Prenatal Diagnosis and Management of Single Ventricle Heart Disease

The Heart of the Matter: A Path to Building Diversity in Pediatric Cardiology

Our essay discusses the impact of underrepresentation in medical training, with a focus on pediatric cardiology. We use the perspective of a physician who is underrepresented in medicine (URiM), and has chosen to pursue a career in pediatric cardiology, to initiate an analysis of the current path toward pediatric cardiology and the factors in undergraduate and graduate medical education which could currently be optimized to improve diversity in training. We argue that a lack of diversity among physicians leads to worse patient outcomes, and we describe steps to improve representation in the field. In order to improve representation in pediatric cardiology, we must reflect upon our current practices and implement systemic changes within cardiology training program recruitment and retention practices. These changes should include continuous mentorship of URiM trainees interested in cardiology and prioritization of research that investigates social determinants of health which may disproportionally affect minority patients.

Addressing Social Determinants of Health in Maternal Cardiovascular Health

Cardiovascular diseases (CVDs) remain the number-one cause of maternal mortality, with over two-thirds of cases being preventable. Social determinants of health (SDoH) encompass the nonmedical social and environmental factors that an individual experiences that have a significant impact on their health. These stressors disproportionately affect socially disadvantaged and minority populations. Pregnancy is a physiologically stressful state that can unmask underlying CVD risk factors and lead to adverse pregnancy outcomes (APOs). Disparities in APOs are particularly pronounced among individuals of color and those from economically disadvantaged backgrounds. This variation underscores healthcare inequity and access, a failure of the healthcare system. Besides short-term negative effects, APOs also are associated strongly with long-term CVDs. APOs therefore must be identified as a cue for early intervention, for the prevention and management of CVD risk factors. This review explores the intricate relationship among maternal morbidity and mortality, SDoH, and cardiovascular health, and the implementation of health policy efforts to reduce the negative impact of SDoH in this patient population. The review emphasizes the importance of comprehensive strategies to improve maternal health outcomes.

Abortion Bans and Resource Utilization for Congenital Heart Disease: A Decision Analysis

OBJECTIVE

To investigate the implications of potential national abortion ban scenarios on the incidence of neonatal single-ventricle cardiac defects.

METHODS

A decision tree model was developed to predict the incidence of neonatal single-ventricle cardiac defects and related outcomes in the United States under four theoretical national abortion bans: 1) abortion restrictions in existence immediately before the June 2022 Dobbs v Jackson Women's Health Organization Supreme Court decision, 2) 20 weeks of gestation, 3) 13 weeks of gestation, and 4) a complete abortion ban. The model included incidence of live births of neonates with single-ventricle cardiac defects, neonatal heart surgery (including heart transplant and extracorporeal membrane oxygenation [ECMO]), and neonatal death. Cohort size was based on national pregnancy incidence and different algorithm decision point probabilities were aggregated from the existing literature. Monte Carlo simulations were conducted with 10,000 iterations per model.

RESULTS

In the scenario before the Dobbs decision, an estimated 6,369,000 annual pregnancies in the United States resulted in 1,006 annual cases of single-ventricle cardiac defects. Under a complete abortion ban, the model predicted a 53.7% increase in single-ventricle cardiac defects, or an additional 9 cases per 100,000 live births. This increase would result in an additional 531 neonatal heart surgeries, 16 heart transplants, 77 ECMO utilizations, and 102 neonatal deaths annually. More restrictive gestational age-based bans are predicted to confer increases in cases of neonatal single-ventricle cardiac defects and related adverse outcomes as well.

CONCLUSION

Universal abortion bans are estimated to increase the incidence of neonatal single-ventricle cardiac defects, associated morbidity, and resource utilization. States considering limiting abortion should consider the implications on the resources required to care for increasing number of children that will be born with significant and complex medical needs, including those with congenital heart disease.

Minimally Invasive Fetal Surgery and the Next Frontier

Most patients with congenital anomalies do not require prenatal intervention. Furthermore, many congenital anomalies requiring surgical intervention are treated adequately after birth. However, there is a subset of patients with congenital anomalies who will die before birth, shortly after birth, or experience severe postnatal complications without fetal surgery. Fetal surgery is unique in that an operation is performed on the fetus as well as the pregnant woman who does not receive any direct benefit from the surgery but rather lends herself to risks, such as hemorrhage, abruption, and preterm labor. The maternal risks involved with fetal surgery have limited the extent to which fetal interventions may be performed but have, in turn, led to technical innovations that have significantly advanced the field. This review will examine congenital abnormalities that can be treated with minimally invasive fetal surgery and introduce the next frontier of prenatal management of fetal surgical pathology.

Surgical Strategies in Single Ventricle Management of Neonates and Infants

No area of congenital heart disease has undergone greater change and innovation than Single Ventricle management over the past 20 years. Surgical and catheter lab interventions have transformed outcomes such that in some subgroups more than 80% of these patients can survive into adulthood. Driven by parallel development in diagnostic imaging and cardiac intensive care, surgical management is focused on the neonatal period as the key time to creating a balanced circulation and limiting pulmonary blood-flow. Different configurations of the circulation including new types of surgical shunts and the role of 'hybrid' circulations provide greater options and better physiology. This overview will focus on these changes in surgical management and timing but also look at the exciting areas of regenerative therapies to improve ventricular function, and the concept of ventricular rehabilitation to achieve biventricular circulations in certain groups of patients. The importance of early (neonatal) intervention and multidisciplinary approach to management is emphasised, as well as looking beyond simply survival but also improving neurodevelopmental outcomes.