Audit of 10 years of referrals for fetal echocardiography

Screening performance of congenital heart defects in first trimester using simple cardiac scan, nuchal translucency, abnormal ductus venosus blood flow and tricuspid regurgitation

OBJECTIVE

The objective of this study was to analyze if the addition of simple cardiac scan in cases with increased nuchal translucency (NT) and/or abnormal ductus venosus (DV) blood flow, and/or tricuspid regurgitation (TCR) can improve detection of congenital heart defects (CHD) in chromosomally normal fetuses without non-cardiac defects at 11-13 + 6 gestational weeks in a population of singleton pregnancies.

METHODS

During the 10 years period, all singleton pregnancies at 11-13 + 6 weeks were routinely scanned for NT, DV blood flow and TCR assessment and, if a single of these parameters was abnormal, simple cardiac scan with 2D gray scale and color and/or directional power Doppler in 4-chamber (4-CV) and 3 vessel and trachea views (3VTV) was performed.

RESULTS

The sensitivity and specificity of NT ≥ 95th + DV R/A a-wave + TCR in detecting CHD were 77% and 97%, respectively, and of simple cardiac scan, 67% and 98%, respectively. Area under the curve of receiver operating characteristic curve of NT ≥ 95th + DV R/A a-wave + TCR was 0.838, and of NT ≥ 95th + DV R/A a-wave + TCR + simple cardiac scan was 0.915.

CONCLUSIONS

In chromosomally normal fetuses without non-cardiac anomalies, addition of simple cardiac scan to the combined first trimester screening parameters improves detection of major CHD during first trimester.

Risk Factors for Mortality in Children with Congenital Heart Disease Delivered at a Brazilian Tertiary Center

OBJECTIVE

This study aims to investigate the incidence of postnatal diagnosis of congenital heart disease (CHD) and the predictive factors for hospital mortality.

METHODS

This retrospective cohort study was conducted at a Brazilian tertiary center, and data were collected from medical records with inclusion criteria defined as any newborn with CHD diagnosed in the postnatal period delivered between 2015 and 2017. Univariate and multivariate analyses were performed to determine the potential risk factors for mortality.

RESULTS

During the 3-year period, 119 (5.3%) children of the 2215 children delivered at our institution were diagnosed with CHD. We considered birth weight (P=0.005), 1st min Apgar score (P=0.001), and CHD complexity (P=0.013) as independent risk factors for in-hospital mortality. The most common CHD was ventricular septal defect. Indeed, 60.5% cases were considered as "complex" or "significant" CHDs. Heart surgeries were performed on 38.9% children, 15 of whom had "complex" or "significant" CHD. A mortality rate of 42% was observed in this cohort, with 28% occurring within the initial 24 h after delivery and 38% occurring in patients admitted for heart surgery.

CONCLUSION

The postnatal incidence of CHD at our service was 5.3%. Low 1st min Apgar score, low birth weight, and CHD complexity were the independent factors that affected the hospital outcome.

A review of the diagnostic accuracy of fetal cardiac anomalies

Objectives: In order to assess the diagnostic accuracy of fetal cardiac anomalies in our Department we undertook a retrospective analysis and compared our results with those of the paediatric cardiologists in the same cases.

Methods: Sixty‐five patients referred for second and third trimester fetal echocardiographic examinations were identified in our database from November 2005 to February 2014. Of these six scans were found to be normal by ultrasound and not referred on to the paediatric cardiologist. An additional six scans were diagnosed to have complex congenital heart disease (CHD) with or without extra cardiac abnormalities and/or aneuploidy. These six patients opted for termination of pregnancy and were also not seen by the paediatric cardiologist. The remaining 53 cases were referred to the paediatric cardiologist. Our results were analysed and then compared to the cardiologist's findings. There were an additional three cases scanned during the pregnancy in our department and diagnosed as normal but ultimately found in the neonatal period, to have CHD.

Results: The ultrasound findings of the 53 cases scanned in our department were analysed and compared to the findings in the cardiologist's reports. The earlier scans tended to describe the abnormal anatomy but showed a reluctance to name any pathology. As training and confidence levels increased the less complex pathologies were correctly identified by our department and confirmed by the cardiologist.

Conclusion: The skills, training and level of confidence required to diagnose fetal cardiac anomalies in our Department have improved over the eight years of the study period, particularly in regards to some of the less complex cardiac pathologies. However the more complex pathologies remain difficult to assess.

The value of 3D and 4D assessments of the fetal heart

The objective of this review was to demonstrate the main tools of three- and four-dimensional ultrasonography, using the spatiotemporal image correlation software and its respective applications for assessing the fetal heart and its vascular connections, along with its potential contribution towards screening for congenital heart diseases. Today, conventional, two-dimensional, echocardiography continues to be the gold standard for diagnosing congenital heart diseases. However, recent studies have demonstrated that spatiotemporal image correlation offers some advantages that boost two-dimensional accuracy in detecting congenital heart diseases, given that the fetal heart assessment can be completed in the absence of the patient (offline) and be discussed by different examiners. Additionally, data volumes can be sent for analysis in reference centers via internet links. Spatiotemporal image correlation also enables direct measurement of heart structures in rendering mode, such as the interventricular septum and the annulus of the atrioventricular valves. Furthermore, it enables assessment of cardiac function when used in association with the virtual organ computer-aided analysis software, thus making it possible to calculate the total systolic function, ejection fraction, and cardiac output.

Prenatal detection of congenital heart diseases: one-year survey performing a screening protocol in a single reference center in Brazil

Objective. To describe the experience of a tertiary center in Brazil to which patients are referred whose fetuses are at increased risk for congenital heart diseases (CHDs). Methods. This was a cross-sectional observational study. The data was collected prospectively, during the year 2012, through a screening protocol of the fetal heart adapted from the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) guideline. We performed a fetal echocardiogram screening for all pregnant women who were referred to the fetal cardiology outpatient obstetrics clinic of a university hospital. The exams were classified as normal or abnormal. The cases considered abnormal were undergone to a postnatal echocardiogram. We categorized the abnormal fetal heart according to severity in “complex,” “significant,” “minor,” and “others.” Results. We performed 271 fetal heart screening. The incidence of abnormal screenings was 9.96% (27 fetuses). The structural CHD when categorized due to severity showed 48.1% (n = 13) of “complex” cases, 18.5% (n = 5) “significant” cases, and 7.4% (n = 2) “minor” cases. The most common referral reason was by maternal causes (67%) followed by fetal causes (33%). The main referral indication was maternal metabolic disease (30%), but there was just one fetus with CHD in such cases (1.2%). CHDs were found in 19/29 fetuses with suspicion of some cardiac abnormality by obstetrician (65.5%). Conclusion. We observed a high rate of CHD in our population. We also found that there was higher incidence of complex cases.

Fetal heart disease: severity, associated anomalies and parental decision

OBJECTIVE

This study describes the association between the complexity of congenital cardiac and extracardiac malformations, and the parental decision of pregnancy continuation or termination.

METHODS

Congenital heart defects (CHD) was diagnosed by ultrasound in 251 fetuses before the 24th week (23 + 6 weeks) of gestation during the four year period from 2007 to 2010. All fetuses from the Utrecht region were referred to our center due to a strict referral pattern. The complexity and severity of the cardiac and possible extracardiac malformations were retrospectively categorized by a pediatric cardiologist and a perinatologist who were blinded to the pregnancy outcome. The groups with and without termination of pregnancy were compared using a univariate analysis and multivariate logistic regression.

RESULTS

In 119 (47%) of the 251 fetuses, parents opted for termination of pregnancy. In 103 of these cases (87%) there was a high complex or lethal cardiac, or a major or lethal extracardiac malformation. Of the 132 continued pregnancies, 42 fetuses (32%) had a high complex or lethal cardiac, or a major or lethal extracardiac malformation. There were significantly more terminations of pregnancy in case of a high or lethal complex cardiac or extracardiac anomaly (71 vs. 15%, p <0.001).

CONCLUSION

Parents opted for termination of pregnancy significantly more often in cases with high complex cardiac and extracardiac malformations. It was rare for parents to opt for pregnancy termination in the absence of a severe cardiac or extracardiac malformation.