that underwent primary surgical repair in infancy.

METHODS

We identified patients born in Southern Nevada, between October 2012 and October 2020, with prenatal care that underwent surgical closure of an isolated large perimembranous ventricular septal defect between 1 and 12 months of age. The description at surgery defined ventricular septal defect morphology. We included only those with situs solitus, levocardia without dextroposition, and without any other cardiovascular abnormality. We analyzed prenatal detection rates for each of the eight years.

RESULTS

We identified 81 patients. Of the 81, 35 (43%) had trisomy 21. We identified no other aneuploidies in those that underwent surgical repair; however, 1 had a 15q13.3 deletion syndrome, and 1 had a 22 q11.2 deletion syndrome. Of the 81, 27 (33%) overall were prenatally diagnosed. Increasing prenatal detection rates strongly correlated with time (R = 0.92, p = .002).

CONCLUSIONS

Trisomy 21 is common in isolated perimembranous ventricular septal defects undergoing primary repair in infancy. Further, prenatal detection rates significantly improved over time, up to 65% detection in the current years.

Cost-effectiveness analysis of newborn pulse oximetry screening to detect critical congenital heart disease in Colombia

BACKGROUND

In many countries, economic assessments of the routine use of pulse oximetry in the detection of Critical Congenital Heart Disease (CCHD) at birth has not yet been carried out. CCHDs necessarily require medical intervention within the first months of life. This assessment is a priority in low and medium resource countries. The purpose of this study was to assess the cost-effectiveness (CE) relation of pulse oximetry in the detection of cases of CCHD in Colombia.

METHODS

A full economic assessment of the cost-effectiveness type was conducted from the perspective of society. A decision tree was constructed to establish a comparison between newborn physical examination plus pulse oximetry, versus physical examination alone, in the diagnosis of CCHDs. The sensitivity and specificity of pulse oximetry were estimated from a systematic review of the literature; to assess resource use, micro-costing analyses and surveys were conducted. The time horizon of the economic evaluation was the first week after birth and until the first year of life. The incremental cost-effectiveness ratio (ICER) was determined and, to control for uncertainty, deterministic and probabilistic sensitivity analysis were made, including the adoption of different scenarios of budgetary impact. All costs are expressed in US dollars from 2017, using the average exchange rate for 2017 [$2,951.15 COP for 1 dollar].

RESULTS

The costs of pulse oximetry screening plus physical examination were $102; $7 higher than physical examination alone. The effectiveness of pulse oximetry plus the physical examination was 0.93; that is, 0.07 more than the physical examination on its own. The ICER was $100 for pulse oximetry screening; that is, if one wishes to increase 1% the probability of a correct CCHD diagnosis, this amount would have to be invested. A willingness to pay of $26.292 USD (direct medical cost) per probability of a correct CCHD diagnosis was assumed.

CONCLUSIONS

At current rates and from the perspective of society, newborn pulse oximetry screening at 24 h in addition to physical examination, and considering a time horizon of 1 week, is a cost-effective strategy in the early diagnosis of CCHDs in Colombia.Trial registration "retrospectively registered".

Challenges with the establishment of congenital cardiac surgery centers in Nigeria: survey of cardiothoracic surgeons and residents

BACKGROUND

There are gaps in understanding the challenges with the establishment of pediatric cardiac surgical practices in Nigeria. The aim of this study was to examine the prospects and challenges limiting the establishment of pediatric cardiac surgical practices in Nigeria from the perspectives of cardiothoracic surgeons and resident doctors.

METHODS

A descriptive study was carried out to articulate the views of the cardiothoracic surgeons and cardiothoracic resident doctors in Nigeria. A self-administered questionnaire was used to generate information from the participants between December 2014 and January 2015. Data were analyzed using the SPSS version 21 statistical software package.

RESULT

Thirty-one of the 51 eligible participants (60.7%) took part in the survey. Twenty-one (67.7%) were specialists/consultants, and 10 (32.3%) were resident doctors in cardiothoracic surgical units. Most of the respondents, 26 (83.9%) acknowledged the enormity of pediatric patients with cardiac problems in Nigeria; however, nearly all such children were referred outside Nigeria for treatment. The dearth of pediatric cardiac surgical centers in Nigeria was attributed to weak health system, absence of skilled manpower, funds, and equipment. Although there was a general consensus on the need for the establishment of open pediatric cardiac surgical centers in the country, their set up mechanisms were not explicit.

CONCLUSIONS

The obvious necessity and huge potentials for the establishment of pediatric cardiac centers in Nigeria cannot be overemphasized. Nevertheless, weakness of the national health system, including human resources remains a daunting challenge. Therefore, local and international partnerships and collaborations with country leadership are strongly advocated to pioneer this noble service.

Role of ultrasound in the management of diabetes in pregnancy

The purpose of this review is to discuss the established role of ultrasound (US) in the management of pregnancy complicated by diabetes mellitus (DM), as well as new developments with regard to the use of US in this situation. We choose to explore the role of US in pregnancy complicated by DM in three areas: (1) Role of US in estimation of fetal weight. (2) Role of US in diagnosis of congenital malformation. (3) Role of US in monitoring diabetic pregnant patients.

The new 3D/4D based spatio-temporal imaging correlation (STIC) in fetal echocardiography: a promising tool for the future

Congenital heart disease is the commonest congenital anomaly. It is much more common than chromosomal malformations and spinal defects. Its estimated incidence is about 4-13 per 1000 live births. Congenital heart disease is a significant cause of fetal mortality and morbidity. Antenatal diagnosis of congenital heart disease is extremely difficult and requires extensive training and expertise. The detection rate of congenital heart disease is very variable and it ranged from 35 to 86% in most studies. In the light of the above, the introduction of the new 3D/4D based spatio-temporal Image Correlation (STIC) is highly welcomed to improve antenatal detection of congenital heart disease. STIC is an automated device incorporated into the ultrasound probe and has the capacity to perform slow sweep to acquire a single 3-dimensional (3D) volume. This acquired volume is composed of a great number of 2-dimension (2D) frames. This volume can be analyzed and reanalyzed as required to demonstrate all the required cardiac views. It also provides the examiner with the ability to review all images in a looped cine sequence. This technology has the ability to improve our ability to examine the fetal heart in the acquired volume and decrease examination time. Using this technique you can share the information and consult colleagues both at your clinical sitting or remotely using the internet.

Preliminary experience with cardiovascular magnetic resonance in evaluation of fetal cardiovascular anomalies

BACKGROUND

The cardiovascular system is the part of the fetal anatomy that most frequently suffers from congenital pathology. This study shows our preliminary experience with fetal cardiovascular magnetic resonance (CMR) to evaluate congenital cardiovascular abnormalities.

METHODS

Between January 2006 and June 2011, Prenatal routine obstetric ultrasound (US), echocardiography and CMR data from 68 pregnant women carrying fetuses with congenital cardiovascular anomalies were compared with postnatal diagnoses (postnatal imagings, surgery and autopsy). All prenatal CMR was performed at 1.5 T. Imaging sequences included steady-state free-precession (SSFP) sequences, real-time SSFP and single-shot turbo spin echo (SSTSE) sequences. The images were analyzed with an anatomic segmental approach by two radiologists.

RESULTS

Fetal CMR yielded the same diagnosis as postnatal findings in 79% (54/68) of patients. The diagnostic sensitivity of routine obstetric US for cardiac anomalies was 46% (31/68). The diagnostic sensitivity of fetal echocardiographic examination by a fetal cardiac specialist was 82% (56/68). In 2 (3%) of 68 cases, diagnoses with both echocardiography and CMR were incorrect when compared with postnatal diagnosis. In ten (15%) cases, diagnosis at echocardiography was incorrect and that at CMR was correct. In twelve (18%) cases, diagnosis at echocardiography was correct and that at CMR was incorrect. Ten cases missed or misdiagnosed by echocardiography but correctly diagnosed by fetal CMR included asplenia syndrome (n = 2), interrupted inferior vena cava of polysplenia syndrome (n = 1), tricuspid incompetence (n = 1), double outlet right ventricle (n = 2), double aortic arch (n = 1), right pulmonary artery hypoplasia (n = 1), right-sided aortic arch of tetralogy of Fallot (n = 1) and hypoplastic left heart syndrome of a twin fetus (n = 1).

CONCLUSION

Fetal CMR is a promising diagnostic tool for assessment of congenital cardiovascular abnormalities, especially in situations that limit echocardiography.

Impact of antenatal diagnosis of hypoplastic left heart syndrome on the clinical presentation and surgical outcomes: the Australian experience

AIM

Antenatal diagnosis of severe congenital heart disease enables planning of perinatal care of affected infants. Congenital heart surgery is highly centralised in Australia, and surgery for hypoplastic left heart syndrome (HLHS) currently takes place at a single institution, in order to ensure case volume. The study aims to review the impact of antenatal diagnosis on the early clinical course of infants with HLHS in Australia.

METHODS

Retrospective review was performed on all neonates who were admitted for management of HLHS between 2001 and 2005 at the Paediatric Cardiac Surgical Unit, The Royal Children's Hospital, Melbourne, Australia.

RESULTS

Sixty neonates with HLHS were admitted, in whom an antenatal diagnosis was present in 46 (77%). Treatment was withdrawn in seven infants, of whom three had prenatal, and 4 had post-natal diagnoses. Antenatally diagnosed infants were commenced on prostaglandin earlier than post-natally diagnosed infants (age 1 h and 55 h respectively), and on paediatric intensive care unit admission had a higher pH (7.31 vs. 7.20), a lower lactate (3.0 vs. 6.7), a lower inspired oxygen fraction (0.21 vs. 0.96) and were less likely to be ventilated (10.8% vs. 92.9%). Infants with an antenatal diagnosis had lower peak creatinine (70 vs. 120) and alanine aminotransferase (29 vs. 242). The survival to intensive care discharge and stage 2 palliation was 74% and 68% respectively, and was not influenced by timing of diagnosis.

CONCLUSIONS

Antenatal diagnosis of HLHS was strongly associated with a superior pre-operative clinical status, but did not influence early survival after surgical palliation.