Physiologic diagnosis of congenital heart disease in cyanotic neonates

Precision fetal cardiology detects cyanotic congenital heart disease using maternal saliva metabolome and artificial intelligence

Prenatal sonographic diagnosis of congenital heart disease (CHD) can lead to improved morbidity and mortality. However, the diagnostic accuracy of ultrasound, the sole prenatal screening tool, remains limited. Failed prenatal or early newborn detection of cyanotic CHD (CCHD) can have disastrous consequences. We therefore sought to use a Precision Fetal Cardiology based approach combining metabolomic profiling of maternal saliva and machine learning, a major branch of artificial intelligence (AI), for the prenatal detection of isolated, non-syndromic cyanotic CHD. Metabolomic analyses using Ultra-High Performance Liquid Chromatography/Mass Spectrometry identified 468 metabolites in the saliva. Six different AI platforms were utilized for the detection of CCHD and CHD overall. AI achieved excellent accuracy for the CCHD detection: Area Under the ROC curve: AUC (95% CI) = 0.819 (0.635-1.00) with a sensitivity and specificity of 92.5% and 87.0%, and for CHD overall: AUC (95% CI) = 0.828 (0.635-1.00) with a sensitivity of 90.5% and specificity of 88.0%. Similarly high accuracies were achieved for the detection of CHD overall: AUC (95% CI) = 0.8488 (0.635-1.00) with a sensitivity of 92.5% and specificity of 91.0%. Pathway analysis showed significant alterations in Arachidonic Acid, Alpha-linoleic acid, and Tryptophan metabolism indicating significant lipid dysfunction in cyanotic CHD. In summary, we report for the first time, the accurate detection of non-syndromic cyanotic CHD using maternal salivary metabolomics. Further, analysis revealed significant alteration of lipid metabolism.

The Utilization of Acetaminophen for Managing PGE1-Induced Fever in Neonates with Critical Congenital Heart Disease

INTRODUCTION

We aimed to retrospectively evaluate the use of acetaminophen, which may be a risk factor for the ductal canal, in the treatment of fever due to prostaglandin E1 (PGE1) infusion in newborns with critical congenital heart disease (CCHD).

METHODS

The study included newborns who were followed-up in our neonatal intensive care unit with the diagnosis of critical congenital heart disease, developed fever due to PGE1 infusion and had acetaminophen administered for antipyretic treatment. The patent ductus arteriosus diameters of the patients were evaluated by echocardiographic imaging before intravenous acetaminophen treatment and at the end of the day of acetaminophen treatment.

RESULTS

PGE1 fever was observed in 10 (6%) of 156 infants with ductus-dependent congenital heart disease. Intravenous acetaminophen treatment administered as an antipyretic in these infants did not cause the narrowing or closure of the ductal canal diameter, which would lead to clinical decompensation if it was closed, and the patients remained hemodynamically stable until surgery.

CONCLUSIONS

It can be considered that controlled and rapidly administered intravenous acetaminophen therapy in the management of fever in neonates with congenital heart disease who develop fever as a side effect of high-dose intravenous PGE1 infusion therapy (≥0.3 mcg/kg/min) may prevent hemodynamic decompensation in these critically ill infants, and as a secondary outcome, it can be speculated that avoiding rapid daily increases in PGE1 maintenance infusion doses may be necessary to limit the number of paracetamol administrations in these infants.

Predictors of high maintenance prostaglandin E1 doses in neonates with critical congenital heart disease-ductal-dependent pulmonary circulation during preoperative care

BACKGROUND

Neonates with critical congenital heart disease of the ductal-dependent pulmonary circulation type (CCHD-DDPC) require prostaglandin E1 (PGE1) to maintain oxygen saturation until surgery. However, the factors contributing to the maintenance doses of PGE1 remain unclear. This study aimed to determine the predictors of high maintenance PGE1 doses in these neonates.

METHODS

This retrospective cohort study included neonates with CCHD-DDPC at Songklanagarind Hospital between January 1, 2006, and December 31, 2021. Factors associated with high maintenance PGE1 doses (> 0.01 mcg/kg/min) were analyzed to identify predictors. Odds ratios were calculated using tabulation and logistic regression analysis. A prediction score was developed for high maintenance PGE1 doses.

RESULTS

Among 96 neonates with CCHD-DDPC, 55 % required high maintenance doses of PGE1. Three factors significantly associated with high maintenance PGE1 doses were patent ductus arteriosus (PDA) size-to-birthweight ratio ≤1.3 mm/kg, initial PGE1 dose >0.03 mcg/kg/min, and preoperative invasive mechanical ventilation. The area under the receiver operating characteristic curve for these three predictors was 0.7409. A predictive score of 0-3 was created based on these factors. The probabilities of receiving a high maintenance dose of PGE1 for patients with overall scores of 0, 1, 2, and 3 were 0.19 (95 % CI: 0.04-0.33), 0.42 (95 % CI: 0.30-0.54), 0.69 (95 % CI: 0.57-0.81), and 0.87 (95 % CI: 0.76-0.99), respectively.

CONCLUSIONS

In neonates with CCHD-DDPC, a PDA size-to-birth weight ratio ≤1.3 mm/kg, an initial dose of PGE1 > 0.03 mcg/kg/min, and preoperative invasive mechanical ventilation were predictors of high maintenance PGE1 doses during the preoperative period.

Congenital Heart Defects and Concurrent Diagnoses in Influenza Hospitalization in the Pediatric Health Information System Study, 2004-2019

Influenza is associated with adverse outcomes in children, although modification by additional medical conditions is not well-documented. We aimed to compare outcomes in children with versus without congenital heart defects (CHDs) who were hospitalized for influenza. We retrospectively evaluated patients 1-18y hospitalized for influenza in the Pediatric Health Information (PHIS) database from 2004 to 2019. Outcomes were compared by CHD presence and then by CHD severity (minor biventricular, major biventricular, and single ventricle disease) using log-binomial regression adjusted for propensity scores accounting for age at admission, sex, and history of asthma. Outcomes included inpatient mortality, intensive care unit (ICU) admission, mechanical ventilation, and length of stay (LOS) > 12 days. To evaluate for effect modification by genetic diagnoses, analyses were repeated stratified by CHD and genetic diagnosis. Among 55,161 children hospitalized for influenza, 2369 (4.3%) had CHDs, including 963 with minor biventricular, 938 with major biventricular, and 468 with single ventricle CHDs. Adjusting for propensity scores, children with CHDs had higher mortality (4.1% versus 0.9%) compared to those without CHDs (risk ratio [RR] 2.5, 95% confidence interval [CI] 1.9-3.4). Children with CHDs were at higher risk of mechanical ventilation (RR 1.6, 95% CI 1.6-1.7), ICU admission (RR 1.9, 95% CI 1.8-2.1), and LOS > 12 days (RR 2.2, 95% CI 2.0-2.3). Compared to those with neither CHD nor genetic condition, children with both had significantly higher risk of all outcomes, with the largest difference for LOS > 12 days (RR 2.3, 95% CI 2.0-2.7). Children with CHDs hospitalized for influenza are particularly susceptible to adverse outcomes compared to those without CHDs. Future studies are needed to corroborate findings in light of influenza vaccination.

Presentation of Complex Congenital Cardiac Anomalies in a Newborn Pediatric Patient: A Case Report

Tricuspid atresia, a critical congenital heart defect (CHD), accounts for approximately 1% of all cases of CHDs. When tricuspid atresia is coupled with numerous other unexpected congenital cardiac anomalies, a patient's condition becomes more serious and more complex. We present a case that demonstrates the stepwise approach to the holistic treatment of congenital tricuspid atresia in the presence of normally related great vessels, a large ventricular septal defect (VSD), atrial septal defect (ASD), and trivial patent ductus arteriosus (PDA). While expanding upon the implementation of chest X-ray imaging, serial transthoracic echocardiogram (TTE) imaging, and the balloon atrial septostomy (BAS) procedure, we also provide insight into the multidisciplinary team-based approach utilized for this patient's case. This case illustrates a rare critical CHD coupled with other, more common congenital anomalies, and suggests that with multidisciplinary management and treatment, it is possible the mortality rates associated with this diagnosis could decline.

Improving the diagnosis and treatment of congenital heart disease through the combination of three-dimensional echocardiography and image guided surgery

OBJECTIVE

The paper aimed to improve the accuracy limitations of traditional two-dimensional ultrasound and surgical procedures in the diagnosis and management of congenital heart disease (chd), and to improve the diagnostic and therapeutic level of chd.

METHOD

This article first collected patient data through real-time imaging and body surface probes, and then diagnosed 150 patients using three-dimensional echocardiography. In order to verify the effectiveness of the combination therapy, 60 confirmed patients were divided into a control group and an experimental group. The control group received conventional two-dimensional ultrasound and surgical treatment, while the experimental group received three-dimensional ultrasound and image guided surgical treatment.

RESULT

In the second diagnosis, the diagnostic accuracy of type 1, type 2, and type 3 in the control group was 84.21%, 84.02%, and 83.38%, respectively. The diagnostic accuracy rates of type 1, type 2, and type 3 in the experimental group were 92.73%, 92.82%, and 92.83%, respectively. In the control group, 2 males and 1 female experienced heart failure after surgery. However, in the experimental group, 0 males and 0 females experienced heart failure after surgery.

CONCLUSION

The combination of three-dimensional echocardiography and image guided surgery can improve diagnostic accuracy and surgical treatment effectiveness, thereby reducing risks and complications, and improving surgical success rate.

Perioperative Management of Emergency Craniotomes in Children With Cyanotic Congenital Heart Disease: A Case Series

While congenital heart disease is not uncommon, cyanotic congenital heart disease (CCHD) accounts for a minor fraction of them. However, when cyanosis is present, it usually indicates a severe or critical illness. Tetralogy of Fallot (TOF) is one of the common CCHDs, representing 7-10% of all congenital cardiac malformations. Double-outlet right ventricle (DORV) is another CCHD similar to the TOF and associated with decreased pulmonary flow, ventricular septal defect (VSD), and aorta receiving blood from both ventricles. Reduced oxygen arterial saturation and increased viscosity by polycythemia induce focal cerebral ischemia, often in the area supplied by the middle cerebral artery leading to brain abscess. Brain abscesses require craniotomy, which is a major surgery. These patients also often show features of sepsis and increased intracranial pressure. The presence of CCHD further complicates the situation, making perioperative management even more challenging. There are studies in the literature on the management of similar cases, and they report successful management in most of them. However, not all such cases need intensive postoperative management. We present four pediatric cases who had either TOF or DORV and had to undergo craniotomy for brain abscess or ventriculoperitoneal shunt placement. We describe case management and highlight the critical features and cases that require prolonged postoperative critical care management.

Spectrum of congenital heart disease in Nepal from 2002-2022: A systematic review and meta-analysis

Background

Congenital heart diseases are recognized as public health concerns worldwide and Nepal is no exception. This study aims to study congenital heart disease in Nepal on grounds of burden, commonest type, common presentations, and associated noncardiac anomalies so that its spectrum can be known for prompt diagnosis and adoption of screening protocols.

Methods

Relevant articles were searched in electronic databases using appropriate search terms and Boolean operators. Data were extracted in Excel and analyzed in Comprehensive Meta-Analysis Software. The proportion was used as an effect measure and a fixed or random-effect model was used as per the heterogeneity. Forest plots were used to give visual feedback.

Results

A total of nine studies were included in the qualitative and quantitative synthesis after a rigorous screening of imported studies. The prevalence of congenital heart disease was 0.7% (Proportion: 0.007; CI: 0.001-0.035; I2: 99.263%). The burden of atrial septal defect was 32.1%, ventricular septal defect was 31.1%, patent ductus arteriosus was 12.6% and Tetralogy of Fallot was 7.3%. The most common presentations were respiratory tract infection (54.7%), developmental delay (49.8%), difficulty in breathing (44.5%), failure to thrive (17.1%), and cyanosis (15.9%).

Conclusions

The prevalence of congenital heart disease in Nepal was 0.7% and the frequency of male patients was higher. The atrial septal defect was the commonest on the whole, while, Tetralogy of Fallot was the commonest among cyanotic variety. Respiratory tract infection was frequently seen at presentation and the most commonly associated noncardiac anomaly was the cleft palate.

Assessment of bone mineral density in children with congenital cyanotic heart disease

BACKGROUND

Cyanotic CHD is one of many disorders in paediatrics that influence the health of children in different clinical aspects. One of the fundamental aspects that may be affected is bone mineral density.

OBJECTIVES

The aim of our study is to assess bone mineral density in children with congenital cyanotic heart disease of different anatomical diagnoses.

DESIGN/METHODS

Cross-sectional, observational study included 39 patients (20 males) with congenital cyanotic heart disease of different anatomical diagnoses following with the cardiology clinic in Mansoura University children's hospital. All patients were subjected to anthropometric measures, oxygen saturation assessment, and lumber bone mineral density using dual-energy X-ray absorptiometry.

RESULTS

Six patients (15.4%) out of the 39 included patients showed bone mineral density reduction, 13 patients (33.3%) showed bone mineral density with Z-score between -1 and -2, while 20 patients (51.3%) showed bone mineral density with Z-score more than -1.

CONCLUSION

Low bone mineral density can be found in children with cyanotic CHD, making it important to consider bone mineral density assessment and early treatment if needed to avoid further complications.

Association Between Maternal Race and the Occurrence of Cyanotic Congenital Heart Disease in the USA

Overall mortality due to congenital heart disease in the United States declined between 1999 and 2017. However, disparities still exist in occurrence and mortality rates among specific racial/ethnic groups in the USA. This study aims to find the association between maternal race and the occurrence of Cyanotic Congenital Heart Disease (CCHD) in the USA. We carry out analysis on a secondary dataset (2017 Natality) obtained from the US Centers for Disease Control and Prevention. This was analyzed using descriptive, bivariate, and regression analysis. This cross-sectional study obtained sociodemographic information-maternal race, independent and confounder variables (explanatory variables), and the occurrence of Cyanotic Congenital Heart Disease (outcome variable) within the reporting States and U.S. territories. There was a report of 3,864,754 live birth out of 325,719,178 USA races and origin populations for the 2017 review year. A total number of 2130 CCHD birth was reported to have occurred out of the 3,8161,947 live births. The Chi-square test showed a statistically significant association between maternal race and the occurrence of CCHD. As well as, the following confounders mother's age, mother's nativity, combined gestation, pre-pregnancy diabetes, pre-pregnancy hypertension, month prenatal care began, smoking status, and Nutrition (WIC) all having a p-value of 0.01 each, respectively. Unadjusted odds ratios at 95 % CI of the association between maternal race and CCHD were 56 % higher among American Indian and Alaska Native women (95% CI 1.13-2.15) than the white racial group. In addition, the Odds were 13% (95% CI 0.78-0.98) and 46% (95% CI 0.43-0.66) less likely amongst Black and Asian or Pacific Islander, respectively. The odds were 402% markedly high for pre-pregnancy diabetes, 159% for pre-pregnancy hypertension, 38 % for smoking status, and 44%, 159%, and 42% respectively for prenatal care from 1st to 2nd months, 4th to 6th months, and 7th to the final month, when compared to no prenatal care. The odds of having a CCHD was 16% less likely for mothers on Nutrition (mothers on WIC) (95% CI 0.77-0.92), 19% (95% CI 0.73-0.90) for mothers age (under 35 years) category, and likewise for mothers born outside of the USA at 39% (95% CI 1.22-1.56). On Adjustment for confounders, the OR for this relationship was on the higher side for many of the variables. The odds of occurrence of CCHD were 59 % higher amongBlack (95% CI 1.27-2.0), 35% among AIAN (95 % CI 1.05-1.74), and 92 % among American Indian and Alaska Native (95 % CI 1.26-2.93) racial categories whencompared to Asian or Pacific Islander categories. The odds of having a CCHD was also elevated on adjustment for mothers born outside of the USA at 39% (95% CI 1.22-1.56), and at from the 7th to final month 94% (95% CI 1.38-2.73). However, the odds were insignificant in other categories and variables. These estimates suggest theoccurrence of a CCHD is associated with the analyzed independent predictor and confounder variables. An association exists between maternal race and the occurrence of cyanotic congenital heart disease in the USA. Further research in this area, may therefore help to diminish the occurrence, morbidity, and or mortality of CCHD in America and globally as well.

Severe Heart Failure in an Infant Born to a Mother Diagnosed With Influenza A Before Delivery

Neonatal myocarditis and heart failure secondary to maternal infection with a myocarditis-associated virus in the weeks preceding delivery is rare. To our knowledge, this is the first report of an infant with myocarditis and heart failure in the setting of a maternal diagnosis of influenza A. Influenza is, however, known to be a cause of myocarditis in children, and several studies have shown vertical transmission of antibodies to influenza. Here, we present a full-term infant who presented with central cyanosis and respiratory distress at 30 minutes of life. No prenatal concerns had been identified. The infant continued to have poor saturations and mixed respiratory and metabolic acidosis despite intubation and administration of 100% FiO2. He was found to have severe biventricular dysfunction on echocardiogram. In discussion with the parents, it was elucidated that the mother had tested positive for influenza A 3 weeks before delivery. The presumptive diagnosis for this infant is heart failure secondary to influenza myocarditis that he contracted in utero. He demonstrated full return of heart function and was discharged home from the Cardiac Intensive Care Unit by day of life 10. Neonates with central cyanosis must be evaluated and treated emergently as these infants are at risk for life-threatening disease and downstream morbidity secondary to tissue hypoxia. The purpose of this case report is to highlight a rare but devastating etiology of cyanosis in neonates and to discuss the recommended course of evaluation and treatment for health care providers.

Early Results of the Persian Registry of Cardiovascular Disease/Congenital Heart Disease (PROVE/CHD) in Isfahan

Background: In 2016, a prospective registry for pediatric patients with congenital heart disease (CHD) was established in Isfahan, Iran. Data on pediatric CHD in Iran are scant; accordingly, we aimed to report the early results of the Persian Registry Of cardioVascular diseasE (PROVE/CHD) Registry in Isfahan. Methods: All patients with CHD and associated defects diagnosed by pediatric cardiologists were assessed via echocardiography for inclusion in the present study between late 2016 and August 2019. The participants' sociodemographic characteristics, maternal history, birth history, medical history, current clinical presentations in the clinic or hospital, paraclinical data, cardiac diagnoses based on the International Classification of Diseases, 10th Revision (ICD-10), disease management plans, and medications were entered into a questionnaire by the subjects' parents/legal custodians and physicians and then transferred to the PROVE/CHD Registry. Results: The PROVE/CHD registry encompasses 1252 patients with CHD (49.9% male) at a mean age of 6.50±6.36 years. The most frequent cardiac diagnoses were ventricular septal defect (39.3%), atrial septal defect (29.7%), patent ductus arteriosus (25.4%), pulmonary stenosis (11.0%), tetralogy of Fallot (6.1%), coarctation of the aorta (5.4%), and aortic stenosis (5.1%), respectively. The most frequent interventions were patent ductus arteriosus closure (4.3%), atrial septal defect closure (3.6%), pulmonary valvuloplasty (2.2%), coarctation of the aorta angioplasty (1.9%), and ventricular septal defect closure (1.1%), correspondingly. The approximate corresponding rates of corrective and palliative surgeries were 32.0% and 13.1%. The corrective surgeries were mainly comprised of ventricular septal defect closure (7.8%), patent ductus arteriosus closure (7.3%), atrial septal defect closure (5.1%), and tetralogy of Fallot repair (3.8%), respectively. The palliative surgeries mainly consisted of the Glenn shunt (9.0%) and pulmonary artery banding (3.6%). Conclusion: The PROVE/CHD Registry collects data on pediatric patients with CHD. The results of this registry can provide epidemiological data and a set of homogeneously defined cases for further studies.

Actionability of commercial laboratory sequencing panels for newborn screening and the importance of transparency for parental decision-making

BACKGROUND

Newborn screening aims to identify individual patients who could benefit from early management, treatment, and/or surveillance practices. As sequencing technologies have progressed and we move into the era of precision medicine, genomic sequencing has been introduced to this area with the hopes of detecting variants related to a vastly expanded number of conditions. Though implementation of genomic sequencing for newborn screening in public health and clinical settings is limited, commercial laboratories have begun to offer genomic screening panels for neonates.

METHODS

We examined genes listed on four commercial laboratory genomic screening panels for neonates and assessed their clinical actionability using an established age-based semi-quantitative metric to categorize them. We identified genes that were included on multiple panels or distinct between panels.

RESULTS

Three hundred and nine genes appeared on one or more commercial panels: 74 (23.9%) genes were included in all four commercial panels, 45 (14.6%) were on only three panels, 76 (24.6%) were on only two panels, and 114 (36.9%) genes were listed on only one of the four panels. Eighty-two genes (26.5%) listed on one or more panels were assessed by our method to be inappropriate for newborn screening and to require additional parental decision-making. Conversely, 249 genes that we previously identified as being highly actionable were not listed on any of the four commercial laboratory genomic screening panels.

CONCLUSIONS

Commercial neonatal genomic screening panels have heterogeneous content and may contain some conditions with lower actionability than would be expected for public health newborn screening; conversely, some conditions with higher actionability may be omitted from these panels. The lack of transparency about how conditions are selected suggests a need for greater detail about panel content in order for parents to make informed decisions. The nuanced activity of gene list selection for genomic screening should be iteratively refined with evidence-based approaches to provide maximal benefit and minimal harm to newborns.