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Moray A, Mugaba PM, Joynt C, McBrien A, Eckersley LG, Phillipos E, Holinski P, Ryerson L, Coe JY, Chandra S, Wong B, Derbyshire M, Lefebvre M, Al Aklabi M, Hornberger LK. Predicting High-Risk Fetal Cardiac Disease Anticipated to Need Immediate Postnatal Stabilization and Intervention with Planned Pediatric Cardiac Operating Room Delivery. J Am Heart Assoc 2024; 13:e031184. [PMID: 38497437 PMCID: PMC11010008 DOI: 10.1161/jaha.123.031184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 01/24/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Distances between delivery and cardiac services can make the care of fetuses with cardiac disease at risk of acute cardiorespiratory instability at birth a challenge. In 2013 we implemented a fetal echocardiography-based algorithm targeting fetuses considered high risk for acute cardiorespiratory instability at ≤2 hours of birth for delivery in our pediatric cardiac operating room of our children's hospital, and, herein, examine our experience. METHODS AND RESULTS We reviewed maternal and postnatal medical records of all fetuses with cardiac disease encountered January 2013 to March 2022 considered high risk for acute cardiorespiratory instability. Secondary analysis was performed including all fetuses with diagnoses of d-transposition of the great arteries/intact ventricular septum (d-TGA/IVS) and hypoplastic left heart syndrome (HLHS) encountered over the study period. Forty fetuses were considered high risk for acute cardiorespiratory instability: 15 with d-TGA/IVS and 7 with HLHS with restrictive atrial septum, 4 with absent pulmonary valve syndrome, 3 with obstructed anomalous pulmonary veins, 2 with severe Ebstein anomaly, 2 with thoracic/intracardiac tumors, and 7 others. Pediatric cardiac operating room delivery occurred for 33 but not for 7 (5 with d-TGA/IVS, 2 with HLHS with restrictive atrial septum). For high-risk cases, fetal echocardiography had a positive predictive value of 50% for intervention/extracorporeal membrane oxygenation/death at ≤2 hours and 70% at ≤24 hours. Of "low-risk" cases, 6/46 with d-TGA/IVS and 0/45 with HLHS required intervention at ≤2 hours. Fetal echocardiography for predicting intervention/extracorporeal membrane oxygenation/death at ≤2 hours had a sensitivity of 67%, specificity 93%, and positive and negative predictive values of 80% and 87%, respectively, for d-TGA/IVS, and 100%, 95%, 71%, and 100% for HLHS, respectively. CONCLUSIONS Fetal echocardiography can predict the need for urgent intervention in a majority with d-TGA/IVS and HLHS and in half of the entire spectrum of high-risk cardiac disease.
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Affiliation(s)
- Amol Moray
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics University of Alberta, Stollery Children's Hospital Edmonton Alberta Canada
| | - Proscovia M Mugaba
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics University of Alberta, Stollery Children's Hospital Edmonton Alberta Canada
| | - Chloe Joynt
- Division of Neonatology, Department of Pediatrics University of Alberta, Stollery Children's Hospital Edmonton Alberta Canada
| | - Angela McBrien
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics University of Alberta, Stollery Children's Hospital Edmonton Alberta Canada
| | - Luke G Eckersley
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics University of Alberta, Stollery Children's Hospital Edmonton Alberta Canada
| | - Ernest Phillipos
- Division of Neonatology, Department of Pediatrics University of Alberta, Stollery Children's Hospital Edmonton Alberta Canada
| | - Paula Holinski
- Division of Critical Care, Department of Pediatrics University of Alberta, Stollery Children's Hospital Edmonton Alberta Canada
- Department of Anesthesia University of Alberta, Stollery Children's Hospital Edmonton Alberta Canada
| | - Lindsay Ryerson
- Division of Critical Care, Department of Pediatrics University of Alberta, Stollery Children's Hospital Edmonton Alberta Canada
| | - James Yashu Coe
- Interventional Cardiology, Division of Cardiology, Department of Pediatrics University of Alberta, Stollery Children's Hospital Edmonton Alberta Canada
| | - Sujata Chandra
- Department of Obstetrics & Gynecology University of Alberta Edmonton Alberta Canada
| | - Billy Wong
- Department of Obstetrics & Gynecology University of Alberta Edmonton Alberta Canada
| | - Michele Derbyshire
- Stollery Pediatric and Mazankowski Adult Cardiac Operating Rooms, Alberta Health Services Edmonton Alberta Canada
| | - Maria Lefebvre
- Alberta Health Services and Stollery Children's Hospital Edmonton Alberta Canada
| | - Mohammed Al Aklabi
- Division of Pediatric Cardiovascular Surgery, Department of Surgery University of Alberta, Stollery Children's Hospital Edmonton Alberta Canada
| | - Lisa K Hornberger
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics University of Alberta, Stollery Children's Hospital Edmonton Alberta Canada
- Department of Obstetrics & Gynecology University of Alberta Edmonton Alberta Canada
- Women & Children's Health Research Institute & Cardiovascular Research Institute, University of Alberta, Stollery Children's Hospital Edmonton Alberta Canada
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2
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Thomas AR, Levy PT, Donofrio MT, Law B, Joynt C, Gupta R, Elshenawy S, Reed D, Pavlek LR, Shepherd J, Gowda SH, Johnson BA, Abdulhayoglu E, Valencia E, Guseh S, Ball MK, Ali N. Call to action: prioritizing delivery room care for neonates with critical congenital heart disease. J Perinatol 2024; 44:321-324. [PMID: 37980393 DOI: 10.1038/s41372-023-01828-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/01/2023] [Accepted: 11/07/2023] [Indexed: 11/20/2023]
Affiliation(s)
- Alyssa R Thomas
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Philip T Levy
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mary T Donofrio
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Brenda Law
- Division of Neonatology, Department of Pediatrics, Stollery Children's Hospital/University of Alberta, Edmonton, AB, Canada
| | - Chloe Joynt
- Division of Neonatology, Department of Pediatrics, Stollery Children's Hospital/University of Alberta, Edmonton, AB, Canada
| | - Ruby Gupta
- Division of Neonatology, Department of Pediatrics, Children's Wisconsin, Milwaukee, WI, USA
| | - Summer Elshenawy
- Division of Neonatology, Department of Pediatrics, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, USA
| | - Danielle Reed
- Division of Neonatology, Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, MO, USA
| | - Leeann R Pavlek
- Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Jennifer Shepherd
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Sharada H Gowda
- Division of Neonatology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Beth Ann Johnson
- Division of Neonatology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Elisa Abdulhayoglu
- Department of Pediatrics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eleonore Valencia
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephanie Guseh
- Division of Maternal Fetal Medicine, Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Molly K Ball
- Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Noorjahan Ali
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern, Dallas, TX, USA
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Levy P, Thomas AR, Law BHY, Joynt C, Gupta R, Elshenawy S, Reed D, Pavlek LR, Shepherd J, Gowda S, Johnson BA, Ball M, Ali N. Multicentre study protocol comparing standard NRP to deveLoped Educational Modules for Resuscitation of Neonates in the Delivery Room with Congenital Heart Disease (LEARN-CHD). BMJ Open 2023; 13:e067391. [PMID: 37019485 PMCID: PMC10083808 DOI: 10.1136/bmjopen-2022-067391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
INTRODUCTION Infants born with critical congenital heart defects (CCHDs) have unique transitional pathophysiology that often requires special resuscitation and management considerations in the delivery room (DR). While much is known about neonatal resuscitation of infants with CCHDs, current neonatal resuscitation guidelines such as the neonatal resuscitation programme (NRP) do not include algorithm modifications or education specific to CCHDs. The implementation of CCHD specific neonatal resuscitation education is further hampered by the large number of healthcare providers (HCPs) that need to be reached. Online learning modules (eLearning) may provide a solution but have not been designed or tested for this specific learning need. Our objective in this study is to design targeted eLearning modules for DR resuscitation of infants with specific CCHDs and compare HCP knowledge and team performance in simulated resuscitations among HCPs exposed to these modules compared with directed CCHD readings. METHODS AND ANALYSIS In a prospective multicentre trial, HCP proficient in standard NRP education curriculum are randomised to either (a) directed CCHD readings or (b) CCHD eLearning modules developed by the study team. The efficacy of these modules will be evaluated using (a) individual preknowledge/postknowledge testing and (b) team-based resuscitation simulations. ETHICS AND DISSEMINATION This study protocol is approved by nine participating sites: the Boston Children's Hospital Institutional Review Board (IRB-P00042003), University of Alberta Research Ethics Board (Pro00114424), the Children's Wisconsin IRB (1760009-1), Nationwide Children's Hospital IRB (STUDY00001518), Milwaukee Children's IRB (1760009-1) and University of Texas Southwestern IRB (STU-2021-0457) and is under review at following sites: University of Cincinnati, Children's Healthcare of Atlanta, Children's Hospital of Los Angeles and Children's Mercy-Kansas City. Study results will be disseminated to participating individuals in a lay format and presented to the scientific community at paediatric and critical care conferences and published in relevant peer-reviewed journals.
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Affiliation(s)
- Philip Levy
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Alyssa R Thomas
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Brenda Hiu Yan Law
- Department of Pediatrics, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Chloe Joynt
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Ruby Gupta
- Department of Pediatrics, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Summer Elshenawy
- Department of Pediatrics, Emory University School of Medicine Atlanta, Atlanta, Georgia, USA
| | - Danielle Reed
- Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, Missouri, USA
| | - Leeann R Pavlek
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Jennifer Shepherd
- Department of Pediatrics, Keck School of Medicine University of Southern California, Los Angeles, California, USA
| | - Sharada Gowda
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Beth Ann Johnson
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Molly Ball
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Noorjahan Ali
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Levy PT, Thomas AR, Wethall A, Perez D, Steurer M, Ball MK. Rethinking Congenital Heart Disease in Preterm Neonates. Neoreviews 2022; 23:e373-e387. [PMID: 35641458 DOI: 10.1542/neo.23-6-e373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Congenital heart disease (CHD) and prematurity are the leading causes of infant mortality in the United States. Importantly, the combination of prematurity and CHD results in a further increased risk of mortality and significant morbidity. The key factors in these adverse outcomes are not well understood, but likely include maternal-fetal environment, perinatal and neonatal elements, and challenging postnatal care. Preterm neonates with CHD are born with "double jeopardy": not only do they experience challenges related to immaturity of the lungs, brain, and other organs, but they also must undergo treatment for cardiac disease. The role of the neonatologist caring for preterm infants with CHD has changed with the evolution of the field of pediatric cardiac critical care. Increasingly, neonatologists invested in the cardiovascular care of the newborn with CHD engage at multiple stages in their course, including fetal consultation, delivery room management, preoperative care, and postoperative treatment. A more comprehensive understanding of prematurity and CHD may inform clinical practice and ultimately improve outcomes in preterm infants with CHD. In this review, we discuss the current evidence surrounding neonatal and cardiac outcomes in preterm infants with CHD; examine the prenatal, perinatal, and postnatal factors recognized to influence these outcomes; identify knowledge gaps; consider research and clinical opportunities; and highlight the ways in which a neonatologist can contribute to the care of preterm infants with CHD.
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Affiliation(s)
- Philip T Levy
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Alyssa R Thomas
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Ashley Wethall
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Danielle Perez
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Martina Steurer
- Department of Pediatrics, University of California San Francisco, San Francisco, CA.,Department of Epidemiology and Biostatistics, California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA
| | - Molly K Ball
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH.,Division of Neonatology, The Ohio State University Wexner Medical Center, Columbus, OH
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