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St Louis JD, Bhat A, Carey JC, Lin AE, Mann PC, Smith LM, Wilfond BS, Kosiv KA, Sorabella RA, Alsoufi B. The American Association for Thoracic Surgery (AATS) 2023 Expert Consensus Document: Recommendation for the care of children with trisomy 13 or trisomy 18 and a congenital heart defect. J Thorac Cardiovasc Surg 2024; 167:1519-1532. [PMID: 38284966 DOI: 10.1016/j.jtcvs.2023.11.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 11/27/2023] [Accepted: 11/30/2023] [Indexed: 01/30/2024]
Abstract
OBJECTIVES Recommendations for surgical repair of a congenital heart defect in children with trisomy 13 or trisomy 18 remain controversial, are subject to biases, and are largely unsupported with limited empirical data. This has created significant distrust and uncertainty among parents and could potentially lead to suboptimal care for patients. A working group, representing several clinical specialties involved with the care of these children, developed recommendations to assist in the decision-making process for congenital heart defect care in this population. The goal of these recommendations is to provide families and their health care teams with a framework for clinical decision making based on the literature and expert opinions. METHODS This project was performed under the auspices of the AATS Congenital Heart Surgery Evidence-Based Medicine Taskforce. A Patient/Population, Intervention, Comparison/Control, Outcome process was used to generate preliminary statements and recommendations to address various aspects related to cardiac surgery in children with trisomy 13 or trisomy 18. Delphi methodology was then used iteratively to generate consensus among the group using a structured communication process. RESULTS Nine recommendations were developed from a set of initial statements that arose from the Patient/Population, Intervention, Comparison/Control, Outcome process methodology following the groups' review of more than 500 articles. These recommendations were adjudicated by this group of experts using a modified Delphi process in a reproducible fashion and make up the current publication. The Class (strength) of recommendations was usually Class IIa (moderate benefit), and the overall level (quality) of evidence was level C-limited data. CONCLUSIONS This is the first set of recommendations collated by an expert multidisciplinary group to address specific issues around indications for surgical intervention in children with trisomy 13 or trisomy 18 with congenital heart defect. Based on our analysis of recent data, we recommend that decisions should not be based solely on the presence of trisomy but, instead, should be made on a case-by-case basis, considering both the severity of the baby's heart disease as well as the presence of other anomalies. These recommendations offer a framework to assist parents and clinicians in surgical decision making for children who have trisomy 13 or trisomy 18 with congenital heart defect.
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Affiliation(s)
- James D St Louis
- Department of Surgery, Children's Hospital of Georgia, Augusta University, Augusta, Ga.
| | - Aarti Bhat
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, Wash
| | - John C Carey
- Department of Pediatrics, University of Utah Health and Primary Children's Hospital, Salt Lake City, Utah
| | - Angela E Lin
- Department of Pediatrics, Mass General Hospital for Children, Boston, Mass
| | - Paul C Mann
- Department of Surgery, Children's Hospital of Georgia, Augusta University, Augusta, Ga
| | - Laura Miller Smith
- Department of Pediatrics, Oregon Health and Science University, Portland, Ore
| | - Benjamin S Wilfond
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, Wash
| | - Katherine A Kosiv
- Department of Pediatrics, Yale University School of Medicine, New Haven, Conn
| | - Robert A Sorabella
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Ala
| | - Bahaaldin Alsoufi
- Department of Surgery, University of Louisville and Norton Children's Hospital, Louisville, Ky
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Patel SR, Michelfelder E. Prenatal Diagnosis of Congenital Heart Disease: The Crucial Role of Perinatal and Delivery Planning. J Cardiovasc Dev Dis 2024; 11:108. [PMID: 38667726 PMCID: PMC11050606 DOI: 10.3390/jcdd11040108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 03/29/2024] [Accepted: 03/29/2024] [Indexed: 04/28/2024] Open
Abstract
Although most congenital heart defects (CHDs) are asymptomatic at birth, certain CHD lesions are at significant risk of severe hemodynamic instability and death if emergent cardiac interventions are not performed in a timely fashion. Therefore, accurate identification of at-risk fetuses and appropriate delivery resource planning according to the degree of anticipated hemodynamic instability is crucial. Fetal echocardiography has increased prenatal CHD detection in recent years due to advancements in ultrasound techniques and improved obstetrical cardiac screening protocols, enabling the prediction of newborns' hemodynamic status. This assessment can guide multidisciplinary resource planning for postnatal care, including selection of delivery site, delivery room management, and transport to a cardiac center based on CHD risk severity. This review will discuss fetal cardiovascular physiology and the circulatory changes that occur at the time of and immediately following birth, outline fetal echocardiographic findings used to risk-stratify newborns with CHDs, and outline principles for neonatal resuscitation and initial transitional care in neonates with these complex CHD lesions.
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Affiliation(s)
- Sheetal R. Patel
- Ann & Robert H Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Erik Michelfelder
- Children’s Healthcare of Atlanta, Emory School of Medicine, Emory University, Atlanta, GA 30265, USA
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Meliota G, Vairo U. Transcatheter Interventions for Neonates with Congenital Heart Disease: A Review. Diagnostics (Basel) 2023; 13:2673. [PMID: 37627932 PMCID: PMC10453781 DOI: 10.3390/diagnostics13162673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/28/2023] [Accepted: 08/12/2023] [Indexed: 08/27/2023] Open
Abstract
Newborns with congenital heart disease often require interventions linked to high morbidity and mortality rates. In the last few decades, many transcatheter interventions have become the first-line treatments for some critical conditions in the neonatal period. A catheter-based approach provides several advantages in terms of procedural time, length of hospitalization, repeatability and neurodevelopmental issues (usually related to cardiopulmonary bypass). The main transcatheter procedures will be reviewed, as they are now valid alternatives to conventional surgical management.
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Affiliation(s)
- Giovanni Meliota
- Pediatric Cardiology, Giovanni XXIII Pediatric Hospital, 70126 Bari, Italy;
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Tran NN, Tran M, Lemus RE, Woon J, Lopez J, Dang R, Votava-Smith JK. Preoperative Care of Neonates With Congenital Heart Disease. Neonatal Netw 2022; 41:200-210. [PMID: 35840337 DOI: 10.1891/nn-2021-0028] [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: 11/25/2022]
Abstract
Congenital heart disease (CHD) is one of the most common types of birth defects, with 40,000 newborns diagnosed yearly in the United States. This article describes: (1) four common heart defects seen in neonatal intensive care units, (2) the typical medical/nursing care of these neonates, and (3) common surgical management for the defects. Hypoplastic left heart syndrome, dextro-transposition of the great arteries, tetralogy of Fallot, and pulmonary atresia with intact ventricular septum are four common types of CHD requiring NICU admission. Knowledge of these defects will help nurses to appropriately manage and treat neonates with these types of CHD.
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Barry OM, Bouhout I, Turner ME, Petit CJ, Kalfa DM. Transcatheter Cardiac Interventions in the Newborn: JACC Focus Seminar. J Am Coll Cardiol 2022; 79:2270-2283. [PMID: 35654498 DOI: 10.1016/j.jacc.2022.03.374] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/21/2022] [Accepted: 03/30/2022] [Indexed: 11/25/2022]
Abstract
For neonates with critical congenital heart disease requiring intervention, transcatheter approaches for many conditions have been established over the past decades. These interventions may serve to stabilize or palliate to surgical next steps or effectively primarily treat the condition. Many transcatheter interventions have evidence-based records of effectiveness and safety, which have led to widespread acceptance as first-line therapies. Other techniques continue to innovatively push the envelope and challenge the optimal strategies for high-risk neonates with right ventricular outflow tract obstruction or ductal-dependent pulmonary blood flow. In this review, the most commonly performed neonatal transcatheter interventions will be described to illustrate the current state of the field and highlight areas of future opportunity.
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Affiliation(s)
- Oliver M Barry
- Division of Pediatric Cardiology, NewYork-Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, New York, USA
| | - Ismail Bouhout
- Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, NewYork-Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, New York, USA
| | - Mariel E Turner
- Division of Pediatric Cardiology, NewYork-Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, New York, USA
| | - Christopher J Petit
- Division of Pediatric Cardiology, NewYork-Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, New York, USA.
| | - David M Kalfa
- Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, NewYork-Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, New York, USA.
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Słodki M. Dextro-transposition of great vessels: difficult to detect prenatally, one of the most dangerous and one of the best prognosed. Transl Pediatr 2022; 11:783-788. [PMID: 35800282 PMCID: PMC9253946 DOI: 10.21037/tp-22-163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 04/29/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Maciej Słodki
- Faculty of Health Sciences, The Mazovian State University, Plock, Poland.,Department of Prenatal Cardiology, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
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Wong J, Kohari K, Bahtiyar MO, Copel J. Impact of prenatally diagnosed congenital heart defects on outcomes and management. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:646-654. [PMID: 35543387 DOI: 10.1002/jcu.23219] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/13/2022] [Accepted: 04/26/2022] [Indexed: 06/14/2023]
Abstract
Fetal echocardiogram aids in prenatal identification of neonates at high risk for congenital heart defects (CHD). Prenatal detection rates for CHD have increased with improved ultrasound technology, the use of the early fetal echocardiography, and standardization of the performance of the fetal echocardiogram. Accurate prenatal detection of CHD, particularly complex CHD, is an important contributor to improved survival rates for patients with CHD. Early detection allows for families to choose whether or not to continue with pregnancy, referral to pediatric cardiology specialists for patient education, and delivery planning. Better psychosocial supports are needed for families with CHD.
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Affiliation(s)
- Jennifer Wong
- Section of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Katherine Kohari
- Section of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Mert Ozan Bahtiyar
- Section of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Joshua Copel
- Section of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut, USA
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Jadczak A, Respondek-Liberska M, Sokołowski Ł, Chrzanowski J, Rizzo G, Araujo Júnior E, Bravo-Valenzuela NJ, Axt-Fliedner R, Słodki M. Hypoplastic left heart syndrome with prenatally diagnosed foramen ovale restriction: diagnosis, management and outcome. J Matern Fetal Neonatal Med 2022; 35:291-298. [PMID: 31986935 DOI: 10.1080/14767058.2020.1716717] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Despite advances in prenatal diagnosis and postnatal intervention/surgery methods, patients with Hypoplastic Left Heart Syndrome (HLHS) and coexisting foramen oval restriction still achieve high mortality rates. Our objective was to determine survival predictors and to find answers to, why restriction develops in some, but not others. METHODS We performed a retrospective analysis of prenatal history and postnatal sequel of 22 patients with HLHS and foramen ovale restriction between 2008 and 2017. RESULTS There were 11 survivors and 11 nonsurvivors. The most significant difference between the two groups pertained to the average time of foramen ovale restriction diagnosis which was 33 weeks for survivors and 28 weeks for nonsurvivors (p = .0416) and the duration of in-utero restriction (9 versus 5 weeks, p = .0213). Twenty patients (20/22) exhibited possible signs of infection. CONCLUSIONS (1) Earlier development and longer presence of foramen ovale restriction in the setting of HLHS is associated with higher short-term mortality regardless of the degree of restriction. (2) Ratio of forward pulmonary vein flow to reverse flow (f/r) expressed as a velocity-time integral (VTI) is a good emergent intervention predictor, but it does not correlate with foramen ovale size and maximal velocity, nor does it influence survival rates. (3) Ultrasonographic signs of possible infection of the fetus is a potential risk factor of foramen ovale restriction development in patients with HLHS.
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Affiliation(s)
- Anna Jadczak
- Department of Prenatal Cardiology, Polish Mother's Memorial Hospital Research Institute, Lódz, Poland
| | - Maria Respondek-Liberska
- Department of Prenatal Cardiology, Polish Mother's Memorial Hospital Research Institute, Lódz, Poland
- Department of Diagnoses and Prevention of Fetal Malformations, Medical University of Lodz, Lódz, Poland
| | - Łukasz Sokołowski
- Department of Prenatal Cardiology, Polish Mother's Memorial Hospital Research Institute, Lódz, Poland
- Department of Obstetrics and Gynecology, Polish Mother's Memorial Hospital, Lódz, Poland
| | - Jędrzej Chrzanowski
- Department of Prenatal Cardiology, Polish Mother's Memorial Hospital Research Institute, Lódz, Poland
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, Lódz, Poland
| | - Giuseppe Rizzo
- Department of Maternal Fetal Medicine, Ospedale Cristo Re Roma, Università degli Studi di Roma "Tor Vergata", Rome, Italy
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
- Medical Course, Municipal University of São Caetano do Sul (USCS), São Paulo, Brazil
| | | | - Roland Axt-Fliedner
- Department of Obstetrics and Gynecology, Division of Prenatal Medicine, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
| | - Maciej Słodki
- Department of Prenatal Cardiology, Polish Mother's Memorial Hospital Research Institute, Lódz, Poland
- Faculty of Health Sciences, The Mazovian State University in Plock, Poland
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Xi L, Wu C, Pan Z, Xiang M. Emergency surgery without stabilization prior to surgical repair for total anomalous pulmonary venous connection reduces duration of mechanical ventilation without reducing survival. J Cardiothorac Surg 2021; 16:213. [PMID: 34340695 PMCID: PMC8328139 DOI: 10.1186/s13019-021-01559-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 06/08/2021] [Indexed: 11/25/2022] Open
Abstract
Background To examine two different operation timing for treating patients with a total anomalous pulmonary venous connection (TAPVC) who need emergency surgery and to summarize the effects of the two operation strategies. Methods A retrospective review of 54 patients with TAPVC who underwent operations within 72 h of presentation between December 2010 and July 2019 at a single institution was conducted. All patients exhibited respiratory or hemodynamic instability that required mechanical ventilation and inotropic support. Forty-four patients received emergency operations between 24 to 72 h due to stabilization of the patient’s condition. Stable hemodynamics were achieved, and a stable internal milieu was maintained before the operation. These patients comprised the Stable group (SG). Rather than being subjected to efforts to obtain stable hemodynamics and maintain a stable internal milieu, ten patients received emergency operations immediately within 24 h of diagnosis or an emergency operation is performed immediately due to uncorrectable acidosis or progressive cardiovascular collapse. These patients comprised the Unstable group (UG). The hospital course, operative data, and outpatient records were reviewed. Results In SG group, there were 23 exhibited the supracardiac type, 15 exhibited the cardiac type, 4 exhibited the cardiac type, and 2 exhibited the mixed cardiac type,3 patients were premature, the rest was term infant, PDA was the most common comorbidities (28 patients), the next is severe tricuspid valve regurgitation (21 patients). In UG group, there were 3 exhibited the supracardiac type, 4 exhibited the cardiac type, 3 exhibited the cardiac type, and no patient exhibited the mixed cardiac type, only 1 patient was premature, the rest were term infant. PDA (6 patients) and severe tricuspid valve regurgitation (5 patients) were the top two comorbidities. The median weight, median age at surgery, mean cardiopulmonary bypass (CPB) duration and mean aortic cross-clamp (ACC) duration were not significantly different between the two groups. The median postoperation durations of ventilator support were 8.1 ± 4.6 (2–13) days in the SG group and 4.9 ± 2.1 (2–18) days in the UG group, resulting in a significant difference (p = 0.008), the Post-op days in ICU and Days of hospitalization were 8.64 ± 4.04 days and 19.9 ± 4.27 days in the SG group and 5.6 ± 2.01 days and 14.7 ± 1.75 days in the UG group (P = 0.026 and 0.002). There were 12 hospital mortalities (27.3%) in the SG group and 2 hospital mortalities (20%) in the UG group, resulting in no significant difference in mortality (p = 0.636). Postoperative complications, such as low cardiac output and arrhythmia, were not significantly different between the two groups. The survival rates in the UG and SG groups at 5 years were 87.5 and 89.9%, respectively. There was no difference in survival between the two groups at the latest follow-up (SG group 89.9% versus UG group 87.5%, p = 0.8115). Conclusion An emergency operation should be performed immediately without any delay, it can reduce duration of mechanical ventilation and Days of hospitalization without reducing mortality.
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Affiliation(s)
- Linyun Xi
- Department of Cardiothoracic Surgery, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, No.136, Zhongshan 2nd Road, Yuzhong Dis, Chongqing, 400014, China.,Chongqing Key Laboratory of Pediatrics, No.136, Zhongshan 2nd Road, Yuzhong Dis, Chongqing, 400014, China
| | - Chun Wu
- Department of Cardiothoracic Surgery, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, No.136, Zhongshan 2nd Road, Yuzhong Dis, Chongqing, 400014, China.,Chongqing Key Laboratory of Pediatrics, No.136, Zhongshan 2nd Road, Yuzhong Dis, Chongqing, 400014, China
| | - Zhengxia Pan
- Department of Cardiothoracic Surgery, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, No.136, Zhongshan 2nd Road, Yuzhong Dis, Chongqing, 400014, China.,Chongqing Key Laboratory of Pediatrics, No.136, Zhongshan 2nd Road, Yuzhong Dis, Chongqing, 400014, China
| | - Ming Xiang
- Department of Cardiothoracic Surgery, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, No.136, Zhongshan 2nd Road, Yuzhong Dis, Chongqing, 400014, China. .,Chongqing Key Laboratory of Pediatrics, No.136, Zhongshan 2nd Road, Yuzhong Dis, Chongqing, 400014, China.
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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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Liu X, Hong HF, Zhang HB, Xu ZM, Liu JF, Zhang H. Neonatal surgical outcomes after prenatal diagnosis of complex congenital heart disease: experiences of a perinatal integrated diagnosis and treatment program. World J Pediatr 2020; 16:494-501. [PMID: 32815119 DOI: 10.1007/s12519-020-00383-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 07/23/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study aimed to evaluate neonatal surgical outcomes of patients diagnosed with complex congenital heart disease (CHD) during pregnancy and treated by the newly initiated "perinatal integrated diagnosis and treatment program (PIDTP)". METHODS We reviewed clinical data of 207 neonates (surgical age ≤ 28 days) who underwent cardiac surgeries in a single center from January 2017 to December 2018, including 31 patients with referrals from the "PIDTP" (integration group) and 176 patients with routine referral treatment (non-integrated group). RESULTS In the integration group, median admission age was 0 days and median age at surgery was 4 days. In the non-integrated group, median admission age was 8 days (P = 0.001) and median age at surgery was 13 days (P = 0.001). The emergency surgery rate in patients with duct-dependent defects was 36% in the integration group and 59% (P = 0.042) in the non-integrated group, respectively. The in-hospital mortality was 16% in the integration group and 14% (P = 0.78) in the non-integrated group. The 2-year cumulative survival rate after surgery was 83.9% ± 6.6% in the integration group and 80.3% ± 3.1% (P = 0.744) in the non-integrated group. According to multivariable regression analysis, independent risk factors for early mortality of overall neonatal cardiac surgery were low body weight, high serum lactate level, postoperative extracorporeal membrane oxygenation (ECMO) support and prolonged cardiopulmonary bypass (CPB) time. CONCLUSIONS PIDTP shortens the postnatal transit interval, reduces the emergency operation rate of neonatal critical CHD, and provides better preoperative status for surgery. Patients treated by the PIDTP tend to have more complicated anatomical deformity and a greater requirement for the operation and postoperative management, but early outcome and follow-up prognosis are satisfactory.
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Affiliation(s)
- Xu Liu
- Department of Cardiothoracic Surgery, Congenital Heart Center, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200217, China
- Shanghai Institute of Congenital Heart Diseases, National Children's Medical Center, Shanghai, China
| | - Hai-Fa Hong
- Department of Cardiothoracic Surgery, Congenital Heart Center, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200217, China
- Shanghai Institute of Congenital Heart Diseases, National Children's Medical Center, Shanghai, China
| | - Hai-Bo Zhang
- Department of Cardiothoracic Surgery, Congenital Heart Center, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200217, China
| | - Zhuo-Ming Xu
- Department of Cardiothoracic Surgery, Congenital Heart Center, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200217, China
| | - Jin-Fen Liu
- Department of Cardiothoracic Surgery, Congenital Heart Center, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200217, China
- Shanghai Institute of Congenital Heart Diseases, National Children's Medical Center, Shanghai, China
| | - Hao Zhang
- Department of Cardiothoracic Surgery, Congenital Heart Center, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200217, China.
- Shanghai Institute of Congenital Heart Diseases, National Children's Medical Center, Shanghai, China.
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Słodki M, Soroka M, Rizzo G, Respondek-Liberska M. Prenatal Atrioventricular Septal Defect (AVSD) as a planned congenital heart disease with different outcome depending on the presence of the coexisting extracardiac abnormalities (ECA) and/or malformations (ECM). J Matern Fetal Neonatal Med 2020; 33:2635-2641. [PMID: 30514144 DOI: 10.1080/14767058.2018.1556254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Prenatal atrioventricular septal defect (AVSD) on frequent occasions coexists with other cardiac or extracardiac abnormalities or malformation which may change the prognosis and the management with the fetus and the newborn. The aim of the research was to assess the prognosis and the outcome of prenatally diagnosed AVSD based on the classification which also includes coexisting extracardiac abnormalities and malformations as well as its influence on the prenatal consultation.Methods: It was a retrospective analysis of 113 patients with prenatally diagnosed AVSD. The group was selected out of 871 patients with CHD. Out of 113 fetuses with AVSD we exclude those in whom AVSD was coexistent with other cardiac malformations (n = 41). Extracardiac abnormalities [ECA] were defined as problems which do not require surgical intervention after delivery, they were usually markers of a genetic syndrome. Extracardiac malformations [ECM] were defined as problems requiring surgical interventions after delivery or lethal malformations. All 72 fetuses with an isolated AVSD were classified to one of the three groups: (1) Simple AVSD - (sAVSD) - a fetus with isolated AVSD without coexisting ECA and ECM (n = 6), (2) sAVSD + ECA - a fetus with isolated AVSD, with coexisting ECA (n = 28), (3) sAVSD + ECM - a fetus with isolated AVSD, with coexisting ECM (n = 38).Results: The pregnancy from the groups sAVSD + ECM were, in fact, more often referred to the prenatal cardiology centers on account of the existing ECM (p=.03). There were no differences between the two subgroups in regard to: the mean age of the pregnancy, the mean age of the fetus at the time of diagnosis and during diagnostic testing at the referral center, the gender of the fetus. An increased nuchal translucency (NT) was most often found in fetuses from the group AVSD + ECA (n = 13/23), which was connected with more frequent occurrence of abnormal karyotype (p=.048). The trisomy 21 more frequently referred to pregnancy with sAVSD + ECA than those with sAVSD + ECM (p=.0006). In the group sAVSD + ECM there was the highest number of fetuses small for the gestational age detected -48.65% (p=.01). Most often premature deliveries were found in the group sAVSD + ECM (72.73%). The duration of gestation in the group sAVSD + ECM turned out to be much shorter than that in the group with the isolated sAVSD (p=.01) and sAVSD + ECA (p=.03). The lowest Apgar score was in the newborns from the group sAVSD + ECM (p=.002). Longer period of gestation was connected with the higher score on Apgar scale (R = 0.541; p=.001). The average delivery weight of the newborns was the lowest in the group sAVSD + ECM (p=.04). sAVSD + ECM was connected with the significantly higher death rate than the isolated sAVSD (p=.0047) or sAVSD + ECA (p<.00001). The fatality rate of the newborns/ fetuses from the pregnancies lasting less than 37 weeks turned out to be much higher than in the case of the remaining pregnancies (sAVSD p=.002).Conclusions: (1) The majority of fetuses with AVSD remained the patients of just obstetricians and prenatal cardiologists because of highly heterogeneous of the coexisting malformations and abnormalities and since they perish in the period of fetal or neonatal life usually they are not seen by the pediatricians or cardiac surgeons. (2) The classification of the AVSD in fetus to a particular group of the prognostic classification of the fetal heart defects helps to plan perinatal management and supplies information regarding the prognosis. (3) The highest mortality rate was in a group of AVSD + ECM, probably due to shorter time of pregnancy duration, fetuses grow restriction and low Apgar score in 1 minute of life.
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Affiliation(s)
- Maciej Słodki
- Faculty of Health Sciences, the State University of Applied Sciences, Płock, Poland
- Department of Prenatal Cardiology, Polish Mother's Memorial Hospital Research Institute, Lódz, Poland
| | - Małgorzata Soroka
- Faculty of Health Sciences, the State University of Applied Sciences, Płock, Poland
| | - Giuseppe Rizzo
- Department of Maternal Fetal Medicine, Ospedale Cristo Re Roma, Università di Roma Tor Vergata, Italy
- Department of Obstetrics and Gynecology The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Maria Respondek-Liberska
- Department of Prenatal Cardiology, Polish Mother's Memorial Hospital Research Institute, Lódz, Poland
- Department of Diagnoses and Prevention of Fetal Malformations, Medical University of Lodz, Poland
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13
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Słodki M, Rizzo G, Augustyniak A, Seligman NS, Zych-Krekora K, Respondek-Liberska M. Retrospective cohort study of prenatally and postnatally diagnosed coarctation of the aorta (CoA): prenatal diagnosis improve neonatal outcome in severe CoA. J Matern Fetal Neonatal Med 2020; 33:947-951. [PMID: 30185080 DOI: 10.1080/14767058.2018.1510913] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Prenatal diagnosis of congenital heart disease (CHD) leads to improved outcome but not mortality rate. This may not be the case for coarctation of the aorta (CoA). The objective of this study is to estimate the effect of a prenatal diagnosis of CoA by comparing neonates with CoA by the time of diagnosis.Materials and methods: The study included 38 neonates with CoA diagnosed prenatally and 102 neonates diagnosed postnatally. The postnatal group was divided into two subgroups: (1) severe CoA: symptoms of CoA within the first 7 days (n = 43) and (2) mild CoA: symptoms within the 8-28th day (n = 34). The neonates diagnosed more than 28 days after delivery were excluded from the study (n = 25). Severe CoA was defined as CHD diagnosed postnatally with clinical symptoms that presented in the first week after birth. Mild CoA was defined as CHD that presented clinical symptoms later than 7 days of life.Results: Prostaglandins were initiated at lower doses (p < .001) in the prenatal group. Severe postnatal CoA was associated with more frequent Neonatal Intensive Care Unit (NICU) visits than mild postnatal CoA (p = .005). The length of hospitalization of neonates with severe postnatal CoA was 10 days longer than compared to the prenatal group, but the difference was not statistically significant. The highest mortality rate was in the severe postnatal CoA group (18.6%) which was significantly higher than the mortality rate in the prenatal group (p = .005).Conclusion: 1. Prenatal identification of fetuses at increased risk of developing CoA may reduce mortality and improve outcome only in neonates with severe CoA (symptoms of CoA within the first 7 days after birth); 2. Prenatal diagnosis of severe CoA was associated with lower prostaglandin doses and lower mortality rate.
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Affiliation(s)
- Maciej Słodki
- Department of Prenatal Cardiology, Polish Mother Memorial Hospital Research Institute, Lodz, Poland
- Faculty of Health Sciences, The State University of Applied Sciences in Płock, Płock, Poland
| | - Giuseppe Rizzo
- Department of Maternal Fetal Medicine, Università Roma Tor Vergata, Rome, Italy
| | - Anna Augustyniak
- Department of Anesthesiology and Intensive Medical Therapy, Polish Mother Memorial Hospital Research Institute, Lodz, Poland
| | - Neil S Seligman
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Rochester Medical Center, Rochester (NY), USA
| | - Katarzyna Zych-Krekora
- Department of Prenatal Cardiology, Polish Mother Memorial Hospital Research Institute, Lodz, Poland
| | - Maria Respondek-Liberska
- Department of Prenatal Cardiology, Polish Mother Memorial Hospital Research Institute, Lodz, Poland
- Department of Diagnoses and Prevention Fetal Malformations Medical University of Lodz, Lodz, Poland
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14
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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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15
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Weber RW, Stiasny B, Ruecker B, Fasnacht M, Cavigelli-Brunner A, Valsangiacomo Buechel ER. Prenatal Diagnosis of Single Ventricle Physiology Impacts on Cardiac Morbidity and Mortality. Pediatr Cardiol 2019; 40:61-70. [PMID: 30121866 DOI: 10.1007/s00246-018-1961-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 08/10/2018] [Indexed: 10/28/2022]
Abstract
We sought to evaluate the impact of prenatal diagnosis on morbidity and mortality in single ventricle (SV) lesions. All consecutive patients with pre- or postnatally diagnosed SV physiology admitted to our centre between January 2001 and June 2013 were reviewed. Primary endpoints included survival until 30 days after bidirectional cavopulmonary connection (BCPC) without transplant or BCPC takedown. Prenatal diagnosis was performed in 160 of 259 cases (62%). After excluding all cases with termination of pregnancy, intrauterine demise or treated with comfort care, a total of 180 neonates were admitted to our centre for treatment, including 87 with a prenatal and 93 with a postnatal diagnosis. Both groups showed similar distribution regarding diagnosis, dominant ventricle and risk factors such as restrictive foramen or some form of atrial isomerism. A larger proportion of postnatally diagnosed children presented at admission with elevated lactate > 10 mmol/l (p = 0.02), a higher dose of prostaglandin (p = 0.0013) and need for mechanical ventilation (p < 0.0001). Critical lesions such as hypoplastic left heart syndrome were an important determinant for morbidity and mortality. Thirty-days survival after BCPC was better in patients with prenatal diagnosis (p = 0.025). Prenatal diagnosis is associated with higher survival in neonates with SV physiology.
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Affiliation(s)
- Roland W Weber
- Pediatric Heart Centre, University Children's Hospital, Steinwiesstrasse 75, 8032, Zurich, Switzerland. .,Children's Research Centre, Zurich, Switzerland.
| | - Brian Stiasny
- Pediatric Heart Centre, University Children's Hospital, Steinwiesstrasse 75, 8032, Zurich, Switzerland.,Children's Research Centre, Zurich, Switzerland
| | - Beate Ruecker
- Pediatric Heart Centre, University Children's Hospital, Steinwiesstrasse 75, 8032, Zurich, Switzerland.,Children's Research Centre, Zurich, Switzerland
| | | | - Anna Cavigelli-Brunner
- Pediatric Heart Centre, University Children's Hospital, Steinwiesstrasse 75, 8032, Zurich, Switzerland.,Children's Research Centre, Zurich, Switzerland
| | - Emanuela R Valsangiacomo Buechel
- Pediatric Heart Centre, University Children's Hospital, Steinwiesstrasse 75, 8032, Zurich, Switzerland.,Children's Research Centre, Zurich, Switzerland
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16
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Peyvandi S, Donofrio MT. Circulatory Changes and Cerebral Blood Flow and Oxygenation During Transition in Newborns With Congenital Heart Disease. Semin Pediatr Neurol 2018; 28:38-47. [PMID: 30522727 DOI: 10.1016/j.spen.2018.05.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
This review aims to describe how the complex events of cardiovascular transition may affect the brain of infants with congenital heart disease (CHD). In particular, we describe the vulnerabilities of the neonatal brain in the transitional period during and immediately after delivery and propose management strategies that can potentially influence neurodevelopmental outcomes in this patient population. Delayed brain development has been identified in the third trimester fetus with certain forms of CHD. Neonates with critical CHD are at risk for brain injury even before their neonatal operation. The transitional period from fetal to neonatal life is marked with hemodynamic changes that can affect cerebral blood flow and oxygenation and may exacerbate injury and influence outcome. We propose specific perinatal management strategies tailored to maternal-fetal pairs aimed at optimizing hemodynamic stability, especially cerebral blood flow and oxygenation, to maximize the neurodevelopmental potential of infants with CHD.
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Affiliation(s)
- Shabnam Peyvandi
- Division of Pediatric Cardiology, University of California San Francisco, Pediatric Heart Center, Benioff Children's Hospital, San Francisco, CA
| | - Mary T Donofrio
- Division of Cardiology, George Washington University, Children's National Health System, Washington, DC.
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17
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Melekoglu AN, Baspinar O. Transcatheter cardiac interventions in neonates with congenital heart disease: A single centre experience. J Int Med Res 2018; 47:615-625. [PMID: 30373426 PMCID: PMC6381459 DOI: 10.1177/0300060518806111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Objective Percutaneous cardiac catheterization has been used as a diagnostic tool and as a therapeutic option in neonates with congenital heart disease (CHD). This study aimed to evaluate the procedural and short-term follow-up data of newborns who underwent cardiac catheterization procedures. Methods This retrospective study reviewed demographic, diagnostic and clinical data from the medical records of newborns who underwent percutaneous transcatheter interventions to treat CHD. Results Forty-six newborns were included in the study. The median gestational week and weight were 35.0 weeks and 2723 g, respectively. The median time to the procedure was 7.6 days. Aortic and pulmonary balloon valvuloplasty, ductal stenting, atrial balloon/blade septostomy and coronary fistula embolization procedures were used. The overall success rate was 73.9% (34 of 46 patients) with a complication rate of 28.3% (13 of 46 patients). Eleven patients (23.9%) underwent reinterventions after initial catheterization. Five patients (10.9%) died in the first 48 h after their procedures. Conclusions Interventional cardiological procedures applied during the neonatal period provide alternative life-saving methods to surgery, especially in developing countries where surgical outcomes are poor and newborn mortality rates are high.
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Affiliation(s)
- Asli Nuriye Melekoglu
- 1 Department of Paediatrics, Division of Neonatology, Malatya Training and Research Hospital, Malatya, Turkey
| | - Osman Baspinar
- 2 Department of Paediatrics, Division of Paediatric Cardiology, Faculty of Medicine, The University of Gaziantep, Gaziantep, Turkey
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18
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Domadia S, Kumar SR, Votava-Smith JK, Pruetz JD. Neonatal Outcomes in Total Anomalous Pulmonary Venous Return: The Role of Prenatal Diagnosis and Pulmonary Venous Obstruction. Pediatr Cardiol 2018; 39:1346-1354. [PMID: 29796693 DOI: 10.1007/s00246-018-1901-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 05/08/2018] [Indexed: 11/28/2022]
Abstract
The objective of this study is to evaluate neonatal outcomes of total anomalous pulmonary venous return (TAPVR) and identify fetal echocardiography findings associated with preoperative pulmonary venous obstruction (PPVO). This retrospective study evaluated TAPVR cases from 2005 to 2014 for preoperative and postoperative outcomes based on prenatal diagnosis, PPVO, and heterotaxy syndrome. Fetal pulmonary and vertical vein Dopplers were analyzed as predictors of PPVO. Of 137 TAPVR cases, 12% were prenatally diagnosed; 60% had PPVO, and 21% had heterotaxy. Of the prenatally diagnosed patients, 63% also had heterotaxy. TAPVR repair was performed in 135 cases and survival to discharge was 82% (112/137). Heterotaxy was the only independent predictor of mortality on multiple regression analysis [OR 5.5 (CI 1.3-16.7), p = 0.02]. PPVO was associated with preoperative acidosis, need for inhaled nitric oxide, and more emergent surgery, but not postoperative mortality. Fetal vertical vein Doppler peak velocity > 0.74 m/s mmHg predicted PPVO (93% sensitivity; 83% specificity) while pulmonary vein Doppler did not. TAPVR has severe neonatal morbidity and mortality with low prenatal diagnosis rates in the absence of heterotaxy. Patients with obstructed TAPVR had greater preoperative morbidity, but only heterotaxy was independently associated with increased postoperative mortality. Vertical vein velocity helped prenatally identify those at risk of PPVO.
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Affiliation(s)
- Shelly Domadia
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - S Ram Kumar
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Division of Cardiothoracic Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jodie K Votava-Smith
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital Los Angeles, 4650 Sunset Blvd. Mailstop #34, Los Angeles, CA, 90027, USA
| | - Jay D Pruetz
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA. .,Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital Los Angeles, 4650 Sunset Blvd. Mailstop #34, Los Angeles, CA, 90027, USA. .,Department of Obstetrics & Gynecology, University of Southern California, Los Angeles, CA, USA.
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19
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Asoglu MR, Bears B, Turan S, Harman C, Turan OM. The factors associated with mode of delivery in fetuses with congenital heart defects. J Matern Fetal Neonatal Med 2018; 33:816-824. [PMID: 30153755 DOI: 10.1080/14767058.2018.1505855] [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] [Indexed: 10/28/2022]
Abstract
Objective: It is not evident whether the mode of delivery (MOD) should be modified in pregnancies complicated by fetal congenital heart defects (CHDs). The question as to whether MOD of CHD infants has a significant impact on neonatal outcome remains elusive. The aim of this study was to evaluate factors associated with MOD and its impact on immediate neonatal outcomes in a cohort of late preterm or term fetuses with CHDs born in a tertiary center.Methods: This retrospective study comprised of singleton pregnancies with known fetal CHDs who delivered after 34 0/7 weeks of gestation over a 7-year period. Fetuses with chromosomal abnormality or stillbirths were excluded. Obstetric risk factors were classified as maternal medical, maternal surgical or fetal comorbidities. MOD was classified as elective cesarean delivery (CD) or attempted vaginal delivery (VD). The latter was further categorized as successful VD or intrapartum CD. The study population was stratified into four categories based on the severity of cardiac abnormalities diagnosed by fetal echocardiography. Immediate neonatal outcomes included Apgar scores and umbilical cord artery pH.Results: Of a total of 222 patients, 79.8% underwent attempted VD and 20.2% had elective CD. Of the attempted VD group, 80.2% had successful VD and 19.8% had intrapartum CD. The frequencies of maternal medical, maternal surgical and fetal comorbidities were higher in the elective CD group than in the attempted VD group and also were higher in the intrapartum CD group than in the successful VD group (p < .05 for all). Multivariate logistic regression models revealed that maternal surgical or fetal comorbidities increased the chance of elective CD and maternal medical or fetal comorbidities decreased the chance of successful VD. The severity of CHDs was not an independent factor that affected MOD. Elective or intrapartum CD did not improve immediate neonatal outcomes.Conclusion: Our results demonstrated that preexisting obstetric comorbidities were significant variables that affected the MOD in fetuses with CHD. Vaginal delivery should be attempted unless obstetric and medical contraindications accompany index pregnancy.
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Affiliation(s)
- Mehmet Resit Asoglu
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Breanne Bears
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sifa Turan
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Christopher Harman
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ozhan M Turan
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
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20
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Sun HY, Proudfoot JA, McCandless RT. Prenatal detection of critical cardiac outflow tract anomalies remains suboptimal despite revised obstetrical imaging guidelines. CONGENIT HEART DIS 2018; 13:748-756. [PMID: 30022603 PMCID: PMC7953202 DOI: 10.1111/chd.12648] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 05/25/2018] [Accepted: 06/03/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Fetal echocardiography can accurately diagnose critical congenital heart disease prenatally, but relies on referrals from abnormalities identified on routine obstetrical ultrasounds. Critical congenital heart disease that is frequently missed due to inadequate outflow tract imaging includes anomalies such as truncus arteriosus, double outlet right ventricle, transposition of the great arteries, tetralogy of Fallot, pulmonary stenosis, and aortic stenosis. OBJECTIVE This study evaluated the prenatal detection rate of critical outflow tract anomalies in a single urban pediatric hospital before and after "AIUM Practice Guideline for the Performance of Obstetric Ultrasound Examinations," which incorporated outflow tract imaging. DESIGN Infants with outflow tract anomalies who required cardiac catheterization and/or surgical procedure(s) in the first 3 months of life were retrospectively identified. This study evaluated two time periods; pre-guidelines from June 2010 to May 2013 and post-guidelines from January 2015 to June 2016. June 2013-December 2014 was excluded as a theoretical period necessary for obstetrical practices to implement the revised guidelines. RESULTS Overall, prenatal diagnosis occurred in 55% of infants with critical outflow tract anomalies; of the three most common defects, prenatal diagnosis occurred in 53% of D-transposition of the great arteries, 63% of tetralogy of Fallot, and 80% of double outlet right ventricle patients. Pre-guidelines, prenatal diagnosis occurred in 52% (52 of 102) infants with critical outflow tract anomalies requiring early cardiac intervention. Post-guidelines, prenatal diagnosis occurred in 61% (33 of 54) infants, not significantly different than the prenatal detection rate pre-guidelines (P = .31). CONCLUSIONS Despite revised obstetrical guidelines highlighting the importance of outflow tract imaging, referrals and prenatal diagnosis of these types of critical congenital heart disease remain low. Education of obstetrical sonographers and practitioners who perform fetal anatomic screening is vital to increase referrals and prenatal detection of critical outflow tract anomalies.
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Affiliation(s)
- Heather Y Sun
- Division of Pediatric Cardiology, Department of
Pediatrics, Rady Children’s Hospital, University of California, San Diego,
San Diego, CA
| | - James A Proudfoot
- Atman Clinical and Translational Research Institute,
University of California, San Diego, La Jolla, CA
| | - Rachel T McCandless
- Division of Pediatric Cardiology, Department of
Pediatrics, Rady Children’s Hospital, University of California, San Diego,
San Diego, CA
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21
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Touma M. Fetal Mouse Cardiovascular Imaging Using a High-frequency Ultrasound (30/45MHZ) System. J Vis Exp 2018. [PMID: 29781990 DOI: 10.3791/57210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Congenital heart defects (CHDs) are the most common cause of childhood morbidity and early mortality. Prenatal detection of the underlying molecular mechanisms of CHDs is crucial for inventing new preventive and therapeutic strategies. Mutant mouse models are powerful tools to discover new mechanisms and environmental stress modifiers that drive cardiac development and their potential alteration in CHDs. However, efforts to establish the causality of these putative contributors have been limited to histological and molecular studies in non-survival animal experiments, in which monitoring the key physiological and hemodynamic parameters is often absent. Live imaging technology has become an essential tool to establish the etiology of CHDs. In particular, ultrasound imaging can be used prenatally without surgically exposing the fetuses, allowing maintaining their baseline physiology while monitoring the impact of environmental stress on the hemodynamic and structural aspects of cardiac chamber development. Herein, we use the High-Frequency Ultrasound (30/45) system to examine the cardiovascular system in fetal mice at E18.5 in utero at the baseline and in response to prenatal hypoxia exposure. We demonstrate the feasibility of the system to measure cardiac chamber size, morphology, ventricular function, fetal heart rate, and umbilical artery flow indices, and their alterations in fetal mice exposed to systemic chronic hypoxia in utero in real time.
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Affiliation(s)
- Marlin Touma
- Neonatal/Congenital Heart Laboratory, Cardiovascular Research Laboratory, David Geffen School of Medicine, University of California, Los Angeles; Children's Discovery and Innovation Institute, Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles;
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22
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Słodki M, Axt-Fliedner R, Zych-Krekora K, Wolter A, Kawecki A, Enzensberger C, Gulczyńska E, Respondek-Liberska M. New method to predict need for Rashkind procedure in fetuses with dextro-transposition of the great arteries. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:531-536. [PMID: 28295809 DOI: 10.1002/uog.17469] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 02/20/2017] [Accepted: 03/07/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Prenatal congenital heart disease classification systems distinguish between critical dextro-transposition of the great arteries (d-TGA) with restriction of the foramen ovale (FO) (which requires a Rashkind procedure within the first 24 h following delivery) and d-TGA for which surgery is planned (after prostaglandin perfusion or Rashkind procedure later than 24 h after delivery). However, current prenatal diagnostic criteria for postnatal FO restriction in d-TGA are inadequate, resulting in a high false-negative rate. We aimed to identify echocardiographic features to predict the urgent need for Rashkind procedure. METHODS We identified retrospectively 98 patients with singleton pregnancy diagnosed prenatally with fetal d-TGA at two European centers from 2006 to 2013. Two groups were compared: (1) those in whom the Rashkind procedure was performed within the first 24 h postnatally; and (2) those who did not undergo a Rashkind procedure before cardiac surgery. Exclusion criteria were: (1) no fetal echocardiography within 3 weeks prior to delivery (n = 18); (2) delivery before 37 weeks of gestation (n = 6); (3) improper or lack of measurement of pulmonary vein maximum flow velocity (n = 10); (4) lack of neonatal follow-up data (n = 9); (5) Rashkind procedure performed more than 24 h after delivery (n = 4). RESULTS Fifty-one patients met the inclusion criteria: 29 who underwent the Rashkind procedure and 22 who did not. There were no differences between these two study groups in terms of maternal age, gestational age at time of fetal echocardiography, fetal biometric measurements, estimated fetal weight, rate of Cesarean delivery, newborn weight or Apgar score at 1 min. There were also no differences during prenatal life between the two groups in terms of fetal cardiac size (heart area/chest area ratio), rate of disproportion between left and right ventricle, FO diameter and maximum velocity of flow through the FO. However, the pulmonary vein maximum velocity was significantly higher in the group requiring a Rashkind procedure (47.62 ± 7.48 vs 32.21 ± 5.47 cm/s; P < 0.001). The cut-off value of 41 cm/s provided maximum specificity (100%) and positive predictive value (100%) at only a slight cost of sensitivity (82%) and NPV (86%). The prenatal appearance of the FO also differed between the groups, the FO valve being flat in 52% of those requiring a Rashkind procedure. CONCLUSIONS In fetuses with d-TGA, prenatal sonographic findings of increased pulmonary venous blood flow and flattened FO valve were associated with the need for a Rashkind procedure within the first 24 h postnatally; these echocardiographic features could be used to predict prenatally a need for the procedure following delivery. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M Słodki
- Prenatal Cardiology, Polish Mother Memorial Hospital Research Institute, Lodz, Poland
- Faculty of Health Sciences, The State University of Applied Sciences in Plock, Plock, Poland
| | - R Axt-Fliedner
- Obstetrics and Gynecology, Division of Prenatal Diagnosis and Therapy, Fetal Cardiac Program, Justus-Liebig University Giessen, Giessen, Germany
| | - K Zych-Krekora
- Prenatal Cardiology, Polish Mother Memorial Hospital Research Institute, Lodz, Poland
| | - A Wolter
- Obstetrics and Gynecology, Division of Prenatal Diagnosis and Therapy, Fetal Cardiac Program, Justus-Liebig University Giessen, Giessen, Germany
| | - A Kawecki
- Obstetrics and Gynecology, Division of Prenatal Diagnosis and Therapy, Fetal Cardiac Program, Justus-Liebig University Giessen, Giessen, Germany
| | - C Enzensberger
- Obstetrics and Gynecology, Division of Prenatal Diagnosis and Therapy, Fetal Cardiac Program, Justus-Liebig University Giessen, Giessen, Germany
| | - E Gulczyńska
- Neonatology, Polish Mother Memorial Hospital Research Institute, Lodz, Poland
| | - M Respondek-Liberska
- Prenatal Cardiology, Polish Mother Memorial Hospital Research Institute, Lodz, Poland
- Diagnosis and Prevention of Fetal Malformations, Medical University, Lodz, Poland
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Murlewska J, Słodki M, Axt-Fliender R, Rizzo G, Sklansky M, Weiner S, Blickstein I, Respondek-Liberska M. Recommendations for Prenatal Echocardiography: A Report from International Prenatal Cardiology Collaboration Group. PRENATAL CARDIOLOGY 2018. [DOI: 10.1515/pcard-2017-0009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
International Prenatal Cardiology Collaboration Group (IPCCG) links specialists from prenatal cardiology all over the world. In this recommendation we would like to focus on the fetal/prenatal echocardiography official report. So far many recommendations focused mainly on technical aspects of the fetal heart examination.
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Affiliation(s)
- Julia Murlewska
- Department of Prenatal Cardiology, Polish Mother’s Memorial Hospital Research Institute, Lodz , Poland
| | - Maciej Słodki
- Department of Prenatal Cardiology, Polish Mother’s Memorial Hospital Research Institute, Lodz , Poland
- Faculty of Health Sciences, The State School of Higher Professional Education in Płock , Poland
| | - Roland Axt-Fliender
- University of Giessen, Ludwigstraße 23, 35390 Gießen , Germany
- University of Marburg, Biegenstraße 10, 35037 Marburg , Germany
| | - Giusseppe Rizzo
- Department of Obstetrics and Gynecology, Università Roma Tor Vergata, Ospedela Fatebenefratelli Isola Tiberina, Rome , Italy
| | - Mark Sklansky
- Division of Pediatric Cardiology, Department of Pediatrics, David Geffen School of Medicine, Los Angeles, California , USA
| | - Stuart Weiner
- Thomas Jefferson University and Hospitals, Philadelphia, Pennsylvania , USA
| | - Isaac Blickstein
- Department of Obstetrics and Gynecology, Kaplan Medical Center, 76100 Rehovot and the Hadassah-Hebrew University School of Medicine, Jerusalem , Israel
| | - Maria Respondek-Liberska
- Department of Prenatal Cardiology, Polish Mother’s Memorial Hospital Research Institute, Lodz , Poland
- Department of Diagnoses and Prevention Fetal Malformations, Medical University of Lodz, Lodz , Poland
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24
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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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25
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Fetale Herzdiagnostik. Monatsschr Kinderheilkd 2017. [DOI: 10.1007/s00112-017-0365-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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26
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Wolter A, Holtmann H, Kawecki A, Degenhardt J, Enzensberger C, Graupner O, Akintürk H, Yerebakan C, Khalil M, Schranz D, Axt-Fliedner R. Perinatal outcomes of congenital heart disease after emergent neonatal cardiac procedures. J Matern Fetal Neonatal Med 2017; 31:2709-2716. [PMID: 28693354 DOI: 10.1080/14767058.2017.1353970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE We compared outcome of neonates with prenatal and post-natal diagnosis of congenital heart disease presenting in our paediatric heart centre between March 2005 and May 2015 who underwent an emergent intervention within 48 h post-partum. MATERIALS AND METHODS In 52/111 (46.8%) with emergent intervention, congenital heart disease was diagnosed prenatally, in 59/111 (53.2%) with no specialized foetal echocardiography, diagnosis was made post-natally. In 98/111 (88.2%), 30-day outcome was known. RESULTS Regarding the entire cohort, 30-day survival did not differ significantly in prenatal and post-natal diagnosis group (71.2 vs. 72.9%; p > .1). Infants with prenatal diagnosis were more likely to be born by caesarean section (59.6% vs. 33.9%, p = .01). Those with post-natal diagnosis had a higher need for intubation (32.7% vs. 52.5%; p < .05). Subgroup analysis of HLH/HLHC (hypoplastic left heart/hypoplastic left heart complex) patients revealed higher number of deaths within 30 days of life in the post-natal diagnosis group, although the difference did not reach statistical significance (5/7, 71.4% vs. 5/20, 25.0%; p = .075). CONCLUSION For newborns who require emergent neonatal cardiac procedures, our results point towards a lower death rate after prenatal diagnosis of HLH/HLHC.
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Affiliation(s)
- Aline Wolter
- a Department of OB/GYN , University Hospital UKGM, Justus-Liebig University, Division of Prenatal Medicine , Giessen , Germany
| | - Helene Holtmann
- a Department of OB/GYN , University Hospital UKGM, Justus-Liebig University, Division of Prenatal Medicine , Giessen , Germany
| | - Andreea Kawecki
- a Department of OB/GYN , University Hospital UKGM, Justus-Liebig University, Division of Prenatal Medicine , Giessen , Germany
| | - Jan Degenhardt
- a Department of OB/GYN , University Hospital UKGM, Justus-Liebig University, Division of Prenatal Medicine , Giessen , Germany
| | - Christian Enzensberger
- a Department of OB/GYN , University Hospital UKGM, Justus-Liebig University, Division of Prenatal Medicine , Giessen , Germany
| | - Oliver Graupner
- b Department of OB/GYN , University Hospital, Klinikum Rechts der Isar, Technische Universität , München , Germany
| | - Hakan Akintürk
- c Pediatric Heart Center, University Hospital UKGM, Justus-Liebig University , Division of Pediatric Heart Surgery , Giessen , Germany
| | - Can Yerebakan
- c Pediatric Heart Center, University Hospital UKGM, Justus-Liebig University , Division of Pediatric Heart Surgery , Giessen , Germany
| | - Markus Khalil
- d Pediatric Heart Center, University Hospital UKGM, Justus-Liebig University , Division of Pediatric Cardiology , Giessen , Germany
| | - Dietmar Schranz
- d Pediatric Heart Center, University Hospital UKGM, Justus-Liebig University , Division of Pediatric Cardiology , Giessen , Germany
| | - Roland Axt-Fliedner
- a Department of OB/GYN , University Hospital UKGM, Justus-Liebig University, Division of Prenatal Medicine , Giessen , Germany
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27
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Patel N, Narasimhan E, Kennedy A. Fetal Cardiac US: Techniques and Normal Anatomy Correlated with Adult CT and MR Imaging. Radiographics 2017; 37:1290-1303. [DOI: 10.1148/rg.2017160126] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Neel Patel
- From the Department of Radiology and Imaging Sciences, University of Utah Hospital and Clinics, 30 N 1099 E, Room 1A71, Salt Lake City, Utah 84132
| | - Evan Narasimhan
- From the Department of Radiology and Imaging Sciences, University of Utah Hospital and Clinics, 30 N 1099 E, Room 1A71, Salt Lake City, Utah 84132
| | - Anne Kennedy
- From the Department of Radiology and Imaging Sciences, University of Utah Hospital and Clinics, 30 N 1099 E, Room 1A71, Salt Lake City, Utah 84132
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28
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Touma M, Reemtsen B, Halnon N, Alejos J, Finn JP, Nelson SF, Wang Y. A Path to Implement Precision Child Health Cardiovascular Medicine. Front Cardiovasc Med 2017; 4:36. [PMID: 28620608 PMCID: PMC5451507 DOI: 10.3389/fcvm.2017.00036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 05/04/2017] [Indexed: 12/17/2022] Open
Abstract
Congenital heart defects (CHDs) affect approximately 1% of live births and are a major source of childhood morbidity and mortality even in countries with advanced healthcare systems. Along with phenotypic heterogeneity, the underlying etiology of CHDs is multifactorial, involving genetic, epigenetic, and/or environmental contributors. Clear dissection of the underlying mechanism is a powerful step to establish individualized therapies. However, the majority of CHDs are yet to be clearly diagnosed for the underlying genetic and environmental factors, and even less with effective therapies. Although the survival rate for CHDs is steadily improving, there is still a significant unmet need for refining diagnostic precision and establishing targeted therapies to optimize life quality and to minimize future complications. In particular, proper identification of disease associated genetic variants in humans has been challenging, and this greatly impedes our ability to delineate gene–environment interactions that contribute to the pathogenesis of CHDs. Implementing a systematic multileveled approach can establish a continuum from phenotypic characterization in the clinic to molecular dissection using combined next-generation sequencing platforms and validation studies in suitable models at the bench. Key elements necessary to advance the field are: first, proper delineation of the phenotypic spectrum of CHDs; second, defining the molecular genotype/phenotype by combining whole-exome sequencing and transcriptome analysis; third, integration of phenotypic, genotypic, and molecular datasets to identify molecular network contributing to CHDs; fourth, generation of relevant disease models and multileveled experimental investigations. In order to achieve all these goals, access to high-quality biological specimens from well-defined patient cohorts is a crucial step. Therefore, establishing a CHD BioCore is an essential infrastructure and a critical step on the path toward precision child health cardiovascular medicine.
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Affiliation(s)
- Marlin Touma
- Department of Pediatrics, Children's Discovery and Innovation Institute, University of California at Los Angeles, Los Angeles, CA, United States.,Cardiovascular Research Laboratory, University of California at Los Angeles, Los Angeles, CA, United States
| | - Brian Reemtsen
- Department of Cardiothoracic Surgery, University of California at Los Angeles, Los Angeles, CA, United States
| | - Nancy Halnon
- Department of Pediatrics, University of California at Los Angeles, Los Angeles, CA, United States
| | - Juan Alejos
- Department of Pediatrics, University of California at Los Angeles, Los Angeles, CA, United States
| | - J Paul Finn
- Department of Radiology, Cardiovascular Imaging, University of California at Los Angeles, Los Angeles, CA, United States
| | - Stanley F Nelson
- Department of Human Genetics, University of California at Los Angeles, Los Angeles, CA, United States
| | - Yibin Wang
- Cardiovascular Research Laboratory, University of California at Los Angeles, Los Angeles, CA, United States.,Department of Anesthesiology, Physiology and Medicine, University of California at Los Angeles, Los Angeles, CA, United States
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29
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Pinto N, Sheng X, Keenan HT, Byrne JLB, Stanton B, Kinney AY. Sonographer-Identified Barriers and Facilitators to Prenatal Screening for Congenital Heart Disease. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2017. [DOI: 10.1177/8756479316677019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Fetal ultrasound screening for congenital heart disease has high detection rates in efficacy studies but not in practice. We investigated sonographers’ perspectives on barriers to screening and their association with intermediate measures of cardiac imaging. Methods: Barriers to fetal heart screening were identified in focus groups with obstetric sonographers. A web-based survey measured reported barriers and sonographers’ ability to interpret fetal heart screening images. Generalized linear random effect models assessed associations between barriers and image interpretation. Results: Four themes were identified: intrinsic barriers (self-efficacy), external barriers (time), informational needs, and provider and patient expectations. Among 224 sonographers surveyed, an average of 77.6% of fetal heart images were interpreted correctly. Perceptions about self-efficacy ( P = .03) and ease of performing imaging ( P = .01) were associated with accuracy of image interpretation. Conclusions: Several sonographer-identified barriers associated with image interpretation may be novel targets for improving prenatal detection of congenital heart disease.
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Affiliation(s)
- Nelangi Pinto
- Division of Pediatric Cardiology, University of Utah, Salt Lake City, UT, USA
| | - Xiaoming Sheng
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Heather T. Keenan
- Pediatric Critical Care Medicine, University of Utah, Salt Lake City, UT, USA
| | - Janice L. B. Byrne
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - Belva Stanton
- Primary Children’s Hospital, Salt Lake City, UT, USA
| | - Anita Y. Kinney
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
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30
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Fetal cardiology: changing the definition of critical heart disease in the newborn. J Perinatol 2016; 36:575-80. [PMID: 26963427 DOI: 10.1038/jp.2016.20] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 01/25/2016] [Accepted: 01/27/2016] [Indexed: 01/14/2023]
Abstract
Infants born with congenital heart disease (CHD) may require emergent treatment in the newborn period. These infants are likely to benefit the most from a prenatal diagnosis, which allows for optimal perinatal planning. Several cardiac centers have created guidelines for the management of these high-risk patients with CHD. This paper will review and compare several prenatal CHD classification systems with a particular focus on the most critical forms of CHD in the fetus and newborn. A contemporary definition of critical CHD is one which requires urgent intervention in the first 24 h of life to prevent death. Such cardiac interventions may be not only life saving for the infant but also decrease subsequent morbidity. Critical CHD cases may require delivery at specialized centers that can provide perinatal, obstetric, cardiology and cardiothoracic surgery care. Fetuses diagnosed in mid-gestation require detailed fetal diagnostics and serial monitoring during the prenatal period, in order to assess for ongoing changes and identify progression to a more severe cardiac status. Critical CHD may progress in utero and there is still much to be learned about how to best predict those who will require urgent neonatal interventions. Despite improved therapeutic capabilities, newborns with critical CHD continue to have significant morbidity and mortality due to compromise that begins in the delivery room. Fetal echocardiography is the best way to predict the need for specialized care at birth to improve outcome. Once the diagnosis is made of critical CHD, delivery at the proper time and in appropriate institution with specific care protocols should be initiated. More work needs to be done to better delineate the risk factors for progression of critical CHD and to determine which newborns will require specialized care. The most frequently described forms of critical CHD requiring immediate intervention include hypoplastic left heart syndrome with intact or severely restricted atrial septum, obstructed total anomalous pulmonary venous return and transposition of the great arteries with restrictive atrial septum.
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31
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Leszczyńska K, Preis K, Respondek-Liberska M, Słodki M, Wood D, Weiner S, Gembruch U, Rizzo G, Achiron R, Pruetz JD, Sklansky M, Cuneo B, Arabin B, Blickstein I. Recommendations for Fetal Echocardiography in Twin Pregnancy in 2016. PRENATAL CARDIOLOGY 2016. [DOI: 10.1515/pcard-2016-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Progress in the fields of fetal cardiology and fetal surgery have been seen not only in singleton pregnancies but also in multiple pregnancies. Proper interpretation of prenatal echocardiography is critical to clinical decision making, family counseling and perinatal management for obstetricians, maternal fetal medicine specialists, neonatologists and pediatric cardiologists. Fetal echocardiography is one of the most challenging and time-consuming prenatal examinations to perform, especially in multiple gestations. Performing just the basic fetal exam in twin gestations may take an hour or more. Thus, it is not practical to perform this exam in all cases of multiple gestations. Therefore our review and recommendations are related to fetal echocardiography in twin gestation.
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Affiliation(s)
| | - Krzysztof Preis
- 1. Department of Obstetrics, Medical University of Gdansk, Poland
| | - Maria Respondek-Liberska
- 2. Department of Diagnoses and Prevention Fetal Malformations, Medical University of Lodz, Poland
- 3. Department of Prenatal Cardiology, Polish Mother’s Memorial Hospital Research Institute, Lodz, Poland
| | - Maciej Słodki
- 3. Department of Prenatal Cardiology, Polish Mother’s Memorial Hospital Research Institute, Lodz, Poland
- 4. Institute of Health Sciences, The State School of Higher Professional Education in Płock, Poland
| | - Dennis Wood
- 5. Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Stuart Weiner
- 6. Thomas Jefferson University and Hospitals, Philadelphia, Pennsylvania, United States of America
| | - Ulli Gembruch
- 7. Department of Obstetrics and Prenatal Medicine, University Bonn Medical School, Bonn, Germany
| | - Giusseppe Rizzo
- 8. Department of Obstetrics and Gynecology, Università Roma Tor Vergata, Ospedela Fatebenefratelli Isola Tiberina, Rome, Italy
| | - Reuven Achiron
- 9. Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Israel
| | - Jay D Pruetz
- 10. Division of Pediatric Cardiology, Children’s Hospital Los Angeles, Los Angeles, CA, United States of America ; Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
| | - Mark Sklansky
- 11. Division of Pediatric Cardiology, Department of Pediatrics, David Geffen School of Medicine, Los Angeles, California, United States of America
| | - Bettina Cuneo
- 12. Department of Pediatric Cardiology, Then Fetal Heart Program, Colorado Fetal Care Center, Colorado Institute for Maternal Fetal Health, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Birgit Arabin
- 13. Center for Mother and Child, Philipps University, Marburg, Germany
| | - Isaac Blickstein
- 14. Department of Obstetrics and Gynecology, Kaplan Medical Center, 76100 Rehovot and the Hadassah-Hebrew University School of Medicine, Jerusalem, Israel
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32
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Słodki M, Respondek-Liberska M. Comment on "Outcomes of critical congenital heart disease requiring emergent neonatal cardiac intervention": a new classification of congenital heart disease. Prenat Diagn 2015; 35:620-1. [PMID: 26041254 DOI: 10.1002/pd.4576] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Revised: 01/15/2015] [Accepted: 02/05/2015] [Indexed: 11/07/2022]
Affiliation(s)
- Maciej Słodki
- Prenatal Cardiology Department, Polish Mother's Memorial Hospital, Research Institute, Lodz, Poland
| | - Maria Respondek-Liberska
- Prenatal Cardiology Department, Polish Mother's Memorial Hospital, Research Institute, Lodz, Poland
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33
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Pruetz JD, Votava-Smith J, Miller DA. Clinical relevance of fetal hemodynamic monitoring: Perinatal implications. Semin Fetal Neonatal Med 2015; 20:217-24. [PMID: 25823939 DOI: 10.1016/j.siny.2015.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Comprehensive assessment of fetal wellbeing involves monitoring of fetal growth, placental function, central venous pressure, and cardiac function. Ultrasound evaluation of the fetus using 2D, color Doppler, and pulse-wave Doppler techniques form the foundation of antenatal diagnosis of structural anomalies, rhythm abnormalities and altered fetal circulation. Accurate and timely prenatal identification of the fetus at risk is critical for appropriate parental counseling, antenatal diagnostic testing, consideration for fetal intervention, perinatal planning, and coordination of postnatal care delivery. Fetal hemodynamic monitoring and serial assessment are vital to ensuring fetal wellbeing, particularly in the setting of complex congenital anomalies. A complete hemodynamic evaluation of the fetus gives important information on the likelihood of a smooth postnatal transition and contributes to ensuring the best possible outcome for the neonate.
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Affiliation(s)
- Jay D Pruetz
- Division of Cardiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Jodie Votava-Smith
- Division of Cardiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - David A Miller
- Department of Obstetrics & Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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34
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Palatnik A, Gotteiner NL, Grobman WA, Cohen LS. Is the "I-Sign" in the 3-Vessel and Trachea View a Valid Tool for Prenatal Diagnosis of D-Transposition of the Great Arteries? JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:1329-1335. [PMID: 26112638 DOI: 10.7863/ultra.34.7.1329] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Prenatal diagnosis of D-transposition of the great arteries remains less frequent compared to other major congenital heart defects. In this study, we examined how often the 3-vessel and trachea view was abnormal in a large series of prenatally diagnosed cases of D-transposition of the great arteries. We found that an abnormal 3-vessel and trachea view in the shape of an "I" ("I-sign"), which represents an anteriorly displaced aorta, was present in all fetuses with D-transposition of the great arteries when a 3-vessel and trachea view was successfully obtained. Therefore we believe that the 3-vessel and trachea view can be used to reliably detect D-transposition of the great arteries during prenatal sonography.
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Affiliation(s)
- Anna Palatnik
- Departments of Obstetrics and Gynecology (A.P., W.A.G., L.S.C.) and Pediatrics (N.L.G.), Northwestern University, Feinberg School of Medicine, Chicago, Illinois USA.
| | - Nina L Gotteiner
- Departments of Obstetrics and Gynecology (A.P., W.A.G., L.S.C.) and Pediatrics (N.L.G.), Northwestern University, Feinberg School of Medicine, Chicago, Illinois USA
| | - William A Grobman
- Departments of Obstetrics and Gynecology (A.P., W.A.G., L.S.C.) and Pediatrics (N.L.G.), Northwestern University, Feinberg School of Medicine, Chicago, Illinois USA
| | - Leeber S Cohen
- Departments of Obstetrics and Gynecology (A.P., W.A.G., L.S.C.) and Pediatrics (N.L.G.), Northwestern University, Feinberg School of Medicine, Chicago, Illinois USA
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35
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Holland BJ, Myers JA, Woods CR. Prenatal diagnosis of critical congenital heart disease reduces risk of death from cardiovascular compromise prior to planned neonatal cardiac surgery: a meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:631-8. [PMID: 25904437 DOI: 10.1002/uog.14882] [Citation(s) in RCA: 149] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 04/17/2015] [Accepted: 04/19/2015] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To determine if prenatal diagnosis improves the chance that a newborn with critical congenital heart disease will survive to undergo planned cardiac surgery. METHODS A systematic review of the medical literature identified eight studies which met the following criteria: compared outcomes between newborns with prenatal and those with postnatal diagnosis of critical congenital heart disease; compared groups of patients with the same anatomical diagnosis; provided detailed information on cardiac anatomy; included detailed information on preoperative cause of death. A meta-analysis was performed to assess differences in preoperative mortality rates between newborns with prenatal diagnosis and those with postnatal diagnosis. Patients with established risk factors for increased mortality (high risk) and those whose families chose comfort care rather than cardiac surgery were excluded. RESULTS In patients with comparable anatomy, standard risk, a parental desire to treat and optimal care, newborns with a prenatal diagnosis of critical congenital heart disease were significantly less likely to die prior to planned cardiac surgery than were those with a comparable postnatal diagnosis (pooled odds ratio, 0.26; 95% CI, 0.08-0.84). CONCLUSIONS For newborns most likely to benefit from treatment for their critical congenital heart disease, because they did not have additional risk factors and their families pursued treatment, prenatal diagnosis reduced the risk of death prior to planned cardiac surgery relative to patients with a comparable postnatal diagnosis. Further study and efforts to improve prenatal diagnosis of congenital heart disease should therefore be considered.
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Affiliation(s)
- B J Holland
- Division of Pediatric Cardiology, Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY, USA
| | - J A Myers
- Child and Adolescent Health Research and Design Support Unit, Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY, USA
| | - C R Woods
- Child and Adolescent Health Research and Design Support Unit, Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY, USA
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