Fetal aortic coarctation: A combination of third-trimester echocardiographic parameters to improve the prediction of postnatal outcome

Prenatal ultrasound prediction of coarctation of the aorta: a nomogram for risk stratification

BACKGROUND

Coarctation of the aorta is one of the most common congenital heart malformations, accounting for approximately 7% of all live births with congenital heart disease. It is crucial to make a definitive prenatal diagnosis as it can inform clinical treatment decisions.

OBJECTIVE

The diagnostic criteria for coarctation of the aorta are still controversial, and there is currently no risk nomogram available to assess the probability of coarctation of the aorta using routine ultrasound parameters. We explored the prenatal diagnostic efficacy of ultrasound parameters and established a nomogram for coarctation of the aorta.

MATERIALS AND METHODS

A total of 101 fetuses with suspected coarctation of the aorta diagnosed by prenatal ultrasound from July 2015 to June 2023 were collected retrospectively. The patients were divided into two groups according to the diagnostic results: a normal group (n=42; gestational weeks, 28.5±6.0) and a coarctation of the aorta group (n=59; gestational weeks, 26.7±5.1). Univariate and multivariate logistic regression analyses were used to identify echocardiographic predictors of coarctation of the aorta. Moreover, the patients were divided into a training set and a validation set in a ratio of 8:2, and a nomogram for the prenatal diagnosis of coarctation of the aorta was established using R.

RESULTS

(1) Aortic isthmus, aortic isthmus z-score, ascending aorta, ascending aorta z-score, pulmonary artery, pulmonary artery z-score, pulmonary artery/ascending aorta ratio, persistent left superior vena cava, and aortic arch dysplasia were the predictive markers of coarctation of the aorta in the univariate logistic regression analysis (P<0.05). (2) Aortic isthmus z-score, ascending aorta z-score, pulmonary artery/ascending aorta ratio, persistent left superior vena cava, and aortic arch dysplasia were identified as the final predictors after multivariate logistic regression analysis (P<0.05). (3) The combined model, which included aortic isthmus z-score, ascending aorta z-score, pulmonary artery/ascending aorta ratio, persistent left superior vena cava, and aortic arch dysplasia, demonstrated a larger area under the receiver operating characteristic curve (AUC) (AUC=0.96, sensitivity=93.22%, specificity=88.10%) than aortic isthmus z-score alone (AUC=0.77, sensitivity=77.97%, specificity=71.43%), ascending aorta z-score alone (AUC=0.78, sensitivity=54.24%, specificity=90.48%), pulmonary artery/ascending aorta ratio alone (AUC=0.68, sensitivity=72.88%, specificity=54.76%), aortic arch dysplasia alone (AUC=0.70, sensitivity=66.10%, specificity=73.81%), and persistent left superior vena cava alone (AUC=0.72, sensitivity=79.66%, specificity=64.29%). The nomogram, which was constructed with these parameters, also exhibited excellent calibration curves and a good decision curve analysis curve.

CONCLUSIONS

The nomogram established by aortic isthmus z-score, ascending aorta z-score, pulmonary artery/ascending aorta ratio, persistent left superior vena cava, and aortic arch dysplasia demonstrated excellent efficacy in the prenatal diagnosis of coarctation of the aorta.

Ultrasound-based incidence of coarctation of the aorta in true and false positive fetuses

To investigate the incidence and significant ultrasound parameter changes of coarctation of the aorta (CoA) among fetuses with suspected CoA, pregnant women with suspected CoA fetuses on prenatal ultrasound examination were prospectively enrolled. The CoA presence was confirmed after birth by computed tomographic angiography, ultrasound, surgery or autopsies. The ultrasound parameters were analyzed. Among 133 fetuses with suspected CoA, 44 (33.1%) pregnant women with CoA fetuses were confirmed after delivery with an age range 20-41 (31.36 ± 4.73) years and a gestational age range 20.5-36.5 (27.35 ± 4.52) weeks, and 89 (66.9%) pregnant women were confirmed to have false-positive CoA fetuses with matched (P > 0.05) age (range 21-44 and mean 30.96 ± 4.59 years) and gestational age (range 19.6-34.1 and mean 28.22 ± 3.28 weeks). Ductus arteriosus (DA) tortuosity was present in significantly (P < 0.05) more false-positive CoA fetuses (15 or 16.85%) than in true CoA fetuses (1 or 2.27%), whereas significantly more intracardiac malformation [25 (56.82%) vs. 31 (34.83%)] and ventricular septal defect [10 (22.73%) vs. 6 (6.74%)] took place in true CoA fetuses than in the counterparts. Significant (P < 0.05) independent risk factors for CoA presence were sagittal view isthmic Z-score (odds ratio or OR 3.62 and 95% confidence interval or CI 2.06-7.15), coarctation shelf (OR 17.71 and 95% CI 5.52-56.78), ascending aortic diameter (OR 109.67 and 95% CI 3.03-21068.82), and DA velocity time integral (VTI) (OR 24.98 and 95% CI 1.26-759.94). The cutoff value and AUC were 0.40 and 0.912, respectively, for the fitted model, -4.24 and 0.779 for isthmus Z-score, 0.35 and 0.685 for the ascending aorta diameter, and 13.78 and 0.623 for DA VTI. In conclusion, many ultrasound parameters are significantly different in CoA fetuses, and sagittal view isthmus Z-score, coarctation shelf, ascending aortic diameter, DA VTI may independently affect CoA presence.

Fetal heart quantification technique improves the prenatal prediction of coarctation of the aorta: A retrospective analysis

Coarctation of the aorta (CoA) ranks among the most prevalent congenital heart defects and poses a life-threatening risk if left undiagnosed. Herein, we utilized fetal heart quantification (HQ) technology to improve the prenatal prediction of CoA. A retrospective analysis was conducted on 64 fetal cases with suspected aortic arch constriction, identified through prenatal ultrasound findings between November 2020 and March 2022 at the Department of Ultrasound, Sir Run Run Shaw Hospital, Zhejiang University. According to the follow-up results, these cases were divided into two groups: 35 cases confirmed as CoA by postpartum surgery or induction, and 29 cases initially suspected of CoA prenatally but subsequently ruled out postnatally. Additionally, 88 cases of normal fetuses were randomly selected as the control group. Both conventional M-mode ultrasound techniques and Fetal HQ software were utilized for fetal analysis across all groups. Parameters related to the heart were measured, including fetal 4-CV length, width, Global Spherical Index (GSI), Mitral Annular Plane Systolic Excursion (MAPSE), areas and ratios of the left and right ventricles, as well as lengths and ratios of the left and right ventricles. Functional measurements of the left and right ventricles included ejection fraction (EF), fractional area change (FAC), global longitudinal strain (GLS), fractional shortening (FS), end-diastolic diameter (ED), and sphericity index (SI). Left ventricular (LV)-GLS, LV-FAC, LV-EF, and LV-EF Z-score could potentially differentiate between true CoA and false CoA or normal groups and serve as potential indicators for the clinical diagnosis of CoA. The receiver operating characteristic (ROC) curves indicated that LV-GLS and LV-EF Z-score have the greatest predictive power for CoA diagnosis. The segments 6-12 of FS in the confirmed CoA group were significantly lower than those in the false CoA and normal groups. Fetal HQ technology, by assessing changes in the size and shape of the heart, can provide relatively reliable parameter support for the prenatal diagnosis of fetal aortic coarctation.

Echocardiographic features and outcomes of fetuses with isolated restrictive foramen ovale or redundant foramen ovale flap using atrial septum excursion index

PURPOSE

This study was designed to investigate the application value of the atrial septum excursion index (ASEI) in fetuses with isolated restrictive foramen ovale (RFO) or redundant foramen ovale flap (RFOF) and the outcomes of these fetuses.

METHODS

This was a retrospective study. Healthy pregnant women who were examined by antenatal fetal echocardiography from January 1, 2019 to December 31, 2021, at Sir Run Run Shaw Hospital were enrolled. One hundred seventy-seven (177) fetuses were categorized into three groups by diagnosis: (1) RFOF (n = 33), (2) RFO (n = 21), and (3) normal (n = 123). Fetal echocardiographic features and postnatal outcomes were collected.

RESULTS

The median ASEIs were 0.50 (range, 0.41-0.65) in the control group, 0.76 (range, 0.67-0.88) in the RFOF group and 0.31 (range, 0.14-0.35) in the RFO group, and the differences were significant (p < 0.001). The ratios of right atrium/left atrium, right ventricle/left ventricle, and pulmonary artery diameter to aorta diameter (PA/AO) and the pulmonary annulus Z-scores were greater in fetuses with RFOF and RFO than in the controls (p < 0.05). Twenty-seven of 33 fetuses (87.9%) with RFOF and 19 of 21 fetuses (90.5%) with RFO had good outcomes after birth.

CONCLUSION

The ASEI may be a new tool for quantitatively assessing the mobility of foramen ovale flaps in fetuses with isolated RFOF or RFO.

Prenatal Diagnosis and Postnatal Outcomes of Persistent Left Superior Vena Cava Associated With Mild Narrow Aorta: A Cohort Study

PURPOSE

To explore prenatal ultrasonic features and prognosis of the persistent left superior vena cava (PLSVC) complicated with mild narrow aorta.

MATERIALS AND METHODS

A retrospective study was conducted involving 1348 fetuses diagnosed with PLSVC prenatally between January 2016 and December 2019. Forty-five fetuses with PLSVC associated with mild narrow aorta were selected from the cohort as the study group and 79 fetuses with isolated PLSCV were recruited randomly as the control group. All clinical and ultrasound results, including images and parameters of cardiac structures, were reviewed retrospectively. General conditions, ultrasound (US) measurements, and fetal prognosis were compared between the groups.

RESULTS

Aorta valve diameter (AOD), Z-score of aorta valve (AODz-score), aortic isthmus diameter (AOIsD), and pulmonary diameter (PAD)/AOD were significantly different in study group than control group no matter in the second or third trimester. Thirty-eight fetuses in study group were born with favorable outcomes after long-term follow-up. A total of 13.16% (5/38) remain mild narrow aorta and 3 of them showed smaller left ventricle after 3 years follow up. Prenatal AODz-score in infants remains mild narrow aorta after 2 years aged was higher than ones' aorta return to normal (P = .01), especially when AODz-score >1.725. Moreover, when prenatal ratio of AOIsD/left subclavian artery was <1.12, it was more likely that the aorta would remain mildly narrow at age 2.

CONCLUSION

Fetuses diagnosed with PLSVC with mild narrow aorta had favorable prognosis. AODz-score and AOIsD/left subclavian artery may be two predictors that reveal the risk of a mildly narrowed aorta remaining after birth.

Fetal cardiac magnetic resonance imaging of the descending aorta in suspected left-sided cardiac obstructions

Background

Severe left-sided cardiac obstructions are associated with high morbidity and mortality if not detected in time. The correct prenatal diagnosis of coarctation of the aorta (CoA) is difficult. Fetal cardiac magnetic resonance imaging (CMR) may improve the prenatal diagnosis of complex congenital heart defects. Flow measurements in the ascending aorta could aid in predicting postnatal CoA, but its accurate visualization is challenging.

Objectives

To compare the flow in the descending aorta (DAo) and umbilical vein (UV) in fetuses with suspected left-sided cardiac obstructions with and without the need for postnatal intervention and healthy controls by fetal phase-contrast CMR flow. A second objective was to determine if adding fetal CMR to echocardiography (echo) improves the fetal CoA diagnosis.

Methods

Prospective fetal CMR phase-contrast flow in the DAo and UV and echo studies were conducted between 2017 and 2022.

Results

A total of 46 fetuses with suspected left-sided cardiac obstructions [11 hypoplastic left heart syndrome (HLHS), five critical aortic stenosis (cAS), and 30 CoA] and five controls were included. Neonatal interventions for left-sided cardiac obstructions (n = 23) or comfort care (n = 1 with HLHS) were pursued in all 16 fetuses with suspected HLHS or cAS and in eight (27%) fetuses with true CoA. DAo or UV flow was not different in fetuses with and without need of intervention. However, DAo and UV flows were lower in fetuses with either retrograde isthmic systolic flow [DAo flow 253 (72) vs. 261 (97) ml/kg/min, p = 0.035; UV flow 113 (75) vs. 161 (81) ml/kg/min, p = 0.04] or with suspected CoA and restrictive atrial septum [DAo flow 200 (71) vs. 268 (94) ml/kg/min, p = 0.04; UV flow 89 vs. 159 (76) ml/kg/min, p = 0.04] as well as in those without these changes. Adding fetal CMR to fetal echo predictors for postnatal CoA did not improve the diagnosis of CoA.

Conclusion

Fetal CMR-derived DAo and UV flow measurements do not improve the prenatal diagnosis of left-sided cardiac obstructions, but they could be important in identifying fetuses with a more severe decrease in blood flow across the left side of the heart. The physiological explanation may be a markedly decreased left ventricular cardiac output with subsequent retrograde systolic isthmic flow and decreased total DAo flow.