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Salve GG, Winlaw DS. Commentary: Learning points from a remarkable success in achieving stable pulmonary blood flow in a very small baby with Ebstein anomaly and a circular shunt. JTCVS Tech 2021; 7:212-213. [PMID: 34318250 PMCID: PMC8311904 DOI: 10.1016/j.xjtc.2021.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 02/16/2021] [Accepted: 02/22/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Gananjay G Salve
- Heart Centre for Children, The Children's Hospital at Westmead, Westmead, Australia
| | - David S Winlaw
- The Heart Institute, Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Freud LR, Wilkins-Haug LE, Beroukhim RS, LaFranchi T, Phoon CK, Glickstein JS, Cumbermack KM, Makhoul M, Morris SA, Sun HY, Ferrer Q, Pedra SR, Tworetzky W. Effect of In Utero Non-Steroidal Anti-Inflammatory Drug Therapy for Severe Ebstein Anomaly or Tricuspid Valve Dysplasia (NSAID Therapy for Fetal Ebstein anomaly). Am J Cardiol 2021; 141:106-112. [PMID: 33217351 DOI: 10.1016/j.amjcard.2020.11.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/02/2020] [Accepted: 11/06/2020] [Indexed: 10/23/2022]
Abstract
Ebstein anomaly (EA) and tricuspid valve dysplasia (TVD) are rare congenital malformations associated with nearly 50% mortality when diagnosed in utero. The diseases often produce severe tricuspid regurgitation (TR) in the fetus and in some cases, pulmonary regurgitation (PR) and circular shunting ensue. Since the ductus arteriosus (DA) plays a critical role in the circular shunt and may be constricted by transplacental nonsteroidal anti-inflammatory drugs (NSAIDs), we sought to assess the effect of NSAIDs on fetuses with EA/TVD. We reviewed mothers of singleton fetuses with EA/TVD and PR, indicative of circular shunting, who were offered NSAIDs at multiple centers from 2010 to 2018. Initial dosing consisted of indomethacin, followed by ibuprofen in most cases. Twenty-one patients at 10 centers were offered therapy at a median gestational age (GA) of 30.0 weeks (range: 20.9 to 34.9). Most (15/21 = 71%) mothers received NSAIDs, and 12 of 15 (80%) achieved DA constriction after a median of 2.0 days (1.0 to 6.0). All fetuses with DA constriction had improved PR; 92% had improved Doppler patterns. Median GA at pregnancy outcome (live-birth or fetal demise) was 36.1 weeks (30.7 to 39.0) in fetuses with DA constriction versus 33 weeks (23.3 to 37.3) in fetuses who did not receive NSAIDs or achieve DA constriction (p = 0.040). Eleven of 12 patients (92%) with DA constriction survived to live-birth, whereas 4 of 9 patients (44%) who did not receive NSAIDs or achieve DA constriction survived (p = 0.046). In conclusion, our findings demonstrate the proof of concept that NSAIDs mitigate circular shunt physiology by DA constriction and improve PR among fetuses with severe EA/TVD. Although the early results are encouraging, further investigation is necessary to determine safety and efficacy.
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Affiliation(s)
- Lindsay R Freud
- Department of Pediatrics, Division of Pediatric Cardiology, Morgan Stanley Children's Hospital of NewYork-Presbyterian, Columbia University Medical Center, New York, New York.
| | - Louise E Wilkins-Haug
- Department of Obstetrics, Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston Massachusetts
| | - Rebecca S Beroukhim
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Terra LaFranchi
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Colin K Phoon
- Department of Pediatrics, Division of Pediatric Cardiology, Hassenfeld Children's Hospital, New York University, New York, New York
| | - Julie S Glickstein
- Department of Pediatrics, Division of Pediatric Cardiology, Morgan Stanley Children's Hospital of NewYork-Presbyterian, Columbia University Medical Center, New York, New York
| | - Kristopher M Cumbermack
- Department of Pediatrics, Division of Pediatric Cardiology, Kentucky Children's Hospital, University of Kentucky, Lexington, Kentucky
| | - Majd Makhoul
- Department of Pediatrics, Division of Pediatric Cardiology, Kentucky Children's Hospital, University of Kentucky, Lexington, Kentucky
| | - Shaine A Morris
- Department of Pediatrics, Division of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Heather Y Sun
- Department of Pediatrics, Division of Pediatric Cardiology, Rady Children's Hospital, University of California-San Diego, San Diego, California
| | - Queralt Ferrer
- Department of Pediatrics, Division of Pediatric Cardiology, University Hospital Vall d'Hebron, Universidad Autonoma de Barcelona, Barcelona, Spain
| | - Simone R Pedra
- Department of Pediatrics, Division of Pediatric Cardiology, Instituto Dante Pazzanese de Cardiologia/Hospital do Coracao da Associacao Sanatorio Sirio, Sao Paulo, Brazil
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Pavlicek J, Klaskova E, Salounova D, Tomaskova H, Piegzova A, Gruszka T, Kacerovsky M. Area of the right atrium of the fetal heart and its significance in fetuses with tricuspid regurgitation. J Matern Fetal Neonatal Med 2021; 35:5253-5259. [PMID: 33478280 DOI: 10.1080/14767058.2021.1876655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The first aim was to develop a nomogram for the area of the right atrium (ARA) of the fetal heart in uncomplicated singleton pregnancies. The second aim was to assess diagnostic indices of ARA to distinguish between tricuspid regurgitation (TR) with and without concomitant congenital heart defect (CDH). METHODS The study was conducted between 2014 and 2019. Fetal echocardiography was performed on fetuses with and without TR. For the first aim, ARA was measured in 460 fetuses without proven structural and chromosomal abnormalities, and for the second aim, ARA was measured in 1077 fetuses with TR. RESULTS A nomogram for the ARA of fetuses with normal hearts was developed. TR was observed in 4.5% (1077/23,771) of euploid fetuses; 4.3% (1020/23,771) of fetuses had TR without a concomitant CHD, and 0.2% (57/23,771) fetuses had TR with a concomitant CHD. No significant differences in ARAs were found between fetuses with normal hearts without TR (n = 22,694) and fetuses with TR without CHD (n = 1020; p = .751). Fetuses with TR and CHDs had different ARA than fetuses with normal hearts without TR and fetuses with TR without CHD (p < .0005 in both cases). CONCLUSIONS ARA seems to be an auxiliary marker to distinguish the presence of CHD in fetuses with TR.
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Affiliation(s)
- Jan Pavlicek
- Department of Pediatrics, Department of Pediatrics and Prenatal Cardiology, University Hospital Ostrava, Ostrava, Czech Republic.,Biomedical Research Center, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Eva Klaskova
- Department of Pediatrics, University Hospital Olomouc and Faculty of Medicine and Dentistry, University of Palacky, Olomouc, Czech Republic.,Fertimed Center for Reproductive Medicine and Infertility, Olomouc, Czech Republic
| | - Dana Salounova
- Department of Mathematical Methods in Economy, Faculty of Economics, Technical University Ostrava, Ostrava, Czech Republic
| | - Hana Tomaskova
- Department of Epidemiology and Public Health, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Alicja Piegzova
- Department of Obstetrics and Gynecology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Tomas Gruszka
- Department of Pediatrics, Department of Pediatrics and Prenatal Cardiology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Marian Kacerovsky
- Biomedical Research Center, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic.,Department of Obstetrics and Gynecology, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
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54
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Wang S, Freud LR, Detterich J, Moon-Grady AJ, Donofrio MT, Jaeggi ET, Szwast AL, Morris SA, Kavanaugh-Mchugh A, Howley LW, van der Velde ME, Cuneo BF, Phoon CK, Tworetzky W, Pruetz JD. Extracardiac Doppler indices predict perinatal mortality in fetuses with Ebstein anomaly and tricuspid valve dysplasia. Prenat Diagn 2021; 41:332-340. [PMID: 33242215 DOI: 10.1002/pd.5873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/22/2020] [Accepted: 11/23/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Ebstein anomaly and tricuspid valve dysplasia (EA/TVD) carry high perinatal mortality. Past studies have focused on cardiac predictors of mortality; we sought to describe the fetal echo (FE) extracardiac Dopplers in this cohort and determine their association with perinatal mortality. METHOD Fetuses with EA/TVD at 23 centers from 2005-2011 were included for retrospective study. Doppler pattern and velocity of the umbilical artery (UA), umbilical vein (UV), ductus venosus (DV), and middle cerebral artery (MCA) were collected. Bivariate and multivariate analyzes were performed. The primary outcome measure was perinatal mortality, defined as fetal demise or neonatal death. RESULTS Of 190 cases that met eligibility criteria, alterations were seen in 50% of UA, 16% of UV, 48% of DV, and 8% of MCA Doppler indices on the last FE (median 27.4 weeks). Independent predictors of perinatal mortality included abnormal UA Doppler pattern of absence or reversed end diastolic flow (OR 9.7) and UV velocity z score <1 (OR 2.5), in addition to diagnosis <32 weeks (OR 4.2) and tricuspid valve (TV) annulus z score ≥6 (OR 5.3). CONCLUSION Abnormal UA Doppler pattern and decreased UV velocity are independent predictors of perinatal mortality in EA/TVD fetuses and should be used to refine mortality risk and guide perinatal management.
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Affiliation(s)
- Shuo Wang
- Department of Pediatrics, Division of Cardiology, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Lindsay R Freud
- Department of Pediatrics, Division of Cardiology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jon Detterich
- Department of Pediatrics, Division of Cardiology, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Anita J Moon-Grady
- Department of Pediatrics, Division of Cardiology, Benioff Children's Hospital, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Mary T Donofrio
- Department of Pediatrics, Division of Cardiology, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Edgar T Jaeggi
- Department of Pediatrics, Division of Cardiology, Hospital for Sick Children, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Anita L Szwast
- Department of Pediatrics, Division of Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Shaine A Morris
- Department of Pediatrics, Division of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Ann Kavanaugh-Mchugh
- Department of Pediatrics, Division of Cardiology, Monroe Carell Jr. Children's Hospital, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Lisa W Howley
- Department of Pediatrics, Division of Cardiology, The Children's Heart Clinic and Children's Minnesota, Minnesota, USA
| | - Mary E van der Velde
- Department of Pediatrics, Division of Cardiology, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Bettina F Cuneo
- Department of Pediatrics, Division of Cardiology, The Children's Heart Clinic and Children's Minnesota, Minnesota, USA
| | - Colin K Phoon
- Department of Pediatrics, Division of Cardiology, Hassenfeld Children's Hospital at NYU Langone, New York University School of Medicine, New York, New York, USA
| | - Wayne Tworetzky
- Department of Pediatrics, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jay D Pruetz
- Department of Pediatrics, Division of Cardiology, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, USA
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55
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Sethi N, Klugman D, Said M, Hom L, Bowers S, Berger JT, Wernovsky G, Donofrio MT. Standardized delivery room management for neonates with a prenatal diagnosis of congenital heart disease: A model for improving interdisciplinary delivery room care. J Neonatal Perinatal Med 2021; 14:317-329. [PMID: 33361613 DOI: 10.3233/npm-200626] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Precise characterization of cardiac anatomy and physiology through fetal echocardiography can predict early postnatal clinical course. Some neonates with prenatally defined critical congenital heart disease have anticipated precipitous compromise during perinatal transition for which specialized, diagnosis-specific delivery room care can be arranged to expeditiously stabilize cardiopulmonary hemodynamics. In this article, we describe our institutional approach to the delivery room care of neonates with prenatally diagnosed congenital heart disease, emphasizing our diagnosis-specific care pathways for newborns with critical disease.
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Affiliation(s)
- N Sethi
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - D Klugman
- Division of Cardiac Critical Care, Children's National Hospital, Washington, DC, USA
| | - M Said
- Division of Neonatology, Children's National Hospital, Washington, DC, USA
| | - L Hom
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - S Bowers
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - J T Berger
- Division of Cardiac Critical Care, Children's National Hospital, Washington, DC, USA
| | - G Wernovsky
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
- Division of Cardiac Critical Care, Children's National Hospital, Washington, DC, USA
| | - M T Donofrio
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
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Freud LR, McElhinney DB, Kalish BT, Escobar-Diaz MC, Komarlu R, Puchalski MD, Jaeggi ET, Szwast AL, Freire G, Levasseur SM, Kavanaugh-McHugh A, Michelfelder EC, Moon-Grady AJ, Donofrio MT, Howley LW, Selamet Tierney ES, Cuneo BF, Morris SA, Pruetz JD, van der Velde ME, Kovalchin JP, Ikemba CM, Vernon MM, Samai C, Satou GM, Gotteiner NL, Phoon CK, Silverman NH, Tworetzky W. Risk Factors for Mortality and Circulatory Outcome Among Neonates Prenatally Diagnosed With Ebstein Anomaly or Tricuspid Valve Dysplasia: A Multicenter Study. J Am Heart Assoc 2020; 9:e016684. [PMID: 33076749 PMCID: PMC7763426 DOI: 10.1161/jaha.120.016684] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background In a recent multicenter study of perinatal outcome in fetuses with Ebstein anomaly or tricuspid valve dysplasia, we found that one third of live‐born patients died before hospital discharge. We sought to further describe postnatal management strategies and to define risk factors for neonatal mortality and circulatory outcome at discharge. Methods and Results This 23‐center, retrospective study from 2005 to 2011 included 243 fetuses with Ebstein anomaly or tricuspid valve dysplasia. Among live‐born patients, clinical and echocardiographic factors were evaluated for association with neonatal mortality and palliated versus biventricular circulation at discharge. Of 176 live‐born patients, 7 received comfort care, 11 died <24 hours after birth, and 4 had insufficient data. Among 154 remaining patients, 38 (25%) did not survive to discharge. Nearly half (46%) underwent intervention. Mortality differed by procedure; no deaths occurred in patients who underwent right ventricular exclusion. At discharge, 56% of the cohort had a biventricular circulation (13% following intervention) and 19% were palliated. Lower tricuspid regurgitation jet velocity (odds ratio [OR], 2.3 [1.1–5.0], 95% CI, per m/s; P=0.025) and lack of antegrade flow across the pulmonary valve (OR, 4.5 [1.3–14.2]; P=0.015) were associated with neonatal mortality by multivariable logistic regression. These variables, along with smaller pulmonary valve dimension, were also associated with a palliated outcome. Conclusions Among neonates with Ebstein anomaly or tricuspid valve dysplasia diagnosed in utero, a variety of management strategies were used across centers, with poor outcomes overall. High‐risk patients with low tricuspid regurgitation jet velocity and no antegrade pulmonary blood flow should be considered for right ventricular exclusion to optimize their chance of survival.
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Affiliation(s)
- Lindsay R Freud
- Division of Cardiology Department of Pediatrics NewYork-Presbyterian Morgan Stanley Children's Hospital Columbia University Medical Center New York NY
| | - Doff B McElhinney
- Division of Cardiology Department of Pediatrics Lucile Packard Children's Hospital Stanford School of Medicine Palo Alto CA
| | - Brian T Kalish
- Division of Newborn Medicine Department of Pediatrics Boston Children's Hospital Harvard Medical School Boston MA
| | - Maria C Escobar-Diaz
- Department of Pediatric Cardiology Hospital Sant Joan de Déu Universitat de Barcelona Spain
| | - Rukmini Komarlu
- Division of Pediatric Cardiology Department of Pediatrics Cleveland Clinic Children's Hospital Lerner College of Medicine at Case Western Reserve University Cleveland OH
| | - Michael D Puchalski
- Division of Cardiology Department of Pediatrics Primary Children's Hospital University of Utah School of Medicine Salt Lake City UT
| | - Edgar T Jaeggi
- Division of Cardiology Department of Paediatrics Hospital for Sick Children University of Toronto Toronto Ontario Canada
| | - Anita L Szwast
- Division of Cardiology Department of Pediatrics Children's Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Grace Freire
- Division of Cardiology Department of Pediatrics Johns Hopkins All Children's Hospital St. Petersburg FL
| | - Stéphanie M Levasseur
- Division of Cardiology Department of Pediatrics NewYork-Presbyterian Morgan Stanley Children's Hospital Columbia University Medical Center New York NY
| | - Ann Kavanaugh-McHugh
- Division of Cardiology Department of Pediatrics Monroe Carell Jr. Children's Hospital Vanderbilt University School of Medicine Nashville TN
| | - Erik C Michelfelder
- Division of Cardiology Department of Pediatrics Children's Healthcare of Atlanta Sibley Heart Center Emory University School of Medicine Atlanta GA
| | - Anita J Moon-Grady
- Division of Cardiology Department of Pediatrics UCSF Benioff Children's Hospital University of California-San Francisco School of Medicine San Francisco CA
| | - Mary T Donofrio
- Division of Cardiology Department of Pediatrics Children's National Medical Center George Washington University School of Medicine and Health Sciences Washington DC
| | - Lisa W Howley
- Division of Cardiology Department of Pediatrics Children's Hospital Colorado University of Colorado School of Medicine Aurora CO
| | - Elif Seda Selamet Tierney
- Division of Cardiology Department of Pediatrics Lucile Packard Children's Hospital Stanford School of Medicine Palo Alto CA
| | - Bettina F Cuneo
- Division of Cardiology Department of Pediatrics Children's Hospital Colorado University of Colorado School of Medicine Aurora CO
| | - Shaine A Morris
- Division of Cardiology Department of Pediatrics Texas Children's Hospital Baylor College of Medicine Houston TX
| | - Jay D Pruetz
- Division of Cardiology Department of Pediatrics Children's Hospital Los Angeles University of Southern California Keck School of Medicine Los Angeles CA
| | - Mary E van der Velde
- Division of Cardiology Department of Pediatrics University of Michigan Congenital Heart Center C.S. Mott Children's Hospital University of Michigan Medical School Ann Arbor MI
| | - John P Kovalchin
- Division of Cardiology Department of Pediatrics Nationwide Children's Hospital Ohio State University College of Medicine Columbus OH
| | - Catherine M Ikemba
- Division of Cardiology Department of Pediatrics Children's Medical Center University of Texas Southwestern Medical School Dallas TX
| | - Margaret M Vernon
- Division of Cardiology Department of Pediatrics Seattle Children's Hospital University of Washington School of Medicine Seattle WA
| | - Cyrus Samai
- Division of Cardiology Department of Pediatrics Children's Healthcare of Atlanta Emory University School of Medicine Atlanta GA
| | - Gary M Satou
- Division of Cardiology Department of Pediatrics Mattel Children's Hospital University of California-Los Angeles David Geffen School of Medicine Los Angeles CA
| | - Nina L Gotteiner
- Division of Cardiology Department of Pediatrics Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine Chicago IL
| | - Colin K Phoon
- Division of Cardiology Department of Pediatrics Hassenfeld Children's Hospital at NYU Langone New York University School of Medicine New York NY
| | - Norman H Silverman
- Division of Cardiology Department of Pediatrics Lucile Packard Children's Hospital Stanford School of Medicine Palo Alto CA.,Division of Cardiology Department of Pediatrics UCSF Benioff Children's Hospital University of California-San Francisco School of Medicine San Francisco CA
| | - Wayne Tworetzky
- Department of Cardiology Boston Children's Hospital Harvard Medical School Boston MA
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Asou T, Kawataki M, Takeda Y, Asai H, Tachibana T, Toyoshima K, Kim KS, Ueda H. Rapid two-stage Starnes approach in high-risk neonates with Ebstein anomaly. Eur J Cardiothorac Surg 2020; 58:957-963. [PMID: 32463872 PMCID: PMC8244831 DOI: 10.1093/ejcts/ezaa139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 03/18/2020] [Accepted: 03/20/2020] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES The purpose of this study is to review the short- and long-term outcomes of high-risk neonates with Ebstein anomaly treated with a newly developed rapid 2-stage Starnes procedure, which is aimed at reducing the size of the enlarged right side of the heart. METHODS Fifty-two foetuses with Ebstein anomaly were analysed in this study and divided into 2 groups. The control group comprised 25 foetuses, referred to us before 2008, and the study group was composed of 27 foetuses, referred to us after 2009. The right atrial area index was defined as high risk when it was >1.5. We applied our management approach to 6 high-risk neonates in the study group. This approach consisted of reducing the size of the right side of the heart through a 2-stage process: (i) right atrial plication without the use of a bypass and (ii) a Starnes procedure. Cox proportional hazards models were used to evaluate the effects of our management approach on the survival rates of the neonates. RESULTS The mean follow-up period was 7.5 ± 3.3 years. All 6 high-risk neonates in the study group survived. The overall hazard ratio was 0.12 (95% confidence interval of 0.03–0.43) in the study group as compared with the control group (P = 0.0007). A Fontan operation was completed in all but 1 case, with the remaining case awaiting a Fontan operation. CONCLUSIONS We suggest that a rapid 2-stage Starnes approach can be effective in the treatment of high-risk neonates with Ebstein anomaly.
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Affiliation(s)
- Toshihide Asou
- Department of Cardiovascular Surgery, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Motoyoshi Kawataki
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Yuko Takeda
- Department of Cardiovascular Surgery, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Hidetsugu Asai
- Department of Cardiovascular Surgery, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Tsuyoshi Tachibana
- Department of Cardiovascular Surgery, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Katsuaki Toyoshima
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Ki-Sung Kim
- Department of Cardiology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Hideaki Ueda
- Department of Cardiology, Kanagawa Children's Medical Center, Yokohama, Japan
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Pinto NM, Morris SA, Moon-Grady AJ, Donofrio MT. Prenatal cardiac care: Goals, priorities & gaps in knowledge in fetal cardiovascular disease: Perspectives of the Fetal Heart Society. PROGRESS IN PEDIATRIC CARDIOLOGY 2020; 59:101312. [PMID: 33100800 PMCID: PMC7568498 DOI: 10.1016/j.ppedcard.2020.101312] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/12/2020] [Indexed: 12/15/2022]
Abstract
Perinatal cardiovascular care has evolved considerably to become its own multidisciplinary field of care. Despite advancements, there remain significant gaps in providing optimal care for the fetus, child, mother, and family. Continued advancement in detection and diagnosis, perinatal care and delivery planning, and prediction and improvement of morbidity and mortality for fetuses affected by cardiac conditions such as heart defects or functional or rhythm disturbances requires collaboration between the multiple types of specialists and providers. The Fetal Heart Society was created to formalize and support collaboration between individuals, stakeholders, and institutions. This article summarizes the challenges faced to create the infrastructure for advancement of the field and the measures the FHS is undertaking to overcome the barriers to support progress in the field of perinatal cardiac care. Progress in perinatal cardiology is challenged by the rarity of fetal cardiac disease, care variation, and barriers to collaboration. The Fetal Heart Society was founded to formalize collaboration between the multiple disciplines in perinatal cardiac care. The FHS facilitates interdisciplinary multicenter research, education and advocacy to provide optimal perinatal cardiac care.
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Affiliation(s)
- Nelangi M Pinto
- Division of Cardiology, Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, UT, United States of America.,Fetal Heart Society, United States of America
| | - Shaine A Morris
- Division of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States of America.,Fetal Heart Society, United States of America
| | - Anita J Moon-Grady
- Division of Cardiology, Department of Pediatrics, University of California San Francisco and UCSF Benioff Children's Hospitals, United States of America
| | - Mary T Donofrio
- Division of Cardiology, Department of Pediatrics, Children's National Hospital and George Washington University School of Medicine and Health Sciences, United States of America.,Fetal Heart Society, United States of America
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59
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Rydzewska K, Sylwestrzak O, Krekora M, Słodki M, Respondek-Liberska M. Ebstein's anomaly: epidemiological analysis and presentation of different prenatal management. J Matern Fetal Neonatal Med 2020; 35:3297-3304. [PMID: 32933366 DOI: 10.1080/14767058.2020.1818207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To present the crucial role of echocardiographic examination in perinatal care and analyze influence of prenatal treatment for neonatal outcome. Furthermore, the attempt to answer the question if there was any relationship between the occurrence of fetal Ebstein's anomaly and environmental risk factors in polish population. METHODS Forty-five prenatal diagnoses of Ebstein's anomaly were compiled over the 21-year period (1998‒2018) form our single unit. The analysis included the assessment of maternal parameters (age, past obstetric history, and place of residence) and fetal parameters (sex, gestational age, anatomy, the fetal cardiovascular condition assessed by the CVPS, associated extracardiac anomalies or malformations, prenatal treatment, delivery and follow-up). RESULTS The average age of gravida was 29.5 years (± 5.2 years) and gravidae <35 years of age accounted for 80% . There were 43 singleton pregnancies and 2 cases of multiple pregnancy. Ebstein's anomaly was mostly (averagely) diagnosed at 28th week of gestation. Forty-three fetuses had normal karyotypes and two had trisomy 21. Cardiomegaly was present in 91% (41) of fetuses. The average heart area to chest area ratio was 0.56 (± 0.12). In 21 cases, there was only fetal monitoring - echocardiographic examinations and postnatal mortality was 44.4%. In 5 cases, transplacental digoxin treatment was administered and mortality was: 40%. In another 5 cases, only steroid therapy was applied and postnatal mortality was 100%. Steroids and transplacental digoxin treatment were administered in 11 cases and mortality was 63.6%. In 3 last cases transplacental digoxin treatment, steroids and maternal hyperoxygenation therapy were given and mortality was 0%. Cesarean section rate was 49%. Moreover, due to Ebstein's anomaly regional peak of occurrence benzopyrene was deliberated as environmental risk factor. CONCLUSIONS Fetal Ebstein's anomaly occurred in our population in healthy young women, expecting their first child and malformation was not related to fetus gender, nor to maternal health condition. Our data can be a new signal for the development of novel treatment strategies in therapy in fetuses with Ebstein's anomaly.
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Affiliation(s)
| | | | - Michał Krekora
- Department of Obstetrics and Gynaecology, Polish Mother's Memorial Hospital, Lodz, Poland
| | - Maciej Słodki
- Faculty of Health Sciences, The State University of Applied Sciences, Plock, Poland.,Department of Prenatal Cardiology, Polish Mother's Memorial Hospital-Research Institute, Lodz, Poland
| | - Maria Respondek-Liberska
- Department of Prenatal Cardiology, Polish Mother's Memorial Hospital-Research Institute, Lodz, Poland.,Department of Diagnosis and Prevention of Fetal Malformations, Medical University of Lodz, Lodz, Poland
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Asoglu MR, Turan OM, Seger L, Kochan M, Turan S. Middle cerebral artery pulsatility index as possible predictive marker for neonatal death in fetuses with tricuspid valve malformation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:552-554. [PMID: 31483895 DOI: 10.1002/uog.20862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/21/2019] [Accepted: 08/23/2019] [Indexed: 06/10/2023]
Affiliation(s)
- M R Asoglu
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - O M Turan
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - L Seger
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - M Kochan
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - S Turan
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
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61
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Ebstein's anomaly in the neonate. Indian J Thorac Cardiovasc Surg 2020; 37:17-25. [PMID: 33603283 DOI: 10.1007/s12055-020-00942-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 01/26/2020] [Accepted: 02/24/2020] [Indexed: 10/24/2022] Open
Abstract
Ebstein's anomaly is a rare congenital heart defect characterized by apical displacement of the tricuspid valve and reduced volume of the true functional right ventricle. In its most severe form, the disease presents as right heart failure and cyanosis in the neonate. Although many of these neonates can be managed conservatively, surgical intervention may become necessary in the sickest of them. Surgical intervention in this subgroup can be challenging and requires meticulous appreciation of the anatomy and physiology on a case to case basis. Multicenter studies are required to define a uniform algorithm and approach towards these patients.
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Masoller N, Gómez Del Rincón O, Herraiz I, Gómez-Montes E, Soveral I, Pérez-Cruz M, Martínez-Biosques C, Granados MA, Bennasar M, Escobar-Diaz MC, Martínez JM, Galindo A. Prediction of Perinatal Mortality in Ebstein's Anomaly Diagnosed in the Second Trimester of Pregnancy. Fetal Diagn Ther 2020; 47:604-614. [PMID: 32018269 DOI: 10.1159/000504979] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 11/25/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Firstly, to describe the outcome of a series of fetuses with Ebstein's anomaly (EA) and, secondly, to study the utility of different second-trimester echocardiographic parameters to predict fetal and neonatal mortality. METHODS 39 fetuses with EA diagnosed between 18 and 28 weeks of gestation were included. Fetal echocardiography included the cardiothoracic ratio (CTR); right atrial (RA) area index; displacement of the tricuspid valve (TV); tricuspid regurgitation; pulmonary artery; and ductus arteriosus flow characteristics. Additionally, 2 novel parameters were obtained: the relative RA area ratio (RA area/cardiac area) and the TV displacement index (TVDI, TV displacement distance/longi-tudinal diameter of the left ventricle). Correlation between the echocardiographic variables and the primary outcome of perinatal mortality or survival at 1 year of life was evaluated. RESULTS From the initial cohort, 8 cases were excluded due to complex congenital heart defects. Termination of pregnancy (TOP) was performed in 15 cases, and fetal death was diagnosed in 3 cases. In the live-born cohort of 13 patients, 4 died in the neonatal period, yielding a perinatal survival rate of 29 and 56%, respectively, after excluding TOP cases. Compared with survivors, nonsurvivors showed a significantly higher CTR (56.7 ± 16.2 vs. 42.6 ± 8.6; p = 0.04), relative RA area ratio (0.39 ± 0.13 vs. 0.25 ± 0.05; p = 0.01), and TVDI (0.62 ± 0.17 vs. 0.44 ± 0.12; p = 0.03) at diagnosis. The best model to predict perinatal mortality was obtained by using a scoring system which included the relative RA area ratio and TVDI (AUC 0.905 [95% CI 0.732-1.000]). CONCLUSIONS Fetuses with a relative RA area ratio ≥0.29 and TVDI ≥0.65 at the second trimester have the highest risk of dying in the perinatal stage.
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Affiliation(s)
- Narcís Masoller
- BCNatal Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Olga Gómez Del Rincón
- BCNatal Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain, .,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain,
| | - Ignacio Herraiz
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynecology, University Hospital 12 de Octubre, 12 de Octubre Research Institute (imas12), Complutense University of Madrid, Madrid, Spain
| | - Enery Gómez-Montes
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynecology, University Hospital 12 de Octubre, 12 de Octubre Research Institute (imas12), Complutense University of Madrid, Madrid, Spain
| | - Iris Soveral
- BCNatal Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Miriam Pérez-Cruz
- BCNatal Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Concepción Martínez-Biosques
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynecology, University Hospital 12 de Octubre, 12 de Octubre Research Institute (imas12), Complutense University of Madrid, Madrid, Spain
| | - Miguel Angel Granados
- Pediatric Heart Institute, Department of Pediatrics, University Hospital 12 de Octubre, Madrid, Spain
| | - Mar Bennasar
- BCNatal Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Josep María Martínez
- BCNatal Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Center for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain
| | - Alberto Galindo
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynecology, University Hospital 12 de Octubre, 12 de Octubre Research Institute (imas12), Complutense University of Madrid, Madrid, Spain
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63
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Torigoe F, Ishida H, Ishii Y, Ishii R, Narita J, Kawazu Y, Kayatani F, Inamura N. Fetal echocardiographic prediction score for perinatal mortality in tricuspid valve dysplasia and Ebstein's anomaly. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:226-232. [PMID: 31008542 DOI: 10.1002/uog.20302] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/12/2019] [Accepted: 04/15/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES Tricuspid valve dysplasia (TVD) and Ebstein's anomaly (EA) diagnosed by fetal echocardiography vary greatly in terms of clinical severity and prognosis. The Celermajer index and Simpson-Andrews-Sharland (SAS) score have been reported previously for the prediction of prognosis in cases of TVD/EA; however, they do not take into account the hemodynamic impact of left ventricular (LV) function, which has recently been implicated as being important in the pathophysiology of TVD/EA. The aim of this study was to develop a novel scoring system that includes LV function for the prediction of perinatal death in fetuses diagnosed with TVD/EA. METHODS The clinical records of 36 fetuses diagnosed prenatally with TVD/EA between 2000 and 2015 in our hospital were reviewed. Univariate analysis was used to assess the association between perinatal death (defined as death between 22 weeks' gestation and 4 weeks after delivery) and gestational age at diagnosis, cardiothoracic area ratio (CTAR), degree of pulmonary artery flow, direction of ductal flow, right-to-left ventricular diameter ratio, tricuspid regurgitation (TR) maximum velocity, Celermajer index, SAS score and LV-Tei index. A new prognostic score, the TRIPP score (TRIcuspid malformation Prognosis Prediction score), was developed using the parameters found to be associated significantly with perinatal death. The predictive value of this score was assessed in an additional nine fetuses diagnosed with TVD/EA. RESULTS Thirty-six fetuses were diagnosed prenatally with TVD/EA, two of which were terminated, one was lost to follow-up and two died before 22 weeks' gestation. Of the 31 included fetuses, 10 (32%) died in the perinatal period. Univariate analysis demonstrated that TR maximum velocity was significantly lower (2.22 ± 0.17 m/s vs 3.26 ± 0.12 m/s; P < 0.001) and SAS score was significantly higher (5.7 ± 0.6 points vs 2.8 ± 0.4 points; P = 0.0014) in cases of perinatal death than in surviving fetuses. The degree of pulmonary artery flow and the direction of ductal flow were also associated significantly with perinatal death (P < 0.01 for both). Notably, LV-Tei index was significantly higher in cases of perinatal death than in surviving fetuses (0.81 ± 0.08 vs 0.50 ± 0.05; P < 0.001). In contrast, there was no significant difference in Celermajer index, CTAR or right-to-left ventricular diameter ratio. Finally, we established a novel combinatorial scoring system, the TRIPP score, including the four significant factors: TR maximum velocity, pulmonary artery flow, direction of ductal flow and LV-Tei index. The TRIPP score was found to predict efficiently perinatal mortality in fetuses with TVD/EA. CONCLUSIONS Our novel combinatorial score of echocardiographic parameters, the TRIPP score, including LV-Tei index, is easy to measure and provides a good tool for the prediction of perinatal mortality in fetuses diagnosed prenatally with TVD/EA. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- F Torigoe
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
- Pediatric Cardiology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - H Ishida
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
- Pediatric Cardiology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Y Ishii
- Pediatric Cardiology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - R Ishii
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
- Pediatric Cardiology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - J Narita
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
- Pediatric Cardiology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Y Kawazu
- Pediatric Cardiology, Osaka Women's and Children's Hospital, Osaka, Japan
- Department of Pediatrics, Toyonaka Municipal Hospital, Osaka, Japan
| | - F Kayatani
- Pediatric Cardiology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - N Inamura
- Pediatric Cardiology, Osaka Women's and Children's Hospital, Osaka, Japan
- Department of Pediatrics, Kindai University Faculty of Medicine, Osaka, Japan
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64
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Khatib N, Gover A, Beloosesky R, Ginsberg Y, Weiner Z, Eigenberg S, Bronshtein M. Early prenatal diagnosis of tricuspid valve dysplasia. J Matern Fetal Neonatal Med 2020; 35:410-413. [PMID: 31990249 DOI: 10.1080/14767058.2020.1718643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To report our experience in early prenatal diagnosis of six cases of tricuspid valve dysplasia (TVD) and to delineate echocardiographic features. METHODS This was a retrospective study which included all the women who attended our clinic for early fetal screening sonography, between 2001 and 2018. The ultrasound screening was done at 11-16 weeks of gestation, and included an anatomic fetal scan and Doppler imaging. The diagnosis of TVD was done based on sonographic features visualized on four chamber view and color mapping of the valve. Complete fetal echocardiography was carried out to rule out additional heart malformations. RESULTS Out of 34,933 early prenatal transvaginal ultrasound screening examinations, six cases of TVD were diagnosed. Five of the pregnancies were terminated as per parental request, and one fetus was delivered at term and died shortly after birth. In three fetuses a chromosomal analysis was performed, one had trisomy 21, one had an abnormal CGH, and the third had a normal karyotype. In two fetuses an autopsy was performed and the diagnosis of TVD was confirmed in both. CONCLUSION Early prenatal detection of TVD is possible and may aid in parental counseling. Larger studies, examining the outcome of TVD should be considered.
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Affiliation(s)
- Nizar Khatib
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Ayala Gover
- Neonatal Intensive Care Unit, Carmel Medical Center, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ron Beloosesky
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Yuval Ginsberg
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Zeev Weiner
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | | | - Moshe Bronshtein
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel.,Faculty of Social Welfare & Health Sciences, University of Haifa, Haifa, Israel
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Eckerström F, Eriksson P, Dellborg M, Lappas G, Rosengren A, Hjortdal VE, Mandalenakis Z. Mortality burden in patients born with Ebstein’s anomaly: a 40-year nationwide cohort study. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2020; 7:312-319. [DOI: 10.1093/ehjqcco/qcz069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 12/20/2019] [Accepted: 01/02/2020] [Indexed: 11/14/2022]
Abstract
Abstract
Aims
Survival rates for unoperated patients with Ebstein’s anomaly (EA) are unknown. We estimated overall long-term mortality in operated and unoperated EA patients, compared with the general population in Sweden.
Methods and results
Using national medical registries, Swedish individuals born 1970–93 and diagnosed with EA between 1970 and 2011 were included. The hazard ratio for overall mortality for EA patients (n = 216) vs. the matched comparison cohort (n = 2160) was 43.7 [95% confidence interval (CI): 24.8–82.5]. Mortality risk for EA patients (vs. controls) decreased as birth period progressed, with hazard ratios declining from 63.6 (95% CI: 26.3–191.8) for those born in the 1970s to 34.4 (95% CI: 15.8–83.1) for those born in the 1980s and 20.2 (95% CI: 1.6–632.5) for those born at the beginning of 1990s. The overall mortality hazard ratios for unoperated and operated patients with EA (vs. controls) were 30.2 (95% CI: 13.8–73.3) and 63.7 (95% CI: 28.1–172.5), respectively. The risk of mortality among unoperated EA patients (vs. controls) declined with progressing birth period, with hazard ratios declining from 58.4 (95% CI: 15.1–415.2) in the 1970s to 22.9 (95% CI: 8.0–75.3) in the 1980s and 10.2 (95% CI: 0.3–395.9) in the 1990s.
Conclusion
Overall all-cause mortality for patients with EA declined dramatically from 64 times to 20 times that of controls without EA, from the 1970s to the early 1990s. Unoperated patients with EA had better survival than did operated patients, possibly reflecting the higher severity of disease or more severe associated cardiac defects in patients undergoing surgery.
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Affiliation(s)
- Filip Eckerström
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensen Boulevard 99, DK-8200 Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensen Boulevard 99, DK-8200 Aarhus, Denmark
| | - Peter Eriksson
- Adult Congenital Heart Unit, Department of Medicine, Sahlgrenska University Hospital, Diagnosvägen 11, SE-41650 Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Blå䲴råket 5B, SE-41345 Gothenburg, Sweden
| | - Mikael Dellborg
- Adult Congenital Heart Unit, Department of Medicine, Sahlgrenska University Hospital, Diagnosvägen 11, SE-41650 Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Blå䲴råket 5B, SE-41345 Gothenburg, Sweden
| | - Georgios Lappas
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Blå䲴råket 5B, SE-41345 Gothenburg, Sweden
| | - Annika Rosengren
- Adult Congenital Heart Unit, Department of Medicine, Sahlgrenska University Hospital, Diagnosvägen 11, SE-41650 Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Blå䲴råket 5B, SE-41345 Gothenburg, Sweden
| | - Vibeke Elisabeth Hjortdal
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensen Boulevard 99, DK-8200 Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensen Boulevard 99, DK-8200 Aarhus, Denmark
| | - Zacharias Mandalenakis
- Adult Congenital Heart Unit, Department of Medicine, Sahlgrenska University Hospital, Diagnosvägen 11, SE-41650 Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Blå䲴råket 5B, SE-41345 Gothenburg, Sweden
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66
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Agarwal P, Agarwal R. Prenatally diagnosed case of tricuspid valve dysplasia: A case report with review of the literature. Indian J Radiol Imaging 2019; 29:452-456. [PMID: 31949352 PMCID: PMC6958872 DOI: 10.4103/ijri.ijri_463_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 08/31/2019] [Accepted: 10/23/2019] [Indexed: 11/04/2022] Open
Abstract
We present a case of fetal tricuspid valve dysplasia (TVD) and pulmonary atresia, diagnosed during a routine obstetric ultrasound scan. Serial fetal echocardiographic evaluations revealed progressively augmented prodigious thickening of the tricuspid valvular and subvalvular structures, which eventually extensively obliterated the right ventricle cavity. Thickened dysplastic valve displayed a "cotton-wool" appearance. Unusual configurations of three vessels in the three-vessel view were also observed on a consecutive gray scale and color Doppler scans. During pregnancy, the fetus exhibited satisfactory growth parameters, and complications of progressive hemodynamic compromise associated with TVD and pulmonary atresia such as grievous hydrops or arrhythmia did not develop till 39 weeks of gravidity.
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Affiliation(s)
- Prateek Agarwal
- Department of Radiodiagnosis, Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India
| | - Rajesh Agarwal
- Department of Ultrasound, Meera Hospital, Shiv Marg, Bani Park, Jaipur, Rajasthan, India
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67
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Rato J, R Sousa A, Teixeira A, Anjos R. Ebstein's anomaly with 'reversible' functional pulmonary atresia. BMJ Case Rep 2019; 12:12/12/e229809. [PMID: 31888914 DOI: 10.1136/bcr-2019-229809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present the case of an infant with prenatal diagnosis, at 32 weeks gestation, of Ebstein's anomaly without anterograde flow from right ventricular to pulmonary atresia (PA)-functional PA with flow reversal in the ductus arteriosus. Prostaglandin E1 was started after birth. Chest X-ray showed severe cardiomegaly and echocardiogram confirmed Ebstein's anomaly with a thickened non-opening pulmonary valve without anterograde flow but with mild regurgitation. Multidisciplinary team decision was to progressively reduce prostaglandins and have an expectant attitude. Peripheral oxygen saturation above 85% was maintained and serial echocardiograms documented progressive reduction of the ductus arteriosus and the opening of the pulmonic valve cusps, with the development of anterograde flow. The newborn was discharged at day 19 of life without the need for any intervention, and at last follow-up remains asymptomatic, with anterograde normal flow in the pulmonary valve.
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Affiliation(s)
- João Rato
- Pediatric Cardiology, Centro Hospitalar de Lisboa Ocidental EPE, Carnaxide, Lisboa, Portugal
| | - Ana R Sousa
- Pediatric Cardiology, Centro Hospitalar de Lisboa Ocidental EPE, Carnaxide, Lisboa, Portugal
| | - Ana Teixeira
- Pediatric Cardiology, Centro Hospitalar de Lisboa Ocidental EPE, Carnaxide, Lisboa, Portugal
| | - Rui Anjos
- Pediatric Cardiology, Hospital Santa Cruz, Carnaxide, Portugal
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68
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Marini D, Xu J, Sun L, Jaeggi E, Seed M. Current and future role of fetal cardiovascular MRI in the setting of fetal cardiac interventions. Prenat Diagn 2019; 40:71-83. [PMID: 31834624 DOI: 10.1002/pd.5626] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 11/01/2019] [Accepted: 11/04/2019] [Indexed: 12/11/2022]
Abstract
Over recent years, technical developments resulting in the feasibility of fetal cardiovascular magnetic resonance (CMR) have provided a new diagnostic tool for studying the human fetal heart and circulation. During the same period, we have witnessed the arrival of several minimally invasive fetal cardiac interventions (FCI) as a possible form of treatment in selected congenital heart diseases (CHDs). The role of fetal CMR in the planning and monitoring of FCI is not yet clear. Indeed, high-quality fetal CMR is not available or routinely offered at most centers caring for patients with prenatally detected CHD. However, in theory, fetal CMR could have much to offer in the setting of FCI by providing complementary anatomic and physiologic information relating to the specific intervention under consideration. Similarly, fetal CMR may be useful as an alternative imaging modality when ultrasound is hampered by technical limitations, for example, in the setting of oligohydramnios and in late gestation. In this review, we summarize current experience of the use of fetal CMR in the diagnosis and monitoring of fetuses with cardiopathies in the setting of a range of invasive in utero cardiac and vascular interventions and medical treatments and speculate about future directions for this versatile imaging medium.
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Affiliation(s)
- Davide Marini
- Division of Pediatric Cardiology, Department of Pediatrics, University of Toronto and Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jiawei Xu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Toronto and Hospital for Sick Children, Toronto, Ontario, Canada
| | - Liqun Sun
- Division of Pediatric Cardiology, Department of Pediatrics, University of Toronto and Hospital for Sick Children, Toronto, Ontario, Canada
| | - Edgar Jaeggi
- Division of Pediatric Cardiology, Department of Pediatrics, University of Toronto and Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mike Seed
- Division of Pediatric Cardiology, Department of Pediatrics, University of Toronto and Hospital for Sick Children, Toronto, Ontario, Canada
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69
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Pruetz JD, Wang SS, Noori S. Delivery room emergencies in critical congenital heart diseases. Semin Fetal Neonatal Med 2019; 24:101034. [PMID: 31582282 DOI: 10.1016/j.siny.2019.101034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Transition from fetal to postnatal life is a complex process. Even in the absence of congenital heart disease, about 4-10% of newborns require some form of assistance in the delivery room. Neonates with complex congenital heart disease should be expected to require significant intervention and thus the resuscitation team must be well prepared for such a delivery. Prenatal assessment including fetal and maternal health in general and detailed information on fetal heart structure, function and hemodynamics in particular are crucial for planning the delivery and resuscitation. In addition, understanding the impact of cardiac structural anomaly and associated altered blood flow on early postnatal transition is essential for success of resuscitation in the delivery room. In this article, we will briefly review transitional circulation focusing on altered hemodynamics of the complex congenital heart diseases and then discuss the process of preparing for these high-risk deliveries. Finally, we will review the pathophysiology resulting from the cardiac structural anomaly with resultant altered fetal circulation and discuss delivery room management of specific critical congenital heart diseases.
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Affiliation(s)
- Jay D Pruetz
- Heart Institute, Division of Cardiology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States; Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Shuo Sue Wang
- Heart Institute, Division of Cardiology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Shahab Noori
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA United States.
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70
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Eckersley LG, Howley LW, van der Velde ME, Khoo NS, Mah K, Brooks P, Colen T, Hornberger LK. Quantitative Assessment of Left Ventricular Dysfunction in Fetal Ebstein's Anomaly and Tricuspid Valve Dysplasia. J Am Soc Echocardiogr 2019; 32:1598-1607. [PMID: 31551185 DOI: 10.1016/j.echo.2019.07.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Fetal Ebstein's anomaly and tricuspid valve dysplasia (EA/TVD) are associated with high perinatal mortality relative to pulmonary atresia with intact ventricular septum (PAIVS), despite both requiring redistribution of the cardiac output (CO) to the left ventricle (LV). LV dysfunction is suspected to contribute to adverse outcomes in EA/TVD. OBJECTIVE We sought to examine global and segmental LV function in fetal EA/TVD with comparison to normal controls and PAIVS. We hypothesized that LV dysfunction in EA/TVD is associated with abnormal LV remodeling and interventricular mechanics. METHODS We retrospectively identified 63 cases of fetal EA/TVD (40 with retrograde ductal flow) and 22 cases of PAIVS encountered from 2004 to 2015 and compared findings to 77 controls of comparable gestational age. We measured the combined CO and global LV function using two-dimensional, Doppler-derived, deformational (six-segmental vector velocity imaging) and dyssynchrony indices (DIs; SD of time to peak), and a novel global DI. RESULTS EA/TVD fetuses demonstrated abnormal LV global systolic function with reduced ejection fraction, fractional area change, and CO, while in PAIVS we observed a normal ejection fraction, fractional area change, and CO. PAIVS, but not EA/TVD, demonstrated increased LV sphericity, suggestive of remodeling, and associated enhanced radial function in the third trimester. In contrast, while EA/TVD fetuses had normal LV segmental longitudinal strain, there was abnormal radial segmental deformation and LV dyssynchrony with increased SD of time to peak and DI. CONCLUSIONS Fetal EA/TVD is associated with a lack of spherical remodeling and presence of mechanical dyssynchrony, which likely contribute to reduced CO and ejection fraction. Clinical monitoring of LV function is warranted in fetal EA/TVD. Further studies incorporating quantification of LV function into prediction models for adverse outcomes are required.
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Affiliation(s)
- Luke G Eckersley
- Division of Cardiology, Department of Pediatrics, Fetal and Neonatal Cardiology Program, Women's and Children Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Lisa W Howley
- Division of Cardiology, Department of Pediatrics, University of Colorado, Denver, Colorado
| | - Mary E van der Velde
- Division of Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Nee S Khoo
- Division of Cardiology, Department of Pediatrics, Fetal and Neonatal Cardiology Program, Women's and Children Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Kandice Mah
- Division of Cardiology, Department of Pediatrics, Fetal and Neonatal Cardiology Program, Women's and Children Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Paul Brooks
- Division of Cardiology, Department of Pediatrics, Fetal and Neonatal Cardiology Program, Women's and Children Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Timothy Colen
- Division of Cardiology, Department of Pediatrics, Fetal and Neonatal Cardiology Program, Women's and Children Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Lisa K Hornberger
- Division of Cardiology, Department of Pediatrics, Fetal and Neonatal Cardiology Program, Women's and Children Health Research Institute, University of Alberta, Edmonton, Alberta, Canada.
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71
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Torigoe T, Mawad W, Seed M, Ryan G, Marini D, Golding F, VAN Mieghem T, Jaeggi E. Treatment of fetal circular shunt with non-steroidal anti-inflammatory drugs. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:841-846. [PMID: 30381862 DOI: 10.1002/uog.20169] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 08/24/2018] [Accepted: 10/19/2018] [Indexed: 06/08/2023]
Abstract
A circular shunt (CS) is a life-threatening condition involving massive shunting of systemic arterial blood via the ductus arteriosus to the left ventricle without traversing the lungs. In the prenatal setting, it occurs mainly in fetuses with severe forms of Ebstein's anomaly (EA) owing to unrestricted ductal flow and significant pulmonary and tricuspid regurgitation. We aimed to improve the fetal hemodynamics and chances of survival of affected fetuses by inducing ductal constriction using transplacental non-steroidal anti-inflammatory drugs (NSAIDs). Following initiation of treatment between 26 and 34 weeks' gestation, three (75%) of four fetuses with EA/CS responded with sustained ductal constriction and improved hemodynamic function, which allowed continuation of pregnancy for 3-7 weeks and elective delivery. All successfully treated cases underwent neonatal surgery immediately after birth to eliminate the CS and survived. This included two neonates that underwent single-ventricle palliation surgery that required postoperative extracorporeal membrane oxygenation and hemofiltration for transient respiratory and renal failure. The one case that did not respond to treatment with NSAIDs was delivered prematurely for progressive fetal compromise and died shortly after birth. Transplacental treatment with NSAIDs represents a novel approach to controlling fetal CS, avoiding in-utero death and prolonging the pregnancy to a more advanced gestational age, thereby potentially increasing the chances of neonatal survival. This treatment should be considered and initiated at an early stage of systemic steal to prevent brain injury due to hypoperfusion. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- T Torigoe
- Fetal Cardiac Program, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - W Mawad
- Fetal Cardiac Program, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Canada
- Diagnostic Imaging Program, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - M Seed
- Fetal Cardiac Program, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Canada
- Diagnostic Imaging Program, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - G Ryan
- Fetal Medicine Unit, Department of Obstetrics & Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - D Marini
- Diagnostic Imaging Program, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - F Golding
- Fetal Cardiac Program, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - T VAN Mieghem
- Fetal Medicine Unit, Department of Obstetrics & Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - E Jaeggi
- Fetal Cardiac Program, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Canada
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72
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Miyoshi T, Katsuragi S, Neki R, Kurosaki KI, Shiraishi I, Nakai M, Nishimura K, Yoshimatsu J, Ikeda T. Cardiovascular profile and biophysical profile scores predict short-term prognosis in infants with congenital heart defect. J Obstet Gynaecol Res 2019; 45:1268-1276. [PMID: 30977251 DOI: 10.1111/jog.13970] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/23/2019] [Indexed: 11/29/2022]
Abstract
AIM To predict the prognosis of infants with congenital heart disease, accurate prenatal diagnosis of structural abnormality and heart failure are both necessary. The aim of this study was to investigate whether cardiovascular profile (CVP) and biophysical profile (BP) scores are useful for predicting prognosis in infants with congenital heart defect (CHD). METHODS A retrospective review of singletons prenatally diagnosed with CHD at a tertiary pediatric cardiac center between 2011 and 2015 was undertaken. RESULTS A total of 202 patients with CHD were analyzed. Perinatal and infant deaths occurred in 16 (7.9%) and 10 cases (5.0%), respectively. Infants with the last CVP score ≤ 5 had 18.7-fold higher perinatal mortality than those with a last CVP score > 5 (P < 0.01). Infants with a last BP score ≤ 6 had 18.7-fold higher perinatal mortality than those with a last BP score > 6 (P < 0.01). Infants with a CVP score decrease in utero had 4.5-fold higher infant mortality than those with an increase or no change (P < 0.01). Multivariate analysis showed that single-ventricle physiology, pre-term birth at <37 weeks of gestation, last CVP score ≤ 5, and last BP score ≤ 6 were independent predictors of perinatal mortality. Single-ventricle physiology and a CVP score decrease were independent predictors of infant mortality. CONCLUSION CVP and BP scores are useful for predicting perinatal prognosis in infants with CHD. A CVP score decrease in utero is associated with infant mortality, suggesting that serial CVP score assessment may be useful for management planning.
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Affiliation(s)
- Takekazu Miyoshi
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Obstetrics and Gynecology, Mie University, Tsu, Japan
| | - Shinji Katsuragi
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Reiko Neki
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Ken-Ichi Kurosaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Isao Shiraishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Michikazu Nakai
- Department of Statistics and Data Analysis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kunihiro Nishimura
- Department of Statistics and Data Analysis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Jun Yoshimatsu
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University, Tsu, Japan
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73
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Qureshi MY, Sommer RJ, Cabalka AK. Tricuspid Valve Imaging and Intervention in Pediatric and Adult Patients With Congenital Heart Disease. JACC Cardiovasc Imaging 2019; 12:637-651. [DOI: 10.1016/j.jcmg.2018.10.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 10/04/2018] [Accepted: 10/18/2018] [Indexed: 12/18/2022]
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74
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Philip S, Philip S, Thampi L, Bharati S. Prenatal diagnosis of ebstein's anomaly: An autopsy correlation predicting poor prognosis. JOURNAL OF THE INDIAN ACADEMY OF ECHOCARDIOGRAPHY & CARDIOVASCULAR IMAGING 2019. [DOI: 10.4103/jiae.jiae_22_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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75
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Dias Moreira AS, Grint K, Stepien R, Shaw G, Peek S. Tricuspid valve dysplasia and a patent foramen ovale resulting in severe tricuspid regurgitation and right-heart dilation in a Red Angus calf. J Vet Cardiol 2018; 21:28-33. [PMID: 30797442 DOI: 10.1016/j.jvc.2018.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 10/12/2018] [Accepted: 10/26/2018] [Indexed: 11/25/2022]
Abstract
A two-month-old Red Angus heifer calf presented to the University of Wisconsin Veterinary Care for evaluation of suspected severe bronchopneumonia. Pertinent physical exam findings included tachycardia, tachypnea, dyspnea with a significant abdominal component, and cyanotic mucous membranes. On thoracic auscultation, wheezes were present bilaterally, as well as a grade 2/6 right apical systolic murmur. Thoracic radiographs revealed cardiomegaly, most severely affecting the right side. Echocardiography showed tricuspid valve dysplasia, resulting in severe tricuspid regurgitation and right-heart dilation, as well as a patent foramen ovale. A postmortem examination confirmed the presence of the aforementioned cardiac abnormalities and revealed only mild pulmonary changes. This case report is the first to describe tricuspid dysplasia in the absence of multiple, complex congenital cardiac abnormalities in a calf, and it highlights the value of echocardiography for an antemortem diagnosis.
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Affiliation(s)
- A S Dias Moreira
- Department of Medical Sciences, School of Veterinary Medicine, University of Wisconsin-Madison, 2015 Linden Drive, Madison, WI 53706, USA.
| | - K Grint
- Department of Medical Sciences, School of Veterinary Medicine, University of Wisconsin-Madison, 2015 Linden Drive, Madison, WI 53706, USA
| | - R Stepien
- Department of Medical Sciences, School of Veterinary Medicine, University of Wisconsin-Madison, 2015 Linden Drive, Madison, WI 53706, USA
| | - G Shaw
- Department of Pathobiological Sciences, School of Veterinary Medicine, University of Wisconsin-Madison, 2015 Linden Drive, Madison, WI 53706, USA
| | - S Peek
- Department of Medical Sciences, School of Veterinary Medicine, University of Wisconsin-Madison, 2015 Linden Drive, Madison, WI 53706, USA
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76
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Voges I, Al-Mallah MH, Scognamiglio G, Di Salvo G. Right Heart-Pulmonary Circulation Unit in Congenital Heart Diseases. Heart Fail Clin 2018; 14:283-295. [PMID: 29966627 DOI: 10.1016/j.hfc.2018.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The right ventricle plays a major role in congenital heart disease. This article describes the right ventricular mechanics in some selected congenital heart diseases affecting the right ventricle in different ways: tetralogy of Fallot, Ebstein anomaly, and the systemic right ventricle.
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Affiliation(s)
- Inga Voges
- Royal Brompton and Harefield Trust, London, UK
| | - Mouaz H Al-Mallah
- National Guard Health Affairs, Riyadh King Abdulaziz Cardiac Center, Riyadh, Saudi Arabia
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77
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Abstract
Evaluation of fetal cardiac function is one of the most important components of fetal echocardiography. Fetal cardiac dysfunction is closely linked to risk of intrauterine fetal demise, in many, but not all cases is indicative of worse postnatal prognosis and may prompt the use of medications or interventions to optimize outcomes. There may be implications for termination versus continuation of pregnancy, an indication for early delivery, a change in location and even mode of delivery. In extreme cases, fetal cardiac dysfunction may prompt prenatal or early neonatal listing for cardiac transplantation. There are several important differences between the fetal and postnatal circulatory physiology which affect echocardiographic assessment of cardiac dysfunction. In this review, we examine the echocardiographic findings according to their underlying pathophysiology with reference to common causes.
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Affiliation(s)
- Luke Eckersley
- Fetal & Neonatal Cardiology Program, Echocardiography Laboratory, Division of Cardiology, Departments of Pediatrics, Women & Children's Health Research, Mazankowski Alberta Heart Institutes, and Cardiovascular Research Centre, University of Alberta, Edmonton, AB, Canada
| | - Lisa K Hornberger
- Fetal & Neonatal Cardiology Program, Echocardiography Laboratory, Division of Cardiology, Departments of Pediatrics, Women & Children's Health Research, Mazankowski Alberta Heart Institutes, and Cardiovascular Research Centre, University of Alberta, Edmonton, AB, Canada.,Departments of Obstetrics & Gynecology, Women & Children's Health Research, Mazankowski Alberta Heart Institutes, and Cardiovascular Research Centre, University of Alberta, Edmonton, AB, Canada
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78
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Geerdink LM, Delhaas T, Helbing WA, du Marchie Sarvaas GJ, Heide HT, Rozendaal L, de Korte CL, Peer PGM, Kuipers IM, Kapusta L. Paediatric Ebstein's anomaly: how clinical presentation predicts mortality. Arch Dis Child 2018; 103:859-863. [PMID: 29567665 DOI: 10.1136/archdischild-2017-313482] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 02/20/2018] [Accepted: 02/24/2018] [Indexed: 01/20/2023]
Abstract
BACKGROUND Forecasting the prognosis of a child when diagnosed with Ebstein's anomaly is difficult. We, therefore, studied which factors at the time of diagnosis are associated with death during childhood. METHODS All consecutive patients (0-18 years) diagnosed with Ebstein's anomaly in the Netherlands between 1980 and 2014 were included. Survival curves were obtained using the Kaplan-Meier method. By using the Cox proportional hazard model, we analysed the factors (at diagnosis) that were associated with death. RESULTS We included 176 patients. Thirty-one patients (18%) died before the age of 18 years. The 1-year survival was 84% and remained stable at 82% from 35 months after diagnosis and onwards. Modified Ross Heart Failure Class 4 at the time of diagnosis was the most important risk factor for death during childhood (HR 12.5, 95% CI 4.4 to 35.9). Furthermore, diagnosis in the neonatal period (HR 4.2, 95% CI 1.5 to 12.0), severe tricuspid valve regurgitation (HR 2.4, 95% CI 1.2 to 5.0), severe right ventricular outflow tract obstruction (HR 3.7, 95% CI 1.8 to 7.7) and a patent ductus arteriosus (HR 2.8, 95% CI 1.3 to 6.0) at the time of diagnosis were univariately associated with death. Multivariable analysis showed that presentation with Heart Failure Class 4 and a ventricular septal defect is the strongest predictor of death in childhood and adolescence. CONCLUSION Patients with Ebstein's anomaly presenting with Heart Failure Class 4 and a ventricular septal defect have a high risk of death during childhood.
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Affiliation(s)
- Lianne M Geerdink
- Department of Paediatric Cardiology, Amalia Children's Hospital, Radboud University Medical Centre, Nijmegen, The Netherlands.,Department of Paediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Tammo Delhaas
- Department of Paediatric Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Willem A Helbing
- Department of Paediatric Cardiology, Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Gideon J du Marchie Sarvaas
- Centre for Congenital Heart Diseases, Beatrix Children's Hospital, University Medical Centre Groningen, Groningen, The Netherlands
| | - Henriette Ter Heide
- Department of Paediatric Cardiology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Lieke Rozendaal
- Department of Paediatric Cardiology, Willem Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
| | - Chris L de Korte
- Medical Ultrasound Imaging Centre, Department of Radiology and Nuclear Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Petronella G M Peer
- Department of Biostatistics, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Irene M Kuipers
- Department of Paediatric Cardiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Livia Kapusta
- Department of Paediatric Cardiology, Amalia Children's Hospital, Radboud University Medical Centre, Nijmegen, The Netherlands.,Department of Paediatrics, Paediatric Cardiology Unit, Tel Aviv Sourasky Medical Centre, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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79
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Alvarez SGV, McBrien A. Ductus arteriosus and fetal echocardiography: Implications for practice. Semin Fetal Neonatal Med 2018. [PMID: 29530740 DOI: 10.1016/j.siny.2018.03.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The ductus arteriosus (DA) is a crucial part of the fetal circulation, both in the normal fetus and in critical congenital heart disease (CHD). It allows shunting between the pulmonary and systemic circulations. In physiological prenatal conditions, the DA lets the majority of right ventricular output bypass the fluid-filled, high-resistance lungs. The DA can cause hemodynamic compromise in the fetus and neonate when constricted or absent (in isolation or in patients with CHD) and may lead to pre- or postnatal sequelae within other systems when forming part of a vascular ring. In CHD, the DA can be interrogated by fetal echocardiography to infer information regarding severity of pulmonary outflow tract obstruction, adequacy of the sub-pulmonary ventricle to supply pulmonary blood flow, and to predict the likelihood of atrial septum restriction in transposition of the great arteries. A good understanding of the DA is crucial for fetal cardiologists.
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Affiliation(s)
- Silvia G V Alvarez
- Fetal and Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada; Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil
| | - Angela McBrien
- Fetal and Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada.
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80
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Abstract
OBJECTIVES Pediatric cardiac intensive care continues to evolve, with rapid advances in knowledge and improvement in clinical outcomes. In the past, the Board of Directors of the Pediatric Cardiac Intensive Care Society created and subsequently updated a list of sentinel references focused on the care of critically ill children with congenital and acquired heart disease. The objective of this article is to provide clinicians with a compilation and brief summary of updated and useful references that have been published since 2012. DATA SELECTION Pediatric Cardiac Intensive Care Society members were solicited via a survey sent out between March 20, 2017, and April 28, 2017, to provide important references that have impacted clinical care. The survey was sent to approximately 523 members. Responses were received from 45 members, of which some included multiple references. DATA EXTRACTION Following review of the list of references, and removing editorials, references were compiled by the first and last author. The final list was submitted to members of the society's Research Briefs Committee, who ranked each publication. DATA SYNTHESIS Rankings were compiled and the references with the highest scores included. Research Briefs Committee members ranked the articles from 1 to 3, with one being highly relevant and should be included and 3 being less important and should be excluded. Averages were computed, and the top articles included in this article. The first (K.C.U.) and last author (K.M.G.) reviewed and developed summaries of each article. CONCLUSIONS This article contains a compilation of useful references for the critical care of children with congenital and acquired heart disease published in the last 5 years. In conjunction with the prior version of this update in 2012, this article may be used as an educational reference in pediatric cardiac intensive care.
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81
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Sanapo L, Pruetz JD, Słodki M, Goens MB, Moon-Grady AJ, Donofrio MT. Fetal echocardiography for planning perinatal and delivery room care of neonates with congenital heart disease. Echocardiography 2017; 34:1804-1821. [DOI: 10.1111/echo.13672] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Laura Sanapo
- Division of Fetal and Transitional Medicine; Children's National Health System; George Washington University; Washington DC USA
| | - Jay D. Pruetz
- Division of Cardiology; Children's Hospital Los Angeles; Keck School of Medicine; University of Southern California; Los Angeles CA USA
| | - Maciej Słodki
- Department of Prenatal Cardiology; Polish Mother's Memorial Hospital Research Institute; Lodz Poland
- Faculty of Health Sciences; The State University of Applied Sciences; Plock Poland
| | - M. Beth Goens
- Special Delivery Service; Pediatric Cardiology; University of New Mexico; Albuquerque NM USA
| | - Anita J. Moon-Grady
- Division of Cardiology; Department of Pediatrics; UCSF Benioff Children's Hospital; San Francisco CA USA
| | - Mary T. Donofrio
- Division of Fetal and Transitional Medicine; Children's National Health System; George Washington University; Washington DC USA
- Fetal Heart Program; Division of Cardiology; Children's National Health System; Washington DC USA
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82
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Bravo-Valenzuela NJ, Peixoto AB, Araujo Júnior E. Prenatal diagnosis of congenital heart disease: A review of current knowledge. Indian Heart J 2017; 70:150-164. [PMID: 29455772 PMCID: PMC5903017 DOI: 10.1016/j.ihj.2017.12.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 12/10/2017] [Accepted: 12/13/2017] [Indexed: 01/16/2023] Open
Abstract
This article reviews important features to improve the diagnosis of congenital heart disease (CHD) by applying ultrasound in prenatal cardiac screening. As low and high-risk pregnancies for CHD are subject to routine obstetric ultrasound, the diagnosis of structural heart defects represents a challenge that involves a team of specialists and subspecialists on fetal ultrasonography. In this review, the images highlight normal anatomy of the heart as well as pathologic cases consistent with cardiac malposition and isomerism, septal defects, pulmonary stenosis/atresia, aortic malformations, hypoplastic left ventricle, conotruncal anomalies, tricuspid dysplasia, and Ebstein’s anomaly, and univentricular heart, among other congenital cardiovascular defects. Anatomical details of most CHD in fetuses were provided by two-dimensional (2D) ultrasound with higher quality imaging, enhancing diagnostic accuracy in a variety of CHD. Moreover, the accuracy of the cardiac defects in obstetrics ultrasound improves the outcome of most CHD, providing planned delivery, aided genetic counseling, and perinatal management.
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Affiliation(s)
| | - Alberto Borges Peixoto
- Department of Obstetrics, Paulista School of Medicine - Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil; Mário Palmério University Hospital, University of Uberaba (UNIUBE), Uberaba, MG, Brazil
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine - Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil.
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83
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Parikh LI, Grantz KL, Iqbal SN, Huang CC, Landy HJ, Fries MH, Reddy UM. Neonatal outcomes in fetuses with cardiac anomalies and the impact of delivery route. Am J Obstet Gynecol 2017; 217:469.e1-469.e12. [PMID: 28578168 DOI: 10.1016/j.ajog.2017.05.049] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 05/14/2017] [Accepted: 05/22/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND Congenital fetal cardiac anomalies compromise the most common group of fetal structural anomalies. Several previous reports analyzed all types of fetal cardiac anomalies together without individualized neonatal morbidity outcomes based on cardiac defect. Mode of delivery in cases of fetal cardiac anomalies varies greatly as optimal mode of delivery in these complex cases is unknown. OBJECTIVE We sought to determine rates of neonatal outcomes for fetal cardiac anomalies and examine the role of attempted route of delivery on neonatal morbidity. STUDY DESIGN Gravidas with fetal cardiac anomalies and delivery >34 weeks, excluding stillbirths and aneuploidies (n = 2166 neonates, n = 2701 cardiac anomalies), were analyzed from the Consortium on Safe Labor, a retrospective cohort study of electronic medical records. Cardiac anomalies were determined using International Classification of Diseases, Ninth Revision codes and organized based on morphology. Neonates were assigned to each cardiac anomaly classification based on the most severe cardiac defect present. Neonatal outcomes were determined for each fetal cardiac anomaly. Composite neonatal morbidity (serious respiratory morbidity, sepsis, birth trauma, hypoxic ischemic encephalopathy, and neonatal death) was compared between attempted vaginal delivery and planned cesarean delivery for prenatal and postnatal diagnosis. We used multivariate logistic regression to calculate adjusted odds ratio for composite neonatal morbidity controlling for race, parity, body mass index, insurance, gestational age, maternal disease, single or multiple anomalies, and maternal drug use. RESULTS Most cardiac anomalies were diagnosed postnatally except hypoplastic left heart syndrome, which had a higher prenatal than postnatal detection rate. Neonatal death occurred in 8.4% of 107 neonates with conotruncal defects. Serious respiratory morbidity occurred in 54.2% of 83 neonates with left ventricular outflow tract defects. Overall, 76.3% of pregnancies with fetal cardiac anomalies underwent attempted vaginal delivery. Among patients who underwent attempted vaginal delivery, 66.1% had a successful vaginal delivery. Women with a fetal cardiac anomaly diagnosed prenatally were more likely to have a planned cesarean delivery than women with a postnatal diagnosis (31.7 vs 22.8%; P < .001). Planned cesarean delivery compared to attempted vaginal delivery was not associated with decreased composite neonatal morbidity for all prenatally diagnosed (adjusted odds ratio, 1.67; 95% confidence interval, 0.85-3.30) or postnatally diagnosed (adjusted odds ratio, 0.99; 95% confidence interval, 0.77-1.27) cardiac anomalies. CONCLUSION Most fetal cardiac anomalies were diagnosed postnatally and associated with increased rates of neonatal morbidity. Planned cesarean delivery for prenatally diagnosed cardiac anomalies was not associated with less neonatal morbidity.
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84
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Pruetz JD, Votava-Smith JK, Chmait HR, Korst LM, Llanes A, Chmait RH. Recipient Twin Circular Shunt Physiology Before Fetal Laser Surgery: Survival and Risks for Postnatal Right Ventricular Outflow Tract Obstruction. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:1595-1605. [PMID: 28370096 DOI: 10.7863/ultra.16.08038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 11/07/2016] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To evaluate risk for congenital heart disease (CHD) in recipient twins with circular shunt physiology (CSP). METHODS This prospective study enrolled twin-twin transfusion syndrome (TTTS) cases from 2006 to 2015. Fetal echocardiography (FE) was performed before laser surgery when cardiac involvement was suspected. Diagnosis of recipient twin CSP required tricuspid and pulmonary regurgitation, right ventricular dysfunction, and flow reversal in the ductus arteriosus. Outcomes were assessed at 30 days after birth. RESULTS Of the 496 TTTS pregnancies, 20 (4%) met the criteria for CSP. Among those born alive, who had documented cardiac outcomes (n = 457), patients with CSP were more likely to have CHD, specifically right ventricular outflow tract obstruction (5 of 18 [27.8%] versus 22 of 439 [5.0%], odd ratio [OR] 7.29, 95% confidence interval [CI] 2.05-24.72, P = .0025). Of the recipient twins with preoperative FE (n = 259, 52%) who were born alive and had documented cardiac outcomes (n = 242), those with CSP were still more likely to have right ventricular outflow tract obstruction (5 of 18 [27.8%] versus 14 of 224 [6.3%], OR 5.77, CI 1.54-20.92, P = .0077). With both analyses, twins with CSP had higher Quintero stage, but similar patient characteristics and 30-day mortality compared with those without CSP. Subgroup analyses of the CSP cohort identified no differences in preoperative characteristics or FE findings predictive of CHD. CONCLUSIONS Recipient twins with preoperative CSP were at increased risk for postnatal right ventricular outflow tract obstruction, but appeared to have comparable survival after fetal laser surgery despite these dramatic pathophysiological prenatal findings. Preoperative FE in TTTS remains important for prediction of postnatal CHD.
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Affiliation(s)
- Jay D Pruetz
- Division of Pediatric Cardiology, Children's Hospital Los Angeles, University of Southern California, Los Angeles, California, USA
- Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jodie K Votava-Smith
- Division of Pediatric Cardiology, Children's Hospital Los Angeles, University of Southern California, Los Angeles, California, USA
| | - Hikmat R Chmait
- Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Lisa M Korst
- Childbirth Research Associates, North Hollywood, California, USA
| | - Arlyn Llanes
- Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ramen H Chmait
- Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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85
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Howley LW, Khoo NS, Moon-Grady AJ, Patel SS, Alrais F, Tworetzky W, Colen T, Brooks P, Trines J, Ojala T, Hornberger LK. Right Atrial Dysfunction in the Fetus with Severely Regurgitant Tricuspid Valve Disease: A Potential Source of Cardiovascular Compromise. J Am Soc Echocardiogr 2017; 30:579-588. [DOI: 10.1016/j.echo.2017.01.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Indexed: 11/28/2022]
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86
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Huang SC, Wu ET, Chen SJ, Huang CH, Shih JC, Chou HW, Chang CI, Chiu IS, Chen YS. Surgical Strategy Toward Biventricular Repair for Severe Ebstein Anomaly in Neonates and Infancy. Ann Thorac Surg 2017; 104:917-925. [PMID: 28434546 DOI: 10.1016/j.athoracsur.2017.01.081] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 01/17/2017] [Accepted: 01/18/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Neonates with severe forms of Ebstein anomaly present a surgical challenge, and the Starnes operation as single ventricle palliation is highly advocated. Cone reconstruction for tricuspid valvuloplasty (TVP) has become a widely accepted technique, although very few cases of TVP have been reported in neonates. This report describes a surgical strategy for neonatal Ebstein anomaly, with an aim toward biventricular repair. METHODS Since 2007, 7 neonates or young infants with severe Ebstein anomalies have received TVP at the National Taiwan University Hospital, Taipei, Taiwan. The principle of cone reconstruction was applied with mobilization of all three leaflets and reattachment to the normal tricuspid annulus. The atrialized right ventricle was not plicated. In patients with pulmonary stenosis, the interatrial communication was not totally closed (n = 5), and a systemic-pulmonary shunt was added if needed (n = 3). RESULTS All patients presented with intractable heart failure or severe cyanosis requiring mechanical ventilation, or both. All patients had marked adherence of the anterior leaflet to the right ventricular free wall. Intracardiac anomalies including ventricular septal defect (n = 2) and tetralogy of Fallot (n = 1) were also repaired simultaneously. Six of the 7 patients (86%) survived. There were no late deaths or repeat TVPs for a median follow-up of 4.3 years (range, 0.8 to 9.9 years). CONCLUSIONS Reconstruction of the tricuspid valve is an acceptable surgical strategy in patients with severe neonatal Ebstein anomaly. Fenestrated atrial septal defect and systemic-pulmonary shunt can help overcome anatomic pulmonary stenosis and high pulmonary resistance in the neonatal period. This surgical strategy has a good survival outcome and preserves the possibility of complete biventricular repair.
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Affiliation(s)
- Shu-Chien Huang
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
| | - En-Ting Wu
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shyh-Jye Chen
- Department of Medical Imaging, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chi-Hsiang Huang
- Department of Anesthesiology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jin-Chung Shih
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hen-Wen Chou
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chung-I Chang
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ing-Sh Chiu
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yih-Sharng Chen
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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87
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Cua CL, Haque U, Santoro S, Nicholson L, Backes CH. Differences in mortality characteristics in neonates with Down's syndrome. J Perinatol 2017; 37:427-431. [PMID: 28079865 DOI: 10.1038/jp.2016.246] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 10/19/2016] [Accepted: 12/01/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Neonates with Down's syndrome (nDS) may have multiple medical issues that place them at increased risk for mortality during the newborn period. Goal of this study was to determine if there are differences in baseline characteristics, medical complications or procedures performed during hospitalization between nDS who survived versus those who died during initial hospitalization. STUDY DESIGN Data from 2000 to 2014 were reviewed using the Pediatric Health Information Systems (PHIS) database on all DS patients admitted to the hospital <30 days postnatal life. Baseline demographics, medical complications, procedures performed and mortality were recorded. Patients were divided into nDS patients who were discharged alive (nDS-a) versus nDS patients who died (nDS-d). Multivariate logistic analysis with odds ratios was performed to determine significant predictors of death. A P<0.05 was considered significant. RESULTS A total of 5737 nDS were evaluated. Overall mortality was 7.5% (431/5737). nDS-d were more likely than nDS-a to have a lower birth weight (1.0 (0.9 to 1.0)), presence of a diaphragmatic hernia (6.9 (1.9 to 25.1), or a cardiac diagnosis of a pulmonary venous abnormality (6.8 (1.9 to 24.4)), Ebstein's anomaly (3.2 (1.2 to 8.5)) or left-sided obstructive lesion (2.0 (1.3 to 3.0). nDS-d were more likely to develop hydrops (5.7 (3.5 to 9.5)) and necrotizing enterocolitis (1.7 (1.2 to 2.6)). In addition, nDS-d had significantly higher odds of requiring mechanical ventilation (20.7 (9.9 to 43.1)) or extracorporeal membrane oxygenation (8.7 (4.7 to 16.1)). CONCLUSIONS A number of characteristics, specifically certain cardiac diagnosis, place nDS at increased risk for mortality. Furthermore, development of specific medical complications or need for particular procedures increases the odds for mortality in nDS. Caregivers should be cognizant that they are taking care of a high-risk population nDS with an increased risk for mortality if these variables are present.
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Affiliation(s)
- C L Cua
- Department of Pediatrics, Heart Center, Nationwide Children's Hospital, Columbus Children's Hospital, Columbus, OH, USA
| | - U Haque
- Department of Pediatrics, Heart Center, Nationwide Children's Hospital, Columbus Children's Hospital, Columbus, OH, USA
| | - S Santoro
- Department of Pediatrics, Heart Center, Nationwide Children's Hospital, Columbus Children's Hospital, Columbus, OH, USA
| | - L Nicholson
- Department of Pediatrics, Heart Center, Nationwide Children's Hospital, Columbus Children's Hospital, Columbus, OH, USA
| | - C H Backes
- Department of Pediatrics, Heart Center, Nationwide Children's Hospital, Columbus Children's Hospital, Columbus, OH, USA
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89
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Arunamata A, Axelrod DM, Bianco K, Balasubramanian S, Quirin A, Tacy TA. Chronic antepartum maternal hyperoxygenation in a case of severe fetal Ebstein's anomaly with circular shunt physiology. Ann Pediatr Cardiol 2017; 10:284-287. [PMID: 28928616 PMCID: PMC5594941 DOI: 10.4103/apc.apc_20_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Perinatal mortality remains high among fetuses diagnosed with Ebstein's anomaly of the tricuspid valve. The subgroup of patients with pulmonary valve regurgitation is at particularly high risk. In the setting of pulmonary valve regurgitation, early constriction of the ductus arteriosus may be a novel perinatal management strategy to reduce systemic steal resulting from circular shunt physiology. We report the use of chronic antepartum maternal oxygen therapy for constriction of the fetal ductus arteriosus and modulation of fetal pulmonary vascular resistance in a late presentation of Ebstein's anomaly with severe tricuspid valve regurgitation, reversal of flow in the ductus arteriosus, and continuous pulmonary valve regurgitation.
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Affiliation(s)
- Alisa Arunamata
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - David M Axelrod
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Katherine Bianco
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Stanford University School of Medicine, Stanford, CA 94304, USA
| | - Sowmya Balasubramanian
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Amy Quirin
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Theresa A Tacy
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA 94304, USA
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90
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Luxford JC, Arora N, Ayer JG, Verrall CE, Cole AD, Orr Y, d'Udekem Y, Sholler GF, Winlaw DS. Neonatal Ebstein Anomaly: A 30-year Institutional Review. Semin Thorac Cardiovasc Surg 2017; 29:206-212. [DOI: 10.1053/j.semtcvs.2017.01.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2017] [Indexed: 11/11/2022]
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91
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Assessment of Progressive Pathophysiology After Early Prenatal Diagnosis of the Ebstein Anomaly or Tricuspid Valve Dysplasia. Am J Cardiol 2017; 119:106-111. [PMID: 27793395 DOI: 10.1016/j.amjcard.2016.09.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 09/01/2016] [Accepted: 09/01/2016] [Indexed: 11/21/2022]
Abstract
In fetuses with Ebstein anomaly or tricuspid valve dysplasia (EA/TVD), poor hemodynamic status is associated with worse neonatal outcome. It is not known whether EA/TVD fetuses with more favorable physiology earlier in gestation progress to more severe disease in the third trimester. We evaluated if echocardiographic indexes in EA/TVD fetuses presenting <24 weeks of gestation are reliable indicators of physiologic status later in pregnancy. This multicenter, retrospective study included 51 fetuses presenting at <24 weeks of gestation with EA/TVD and serial fetal echocardiograms ≥4 weeks apart. We designated the following as markers of poor outcome: absence of anterograde flow across the pulmonary valve, pulmonary valve regurgitation, cardiothoracic area ratio >0.48, left ventricular (LV) dysfunction, or tricuspid valve (TV) annulus Z-score >5.6. Median gestational age at diagnosis was 21 weeks (range, 18 to 24). Eighteen fetuses (35%) had no markers for poor hemodynamic status initially, whereas only 7 of these continued to have no markers of poor outcome in the third trimester. Nine of 27 fetuses (33%) with anterograde pulmonary blood flow on the first echocardiogram developed pulmonary atresia; 7 of 39 (18%) developed new pulmonary valve regurgitation. LV dysfunction was present in 2 (4%) patients at <24 weeks but in 14 (37%) later (p <0.001). The TV annulus Z-score and cardiothoracic area both increased from diagnosis to follow-up. In conclusion, progressive hemodynamic compromise was common in this cohort. Our study highlights that care must be taken in counseling before 24 weeks, as the absence of factors associated with poor outcome early in pregnancy may be falsely reassuring.
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92
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Fukami T, Goto M, Matsuoka S, Sorano S, Tohyama A, Yamamoto H, Nakamura S, Matsuoka R, Tsujioka H, Eguchi F. Monochorionic-diamniotic discordant growth in a twin pregnancy with one fetus affected by Ebstein's anomaly of tricuspid leaflets. Clin Case Rep 2016; 4:682-6. [PMID: 27386129 PMCID: PMC4929806 DOI: 10.1002/ccr3.586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 02/12/2016] [Accepted: 05/03/2016] [Indexed: 12/31/2022] Open
Abstract
Our patient was diagnosed as having discordant twin growth with Ebstein's anomaly in the larger fetus. Cardiac function was deteriorated in accordance with progression of gestational age. Our observation indicated cardiac failure of the larger fetus. The most important issue in this situation is management of the timing of delivery.
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Affiliation(s)
- Tatsuya Fukami
- Department of Obstetrics and GynecologyASO Iizuka Hospital3‐83 Yoshio‐machiIizukaFukuoka820‐8505Japan
| | - Maki Goto
- Department of Obstetrics and GynecologyASO Iizuka Hospital3‐83 Yoshio‐machiIizukaFukuoka820‐8505Japan
| | - Sakiko Matsuoka
- Department of Obstetrics and GynecologyASO Iizuka Hospital3‐83 Yoshio‐machiIizukaFukuoka820‐8505Japan
| | - Sumire Sorano
- Department of Obstetrics and GynecologyASO Iizuka Hospital3‐83 Yoshio‐machiIizukaFukuoka820‐8505Japan
| | - Atsushi Tohyama
- Department of Obstetrics and GynecologyASO Iizuka Hospital3‐83 Yoshio‐machiIizukaFukuoka820‐8505Japan
| | - Hiroko Yamamoto
- Department of Obstetrics and GynecologyASO Iizuka Hospital3‐83 Yoshio‐machiIizukaFukuoka820‐8505Japan
| | - Sumie Nakamura
- Department of Obstetrics and GynecologyASO Iizuka Hospital3‐83 Yoshio‐machiIizukaFukuoka820‐8505Japan
| | - Ryoei Matsuoka
- Department of Obstetrics and GynecologyASO Iizuka Hospital3‐83 Yoshio‐machiIizukaFukuoka820‐8505Japan
| | - Hiroshi Tsujioka
- Department of Obstetrics and GynecologyASO Iizuka Hospital3‐83 Yoshio‐machiIizukaFukuoka820‐8505Japan
| | - Fuyuki Eguchi
- Department of Obstetrics and GynecologyASO Iizuka Hospital3‐83 Yoshio‐machiIizukaFukuoka820‐8505Japan
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Kelle AM, Bentley SJ, Rohena LO, Cabalka AK, Olson TM. Ebstein anomaly, left ventricular non-compaction, and early onset heart failure associated with a de novo α-tropomyosin gene mutation. Am J Med Genet A 2016; 170:2186-90. [DOI: 10.1002/ajmg.a.37745] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 05/03/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Angela M. Kelle
- Division of Pediatric Cardiology; Department of Pediatric and Adolescent Medicine; Mayo Clinic; Rochester Minnesota
| | - S. Jared Bentley
- Division of Pediatric Cardiology; Department of Pediatrics; San Antonio Military Pediatric Center; Fort Sam Houston Texas
| | - Luis O. Rohena
- Division of Medical Genetics; Department of Pediatrics; San Antonio Military Medical Center; Fort Sam Houston Texas
| | - Allison K. Cabalka
- Division of Pediatric Cardiology; Department of Pediatric and Adolescent Medicine; Mayo Clinic; Rochester Minnesota
| | - Timothy M. Olson
- Division of Pediatric Cardiology; Department of Pediatric and Adolescent Medicine; Mayo Clinic; Rochester Minnesota
- Division of Cardiovascular Diseases; Department of Internal Medicine; Mayo Clinic; Rochester Minnesota
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Wertaschnigg D, Manlhiot C, Jaeggi M, Seed M, Dragulescu A, Schwartz SM, van Arsdell G, Jaeggi ET. Contemporary Outcomes and Factors Associated With Mortality After a Fetal or Neonatal Diagnosis of Ebstein Anomaly and Tricuspid Valve Disease. Can J Cardiol 2016; 32:1500-1506. [PMID: 27476984 DOI: 10.1016/j.cjca.2016.03.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 03/16/2016] [Accepted: 03/16/2016] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Ebstein anomaly (EA) and tricuspid valve dysplasia (TVD) are rare anomalies and data on outcomes after a fetal or neonatal EA/TVD diagnosis are conflicting. METHODS To examine the outcome and identify markers predictive of mortality, we reviewed our single-centre experience from 2000-2014. Variables were analyzed separately for cases diagnosed in utero without pregnancy termination and for all live-born patients. RESULTS Of 47 fetal cases, 8 (17%) died in utero and 10 (21%) as neonates. Independent predictors associated with fetal demise included severe tricuspid regurgitation with a Doppler gradient < 40 mm Hg (odds ratio, 1.22 per mm Hg deduction; P = 0.003) and pulmonary regurgitation (odds ratio, 11.4; P = 0.03) at the baseline examination. A novel prognostic score (range, 0-10) combining the severity of 5 echocardiographic findings was independently associated with overall mortality (hazard ratio [HR], 1.39 per point increase; P = 0.01). Survival rates of 66 live births at 1 month, 1 year, and 5 years were 86%, 82%, and 80% respectively, and 75%, 60%, and 55% remained free from surgery at the same points in time. Factors associated with postnatal death in multivariate analysis included a younger gestational age at birth (HR per week, 1.59; P < 0.001), tricuspid annulus diameter (HR per z-score increase, 1.76; P = 0.004), and no pulmonary forward flow (HR, 4.63; P = 0.03). CONCLUSIONS Our experience with fetal and neonatal EA/TVD shows better survival rates than previously reported. Mortality after a fetal diagnosis was significantly associated with hemodynamic changes indicative of a circular shunt, including pulmonary and tricuspid regurgitation severe enough to cause diastolic umbilical arterial flow reversal.
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Affiliation(s)
- Dagmar Wertaschnigg
- Labatt Family Heart Center, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Cedric Manlhiot
- Labatt Family Heart Center, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Jaeggi
- Labatt Family Heart Center, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Mike Seed
- Labatt Family Heart Center, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Andreea Dragulescu
- Labatt Family Heart Center, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Steven M Schwartz
- Labatt Family Heart Center, Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Glen van Arsdell
- Labatt Family Heart Center, Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Edgar T Jaeggi
- Labatt Family Heart Center, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
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95
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Sanapo L, Moon-Grady AJ, Donofrio MT. Perinatal and Delivery Management of Infants with Congenital Heart Disease. Clin Perinatol 2016; 43:55-71. [PMID: 26876121 DOI: 10.1016/j.clp.2015.11.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Advances in fetal echocardiography have improved prenatal diagnosis of congenital heart disease (CHD) and allowed better delivery and perinatal management. Some newborns with CHD require urgent intervention after delivery. In these cases, delivery close to a pediatric cardiac center may be considered, and the presence of a specialized cardiac team in the delivery room or urgent transport of the infant should be planned in advance. Delivery planning, monitoring in labor, rapid intervention at birth if needed, and avoidance of iatrogenic preterm delivery have the potential to improve outcomes for infants with prenatally diagnosed CHD.
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Affiliation(s)
- Laura Sanapo
- Division of Fetal and Transitional Medicine, Children's National Health System, 111 Michigan Avenue, Northwest, Suite M3-118, Washington, DC 20010, USA
| | - Anita J Moon-Grady
- Fetal Cardiovascular Program, UCSF Benioff Children's Hospitals, University of California San Francisco, 550 16th Street, 5th Floor, Box 0544, San Francisco, CA 94158, USA
| | - Mary T Donofrio
- Division of Fetal and Transitional Medicine, Children's National Health System, 111 Michigan Avenue, Northwest, Suite M3-118, Washington, DC 20010, USA; Fetal Heart Program, Division of Cardiology, Children's National Health System, 111 Michigan Avenue, Northwest, Washington, DC 20010, USA.
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96
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Abuhamad A, Donofrio MT. The Fetal Heart Society: facilitating multidisciplinary collaborative fetal cardiovascular research. Prenat Diagn 2016; 36:489-91. [PMID: 26918283 DOI: 10.1002/pd.4794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 02/16/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Alfred Abuhamad
- Eastern Virginia Medical School-OB/GYN, Norfolk, 2350, United States
| | - Mary T Donofrio
- Children's National Medical Center, Washington, DC, 20010, United States
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Donofrio MT, Rychik J, Donofrio MT, Moon-Grady AJ, Rychik J, Puchalski MD, Tworetzky W, Cuneo BF, Abuhamad AZ, Ayers NA, Copel JA, Gardiner HM, Golding F, Freud LR, Jaeggi ET, Lee W, Miller S, Morris SA, Peyvandi S, Schidlow DN, Silverman NH. Multidisciplinary Collaboration in Fetal Cardiovascular Research: The Time Has Come. J Am Soc Echocardiogr 2016; 29:140-2. [DOI: 10.1016/j.echo.2015.11.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Indexed: 11/15/2022]
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98
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Morray B. Preoperative Physiology, Imaging, and Management of Ebstein's Anomaly of the Tricuspid Valve. Semin Cardiothorac Vasc Anesth 2015; 20:74-81. [PMID: 26620137 DOI: 10.1177/1089253215616499] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Ebstein's anomaly of the tricuspid valve (TV) refers to an embryological derangement of TV formation causing tethering of the septal and posterior leaflets of the valve to the underlying myocardium and apical displacement of the effective valve annulus, resulting in significant TV insufficiency and dilation of the right heart structures. The pathological abnormalities of the valve can vary significantly, resulting in a wide range of clinical presentations. Fetal diagnosis and neonatal presentations of the disease are typically the most severe and are associated with the highest mortality rates. Patients with less-severe disease will present later in life with symptoms of right heart failure and tachyarrhythmias. Medical and surgical management strategies are driven by the age at presentation, severity of disease, and any associated cardiac abnormalities. There are an increasing number of surgical options focused on valve repair.
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99
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Ross FJ, Latham GJ, Richards M, Geiduschek J, Thompson D, Joffe D. Perioperative and Anesthetic Considerations in Ebstein’s Anomaly. Semin Cardiothorac Vasc Anesth 2015; 20:82-92. [DOI: 10.1177/1089253215605390] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Ebstein’s anomaly is a complex and heterogeneous form of congenital heart disease characterized by malformation and apical displacement of the tricuspid valve leaflets. Patients may present at any time from the neonatal period to adulthood with symptoms ranging from cardiac failure and cyanosis to paroxysmal arrhythmias. Depending on the timing of presentation, various surgical options are available for the management of symptomatic patients. This review will discuss the perioperative and anesthetic management of patients with Ebstein’s anomaly with reference to the more common surgical approaches.
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Affiliation(s)
- Faith J. Ross
- Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Gregory J. Latham
- Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Michael Richards
- Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Jeremy Geiduschek
- Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Douglas Thompson
- Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Denise Joffe
- Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA, USA
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