Fetal diagnosis of hypoplastic left heart, associations and outcomes in the current era

Analysis of the Results of Sonographic Screening Examinations According to the Maternity Guidelines Before and After the Introduction of the Extended Basic Screening (IIb Screening) in Hesse

AIM OF THE STUDY

The aim of the study is to examine the detection rates of malformations before and after the introduction of extended basic screening in Hesse by the Federal Joint Committee (Gemeinsamer Bundesausschuss, GQH) on July 1, 2013.

METHOD

This is a retrospective, mainly exploratory data analysis of quality assurance data from the Office for Quality Assurance in Hesse (GQH). The data was collected in the period from January 1, 2010 to December 31, 2016 in the obstetric departments of the Hessian hospitals using documentation forms. The classification and evaluation of the diagnoses is based on ICD-10-GM-2019.

RESULTS

At least one malformation is present in 0.7% of the cases. With a share of 30.0%, most of the congenital malformations are from the musculoskeletal system. 12.2% of the malformations come from the facial cleft, closely followed by malformations of the circulatory system with 11.3%. The highest prenatal detection rate (PDR) is found in congenital malformations of the nervous system at 56.8%. The lowest PDR is found in those of the genital organs with 2.1%. The PDR of cardiovascular malformations is 32.9%. Overall, a PDR of 25.2% is achieved. There was no change in the number of prenatal malformation diagnoses after the introduction of extended basic ultrasound. The distribution of malformation diagnoses not detected prenatally to the organ systems also has not changed after the introduction.

CONCLUSION

The introduction of extended basic ultrasound did not bring the desired improvement with regard to the PDR in Hesse. Alternative approaches should be considered.

Hypoplastic Left Heart Syndrome: A Review

Hypoplastic left heart syndrome is a rare and poorly understood congenital disorder featuring a univentricular myocardium, invariably resulting in early childhood death if left untreated. The process to palliate this congenital cardiomyopathy is of high complexity and may include invasive interventions in the first week of life. The preferred treatment strategy involves a staged correction with 3 surgical procedures at different points in time. The Norwood procedure is usually performed within the first weeks of life and aims to increase systemic circulation and relieve pulmonary vascular pressure. This procedure is followed by the bidirectional Glenn and the Fontan procedures in later life, which offer to decrease stress in the ventricular chamber. The prognosis of children with this disease has greatly improved in the past decades; however, it is still largely driven by multiple modifiable and nonmodifiable variables. Novel and clever alternatives have been proposed to improve the survival and neurodevelopment of these patients, although they are not used as standard of care in all centers. The neurodevelopmental outcomes among these patients have received particular attention in the last decade in light to improve this very limiting associated comorbidity that compromises quality of life.

Evaluation of right ventricular myocardial deformation properties in fetal hypoplastic left heart by two-dimensional speckle tracking echocardiography

PURPOSE

Right ventricular (RV) function influences the outcome of hypoplastic left heart (HLH) patients. This study aimed to confirm the assumption of prenatal RV remodeling and possible influencing factors of myocardial restructuring using two-dimensional speckle tracking echocardiography (2D STE).

METHODS

This is a retrospective cross-sectional cohort study including HLH fetuses and gestational age-matched controls. Based on a four-chamber view, cine loops were stored with 60 frames per second. Global longitudinal peak systolic strain (GLPSS) of the RV was retrospectively determined and compared to healthy controls. Furthermore, HLH subgroups were built according to the presence of left ventricular endocardial fibroelastosis (LV-EFE) and restrictive foramen ovale (FO) to investigate the effect of these compromising factors on myocardial deformation.

RESULTS

A total of 41 HLH fetuses and 101 controls were included. Gestational age at fetal assessment was similarly distributed in both groups (controls: 26.0 ± 5.6 weeks vs. HLH: 29.1 ± 5.6 weeks). Relating to RV-GLPSS values, fetuses with HLH demonstrated lower mean values than healthy control fetuses (- 15.65% vs. - 16.80%, p = 0.065). Cases with LV-EFE (n = 11) showed significantly lower mean values compared to such without LV-EFE (n = 30) (RV-GLPSS: - 12.12% vs. - 16.52%, p = 0.003). No significant differences were observed for cases with FO restriction (n = 10).

CONCLUSIONS

In HLH the RV undergoes prenatal remodeling, leading to an adaptation of myocardial function to LV conditions. Further explorations by STE should expand knowledge about RV contraction properties in HLH and its impact on surgical outcome.

Ethical issues after pre-natal diagnosis

Following pre-natal diagnosis of congenital heart defect parents and family face a dramatic psychological crisis because of their state of shock, contradictory information available on potential outcomes, limited availability of time for decisions and for autonomous choices. Counselling the parents can present additional difficulties due to influence of education, cultural and religious background, individual cognitive and emotional processes, and cross-cultural patient care is a challenging issue for the caregivers. Type and quality of messages transmitted by the caregivers determine the counselling process, with the risk of misunderstandings particularly high with reduced available evidence, or with different outcomes accordingly with the various alternatives of treatment. Since the introduction of pre-natal diagnosis for congenital abnormality, interruption of pregnancy became available on these grounds in many Western countries, and the numbers of babies born with congenital heart defects has declined significantly despite concomitant advances in treatment options and outcomes. Detailed and objective information, with all available options, should be provided after pre-natal diagnosis of congenital heart defect. One of the major achievements of pediatric medicine in the last 50 years is the increased understanding of the pathogenetic causal mechanisms of congenital heart defects as well as its treatment. For congenital heart defects the progress of surgical treatments allowed a huge proportion of these children to reach adult life with a decent quality of life and social integration. Therefore, must be a considerable concern that universal pre-natal diagnosis widespread pregnancy interruption may obviate those gains. A reduction in the post-natal population undergoing treatment may have a significantly deleterious effect on the expertise of the caregivers, producing a reduction in outcome quality. With all respect for the parental choices and the obligations to follow the national laws, is necessary to remark that our society is genuinely ambivalent.

A "holistic" sonographic view on congenital heart disease: How automatic reconstruction using fetal intelligent navigation echocardiography eases unveiling of abnormal cardiac anatomy part II-Left heart anomalies

Volume ultrasound has been shown to provide valid complementary information on fetal anatomy. Four-dimensional assessment (4D) of the fetal cardiovascular system using spatial-temporal image correlation (STIC) allows for detailed examination of a highly complex organ from the early second trimester onward. There is compelling evidence that this technique harbors quite a number of diagnostic opportunities, but manual navigation through STIC volume datasets is highly operator dependent. In fact, STIC is not incorporated yet into daily practice. Application of the novel fetal intelligent navigation echocardiography (FINE) considerably simplifies fetal cardiac volumetric examinations. This automatic technique applied on cardiac volume datasets reportedly has both high sensitivity and specificity for the detection of congenital heart defects (CHDs). Part I reviewed current data regarding detection rates of CHDs and illustrated the additional value of an automatic approach in delineating cardiac anatomy exemplified by congenital lesions of the right heart. In part II of this pictorial essay, we focused on left heart anomalies and aimed to tabulate recent findings on the quantification of normal and abnormal cardiac anatomy.

Current perspective and scope of fetal therapy: part 1

Fetal therapy term has been described for any therapeutic intervention either invasive or noninvasive for the purpose of correcting or treating any fetal malformation or condition. Fetal therapy is a rapidly evolving specialty and has gained pace in last two decades and now fetal intervention is being tried in many malformations with rate of success varying with the type of different fetal conditions. The advances in imaging techniques have allowed fetal medicine persons to make earlier and accurate diagnosis of numerous fetal anomalies. Still many fetal anomalies are managed postnatally because the fetal outcomes have not changed significantly with the use of fetal therapy and this approach avoids unnecessary maternal risk secondary to inutero intervention. The short-term maternal risk associated with fetal surgery includes preterm labor, premature rupture of membranes, uterine wall bleeding, chorioamniotic separation, placental abruption, chorioamnionitis, and anesthesia risk. Whereas, maternal long-term complications include risk of infertility, uterine rupture, and need for cesarean section in future pregnancies. The decision for invasive fetal therapy should be taken after discussion with parents about the various aspects like postnatal fetal outcome without fetal intervention, possible outcome if the fetal intervention is done, available postnatal intervention for the fetal condition, and possible short-term and long-term maternal complications. The center where fetal intervention is done should have facility of multi-disciplinary team to manage both maternal and fetal complications. The major issues in the development of fetal surgery include selection of patient for intervention, crafting effective fetal surgical skills, requirement of regular fetal and uterine monitoring, effective tocolysis, and minimizing fetal and maternal fetal risks. This review will cover the surgical or invasive aspect of fetal therapy with available evidence and will highlight the progress made in the management of fetal malformations in last two decades.

New Aspects in the Diagnosis and Therapy of Fetal Hypoplastic Left Heart Syndrome

Fetal hypoplastic left heart syndrome (HLHS) is a severe congenital heart disease with a lethal prognosis without postnatal therapeutic intervention or surgery. The aim of this article is to give a brief overview of new findings in the field of prenatal diagnosis and the therapy of HLHS. As cardiac output in HLHS children depends on the right ventricle (RV), prenatal assessment of fetal RV function is of interest to predict poor functional RV status before the RV becomes the systemic ventricle. Prenatal cardiac interventions such as fetal aortic valvuloplasty and non-invasive procedures such as maternal hyperoxygenation seem to be promising treatment options but will need to be evaluated with regard to long-term outcomes. Novel approaches such as stem cell therapy or neuroprotection provide important clues about the complexity of the disease. New aspects in diagnostics and therapy of HLHS show the potential of a targeted prenatal treatment planning. This could be used to optimize parental counseling as well as pre- and postnatal management of affected children.

Perinatal outcomes of congenital heart disease after emergent neonatal cardiac procedures

PURPOSE

We compared outcome of neonates with prenatal and post-natal diagnosis of congenital heart disease presenting in our paediatric heart centre between March 2005 and May 2015 who underwent an emergent intervention within 48 h post-partum.

MATERIALS AND METHODS

In 52/111 (46.8%) with emergent intervention, congenital heart disease was diagnosed prenatally, in 59/111 (53.2%) with no specialized foetal echocardiography, diagnosis was made post-natally. In 98/111 (88.2%), 30-day outcome was known.

RESULTS

Regarding the entire cohort, 30-day survival did not differ significantly in prenatal and post-natal diagnosis group (71.2 vs. 72.9%; p > .1). Infants with prenatal diagnosis were more likely to be born by caesarean section (59.6% vs. 33.9%, p = .01). Those with post-natal diagnosis had a higher need for intubation (32.7% vs. 52.5%; p < .05). Subgroup analysis of HLH/HLHC (hypoplastic left heart/hypoplastic left heart complex) patients revealed higher number of deaths within 30 days of life in the post-natal diagnosis group, although the difference did not reach statistical significance (5/7, 71.4% vs. 5/20, 25.0%; p = .075).

CONCLUSION

For newborns who require emergent neonatal cardiac procedures, our results point towards a lower death rate after prenatal diagnosis of HLH/HLHC.

Evaluation of right ventricular function in fetal hypoplastic left heart syndrome by color tissue Doppler imaging

OBJECTIVE

Postnatal outcome of fetuses with hypoplastic left heart syndrome (HLHS) is determined mainly by right ventricular function. Our study examines whether there are differences in right ventricular function during gestation of fetuses with HLHS compared with healthy fetuses.

METHODS

A prospective study was conducted including 20 fetuses with HLHS and 20 gestational age-matched controls. Peak systolic and diastolic right ventricular free wall velocities were assessed using color tissue Doppler imaging (c-TDI). Subsequently, isovolumic time intervals, ejection time (ET'), E'/A' ratio and tissue Doppler-derived myocardial performance index (MPI') were calculated. Possible changes to c-TDI indices during the course of pregnancy in both the HLHS group and the control group were investigated.

RESULTS

Examination of right ventricular function revealed significantly lower E' velocities (13.6 vs 21.0 cm/s; P = 0.017) and E'/A' ratios (0.55 vs 0.76; P = 0.012) and prolonged isovolumic contraction time (ICT') (57.0 vs 45.7 ms; P = 0.008) in the HLHS group compared with healthy fetuses. Furthermore, isovolumic relaxation time and MPI' increased significantly with gestational age in HLHS fetuses but not in controls. Values for systolic and diastolic peak velocities (E', A', S'), ET' and ICT' did not change significantly during gestation in either group.

CONCLUSION

Right ventricular function in HLHS is altered as early as in fetal life, well before palliative surgery is performed. Future research should provide further insight into ventricular remodeling during gestation in cases of HLHS. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Evaluation of right ventricular function in fetuses with hypoplastic left heart syndrome using tissue Doppler techniques

OBJECTIVE

The outcome of patients with hypoplastic left heart syndrome (HLHS) is influenced by right ventricular function. This study aimed to investigate whether differences in right ventricular function of fetuses with HLHS are present during gestation.

METHODS

This was a prospective study comprising 14 fetuses with HLHS (28 measurements obtained in total) and 28 normal control fetuses (31 measurements obtained in total). The two groups were matched for gestational age. Ultrasound M-mode was used to assess displacement of the tricuspid annulus. Spectral Doppler and myocardial tissue Doppler-derived inflow and outflow velocities were assessed. Tricuspid valve peak early wave to peak active wave (E/A) ratio, the early wave to early diastolic annular relaxation velocity (E/E') ratio and the tissue Doppler-derived myocardial performance index (MPI') were calculated.

RESULTS

E-wave velocity was significantly higher in fetuses with HLHS than in control fetuses (mean, 40.14 cm/s vs 35.47 cm/s; P < 0.05, respectively), and A-wave velocity in fetuses with HLHS showed a tendency for higher values in the right ventricle compared with normal control fetuses, but this did not reach statistical significance (61.16 cm/s vs 54.64 cm/s; P = 0.08). The E/A ratio increased during gestation in controls, but this increase was not seen in HLHS fetuses. Peak annular velocity during atrial contraction (A') and the E/E' ratio were significantly lower in controls than in HLHS fetuses: 9.50 cm/s vs 10.39 cm/s (P < 0.05) and 5.77 vs 7.37 (P < 0.05), respectively. There were no differences for right-ventricular MPI' or tricuspid annular plane systolic excursion between HLHS fetuses and controls.

CONCLUSION

The results of this study show that altered right ventricular function in HLHS infants may develop antenatally. It is hoped that confirmation of these findings using Doppler-independent techniques will lead to further exploration of ventricular function in HLHS fetuses. Consequently, parental counseling and postnatal management strategies could be influenced.

"Functionally" univentricular hearts: impact of pre-natal diagnosis

Within the last few decades the pre-natal echocardiographic diagnosis of congenital heart defects has made substantial progresses, particularly for the identification of complex malformation. "Functionally" univentricular hearts categorize a huge variety of heart malformations. Since no one of the patients with these congenital heart defects can ever undergo a bi-ventricular type of repair, early recognition and decision-making from the neonatal period are required in order to allow for appropriate multiple-step diagnostic and treatment procedures, either of interventional cardiology and/or surgery, on the pathway of "univentricular" heart. In the literature strong disagreements exist about the potential impact of the pre-natal diagnosis on the early and late outcomes of complex congenital heart defects. This review of the recent reports has been undertaken to better understand the impact of pre-natal diagnosis in "functionally" univentricular hearts taking into consideration the following topics: pre-natal screening, outcomes and survival, general morbidity, neurologic and developmental consequences, pregnancy management and delivery planning, resources utilization and costs/benefits issues, ethical implications, parents counseling, and interruption of pregnancy versus treatment.