Prenatal screening for cardiac anomalies: the value of routine addition of the aortic root to the four-chamber view

OBJECTIVE

To determine whether the addition of the aortic-root view would detect more congenital cardiac anomalies than a standard four-chamber view alone.

METHODS

The study included fetuses of 14 weeks' gestation or more who were scanned in our unit during a 28-month period. Outcome information was obtained from postnatal echocardiograms and autopsies. Abnormal hearts were classified as to whether the four-chamber or aortic-root view was abnormal.

RESULTS

There were 5967 fetuses in whom a four-chamber view could be obtained. In 5111 of these, an aortic-root view could also be obtained. The four-chamber view detected 24 (47%) of the 51 fetuses with abnormal hearts. Adding the aortic-root view increased the sensitivity to 78%.

CONCLUSIONS

Visualization of the aortic root is a quick and easy means of evaluating the aortic outflow tract during routine scanning. Adding the aortic-root view to the standard four-chamber view will result in the detection of most cardiac anomalies prenatally.

[Screening for fetal heart defects in the four chamber view with evaluation of larger arteries: possibilities and limits]

The four-chamber view and the visualization of the root of the left and right ventricular outflow tracts has been proposed as a screening method for the detection of congenital heart disease in the fetus. In order to study the diagnostical value of the method we investigated 1600 fetuses between the 17th and 40th gestational week without anamnestic risk for congenital heart disease with this screening method in a two years' period. We found 33 fetuses to have an abnormality either in the four-chamber view or in the ventricular outflow tracts. The sensitivity of the method in the detection of congenital heart disease was found to be 81%, the specificity 99% and the positive predictive value 88%. Women at high risk for congenital heart disease in the fetus should still undergo a more detailed echocardiographic examination to maximize the sensitivity in the detection of structural heart defects. Nevertheless, the described screening procedure is an effective and feasible method to detect fetuses with severe congenital heart disease, whose prognosis may be improved by the delivery in a perinatological center.

[Echocardiography in the diagnosis and prevention of congenital heart defects of a primarily genetic etiology]

Over the period from January 1982 to June 1989 the authors examined 1723 children and adolescents with congenital heart diseases (CHD), hospitalized in the Institute of Cardiovascular Diseases in Bratislava. Of these patients, 96 (5.6%) had CHD of primarily genetic etiology: monogenic diseases 51 (3%), chromosomal anomalies 45 (2.6%) patients. In indicated cases (polystigmatization, positive family history) the relatives were examined. Echocardiographic examination of 203 relatives of patients with genetically determined CHD yielded positive echocardiographic findings in 32 subjects (15.5%). In relatives of patients with CHD of primarily genetic etiology, even structural changes which hemodynamically are not severe may be of value for individuals who are carriers of pathologic genetic information. Echocardiography is a contribution not only to diagnosis but also to prevention of CHD in association with adequate genetic counselling. (Tab. 4, Ref. 7.)

The child at risk for developing heart disease. 3

We discuss how to identify the child at risk for developing or having heart disease. We describe both the child at risk for developing adult-onset heart disease and the child or fetus at risk for having congenital heart disease. With respect to the child at risk for developing adult-onset heart disease, we concentrate on how four risk factors (cigarette smoking, hyperlipidemia, reduced physical activity, and obesity) affect the development of cardiovascular disease, and we review the types of therapy currently being used to modify them. We also discuss the etiological factors related to the risk of developing congenital heart disease, such as single-gene conditions, known cardiac teratogens, chromosomal anomalies, and multifactorial inheritance.

[Predicting congenital cardiovascular defects on the basis of their immunogenetic characteristics]

The study was undertaken to examine 80 children with congenital heart and vessel malformations, their parents (50 married couples), and 100 families with healthy children. The antigen typing of the HLA system was accomplished by using the Terasaki microlymphocytotoxic test. A statistically significant correlation was found between B35 antigens and septal malformations, vascular diseases, and congenital cardiomyopathies. The unfavorable obstetric history was shown to play a role in the occurrence of developmental malformations. The data of an analysis of HLA antigens in the parents of the children with congenital malformations suggest that a marked HLA antigen compatibility of married couples is one of the cause of pregnancy complications and developmental malformations in their offspring.

Detection of cardiac problems among school children by health screening

A study was undertaken to assess the types of cardiac diseases and dysrhythmias in a healthy population of 651,794 school children who underwent general health screening between January 1981 to December 1986. Congenital heart lesions were diagnosed in 1159 (0.18 per cent), the majority being mitral valve prolapse (MVP; 0.08 per cent), small ventricular septal defects (VSD; 0.04 per cent), mild pulmonary stenosis (PS; 0.03 per cent), and small atrial septal defects (ASD; 0.02 per cent). Other lesions detected were patent ductus arteriosus (PDA), coarctation of aorta (CoA), Fallot's Tetralogy (FT) and total anomalous pulmonary venous drainage (TAPVD). Of these, five had surgical closure of ASD, eight and ligation of PDA, and one had correction for TAPVD. Cardiac dysrhythmias were seen in 350 patients; consisting of premature ventricular contractions (PVC) in 186, right bundle branch block (RBBB) in 132, atrial ectopics (AE) in 17, sinus node dysfunction in five, atrioventricular (AV) block in seven, Wolff-Parkinson-White (WPW) syndrome in two, and paroxysmal atrial tachycardia (PAT) in one boy. Associated congenital heart lesions were found in 110 patients. The cardiac screening programme has resulted in a significant detection of cardiac abnormalities among apparently healthy school children. Early detection of cardiac disease has resulted in early remedial measures to be taken and thus improved cardiological care.

The causes and underlying developmental mechanisms of congenital cardiovascular malformations: a critical review

Cardiovascular malformations are the second most common type of birth defect, occurring in 5-8/1,000 livebirths with a still higher prevalence among stillborn infants and spontaneously aborted embryos and fetuses. Dealing effectively with the high frequency of heart defects means reducing the incidence of cardiac malformations in the world. In this paper we cite some of the genetic and environmental risk factors associated with congenital cardiovascular malformations, describe the putative biochemical nature of the genetic predisposition relative to environmentally induced teratogenesis, and either support or discourage the use of available methods as strategies in preventing cardiovascular anomalies.

Pharmacology of dextroamphetamine-induced cardiovascular malformations in the chick embryo

We have observed dextroamphetamine sulfate to cause cardiovascular malformations in the 4-day-old chick embryo. Essentially all malformations were of the heart and great vessels. About one-half of these were the abnormal persistence of the left fourth aortic arch. Ventricular septal defects comprised the vast majority of the other malformations. Since d-amphetamine has both a direct and, more importantly, an indirect mode of alpha and beta adrenergic stimulation, three drugs were used to try to inhibit malformation production: alpha-methyl-p-tyrosine (AMT), a catecholamine synthesis inhibitor; metoprolol, a beta 1 blocker; and phentolamine, an alpha blocker. When given with d-amphetamine, all three drugs significantly reduced the malformation rate resulting from d-amphetamine alone. We speculate that the embryonic chick is capable of responding to the alpha and/or beta properties of dextroamphetamine sulfate. These properties may be causally related to the malformations observed.

Cardiovascular research: decades of progress, a decade of promise

Mortality due to cardiovascular diseases has decreased more than 30 percent in the last 30 years, and this decline has accelerated so much that over 60 percent of it has occurred between 1970 and 1980. The past and present contributions of advances in cardiovascular research to this decline are reviewed. Although three have been significant research accomplishments, too many people still die of heart and blood vessel diseases. Continued emphasis must be placed on research in the areas of etiology and pathogenesis, on validating potentially beneficial research hypotheses, and on the translation and dissemination of research results to the health care practitioner and the public. Only then can our long-term goal, the prevention of cardiovascular disease, be fully realized.

Maternal phenylketonuria--results of dietary therapy

Untreated maternal phenylketonuria (PKU) may result in nonphenylketonuric offspring with mental retardation, microcephaly, congenital heart disease, and low birth weight. We obtained information about 34 pregnancies in which dietary therapy was instituted to lower the concentration of phenylalanine in maternal blood in an attempt to avoid fetal damage. The outcomes varied from mental normality with no evidence of fetal effect to neonatal death due to congenital heart disease. Dietary therapy with control of the maternal biochemical abnormalities is not yet of proved efficacy in preventing these fetal effects. The available data tend to support initiation of dietary therapy prior to conception for best results, but the number of cases is small and points to the need for further research.