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Meng H, Luo ZL, Shen Y, Liu QQ, Li MZ, Gao YM. Accurate prenatal diagnosis of coarctation of the aorta by 3-step echocardiographic diagnostic protocol. BMC Pediatr 2024; 24:552. [PMID: 39192246 DOI: 10.1186/s12887-024-04851-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 05/22/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND Coarctation of the aorta (CoA) is the most common undiagnosed congenital heart defect during prenatal screening. High false positive and false negative rates seriously affect prenatal consultation and postnatal management. The objective of the study was to assess the utility of various measurements to predict prenatal CoA and to derive a diagnostic algorithm. METHODS One hundred and fifty-four fetuses with suspected CoA who presented at Fuwai Hospital between December 2017 and August 2021 were enrolled and divided into confirmed CoA cases (n = 47) and false positive cases (n = 107), according to their postnatal outcomes. The transverse aortic arch, isthmus, and descending aorta were measured in the long-axis view of the aortic arch. The angle between the transverse aortic arch (TAO) and the descending aortic arch (DAO) was defined as the TAO-DAO angle and measured in the long axis or sagittal view. Based on the database in GE Voluson E10 and the formula (Z = [Formula: see text]), the standard score (Z-score) of the dimensions of the aorta were calculated in relation to the gestational age. The main echocardiographic indices were combined to design a 3-step diagnostic protocol. The TAO-DAO angle was used as the first step in the diagnostic model. The diameter of the transverse arch and the Z-score of the isthmus were the second step. The third-step indices included a Z-score of the transverse arch, diameter of the isthmus, distance from the left subclavian artery (LSA) to left common carotid artery (LCCA), the ratio of isthmus diameter and LSA diameter and ratio of the distances (the distance between the LSA and LCCA to the distance between the right innominate artery and LCCA). The receiver operating characteristic (ROC) curve determined the predictive capability of each diagnostic parameter, and the kappa test determined the diagnostic accuracy of the proposed model. RESULTS The cases with confirmed CoA had thinner transverse arches (1.92 ± 0.32 mm vs. 3.06 ± 0.67 mm, P = 0.0001), lower Z-scores of the isthmus (-8.97 ± 1.45 vs. -5.65 ± 1.60, P = 0.0001), smaller TAO-DAO angles (105.54 ± 11.51° vs. 125.29 ± 8.97°, P = 0.0001) and larger distance between the LSA and LCCA (4.45 ± 1.75 mm vs. 2.74 ± 1.07 mm, P = 0.0001) than the false positive cases. The area under the curve (AUC) was 0.947 (95% CI 0.91-0.98) for the TAO-DAO angle ≤ 115.75°, 0.942 (95% CI 0.91-0.98) for the transverse arch diameter ≤ 2.31 mm, 0.937 (95% CI 0.90-0.98) for the Z-score of the isthmus ≤ -7.5, and 0.975 (95% CI 0.95-1.00) for the 3-step diagnostic protocol with 97.8% sensitivity and 97.2% specificity. The kappa test showed that the model's diagnostic accuracy was consistent with postnatal outcomes (kappa value 0.936, P = 0.0001). CONCLUSIONS The 3-step diagnostic protocol included the three most useful measurements and the additional indices with appropriate cut-off values. The algorithm is useful for the detection of aortic coarctation in fetuses with a high degree of accuracy. TRIAL REGISTRATION Retrospectively registered.
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Affiliation(s)
- Hong Meng
- Department of Echocardiography, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, P. R. China.
| | - Zhi-Ling Luo
- Department of Echocardiography, Fuwai Yunnan Cardiovascular Hospital Kunming, Kunming, 650102, China
| | - Yan Shen
- Department of Echocardiography, Fuwai Yunnan Cardiovascular Hospital Kunming, Kunming, 650102, China
| | - Qian-Qian Liu
- Department of Echocardiography, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, P. R. China
| | - Mu-Zi Li
- Department of Echocardiography, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, P. R. China
| | - Yi-Ming Gao
- Department of Echocardiography, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, P. R. China
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Ginsberg GM, Drukker L, Pollak U, Brezis M. Cost-utility analysis of prenatal diagnosis of congenital cardiac diseases using deep learning. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2024; 22:44. [PMID: 38773527 PMCID: PMC11110271 DOI: 10.1186/s12962-024-00550-3] [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: 02/23/2024] [Accepted: 04/24/2024] [Indexed: 05/24/2024] Open
Abstract
BACKGROUND Deep learning (DL) is a new technology that can assist prenatal ultrasound (US) in the detection of congenital heart disease (CHD) at the prenatal stage. Hence, an economic-epidemiologic evaluation (aka Cost-Utility Analysis) is required to assist policymakers in deciding whether to adopt the new technology. METHODS The incremental cost-utility ratios (CUR), of adding DL assisted ultrasound (DL-US) to the current provision of US plus pulse oximetry (POX), was calculated by building a spreadsheet model that integrated demographic, economic epidemiological, health service utilization, screening performance, survival and lifetime quality of life data based on the standard formula: CUR = Increase in Intervention Costs - Decrease in Treatment costs Averted QALY losses of adding DL to US & POX US screening data were based on real-world operational routine reports (as opposed to research studies). The DL screening cost of 145 USD was based on Israeli US costs plus 20.54 USD for reading and recording screens. RESULTS The addition of DL assisted US, which is associated with increased sensitivity (95% vs 58.1%), resulted in far fewer undiagnosed infants (16 vs 102 [or 2.9% vs 15.4%] of the 560 and 659 births, respectively). Adoption of DL-US will add 1,204 QALYs. with increased screening costs 22.5 million USD largely offset by decreased treatment costs (20.4 million USD). Therefore, the new DL-US technology is considered "very cost-effective", costing only 1,720 USD per QALY. For most performance combinations (sensitivity > 80%, specificity > 90%), the adoption of DL-US is either cost effective or very cost effective. For specificities greater than 98% (with sensitivities above 94%), DL-US (& POX) is said to "dominate" US (& POX) by providing more QALYs at a lower cost. CONCLUSION Our exploratory CUA calculations indicate the feasibility of DL-US as being at least cost-effective.
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Affiliation(s)
- Gary M Ginsberg
- Braun School of Public Health, Hebrew University, Jerusalem, Israel.
- HECON, Health Economics Consultancy, Jerusalem, Israel.
| | - Lior Drukker
- Department of Obstetrics and Gynecology, Rabin-Belinson Medical Center, Petah Tikva, Israel
- School of Medicine, Faculty of Medical and Health Sciences, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Uri Pollak
- Pediatric Critical Care Sector, Hadassah University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University Medical Center, Jerusalem, Israel
| | - Mayer Brezis
- Braun School of Public Health, Hebrew University, Jerusalem, Israel
- Center for Quality and Safety, Hadassah University Medical Center, Jerusalem, Israel
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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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Gong T, Zhang F, Feng L, Zhu X, Deng D, Ran T, Li L, Kong L, Sun L, Ji X. Diagnosis and surgical outcomes of coarctation of the aorta in pediatric patients: a retrospective study. Front Cardiovasc Med 2023; 10:1078038. [PMID: 37554364 PMCID: PMC10405080 DOI: 10.3389/fcvm.2023.1078038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 07/10/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Coarctation of the aorta (CoA) is a common congenital cardiovascular malformation, and improvements in the diagnostic process for surgical decision-making are important. We sought to compare the diagnostic accuracy of transthoracic echocardiography (TTE) with computed tomographic angiography (CTA) to diagnose CoA. METHODS We retrospectively reviewed 197 cases of CoA diagnosed by TTE and CTA and confirmed at surgery from July 2009 to August 2019. RESULTS The surgical findings confirmed that 19 patients (9.6%) had isolated CoA and 178 (90.4%) had CoA combined with other congenital cardiovascular malformations. The diagnostic accuracy of CoA by CTA was significantly higher than that of TTE (χ2 = 6.52, p = 0.01). In contrast, the diagnostic accuracy of TTE for associated cardiovascular malformations of CoA was significantly higher than that of CTA (χ2 = 15.36, p < 0.0001). Infants and young children had more preductal type of CoA, and PDA was the most frequent cardiovascular lesion associated with CoA. The pressure gradient was significantly decreased after the first operation, similar at 6 months, 1 year, and 3 years follow-ups by TTE. CONCLUSIONS CTA is more accurate as a clinical tool for diagnosing CoA; however, TTE with color Doppler can better identify associated congenital cardiovascular malformations. Therefore, combining TTE and CTA would benefit clinical evaluation and management in patients suspected of CoA. TTE was valuable for post-operation follow-up and clinical management.
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Affiliation(s)
- Ting Gong
- Department of Ultrasound, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Department of Ultrasound, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Feiyan Zhang
- Department of Ultrasound, Children’s Hospital of Chongqing Medical University, Chongqing, China
- Department of Ultrasound, The First Affiliated Hospital of Chongqing Medical and Pharmaceutical College, Chongqing, China
| | - Lingxin Feng
- Department of Ultrasound, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Xu Zhu
- Department of Ultrasound, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Dan Deng
- School of Medical Imaging, Changsha Medical University, Changsha, China
| | - Tingting Ran
- Department of Ultrasound, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Liling Li
- Department of Ultrasound, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Li Kong
- Department of Ultrasound, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Liqun Sun
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Xiaojuan Ji
- Department of Ultrasound, Children’s Hospital of Chongqing Medical University, Chongqing, China
- Department of Ultrasound, Chongqing General Hospital, Chongqing, China
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Hermida U, van Poppel MPM, Lloyd DFA, Steinweg JK, Vigneswaran TV, Simpson JM, Razavi R, De Vecchi A, Pushparajah K, Lamata P. Learning the Hidden Signature of Fetal Arch Anatomy: a Three-Dimensional Shape Analysis in Suspected Coarctation of the Aorta. J Cardiovasc Transl Res 2023; 16:738-747. [PMID: 36301513 PMCID: PMC10299929 DOI: 10.1007/s12265-022-10335-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 10/13/2022] [Indexed: 10/31/2022]
Abstract
Neonatal coarctation of the aorta (CoA) is a common congenital heart defect. Its antenatal diagnosis remains challenging, and its pathophysiology is poorly understood. We present a novel statistical shape modeling (SSM) pipeline to study the role and predictive value of arch shape in CoA in utero. Cardiac magnetic resonance imaging (CMR) data of 112 fetuses with suspected CoA was acquired and motion-corrected to three-dimensional volumes. Centerlines from fetal arches were extracted and used to build a statistical shape model capturing relevant anatomical variations. A linear discriminant analysis was used to find the optimal axis between CoA and false positive cases. The CoA shape risk score classified cases with an area under the curve of 0.907. We demonstrate the feasibility of applying a SSM pipeline to three-dimensional fetal CMR data while providing novel insights into the anatomical determinants of CoA and the relevance of in utero arch anatomy for antenatal diagnosis of CoA.
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Affiliation(s)
- Uxio Hermida
- Department of Biomedical Engineering, School of Biomedical Engineering and Imaging Sciences, King's College London, St Thomas' Hospital, 5Th Floor Becket House, 1 Lambeth Palace Road, London, SE1 7EH, UK
| | - Milou P M van Poppel
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, St Thomas' Hospital, London, SE1 7EH, UK
| | - David F A Lloyd
- Department of Perinatal Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, St Thomas' Hospital, London, SE1 7EH, UK
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, SE1 7EH, UK
| | - Johannes K Steinweg
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, St Thomas' Hospital, London, SE1 7EH, UK
| | - Trisha V Vigneswaran
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, SE1 7EH, UK
- Harris Birthright Centre, Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - John M Simpson
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, SE1 7EH, UK
- Harris Birthright Centre, Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - Reza Razavi
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, St Thomas' Hospital, London, SE1 7EH, UK
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, SE1 7EH, UK
| | - Adelaide De Vecchi
- Department of Biomedical Engineering, School of Biomedical Engineering and Imaging Sciences, King's College London, St Thomas' Hospital, 5Th Floor Becket House, 1 Lambeth Palace Road, London, SE1 7EH, UK
| | - Kuberan Pushparajah
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, St Thomas' Hospital, London, SE1 7EH, UK
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, SE1 7EH, UK
| | - Pablo Lamata
- Department of Biomedical Engineering, School of Biomedical Engineering and Imaging Sciences, King's College London, St Thomas' Hospital, 5Th Floor Becket House, 1 Lambeth Palace Road, London, SE1 7EH, UK.
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Haxel CS, Johnson JN, Hintz S, Renno MS, Ruano R, Zyblewski SC, Glickstein J, Donofrio MT. Care of the Fetus With Congenital Cardiovascular Disease: From Diagnosis to Delivery. Pediatrics 2022; 150:189887. [PMID: 36317976 DOI: 10.1542/peds.2022-056415c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The majority of congenital cardiovascular disease including structural cardiac defects, abnormalities in cardiac function, and rhythm disturbances can be identified prenatally using screening obstetrical ultrasound with referral for fetal echocardiogram when indicated. METHODS Diagnosis of congenital heart disease in the fetus should prompt assessment for extracardiac abnormalities and associated genetic abnormalities once maternal consent is obtained. Pediatric cardiologists, in conjunction with maternal-fetal medicine, neonatology, and cardiothoracic surgery subspecialists, should counsel families about the details of the congenital heart defect as well as prenatal and postnatal management. RESULTS Prenatal diagnosis often leads to increased maternal depression and anxiety; however, it decreases morbidity and mortality for many congenital heart defects by allowing clinicians the opportunity to optimize prenatal care and plan delivery based on the specific lesion. Changes in prenatal care can include more frequent assessments through the remainder of the pregnancy, maternal medication administration, or, in selected cases, in utero cardiac catheter intervention or surgical procedures to optimize postnatal outcomes. Delivery planning may include changing the location, timing or mode of delivery to ensure that the neonate is delivered in the most appropriate hospital setting with the required level of hospital staff for immediate postnatal stabilization. CONCLUSIONS Based on the specific congenital heart defect, prenatal echocardiogram assessment in late gestation can often aid in predicting the severity of postnatal instability and guide the medical or interventional level of care needed for immediate postnatal intervention to optimize the transition to postnatal circulation.
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Affiliation(s)
- Caitlin S Haxel
- The University of Vermont Children's Hospital, Burlington, Vermont
| | | | - Susan Hintz
- Stanford University, Lucille Salter Packard Children's Hospital, Palo Alto, California
| | - Markus S Renno
- University Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | | | - Julie Glickstein
- Columbia University Vagelos School of Medicine, Morgan Stanley Children's Hospital, New York, New York
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Wutthigate P, Simoneau J, Renaud C, Altit G. Early Echocardiography Predicts Intervention Need in Antenatal Suspicion of Coarctation of the Aorta. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2022; 1:167-173. [PMID: 37969934 PMCID: PMC10642135 DOI: 10.1016/j.cjcpc.2022.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/02/2022] [Indexed: 11/17/2023]
Abstract
Background Coarctation of the aorta (CoA) is challenging to diagnose in early postnatal life. We aimed to describe the resource utilization and predictors for the need of intervention in an antenatal suspicion of CoA. Methods A retrospective study of infants with an antenatal suspicion of CoA born at ≥37 weeks was performed. Those not requiring intervention (normal) were compared with those who required cardiac surgery (CoA). Strain was measured using speckle-tracking echocardiography. Results A total of 51 newborns were included; 40 (78%) were considered normal and 11 (22%) underwent intervention. Echocardiography occurred within the first day of life for both groups. Right ventricular (RV) predominance was present in the CoA group, as demonstrated by the left ventricular (LV) end-systolic eccentricity index (1.60 [0.28] vs 2.16 [0.45]; P < 0.001) and by a larger RV end-diastolic area (EDA) in apical 4-chamber (A4C) relative to LV-EDA-with a ratio of 1.56 [0.23] vs 1.02 [0.2]; P < 0.001. An RV/LV EDA ratio in A4C ≥1.3 had a high probability for CoA (area under the curve = 0.97). Newborns with CoA had a lower RV deformation (peak systolic strain rate: -0.98 [0.17] vs -0.83 [0.2]; P = 0.02). Intraclass correlation coefficient for the EDA ratio revealed a good inter-rater agreement (0.76; 95% confidence interval: 0.55-0.87). Analysis with rater #2 revealed that the EDA ratio ≥1.3 predicted 100% of CoA. Conclusions The majority of those with an antenatal suspicion of CoA did not require intervention but were high consumers of resources. Within the first day of life, the ventricular EDA ratio in A4C may help predicting those with true CoA requiring intervention.
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Affiliation(s)
- Punnanee Wutthigate
- Division of Neonatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jessica Simoneau
- Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Québec, Canada
- Division of Neonatology, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Québec, Canada
| | - Claudia Renaud
- Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Québec, Canada
- Division of Pediatric Cardiology, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Québec, Canada
| | - Gabriel Altit
- Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Québec, Canada
- Division of Neonatology, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Québec, Canada
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Liu J, Cao H, Zhang L, Hong L, Cui L, Song X, Ma J, Shi J, Zhang Y, Li Y, Wang J, Xie M. Incremental value of myocardial deformation in predicting postnatal coarctation of the aorta: establishment of a novel diagnostic model. J Am Soc Echocardiogr 2022; 35:1298-1310. [PMID: 35863545 DOI: 10.1016/j.echo.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 06/12/2022] [Accepted: 07/04/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Prenatal detection of coarctation of the aorta (CoA) still suffers from high false-positive and false-negative rates. The objective of this study was to develop a novel model to improve the diagnostic accuracy of fetal CoA. METHODS A retrospective study was conducted in 122 fetuses with suspected CoA who also had postnatal follow-ups. Fetuses with confirmed diagnosis of CoA after birth were defined as CoA group, and Non-CoA group were those false-positives. Conventional fetal echocardiographic measurements, including great arterial dimensions and flow characteristics were obtained. Left ventricular (LV) functional parameters were determined using two-dimensional speckle tracking echocardiography. A novel multi-parametric diagnostic model, including gestational age (GA) at diagnosis, aortic isthmus (AOI) Z-score and LV longitudinal strain (LVLS), was developed by univariate and multivariate logistic regression analyses. The model was validated prospectively by a validation cohort of 48 fetuses. RESULTS CoA was confirmed in 62/122 (50.8%) cases after birth. Fetuses with postnatal CoA were diagnosed significantly earlier than false-positives (median (interquartile range), 24.5 (23.3-26.4) vs 27.8 (24.5-30.4) weeks; P < .001). The Z-scores of aortic dimensions (aortic valve annulus, ascending aorta, transverse aortic arch and AOI) were significantly smaller (all P < .001), while the Z-scores of pulmonary dimensions (pulmonary valve annulus and main pulmonary artery) were significantly greater (all P < .05), in cases of confirmed CoA than false-positives. Compared with Non-CoA group, CoA group displayed lower LV ejection fraction (P = .005), LV fractional area change (P < .001) and LVLS (P < .001). A multivariate logistic regression model incorporating GA (odds ratio (OR): 0.74, 95% confidence interval (CI): 0.60-0.88; P = .001), AOI Z-score (OR: 0.20, 95% CI: 0.08-0.41; P < .001) and LVLS (OR: 1.79, 95% CI: 1.41-2.42; P < .001) was established to diagnose CoA more accurately (Akaike information criterion: 81.77, C-statistics: 0.945). The performance of this model was confirmed prospectively in the validation cohort. CONCLUSIONS In fetuses with suspected CoA, speckle tracking analysis of LVLS may have an incremental value in predicting postnatal CoA. Our diagnostic model, including GA, AOI Z-score and LVLS, may provide a good tool for the stratification of the risk in fetal CoA and contribute to patient-specific perinatal management.
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Affiliation(s)
- Juanjuan Liu
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Clinical Research Center for Medical Imaging in Hubei Province, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Haiyan Cao
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Clinical Research Center for Medical Imaging in Hubei Province, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Li Zhang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Clinical Research Center for Medical Imaging in Hubei Province, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China; Shenzhen Huazhong University of Science and Technology Research Institute, Shenzhen 518057, China
| | - Liu Hong
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Clinical Research Center for Medical Imaging in Hubei Province, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Li Cui
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Clinical Research Center for Medical Imaging in Hubei Province, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Xiaoyan Song
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Clinical Research Center for Medical Imaging in Hubei Province, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Jing Ma
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Clinical Research Center for Medical Imaging in Hubei Province, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Jiawei Shi
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Clinical Research Center for Medical Imaging in Hubei Province, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Yi Zhang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Clinical Research Center for Medical Imaging in Hubei Province, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Yuman Li
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Clinical Research Center for Medical Imaging in Hubei Province, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Jing Wang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Clinical Research Center for Medical Imaging in Hubei Province, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
| | - Mingxing Xie
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Clinical Research Center for Medical Imaging in Hubei Province, Wuhan 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China; Shenzhen Huazhong University of Science and Technology Research Institute, Shenzhen 518057, China; Tongji Medical College and Wuhan National Laboratory for Optoelectronics, Huazhong University of Science and Technology, Wuhan 430022, China.
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Yang EL, Levy PT, Critser PJ, Dukhovny D, Evers PD. The Clinical and Cost Utility of Cardiac Catheterizations in Infants with Bronchopulmonary Dysplasia. J Pediatr 2022; 246:56-63.e3. [PMID: 35430250 DOI: 10.1016/j.jpeds.2022.04.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/17/2022] [Accepted: 04/08/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To evaluate the cost-utility of catheterization-obligate treatment in preterm infants with pulmonary hypertension, as compared with empiric initiation of sildenafil based on echocardiographic findings alone. STUDY DESIGN A Markov state transition model was constructed to simulate the clinical scenario of a preterm infant with echocardiographic evidence of pulmonary hypertension associated with bronchopulmonary dysplasia (BPD) and without congenital heart disease under consideration for the initiation of pulmonary vasodilator therapy via one of two modeled treatment strategies-empiric or catheterization-obligate. Transitional probabilities, costs and utilities were extracted from the literature. Forecast quality-adjusted life-years was the metric for strategy effectiveness. Sensitivity analyses for each variable were performed. A 1000-patient Monte Carlo microsimulation was used to test the durability of our findings. RESULTS The catheterization-obligate strategy resulted in an increased cost of $10 778 and 0.02 fewer quality-adjusted life-years compared with the empiric treatment strategy. Empiric treatment remained the more cost-effective paradigm across all scenarios modeled through one-way sensitivity analyses and the Monte Carlo microsimulation (cost-effective in 98% of cases). CONCLUSIONS Empiric treatment with sildenafil in infants with pulmonary hypertension associated with BPD is a superior strategy with both decreased costs and increased effectiveness when compared with catheterization-obligate treatment. These findings suggest that foregoing catheterization before the initiation of sildenafil is a reasonable strategy in preterm infants with uncomplicated pulmonary hypertension associated with BPD.
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Affiliation(s)
- Emily L Yang
- Division of Pediatric Cardiology, Oregon Health and Sciences University, Portland, OR.
| | - Philip T Levy
- Division of Newborn Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA; Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Paul J Critser
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Dmitry Dukhovny
- Division of Neonatology, Oregon Health and Sciences University, Portland, OR
| | - Patrick D Evers
- Division of Pediatric Cardiology, Oregon Health and Sciences University, Portland, OR
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10
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Arya B, Maskatia SA. Coarctation of the aorta: Prenatal assessment, postnatal management and neonatal outcomes. Semin Perinatol 2022; 46:151584. [PMID: 35422354 DOI: 10.1016/j.semperi.2022.151584] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Coarctation of the aorta (Coa) is a potentially life threatening diagnosis. It occurs in 0.3 per 1000 live births and accounts for 6-8% of all infants with congenital heart defects. Neonates with severe Coa may be completely asymptomatic at birth, as the ductus arteriosus can provide flow to the lower body. Those who are not diagnosed prenatally may be diagnosed only after constriction of the ductus arteriosus, when they present in cardiogenic shock. This group has a higher risk for mortality and morbidity relative to those diagnosed prenatally. Despite the increasing practice of universal pulse oximetry screening, many cases with significant coarctation of the aorta still go undiagnosed in the newborn period. In this article, we present the pathophysiology, diagnosis, presentation, treatment and outcomes of Coa.
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Affiliation(s)
- Bhawna Arya
- University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA, United States.
| | - Shiraz A Maskatia
- Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, CA, United States
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11
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Schoeneberg L, Prodhan P, Spray B, Akmyradov C, Zakaria D. Risk Factors for Increased Post-operative Length of Stay in Children with Coarctation of Aorta. Pediatr Cardiol 2021; 42:1567-1574. [PMID: 34052859 DOI: 10.1007/s00246-021-02641-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/18/2021] [Indexed: 11/29/2022]
Abstract
Coarctation of the aorta is a relatively common congenital heart disease occurring in 0.4-0.6 per 1000 live births with a low mortality rate. This is a retrospective study, with data abstracted from the Pediatric Health Information System database (PHIS). The study sample included pediatric patients less than or equal to 3 months of age discharged from a PHIS participating hospital between January 1, 2004 and December 31, 2018 who underwent surgical repair of isolated COA. The primary outcome for the study was post-operative hospital length of stay (PH-LOS), and the secondary outcome was in-hospital mortality. Patient demographics, comorbidities, procedures, and outcomes were assessed for statistical differences between eras. A total of 5354 patients were included in the study. The study highlights an increasing trend in PH-LOS and NICU hospital length of stay (NICU-LOS) across the investigated eras. Prematurity (before 37 weeks gestation) was an independent risk factor associated with both longer post-operative length of the stay and higher mortality. In addition, congenital anomalies, respiratory and abdominal surgeries have a significant impact on the post-operative hospital stay. In conclusion, this study is the largest published systematic assessment of PH-LOS in patients with isolated COA repair during infancy to date and identifies independent risk factors of increased PH-LOS.
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Affiliation(s)
- Laura Schoeneberg
- Department of Pediatrics (Cardiology and Pediatric Intensive Care), University of Arkansas for Medical Sciences, Arkansas Children's Hospital, 1 Children's Way, Slot 512-1, Little Rock, AR, 72202, USA
| | - Parthak Prodhan
- Department of Pediatrics (Cardiology and Pediatric Intensive Care), University of Arkansas for Medical Sciences, Arkansas Children's Hospital, 1 Children's Way, Slot 512-1, Little Rock, AR, 72202, USA
| | - Beverly Spray
- Arkansas Children's Research Institute (Biostatistics), Little Rock, USA
| | - Chary Akmyradov
- Arkansas Children's Research Institute (Biostatistics), Little Rock, USA
| | - Dala Zakaria
- Department of Pediatrics (Cardiology and Pediatric Intensive Care), University of Arkansas for Medical Sciences, Arkansas Children's Hospital, 1 Children's Way, Slot 512-1, Little Rock, AR, 72202, USA.
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12
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Validation of Prenatal Aortic Arch Angle Measurements in the Diagnosis of Neonatal Coarctation of the Aorta. Pediatr Cardiol 2021; 42:1365-1371. [PMID: 33903942 DOI: 10.1007/s00246-021-02620-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
Prenatal prediction of coarctation of the aorta (CoA) is challenging. Methods identifying prenatal CoA have high sensitivity with significant false positives. We previously derived prenatal aortic arch angles for identifying CoA with high sensitivity and specificity and aim to validate these angles and compare them with a model utilizing ascending aorta (AAo) and isthmus (Aoi) measures. Retrospective case/cohort study of fetuses with prenatal suspicion for CoA. 35 fetuses were included. Measurements included: ascending-descending aortic angle (AAo.DAo), transverse-descending aortic angle (TAo.DAo); diameters and z-scores of Aoi from sagittal (Aoi-sag), three-vessel (Aoi-3VV) view and AAo. Discriminant functions for the 5 variables were compared using histograms and positive/negative predictive values (PPV/NPV). CoA was confirmed in 28/35 neonates. The PPV and NPV for angle measures were 100% and 77%. The AAo + Aoi-3VV model PPV and NPV were 92% and 80% and Aoi-sag + Aoi-3VV model were 82% and 71%. A linear discriminant model utilizing the 3 most predictive variables improved NPV to 90% and PPV to 100%. In conclusion, we validate that angle measures are superior to standard models of predicting CoA. An optimized 3 variable model maintains accuracy of identifying CoA while eliminating false positives.
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13
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Barris DM, Brailovschi Y, Shah A, Levasseur S, Nhan-Chang CL, Miller R, Simpson L, Freud LR. The role of fetal echocardiogram after detection of extracardiac anomalies in utero (fetal echocardiogram for extracardiac malformations). Prenat Diagn 2021; 41:1134-1139. [PMID: 34269470 DOI: 10.1002/pd.6012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/16/2021] [Accepted: 06/30/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE We aimed to investigate the utility of comprehensive screening fetal echocardiography (FE) for patients diagnosed with any type of fetal extracardiac malformation (ECM) at a single multidisciplinary fetal center. METHODS We retrospectively reviewed all patients presenting to our referral center for FE due to a prenatal diagnosis of ECM (January 2013-December 2018). RESULTS Among 641 patients with ≥1 ECM referred for FE, 78 (12.2%) had CHD diagnosed at 25.6 ± 0.5 weeks. The frequency of CHD by type of ECM ranged from 35.1% for craniofacial to 9.8% for thoracic. Increasing number of fetal ECMs was strongly associated with CHD: odds ratio 2.01 (95% confidence interval: 1.06-3.69) for two ECMs, 9.57 (2.00-49.05) for three ECMs, and 11.68 (3.84-37.15) for more than three ECMs. Of fetuses with ECM and an abnormal genetic finding, 33.3% had CHD as compared to 10.9% of those without (p < 0.0001). Obstetric anatomy sonogram detected 43.6% of CHD. CONCLUSION CHD was commonly diagnosed among fetuses with any type of ECM at our center but was not always detected on obstetric sonogram. As the presence of CHD may impact decision-making and perinatal care, patients with a diagnosis of any fetal ECM should be considered for FE.
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Affiliation(s)
- David M Barris
- Department of Pediatrics, Columbia University Irving Medical Center, Morgan Stanley Children's Hospital of NewYork Presbyterian, New York City, New York, USA
| | - Yaniv Brailovschi
- Department of Obstetrics, Lenox Hill Hospital, Northwell Health, New York City, New York, USA
| | - Amee Shah
- Department of Pediatrics, Columbia University Irving Medical Center, Morgan Stanley Children's Hospital of NewYork Presbyterian, New York City, New York, USA
| | - Stéphanie Levasseur
- Department of Pediatrics, Columbia University Irving Medical Center, Morgan Stanley Children's Hospital of NewYork Presbyterian, New York City, New York, USA
| | - Chia-Ling Nhan-Chang
- Department of Obstetrics, Columbia University Irving Medical Center, Morgan Stanley Children's Hospital of NewYork Presbyterian, New York City, New York, USA
| | - Russell Miller
- Department of Obstetrics, Columbia University Irving Medical Center, Morgan Stanley Children's Hospital of NewYork Presbyterian, New York City, New York, USA
| | - Lynn Simpson
- Department of Obstetrics, Columbia University Irving Medical Center, Morgan Stanley Children's Hospital of NewYork Presbyterian, New York City, New York, USA
| | - Lindsay R Freud
- Department of Pediatrics, Columbia University Irving Medical Center, Morgan Stanley Children's Hospital of NewYork Presbyterian, New York City, New York, USA
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14
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Aortic valve surgery: management and outcomes in the paediatric population. Eur J Pediatr 2021; 180:3129-3139. [PMID: 33970315 PMCID: PMC8429384 DOI: 10.1007/s00431-021-04092-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 04/18/2021] [Accepted: 04/25/2021] [Indexed: 11/02/2022]
Abstract
Congenital anomalies of the aortic valve frequently necessitate intervention in childhood. The most common aortic valve pathologies present in childhood are aortic stenosis and insufficiency. Presentation of aortic valve disease depends on severity and presence of concomitant syndromes and valvular disorders. Treatment options are largely categorised as medical, percutaneous repair or surgical repair and replacement. Surgical techniques have been refined over the last few years making this the mainstay of treatment in paediatric cases. Whilst repair is considered in most instances before replacement, there are substantial limitations which are reflected in the frequency of reintervention and restenosis rate. Replacements are typically undertaken with tissue or mechanical prosthesis. The current gold-standard aortic valve replacement surgery is called the Ross procedure-where replacement is undertaken with a competent pulmonic valve and a simultaneous pulmonary homograft.Conclusion: In this review, we aim to outline the various surgical options and discuss efficacy and complications of various interventions. What is Known: • Congenital aortic valve defects repair options medically and surgically What is New: • Comparisons between surgical options for aortic valve repair including efficacy, risks and long-term outcomes.
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15
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Fetal Echocardiographic Dimension Indices: Important Predictors of Postnatal Coarctation. Pediatr Cardiol 2021; 42:517-525. [PMID: 33355680 PMCID: PMC7990842 DOI: 10.1007/s00246-020-02509-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 11/17/2020] [Indexed: 11/11/2022]
Abstract
The aim of the study is to identify reliable quantitative fetal echocardiographic predictors for postnatal development of coarctation (CoA). In this retrospective study, we included 65 fetuses with a prenatally suspected, isolated CoA, born 2010-2018. Dimensions of the cardiac structures, aortic, and ductal arches expressed as ratios and Z-scores were analyzed in relation to outcome. Fetuses that developed CoA postnatally (34%) exhibited significantly smaller Z-scores of left cardiac structures from the mitral valve to the aortic isthmus. The most sensitive and specific predictors were a carotid-subclavian artery index (CSAI) of < 0.78 (92.3% sensitivity, 96.8% specificity) or a product of isthmus-to-duct ratio in the three-vessel trachea view (3VT) and the mitral-to-tricuspid valve ratio (I/D3VTxMV/TV) of < 0.37 (100% sensitivity, 94.6% specificity). When comparing different Z-score datasets, we observed large and highly significant differences. Postnatal CoA can be predicted with high accuracy during fetal life using CSAI or I/D3VTxMV/TV. The latter may be particularly useful if adequate sagittal aortic arch images cannot be obtained. As significant and clinically unacceptable differences in Z-scores were observed for the same measurements, this calls for a large multi-center collaboration to generate reliable fetal echocardiographic Z-scores.
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16
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Vigneswaran TV, Zidere V, Chivers S, Charakida M, Akolekar R, Simpson JM. Impact of prospective measurement of outflow tracts in prediction of coarctation of the aorta. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:850-856. [PMID: 31875324 DOI: 10.1002/uog.21957] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/12/2019] [Accepted: 12/13/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Prenatal diagnosis of coarctation of the aorta (CoA) is associated with reduced mortality and morbidity, however, accurate prenatal prediction remains challenging. To date, studies have used retrospective measurements of the outflow tracts to evaluate their potential to predict CoA. Our primary objective was to evaluate prospectively acquired measurements of the outflow tracts in fetuses with prenatally suspected CoA. A secondary aim was to report the postnatal prevalence of bicuspid aortic valve in this cohort. METHODS Pregnancies with suspicion of isolated CoA and with a minimum of 6 months' postnatal follow-up available were identified from the cardiac database of a tertiary fetal cardiology center in the UK, between January 2002 and December 2017. Measurement of the aortic valve, pulmonary valve, distal transverse aortic arch (DTAA) and arterial duct (AD) diameters were undertaken routinely in fetuses with suspected CoA during the study period. Z-scores were computed using published reference ranges based on > 7000 fetuses from our own unit. RESULTS Of 149 pregnancies with prenatally suspected CoA included in the study, CoA was confirmed within 6 months after birth in 77/149 (51.7%) cases. DTAA diameter Z-score and the Z-score of second-trimester DTAA/AD diameter ratio were smaller in fetuses with postnatally confirmed CoA than those in false-positive cases (-2.8 vs -1.9; P = 0.039 and -3.13 vs -2.61; P = 0.005, respectively). Multiple regression analysis demonstrated that the Z-scores of DTAA and AD diameters were the only significant predictors of postnatal CoA (P = 0.001). Bicuspid aortic valve was identified in 30% of the false-positive cases. CONCLUSIONS Measurement of DTAA and AD diameter Z-scores can be used to ascertain risk for postnatal CoA in a selected cohort. The high incidence of bicuspid aortic valve in false-positive cases merits further study with respect to both etiology and longer-term significance. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- T V Vigneswaran
- Harris Birthright Centre, Fetal Medicine Research Institute, King's College Hospital, London, UK
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's & St Thomas' NHS Trust, London, UK
- Department of Biomedical Engineering, King's College Hospital, London, UK
| | - V Zidere
- Harris Birthright Centre, Fetal Medicine Research Institute, King's College Hospital, London, UK
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's & St Thomas' NHS Trust, London, UK
| | - S Chivers
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's & St Thomas' NHS Trust, London, UK
| | - M Charakida
- Harris Birthright Centre, Fetal Medicine Research Institute, King's College Hospital, London, UK
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's & St Thomas' NHS Trust, London, UK
- Department of Biomedical Engineering, King's College Hospital, London, UK
| | - R Akolekar
- Harris Birthright Centre, Fetal Medicine Research Institute, King's College Hospital, London, UK
- Department of Obstetrics & Gynaecology, Medway Maritime Hospital, Gillingham, Kent, UK
| | - J M Simpson
- Harris Birthright Centre, Fetal Medicine Research Institute, King's College Hospital, London, UK
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's & St Thomas' NHS Trust, London, UK
- Department of Biomedical Engineering, King's College Hospital, London, UK
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17
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Belfrage K, Richards B, Corbitt R, Hersey D, Texter K, Stiver C, Cua CL. Initial fetal to initial postnatal echocardiogram in uncomplicated atrioventricular septal defects: Do significant changes occur? Echocardiography 2020; 37:2102-2106. [PMID: 33169446 DOI: 10.1111/echo.14923] [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: 08/07/2020] [Revised: 09/01/2020] [Accepted: 10/24/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Yield of serial echocardiography in fetuses with atrioventricular septal defects (fAVSD) has not been well defined. The goal of this study was to document if any major changes occurred from initial fetal to initial postnatal echocardiogram in uncomplicated fAVSD. METHODS fAVSD were excluded if initial fetal scan documented complex CHD or any concerns. Changes in ventricular function, valvular regurgitation, or diagnosis between first fetal and first postnatal echocardiogram were recorded. RESULTS Fifty-seven fAVSD met criteria. Ninety-six fetal echocardiograms were done in 57 patients. Initial fetal scan was performed at 24.3 ± 3.7 weeks of estimated gestational age. All fAVSD had normal function, 38 had no atrioventricular valve regurgitation (AVVR), and 19 had mild AVVR. First postnatal echocardiogram was performed at 6.3 ± 15.3 days. Fifty-six patients had normal function, 1 patient had mild dysfunction, 16 patients had no AVVR, 36 had mild AVVR, and 5 had moderate AVVR. Three patients (5%) had an improvement in AVVR by one degree, 27 patients (47%) had no change in AVVR, 24 patients (42%) had an increase in AVVR by one degree, and 3 patients (5%) had an increase in AVVR by two degrees. There was no major missed anatomical diagnosis from first prenatal to first postnatal echocardiogram. CONCLUSION In fAVSD that had no concerns on their initial fetal echocardiogram, the majority of patients had no major changes noted between their initial fetal echocardiogram and their first postnatal echocardiogram. Repeat fetal echocardiograms may not necessarily be needed in this cohort of patients.
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Affiliation(s)
| | | | - Rebecca Corbitt
- Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
| | - Diane Hersey
- Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
| | - Karen Texter
- Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
| | - Corey Stiver
- Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
| | - Clifford L Cua
- Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
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18
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Hede SV, DeVore G, Satou G, Sklansky M. Neonatal management of prenatally suspected coarctation of the aorta. Prenat Diagn 2020; 40:942-948. [PMID: 32277716 DOI: 10.1002/pd.5696] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 03/24/2020] [Accepted: 03/28/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVES (a) To determine the false-positive rate among newborns with prenatally suspected coarctation of the aorta (CoA) within the UCLA Health system, (b) to compare patient and maternal interventions and outcomes between false-positive cases and normal controls, and (c) to determine the timing of clinical presentation of CoA. METHODS We performed a single-center, retrospective case control study of all fetuses with suspected isolated CoA who underwent both fetal echocardiographic evaluation and subsequent delivery at UCLA between January 1, 2011, and December 31, 2018. Maternal and neonatal medical records were reviewed for demographic and clinical data, for cases of suspected CoA and for controls. A separate review of our institution's surgical database was performed to identify characteristics of all patients (neonatal and pediatric) with isolated CoA who underwent surgical repair during the same time period. RESULTS Among the 50 fetal cases of isolated suspected CoA who delivered at our institution, 47 patients (94%) were found to be normal (false positives). Compared with normal controls, patients with suspected CoA were more likely to have delayed maternal bonding, delayed feeding, admission to the intensive care unit, performance of neonatal echocardiograms, initiation of intravenous fluids and initiation of prostaglandin E1, and a longer length of hospital stay. Among the 38 patients undergoing CoA repair at our institution during the study period, four patients were prenatally diagnosed and no patient presented clinically with symptoms before 48 hours after delivery. CONCLUSION Compared with normal controls, patients with prenatally suspected coarctation are more likely to have delayed maternal bonding, delayed feeding, more frequent neonatal echocardiograms, and longer length of hospital stay. Further refinement of neonatal management may improve postnatal care.
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Affiliation(s)
- Sannya V Hede
- Division of Pediatric Cardiology, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Greggory DeVore
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Gary Satou
- Division of Pediatric Cardiology, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Mark Sklansky
- Division of Pediatric Cardiology, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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19
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Lehnert A, Villemain O, Gaudin R, Méot M, Raisky O, Bonnet D. Risk factors of mortality and recoarctation after coarctation repair in infancy. Interact Cardiovasc Thorac Surg 2020; 29:469-475. [PMID: 31089681 DOI: 10.1093/icvts/ivz117] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 04/05/2019] [Accepted: 04/10/2019] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES The main challenge of aortic coarctation (CoA) repair in infants is to obtain durable results without morbidity. We aimed to describe predictors of aortic arch reintervention after aortic CoA repair. METHODS Between January 2000 and March 2014, we retrospectively included consecutive infants with isolated CoA or CoA with ventricular septal defect (CoA + VSD) who had surgical repair of the aortic arch before 3 months of age. RESULTS Five hundred and thirty patients were included: 308 (58%) patients had isolated CoA and 222 (42%) patients had CoA + VSD. Three hundred and eighty-five patients (72.6%) had CoA repair, 51 patients (9.6%) had CoA repair with closure of VSD and 94 patients (17.8%) had CoA repair with pulmonary artery banding. Mean age at operation was 13 ± 1.6 days, with 294 patients (55.5%) operated on before 2 weeks. Median follow-up was 7.57 years. Sixty-one patients (11.5%) needed reintervention on the aortic arch. Freedom from aortic arch reintervention was 90% at 1 year and 88.5% at 5 years. Proportions of aortic arch reintervention were similar in the different surgical strategy groups (P = 0.80). However, in patients receiving prostaglandin E1 (PGE1), the end-to-end repair was at higher risk of recoarctation compared to the extended end-to-side repair (P = 0.033). The risk factors of aortic arch reintervention were age at repair <15 days (P = 0.034) and the need for PGE1 infusion at surgery (P = 0.0043). CONCLUSIONS CoA repair in young infants has an overall good outcome. The use of PGE1 may modify the aortic arch anatomy and mask the boundaries of the resection to be performed. PGE1 treatment should be studied more specifically in another study to improve preoperative management.
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Affiliation(s)
| | - Olivier Villemain
- M3C-Necker Enfants Malades, AP-HP, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Régis Gaudin
- M3C-Necker Enfants Malades, AP-HP, Paris, France
| | - Mathilde Méot
- M3C-Necker Enfants Malades, AP-HP, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Olivier Raisky
- M3C-Necker Enfants Malades, AP-HP, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Damien Bonnet
- M3C-Necker Enfants Malades, AP-HP, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,UMR-1163 INSERM, Institut IMAGINE, IcarP Cardiology, Paris, France
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20
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Wang H, Lei W, Liu J, Yang B, Li H, Huang D. The Diastolic and Systolic Velocity-Time Integral Ratio of the Aortic Isthmus Is a Sensitive Indicator of Aortic Coarctation in Fetuses. J Am Soc Echocardiogr 2019; 32:1470-1476. [PMID: 31443942 DOI: 10.1016/j.echo.2019.06.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 06/13/2019] [Accepted: 06/13/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Prenatal diagnosis of coarctation of the aorta (CoA) is challenging and is affected by high false-positive and false-negative rates. The aim of this study was to identify sonographic criteria to improve the identification of fetal CoA. METHODS A retrospective review was conducted of subjects with prenatal suspicion for CoA who also had postnatal follow-up. Sixty-nine fetuses were identified with possible CoA, and 47 normal fetuses were selected as control subjects. Retrospective measurements of right ventricular/left ventricular ratio, pulmonary artery/aorta ratio, aortic isthmus (AOI) Z score, diastolic velocity-time integral (VTID), and systolic velocity-time integral (VTIS) at the AOI were recorded. Receiver operating characteristic curve analysis identified the parameter most predictive of postnatal CoA. RESULTS When comparing subjects with (n = 31) and without (n = 38) CoA, significant differences were detected for the AOI Z score, VTID, VTID/VTIS ratio, and VTID/(VTID + VTIS) ratio (P < .001). The areas under the receiver operating characteristic curve were 0.92, 0.92, 0.78, 0.74, 0.71, and 0.68 for the VTID/VTIS ratio, VTID/(VTID + VTIS) ratio, VTID, AOI Z score (sagittal view), AOI Z score (three-vessel tracheal view), and pulmonary artery/aorta ratio, respectively. There was a 25% (95% CI, 14%-35%) improvement in the area under the curve after adding the VTID/VTIS ratio to the basic model (AOI Z score [sagittal view]), and this ratio (after transformation) showed significantly better discrimination and reclassification ability for determining CoA. The pulmonary artery/aorta ratio, VTID, VTID/VTIS ratio, and VTID/(VTID + VTIS) ratio were stable throughout the normal fetal developmental period in this study. CONCLUSIONS In cases with suspected prenatal diagnosis of CoA, evaluation of spectral Doppler measurements, such as the VTID/VTIS ratio, may enhance the accuracy of diagnosis with fetal echocardiography.
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Affiliation(s)
- Hongying Wang
- Department of Medical Ultrasonics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Wenjia Lei
- Department of Medical Ultrasonics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Jinrong Liu
- Department of Medical Ultrasonics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Boyang Yang
- Department of Medical Ultrasonics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Huixian Li
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Danping Huang
- Department of Medical Ultrasonics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.
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Cangussú LR, Lopes MR, Barbosa RHDA. The importance of the early diagnosis of aorta coarctation. ACTA ACUST UNITED AC 2019; 65:240-245. [PMID: 30892450 DOI: 10.1590/1806-9282.65.2.240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 06/20/2018] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Coarctation of the aorta is a congenital heart disease characterized by a narrowing that occurs in the aortic artery. This constriction can occur anywhere along its entire length; however, it is more common between the origin of the left subclavian artery and the ductus arteriosus. Its incidence corresponds to 3 cases per 10,000 births. Thus, it is a common cardiopathy, but with high mortality and morbidity rates, which are related to a failure in the early diagnosis. METHOD In the research, articles of the national and international literature in Pubmed, Scielo and Lilacs databases were selected using the following descriptors: coarctation, aorta, diagnosis, heart diseases, congenital abnormalities. RESULTS The pathophysiology of CoA and its systemic implications in the life of newborn and adults are well elucidated. However, due to the lack of habit to palpate pulses and to check the blood pressure in both upper and lower limbs during the physical examination, it is still a pathology little diagnosed in childhood. There are several techniques used in the repair of coarctation, each with their specifics, although, when not treated, aneurysms, heart failure, coronary diseases, and stroke are the main complications arising from the evolution of this pathology, which explains the low survival rate of these patients. CONCLUSION Coarctation of the aorta is, therefore, a cardiac malformation of significant importance due to its incidence and its significant mortality risk. In this sense, the early diagnosis stands out as an essential piece for better prognosis of the patient.
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Affiliation(s)
- Luana Resende Cangussú
- Medical student, Federal University of Vale do São Francisco, Paulo Afonso, Bahia, Brasil
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