Prevalence of Congenital Heart Disease at Live Birth in China

The use of high-resolution SNP arrays to detect congenital cardiac defects

OBJECTIVE

Copy number variations (CNVs) detected by high-resolution single nucleotide polymorphism microarrays (SNP arrays) have been associated with congenital heart defects (CHDs). The genetic mechanism underlying the development of CHDs remains unclear.

METHODS

High-resolution SNP arrays were used to detect CNVs and traditional chromosomal analyses, respectively, were carried out on 60 and 249 fetuses from gestational 12-37 weeks old, having isolated or complex CHDs that were diagnosed using prenatal ultrasound.

RESULTS

Twenty of the 60 fetuses (33.5%) had abnormalities, of which 23 CNVs (12 pathogenic, five probable pathogenic and six of undetermined significance) were detected by SNP arrays, and two distinct CNVs were present in three of these fetuses. In addition, in 39 patients with isolated congenital heart disease who had normal karyotypes, abnormal CNVs were present in 28.2% (11/39), and in patients with complex coronary artery disease, 19.0% (4/21) had abnormal karyotypes and 42.9% (9/21) had abnormal CNVs. In patients with complex coronary artery disease, 19.0% (4/21) had abnormal karyotypes and 42.9% (9/21) had abnormal CNVs.

CONCLUSIONS

In conclusion, genome-wide high-resolution SNP array can improve the diagnostic rate and uncover additional pathogenic CNVs. The submicroscopic deletions and duplications of Online Mendelian Inheritance in Man (OMIM) genes found in this study have haploinsufficient (deletion) or triplosensitive (duplication) traits, which further clarify the etiology and inheritance of CHDs.

PFOS and PFOSA induce oxidative stress-mediated cardiac defects in zebrafish via PPARγ and AHR pathways, respectively

Perfluorooctane sulfonate (PFOS) and its precursor, perfluorooctane sulfonamide (PFOSA), are widespread in the environment. Evidence suggests a strong link between maternal exposure to PFOS/PFOSA and congenital heart diseases in the offspring, but the underlying mechanisms remain unclear. We hypothesized that PFOS and PFOSA induce cardiac defects through the peroxisome proliferator-activated receptor gamma (PPARγ) and aryl hydrocarbon receptor (AHR) pathways, respectively. In this study, we demonstrated that exposing zebrafish embryos to either PFOSA or PFOS caused cardiac malformations and dysfunction. Both PFOS and PFOSA induced reactive oxygen species (ROS) overproduction, mitochondrial damage, and apoptosis in zebrafish larvae hearts. Blockade of PPARγ through either pharmaceutical inhibition or genetic knockdown only attenuated the changes caused by PFOS, but not those elicited by PFOSA. Conversely, inhibition of AHR alleviated the adverse effects induced by PFOSA but not by PFOS. Both PFOSA and PFOS exhibited similar binding affinities to AHR using molecular docking techniques. The varying ability of PFOS and PFOSA to induce AHR activity in zebrafish embryonic hearts can be attributed to their different capabilities for activating PPARγ. In summary, our findings indicate that PFOS and PFOSA induce excessive ROS production in zebrafish larvae via the PPARγ and AHR pathways, respectively. This oxidative stress in turn causes mitochondrial damage and apoptosis, leading to cardiac defects.

Trends in under-five mortality rate in China, 1996-2020: a Joinpoint regression and correlation analysis

OBJECTIVES

To analyse annual trends of the under-five mortality rate (U5MR) and main cause-specific U5MR in China from 1996 to 2020 and to assess the potential correlation of the healthcare system and health expenditure with the U5MR in China.

DESIGN

A retrospective observational study using national data from 1996 to 2020. Joinpoint regression was employed to model U5MR trends and Pearson correlation analysis was conducted to examine the relationship between healthcare system factors, health expenditure and U5MR.

SETTING

Nationwide study covering both rural and urban populations across China over a 25-year period.

RESULTS

The U5MR in China experienced a three-stage decline from 1996 to 2020 with an average annual percentage rate change (AAPC) of -7.27 (p<0.001). The AAPC of the rural U5MR (-7.07, p<0.001) was higher than that in urban areas (-5.57, p<0.001). Among the five main causes, the decrease in pneumonia-caused U5MR was the fastest while the decreases in congenital heart disease and accidental asphyxia were relatively slow. The rates of hospital delivery (r=-0.981, p<0.001), neonatal visits (r=-0.848, p<0.001) and systematic health management (r=-0.893, p<0.001) correlated negatively with U5MR. The proportion of government health expenditure in the total health expenditure (THE) correlated negatively with the national U5MR (r=-0.892, p<0.001) while the proportion of out-of-pocket health expenditure in THE correlated positively (r=0.902, p<0.001).

CONCLUSION

China made significant advances in reducing U5MR from 1996 to 2020. The rural-urban gap in U5MR has narrowed, though rural areas remain a key concern. To further reduce U5MR, China should focus on rural areas, pay more attention to congenital heart disease and accidental asphyxia, further improve its health policies, and continue to increase the government health expenditure.

Maternal exposure to ambient ozone and fetal congenital heart defects: a national multicenter study in China

BACKGROUND

Ambient O3 has demonstrated an aggravated increasing trend in the context of global warming. The available evidence of maternal exposure to ambient O3 on fetal congenital heart defects (CHD) is still limited, especially in high polluted areas.

OBJECTIVE

To examine associations of maternal exposure to ambient O3 during early pregnancy with fetal CHDs.

METHODS

We conducted a national multicenter study in 1313 hospitals from 26 provinces in China and collected a total of 27,817 participants at high risk of CHD from 2013 to 2021. Exposure to ambient O3 during the embryonic period, preconception, the first trimester and periconception was assessed by extracting daily concentrations from a validated grid dataset at each subject's residential district. CHDs were diagnosed based on fetal echocardiography.

RESULTS

Each 10 µg/m3 increase of exposure to ambient O3 during the embryonic period was approximately linearly associated with a 12.7% (odds ratio [OR]: 1.127, 95% confidence interval [CI]: 1.098, 1.155) increase in odds of pooled CHD (p < 0.001). The associations remain robust after adjusting for ambient PM2.5 and NO2 exposure. The odds of different types of CHD in association with ambient O3 exposure varied greatly. We observed significant association of ambient O3 exposure with ventricular septal defect (VSD), tetralogy of Fallot (TOF); pulmonary stenosis (PS), pulmonary atresia (PA), transposition of great arteries (TGA) and persistent left superior vena cava (PLSVC), with TOF demonstrating the strongest estimates (OR: 1.194, 95% CI:1.107, 1.288). The estimates for preconception, the first trimester and periconception demonstrate consistent findings with the main analyses, indicating stronger associations of ambient O3 exposure during the periconception period.

IMPACT

Our study provides evidence that higher ambient O3 during early pregnancy was significantly associated with increased odds of fetal CHD. Our findings suggest that pregnant women, clinical practitioners, and policy makers need to pay more attention to the exposure to higher ambient O3 during early pregnancy to reduce the risk of developing CHD and to improve outcomes across the life span.

Relationship between maternal serum uric acid in the first trimester and congenital heart diseases in offspring: A prospective cohort study

Objective

This study aimed to investigate the relationship between maternal serum uric acid levels in the first trimester and the incidence of congenital heart diseases (CHDs) in offspring.

Methods

This prospective cohort study was conducted in the southeast of China and involved 21,425 pregnant women and their offspring in the final analysis between 2019 and 2022. Fasting blood samples from pregnant women participating in the Fujian birth cohort study (11.3 ± 1.40 weeks of gestation) were analyzed for serum uric acid levels. The perinatal outcome was the incidence of CHDs. All fetuses with CHDs were confirmed by echocardiography doctors and pediatric cardiologists. Logistic regression analysis and restricted cubic spline (RCS) modeling were employed to investigate the relationship between serum uric acid level and the incidence of CHDs.

Results

We observed that maternal log2-transformed values of serum uric acid were strongly associated with odds of CHDs in offspring (adjusted odds ratio [AOR] 1.589, 95 % CI [1.149, 2.198]). Compared to the lowest quartile, the AORs for maternal uric acid levels in the other quartiles and the corresponding risk of CHDs in offspring were 1.363 (95 % CI [1.036, 1.793]), 1.213 (95 % CI [0.914, 1.610]), and 1.472 (95 % CI [1.112, 1.949]), respectively. Hyperuricemia in the first trimester significantly increased the risk of CHDs in offspring 1.837 (95 % CI [1.073, 3.145]). Furthermore, RCS showed a linear relationship between maternal serum uric acid levels in the first trimester and the incidence of CHDs (P for nonlinearity = 0.71).

Conclusions

The results of this study indicated that elevated maternal serum uric acid levels in the first trimester were associated with an increased incidence of CHDs in offspring.

Association of copy number variation in X chromosome-linked PNPLA4 with heterotaxy and congenital heart disease

BACKGROUND

Heterotaxy (HTX) is a thoracoabdominal organ anomaly syndrome and commonly accompanied by congenital heart disease (CHD). The aim of this study was to analyze rare copy number variations (CNVs) in a HTX/CHD cohort and to examine the potential mechanisms contributing to HTX/CHD.

METHODS

Chromosome microarray analysis was used to identify rare CNVs in a cohort of 120 unrelated HTX/CHD patients, and available samples from parents were used to confirm the inheritance pattern. Potential candidate genes in CNVs region were prioritized via the DECIPHER database, and PNPLA4 was identified as the leading candidate gene. To validate, we generated PNPLA4 -overexpressing human induced pluripotent stem cell lines as well as pnpla4 -overexpressing zebrafish model, followed by a series of transcriptomic, biochemical and cellular analyses.

RESULTS

Seventeen rare CNVs were identified in 15 of the 120 HTX/CHD patients (12.5%). Xp22.31 duplication was one of the inherited CNVs identified in this HTX/CHD cohort, and PNPLA4 in the Xp22.31 was a candidate gene associated with HTX/CHD. PNPLA4 is expressed in the lateral plate mesoderm, which is known to be critical for left/right embryonic patterning as well as cardiomyocyte differentiation, and in the neural crest cell lineage. Through a series of in vivo and in vitro analyses at the molecular and cellular levels, we revealed that the biological function of PNPLA4 is importantly involved in the primary cilia formation and function via its regulation of energy metabolism and mitochondria-mediated ATP production.

CONCLUSIONS

Our findings demonstrated a significant association between CNVs and HTX/CHD. Our data strongly suggested that an increased genetic dose of PNPLA4 due to Xp22.31 duplication is a disease-causing risk factor for HTX/CHD.

Risk-prediction nomogram for congenital heart disease in offspring of Chinese pregnant women

BACKGROUND

The identification and assessment of environmental risks are crucial for the primary prevention of congenital heart disease (CHD). We were aimed to establish a nomogram model for CHD in the offspring of pregnant women and validate it using a large CHD database in Northwest China.

METHODS

A survey was conducted among 29,204 women with infants born between 2010 and 2013 in Shaanxi province, Northwest China. Participants were randomly assigned to the training set and to the validation set at a ratio of 7:3. The importance of predictive variables was assessed using random forest. A multivariate logistic regression model was used to construct the nomogram for the prediction of CHD.

RESULTS

Multivariate analyses revealed that the gravidity, preterm birth history, family history of birth defects, infection, taking medicine, tobacco exposure, pesticide exposure and singleton/twin pregnancy were significant predictive risk factors for CHD in the offspring of pregnant women. The area under the receiver operating characteristic curve for the prediction model was 0.716 (95% CI: 0.671, 0.760) in the training set and 0.714 (95% CI: 0.630, 0.798) in the validation set, indicating moderate discrimination. The prediction model exhibited good calibration (Hosmer-Lemeshow χ2 = 1.529, P = 0.910).

CONCLUSIONS

We developed and validated a predictive nomogram for CHD in offspring of Chinese pregnant women, facilitating the early prenatal assessment of the risk of CHD and aiding in health education.

Interatrial Communications: Prevalence and Subtypes in 12,385 Newborns-a Copenhagen Baby Heart Study

The prevalence of interatrial communications in newborns, i.e., patent foramen ovale or atrial septal defect, was previously reported to be between 24 and 92%, but the area has been impeded by lack of a universal classification method. A recently published novel echocardiographic diagnostic algorithm for systematic classification of interatrial communications had inter-and intraobserver agreements superior to standard expert assessment. This study aimed to determine the prevalence of subtypes of interatrial communications on transthoracic echocardiography in newborns. Echocardiograms of newborns aged 0-30 days were prospectively collected in the population-based cohort study Copenhagen Baby Heart Study in 2017-2018 and analyzed according to the new diagnostic algorithm, classifying interatrial communications into three subtypes of patent foramen ovale and three subtypes of atrial septal defects. Echocardiograms from 15,801 newborns were analyzed; 3416 (21.6%) were excluded due to suboptimal image quality or severe structural heart disease (n = 3), leaving 12,385 newborns (aged 12 [interquartile range 8; 15] days, 48.2% female) included in the study. An interatrial communication was detected in 9766 (78.9%) newborns. According to the algorithm, 9029 (72.9%) had a patent foramen ovale, while 737 (6.0%) fulfilled criteria for an atrial septal defect, further divided into subtypes. An interatrial communication was seen on echocardiography in almost 80% of newborns aged 0-30 days. Patent foramen ovale was 12 times more frequent than atrial septal defects. The observed prevalence of atrial septal defects was higher than previously reported. Follow up studies could distinguish which interatrial communications require follow-up or intervention. ClinicalTrial.gov, NCT02753348, posted April 27, 2016, [ https://classic.clinicaltrials.gov/ct2/show/NCT02753348 ].

Nationwide Birth Prevalence of Crucial Congenital Heart Defects From 2014 to 2018 in Korea

BACKGROUND AND OBJECTIVES

A comprehensive survey of congenital heart disease (CHD) prevalence has not yet been conducted in South Korea. This study aimed to investigate the prevalence of CHDs in Korean children and lay the foundation for national CHD epidemiology.

METHODS

Target patients were infantile crucial CHDs, which include critical CHDs (requiring urgent procedures after birth with common hypoxemic defects) and diverse categorical defects excluding simple shunt defects. Data were obtained from the National Health Insurance Service over a 5-year period (2014-2018). Birth prevalence (new cases per 1,000 live births) of CHDs in Korea was analyzed and compared with that of other countries.

RESULTS

The birth prevalences of right heart obstructive defects (pulmonary valve stenosis and pulmonary atresia), conus anomalies (tetralogy of Fallot and double outlet right ventricle), and total anomalous pulmonary venous return showed significant increases in the East Asian group (P < 0.001), whereas those of left heart obstructive defects (coarctation of aorta, aortic stenosis, and hypoplastic left heart syndrome), truncus anomalies (D-transposition of great artery and persistent truncus arteriosus), atrioventricular septal defect, and hypoplastic right heart syndrome were significantly decreased in the East Asian group (P < 0.001).

CONCLUSIONS

The overall birth prevalence of crucial CHDs in Korea was similar to that of critical CHDs in previous studies from other countries. Some subtypes of right heart obstructive defects, left heart obstructive defects, and conotruncal anomalies showed significant differences between East Asian and Western populations. This study contributes to a foundation for national CHD epidemiology in Korean children.

Perinatal prevalence of birth defects in the Mainland of China, 2000-2021: a systematic review and meta-analysis

BACKGROUND

Although birth defects are of great concern globally, the latest national prevalence has not yet been quantified in China. We conducted a systematic review and meta-analysis to estimate the perinatal prevalence of birth defects in the Mainland of China between 2000 and 2021.

METHODS

We performed a systematic literature search of six databases for relevant articles published between January 1, 2000, and March 1, 2023. We included published studies that reported data on the perinatal prevalence of birth defects in the Mainland of China. The DerSimonian and Laird random-effects models were used to estimate the pooled prevalence and its 95% confidence interval (CI). We also conducted subgroup analyses and univariable meta-regressions to explore differences in prevalence by time period, geographic region, and other characteristics.

RESULTS

We included 254 studies reporting the perinatal prevalence of birth defects and 86 studies reporting only the prevalence of specific types of birth defects. Based on 254 studies covering 74,307,037 perinatal births and 985,115 cases with birth defects, the pooled perinatal prevalence of birth defects was 122.54 (95% CI 116.20-128.89) per 10,000 perinatal births in the Mainland of China during 2000-2021. Overall, the perinatal prevalence of birth defects increased from 95.60 (86.51-104.69) per 10,000 in 2000-2004 to 208.94 (175.67-242.22) per 10,000 in 2020-2021. There were also significant disparities among different geographical regions. Congenital heart defects (33.35 per 10,000), clefts of the lip and/or palate (13.52 per 10,000), polydactyly (12.82 per 10,000), neural tube defects (12.82 per 10,000), and inborn errors of metabolism (11.41 per 10,000) were the five most common types of birth defects. The perinatal prevalence among males was significantly higher than that among females (β = 2.44 × 10-3, P = 0.003); a higher perinatal prevalence of birth defects was observed among perinatal births whose mothers were ≥ 35 years (β = 4.34 × 10-3, P < 0.001).

CONCLUSION

Comprehensive and sustained efforts are needed to strengthen surveillance and detection of birth defects, improve prenatal and postnatal healthcare, and promote rehabilitation, especially in underdeveloped areas.

Maternal Oxidative Balance Score during Pregnancy and Congenital Heart Defects

The relationship between maternal oxidative balance score (OBS) in pregnancy, representing overall oxidative balance status by integrating dietary and lifestyle factors, and congenital heart defects (CHD) remains unclear; therefore, this study attempted to explore their associations among the Chinese population. We conducted a case-control study including 474 cases and 948 controls in Northwest China. Pregnant women were interviewed to report diets and lifestyles in pregnancy by structured questionnaires. Logistic regression models were used to estimate the adjusted ORs (95%CIs). Maternal OBS ranged from 6 to 34 among cases, and 5 to 37 among controls. Comparing the highest with the lowest tertile group, the adjusted OR for CHD was 0.31 (0.19-0.50). The CHD risk was reduced by 7% (OR = 0.93, 95%CI = 0.90-0.95) in association with per 1 higher score of OBS during pregnancy. The inverse relationship between maternal OBS and CHD risk appeared to be more pronounced among participants in urban areas (OR = 0.89, 95%CI = 0.86-0.93). Maternal OBS during pregnancy showed good predictive values for fetal CHD, with the areas under the receiver operating characteristic curve 0.78 (0.76-0.81). These findings highlighted the importance of reducing oxidative stress through antioxidant-rich diets and healthy lifestyles among pregnant women to prevent fetal CHD.

Atrial Septal Defect Detection in Children Based on Ultrasound Video Using Multiple Instances Learning

Thoracic echocardiography (TTE) can provide sufficient cardiac structure information, evaluate hemodynamics and cardiac function, and is an effective method for atrial septal defect (ASD) examination. This paper aims to study a deep learning method based on cardiac ultrasound video to assist in ASD diagnosis. We chose four standard views in pediatric cardiac ultrasound to identify atrial septal defects; the four standard views were as follows: subcostal sagittal view of the atrium septum (subSAS), apical four-chamber view (A4C), the low parasternal four-chamber view (LPS4C), and parasternal short-axis view of large artery (PSAX). We enlist data from 300 children patients as part of a double-blind experiment for five-fold cross-validation to verify the performance of our model. In addition, data from 30 children patients (15 positives and 15 negatives) are collected for clinician testing and compared to our model test results (these 30 samples do not participate in model training). In our model, we present a block random selection, maximal agreement decision, and frame sampling strategy for training and testing respectively, resNet18 and r3D networks are used to extract the frame features and aggregate them to build a rich video-level representation. We validate our model using our private dataset by five cross-validation. For ASD detection, we achieve 89.33 ± 3.13 AUC, 84.95 ± 3.88 accuracy, 85.70 ± 4.91 sensitivity, 81.51 ± 8.15 specificity, and 81.99 ± 5.30 F1 score. The proposed model is a multiple instances learning-based deep learning model for video atrial septal defect detection which effectively improves ASD detection accuracy when compared to the performances of previous networks and clinical doctors.

Comparison of Different Ultrasonic Screening Methods and Analysis of High Risk Factors for Fetal Cardiac Malformation in Second Trimester of Pregnancy

Current study aims to compare the application of two-dimensional (2D) color doppler ultrasound (CDU) and four-dimensional (4D) ultrasound spatiotemporal image correlation (STIC) in fetal congenital heart disease in the second trimester of pregnancy and to analyze the high risk factors of the disease. From August 2019 to July 2021, 135 second-trimester patients with highly suspected congenital heart malformations were selected who underwent prenatal screening at South Taihu Hospital Affiliated to Huzhou University. 2D-CDU, 4D STIC, and postnatal examination were completed in all patients. 2D-CDU, 4D STIC and 2D-CDU combined with 4D STIC were used to detect fetal cardiac malformations and classify cardiac malformations. The sensitivity, specificity, positive predictive value, negative predictive value and coincidence rate of 2D-CDU, 4D STIC and 2D-CDU combined with 4D STIC were compared. The results of 2D-CDU, 4D STIC and 2D-CDU combined with 4D STIC screening were analyzed for consistency using the results of postpartum diagnosis as the gold standard. Moreover, effects of maternal gestational factors on fetal cardiac malformations by univariate and multivariate analysis. 2D-CDU combined with 4D STIC showed significantly higher section display number than 2D-CDU or 4D STIC in the view of ductal arch, aortic arch, and aortic short-axis. A total of 45 cases of fetal congenital heart malformation were detected in 135 patients in the second trimester, 40, 38 or 42 cases were detected by 2D-CDU, 4D STIC or 2D-CDU combined with 4D STIC, respectively. The sensitivity, specificity, positive predictive value, negative predictive value and coincidence rate of 2D-CDU combined with 4D ultrasound in congenital heart malformation screening were higher than those of 2D-CDU or 4D STIC. Kappa agreement analysis showed that the diagnostic results of 4D STIC and 2D-CDU combined with 4D ultrasound in fetuses with suspected congenital heart malformation were in excellent agreement (κ > 0.75), while 2D-CDU was in good agreement with postpartum diagnosis (κ < 0.75). Univariate and multivariate regression analysis revealed that maternal age ≥ 35, drinking during pregnancy, and history of adverse pregnancy and childbirth were all independent risk factors for fetal cardiac malformations, while folic acid supplementation was an independent protective factor for fetal cardiac malformations. 2D-CDU combined with 4D echocardiography may be superior to single 2D-CDU or 4D STIC in the screening of fetal congenital heart malformation in the second trimester. In order to reduce the incidence of fetal heart anomalies, we should strengthen the screening of pregnancy anomalies in high-risk pregnant women and control the risk factors.

A "twelve-section ultrasonic screening and diagnosis method" and management system for screening and treating neonatal congenital heart disease at the grassroots level in Tang County, Hebei Province, China

BACKGROUND

To explore a method for screening and diagnosing neonatal congenital heart disease (CHD) applicable to grassroots level, evaluate the prevalence of CHD, and establish a hierarchical management system for CHD screening and treatment at the grassroots level.

METHODS

A total of 24,253 newborns born in Tang County between January 2016 and December 2020 were consecutively enrolled and screened by trained primary physicians via the "twelve-section ultrasonic screening and diagnosis method" (referred to as the "twelve-section method"). Specialized staff from the CHD Screening and Diagnosis Center of Hebei Children's Hospital regularly visited the local area for definite diagnosis of CHD in newborns who screened positive. Newborns with CHD were managed according to the hierarchical management system.

RESULTS

The centre confirmed that, except for 2 newborns with patent ductus arteriosus missed in the diagnosis of ventricular septal defect combined with severe pulmonary hypertension, newborns with other isolated or concomitant simple CHDs were identified at the grassroots level. The sensitivity, specificity and diagnostic coincidence rate of the twelve-section method for screening complex CHD were 92%, 99.6% and 84%, respectively. A total of 301 children with CHD were identified. The overall CHD prevalence was 12.4‰. According to the hierarchical management system, 113 patients with simple CHD recovered spontaneously during local follow-up, 48 patients continued local follow-up, 106 patients were referred to the centre for surgery (including 17 patients with severe CHD and 89 patients with progressive CHD), 1 patient died without surgery, and 8 patients were lost to follow-up. Eighteen patients with complex CHD were directly referred to the centre for surgery, 3 patients died without surgery, and 4 patients were lost to follow-up. Most patients who received early intervention achieved satisfactory results. The mortality rate of CHD was approximately 28.86 per 100,000 children.

CONCLUSIONS

The "twelve-section method" is suitable for screening neonatal CHD at the grassroots level. The establishment of a hierarchical management system for CHD screening and treatment is conducive to the scientific management of CHD, which has important clinical and social significance for early detection, early intervention, reduction in mortality and improvement of the prognosis of complex and severe CHDs.

Association of maternal weight gain in early pregnancy with congenital heart disease in offspring: a China birth cohort study

OBJECTIVES

Little study has reported the association of maternal weight gain in early pregnancy with fetal congenital heart disease (CHD). We aimed to explore the potential relationship based on a China birth cohort while adjusting by multiple factors.

DESIGN

Cohort study.

SETTING

China birth cohort study conducted from 2017 to 2021.

PARTICIPANTS

The study finally included 114 672 singleton pregnancies in the 6-14 weeks of gestation, without missing data or outliers, loss to follow-up or abnormal conditions other than CHD. The proportion of CHD was 0.65% (749 cases).

PRIMARY AND SECONDARY OUTCOME MEASURES

Association between maternal pre-pregnancy weight gain and CHD in the offspring were analysed by multivariate logistic regression, with the unadjusted, minimally adjusted and maximally adjusted methods, respectively.

RESULTS

The first-trimester weight gain showed similar discrimination of fetal CHD to that period of maternal body mass index (BMI) change (DeLong tests: p=0.091). Compared with weight gain in the lowest quartile (the weight gain less than 0.0 kg), the highest quartile (over 2.0 kg) was associated with a higher risk of fetal CHD in unadjusted (OR 1.36, 95% CI: 1.08 to 1.72), minimally adjusted (adjusted OR (aOR) 1.29, 95% CI: 1.02 to 1.62) and maximally adjusted (aOR 1.29, 95% CI: 1.02 to 1.63) models. The association remains robust in pregnant women with morning sickness, normal pre-pregnancy BMI, moderate physical activity, college/university level, natural conception or with folic acid (FA) and/or multivitamin supplementation.

CONCLUSIONS AND RELEVANCE

Although the association of maternal pre-pregnancy weight gain on fetal CHD is weak, the excessive weight gain may be a potential predictor of CHD in the offspring, especially in those with morning sickness and other conditions that are routine in the cohort, such as normal pre-pregnancy BMI, moderate physical activity, college/university level, natural conception or with FA and/or multivitamin supplementation.

[Clinical Characteristics Analysis of 1051 Cases of Cleft Lip With/Without Cleft Palate in the Ethnic Tibetan Population]

Objective

To examine the characteristics of the prevalence of congenital cleft lip with/without cleft palate in the ethnic Tibetan population and to provide support for the precise prevention and treatment of cleft lip with/without cleft palate in the Tibetan population.

Methods

The clinical data of Tibetan patients with cleft lip with/without cleft palate were collected and the clinical characteristics of the patients were analyzed. The patients' age ranged from 2 months to 51 years old. All the subjects were admitted to West China Stomatology Hospital, Sichuan University for the treatment of cleft lip with/without cleft palate between January 2016 and August 2023. Most of the subjects came from Sichuan Province and the Tibet Autonomous Region.

Results

A total of 1051 patients were enrolled and children aged under 12 months (460 cases) accounted for the largest proportion. Among the subjects, 383 had cleft lip only (36.44%), 140 had cleft palate only (13.32%), and 528 had cleft lip with cleft palate (50.24%). The male-to-female ratios of patients with cleft lip only (0.99∶1), cleft palate only (0.54∶1), and cleft lip with cleft palate (1.67∶1) exhibited significant differences (P<0.001). However, there was no significant difference in the male-to-female ratio in patients with cleft lip only or those with cleft lip with cleft palate when the subjects were divided into two groups according to whether they had unilateral or bilateral cleft lip with/without cleft palate. Most of the patients with bilateral cleft lip were female, while most of the patients with unilateral cleft lip and unilateral or bilateral cleft lip with cleft palate were male. The unilateral cleft lip with/without cleft palate was located predominantly on the left side. Syndromic cleft lip with/without cleft palate accounted for 3.43% of all the cases and the most common concomitant deformity was congenital heart disease. 3.81% (40 cases) of the patients had a family history. In the patients with cleft lip only and those with cleft palate only, the proportion of patients having parents with corresponding phenotypes was higher than those of other phenotypes of cleft lip with/without cleft palate. Regarding the birth time distribution of the children with cleft lip with/without cleft palate, Spring saw the highest number of births of these children (311 cases, 29.59%), while Winter saw the lowest number of births (231 cases, 21.98%).

Conclusion

The cases of cleft lip with/without cleft palate in the ethnic Tibetan population are predominantly cleft lip and palate. Unilateral cleft lip only or cleft lip with palate is predominantly located on the left side. Lip disease phenotypes may be more heritable.

Size-dependent toxicity of polystyrene microplastics on the gastrointestinal tract: Oxidative stress related-DNA damage and potential carcinogenicity

Microplastics (MPs) and nanoplastics (NPs) have been generally regarded as emerging pollutants and received worldwide attention in recent years. Water and food consumption are the primary pathways for human exposure to MPs/NPs, thus gastrointestinal tracts may be susceptible to their toxicity. Although the recent report has indicated the presence of MPs/NPs in multiple human organs, little is known about their gastric effects. Therefore, this study focused on the adverse effects of polystyrene microplastics (PS-MPs) on gastric epithelium in vivo and in vitro. Surface-enhanced Raman spectroscopy (SERS) revealed the distribution of PS-MPs was associated with their particle sizes, and predominantly concentrated in gastric tissues. Gastric barrier injury and mitochondrial damage were observed in rats after exposure to PS-MPs. Compared with the larger ones, polystyrene nanoplastics (PS-NPs) more significantly reduced the activity of antioxidant enzymes while enhancing the level of MDA, 8-OhdG and γ-H2AX. Meanwhile, PS-MPs caused upregulation of β-catenin/YAP through redox-dependent regulation of nucleoredoxin (NXN) and dishevelled (Dvl). These findings supported the size-dependent effects of PS-MPs on oxidative stress and DNA damage. Moreover, the redox-dependent activation of the β-catenin/YAP cascade suggested a novel toxic mechanism for PS-MPs and implied the potential carcinogenic effects.

Association between lipid profile in early pregnancy and the risk of congenital heart disease in offspring: a prospective cohort study

This study aimed to investigate the association of lipid profile in early pregnancy and the risk of congenital heart disease (CHD) in offspring. This study was a prospective cohort design based on the Fujian Birth Cohort Study in China. We recruited pregnant women at ≤ 14 weeks of gestation between 2019 and 2022, and all participants in this study filled out the questionnaire about periconceptional exposure. Simultaneously, we collected participants' fasting blood samples to measure their lipid profile by automatic biochemical analyzer. The outcome was defined as offspring with CHD. A multivariable logistic regression model was used to calculate adjusted odds ratio (AOR) risk estimates, which indicate the associations between maternal lipid profiles and CHD in offspring. Restricted cubic splines were used to estimate their nonlinear relationship. A total of 21,425 pregnant women with an average gestational age of 11.3 (± 1.40) weeks were included in the analysis. The higher triglyceride (AOR 1.201, 95% CI [1.036, 1.394]), low-density lipoprotein (AOR 1.216, 95% CI [1.048, 1.410]), apolipoprotein B (Apo B) (AOR 2.107, 95% CI [1.179, 3.763]) levels were correlated with increased odds of CHD in offspring, while high-density lipoprotein (OR 0.672, 95% CI [0.490, 0.920]) related with decreased odds of CHD in offspring. The restricted cubic spline suggested a nonlinear relationship between total cholesterol (TC) levels and the risk of CHD in offspring (P = 0.0048), but no significant nonlinear relationships were found in other lipid profile. Apolipoprotein A was not related to the risk of CHD in offspring as either a continuous variable or a hierarchical variable. Elevated lipid profile in early pregnancy levels are associated with an increased risk of CHD in offspring. Additionally, there is a non-linear relationship between TC levels and the risk of CHD in offspring.

Study on the trend of congenital heart disease inpatient costs and its influencing factors in economically underdeveloped areas of China, 2015-2020: a case study of Gansu Province

Background

Economic data on congenital heart disease are scarce in economically underdeveloped areas of China. Therefore, this study aimed to shed light on the level and changing trend of congenital heart disease inpatients' economic burden in underdeveloped areas.

Method

This study used a multi-stage stratified cluster sampling method to select 11,055 inpatients with congenital heart disease from 197 medical and health institutions in Gansu Province. Their medical records and expenses were obtained from the Hospital Information System. Univariate analysis was conducted using the rank sum test and Spearman rank correlation. Quantile regression and random forest were used to analyze the influencing factors.

Results

From 2015 to 2020, the average length of stay for congenital heart disease patients in Gansu Province was 10.09 days, with an average inpatient cost of USD 3,274.57. During this period, the average inpatient costs per time increased from USD 3,214.85 to USD 3,403.41, while the average daily inpatient costs increased from USD 330.05 to USD 376.56. The average out-of-pocket costs per time decreased from USD 2,305.96 to USD 754.77. The main factors that affected the inpatient costs included length of stay, cardiac procedure, proportion of medications, age, and hospital level.

Conclusion

Congenital heart disease causes a significant economic burden on both families and society. Therefore, to further reduce the patient's financial burden, the length of stay should be reasonably reduced, and the rational distribution of medical resources should be continuously promoted to ensure equitable access to healthcare services.

The effect of China's birth policy changes on birth defects-A large hospital-based cross-sectional study

A retrospective analysis of birth data hospital-based obtained from 14 monitoring areas in the Huaihe River Basin from 2009 to 2019 was conducted. Trend in the total prevalence of birth defects (BDs) and subgroups were analyzed using the Joinpoint Regression model. The incidence of BDs increased gradually from 118.87 per 10,000 in 2009 to 241.18 per 10,000 in 2019 (AAPC = 5.91, P < 0.001). Congenital heart diseases were the most common subtype of BDs. The proportion of maternal age younger than 25 decreased but the age 25-40 years increased significantly (AAPC<20=-5.58; AAPC20-24=-6.38; AAPC25-29 = 5.15; AAPC30-35 = 7.07; AAPC35-40 = 8.27; All P < 0.05). Compared with the one-child policy period, the risk of BDs was greater for groups among maternal age younger than 40 years during the partial and universal two-child policy period (P < 0.001). The incidence of BDs and the proportion of women with advanced maternal age in Huaihe River Basin is increasing. There was an interaction between changes in birth policy and the mother's age on the risk of BDs.

Machine learning prediction model of major adverse outcomes after pediatric congenital heart surgery-a retrospective cohort study

BACKGROUND

Major adverse postoperative outcomes (APOs) can greatly affect mortality, hospital stay, care management and planning, and quality of life. This study aimed to evaluate the performance of five machine learning (ML) algorithms for predicting four major APOs after pediatric congenital heart surgery and their clinically meaningful model interpretations.

METHODS

Between August 2014 and December 2021, 23,000 consecutive pediatric patients receiving congenital heart surgery were enrolled. Based on the split date of 1 January 2019, we selected 13,927 participants for the training cohort, and 9,073 participants for the testing cohort. Four predefined major APOs including low cardiac output syndrome (LCOS), pneumonia, renal failure, and deep venous thrombosis (DVT) were investigated. 39 clinical and laboratory features were inputted in five ML models: light gradient boosting machine (LightGBM), logistic regression (LR), support vector machine, random forest, and CatBoost. The performance and interpretations of ML models were evaluated using the area under the receiver operating characteristic curve (AUC) and Shapley Additive Explanations (SHAP).

RESULTS

In the training cohort, CatBoost algorithms outperformed others with the mean AUCs of 0.908 for LCOS and 0.957 for renal failure, while LightGBM and LR achieved the best mean AUCs of 0.886 for pneumonia and 0.942 for DVT, respectively. In the testing cohort, the best-performing ML model for each major APOs with the following mean AUCs: LCOS (LightGBM), 0.893 (95% confidence interval (CI), 0.884-0.895); pneumonia (LR), 0.929 (95% CI, 0.926-0.931); renal failure (LightGBM), 0.963 (95% CI, 0.947-0.979), and DVT (LightGBM), 0.970 (95% CI, 0.953-0.982). The performance of ML models using only clinical variables was slightly lower than those using combined data, with the mean AUCs of 0.873 for LCOS, 0.894 for pneumonia, 0.953 for renal failure, and 0.933 for DVT. The SHAP showed that mechanical ventilation time was the most important contributor of four major APOs.

CONCLUSIONS

In pediatric congenital heart surgery, the established ML model can accurately predict the risk of four major APOs, providing reliable interpretations for high-risk contributor identification and informed clinical decisions making.

The risk of attention-deficit hyperactivity disorder among children with congenital heart disease: A systematic review and meta-analysis

BACKGROUND

Although current treatments are effective in dealing with congenital heart disease (CHD), non-cardiac comorbidities such as attention-deficit hyperactivity disorder (ADHD) have received widespread attention. The purpose of this systematic review and meta-analysis is to assess the risk of ADHD associated with CHD.

METHODS

The literature search was carried out systematically through eight different databases by the end of September 2022. Either a fixed- or a random-effects model was used to calculate the overall combined risk estimates. The heterogeneity of the studies was assessed by the Cochran Q test and the I2 statistic. Subgroup and sensitivity analyses were used to explore the potential sources of heterogeneity.

RESULTS

Eleven studies were included in this study, which involved a total of 296 741 participants. Our study showed that the children with CHD were at a significantly increased risk of ADHD compared with the reference group (OR = 2.98, 95% CI: 2.18-4.08). The results were moderately heterogeneous. These factors including study design, geographic region and study quality were identified as the first three of the most relevant heterogeneity moderators by subgroup analyses. Sensitivity analysis yielded consistent results. There was no evidence of publication bias.

CONCLUSIONS

The present study suggests that CHD children have a significantly higher risk of ADHD when compared with those without CHD. Early identification and intervention of ADHD is important to reduce its symptoms and adverse effects; therefore, clinicians should increase screening for ADHD in children with CHD and intervene promptly to reduce its effects whenever possible.

Application of dual-energy CT with prospective ECG-gating in cardiac CT angiography for children: Radiation and contrast agent dose

OBJECTIVE

This research aimed to investigate the feasibility of utilizing dual-energy CT virtual monoenergetic images (VMI1) with prospective electrocardiogram (ECG2) gating for reducing radiation and contrast agent doses in pediatric patients with congenital heart disease (CHD3).

METHODS

There were 100 pediatric patients with CHD included in this study. Group A (n = 50) underwent dual-energy scanning with prospective ECG-gating, and group B (n = 50) underwent conventional scanning with retrospective ECG-gating. Comparative analysis of CT values of lumen, objective image quality assessment, subjective image quality evaluations, and diagnostic efficacy were performed.

RESULTS

CT values, image noise, signal-to-noise ratio (SNR4), and contrast-to-noise ratio (CNR5) were significantly affected by the VMI energy level, and they all increased with decreasing energy levels (P > 0.05). Combining subjective evaluation, the 45 keV VMI was considered the optimum image in group A. The 45 keV VMI exhibited higher CT values of lumen compared to conventional scanning images (P < 0.003 ∼ 0.836), but meanwhile, the image noise was also higher in the 45 keV VMI (P = 0.004). Differences between the two groups in SNR, CNR, and diagnostic accuracy were not statistically significant. Compared to group B, the 45 keV VMI showed fewer contrast-induced artifacts (P < 0.001) and higher image quality score (P = 0.037). Group A had a 64 % reduction in radiation dose and a 40 % decrease in iodine dose compared to group B.

CONCLUSION

The combination of dual-energy CT with prospective ECG-gating reduces radiation and iodine doses in pediatric patients with CHD. The 45 keV VMI can provide clinically acceptable image quality while declining contrast agent artifacts.

Incidence, distribution, disease spectrum, and genetic deficits of congenital heart defects in China: implementation of prenatal ultrasound screening identified 18,171 affected fetuses from 2,452,249 pregnancies

BACKGROUND

Congenital heart defects (CHDs) are the most common birth defects. Assessment of the incidence, distribution, disease spectrum, and genetic deficits of fetal CHDs in China is urgently needed.

METHODS

A national echocardiography screening program for fetal CHDs was implemented in 92 prenatal screening-diagnostic centers in China.

FINDINGS

A total of 18,171 fetal CHD cases were identified from 2,452,249 pregnancies, resulting in 7·4/1,000 as the national incidence rate of fetal CHD. The incidences of fetal CHD in the six geographical regions, the southern, central, eastern, southwestern, northern, and northwestern, were 7·647 (CI: 7·383-7·915), 7·839 (CI: 7·680-8·000), 7·647 (CI: 7·383-7·915), 7·562 (CI: 7·225-7·907), 5·618 (CI: 5·337-5·906), and 4·716 (CI: 4·341-5·108), respectively, per 1,000 pregnancies. Overall, ventricular septal defect was the most common fetal CHD, accounting for 17.04% of screened pregnancies nationwide, and tetralogy of Fallot, the most common anomaly in the major defect of fetal CHD, was the second most common, accounting for 9.72%. A total of 76.24% cases of fetal CHD were found to be an isolated intracardiac single defect. The remaining 23.76% of cases of fetal CHD had multiple heart defects. Among all extracardiac malformations, the central nervous system (CNS) was the most common tissue with extracardiac anomalies associated with CHD, accounting for 22.89% of fetal CHD cases. Chromosomal karyotyping identified trisomy 18 as the most common chromosomal abnormality in fetal CHD. We also documented that CHD-containing syndromes could be identified with a comprehensive approach integrating prenatal ultrasound, MRI, pathological autopsy, and cytogenetics and molecular genetics.

CONCLUSION

Implementation of prenatal echocardiography as a practically feasible platform to screen fetal CHD will reduce the financial and emotional burden of CHD, which may facilitate intrauterine and neonatal intervention of CHD.

Association between postoperative exposure to fine particulate matter and patency of the right ventricle-pulmonary artery conduit

BACKGROUND

Ambient air pollution is a leading risk factor for cardiovascular diseases. No study has investigated the association between exposure to fine particulate matter <2.5 μm in aerodynamic diameter (PM2.5) and the prognosis of patients undergoing surgery for the right ventricle-pulmonary artery (RV-PA) conduit.

METHODS

From 2013 to 2020, patients with six complicated congenital heart defects who had undergone surgery for the RV-PA conduit were selected. Four conduit materials were used: bovine jugular vein graft (BJV), pulmonary homograft (PHG), aortic homograft (AHG), and handmade tri-leaflet expanded polytetrafluoroethylene (ePTFE) conduit. Telephone interviews were used to confirm the postoperative address of patients. The monthly average PM2.5 concentration was obtained from the ChinaHighPM2.5 dataset using the place of residence of patients. By comparing findings of echocardiography undertaken before patients' return to their residence and during re-examination, we defined an increase in the trans-conduit peak velocity of ≥1.5 m/s as the study endpoint.

RESULTS

We enrolled 232 patients. Compared with BJV conduits, homografts (AHGs and PHGs) (0.052 (95 % CI = 0.005-0.558), P = 0.015) and ePTFE conduits (0.009 (95 % CI = 0.002-0.054), P < 0.001) were protective factors. The cumulative monthly PM2.5 concentration (10 μg/m3) was a risk factor (1.014 (95 % CI = 1.001-1.026), P = 0.028). Winter experience was a risk factor (1.971 (95 % CI: 1.021-3.804), P = 0.043). In the subgroup analysis, Spearman correlation analysis indicated BJV conduits (r = 0.680, P < 0.001), PHGs (r = 0.559, P = 0.020), and AHGs (r = 0.745, P = 0.021) had medium-to-high positive correlations between the cumulative PM2.5 concentration and change in the conduit velocity. For ePTFE, the correlation was weak and not significant (r = 0.222, P = 0.073).

CONCLUSIONS

Postoperative exposure to PM2.5 affects the patency of biologic prosthetic conduits (especially xenografts). The increase in the velocity of the ePTFE conduit is not associated with PM2.5 exposure, and is a suitable material for patients living in areas with high pollutant concentrations.

Association of maternal methionine synthase reductase gene polymorphisms with the risk of congenital heart disease in offspring: a hospital-based case-control study

BACKGROUND

Evidence suggests that periconceptional folic acid supplementation may prevent congenital heart disease (CHD). Methionine synthase reductase (MTRR) is one of the key regulatory enzymes in the folate metabolic pathway. This study aimed to comprehensively evaluate the association of single nucleotide polymorphisms (SNPs) in the maternal MTRR gene with CHD risk in offspring.

METHODS

A hospital-based case-control study involving 740 mothers of CHD cases and 683 health controls was conducted.

RESULTS

The study showed that maternal MTRR gene polymorphisms at rs1532268 (C/T vs. C/C: aOR = 1.524; T/T vs. C/C: aOR = 3.178), rs1802059 (G/A vs. G/G: aOR = 1.410; A/A vs. G/G: aOR = 3.953), rs2287779 (G/A vs. G/G: aOR = 0.540), rs16879334 (C/G vs. C/C: aOR = 0.454), and rs2303080 (T/A vs. T/T: aOR = 0.546) were associated with the risk of CHD. And seven haplotypes were observed to be associated with the risk of CHD, T-G-A haplotype (OR = 1.298), C-A-C-C (OR = 4.824) and A-G haplotype (OR = 1.751) were associated with increased risk of CHD in offspring; A-A-A (OR = 0.773), T-A-A (OR = 0.557), G-A-C-C (OR = 0.598) and G-C (OR = 0.740) were associated with decreased risk of CHD in offspring.

CONCLUSIONS

Maternal MTRR gene polymorphisms were associated with CHD in offspring, and its haplotypes have affected the occurrence of CHD. Furthermore, given the complexity and heterogeneity of CHD, the mechanisms by which these factors influence offspring cardiac development remain unknown, and studies in larger samples in an ethnically diverse population are needed.

Noncardiac anomalies in children with congenital heart disease

Introduction

Noncardiac anomalies (NCAs) in patients with congenital heart defects (CHDs) are crucial for perioperative management and etiology studies. This study aimed to investigate NCAs in Chinese children with CHDs.

Methods

Medical records for CHD-diagnosed children hospitalized from 1 January 2015 to 31 December 2019 were collected and subjected to retrospective analyses to excavate potential association rules between CHDs and noncardiac malformations.

Results

A total of 3,788 CHD patients were included in this study. The main phenotypes of CHD were Ventricular Septal Defect (VSD, 33.69%), Atrial Septal Defect (ASD, 12.72%), and Tetralogy of Fallot (TOF, 5.54%). A total of 887 (23.42%) cases showed noncardiac anomalies, which were mainly associated with the central nervous system (34.61%), nose/ear/mandibular/face (19.39%), genitourinary system (15.78%), and musculoskeletal system (15.56%). Compared to other CHD subtypes, septal defects had a lower percentage of associated NCAs (P = 3.7 × 10-9) while AVSD had a higher percentage (P = 0.0018).

Disscussion

NCAs are prevalent among CHD-diagnosed children in China, and the spectrums of NCAs in different CHD subcategories were different.

An 18-year evolution of congenital heart disease in China: An echocardiographic database-based study

OBJECTIVE

Data on the evolution of congenital heart disease (CHD) in China remain scarce. Based on a Chinese echocardiography database, we analyzed the observed rate (OR) and spectrum changes of CHD over the past 18 years with a focus on the congenital aortic valve malformation (CAVM) and Adult CHD (ACHD).

METHODS AND RESULTS

The transthoracic echocardiographic data of 682,565 records from 2003 to 2020 were retrospectively reviewed at Fujian Medical University Union Hospital, China. A total of 37,200 CHD cases were recruited in this study. Over the three periods (from 2003 to 2008, 2009-2014, to 2015-2020), the OR of Total CHD decreased (106.72, 90.64, and 67.43 per 1000 cases, respectively); the proportion of Simple CHD to Total CHD increased (80.96%, 83.41%, and 87.97%, respectively), with a decrease in the proportion of Complex CHD (18.11%, 15.51%, and 10.42%, respectively) (p < 0.05 for all). The proportion of ACHD increased in most types of CHD [Total CHD: 25.79%, 27.84%, and 31.43%; CAVM: 69.02%, 73.42%, and 78.16%; CAVM with aortic stenosis (AS): 67.42%, 70.73%, and 79.25%; respectively, p < 0.05 for all], with a much higher proportion in both CAVM and CAVM with AS than in the other CHD types. The proportion of CHD patients receiving intervention increased over the designated periods.

CONCLUSIONS

This study depicts the longitudinal changes of CHD in the Chinese population with a single-center echocardiographic data, revealing an increased proportion of Simple CHD, ACHD (including CAVM and CAVM with AS), and a decreased OR of Total CHD and proportion of Complex CHD.

Artificial intelligence-enabled 8-lead ECG detection of atrial septal defect among adults: a novel diagnostic tool

Background

Patients with atrial septal defect (ASD) exhibit distinctive electrocardiogram (ECG) patterns. However, ASD cannot be diagnosed solely based on these differences. Artificial intelligence (AI) has been widely used for specifically diagnosing cardiovascular diseases other than arrhythmia. Our study aimed to develop an artificial intelligence-enabled 8-lead ECG to detect ASD among adults.

Method

In this study, our AI model was trained and validated using 526 ECGs from patients with ASD and 2,124 ECGs from a control group with a normal cardiac structure in our hospital. External testing was conducted at Wuhan Central Hospital, involving 50 ECGs from the ASD group and 46 ECGs from the normal group. The model was based on a convolutional neural network (CNN) with a residual network to classify 8-lead ECG data into either the ASD or normal group. We employed a 10-fold cross-validation approach.

Results

Statistically significant differences (p < 0.05) were observed in the cited ECG features between the ASD and normal groups. Our AI model performed well in identifying ECGs in both the ASD group [accuracy of 0.97, precision of 0.90, recall of 0.97, specificity of 0.97, F1 score of 0.93, and area under the curve (AUC) of 0.99] and the normal group within the training and validation datasets from our hospital. Furthermore, these corresponding indices performed impressively in the external test data set with the accuracy of 0.82, precision of 0.90, recall of 0.74, specificity of 0.91, F1 score of 0.81 and the AUC of 0.87. And the series of experiments of subgroups to discuss specific clinic situations associated to this issue was remarkable as well.

Conclusion

An ECG-based detection of ASD using an artificial intelligence algorithm can be achieved with high diagnostic performance, and it shows great clinical promise. Our research on AI-enabled 8-lead ECG detection of ASD in adults is expected to provide robust references for early detection of ASD, healthy pregnancies, and related decision-making. A lower number of leads is also more favorable for the application of portable devices, which it is expected that this technology will bring significant economic and societal benefits.

Improving the Quality of Fetal Heart Ultrasound Imaging With Multihead Enhanced Self-Attention and Contrastive Learning

Fetal congenital heart disease (FCHD) is a common, serious birth defect affecting ∼1% of newborns annually. Fetal echocardiography is the most effective and important technique for prenatal FCHD diagnosis. The prerequisites for accurate ultrasound FCHD diagnosis are accurate view recognition and high-quality diagnostic view extraction. However, these manual clinical procedures have drawbacks such as, varying technical capabilities and inefficiency. Therefore, the automatic identification of high-quality multiview fetal heart scan images is highly desirable to improve prenatal diagnosis efficiency and accuracy of FCHD. Here, we present a framework for multiview fetal heart ultrasound image recognition and quality assessment that comprises two parts: a multiview classification and localization network (MCLN) and an improved contrastive learning network (ICLN). In the MCLN, a multihead enhanced self-attention mechanism is applied to construct the classification network and identify six accurate and interpretable views of the fetal heart. In the ICLN, anatomical structure standardization and image clarity are considered. With contrastive learning, the absolute loss, feature relative loss and predicted value relative loss are combined to achieve favorable quality assessment results. Experiments show that the MCLN outperforms other state-of-the-art networks by 1.52-13.61% when determining the F1 score in six standard view recognition tasks, and the ICLN is comparable to the performance of expert cardiologists in the quality assessment of fetal heart ultrasound images, reaching 97% on a test set within 2 points for the four-chamber view task. Thus, our architecture offers great potential in helping cardiologists improve quality control for fetal echocardiographic images in clinical practice.

Classification of normal and abnormal fetal heart ultrasound images and identification of ventricular septal defects based on deep learning

OBJECTIVES

Congenital heart defects (CHDs) are the most common birth defects. Recently, artificial intelligence (AI) was used to assist in CHD diagnosis. No comparison has been made among the various types of algorithms that can assist in the prenatal diagnosis.

METHODS

Normal and abnormal fetal ultrasound heart images, including five standard views, were collected according to the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) Practice guidelines. You Only Look Once version 5 (YOLOv5) models were trained and tested. An excellent model was screened out after comparing YOLOv5 with other classic detection methods.

RESULTS

On the training set, YOLOv5n performed slightly better than the others. On the validation set, YOLOv5n attained the highest overall accuracy (90.67 %). On the CHD test set, YOLOv5n, which only needed 0.007 s to recognize each image, had the highest overall accuracy (82.93 %), and YOLOv5l achieved the best accuracy on the abnormal dataset (71.93 %). On the VSD test set, YOLOv5l had the best performance, with a 92.79 % overall accuracy rate and 92.59 % accuracy on the abnormal dataset. The YOLOv5 models achieved better performance than the Fast region-based convolutional neural network (RCNN) & ResNet50 model and the Fast RCNN & MobileNetv2 model on the CHD test set (p<0.05) and VSD test set (p<0.01).

CONCLUSIONS

YOLOv5 models are able to accurately distinguish normal and abnormal fetal heart ultrasound images, especially with respect to the identification of VSD, which have the potential to assist ultrasound in prenatal diagnosis.

Cardiopulmonary functional capacity in Taiwanese children with ventricular septal defects

BACKGROUND

Children with ventricular septal defects (VSDs) are considered to have no difference in cardiopulmonary functional capacity with healthy children of the same age; however, studies have shown contradictory findings. The aim of this study was to assess whether Taiwanese children with VSDs exhibited cardiopulmonary deficits.

METHODS

This is a retrospective cohort study with the data collected from January 2010 to December 2021. All patients and controls (age-, sex-, and body mass index -matched) underwent cardiopulmonary exercise testing (CPET) and pulmonary function test.

RESULTS

In total, 157 VSD patients (80 patients with surgically closed VSDs, 77 patients with unrepaired VSDs) and 157 healthy controls were recruited. Pulmonary function test showed significant among-group differences in maximal voluntary ventilation (MVV) (p = 0.015). The surgically closed group had lower MVV compared to the control group. Regarding CPET, we found VSD patients had lower peak oxygen uptake than the controls (surgically closed group: 30.84 ± 6.27 ml/kg/min; unrepaired group: 32.00 ± 5.95 ml/kg/min; control group: 36.76 ± 6.50 ml/kg/min, p < 0.001). There was also significant among-group differences in aerobic capacity (surgically closed group: 21.20 ± 4.39 ml/kg/min; unrepaired group: 21.68 ± 4.47 ml/kg/min; control group: 26.25 ± 4.33 ml/kg/min, p < 0.001). In addition, the surgically closed group had lower heart rate average at anaerobic threshold than the control group (surgically closed group: 138.11 ± 16.42 bpm; control group: 145.78 ± 15.53 bpm, p = 0.002).

CONCLUSION

Taiwanese children with VSD, whether surgically closed or not, have poorer cardiopulmonary performance than age-matched healthy children, and the results of the surgically closed group were even worse.

Four-section approach of fetal congenital heart disease at 11-13+6 weeks

Objective

The objective of the study is to explore the value of the four-section approach in detecting fetal heart defects in the first trimester (11-13+6 weeks), analyze the reasons for the inconsistency between the results of ultrasound examination in the first trimester and subsequent verification, and describe the most common abnormal flow patterns of four sections.

Materials and methods

Between June 2019 and June 2021, a prenatal four-section approach (upper abdominal transverse section, four-chamber section, three vessel-trachea section, and bilateral subclavian artery section) with verification results in early pregnancy was analyzed.

Results

In total, 9,533 fetuses were included. Finally, 176 fetuses with congenital heart disease (CHD), containing 34 types, were identified. The total detection rate of cardiac abnormalities was 1.85%. 102 cases were accurately diagnosed by ultrasonography during early pregnancy. A total of 74 fetuses who had inconsistent results between fetal cardiac ultrasound and verification in early pregnancy were reported, of which the cases of 22 fetuses were inconsistent due to disease evolution and progression and the cases of 52 fetuses were inconsistent due to missed diagnosis and misdiagnosis. The sensitivity, specificity, positive predictive value, and negative predictive value of the four-section approach were 67.05%, 99.96%, 96.58%, and 99.33%, respectively. In this study, a total of 30 abnormal ultrasonic imaging patterns in four sections were summarized.

Conclusion

We confirmed that the four-section approach in early pregnancy has a good diagnostic efficacy for fetal CHD. Intrauterine evolution of the fetal heart, missed diagnosis, and misdiagnosis are the reasons for the inconsistency between the results of early pregnancy ultrasound and subsequent verification. This study also presents the abnormal imaging patterns of four scan sections of CHD in early pregnancy, which are instructive for the rapid identification and diagnosis of CHD in the first trimester.

Current status and challenges in prenatal and neonatal screening, diagnosis, and management of congenital heart disease in China

Congenital heart disease (CHD), a wide spectrum of diseases with varied outcomes, is the most common congenital malformation worldwide. In this Series of three papers, we describe the burden of CHD in China; the development of screening, diagnosis, treatment, and follow-up strategies; and challenges associated with the disease. We also propose solutions and recommendations for policies and actions to improve the outcomes of CHD. In the first paper in this Series, we focus on prenatal and neonatal screening, diagnosis, and management of CHD. Based on advanced international knowledge, the Chinese Government has developed a network system comprising prenatal screening, diagnosis of CHD subtypes, specialist consultation appointments, and treatment centres for CHD. A new professional discipline, fetal cardiology, has been formed and rapidly developed. Consequently, the overall coverage of prenatal and neonatal screening and the accuracy of CHD diagnoses have gradually improved, and the neonatal CHD mortality rate has decreased substantially. However, China still faces several challenges in the prevention and treatment of CHD, such as insufficient diagnostic capabilities and unqualified consultation services in some regions and rural areas. TRANSLATION: For the Chinese translation of the abstract see Supplementary Materials section.

Dietary Inflammatory Index during Pregnancy and Congenital Heart Defects

The relationship between diet-related inflammation during pregnancy and congenital heart defects (CHD) is unclear. This study attempted to investigate the association between the dietary inflammation index (DII) during pregnancy, reflecting the overall inflammatory potential of the maternal diet, and CHD in Northwest China. A case-control study with 474 cases and 948 controls was performed in Xi'an City, China. Eligible women awaiting delivery were recruited, and their dietary and other information during pregnancy was collected. Logistic regression models were applied to estimate the risk of CHD in association with DII. The maternal DII ranged from -1.36 to 5.73 in cases, and 0.43 to 5.63 in controls. Pregnant women with per 1 higher DII score were at 31% higher risk of fetal CHD (OR = 1.31, 95%CI = 1.14-1.51), and the adjusted OR (95%CI) comparing the pro-inflammatory diet group with the anti-inflammatory diet group was 2.04 (1.42-2.92). The inverse association of maternal DII score with CHD risk was consistent across various subgroups of maternal characteristics. Maternal DII in pregnancy had good predictive value for CHD in offspring, with the areas under the receiver operating characteristic curve higher than 0.7. These findings suggested that avoiding a pro-inflammatory diet in pregnancy should be emphasized in the prevention of CHD.

Maternal exposure to housing renovation during the periconceptional period and the risk of offspring with isolated congenital heart disease: a case-control study

BACKGROUND

Congenital heart disease (CHD) is the most prevalent birth defect in recent decades. The aim of this research was to examine the association between maternal housing renovation exposure during the periconceptional period and isolated congenital heart disease (CHD) in their offspring.

METHODS

A multi-hospitals case-control study was conducted from six tertiary A hospitals in Xi'an, Shaanxi, Northwest China based on questionnaires and interviews to address this question. The cases included fetuses or newborns diagnosed with CHD. Controls consisted of healthy newborns without birth defects. In total, 587 cases and 1180 controls were enrolled in this study. The association between maternal periconceptional housing renovation exposure and isolated CHD for offspring was assessed by estimating odds ratios (OR) with multivariate logistic regression models.

RESULTS

After adjusting for potential confounding variables, it was found that maternal exposure to home improvement projects was associated with a higher probability of isolated CHD in offspring (adjusted OR: 1.77, 95% CI: 1.34, 2.33). Additionally, the risk of the ventricular septal defect (VSD) and patent ductus arteriosus (PDA) for CHD types was significantly associated with maternal exposure to housing renovations (VSD: adjusted OR = 1.56, 95% CI: 1.01, 2.41; PDA: adjusted OR = 2.50, 95% CI: 1.41, 4.45).

CONCLUSIONS

Our study suggests that maternal exposure to housing renovation during the periconceptional period was associated with an increased risk of isolated CHD in offspring. Consequently, it would be beneficial to avoid living in a renovated home from 12 months before pregnancy through the first trimester to lower isolated CHD in infants.

Prevalence of congenital heart disease according to the echocardiography findings in 8145 neonates, multicenter study in southern Iran

Introduction

Congenital heart disease (CHD), the lethal congenital anomaly in newborns, is multifactorial, with environmental and genetic factors contributing to its occurrence. Although some studies on the prevalence of CHD have been conducted throughout the country, this large‐scale study aims to provide information on the prevalence of various types of CHDs in newborns according to the echocardiography findings.

Patients and Methods

Over 3 years, 8145 neonates with suspected CHD who underwent echocardiography by a trained pediatric cardiologist were included in this multicenter, cross‐sectional observational study. CHD was categorized into two major groups; cyanotic and acyanotic heart disease. The SPSS version 22 software was used to analyze the data with a significance level set at 0.05.

Results

Of 8145 neonates who were referred to our centers with CHD symptoms, 6307 were indicated for echocardiography. The mean age of the studied population was 8.5 ± 9.3 days and the male‐to‐female ratio was 2.6, especially in the arterial septal defect (ASD), ventricular septal defect (VSD), and patent ductus arteriosus (PDA) groups. 77.2% of patients had acyanotic heart disease (100 in 1000 neonates) with ASD as the most common one and 9% were diagnosed with cyanotic heart disease (11 in 1000 neonates) with transposition of the great arteries as the most common form and the aortopulmonary window was the rarest form.

Conclusion

This large prospective, multicenter screening study reported arterial septal defect (85%) and patents with ductus arteriosus (32%) as the most frequent type of CHD. Moreover, the prevalence of male patients was significantly higher. This information would be helpful for health policy makers, stakeholders, and general practitioners in regions where there are no trained pediatric cardiologist fellowships and limited access to echocardiography devices for better management of CHD.

Impact of Newborn Screening Programme for Congenital Heart Disease in Shanghai: a five-year observational study in 801,831 newborns

Background

Newborn Screening Programme for Congenital Heart Disease (CHD) in Shanghai has been in operation for over 5 years, and its feasibility and effectiveness still lack a systematic and comprehensive evaluation. This study aimed to detail the implementation of the programme and evaluate its results, benefits, and reliability in clinical practice.

Methods

This study was an observational study involving all newborns received CHD screening in Shanghai from 2017 to 2021. Pulse oximetry (POX) plus cardiac murmur auscultation (namely the dual-index method) was used for CHD screening in newborns aged 6-72 h. Newborns who screened positive was recommended for echocardiography, and those diagnosed with CHD would be planned for further evaluation and intervention. Data were aggregated by birth year and district of birth. Results of neonatal CHD screening, diagnosis and treatment, and temporal trends of infant mortality rate (IMR) and the proportion of under-five mortality (U5M) attributed to CHD were analysed. A retrospective cohort study was also conducted to assess the reliability of the dual-index method in clinical practice.

Findings

In total, 801,831 (99.48%) newborns were screened for CHD, 16,489 (2.06%) were screened positive, and 3541 (21.47%) of the screened-positive newborns were identified with CHD. Seven hundred and fifty-two patients with CHD received surgical or interventional treatment with a successful rate of 94.81%. The period from 2015 to 2021 witnessed an approximately twofold decrease in IMR from 4.58‰ to 2.30‰, and a downtrend in the proportion of U5M attributed to CHD from 25.93% to 16.61%. High sensitivity and specificity of the dual-index method in clinical practice were observed for both critical (100.00% and 97.72%) and major CHD (98.47% and 97.76%).

Interpretation

Newborn screening programme for CHD has been well implemented in Shanghai, and this programme is a successful public health intervention to reduce infant death. Our study provides encouraging evidence and experience for implementing newborn screening programme for CHD nationwide in China.

Funding

This study was supported by the National Key Research and Development Programme of China (2021YFC2701004 and 2016YFC1000506), CAMS Innovation Fund for Medical Sciences (2019-I2M-5-002), and Three-Year Planning for Strengthening the Construction of Public Health System in Shanghai (No. GWIV-24).

Ambient air pollutants in the first trimester of pregnancy and birth defects: an observational study

OBJECTIVES

As current studies on the relationships between air pollutants exposure during the first trimester and birth defects were not fully elucidated, this study aimed to assess the association between selected air pollutants and birth defects.

DESIGN

An observational study.

PARTICIPANTS

We obtained 70 854 singletons with gestational age <20 weeks who were delivered at a large maternal and child healthcare centre in Wuhan, China.

OUTCOME MEASURES

Birth defects data and daily average concentration of ambient particulate matter ≤10 µm diameter (PM₁₀), PM ≤2.5 µm diameter (PM_2.5), sulfur dioxide (SO₂) and nitrogen dioxide (NO₂) were obtained. Logistic regression analysis was applied to assess the association between maternal air pollutants exposure during first trimester and total birth defects, congenital heart defects (CHDs), limb defects and orofacial clefts with adjustments of potential covariates.

RESULTS

There were a total of 1352 birth defect cases included in this study, with a prevalence of 19.08‰. Maternal exposed to high concentrations of PM₁₀, PM_2.5, NO₂ and SO₂ in the first trimester were significantly associated with elevated ORs of birth defects (ORs ranged from 1.13 to 1.23). Additionally, for male fetuses, maternal exposed to high PM_2.5 concentration was associated with an elevated odd of CHDs (OR 1.27, 95% CI 1.06 to 1.52). In the cold season, the ORs of birth defects were significantly increased among women exposed to PM_2.5 (OR 1.64, 95% CI 1.41 to 1.91), NO₂ (OR 1.22, 95% CI 1.08 to 1.38) and SO₂ (OR 1.26, 95% CI 1.07 to 1.47).

CONCLUSIONS

This study showed unfavourable effects of air pollutants exposure during the first trimester on birth defects. Especially, the association between maternal PM_2.5 exposure and CHDs was only observed among male fetuses, and stronger effects of PM_2.5, NO₂ and SO₂ exposure on birth defects were observed in the cold season.

Pulmonary arterial hypertension associated with congenital heart disease: An omics study

Pulmonary arterial hypertension associated with congenital heart disease (PAH-CHD) is a severely progressive condition with uncertain physiological course. Hence, it has become increasingly relevant to clarify the specific mechanisms of molecular modification, which is crucial to identify more treatment strategies. With the rapid development of high-throughput sequencing, omics technology gives access to massive experimental data and advanced techniques for systems biology, permitting comprehensive assessment of disease occurrence and progression. In recent years, significant progress has been made in the study of PAH-CHD and omics. To provide a comprehensive description and promote further in-depth investigation of PAH-CHD, this review attempts to summarize the latest developments in genomics, transcriptomics, epigenomics, proteomics, metabolomics, and multi-omics integration.

Zinc status in public health: exploring emerging research trends through bibliometric analysis of the historical context from 1978 to 2022

The current study aims to provide a roadmap for future research by analyzing the research structures and trends in scholarly publications related to the status of zinc in public health. Only journal articles published between 1978 and 2022 are included in the refined bibliographical outputs retrieved from the Web of Science (WoS) database. The first section announces findings based on WoS categories, such as discipline heterogeneity, times cited and publications over time, and citation reports. The second section then employs VoSViewer software for bibliometric analysis, which includes a thorough examination of co-authorship among researchers, organizations, and countries and a count of all bibliographic databases among documents. The final section discusses the research's weaknesses and strengths in zinc status, public health, and potential future directions; 7158 authors contributed to 1730 papers (including 339 with publications, more than three times). "Keen, C.L." is a researcher with the most publications and a better understanding of zinc status in public health. Meanwhile, the USA has been the epicenter of research on the status of zinc in public health due to the highest percentage of publications with the most citations and collaboration with the rest of the world, with the top institution being the University of California, Davis. Future research can be organized collaboratively based on hot topics from co-occurrence network mapping and bibliographic couplings to improve zinc status and protect public health.

Genetic architecture in neonatal intensive care unit patients with congenital heart defects: a retrospective study from the China Neonatal Genomes Project

BACKGROUND

Congenital heart defects (CHDs) are the most common type of birth defects. The genetic aetiology of CHD is complex and incompletely understood. The overall distribution of genetic causes in patients with CHD from neonatal intensive care units (NICUs) needs to be studied.

METHODS

CHD cases were extracted from the China Neonatal Genomes Project (2016-2021). Next-generation sequencing results and medical records were retrospectively evaluated to note the frequency of genetic diagnosis and the respective patient outcomes.

RESULTS

In total, 1795 patients were included. The human phenotype ontology term of atrial septal defect, patent ductus arteriosus and ventricular septal defect account for a large portion of the CHD subtype. Co-occurring extracardiac anomalies were observed in 35.1% of patients. 269 of the cases received genetic diagnoses that could explain the phenotype of CHDs, including 172 copy number variations and 97 pathogenic variants. The detection rate of trio-whole-exome sequencing was higher than clinical exome sequencing (21.8% vs 14.5%, p<0.05). Further follow-up analysis showed the genetic diagnostic rate was higher in the deceased group than in the surviving group (29.0% vs 11.9%, p<0.05).

CONCLUSION

This is the largest cohort study to explore the genetic spectrum of patients with CHD in the NICU in China. Our findings may benefit future work on improving genetic screening and counselling for NICU patients with CHD.

Identifying Predictors of Psychological Problems Among Adolescents With Congenital Heart Disease for Referral to Psychological Care: A Pilot Study

Background

The lifelong care of patients with congenital heart disease (CHD) typically begins at a young age, giving paediatric cardiologists a unique perspective on the mental health of their patients. Our aim was to describe and predict reported psychological problems among adolescents with CHD.

Methods

A retrospective review was performed on patients aged 12-17 years who presented to the congenital cardiology clinic during a 1-year timeframe. The presence of psychological problems was collected along with CHD class, clinical history, developmental delay, and patient demographics. We described the prevalence of psychological problems and then, using machine learning algorithms, trained and tested optimal predictive models.

Results

Of the 397 patients who met inclusion criteria, the lifetime prevalence of any reported psychological problem was 35.5%. The most prevalent reported problems were attention-deficit/hyperactivity disorder (18.9%), anxiety (17.6%), and depression (16.1%). Contrary to our expectations, we could not predict the presence or absence of any psychological problem using routine clinical data. Instead, we found multivariate models predicting depression and attention-deficit/hyperactivity disorder with promising accuracy. Prediction of anxiety was less successful.

Conclusions

Approximately 1 of 3 adolescents with CHD presented with the lifetime prevalence of 1 or more psychological problems. Congenital cardiac programmes are in a position of influence to respond to these problems and impact their patients' mental health as part of a comprehensive care plan. The discovered models using routine clinical data predicted specific psychological problems with varying accuracy. With further validation, these models could become the tools of routine recommendations for referral to psychological care.

Associated factors for prenatally diagnosed fetal congenital heart diseases

OBJECTIVE

Current studies have suggested that fetal congenital heart diseases (CHDs) are caused by various factors. However, few data in this field is available in China. This study aimed to detect associated factors of prenatally diagnosed fetal CHD in a large sample in China.

STUDY DESIGN

Pregnant women who underwent fetal echocardiography were recruited in our hospital between May 2018 and September 2019. The maternal sociodemographic and lifestyle characteristics and some fetal factors were obtained. We used forward stepwise logistic regression analysis to assess risk of fetal CHD associated with various factors.

RESULTS

A total of 5024 subjects were enrolled, of whom 875 had CHD fetuses. Among the fetal CHD group (N = 875), critical CHDs account for 27%, of which Tetralogy of Fallot is the most (7.1%), followed by coarctation of aorta (4.0%), double-outlet right ventricle (2.9%). The forward stepwise logistic regression models revealed that history of spontaneous abortion (OR = 1.59, 95% CI 1.33-1.91, P = 0.000), upper respiratory tract infection during early pregnancy (OR = 1.30, 95% CI 1.04-1.62, P = 0.020), mental stress during early pregnancy (OR = 2.37, 95% CI 1.15-4.91, P = 0.020), single umbilical artery (OR = 2.30, 95% CI 1.18-4.51, P = 0.015), and paternal smoking (OR = 1.21, 95% CI 1.02-1.44, P = 0.027) are positively associated with an increased risk of fetal CHD.

CONCLUSION

We identified several factors positively associated with fetal CHD. These findings suggest that it is important to strengthen healthcare and prenatal counseling for women with these factors.

Maternal periconceptional environmental exposure and offspring with congenital heart disease: a case-control study in Guangzhou, China

BACKGROUND

Congenital heart defects (CHDs) are a major global health problem, yet their crucial environmental risk factors are still unclear. We aimed to explore the associations between maternal periconceptional environmental exposures and all CHDs, isolated and multiple CHDs and CHDs subtypes.

METHOD

A case-control study including 675 infants with CHDs and 1545 healthy controls was conducted. Participating mothers who delivered in Guangzhou from October 2019 to November 2021 were recruited. To examine the independent associations between maternal periconceptional environmental exposure and offspring with CHDs, we calculated odds ratios (ORs) and 95% confidence intervals (CIs) using multivariable logistic regression model.

RESULTS

Maternal exposure to living near main roads [adjusted OR (aOR) = 1.94, 95% CI = 1.06-3.56] and housing renovation (aOR = 1.94, 95% CI = 1.03-3.67) during the periconceptional period were positively related to a greater risk of all CHDs, similar results were also found in isolated CHDs rather than multiple CHDs. Additionally, living near main roads was positively associated with secundum atrial septal defect/patent foramen ovale (aOR = 2.65, 95% CI = 1.03-6.81) and housing renovation was strongly positively associated with ventricular septal defect (aOR = 5.08, 95% CI = 2.05-12.60). However, no association was observed between incense burning and family relationships and all CHDs, isolated and multiple CHDs and CHDs subtypes.

CONCLUSION

Living near main roads and housing renovation during the periconceptional period are significantly associated with the increased risks for all CHDs and isolated CHDs. Further study is needed to extend sample size to explore the effects of time and frequency of burning incense and family relationships on CHDs in offspring.

Association between placental DNA methylation and fetal congenital heart disease

Congenital heart disease (CHD) is a worldwide problem with high morbidity and mortality. Early diagnosis of congenital heart disease is still a challenge in clinical work. In recent years, few studies indicated that placental methylation may be predictors of CHD. More studies are needed to confirm the association between placental methylation and CHD. The aim of this study was to investigate the association between prenatal placental DNA methylation and CHD. Placental tissues were obtained from four fetuses during the second trimester with isolated, non-syndromic congenital heart disease, including three cases with double outlet right ventricle (DORV) and one case with tetralogy of Fallot (TOF), and four unaffected fetuses as controls. The Illumina Infinium Human Methylation 850K BeadChip assay was employed to identify differential methylation sites (DMSs) and differential methylation regions (DMRs). Differential methylation was evaluated by comparing the β-values for individual CpG loci in cases vs. controls. In addition, the function of genes was assessed through KEGG enrichment analysis, Gene Ontology (GO) analysis and KEGG pathway analysis. Compared with the control group, we identified 9625 differential methylation genes on 26,202 DMSs (p < 0.05), of which 6997 were hyper-methylation and 2628 were hypo-methylation. The top 30 terms of GO biological process and KEGG enrichment analysis of DMSs were connected with multiple important pathways of heart development and disease. Ten differentially methylated regions and the genes related to DMRs, such as TLL1, CRABP1, FDFT1, and PCK2, were identified. The deformity caused by the loss of function of these genes is remarkably consistent with the clinical phenotype of our cases. The DNA methylation level of placental tissue is closely associated with fetal congenital heart disease.

The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: Management of infants and neonates with tetralogy of Fallot

OBJECTIVE

Despite decades of experience, aspects of the management of tetralogy of Fallot with pulmonary stenosis (TOF) remain controversial. Practitioners must consider newer, evolving treatment strategies with limited data to guide decision making. Therefore, the TOF Clinical Practice Standards Committee was commissioned by the American Association for Thoracic Surgery to provide a framework on this topic, focused on timing and types of interventions, management of high-risk patients, technical considerations during interventions, and best practices for assessment of outcomes of the interventions. In addition, the group was tasked with identifying pertinent research questions for future investigations. It is recognized that variability in institutional experience could influence the application of this framework to clinical practice.

METHODS

The TOF Clinical Practice Standards Committee is a multinational, multidisciplinary group of cardiologists and surgeons with expertise in TOF. With the assistance of a medical librarian, a citation search in PubMed, Embase, Scopus, and Web of Science was performed using key words related to TOF and its management; the search was restricted to the English language and the year 2000 or later. Articles pertaining to pulmonary atresia, absent pulmonary valve, atrioventricular septal defects, and adult patients with TOF were excluded, as well as nonprimary sources such as review articles. This yielded nearly 20,000 results, of which 163 were included. Greater consideration was given to more recent studies, larger studies, and those using comparison groups with randomization or propensity score matching. Expert consensus statements with class of recommendation and level of evidence were developed using a modified Delphi method, requiring 80% of the member votes with 75% agreement on each statement.

RESULTS

In asymptomatic infants, complete surgical correction between age 3 and 6 months is reasonable to reduce the length of stay, rate of adverse events, and need for a transannular patch. In the majority of symptomatic neonates, both palliation and primary complete surgical correction are useful treatment options. It is reasonable to consider those with low birth weight or prematurity, small or discontinuous pulmonary arteries, chromosomal anomalies, other congenital anomalies, or other comorbidities such as intracranial hemorrhage, sepsis, or other end-organ compromise as high-risk patients. In these high-risk patients, palliation may be preferred; and, in patients with amenable anatomy, catheter-based procedures may prove favorable over surgical palliation.

CONCLUSIONS

Ongoing research will provide further insight into the role of catheter-based interventions. For complete surgical correction, both transatrial and transventricular approaches are effective; however, the smallest possible ventriculotomy should be utilized. When possible, the pulmonary valve should be spared; and if unsalvageable, reconstruction can be considered. At the conclusion of the operation, adequate relief of the right ventricular outflow obstruction should be confirmed, and identification of a significant fixed anatomical obstruction should prompt further intervention. Given our current knowledge and the gaps identified, we propose several key questions to be answered by future research and potentially by a TOF registry: When to palliate or proceed with complete surgical correction, as well as the ideal type of palliation; the optimal surgical approach for complete repair for the best long-term preservation of right ventricular function; and the utility, efficacy, and durability of various pulmonary valve preservation and reconstruction techniques.

Identification and functional analysis of variants of MYH6 gene promoter in isolated ventricular septal defects

BACKGROUND

Ventricular septal defect is the most common form of congenital heart diseases. MYH6 gene has a critical effect on the growth and development of the heart but the variants in the promoter of MYH6 is unknown.

PATIENTS AND METHODS

In 604 of the subjects (311 isolated and sporadic ventricular septal defect patients and 293 healthy controls), DNA was extracted from blood samples and MYH6 gene promoter region variants were analyzed by sequencing. Further functional verification was performed by cellular experiments using dual luciferase reporter gene analysis, electrophoretic mobility shift assays, and bioinformatics analysis.

RESULTS

Nine variants were identified in the MYH6 gene promoter and two of those variants [g.4085G>C(rs1222539675) and g.4716G>A(rs377648095)] were only found in the ventricular septal defect patients. Cellular function experiments showed that these two variants reduced the transcriptional activity of the MYH6 gene promoter (p < 0.001). Further analysis with online JASPAR database suggests that these variants may alter a set of putative transcription factor binding sites that possibly lead to changes in myosin subunit expression and ventricular septal defect formation.

CONCLUSIONS

Our study for the first time identifies variants in the promoter region of the MYH6 gene in Chinese patients with isolated and sporadic ventricular septal defect. These variants significantly reduced MYH6 gene expression and affected transcription factor binding sites and therefore are pathogenic. The present study provides new insights in the role of the MYH6 gene promoter region to better understand the genetic basis of VSD formation.

Dietary Quality during Pregnancy and Congenital Heart Defects

Limited studies on maternal dietary quality indices and congenital heart defects (CHD) are available. This study aimed to explore the relationship between dietary quality in pregnancy and CHD among the Chinese population. A case-control study was performed in Northwest China, and 474 cases and 948 controls were included. Eligible women waiting for delivery were interviewed to recall diets and other information during pregnancy. Dietary quality was assessed by the Global Diet Quality Score (GDQS) and Mediterranean Diet Score (MDS). Logistic regression models were adopted to evaluate the associations of dietary quality scores with CHD. Pregnant women with higher scores of GDQS and MDS were at a lower risk of fetal CHD, and the adjusted ORs comparing the extreme quartiles were 0.26 (95%CI: 0.16−0.42; Ptrend < 0.001) and 0.53 (95%CI: 0.34−0.83; Ptrend = 0.007), respectively. The inverse associations of GDQS and MDS with CHD appeared to be stronger among women with lower education levels or in rural areas. Maternal GDQS and MDS had good predictive values for fetal CHD, with the areas under the receiver operating characteristic curves close to 0.8. Efforts to improve maternal dietary quality need to be strengthened to decrease the prevalence of CHD among the Chinese population.