Improving detection of fetal cardiac anomalies: a fetal echocardiogram for every fetus?

Approaching Universal Prenatal Detection of Significant Cardiovascular Malformations in Nevada

OBJECTIVE

To report our recent experience with prenatal detection of significant cardiovascular malformations (CVMs) in Nevada's state-wide maternal population receiving prenatal care.

METHODS

We queried our databases for those with significant CVMs diagnosed pre- or postnatally between May 1, 2021, and April 30, 2024. We defined CVMs as those that required, would have required, or will likely require a therapeutic procedure in the first 12 months. Additionally, we included those with atrioventricular and ventriculoarterial discordance and left isomeric situs, both unaccompanied by additional CVMs, and congenital complete heart block. We defined routine prenatal care as obstetric care, which included at least one fetal anatomical survey ultrasound.

RESULTS

We identified 390 cases of significant CVMs. Of the 390 cases, 359 (92%) had prenatal care over the three-year observation period, with prenatal detection rates for the three 12-month intervals: 76% (87/115), 87% (94/108), and 95% (129/136) respectively (p < 0.001 by chi-square). A total of 310 prenatal diagnoses were made from comprehensive fetal echocardiograms performed on 8397 pregnant women at maternal-fetal-medicine centers.

CONCLUSION

To our knowledge, these results represent the highest prenatal detection rate for significant CVMs, in a state-wide maternal population in the United States.

Prenatal diagnosis of hypoplastic aortic arch without intracardiac malformations: The nevada experience

OBJECTIVE

We reviewed our center's experience with neonatal and infant hypoplastic aortic arch, unassociated with intracardiac malformations, and investigated changes in prenatal detection rates over time for those requiring therapeutic procedures.

METHODS

We identified all prenatal diagnoses of hypoplastic aortic arch with situs solitus, unassociated with intracardiac malformations, made in Nevada between May 2017 and April 2022. In addition, we identified all those 0-180 days old, with prenatal care, that underwent a surgical or interventional cardiac catheterization aortic arch procedure, whether prenatally or postnatally diagnosed. We excluded those with ventricular septal defects, functionally univentricular hearts, interrupted aortic arches, or any associated malformation requiring an additional surgical or interventional procedure ≤6 months old. Additionally, we calculated prenatal detection rates for those undergoing a surgical or interventional catheterization procedure for each of the 5 years.

RESULTS

We identified 107 patients prenatally and postnatally. Of the 107 patients, 56 (34 prenatally diagnosed and 22 postnatally diagnosed) underwent an aortic arch procedure, and 51 additionally prenatally diagnosed, live-born infants did not undergo a procedure. Of the 56 procedures, 2 were by interventional catheterization, and 54 underwent a surgical repair. Prenatal detection for those undergoing a procedure statistically significantly increased over the 5 years from 38% to 82%, rho = 0.95 (p = .04).

CONCLUSIONS

Currently in Nevada, our prenatal detection rate is >80% in the general population for those between 0 and 6 months old who require a therapeutic procedure for aortic arch obstruction without intracardiac malformations.

Concordance Between Obstetric Anatomic Ultrasound and Fetal Echocardiography in Detecting Congenital Heart Disease in High-risk Pregnancies

OBJECTIVES

To evaluate the concordance between second-trimester anatomic ultrasound and fetal echocardiography in detecting minor and critical congenital heart disease in pregnancies meeting American Heart Association criteria.

METHODS

We conducted a retrospective cohort study of pregnancies in which a second-trimester fetal anatomic ultrasound examination (18-26 weeks) and fetal echocardiography were performed between 2012 and 2018 at our institution based on American Heart Association recommendations. Anatomic ultrasound studies were interpreted by maternal-fetal medicine specialists and fetal echocardiographic studies by pediatric cardiologists. Our primary outcome was the proportion of critical congenital heart disease (CCHD) cases not detected by anatomic ultrasound but detected by fetal echocardiography. The secondary outcome was the proportion of total congenital heart disease cases missed by anatomic ultrasound but detected by fetal echocardiography. Neonatal medical records were reviewed for all pregnancies when obtained and available.

RESULTS

Overall, 722 studies met inclusion criteria. Anatomic ultrasound and fetal echocardiography were in agreement in detecting cardiac abnormalities in 681(96.1%) studies (κ = 0.803; P < .001). The most common diagnosis not identified by anatomic ultrasound was a ventricular septal defect, accounting for 9 of 12 (75%) missed congenital heart defects. Of 664 studies with normal cardiac findings on the anatomic ultrasound examinations, no additional instances of CCHD were detected by fetal echocardiography. No unanticipated instances of CCHD were diagnosed postnatally.

CONCLUSIONS

With current American Heart Association screening guidelines, automatic fetal echocardiography in the setting of normal detailed anatomic ultrasound findings provided limited benefit in detecting congenital heart defects that would warrant immediate postnatal interventions. More selective use of automatic fetal echocardiography in at-risk pregnancies should be explored.

The added value of screening fetal echocardiography after normal cardiac views on a detailed ultrasound

OBJECTIVE

Evaluate fetal echocardiography's ability to detect critical (lesions requiring immediate neonatal intensive care) congenital heart disease (CHD) after normal anatomic cardiac views on detailed ultrasound.

METHODS

Singletons with both a detailed ultrasound at 18 + 0 to 22 + 6 weeks and echocardiogram performed at least 14 days later and at 20 + 0 to 24 + 6 weeks. Cases with cardiac pathology on detailed ultrasound were excluded. Different combinations of cardiac views were described: Basic (four-chamber, outflow tracts), Expanded (plus three-vessel view), and Complete (plus ductal/aortic arches). "Normal" was defined on either 2D gray scale or color Doppler. Primary outcome was rates of critical CHD missed on ultrasound but seen on fetal echocardiogram.

RESULTS

One thousand two hundred twenty-three women had normal Basic cardiac views. One thousand one hundred ninety (97.3%) were confirmed normal on echocardiogram. Twenty-one (1.71%) total CHDs were missed, and three were critical (0.25%; 95% CI, 0.03%-0.53%). Of the 1,223 women, 763 had Complete views. Ten (1.31%) total CHDs were missed and one (0.13%; 95% CI, 0.13%-0.36%) was confirmed critical.

CONCLUSION

Fetal echocardiography can increase CHD detection despite normal cardiac anatomy on detailed ultrasound; however, CHDs missed are rarely critical. Approximately 750 fetal echocardiograms need to be performed to detect one critical CHD with Complete normal cardiac views on detailed ultrasound.

Advancing Prenatal Detection of Congenital Heart Disease: A Novel Screening Protocol Improves Early Diagnosis of Complex Congenital Heart Disease

OBJECTIVES

Prenatal diagnosis of complex congenital heart disease (CHD) during routine obstetric ultrasound (US) examinations improves postnatal outcomes, but sensitivity is low (<40%). Our objective was to improve our prenatal detection of complex CHD with implementation of a specific screening protocol.

METHODS

From January 2003 to December 2013, 506 consecutive confirmed cases of complex CHD in the province of Manitoba, Canada, were analyzed to compare the sensitivity and positive predictive value of prenatal US detection of complex CHD before and after the introduction of a novel prenatal screening protocol. The intervention was done in October 2004, emphasizing screening and not diagnosis of complex CHD. It involved education, practical scanning tips, a checklist, and feedback on cases. We also assessed the effect of the intervention in different screening settings: community hospitals, tertiary hospitals, and fetal assessment units.

RESULTS

The sensitivity for detecting complex CHD increased from 29.8% to 88.3% (P < .0001), while the positive predictive value remained high. The largest improvement in detection was found for US units in community hospitals (52.4% higher; P < .0001), followed by tertiary hospitals (39.9%; P = .0004), and fetal assessment units (7.2%; P = .16). Additionally, there was a significant decrease in the presentation of neonates in critical condition from before to after the implementation (24.3% to 13.1%, respectively; P = .0165).

CONCLUSIONS

Implementing a focused routine prenatal screening protocol can vastly improve detection rates of critical cardiac abnormalities. The improvement in community hospitals was particularly important because early detection ensured that the birth was planned to take place in an appropriate facility. Our novel protocol can be performed by all sonographers, regardless of experience, equipment used, and hospital setting.

Isolated Single Umbilical Artery and Fetal Echocardiography: A 25-Year Experience at a Tertiary Care City Hospital

OBJECTIVES

To review our 25-year experience with a single umbilical artery and fetal echocardiography to estimate the need for this test in cases of an isolated single umbilical artery.

METHODS

We conducted a retrospective review of 436 patients with a diagnosis of a single umbilical artery at our institution between 1990 and 2015. Two hundred eighty-eight women had both an anatomic survey and a fetal echocardiogram. Pregnancies with concurrent extracardiac anomalies or aneuploidy were excluded. The study population was divided into 3 groups based on cardiac views on the anatomic survey: normal, incomplete, and suspicious. Echocardiographic results were compared among the 3 groups. The primary outcome measure was the incidence of cardiac anomalies in the normal group at fetal echocardiography. The data were analyzed by the χ² test or Fisher exact test.

RESULTS

The mean maternal age ± SD of the group was 29.2 ± 6.2 years; 44.1% were primiparas. The mean gestational age at diagnosis was 22.6 ± 5.2 weeks, and the mean gestational age at fetal echocardiography was 25.1 ± 3.6 weeks. In the normal group, 99.1% (230 of 232) of women had a normal fetal echocardiogram; the 2 abnormal cases were ventricular septal defects. Normal echocardiograms were obtained in 81.8% (36 of 44) and 25.0% (3 of 12) of the "incomplete" and "suspicious" groups, respectively.

CONCLUSIONS

Fetuses with a single umbilical artery, in the absence of structural abnormalities, and with normal cardiac views at the time of the anatomic survey do not warrant an echocardiogram.

Proceedings: Beyond Ultrasound First Forum on Improving the Quality of Ultrasound Imaging in Obstetrics and Gynecology

The Beyond Ultrasound First Forum was conceived to increase awareness that the quality of obstetric and gynecologic ultrasound can be improved, and is inconsistent throughout the country, likely due to multiple factors, including the lack of a standardized curriculum and competency assessment in ultrasound teaching. The forum brought together representatives from many professional associations; the imaging community including radiology, obstetrics and gynecology, and emergency medicine among others; in addition to government agencies, insurers, industry, and others with common interest in obstetric and gynecologic ultrasound. This group worked together in focus sessions aimed at developing solutions on how to standardize and improve ultrasound training at the resident level and beyond. A new curriculum and competency assessment program for teaching residents (obstetrics and gynecology, radiology, and any other specialty doing obstetrics and gynecology ultrasound) was presented, and performance measures of ultrasound quality in clinical practice were discussed. The aim of this forum was to increase and unify the quality of ultrasound examinations in obstetrics and gynecology with the ultimate goal of improving patient safety and quality of clinical care. This report describes the proceedings of this conference including possible approaches to resident teaching and means to improve the inconsistent quality of ultrasound examinations performed today.

Proceedings: Beyond Ultrasound First Forum on improving the quality of ultrasound imaging in obstetrics and gynecology

The Beyond Ultrasound First Forum was conceived to increase awareness that the quality of obstetric and gynecologic ultrasound can be improved, and is inconsistent throughout the country, likely due to multiple factors, including the lack of a standardized curriculum and competency assessment in ultrasound teaching. The forum brought together representatives from many professional associations; the imaging community including radiology, obstetrics and gynecology, and emergency medicine among others; in addition to government agencies, insurers, industry, and others with common interest in obstetric and gynecologic ultrasound. This group worked together in focus sessions aimed at developing solutions on how to standardize and improve ultrasound training at the resident level and beyond. A new curriculum and competency assessment program for teaching residents (obstetrics and gynecology, radiology, and any other specialty doing obstetrics and gynecology ultrasound) was presented, and performance measures of ultrasound quality in clinical practice were discussed. The aim of this forum was to increase and unify the quality of ultrasound examinations in obstetrics and gynecology with the ultimate goal of improving patient safety and quality of clinical care. This report describes the proceedings of this conference including possible approaches to resident teaching and means to improve the inconsistent quality of ultrasound examinations performed today.

Universal Pulse Oximetry Screening for Early Detection of Critical Congenital Heart Disease

Critical congenital heart disease (CCHD) is a major cause of infant death and morbidity worldwide. An early diagnosis and timely intervention can significantly reduce the likelihood of an adverse outcome. However, studies from the United States and other developed countries have shown that as many as 30%–50% of infants with CCHD are discharged after birth without being identified. This diagnostic gap is likely to be even higher in low-resource countries. Several large randomized trials have shown that the use of universal pulse-oximetry screening (POS) at the time of discharge from birth hospital can help in early diagnosis of these infants. The objective of this review is to share data to show that the use of POS for early detection of CCHD meets the criteria necessary for inclusion to the universal newborn screening panel and could be adopted worldwide.

Screening for congenital heart disease during anatomical survey ultrasonography

Congenital heart disease (CHD) is among the most common congenital abnormalities. The prevalence of CHD ranges between 0.6% and 1.2% of live births. Despite its high prevalence, CHD is also among the most commonly missed abnormalities during prenatal ultrasound examination. A simple yet systematic approach to fetal heart examination, regular feedback, and implementation of training programs could improve detection rates and, in turn, neonatal outcome.

Costs of prenatal detection of congenital heart disease

Little information is available about the transportation costs incurred from the missed prenatal diagnosis of congenital heart disease (CHD). The objectives of the present study were to analyze the costs of emergency transportation related to the postnatal diagnosis of major CHD and to perform a cost/benefit analysis of additional training for ultrasound technicians to study the implications of improved prenatal detection rates. The 1-year costs incurred for emergency transportation of pre- and postnatally diagnosed infants with CHD in Northern California and North Western Nevada were calculated and compared. The prenatal detection rate in our cohort (n = 147) was 30.6%. Infants postnatally diagnosed were 16.5 times more likely (p <0.001) to require emergency transport. The associated emergency transportation costs were US$542,143 in total for all patients with CHD. The mean cost per patient was $389.00 versus $5,143.51 for prenatally and postnatally diagnosed infants, respectively (p <0.001). Assuming an improvement in detection rates after 1-day training for ultrasound technicians, the investment in training cost can be recouped in 1 year if the detection rate increased by 2.4% to 33%. Savings of $6,543,476 would occur within 5 years if the detection rate increased to 50%. In conclusion, CHD diagnosed postnatally results in greater costs related to emergency transportation of ill infants. Improving the prenatal detection rates through improved ultrasound technician training could result in considerable cost savings.

Prenatal screening for major congenital heart disease: superiority of outflow tracts over the 4-chamber view

OBJECTIVE

The purpose of this study was to determine the relative importance of the 4-chamber view (4CV) compared with the outflow tract views (OFTVs) in prenatal screening for major congenital heart disease (CHD).

METHODS

We prospectively evaluated 200 consecutive infants undergoing cardiac surgery at our institution for major CHD. By reviewing the infants' medical records and conducting bedside interviews with their parents or guardians, we evaluated detection rates both prenatally and postnatally (before and after discharge to home), and we noted any prenatally identifiable risk factors for CHD. For each infant, we determined whether the 4CV or OFTVs would be expected to have been normal or abnormal on routine midgestation screening fetal sonography.

RESULTS

A prenatal diagnosis of CHD was made in 65 infants (33%): 30 of 124 low-risk pregnancies (24%) and 35 of 76 high-risk pregnancies (46%). An abnormal screening midgestation 4CV would have been expected in up to 63% of the infants, whereas abnormal midgestation OFTVs would have been expected in up to 91% of the infants. Thus, the potential sensitivity for detecting major CHD was higher with the OFTVs than with the 4CV (91% versus 63%; P < .001). Moreover, the OFTVs were more sensitive than the 4CV for detecting ductal-dependent forms of CHD. Diagnosis after discharge to home occurred in 39 of 135 postnatal diagnoses (29%), including many cases of isolated outflow tract abnormalities requiring early invasive intervention.

CONCLUSIONS

Cases of major neonatal CHD with OFTV abnormalities predominate over cases with 4CV abnormalities, particularly among those forms of CHD requiring early invasive intervention.

Quality of 2- and 3-dimensional fast acquisition fetal cardiac imaging at 18 to 22 weeks: ramifications for screening

OBJECTIVE

The purpose of this study was to evaluate the frequency with which 6 different fetal cardiac views taken during a fetal ultrasound examination at 18 to 22 weeks' gestation can be obtained satisfactorily for cardiac anomaly screening using either a 2-dimensional (2D) static or 3-dimensional (3D) fast acquisition technique.

METHODS

A prospective study of 100 low-risk women undergoing an anatomic survey was performed. Standard static 2D and 3D fast acquisition volumes were obtained on all patients. The 2D and 3D images were assigned, in a random order, to be independently graded by 3 reviewers. The degree of inter-reviewer agreement was assessed through the use of the Cohen kappa statistic. The factors contributing to satisfactory imaging were evaluated by random effects logistic regression.

RESULTS

A significant proportion of both 2D and 3D images were judged unsatisfactory for screening purposes. However, 2D images were significantly more likely, for all cardiac views, to be judged satisfactory (P < .05). The odds ratios for the 2D technique's being more likely than the 3D technique to provide images satisfactory for screening were 2.6 for the 4-chamber view, 2.4 for the right ventricular outflow tract, 4 for the left ventricular outflow tract, 3.2 for the 3-vessel view, 8.6 for the aortic arch, and 2.2 for the ductal arch.

CONCLUSIONS

In this prospective study, static 2D imaging was significantly more likely than fast acquisition 2D imaging to yield cardiac views of high enough quality to satisfactorily screen for anomalies.