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Rakha S. Initiating a Fetal Cardiac Program from Scratch in Low- and Middle-Income Countries: Structure, Challenges, and Hopes for Solutions. Pediatr Cardiol 2024:10.1007/s00246-024-03479-9. [PMID: 38639814 DOI: 10.1007/s00246-024-03479-9] [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: 12/27/2023] [Accepted: 03/19/2024] [Indexed: 04/20/2024]
Abstract
Although fetal cardiac programs are well established in developed countries, establishing an efficient program in low- and middle-income countries (LMICs) is still considered a significant challenge. Substantial obstacles usually face the initiation of fetal cardiac service from scratch in LMICs. The primary structural frame of a successful fetal cardiac program is described in detail, emphasizing the required team members. The potential challenges for starting fetal cardiac services in LMICs include financial, awareness-related, prenatal obstetric screening, sociocultural, psychosocial, and social support factors. These challenges could be solved by addressing these barriers, such as collecting funds for financial support, raising awareness among families and health care providers, telemedicine, building international health partnerships, modifying training protocols for fetal cardiologists and sonographers, and initiating support groups and social services for families with confirmed fetal cardiac disease. Initiating a successful fetal cardiac program requires multi-aspect structural planning. The challenges for program initiation require diverse efforts, from modified training and promoting awareness of care providers and the community to governmental and nonprofit organizations' collaborations for proper building and utilization of program resources.
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Affiliation(s)
- Shaimaa Rakha
- Pediatric Cardiology Unit, Department of Pediatrics, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
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2
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He R, Hornberger LK, Kaur A, Crawford S, Boehme C, McBrien A, Eckersley L. Risk of major congenital heart disease in pregestational maternal diabetes is modified by hemoglobin A1c. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:378-384. [PMID: 37594210 DOI: 10.1002/uog.27456] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/26/2023] [Accepted: 08/04/2023] [Indexed: 08/19/2023]
Abstract
OBJECTIVES The association between pregestational diabetes mellitus (PDM) and risk of congenital heart disease (CHD) is well recognized; however, the importance of glycemic control and other coexisting risk factors during pregnancy is less clear. We sought to determine the relative risk (RR) of major CHD (mCHD) among offspring from pregnancies complicated by PDM and the effect of first-trimester glycemic control on mCHD risk. METHODS We determined the incidence of mCHD (requiring surgery within 1 year of birth or resulting in pregnancy termination or fetal demise) among registered births in Alberta, Canada. Linkage of diabetes status, maximum hemoglobin A1c (HbA1c) at < 16 weeks' gestation and other covariates was performed using data from the Alberta Perinatal Health Program registry. Risk of mCHD according to HbA1c was estimated as an adjusted RR (aRR), calculated using log-binomial modeling. RESULTS Of 1412 cases of mCHD in 594 773 (2.37/1000) births in the study period, mCHD was present in 48/7497 with PDM (6.4/1000; RR, 2.8 (95% CI, 2.1-3.7); P < 0.0001). In the entire cohort, increased maternal age (aRR, 1.03 (95% CI, 1.02-1.04); P < 0.0001) and multiple gestation (aRR, 1.37 (95% CI, 1.1-1.8); P = 0.02) were also associated with mCHD risk, whereas maternal prepregnancy weight > 91 kg was not. The stratified risk for mCHD associated with HbA1c ≤ 6.1%, > 6.1-8.0% and > 8.0% was 4.2/1000, 6.8/1000 and 17.1/1000 PDM/gestational diabetes mellitus births, respectively; the aRR of mCHD associated with PDM and HbA1c > 8.0% was 8.5 (95% CI, 5.0-14.4) compared to those without diabetes and 5.5 (95% CI, 1.6-19.4) compared to PDM with normal HbA1c (≤ 6.1%). CONCLUSIONS PDM is associated with a RR of 2.8 for mCHD, increasing to 8.5 in those with HbA1c > 8%. These data should facilitate refinement of referral indications for high-risk pregnancy screening. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- R He
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - L K Hornberger
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - A Kaur
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - S Crawford
- Alberta Perinatal Health Program, Alberta Health Services, AB, Canada
| | - C Boehme
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - A McBrien
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - L Eckersley
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women & Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
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Medjedovic E, Begic Z, Stanojevic M, Aziri B, Begic E, Djukic M, Mladenovic Z, Kurjak A. Left atrial strain in fetal echocardiography - could it be introduced to everyday clinical practice? J Perinat Med 2024; 52:230-238. [PMID: 38095322 DOI: 10.1515/jpm-2023-0359] [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: 08/30/2023] [Accepted: 11/11/2023] [Indexed: 02/09/2024]
Abstract
OBJECTIVES Prenatal cardiology is a part of preventive cardiology based on fetal echocardiography and fetal interventional cardiology, which facilitates treatment of congenital heart defects (CHD) in pediatric patients and consequently in adults. Timely prenatal detection of CHD plays a pivotal role in facilitating the appropriate referral of pregnant women to facilities equipped to provide thorough perinatal care within the framework of a well-structured healthcare system. The aim of this paper is to highlight the role of left atrial strain (LAS) in prenatal evaluation of fetal heart and prediction of structural and functional disorders. METHODS We conducted a comprehensive literature review searching PubMed for articles published from inception up until August 2023, including the search terms "left atrial strain", "fetal echocardiography", and "prenatal cardiology" combined through Boolean operators. In addition, references lists of identified articles were further reviewed for inclusion. RESULTS Our review underscores the significance of LAS parameters in fetal echocardiography as a screening tool during specific gestational windows (starting from 11 to 14 weeks of gestation, followed by better visualization between 18 and 22 weeks of gestation). The left atrial strain technique and its parameters serve as valuable indicators, not only for identifying cardiac complications but also for predicting and guiding therapeutic interventions in cases of both cardiac and noncardiac pregnancy complications in fetuses. Evidence suggests establishment of second-trimester reference strain and strain rate values by speckle-tracking echocardiography in the healthy fetal cohort is essential for the evaluation of myocardial pathologies during pregnancy. CONCLUSIONS Finding of LAS of fetal heart is feasible and probably can have potential for clinical and prognostic implications.
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Affiliation(s)
- Edin Medjedovic
- Clinic of Gynecology and Obstetrics, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
- Department of Gynecology, Obstetrics and Reproductive Medicine, School of Medicine, Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina
| | - Zijo Begic
- Department of Cardiology, Pediatric Clinic, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Milan Stanojevic
- Department of Obstetrics and Gynecology, University Hospital "Sveti Duh", Zagreb, Croatia
| | - Buena Aziri
- Department of Pharmacology, Sarajevo Medical School, Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina
| | - Edin Begic
- Department of Pharmacology, Sarajevo Medical School, Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina
- Department of Cardiology, General Hospital "Prim. Dr. Abdulah Nakas", Sarajevo, Bosnia and Herzegovina
| | - Milan Djukic
- Department of Cardiology, University Children's Hospital, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Zorica Mladenovic
- Department of Cardiology, Military Medical Academy, University of Defense, Belgrade, Serbia
- Faculty of Medicine, University of Defense, Belgrade, Serbia
| | - Asim Kurjak
- Department of Obstetrics and Gynecology, University Hospital "Sveti Duh", Zagreb, Croatia
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Paul EA, Cohen J, Geiger MK. Cardiac problems in the fetus: a review for pediatric providers. Curr Opin Pediatr 2023; 35:523-530. [PMID: 37466056 DOI: 10.1097/mop.0000000000001274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
PURPOSE OF REVIEW The aim of this study was to provide pediatric providers with a review of the diagnosis and management of fetal cardiac disease in the current era. RECENT FINDINGS Prenatal detection of congenital heart disease (CHD) has improved but is still imperfect. In experienced hands, fetal echocardiography can detect severe CHD as early as the first trimester and a majority of more subtle conditions in the second and third trimesters. Beyond detection, a prenatal diagnosis allows for lesion-specific counseling for families as well as for development of a multidisciplinary perinatal management plan, which may involve in-utero treatment. Given the diversity of cardiac diagnoses and the rarity of some, collaborative multicenter fetal cardiac research has gained momentum in recent years. SUMMARY Accurate diagnosis of fetal cardiac disease allows for appropriate counseling, pregnancy and delivery planning, and optimization of immediate neonatal care. There is potential for improving fetal CHD detection rates. Fetal interventions are available for certain conditions, and fetal and pediatric cardiac centers have developed management plans specific to the expected postnatal physiology.
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Affiliation(s)
- Erin A Paul
- Division of Pediatric Cardiology, Mount Sinai Kravis Children's Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Hornberger LK, Eckersley LG. Reply to Letter: Resources to Learn the 3-Vessel and Trachea Sweep and Other Nonstandard Views for Cardiac Screening. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:1251-1252. [PMID: 36567093 DOI: 10.1016/j.jogc.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Lisa K Hornberger
- Fetal & Neonatal Cardiology Program, University of Alberta, Edmonton, AB.
| | - Luke G Eckersley
- Fetal & Neonatal Cardiology Program, University of Alberta, Edmonton, AB
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Kaur A, Hornberger LK, Fruitman D, Ngwezi DP, Chandra S, Eckersley LG. Trends in the Prenatal Detection of Major Congenital Heart Disease in Alberta From 2008-2018. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:895-900. [PMID: 35513257 DOI: 10.1016/j.jogc.2022.03.020] [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: 01/05/2022] [Revised: 03/19/2022] [Accepted: 03/21/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The effect of expanded obstetrical ultrasound cardiac views on the diagnosis of fetal congenital heart disease (CHD) has not been fully examined at a population level. We hypothesized there has been a significant increase in the prenatal detection of CHD in Alberta, particularly for CHD associated with cardiac outflow tract and 3-vessel view abnormalities. METHODS Using provincial databases, we retrospectively identified all fetuses and infants diagnosed between 2008 and 2018 in Alberta with major CHD requiring surgical intervention within the first postnatal year. We evaluated individual lesions and categorized CHDs into the following groups based on the obstetrical ultrasound cardiac views required for detection: (1) 4-chamber view (e.g., hypoplastic left heart syndrome, Ebstein's anomaly, single ventricle); (2) outflow tract view (e.g., tetralogy of Fallot, d-transposition, truncus arteriosus); (3) 3-vessel or other non-standard cardiac views (e.g., coarctation, anomalous pulmonary veins); and (4) isolated ventricular septal defects using any view. RESULTS Of 1405 cases of major CHD, 814 (58%) were prenatally diagnosed. Over the study period, prenatal detection increased in all groups, with the greatest increase observed for groups 1 and 2 (75%-88%; P = 0.008 and 56%-79%; P = 0.0002, respectively). Although rates of prenatal detection also increased for groups 3 and 4 (27%-43%; P = 0.007 and 13%-30%; P = 0.04, respectively), fewer than half of the cases in each group were detected prenatally, even in more recent years. CONCLUSIONS While rates of prenatal detection of CHD have significantly improved during the past decade, many defects with abnormal 3-vessel and non-standard views, as well as isolated ventricular septal defects, still go undetected.
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Affiliation(s)
- Amanpreet Kaur
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women's & Children's Health Research Institute, University of Alberta, Edmonton, AB
| | - Lisa K Hornberger
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women's & Children's Health Research Institute, University of Alberta, Edmonton, AB.
| | - Deborah Fruitman
- Division of Cardiology, Department of Pediatrics, University of Calgary, Calgary AB
| | - Deliwe P Ngwezi
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women's & Children's Health Research Institute, University of Alberta, Edmonton, AB
| | - Sujata Chandra
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Women's & Children's Health Research Institute, University of Alberta, Edmonton, AB
| | - Luke G Eckersley
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women's & Children's Health Research Institute, University of Alberta, Edmonton, AB
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Affiliation(s)
- John Simpson
- Fetal Cardiology Service, Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, United Kingdom (J.S.)
| | - Lisa K Hornberger
- Fetal and Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics (L.K.H.), Women and Children's Health Research Institute, University of Alberta, Edmonton, Canada.,Department of Obstetrics and Gynecology (L.K.H.), Women and Children's Health Research Institute, University of Alberta, Edmonton, Canada
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Hornberger LK, McBrien A. Extracardiac Pathology in Fetal Heart Disease: What You See Is Not Always What You Get. J Am Coll Cardiol 2021; 78:2323-2325. [PMID: 34857094 DOI: 10.1016/j.jacc.2021.09.1359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 09/21/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Lisa K Hornberger
- Fetal and Neonatal Cardiology Program, Pediatric Cardiology, Women's and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada.
| | - Angela McBrien
- Fetal and Neonatal Cardiology Program, Pediatric Cardiology, Women's and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada. https://twitter.com/angmcbrien
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