Prenatal Sonographic Predictors of Neonatal Coarctation of the Aorta

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.

A New Method Using the Four-Chamber View to Identify Fetuses With Subsequently Confirmed Postnatal Aortic Coarctation

OBJECTIVE

To determine the sensitivity, specificity, and false-positive rate among fetuses suspected prenatally to have coarctation of the aorta (CoA) using size and shape measurements of the fetal heart from the four-chamber view (4CV).

METHODS

This was a retrospective study of 108 fetuses identified by pediatric cardiologists to be at risk for CoA. 4CV s from the last antenatal ultrasound performed by the cardiologists were analyzed. The end-diastolic area was computed using the point-to-point trace method around the epicardial border of the 4CV, and the largest end-diastolic length and width were measured from the epicardium to the epicardium to compute the global sphericity index (GSI) (length/width). Using speckle tracking analysis, the ventricular end-diastolic area, length, basal and mid-chamber widths were measured. The sphericity index of the base and mid-chamber of the ventricles was computed (length/width). In addition, the end-diastolic area ratios were computed as follows: right ventricular area/4CV area and the left ventricular area/4CV area. The z-scores for the above measurements were computed. Using logistic regression analysis, coefficients for predicting the probability of CoA from a test group of 27 fetuses with CoA and 27 without CoA was done. The logistic regression equation derived from the test group was applied to a validation group of 27 fetuses with CoA and 27 fetuses without CoA.

RESULTS

The regression equation from the test group identified the following end-diastolic measurements: 4CV GSI, RV area/heart area, LV base SI, and the RV Base SI. The test group consisted of 14 of 27 fetuses with an isolated CoA (52%) and 13 of 27 (48%) with additional heart abnormalities. For the validation group, 10 of 27 (37%) had an isolated CoA, and 17 (63%) had additional cardiac abnormalities. Using the logistic regression equation derived from the test group (54 fetuses: 27 with CoA and 27 without CoA), the validation group (54 fetuses: 27 with CoA and 27 without CoA) demonstrated the following: sensitivity for detecting CoA of 98.15%, specificity 98.15%, and a false-positive rate of 1.85%. When the logistic regression was applied to the test group of fetuses with isolated CoA, 100% (14/14) were identified with logistic regression analysis. For the validation group, 9 of 10 (90%) of fetuses with isolated CoA were identified using the logistic regression equation.

CONCLUSIONS

Using length, width, and area measurements of the 4CV and ventricles from which ratios are computed detects 98.15% of high-risk fetuses who will demonstrate CoA following birth, with a specificity of 98.15%, or a false-positive rate of 1.85%.

Ultrasound parameters of arteries and heart in normal fetuses

BACKGROUND

Currently, no normal ultrasound data of the fetuses during the 20-40 gestation have been obtained for references of fetal growth and development. If such ultrasound data existed for prenatal diagnosis of possible diseases and abnormalities, neonates would be able to get timely treatment immediately after birth. This study was thus performed to obtain ultrasound parameters of normal fetuses during the 20-40 week gestation and the distribution of ultrasound parameters with the gestational age for references of detecting potential fetal diseases and abnormalities.

METHODS

Normal fetuses without any abnormalities were enrolled, and the ultrasound parameters of the general biology, arteries, and aorta were measured and analyzed.

RESULTS

417 normal fetuses were enrolled. A significant (P < 0.05) negative correlation with the gestational age was detected in the peak systolic velocity/peak diastolic velocity (S/D), pulsatility index (PI) and resistance index (RI) of the umbilical artery (UA). A relatively stable relationship with the gestational age was detected in the fetal weight%, S/D, PI and RI of the middle cerebral artery (MCA), peak systolic velocity (PSV) and velocity time integral (VTI) of the intra-abdominal UA, fetal heart to chest ratio, mitral valve (MV)- and tricuspid valve (TV)-E/A peak flow velocity, aortic isthmic Z-score and displacement, distance between the brachiocephalic artery-left common carotid artery (BA-LCCA) and LCCA-left subclavian artery (LSA), Z-score of aorta, ascending aorta (AAO), pulmonary artery (PA), main pulmonary artery (MPA), and descending aorta (DAO). A significant (P < 0.05) positive correlation with the gestational age was detected in the fetal biological data, MCA PSV and VTI, free-UA PSV and VTI and cardio-thoracic ratio, cardiac parameters, ductus arteriosus (DA) and isthmus diameter, aortic parameters, PA and MPA diameter, MPA PSV and VTI, isthmus flow volume and velocity and PA flow volume, DA and BA parameters, and LCCA and LSA parameters (flow volume, PSV, and VTI).

CONCLUSION

A certain correlation and distribution trend is detected in the ultrasound parameters of normal fetuses, and the ratios among different parameters remain relative stable. These findings can be used for determination of abnormal growth of the fetuses in prenatal ultrasound scan.

Role of artificial-intelligence-assisted automated cardiac biometrics in prenatal screening for coarctation of aorta

OBJECTIVE

Although remarkable strides have been made in fetal medicine and the prenatal diagnosis of congenital heart disease, around 60% of newborns with isolated coarctation of the aorta (CoA) are not identified prior to birth. The prenatal detection of CoA has been shown to have a notable impact on survival rates of affected infants. To this end, implementation of artificial intelligence (AI) in fetal ultrasound may represent a groundbreaking advance. We aimed to investigate whether the use of automated cardiac biometric measurements with AI during the 18-22-week anomaly scan would enhance the identification of fetuses that are at risk of developing CoA.

METHODS

We developed an AI model capable of identifying standard cardiac planes and conducting automated cardiac biometric measurements. Our data consisted of pregnancy ultrasound image and outcome data spanning from 2008 to 2018 and collected from four distinct regions in Denmark. Cases with a postnatal diagnosis of CoA were paired with healthy controls in a ratio of 1:100 and matched for gestational age within 2 days. Cardiac biometrics obtained from the four-chamber and three-vessel views were included in a logistic regression-based prediction model. To assess its predictive capabilities, we assessed sensitivity and specificity on receiver-operating-characteristics (ROC) curves.

RESULTS

At the 18-22-week scan, the right ventricle (RV) area and length, left ventricle (LV) diameter and the ratios of RV/LV areas and main pulmonary artery/ascending aorta diameters showed significant differences, with Z-scores above 0.7, when comparing subjects with a postnatal diagnosis of CoA (n = 73) and healthy controls (n = 7300). Using logistic regression and backward feature selection, our prediction model had an area under the ROC curve of 0.96 and a specificity of 88.9% at a sensitivity of 90.4%.

CONCLUSIONS

The integration of AI technology with automated cardiac biometric measurements obtained during the 18-22-week anomaly scan has the potential to enhance substantially the performance of screening for fetal CoA and subsequently the detection rate of CoA. Future research should clarify how AI technology can be used to aid in the screening and detection of congenital heart anomalies to improve neonatal outcomes. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Diagnostic accuracy of prenatal ultrasound in coarctation of aorta: systematic review and individual participant data meta-analysis

OBJECTIVE

To determine the diagnostic accuracy of prenatal ultrasound in detecting coarctation of the aorta (CoA).

METHODS

An individual participant data meta-analysis was performed to report on the strength of association and diagnostic accuracy of different ultrasound signs in detecting CoA prenatally. MEDLINE, EMBASE and CINAHL were searched for studies published between January 2000 and November 2021. Inclusion criteria were fetuses with suspected isolated CoA, defined as ventricular and/or great vessel disproportion with right dominance on ultrasound assessment. Individual participant-level data were obtained by two leading teams. PRISMA-IPD and PRISMA-DTA guidelines were used for extracting data, and the QUADAS-2 tool was used for assessing quality and applicability. The reference standard was CoA, defined as narrowing of the aortic arch, diagnosed after birth. The most commonly evaluated parameters on ultrasound, both in B-mode and on Doppler, constituted the index test. Summary estimates of sensitivity, specificity, diagnostic odds ratio (DOR) and likelihood ratios were computed using the hierarchical summary receiver-operating-characteristics model.

RESULTS

The initial search yielded 72 studies, of which 25 met the inclusion criteria. Seventeen studies (640 fetuses) were included. On random-effects logistic regression analysis, tricuspid valve/mitral valve diameter ratio > 1.4 and > 1.6, aortic isthmus/arterial duct diameter ratio < 0.7, hypoplastic aortic arch (all P < 0.001), aortic isthmus diameter Z-score of < -2 in the sagittal (P = 0.003) and three-vessel-and-trachea (P < 0.001) views, pulmonary artery/ascending aorta diameter ratio > 1.4 (P = 0.048) and bidirectional flow at the foramen ovale (P = 0.012) were independently associated with CoA. Redundant foramen ovale was inversely associated with CoA (P = 0.037). Regarding diagnostic accuracy, tricuspid valve/mitral valve diameter ratio > 1.4 had a sensitivity of 72.6% (95% CI, 48.2-88.3%), specificity of 65.4% (95% CI, 46.9-80.2%) and DOR of 5.02 (95% CI, 1.82-13.9). The sensitivity and specificity values were, respectively, 75.0% (95% CI, 61.1-86.0%) and 39.7% (95% CI, 27.0-53.4%) for pulmonary artery/ascending aorta diameter ratio > 1.4, 47.8% (95% CI, 14.6-83.0%) and 87.6% (95% CI, 27.3-99.3%) for aortic isthmus diameter Z-score of < -2 in the sagittal view and 74.1% (95% CI, 58.0-85.6%) and 62.0% (95% CI, 41.6-78.9%) for aortic isthmus diameter Z-score of < -2 in the three-vessel-and-trachea view. Hypoplastic aortic arch had a sensitivity of 70.0% (95% CI, 42.0-88.6%), specificity of 91.3% (95% CI, 78.6-96.8%) and DOR of 24.9 (95% CI, 6.18-100). The diagnostic yield of prenatal ultrasound in detecting CoA did not change significantly when considering multiple categorical parameters. Five of the 11 evaluated continuous parameters were independently associated with CoA (all P < 0.001) but all had low-to-moderate diagnostic yield.

CONCLUSIONS

Several prenatal ultrasound parameters are associated with an increased risk for postnatal CoA. However, diagnostic accuracy is only moderate, even when combinations of parameters are considered. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Fetal echocardiographic features associated with bicuspid aortic valve

BACKGROUND

Prenatal diagnosis of bicuspid aortic valve is challenging. Bicuspid aortic valve is often associated with aortic dilation.

METHODS

Fetuses with postnatally confirmed bicuspid aortic valve were gestational age-matched with normal controls. Complex lesions were excluded. Aortic valve and arch measurements by two blinded investigators were compared.

RESULTS

We identified 27 cases and 27 controls. Estimated fetal weight percentile was lower in cases than controls. Seven cases had one or more significant lesions including perimembranous ventricular septal defects (n = 2), isolated annular hypoplasia (n = 2), and/or arch hypoplasia/coarctation (n = 4). Fetuses with bicuspid aortic valves had significantly smaller median z-scores of the aortic annulus (-1.60 versus -0.53, p < 0.001) and root (-1.10 versus -0.53, p = 0.040), and larger ratios of root to annulus (1.32 versus 1.21, p < 0.001), sinotubular junction to annulus (1.07 versus 0.99, p < 0.001), ascending aorta to annulus (1.29 versus 1.18, p < 0.001), and transverse aorta to annulus (1.04 versus 0.96, p = 0.023). Leaflets were "doming" in 11 cases (41%) and 0 controls (p = 0.010), "thickened" in 10 cases (37%) and 0 controls (p = 0.002). We noted similar findings in the subgroup without significant additional cardiac defects.

CONCLUSIONS

The appearance of doming or thickened aortic valve leaflets on fetal echocardiogram is associated with bicuspid aortic valve. Compared to controls, fetuses with bicuspid aortic valve had smaller aortic annulus sizes (possibly related to smaller fetal size) without proportionally smaller aortic measurements, resulting in larger aortic dimension to annulus ratios. Despite inherent challenges of diagnosing bicuspid aortic valve prenatally, these findings may increase suspicion and prompt appropriate postnatal follow-up.

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.

Prenatal prediction of Shone's complex. The role of the degree of ventricular disproportion and speckle-tracking analysis

OBJECTIVES

Shone's complex (SC) is characterized by sequential obstructions of left ventricular (LV) inflow and outflow. It can be associated with poor long-term prognosis when compared to Simple-Aortic Coarctation (S-CoA). We aimed to assess whether the degree of ventricular disproportion and 2D-speckle-tracking echocardiography (2D-STE) could improve the accuracy of prenatal prediction of SC.

METHODS

75 consecutive fetuses were retrospectively enrolled from January 2010 to June 2021. Fetuses were divided into 4 groups (Group 1: SC; Group 2: S-CoA; Group 3: False Positive-Coarctation of the Aorta [FP-CoA]; group 4: controls). Comparisons for echocardiographic measures and myocardial deformation indices were performed. A receiver operating characteristic (ROC) analysis was performed on the MV/TV (mitral valve/tricuspid valve ratio) and LV GLS (global longitudinal strain) values to identify cut-offs to separate group 1 and 2 fetuses.

RESULTS

SC fetuses showed a significant reduction in MV/TV when compared to S-CoA and FP-CoA fetuses (p<0.001). LV GLS in SC fetuses was significantly reduced compared to S-CoA fetuses (-13.3 ± 2.1% vs. -17.0 ± 2.2%, p=0.001). A cut-off value of 0.59 for MV/TV and -15.35% for LV GLS yielded a sensitivity of 76 and 82% and a specificity of 71 and 83% respectively in separating SC vs. S-CoA fetuses.

CONCLUSIONS

SC fetuses showed a more severe degree of ventricular disproportion and a lower LV GLS compared to S-CoA, FP-CoA and control fetuses. MV/TV and GLS are both predictors of SC. These findings may improve the quality of prenatal parental counselling.

A clinical prediction model to estimate the risk for coarctation of the aorta: From fetal to newborn life

AIM

A prenatal diagnosis of coarctation of the aorta (CoA) is challenging. This study aimed to develop a coarctation probability model incorporating prenatal cardiac sonographic markers to estimate the probability of an antenatal diagnosis of CoA.

METHODS

We reviewed 89 fetuses as an investigation cohort with prenatal suspicion for CoA and categorized them into three subgroups: severe CoA: symptomatic CoA and surgery within the first 3 months; mild CoA: surgery within 4 months to 1 year (29); and false-positive CoA: not requiring surgery (45). Logistic regression was used to create a multiparametric model, and a validation cohort of 86 fetuses with suspected CoA was used to validate the model.

RESULTS

The prediction model had an optimal criterion >0.25 (sensitivity of 97.7%; specificity of 59.1%), and the area under the receiver operator curve was 0.85. The parameters and their cut-off values were as follows: left common carotid artery to left subclavian artery distance/distal transverse arch (LCCA-LSCA)/DT Index >1.77 (sensitivity 62%, specificity 88%, 95% confidence interval [CI]: 0.6-0.8), and z-score of AAo peak Doppler > -1.7 (sensitivity 77%, specificity 56%, 95% CI: 0.6-0.8). The risk assessment demonstrated that fetuses with a model probability >60% should have inpatient observation for a high risk of CoA, whereas fetuses with a model probability <15% should not undergo clinical follow-up.

CONCLUSION

The probability model performs well in predicting CoA outcomes postnatally and can also improve the accuracy of risk assessment. The objectivity of its parameters may allow its implementation in multicenter studies of fetal cardiology.

Incremental value of myocardial deformation in predicting postnatal coarctation of the aorta: establishment of a novel diagnostic model

BACKGROUND

Prenatal detection of coarctation of the aorta (CoA) still suffers from high false-positive and false-negative rates. The objective of this study was to develop a novel model to improve the diagnostic accuracy of fetal CoA.

METHODS

A retrospective study was conducted in 122 fetuses with suspected CoA who also had postnatal follow-ups. Fetuses with confirmed diagnosis of CoA after birth were defined as CoA group, and Non-CoA group were those false-positives. Conventional fetal echocardiographic measurements, including great arterial dimensions and flow characteristics were obtained. Left ventricular (LV) functional parameters were determined using two-dimensional speckle tracking echocardiography. A novel multi-parametric diagnostic model, including gestational age (GA) at diagnosis, aortic isthmus (AOI) Z-score and LV longitudinal strain (LVLS), was developed by univariate and multivariate logistic regression analyses. The model was validated prospectively by a validation cohort of 48 fetuses.

RESULTS

CoA was confirmed in 62/122 (50.8%) cases after birth. Fetuses with postnatal CoA were diagnosed significantly earlier than false-positives (median (interquartile range), 24.5 (23.3-26.4) vs 27.8 (24.5-30.4) weeks; P < .001). The Z-scores of aortic dimensions (aortic valve annulus, ascending aorta, transverse aortic arch and AOI) were significantly smaller (all P < .001), while the Z-scores of pulmonary dimensions (pulmonary valve annulus and main pulmonary artery) were significantly greater (all P < .05), in cases of confirmed CoA than false-positives. Compared with Non-CoA group, CoA group displayed lower LV ejection fraction (P = .005), LV fractional area change (P < .001) and LVLS (P < .001). A multivariate logistic regression model incorporating GA (odds ratio (OR): 0.74, 95% confidence interval (CI): 0.60-0.88; P = .001), AOI Z-score (OR: 0.20, 95% CI: 0.08-0.41; P < .001) and LVLS (OR: 1.79, 95% CI: 1.41-2.42; P < .001) was established to diagnose CoA more accurately (Akaike information criterion: 81.77, C-statistics: 0.945). The performance of this model was confirmed prospectively in the validation cohort.

CONCLUSIONS

In fetuses with suspected CoA, speckle tracking analysis of LVLS may have an incremental value in predicting postnatal CoA. Our diagnostic model, including GA, AOI Z-score and LVLS, may provide a good tool for the stratification of the risk in fetal CoA and contribute to patient-specific perinatal management.

Fetal cardiac sectional schemas - Normal and abnormal. Part 1: Upper abdominal and thoracic sections

Background

A representational illustrated cardiac schema is useful for understanding and interpreting normal and abnormal fetal echocardiographic findings.

Aim

Normal and abnormal fetal echocardiographic images can be better appreciated with the support of sectional schemas.

Settings and Design

An attempt is made to include normal and abnormal variations in both grayscale and color images for easy understanding with the help of the schemas.

Materials and Methods

The fetal cardiac sectional schemas are drawn by the author, using Microsoft Office Word drawing canvas. It is based on the best grayscale, color Doppler, power-angio, 3-dimensional, and high definition flow ultrasound images, supported by embryological and anatomic specimens in literature. Different sections are drawn in accordance with the planes suggested by Society for Maternal-Fetal Medicine, Society of Radiologists in Ultrasound, American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American College of Radiology, and American Society of Echocardiography. Every effort has been meticulously pursued to match with the best ultrasound images with minor modifications for better clarity, understanding, and reproducibility.

Results

The drawings include normal and most of the common cardiac anomalies depicting different sectional views starting from the abdomen and upward. Each drawing complies with the ultrasound images. Users with basic computer knowledge can easily modify these images using them as templates for reference, reporting, and publications.

Conclusions

An attempt is made to represent the fetal echocardiographic images by simplified memorable sectional schemas. These schemas will facilitate a better understanding and interpretation of various normal and abnormal fetal echocardiographic images. Being electronically transmittable, these schemas can be used as templates for further modifications.

Speckle-Tracking Global Longitudinal and Regional Strain Analysis in Neonates with Coarctation of Aorta: A Case-Control Study

Our objectives are to compare speckle-tracking peak global longitudinal (pGLS) and regional strain values in neonates with coarctation of aorta (CoA) and control groups. Echocardiographic parameters measured by speckle-tracking were studied in a retrospective single-center study. A comparison of pGLS and segmental deformation between neonates with CoA and control group was performed using a three-way mixed ANOVA model. There was a significant difference in the means of segmental strain values between CoA and control group at the apical (p = 0.018) and basal segments (p = 0.031) of the interventricular septum and at the apical segment (p = 0.026) of the left ventricle (LV). After correcting for multiple comparisons, the results had a tendency toward statistical significance (adjusted-p < 0.10). There was significant difference in the mean values of pGLS [F(1, 39) = 7.61, p = 0.009, adjusted p = 0.018] between the studied groups. The results of ROC analysis showed that a cut-off value of −16.60% for pGLS provided an estimated sensitivity of 92.31% (95% CI: [63.97, 99.81]) and 71.43% specificity (95% CI: [51.33, 86.78]) for the diagnosis of CoA in neonates (AUC = 0.794, 95% CI: [0.66, 0.93]). pGLS can be regarded as a feasible and reproducible parameter reflecting LV dysfunction in newborns with CoA when compared to newborns with a false-positive diagnosis.

A Fetal Risk Stratification Pathway for Neonatal Aortic Coarctation Reduces Medical Exposure

OBJECTIVE

To test the hypothesis that a fetal stratification pathway will effectively discriminate between infants at different levels of risk for surgical coarctation and reduce unnecessary medicalization.

STUDY DESIGN

We performed a pre-post nonrandomized study in which we prospectively assigned fetuses with prenatal concern for coarctation to 1 of 3 risk categories and implemented a clinical pathway for postnatal management. Postnatal clinical outcomes were compared with those in a historical control group that were not triaged based on the pathway.

RESULTS

The study cohort comprised 109 fetuses, including 57 treated along the fetal coarctation pathway and 52 historical controls. Among mild-risk fetuses, 3% underwent surgical coarctation repair (0% of those without additional heart defects), compared with 27% of moderate-risk and 63% of high-risk fetuses. The combined fetal aortic, mitral, and isthmus z-score best discriminated which infants underwent surgery (area under the curve = 0.78; 95% CI, 0.66-0.91). Compared with historical controls, infants triaged according to the fetal coarctation pathway had fewer delivery location changes (76% vs 55%; P = .025) and less umbilical venous catheter placement (74% vs 51%; P = .046). Trends toward shorter intensive care unit stay, hospital stay, and time to enteral feeding did not reach statistical significance.

CONCLUSIONS

A stratified risk-assignment pathway effectively identifies a group of fetuses with a low rate of surgical coarctation and reduces unnecessary medicalization in infants who do not undergo aortic surgery. Incorporation of novel measurements or imaging techniques may improve the specificity of high-risk criteria.

Application of a Global Multiparameter Scoring System for the Prenatal Prediction of Coarctation of the Aorta

To assess prospectively the capability of our previously reported global multiparameter scoring system to predict coarctation of the aorta (CoAo) in fetuses with cardiac asymmetry, we applied and analyzed the performance of our scoring system in predicting postnatal CoAo in fetuses undergoing prenatal echocardiographic assessment because of cardiac asymmetry between 2011 and 2021, and we determined the cut-off points of the score with the best balance between specificity and sensitivity, and of maximum sensitivity and specificity. CoAo was confirmed in 39/179 newborns (21.8%). We found a significantly higher probability of CoAo in fetuses with CoAo than in cases without CoAo (84.2 ± 18.2% vs. 26.0 ± 28.6%, p < 0.001). The AUC of the ROC of the score was 0.93 (95% CI 0.89–0.97). The cut-off value with the best balance between specificity and sensitivity was a predicted risk of ≥53% (sensitivity 92.3% and specificity 80.0%). The cut-off point of maximum sensitivity was ≥35% (sensitivity 100% and specificity 72.9%), and that of maximum specificity was ≥96% (sensitivity 43.6% and specificity 96.4%). In none of the fetuses with a probability of CoAo < 35% was this condition confirmed after birth. This occurred in 102 fetuses in the whole study population (57%) and in 84 of the 111 in whom CoAo was suspected beyond 28 weeks (75.7%). This multiparameter score allows an adequate discrimination between fetuses without CoAo and those with CoAo, reducing the false positive diagnoses in cardiac asymmetry.

Improved detection of coarctation of the aorta using speckle-tracking analysis of fetal heart on last examination prior to delivery

OBJECTIVE

The false-positive rate for prenatal diagnosis of coarctation of the aorta (FP-CoA) commonly exceeds 50%, with an accurate detection rate of < 50%. This study was conducted to determine if the sensitivity for prenatal detection of true CoA and the FP-CoA rate could be improved by evaluating the fetal epicardial size and shape in the four-chamber view (4CV) and the endocardial right (RV) and left (LV) ventricular size, shape and contractility.

METHODS

We analyzed retrospectively Digital Imaging and Communications in Medicine (DICOM) clips of the 4CV from the last examination prior to delivery in a series of 108 fetuses with CoA suspected prenatally by pediatric cardiologists using traditional diagnostic criteria. Postnatal evaluation distinguished those fetuses which subsequently required CoA surgery (true positives; true CoA) from those that were FP-CoA. Postnatal cardiac abnormalities were identified for each group. For the prenatal evaluation, we measured the 4CV end-diastolic epicardial area, circumference, length, width and global sphericity index. Speckle-tracking analysis was used to compute the endocardial RV and LV end-diastolic area, length, 24-segment sphericity index, 24-segment transverse width and the following functional parameters: fractional area change; global longitudinal, free-wall and septal-wall strain; basal-apical-length, basal free-wall and basal septal-wall fractional shortening; septal-wall annular plane systolic excursion; 24-segment transverse-width fractional shortening; and LV end-diastolic and end-systolic volumes, stroke volume, cardiac output and ejection fraction. In addition, the RV/LV end-diastolic area ratio was computed. Using a control group of 200 normal fetuses, the mean and SD for each of the above cardiac measurements was used to compute the Z-scores for each measurement in each of the 108 study fetuses. Logistic regression analysis was then performed on the Z-score values to identify variables that separated the true CoA group from the FP-CoA group.

RESULTS

Of the 108 study fetuses, 54 were confirmed postnatally to have true CoA and 54 were FP-CoA. Right/left area disproportion > 90^th  centile was present in 80% (n = 43) of the true-CoA fetuses and 76% (n = 41) of the FP-CoA fetuses. Fetuses with true CoA had a significantly greater number of associated cardiac abnormalities (93%, n = 50) compared with the FP-CoA fetuses (61%, n = 33) (P < 0.001). The most common associated malformations were bicuspid aortic valve (true CoA, 46% (n = 25) vs FP-CoA, 22% (n = 12); P < 0.01), aortic arch hypoplasia (true CoA, 31% (n = 17) vs FP-CoA, 11% (n = 6); P < 0.01), ventricular septal defect (true CoA, 33% (n = 18) vs FP-CoA, 11% (n = 6); P < 0.05) and mitral valve abnormality (true CoA, 30% (n = 16) vs FP-CoA, 4% (n = 2); P < 0.01). Logistic regression analysis identified 28 variables that correctly identified 96% (52/54) of the fetuses with true CoA, with a false-positive rate of 4% (2/54) and a false-negative rate of 4% (2/54). These variables included the epicardial size in the 4CV, size and shape of RV and LV, and abnormal contractility of RV and LV. The area under the receiver-operating-characteristics curve was 0.98 (SE, 0.023; 95% CI, 0.84-1). There was no significant difference in the percent of fetuses with RV/LV area disproportion between those with CoA and those that were FP-CoA.

CONCLUSIONS

Speckle-tracking analysis of multiple ventricular measurements may be helpful to refine the diagnosis in fetuses that are suspected to have CoA prenatally. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Fetal Echocardiographic Dimension Indices: Important Predictors of Postnatal Coarctation

The aim of the study is to identify reliable quantitative fetal echocardiographic predictors for postnatal development of coarctation (CoA). In this retrospective study, we included 65 fetuses with a prenatally suspected, isolated CoA, born 2010-2018. Dimensions of the cardiac structures, aortic, and ductal arches expressed as ratios and Z-scores were analyzed in relation to outcome. Fetuses that developed CoA postnatally (34%) exhibited significantly smaller Z-scores of left cardiac structures from the mitral valve to the aortic isthmus. The most sensitive and specific predictors were a carotid-subclavian artery index (CSAI) of < 0.78 (92.3% sensitivity, 96.8% specificity) or a product of isthmus-to-duct ratio in the three-vessel trachea view (3VT) and the mitral-to-tricuspid valve ratio (I/D_3VTxMV/TV) of < 0.37 (100% sensitivity, 94.6% specificity). When comparing different Z-score datasets, we observed large and highly significant differences. Postnatal CoA can be predicted with high accuracy during fetal life using CSAI or I/D_3VTxMV/TV. The latter may be particularly useful if adequate sagittal aortic arch images cannot be obtained. As significant and clinically unacceptable differences in Z-scores were observed for the same measurements, this calls for a large multi-center collaboration to generate reliable fetal echocardiographic Z-scores.

Neonatal management of prenatally suspected coarctation of the aorta

OBJECTIVES

(a) To determine the false-positive rate among newborns with prenatally suspected coarctation of the aorta (CoA) within the UCLA Health system, (b) to compare patient and maternal interventions and outcomes between false-positive cases and normal controls, and (c) to determine the timing of clinical presentation of CoA.

METHODS

We performed a single-center, retrospective case control study of all fetuses with suspected isolated CoA who underwent both fetal echocardiographic evaluation and subsequent delivery at UCLA between January 1, 2011, and December 31, 2018. Maternal and neonatal medical records were reviewed for demographic and clinical data, for cases of suspected CoA and for controls. A separate review of our institution's surgical database was performed to identify characteristics of all patients (neonatal and pediatric) with isolated CoA who underwent surgical repair during the same time period.

RESULTS

Among the 50 fetal cases of isolated suspected CoA who delivered at our institution, 47 patients (94%) were found to be normal (false positives). Compared with normal controls, patients with suspected CoA were more likely to have delayed maternal bonding, delayed feeding, admission to the intensive care unit, performance of neonatal echocardiograms, initiation of intravenous fluids and initiation of prostaglandin E1, and a longer length of hospital stay. Among the 38 patients undergoing CoA repair at our institution during the study period, four patients were prenatally diagnosed and no patient presented clinically with symptoms before 48 hours after delivery.

CONCLUSION

Compared with normal controls, patients with prenatally suspected coarctation are more likely to have delayed maternal bonding, delayed feeding, more frequent neonatal echocardiograms, and longer length of hospital stay. Further refinement of neonatal management may improve postnatal care.

Evaluation of Fetal Left Ventricular Size and Function Using Speckle-Tracking and the Simpson Rule

OBJECTIVES

This study was conducted to evaluate left ventricular (LV) size and function in healthy fetuses and to test a cohort of fetuses at risk for abnormal function using speckle-tracking software.

METHODS

Two hundred control fetuses were examined between 20 and 40 weeks' gestation. With the use of offline speckle-tracking software, the end-diastolic and end-systolic volumes were measured and the following computed: stroke volume (SV), SV per kilogram, cardiac output (CO), CO per kilogram, and ejection fraction. These were regressed against 7 independent variables related to the size, weight, and age of the fetuses. Five fetuses with risk factors for LV dysfunction were examined to sample the validity of the data from the control group.

RESULTS

The R² values for measurements of the end-diastolic volume, SV, and CO correlated with the 7 independent variables of fetal size and age (0.7-0.78), whereas the SV/kg, CO/kg, and ejection fraction had lower R² values (0.02-0.1). The measurements were normally distributed (Shapiro-Wilke > 0.5). The 5 fetuses at risk for abnormal LV function had measurements of LV size and function that were consistent with the expected pathologic condition.

CONCLUSIONS

Speckle tracking can provide a comprehensive evaluation of the size and function of the fetal LV.

Comprehensive Evaluation of Fetal Cardiac Ventricular Widths and Ratios Using a 24-Segment Speckle Tracking Technique

INTRODUCTION

This study was conducted to evaluate the 24-segment transverse widths of the right and left ventricles distributed from the base to the apex of the ventricular chambers and compute the right ventricular (RV)/left ventricular (LV) ratios for each segment.

METHODS

Two hundred control fetuses were examined between 20 and 40 weeks' gestation. Using offline speckle-tracking software, the 24 end-diastolic transverse widths were computed and the RV/LV ratios were regressed against 7 independent variables related to the size, weight, and age of the fetuses. Five fetuses with coarctation of the aorta and 5 fetuses with pulmonary stenosis were examined to exemplify the utility of these measurements.

FINDINGS

The 24-segment transverse widths were associated with changes in fetal size, weight, and age. Regression equations were developed to describe these changes with R² values between .5 and .82. The measurements were normally distributed (Shapiro-Wilk > 0.5). The RV/LV ratio for the 24 segments did not strongly correlate (R²  = .001 to -.2) with fetal size, weight, or gestational age. Fetuses with coarctation of the aorta and pulmonary stenosis demonstrated characteristic changes in the 24-segment transverse widths and the RV/LV ratios in the basal (segments 1-8), mid (segments 9-16) and apical (segments 17-24) sections of the ventricles.

CONCLUSIONS

The 24-segment transverse widths of the right and left ventricles and the RV/LV ratios provide a comprehensive method to examine the width of the ventricular chambers.

Fetal Echocardiographic Measures to Improve the Prenatal Diagnosis of Coarctation of the Aorta

The objective of this study is to identify fetal echocardiographic measures that predict postnatal coarctation of the aorta (CoA). A retrospective review of patients from 2013 to 2017 identified 13 cases of prenatal diagnosis of CoA confirmed postnatally and 14 cases of prenatal diagnosis of CoA with normal arches postnatally. There were 30 controls. Measurements were made and indices applied on all available longitudinal fetal echocardiograms for each patient. Linear mixed effects models were used to examine the between-group differences in the trajectories of the measurements. Significant differences were seen in the true CoA group for the following: smaller distal transverse arch diameter to distance between the left common carotid and left subclavian arteries (DT/LCA-LSCA) index (p = 0.04), smaller distal transverse arch diameter (p = 0.005), and longer brachiocephalic to left common carotid artery (LCA) (p = 0.004) and LCA-left subclavian artery (LSCA) distances (p < 0.0001). Additionally, the LCA/DT index trend appears to differentiate false positives from true coarctations (p < 0.03). The fetal echocardiographic DT/LCA-LSCA index, brachiocephalic-LCA distance and LCA-LSCA distance are significant predictors of postnatal coarctation. The LCA/DT index trend over time may differentiate which of those patients with prenatal concern for coarctation are more likely to develop coarctation postnatally. The use of fetal echocardiographic measures may improve prenatal detection and predication of postnatal coarctation.

Isolated coarctation of the aorta in the fetus: A diagnostic challenge

Isolated coarctation of the aorta (CoA) is estimated by the Centers for Disease Control and Prevention to account for 4%-6% of all congenital heart disease (CHD) in the United States, with a reported prevalence of ~4 per 10 000 live births. Prenatal recognition of coarctation is important as it may improve neonatal survival and reduce morbidity. However, despite advances in imaging and the trend toward detailed aortic arch assessment as part of a comprehensive fetal echocardiogram, isolated CoA may still elude prenatal detection, with potentially lethal consequences if the diagnosis is not suspected and the patent ductus arteriosus (PDA) closes spontaneously in postnatal life. The purpose of this review is to outline the methods of antenatal aortic arch evaluation in the current era, discuss "red flags" that raise the suspicion for CoA, including associated anomalies and serve as a repository of the most up to date information regarding its diagnosis in utero and its perinatal management. Other aortic arch abnormalities, such as interrupted aortic arch, or CoA associated with complex single ventricles, are not included in this review.

Twenty-four Segment Transverse Ventricular Fractional Shortening: A New Technique to Evaluate Fetal Cardiac Function

OBJECTIVES

Because of various fetal and maternal disease states, this study was conducted to evaluate the fractional shortening of 24 transverse segments distributed from the base to the apex of the ventricular chambers.

METHODS

Two hundred control fetuses were examined between 20 and 40 weeks' gestation. The transverse displacement of the ventricular endocardium during the cardiac cycle was computed by using offline software. From the output of the analysis, 24 end-diastolic and end-systolic segments were measured from the base (segment 1) to the apex (segment 24) of the right and left ventricles, and the fractional shortening was computed: [(end-diastolic length - end-systolic length)/end-diastolic length] × 100. Examples of fetal cardiovascular abnormalities were selected to demonstrate the utility of this technique.

RESULTS

The fractional shortening for each segment was independent of gestational age and fetal biometric measurements. There was no significant difference in fractional shortening for segments 1 to 5 between the right and left ventricles. However, the fractional shortening of the left ventricle was significantly greater (P < .0001) than that of the right ventricle for segments 6 to 24, suggesting that the mid and apical segments of the left ventricle have increased displacement toward the center of the chamber compared to the right ventricle. Fetuses with various cardiac structural abnormalities had abnormal fractional shortening values.

CONCLUSIONS

The fractional shortening of 24 segments of the right and left ventricles provides a comprehensive method to examine the contractility of the ventricular chambers.

Modeling of coarctation of aorta in human fetuses using 3D/4D fetal echocardiography and computational fluid dynamics

OBJECTIVES

We sought to develop a hemodynamic model of aortic and ductal arches using computational fluid dynamics (CFD) and 3D/4D spatio-temporal image correlation (STIC) fetal echocardiography and to investigate the hemodynamics of coarctation of aorta (CoA) in human fetuses using this approach.

METHODS

We obtained 3D/4D STIC fetal echocardiographic images of the aortic and ductal arches (DA) in five normal fetuses. Based on these images, we simulated the hemodynamics in the two arches using CFD. Subsequently, we reduced the dimensions of aortic isthmus from 100% to 85%, 70%, 55%, 40%, and 25% of the original dimension digitally. Numerical simulation was repeated in each condition, and flow profile, velocity, pressure, and wall shear stress (WSS) were compared with those of the baseline normal aortic and ductal arches.

RESULTS

With the progressive narrowing in the aortic isthmus, there were alterations in the flow profile, velocity, pressure, and WSS. The downstream vortexes disappeared, and the double helix profile became single helix. When the aortic isthmus reduced by 55% in dimension, there was an exponential increase in velocity and WSS and decrease in pressure.

CONCLUSIONS

The aortic and ductal arch geometry and flow lead to the alterations in flow profile, velocity, pressure, and WSS in the aortic isthmus in normal and CoA models, which are conductive of ductal issue migration into these areas. A 55% reduction in the dimension of aortic isthmus is associated with exponential change in velocity, pressure, and WSS, a probable threshold for hemodynamically significant CoA.