1
|
Dedeoglu R, Akbulut DG, Turkmen E, Dedeoglu S, Bornaun H. Perinatal outcomes following early prenatal diagnosis: insights from a single-center experience with Ebstein anomaly and tricuspid valve dysplasia. Arch Gynecol Obstet 2024; 310:1491-1497. [PMID: 38683395 DOI: 10.1007/s00404-024-07509-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 04/07/2024] [Indexed: 05/01/2024]
Abstract
PURPOSE Ebstein anomaly (EA) and tricuspid valve dysplasia (TVD) represent uncommon congenital malformations of the tricuspid valve. The purpose of this study is to report on current perinatal outcomes of EA/TVD in our center and to investigate clinical and fetal echocardiographic predictors of perinatal mortality. METHODS AND RESULTS We performed a retrospective study among fetuses diagnosed from January 2014 to December 2023. Clinical and echocardiographic data were obtained from hospital records of Research and Education Hospital. The primary outcome was perinatal mortality. Of 21 fetuses diagnosed, there were 1 lost to follow-up, 1 termination, and 7 demises. In the live-born cohort of 12 live-born patients, 2 died before discharge, yielding an overall perinatal mortality of 50%. The median gestational age at diagnosis was 23 for non-survivors and 24 weeks for survivors. Birth weight was lower in non-survivors (2430 g vs 2990 g). Tricuspid insufficiency severity varied insignificantly. Non-survivors exhibited higher rates of hydrops, functional atresia, and absent antegrade flow (p < 0.05). Two infants with severe tricuspid insufficiency and congenital abnormalities died postnatally. The limited dataset enables further analysis for a predictive model. Notably, all non-survivors displayed hydrops, functional atresia, and absent antegrade flow, hindering definitive determination of the most impactful parameter on survival estimation. CONCLUSION Perinatal mortality remains notably elevated in fetuses with EA/TVD. The individuals at the highest risk are those with antegrade flow loss and functional atresia of pulmonary valve, this high-risk subgroup could benefit from targeted interventions, such as novel prenatal therapies or a more comprehensive perinatal approach involving optimized timing of delivery and postnatal interventional strategies.
Collapse
Affiliation(s)
- Reyhan Dedeoglu
- Department of Pediatric Cardiology, İstanbul University-Cerrahpaşa Cerrahpaşa Medical School, Istanbul, Turkey.
| | - Damla Gokcer Akbulut
- Department of Pediatric Cardiology, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Emine Turkmen
- Department of Obstetrics and Gynecology, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Savas Dedeoglu
- Department of Pediatrics, Uskudar University Medical Faculty, Istanbul, Turkey
| | - Helen Bornaun
- Department of Pediatric Cardiology, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| |
Collapse
|
2
|
Konstantinov IE, Chai P, Bacha E, Caldarone CA, Da Silva JP, Da Fonseca Da Silva L, Dearani J, Hornberger L, Knott-Craig C, Del Nido P, Qureshi M, Sarris G, Starnes V, Tsang V. The American Association for Thoracic Surgery (AATS) 2024 expert consensus document: Management of neonates and infants with Ebstein anomaly. J Thorac Cardiovasc Surg 2024; 168:311-324. [PMID: 38685467 DOI: 10.1016/j.jtcvs.2024.04.018] [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: 02/29/2024] [Revised: 03/27/2024] [Accepted: 04/03/2024] [Indexed: 05/02/2024]
Abstract
OBJECTIVES Symptomatic neonates and infants with Ebstein anomaly (EA) require complex management. A group of experts was commissioned by the American Association for Thoracic Surgery to provide a framework on this topic focusing on risk stratification and management. METHODS The EA Clinical Congenital Practice Standards Committee is a multinational and multidisciplinary group of surgeons and cardiologists with expertise in EA. A citation search in PubMed, Embase, Scopus, and Web of Science was performed using key words related to EA. The search was restricted to the English language and the year 2000 or later and yielded 455 results, of which 71 were related to neonates and infants. Expert consensus statements with class of recommendation and level of evidence were developed using a modified Delphi method, requiring 80% of members votes with at least 75% agreement on each statement. RESULTS When evaluating fetuses with EA, those with severe cardiomegaly, retrograde or bidirectional shunt at the ductal level, pulmonary valve atresia, circular shunt, left ventricular dysfunction, or fetal hydrops should be considered high risk for intrauterine demise and postnatal morbidity and mortality. Neonates with EA and severe cardiomegaly, prematurity (<32 weeks), intrauterine growth restriction, pulmonary valve atresia, circular shunt, left ventricular dysfunction, or cardiogenic shock should be considered high risk for morbidity and mortality. Hemodynamically unstable neonates with a circular shunt should have emergent interruption of the circular shunt. Neonates in refractory cardiogenic shock may be palliated with the Starnes procedure. Children may be assessed for later biventricular repair after the Starnes procedure. Neonates without high-risk features of EA may be monitored for spontaneous closure of the patent ductus arteriosus (PDA). Hemodynamically stable neonates with significant pulmonary regurgitation at risk for circular shunt with normal right ventricular systolic pressure should have an attempt at medical closure of the PDA. A medical trial of PDA closure in neonates with functional pulmonary atresia and normal right ventricular systolic pressure (>20-25 mm Hg) should be performed. Neonates who are hemodynamically stable without pulmonary regurgitation but inadequate antegrade pulmonary blood flow may be considered for a PDA stent or systemic to pulmonary artery shunt. CONCLUSIONS Risk stratification is essential in neonates and infants with EA. Palliative comfort care may be reasonable in neonates with associated risk factors that may include prematurity, genetic syndromes, other major medical comorbidities, ventricular dysfunction, or sepsis. Neonates who are unstable with a circular shunt should have emergent interruption of the circular shunt. Neonates who are unstable are most commonly palliated with the Starnes procedure. Neonates who are stable should undergo ductal closure. Neonates who are stable with inadequate pulmonary flow may have ductal stenting or a systemic-to-pulmonary artery shunt. Subsequent procedures after Starnes palliation include either single-ventricle palliation or biventricular repair strategies.
Collapse
Affiliation(s)
- Igor E Konstantinov
- Department of Cardiothoracic Surgery, Royal Children's Hospital, Parkville, Australia; Department of Paediatrics, University of Melbourne, Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia.
| | - Paul Chai
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, Ga
| | - Emile Bacha
- Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, NY
| | | | - Jose Pedro Da Silva
- Division of Cardiothoracic Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa
| | | | - Joseph Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Lisa Hornberger
- Department of Pediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Christopher Knott-Craig
- Division of Cardiothoracic Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tenn
| | - Pedro Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | | | - George Sarris
- Department of Pediatric Heart Surgery, Mitera Children's Hospital, Athens, Greece
| | - Vaughn Starnes
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Victor Tsang
- Cardiothoracic Unit, Great Ormond Street Hospital, London, United Kingdom
| |
Collapse
|
3
|
Guo X, Li Y, Zhao B, He Y. Study on the correlation between retrograde ductus arteriosus flow and right ventricular function evaluated by Z-score of tricuspid annular plane systolic excursion in fetuses with Ebstein anomaly. JOURNAL OF CLINICAL ULTRASOUND : JCU 2024; 52:717-722. [PMID: 38655706 DOI: 10.1002/jcu.23695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 04/05/2024] [Accepted: 04/06/2024] [Indexed: 04/26/2024]
Abstract
PURPOSE To analyze the influence of RV dysfunction evaluated by Free-angle M-mode (FAM) TAPSE Z-score on retrograde ductus arteriosus flow (RDAF) in fetuses with Ebstein anomaly (EA). METHODS A retrospective cohort study of 30 EA and 60 normal fetuses were enrolled. The EA group was divided into two groups: with RDAF (EA-RDAF group) and without RDAF (EA-NRDAF group). FAM was used to measure TAPSE of EA and normal fetuses, and Z-scores were calculated. The differences of FAM-TAPSE Z-score, gestational week (GW), maternal age (MA), and mitral valve-tricuspid valve distance (MTD) between three groups were compared. The correlation and binary logistic regression between FAM-TAPSE Z-score, GW, MA, MTD, and RDAF were analyzed. RESULTS FAM-TAPSE Z-score was significantly lower in EA-RDAF group compared to other groups (p < 0.05). FAM-TAPSE Z-score, GW, and MA were negatively correlated with RDAF (p < 0.05), but no correlation was found between TR, MDT, and RDAF (p > 0.05). Multivariate logistic regression showed that FAM-TAPSE Z-score was an independent influencing factor for RDAF (OR = 0.102, p < 0.05). CONCLUSION RV dysfunction is an independent factor leading to RDAF in EA fetus, which provides a feasible theoretical basis for further study on improvement of RV function through intrauterine treatment to delay and prevent the RDAF, to avoid death cycle and improve live-birth rate.
Collapse
Affiliation(s)
- Xianfeng Guo
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yilin Li
- Department of Anesthesia, Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Bowen Zhao
- Department of Diagnostic Ultrasound and Echocardiography, Sir Run Run Shaw Hospital, Zhejiang University College of Medicine, Hangzhou, Zhejiang, China
| | - Yihua He
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
4
|
Liu L, Luo Y, Deng Y, Liang Y, Xie L. Echocardiographic findings and pregnancy outcomes for fetuses with complete closure of the ductus arteriosus. JOURNAL OF CLINICAL ULTRASOUND : JCU 2024; 52:737-744. [PMID: 38662985 DOI: 10.1002/jcu.23701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 04/07/2024] [Accepted: 04/12/2024] [Indexed: 07/11/2024]
Abstract
OBJECTIVE We aimed to analyze the echocardiographic characteristics and pregnancy outcomes for fetuses with premature complete closure of the fetal ductus arteriosus. METHODS A retrospective analysis was performed for eight cases of premature ductus arteriosus closure diagnosed by prenatal ultrasonography in the Hunan Maternal and Child Health Hospital from July 2019 to August 2022, and the characteristics of fetal echocardiography and pregnancy outcomes of the eight cases were analyzed and summarized. RESULTS In all cases, the intima of the ductus arteriosus was thickened and occluded, the ductus arteriosus could be seen with slightly hyperechogenic, and no blood flow signal was found in the ductus arteriosus by Doppler ultrasonography. The right heart was enlarged in seven cases, and the whole heart was enlarged in one case. Tricuspid valve regurgitation was observed to different degrees, of which seven cases were severe and one case was moderate. The pulmonary arteries of eight patients had varying degrees of widening. All eight cases were delivered by cesarean section, and one newborn died after follow-up. The prognosis of the other newborns was good. CONCLUSION The parameters of prenatal echocardiography are helpful for the prognosis of fetuses with premature closure of the ductus arteriosus. Early prenatal detection, close observation, and clinical guidance can be used to select the right time of delivery.
Collapse
Affiliation(s)
- Lixia Liu
- Department of Ultrasound, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan, China
| | - Yingchun Luo
- Department of Ultrasound, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan, China
| | - Ying Deng
- Department of Ultrasound, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan, China
| | - Yanling Liang
- Department of Ultrasound, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan, China
| | - Lulu Xie
- Department of Ultrasound, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan, China
| |
Collapse
|
5
|
Lillitos PJ, Nolan O, Cave DGW, Lomax C, Barwick S, Bentham JR, Seale AN. Fetal single ventricle journey to first postnatal procedure: a multicentre UK cohort study. Arch Dis Child Fetal Neonatal Ed 2024; 109:384-390. [PMID: 38123956 DOI: 10.1136/archdischild-2023-326213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/30/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVES UK single ventricle (SV) palliation outcomes after first postnatal procedure (FPP) are well documented. However, survival determinants from fetal diagnosis to FPP are lacking. To better inform parental-fetal counselling, we examined factors favouring survival at two large UK centres. DESIGN Retrospective multicentre cohort study. SETTING Two UK congenital cardiac centres: Leeds and Birmingham. PATIENTS SV fetal diagnoses from 2015 to 2021. MAIN OUTCOME MEASURES Survival from fetal diagnosis with intention to treat (ITT) to birth and then FPP. Maternal, fetal and neonatal risk factors were assessed. RESULTS There were 666 fetal SV diagnoses with 414 (62%) ITT. Of ITT, 381 (92%) were live births and 337 (81%) underwent FPP. Survival (ITT) to FPP was notably reduced for severe Ebstein's 14/22 (63.6%), unbalanced atrioventricular septal defect 32/45 (71%), indeterminate SV 3/4 (75%), mitral atresia 8/10 (80%) and hypoplastic left heart syndrome 127/156 (81.4%). Biventricular pathway was undertaken in five (1%). After multivariable adjustment, prenatal risk factors for mortality were increasing maternal age (OR 1.05, 95% CI 1.0 to 1.1), non-white ethnicity (OR 2.6, 95% CI 1.4 to 4.8), extracardiac anomaly (OR 6.34, 95% CI 1.8 to 22.7) and hydrops (OR 7.39, 95% CI 1.2 to 45.1). Postnatally, prematurity was significantly associated with mortality (OR 6.3, 95% CI 2.3 to 16.8). CONCLUSIONS Around 20% of ITT fetuses diagnosed with SV will not reach FPP. Risk varies according to the cardiac lesion and is significantly influenced by the presence of an extracardiac anomaly, fetal hydrops, ethnicity, increasing maternal age and gestation at birth. These data highlight the need for fetal preprocedure data to be used in conjunction with procedural outcomes for fetal counselling.
Collapse
Affiliation(s)
- Peter John Lillitos
- Department of Congenital Heart Disease, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Oscar Nolan
- Department of Cardiology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Daniel G W Cave
- Department of Congenital Heart Disease, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Catherine Lomax
- Department of Cardiology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Shuba Barwick
- Department of Congenital Heart Disease, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - James R Bentham
- Department of Congenital Heart Disease, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Anna N Seale
- Department of Cardiology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| |
Collapse
|
6
|
Bravo-Valenzuela NJ, Rizzo G, Mappa I, Respondek-Liberska M, Słodki M, Amorim LAR, Araujo Júnior E. Prenatal Cardiac Ultrasound Markers of Outcomes in Ebstein's Anomaly: An International Multicenter Case Series. Pediatr Cardiol 2024:10.1007/s00246-024-03530-9. [PMID: 38825661 DOI: 10.1007/s00246-024-03530-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 05/20/2024] [Indexed: 06/04/2024]
Abstract
This study aimed to analyze prenatal cardiac ultrasound markers of outcome in fetuses with Ebstein's anomaly (EA). From a retrospective database, 35 fetuses diagnosed with EA at fetal medicine centers in Brazil, Italy, and Poland were retrieved. The primary outcome was perinatal mortality. We analyzed prenatal cardiac ultrasound markers of outcomes and perinatal follow-up. Gestational age at diagnosis, extracardiac fetal anomalies, spontaneous fetal demise, and gestational age at each event were recorded. In postnatal survivors, data on cardiac surgery and short-term postoperative outcomes were collected. Our study included a cohort of 35 fetuses with EA (mean gestational age of 29.4 weeks), in which 6 fetuses were excluded due to termination of pregnancy (3), pregnancy still ongoing (2), and missed follow-up (1). Of the remaining 29 cases, severe tricuspid regurgitation and absence of anterograde pulmonary flow (pulmonary atresia) were observed in 88%. Significant cardiomegaly accounts for 58% of these data with a mean cardiothoracic ratio of 0.59. The cardiovascular profile (CVS) score ≤ 6 in six patients with one survival (4 fetal deaths, one stillbirth, and one survival). All fetuses with CVS score of 5 had intrauterine demise. Seventeen fetuses were born alive (53.1% of 29 cases). Of the remaining fetuses, one (1%) fetal was a stillbirth, six (20%) fetuses were neonatal deaths, and five (17%) fetuses were fetal deaths. Of the nineteen patients who underwent surgery to correct the cardiac defect, 17 survived after surgery. Among the survivors, biventricular cardiac repair was performed using the cone technique (da Silva's approach) in the majority of cases. We observed 2 abnormal karyotypes among in the remaining 29 fetuses. One of the patients with abnormal karyotype was a fetus with ascites and large for gestational age. The other patient with abnormal karyotype underwent cardiac surgery and progressed to neonatal death. Nine patients (25%) had extracardiac anomalies (genitourinary anomalies and single umbilical artery), being that 2 of them are alive and 4 died (2 had fetal and 2 neonatal death). Fetal EA is associated with high mortality. The most common prenatal marker associated with non-survival was CVP score ≤ 6. Fetuses that survived and underwent postnatal corrective surgery are significantly favorable outcomes.
Collapse
Affiliation(s)
- Nathalie Jeanne Bravo-Valenzuela
- Department of Pediatrics, Pediatric Cardiology, School of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro-RJ, Brazil
| | - Giuseppe Rizzo
- Department of Obstetrics and Gynecology, Policinico Tor Vergata, University of Rome Tor Vergata, Rome, Italy
| | - Ilenia Mappa
- Department of Obstetrics and Gynecology, Policinico Tor Vergata, University of Rome Tor Vergata, Rome, Italy
| | - Maria Respondek-Liberska
- Prenatal Cardiology Department, Research Institute Polish Mother's Memorial Hospital, Lodz, Poland
| | - Maciej Słodki
- Collegium Medicum, The Mazovian State University, Plock, Poland
| | - Luciane Alves Rocha Amorim
- Postgraduate Program in Health Sciences, Medical School, Federal University of Amazonas (UFAM), Manaus-AM, Brazil
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo-SP, Brazil, Rua Belchior de Azevedo, 156 Apto. 111 Torre Vitória, 05089-030.
- Discipline of Woman Health, Municipal University of São Caetano Do Sul (USCS), São Caetano Do Sul-SP, Brazil.
| |
Collapse
|
7
|
Mustafa HJ, Aghajani F, Bairmani ZA, Khalil A. Transplacental non-steroidal anti-inflammatory drugs versus expectant management in fetal Ebstein anomaly with circular shunt: Systematic review and meta-analysis. Prenat Diagn 2024; 44:773-782. [PMID: 37902170 DOI: 10.1002/pd.6446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 09/11/2023] [Accepted: 09/14/2023] [Indexed: 10/31/2023]
Abstract
Ebstein anomaly (EA) is a rare congenital cardiac malformation associated with high perinatal mortality. In this systematic review and meta-analysis, we aimed to investigate the outcomes of pregnancies affected by EA or tricuspid valve dysplasia (TVD) with circular shunt, focusing on two prenatal management approaches: (1) expectant management (EM) and (2) transplacental non-steroidal anti-inflammatory drugs (NSAID) therapy. We searched PubMed, Scopus, and Web of Science systematically from its inception until June 2023. The random-effect model was used to pool the data. Heterogeneity was assessed using the I2 value. Twenty-one studies with a total of 610 fetuses with EA/TVD with circular shunt were included in the synthesis, of which 17 studies (583 fetuses) were on EM and 4 studies (27 fetuses) used transplacental NSAID therapy. The NSAID group had higher rates of moderate to severe tricuspid regurgitation, hydrops, and pericardial effusion on prenatal ultrasound compared with the EM group. However, ductal constriction was achieved in 81% of NSAID cases, mitigating the disease pathophysiology, although 65% of them experienced oligohydramnios. Notably, the NSAID group showed significantly higher rates of live birth (86%) and survival to hospital discharge (89%) compared with the EM group (67% and 43%, respectively). Despite these promising results, it's important to acknowledge that the number of cases treated with NSAIDs was small, with limited safety data. Therefore, caution is advised in interpreting these findings, and patients considering NSAID therapy should be informed about these limitations. Future multicenter studies are necessary to further explore the safety and effectiveness of NSAID therapy in this particular population.
Collapse
Affiliation(s)
- Hiba J Mustafa
- Division of Maternal-Fetal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
- The Fetal Center at Riley Children's and Indiana University Health, Indianapolis, Indiana, USA
| | - Faezeh Aghajani
- BCNatal Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Zinah A Bairmani
- Department of Pharmacology & Experimental Therapeutics, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| |
Collapse
|
8
|
Coacci S, Alston ELJ, Yamasaki T, Ronai C, Sanders SP, Carreon CK. The Connection Between Anatomical Substrate and Clinical Severity in Fetal Ebstein Anomaly. Pediatr Dev Pathol 2024:10935266241250235. [PMID: 38762771 DOI: 10.1177/10935266241250235] [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: 05/20/2024]
Abstract
Ebstein anomaly (EA) is a rare congenital heart defect characterized by abnormal development of the tricuspid valve (TV) and right ventricular myocardium. This study documents 2 dramatic cases of fetal EA characterized by hydrops and cardiomegaly, leading to intrauterine or early neonatal death. These clinical outcomes were associated with morphological abnormalities including severe tricuspid regurgitation, unguarded TV orifice, pulmonary atresia, and flattened right ventricular myocardium. This study highlights that these adverse anatomical features may result in unfavorable clinical outcomes in fetal EA. While timely identification of such features by prenatal ultrasound is crucial for providing accurate prognostic stratification and guiding treatment decisions, fetopsy may be necessary to discern EA among the spectrum of right-heart anomalies.
Collapse
Affiliation(s)
- Sara Coacci
- The Cardiac Registry, Departments of Cardiology, Pathology, and Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
- Vita-Salute San Raffaele University, IRCCS Policlinico San Donato Hospital, Milan, Italy
| | - Erin L J Alston
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Takato Yamasaki
- The Cardiac Registry, Departments of Cardiology, Pathology, and Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
- Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Christina Ronai
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Stephen P Sanders
- The Cardiac Registry, Departments of Cardiology, Pathology, and Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Chrystalle Katte Carreon
- The Cardiac Registry, Departments of Cardiology, Pathology, and Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| |
Collapse
|
9
|
Kavanaugh-McHugh A, Zuckerwise LC, Killen SAS, Morris EA, Sullivan RT, Alrifai MW, Bichell DP, Smith-Parrish M, Freud L. Management of Ebstein Anomaly in the Current Era: The Story of One Fetus and the Collaboration of Many-A Case Report. J Cardiovasc Dev Dis 2024; 11:147. [PMID: 38786969 PMCID: PMC11122070 DOI: 10.3390/jcdd11050147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/05/2024] [Accepted: 05/08/2024] [Indexed: 05/25/2024] Open
Abstract
Collaborative multicenter research has significantly increased our understanding of fetal Ebstein anomaly, delineating risk factors for adverse outcomes as well as predictors of postnatal management. These data are incorporated into prenatal care and therapeutic strategies and inform family counseling and delivery planning to optimize care. This report details the translation of findings from multicenter studies into multidisciplinary prenatal care for a fetus with Ebstein anomaly, supraventricular tachycardia, and a circular shunt, including transplacental therapy to control arrhythmias and achieve ductal constriction, informed and coordinated delivery room management, and planned univentricular surgical palliation.
Collapse
Affiliation(s)
- Ann Kavanaugh-McHugh
- Thomas. P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Lisa C Zuckerwise
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Virginia School of Medicine, Charlottesville, VA 22908, USA
| | - Stacy A S Killen
- Thomas. P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Emily A Morris
- Division of Neonatology, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Rachel T Sullivan
- Thomas. P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Mhd Wael Alrifai
- Division of Neonatology, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - David P Bichell
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Melissa Smith-Parrish
- Division of Critical Care Medicine, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Lindsay Freud
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON M5G 1X8, Canada
| |
Collapse
|
10
|
Patel SR, Michelfelder E. Prenatal Diagnosis of Congenital Heart Disease: The Crucial Role of Perinatal and Delivery Planning. J Cardiovasc Dev Dis 2024; 11:108. [PMID: 38667726 PMCID: PMC11050606 DOI: 10.3390/jcdd11040108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 03/29/2024] [Accepted: 03/29/2024] [Indexed: 04/28/2024] Open
Abstract
Although most congenital heart defects (CHDs) are asymptomatic at birth, certain CHD lesions are at significant risk of severe hemodynamic instability and death if emergent cardiac interventions are not performed in a timely fashion. Therefore, accurate identification of at-risk fetuses and appropriate delivery resource planning according to the degree of anticipated hemodynamic instability is crucial. Fetal echocardiography has increased prenatal CHD detection in recent years due to advancements in ultrasound techniques and improved obstetrical cardiac screening protocols, enabling the prediction of newborns' hemodynamic status. This assessment can guide multidisciplinary resource planning for postnatal care, including selection of delivery site, delivery room management, and transport to a cardiac center based on CHD risk severity. This review will discuss fetal cardiovascular physiology and the circulatory changes that occur at the time of and immediately following birth, outline fetal echocardiographic findings used to risk-stratify newborns with CHDs, and outline principles for neonatal resuscitation and initial transitional care in neonates with these complex CHD lesions.
Collapse
Affiliation(s)
- Sheetal R. Patel
- Ann & Robert H Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Erik Michelfelder
- Children’s Healthcare of Atlanta, Emory School of Medicine, Emory University, Atlanta, GA 30265, USA
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Bitterman Y, Friedberg MK. Ventricular-Ventricular Interactions in Critically Ill Infants with Ebstein Anomaly or Dysplasia of the Tricuspid Valve: Time to Remember the Forgotten Left Ventricle. J Am Soc Echocardiogr 2024; 37:255-258. [PMID: 38029862 DOI: 10.1016/j.echo.2023.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 11/20/2023] [Indexed: 12/01/2023]
Affiliation(s)
- Yuval Bitterman
- The Labatt Family Heart Centre, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Mark K Friedberg
- The Labatt Family Heart Centre, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
13
|
Rivera-Ibarguen S, Jiménez-Carbajal MG, Gamboa-Lopez CA, Garcia-Lezama M, Roldan-Valadez E. Top 100 Most Cited Papers on Multimodality Imaging for Complex Congenital Heart Disease. A Bibliometric Analysis. Curr Probl Cardiol 2024; 49:102028. [PMID: 37553062 DOI: 10.1016/j.cpcardiol.2023.102028] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/04/2023] [Indexed: 08/10/2023]
Abstract
Complex congenital heart disease (CCHD) is a group of heart defects present at birth. Some imaging methods can support the diagnosis of these pathologies, such as echocardiography, computed tomography, and magnetic resonance imaging. This study aimed to perform a bibliometric analysis of the top 100 articles cited on CCHD. Articles from 2013 to 2023 found in Scopus were scanned using 15 CCHD topics titles crossed with echocardiography, computed tomography, and magnetic resonance imaging. Duplicated manuscripts were eliminated using Microsoft Excel software, and the publications were ranked according to their citation count. This study selected and analyzed the top 100 most cited English-language papers. The top 100 most cited publications accumulated 16,563 citations. The manuscript with the most citations obtained 1086, representing 6.55% of the total citations. The year 2014 had the highest number of publications, with 27 papers. The first authors had affiliations from 44 countries; the United States was the country that contributed the most, with 54 manuscripts. Boston Children's Hospital was the institution that provided more articles to the top 100. Finally, the Ebstein anomaly was the topic with the highest number of citations. This study identified the 100 most cited on CCHD, and the results obtained can provide practical guidance to clinicians and researchers to familiarize themselves with the most influential publications in this field.
Collapse
Affiliation(s)
| | | | | | | | - Ernesto Roldan-Valadez
- Hospital General de Mexico 'Dr. Eduardo Liceaga', Mexico City, Mexico; Department of Radiology, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
| |
Collapse
|
14
|
Stephens EH, Dearani JA. Commentary: Neonatal Ebstein: Starnes procedure first … Fontan not necessarily the last. J Thorac Cardiovasc Surg 2023; 166:1744-1745. [PMID: 37690623 DOI: 10.1016/j.jtcvs.2023.08.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/19/2023] [Indexed: 09/12/2023]
Affiliation(s)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
| |
Collapse
|
15
|
Narang K, Wyatt M, O'Leary P, Qureshi MY, Kolbe A, Stephens EH, Dearani JA, Ruano R. Novel approach to prenatal predictors of outcomes for fetuses with severe Ebstein anomaly. J Matern Fetal Neonatal Med 2023; 36:2271626. [PMID: 37904503 DOI: 10.1080/14767058.2023.2271626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 10/11/2023] [Indexed: 11/01/2023]
Abstract
OBJECTIVE Ebstein anomaly (EA) is a cardiac malformation with highly variable presentation and severity with limited perinatal management options. We present incorporation of fetal lung measurements into a multidisciplinary evaluation for counseling and predicting postnatal outcomes in patients with severe EA. METHODS Five fetuses with severe fetal EA were reviewed. Third trimester sonographic observed/expected total lung area (O/E TLA) and lung to head ratio (O/E LHR), fetal MRI total fetal lung volume ratio (O/E-TFLV), echocardiographic cardio-thoracic ratio (CT ratio), sonographic estimated fetal weight (EFW) by Hadlock formula and presence of hydrops, were used to guide perinatal management. RESULTS Three of five had appropriate fetal growth, were delivered at term in a cardiac operative suite, and underwent immediate intervention with good neonatal outcomes. Two had severe fetal growth restriction (FGR), CT ratios > 0.8 and O/E LHR and TLA < 25%. One of which delivered prematurely with neonatal demise and one suffered in utero demise at 34 weeks. CONCLUSIONS FGR, hydrops, increased CT ratio and reduced O/E LHR and TFLV are potential prognosticators of poor outcomes in severe EA, and should be validated in larger cohorts that would allow for a statistical analysis of the predictive utility of these measurements.
Collapse
Affiliation(s)
- Kavita Narang
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Michelle Wyatt
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Patrick O'Leary
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - M Yasir Qureshi
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Amy Kolbe
- Pediatric Radiology Division, Department of Radiology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Elizabeth H Stephens
- Department of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Rodrigo Ruano
- Division Chief of Maternal-Fetal Medicine, Director UHealth Jackson Fetal Care, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| |
Collapse
|
16
|
Dobson CP, Christopher AB, Castro-Medina M, Viegas ML, Da Silva JP, Da Silva LDF. Using DaSilva Cone Operation to Establish 1.5 or 2 Ventricle Circulation After Initial Single Ventricle Palliation with Starnes Procedure. Pediatr Cardiol 2023:10.1007/s00246-023-03336-1. [PMID: 38038752 DOI: 10.1007/s00246-023-03336-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/21/2023] [Indexed: 12/02/2023]
Abstract
Ebstein anomaly (EA) is a congenital dysplasia of the tricuspid valve resulting in reduced right ventricular (RV) volume and tricuspid regurgitation. Severe EA in the neonatal period is associated with high mortality. The Starnes procedure (fenestrated RV exclusion) is reserved for EA patients with cardiogenic shock and has previously committed patients to single ventricle (SV) palliation. In this report, we present the results of a strategy to redirect patients utilizing the Da Silva Cone operation to achieve a 2 or 1.5 ventricle circulation. Single-center retrospective study including all consecutive cases of Da Silva Cone operation after Starnes procedure. Between 2019 and 2023, six conversions from Starnes procedure to Cone reconstruction were performed. All were critically ill before their Starnes procedure; four on extracorporeal membrane oxygenation. Two patients were successfully rerouted to a two-ventricle repair; the remainder to 1.5 ventricle circulation. RV pressure estimates showed no correlation with success. Post-Cone intensive care and hospital stays were brief, median 5 and 6 days, respectively. All are between 2.5 and 6 years old, without indications for SV palliation. There were no deaths, with follow up ranging 1 month-4 years. No repeat interventions were performed on the tricuspid valves. One subject had a surgical pulmonary valve replacement. Tricuspid regurgitation was mild in all. The Da Silva Cone operation offers successful redirection of EA patients from a SV pathway to a 1.5 or 2 ventricle pathway after Starnes procedure. The approach is feasible and durable in midterm follow-up. The decision to initially proceed with Starnes need not be an irrevocable decision to continue down a SV palliation pathway.
Collapse
Affiliation(s)
- Craig P Dobson
- Division of Pediatric Cardiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
| | - Adam B Christopher
- Division of Pediatric Cardiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Mario Castro-Medina
- Department of Cardiothoracic Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Melita L Viegas
- Department of Cardiothoracic Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Jose Pedro Da Silva
- Department of Cardiothoracic Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | | |
Collapse
|
17
|
Knott-Craig CJ, Ramakrishnan K, Chang J, Parkerson S, Kramer J, Boston US, Joshi V, Johnson J. Ebstein anomaly: A personalized approach to symptomatic neonates. J Thorac Cardiovasc Surg 2023; 166:955-959. [PMID: 37257559 DOI: 10.1016/j.jtcvs.2023.05.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/03/2023] [Accepted: 05/23/2023] [Indexed: 06/02/2023]
Affiliation(s)
- Christopher J Knott-Craig
- Division of Pediatric Cardiovascular Surgery, Le Bonheur Children's Hospital, Memphis, Tenn; Department of Surgery, University of Tennessee Health Sciences Center, Memphis, Tenn.
| | - Karthik Ramakrishnan
- Division of Pediatric Cardiovascular Surgery, Le Bonheur Children's Hospital, Memphis, Tenn; Department of Surgery, University of Tennessee Health Sciences Center, Memphis, Tenn
| | - James Chang
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, Memphis, Tenn
| | - Sarah Parkerson
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, Memphis, Tenn
| | - Jennifer Kramer
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, Memphis, Tenn; Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tenn
| | - Umar S Boston
- Division of Pediatric Cardiovascular Surgery, Le Bonheur Children's Hospital, Memphis, Tenn; Department of Surgery, University of Tennessee Health Sciences Center, Memphis, Tenn
| | - Vijaya Joshi
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, Memphis, Tenn; Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tenn
| | - Jason Johnson
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, Memphis, Tenn; Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tenn
| |
Collapse
|
18
|
Udine M, Donofrio MT. The Role of the Neonatologist in Fetuses Diagnosed with Congenital Heart Disease. Neoreviews 2023; 24:e553-e568. [PMID: 37653086 DOI: 10.1542/neo.24-9-e553] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Prenatal diagnosis of congenital heart disease (CHD) can decrease preoperative morbidity and mortality. Delivery room planning can improve cardiac hemodynamics and time to critical catheter and surgical interventions. Care algorithms have defined lesion-specific level-of-care assignments and delivery room action plans that can facilitate team-based approaches to safe deliveries. Neonatologists play critical roles in the care of fetuses diagnosed with CHD, from the time of diagnosis through the postnatal intensive care unit (ICU) stays. Prenatally, neonatologists are members of the multidisciplinary counseling teams, with expertise to counsel expectant parents about what to expect during the ICU stay, which is especially valuable in CHD associated with extracardiac or genetic anomalies. Neonatologists' role in delivery planning includes identification of the optimal delivery location and allocation of appropriate personnel and resources. After delivery, postnatal care considerations include hemodynamic stability, optimization of end-organ function, genetics consultation, developmentally appropriate care practices to encourage caregiver bonding, and optimization of care to improve neurodevelopmental outcomes of neonates with CHD.
Collapse
Affiliation(s)
- Michelle Udine
- Division of Cardiology, Children's National Hospital, Washington, DC
| | - Mary T Donofrio
- Division of Cardiology, Children's National Hospital, Washington, DC
| |
Collapse
|
19
|
Snoep MC, Bet BB, Zwanenburg F, Knobbe I, Linskens IH, Pajkrt E, Rozendaal L, Van der Meeren LE, Clur SA, Haak MC. Factors related to fetal demise in cases with congenital heart defects. Am J Obstet Gynecol MFM 2023; 5:101023. [PMID: 37220848 DOI: 10.1016/j.ajogmf.2023.101023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/04/2023] [Accepted: 05/15/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND Congenital heart defects are the most common congenital anomaly. Despite the increasing survival of these children, there is still an increased incidence of fetal demise, frequently attributed to cardiac failure. Considering that abnormal placental development has been described in congenital heart disease, our hypothesis is that placental insufficiency may contribute to fetal death in congenital heart disease. OBJECTIVE This study aimed to assess cases with fetal congenital heart disease and intrauterine demise, and analyze factors that are related to the demise. STUDY DESIGN All congenital heart disease cases diagnosed prenatally during the period January 2002 to January 2021 were selected from the regional prospective congenital heart disease registry, PRECOR. Multiple pregnancies and pregnancies with fetal trisomy 13 or 18, triploidy, and Turner's syndrome were excluded from the analysis, because fetal demise is attributed to the chromosomal abnormality in these cases. Cases were categorized into 4 groups based on the possible cause of fetal death as follows: cardiac failure, additional (genetic) diagnosis, placental insufficiency, and a group in which no cause was found. A separate analysis was performed for isolated congenital heart disease cases. RESULTS Of the 4806 cases in the PRECOR registry, 112 had fetal demise, of which 43 were excluded from the analysis (13 multiple pregnancies, 30 genetic). Of these, 47.8% were most likely related to cardiac failure, 42.0% to another (genetic) diagnosis, and 10.1% to placental insufficiency. No cases were allocated to the group with an unknown cause. Only 47.8% of the cases had isolated congenital heart disease, and in this group 21.2% was most likely related to placental insufficiency. CONCLUSION This study shows that in addition to cardiac failure and other (genetic) diagnoses, placental factors play an important role in fetal demise in congenital heart disease, especially in cases of isolated heart defects. Therefore, these findings support the importance of regular ultrasonographic assessment of fetal growth and placental function in fetal congenital heart disease.
Collapse
Affiliation(s)
- Maartje C Snoep
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands (Drs. Snoep, Drs. Zwanenburg, and Prof. Haak).
| | - Bo B Bet
- Department of Obstetrics and Fetal Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands (Drs. Bet, Drs. Linskens, and Prof. Pajkrt)
| | - Fleur Zwanenburg
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands (Drs. Snoep, Drs. Zwanenburg, and Prof. Haak)
| | - Ingmar Knobbe
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands (Drs. Knobbe and Drs. Rozendaal)
| | - Ingeborg H Linskens
- Department of Obstetrics and Fetal Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands (Drs. Bet, Drs. Linskens, and Prof. Pajkrt)
| | - Eva Pajkrt
- Department of Obstetrics and Fetal Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands (Drs. Bet, Drs. Linskens, and Prof. Pajkrt)
| | - Lieke Rozendaal
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands (Drs. Knobbe and Drs. Rozendaal)
| | - Lotte E Van der Meeren
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands (Drs. Van der Meeren); Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands (Drs. Van der Meeren)
| | - Sally-Ann Clur
- Department of Pediatric Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands (Drs. Clur)
| | - Monique C Haak
- Department of Obstetrics and Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands (Drs. Snoep, Drs. Zwanenburg, and Prof. Haak)
| |
Collapse
|
20
|
Cantinotti M, McMahon CJ, Marchese P, Köstenberger M, Scalese M, Franchi E, Santoro G, Assanta N, Jacquemyn X, Kutty S, Giordano R. Echocardiographic Parameters for Risk Prediction in Borderline Right Ventricle: Review with Special Emphasis on Pulmonary Atresia with Intact Ventricular Septum and Critical Pulmonary Stenosis. J Clin Med 2023; 12:4599. [PMID: 37510714 PMCID: PMC10380858 DOI: 10.3390/jcm12144599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 05/26/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
The aim of the present review is to highlight the strengths and limitations of echocardiographic parameters and scores employed to predict favorable outcome in complex congenital heart diseases (CHDs) with borderline right ventricle (RV), with a focus on pulmonary atresia with intact ventricular septum and critical pulmonary stenosis (PAIVS/CPS). A systematic search in the National Library of Medicine using Medical Subject Headings and free-text terms including echocardiography, CHD, and scores, was performed. The search was refined by adding keywords "PAIVS/CPS", Ebstein's anomaly, and unbalanced atrioventricular septal defect with left dominance. A total of 22 studies were selected for final analysis; 12 of them were focused on parameters to predict biventricular repair (BVR)/pulmonary blood flow augmentation in PAIVS/CPS. All of these studies presented numerical (the limited sample size) and methodological limitations (retrospective design, poor definition of inclusion/exclusion criteria, variability in the definition of outcomes, differences in adopted surgical and interventional strategies). There was heterogeneity in the echocardiographic parameters employed and cut-off values proposed, with difficultly in establishing which one should be recommended. Easy scores such as TV/MV (tricuspid/mitral valve) and RV/LV (right/left ventricle) ratios were proven to have a good prognostic accuracy; however, the data were very limited (only two studies with <40 subjects). In larger studies, RV end-diastolic area and a higher degree of tricuspid regurgitation were also proven as accurate predictors of successful BVR. These measures, however, may be either operator and/or load/pressure dependent. TV Z-scores have been proposed by several authors, but old and heterogenous nomograms sources have been employed, thus producing discordant results. In summary, we provide a review of the currently available echocardiographic parameters for risk prediction in CHDs with a diminutive RV that may serve as a guide for use in clinical practice.
Collapse
Affiliation(s)
- Massimiliano Cantinotti
- Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
- Institute of Clinical Physiology, 56124 Pisa, Italy
| | - Colin Joseph McMahon
- Department of Pediatric Cardiology, Childrens Health Ireland, D12 N512 Dublin, Ireland
- School of Medicine, University College Dublin, D04 V1W8 Dublin, Ireland
| | - Pietro Marchese
- Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
- Istituto di Scienze Della Vita (ISV), Scuola Superiore Sant'Anna, 56127 Pisa, Italy
| | - Martin Köstenberger
- Department of Pediatrics, Division of Pediatric Cardiology, Medical University Graz, 8036 Graz, Austria
| | - Marco Scalese
- Istituto di Scienze Della Vita (ISV), Scuola Superiore Sant'Anna, 56127 Pisa, Italy
| | - Eliana Franchi
- Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
| | | | - Nadia Assanta
- Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
| | - Xander Jacquemyn
- Helen B. Taussig Heart Center, Department of Pediatrics, Johns Hopkins Hospital, Baltimore, MD 21205, USA
| | - Shelby Kutty
- Helen B. Taussig Heart Center, Department of Pediatrics, Johns Hopkins Hospital, Baltimore, MD 21205, USA
| | - Raffaele Giordano
- Adult and Pediatric Cardiac Surgery, Department Advanced Biomedical Sciences, University of Naples "Federico II", 80131 Naples, Italy
| |
Collapse
|
21
|
Jepson BM, Metz TD, Miller TA, Son SL, Ou Z, Presson AP, Nance A, Pinto NM. Pregnancy loss in major fetal congenital heart disease: incidence, risk factors and timing. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:75-87. [PMID: 37099500 DOI: 10.1002/uog.26231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/09/2023] [Accepted: 04/14/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE Fetuses with congenital heart disease (CHD) are at increased risk of pregnancy loss compared with the general population. We aimed to assess the incidence, timing and risk factors of pregnancy loss in cases with major fetal CHD, overall and according to cardiac diagnosis. METHODS This was a retrospective, population-level cohort study of fetuses and infants diagnosed with major CHD between 1997 and 2018 identified by the Utah Birth Defect Network (UBDN), excluding cases with termination of pregnancy and minor cardiovascular diagnoses (e.g. isolated aortic/pulmonary pathology and isolated septal defects). The incidence and timing of pregnancy loss were recorded, overall and according to CHD diagnosis, with further stratification based on presence of isolated CHD vs additional fetal diagnosis (genetic diagnosis and/or extracardiac malformation). Adjusted risk of pregnancy loss was calculated and risk factors were assessed using multivariable models for the overall cohort and prenatal diagnosis subgroup. RESULTS Of 9351 UBDN cases with a cardiovascular code, 3251 cases with major CHD were identified, resulting in a study cohort of 3120 following exclusion of cases with pregnancy termination (n = 131). There were 2956 (94.7%) live births and 164 (5.3%) cases of pregnancy loss, which occurred at a median gestational age of 27.3 weeks. Of study cases, 1848 (59.2%) had isolated CHD and 1272 (40.8%) had an additional fetal diagnosis, including 736 (57.9%) with a genetic diagnosis and 536 (42.1%) with an extracardiac malformation. The observed incidence of pregnancy loss was highest in the presence of mitral stenosis (< 13.5%), hypoplastic left heart syndrome (HLHS) (10.7%), double-outlet right ventricle with normally related great vessels or not otherwise specified (10.5%) and Ebstein's anomaly (9.9%). The adjusted risk of pregnancy loss was 5.3% (95% CI, 3.7-7.6%) in the overall CHD population and 1.4% (95% CI, 0.9-2.3%) in cases with isolated CHD (adjusted risk ratio, 9.0 (95% CI, 6.0-13.0) and 2.0 (95% CI, 1.0-6.0), respectively, based on the general population risk of 0.6%). On multivariable analysis, variables associated with pregnancy loss in the overall CHD population included female fetal sex (adjusted odds ratio (aOR), 1.6 (95% CI, 1.1-2.3)), Hispanic ethnicity (aOR, 1.6 (95% CI, 1.0-2.5)), hydrops (aOR, 6.7 (95% CI, 4.3-10.5)) and additional fetal diagnosis (aOR, 6.3 (95% CI, 4.1-10)). On multivariable analysis of the prenatal diagnosis subgroup, years of maternal education (aOR, 1.2 (95% CI, 1.0-1.4)), presence of an additional fetal diagnosis (aOR, 2.7 (95% CI, 1.4-5.6)), atrioventricular valve regurgitation ≥ moderate (aOR, 3.6 (95% CI, 1.3-8.8)) and ventricular dysfunction (aOR, 3.8 (95% CI, 1.2-11.1)) were associated with pregnancy loss. Diagnostic groups associated with pregnancy loss were HLHS and variants (aOR, 3.0 (95% CI, 1.7-5.3)), other single ventricles (aOR, 2.4 (95% CI, 1.1-4.9)) and other (aOR, 0.1 (95% CI, 0-0.97)). Time-to-pregnancy-loss analysis demonstrated a steeper survival curve for cases with an additional fetal diagnosis, indicating a higher rate of pregnancy loss compared to cases with isolated CHD (P < 0.0001). CONCLUSIONS The risk of pregnancy loss is higher in cases with major fetal CHD compared with the general population and varies according to CHD type and presence of additional fetal diagnoses. Improved understanding of the incidence, risk factors and timing of pregnancy loss in CHD cases should inform patient counseling, antenatal surveillance and delivery planning. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- B M Jepson
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - T D Metz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - T A Miller
- Division of Pediatric Cardiology, Maine Medical Center, Portland, ME, USA
| | - S L Son
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado, Aurora, CO, USA
| | - Z Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - A P Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - A Nance
- Utah Birth Defect Network, Office of Children with Special Healthcare Needs, Division of Family Health, Utah Department of Health and Human Services, Salt Lake City, UT, USA
| | - N M Pinto
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
22
|
Ikegawa T, Kim KS, Kawataki M, Ichikawa Y, Ono S, Yanagi S, Ueda H. Late-gestation prediction of outcome in tricuspid valve dysplasia and Ebstein's anomaly using fetal tricuspid regurgitation waveform analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:593-600. [PMID: 36273401 DOI: 10.1002/uog.26097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 10/05/2022] [Accepted: 10/12/2022] [Indexed: 05/04/2023]
Abstract
OBJECTIVE To investigate the criteria, based on fetal TR waveforms in late gestation, to predict biventricular circulation (BV) after birth in cases of tricuspid valve dysplasia (TVD) or Ebstein's anomaly diagnosed during the fetal period. METHODS We included 35 consecutive cases diagnosed with TVD or Ebstein's anomaly during the fetal period between January 2008 and December 2021 at Kanagawa Children's Medical Center, Kanagawa, Japan. The maximum velocity and change in pressure over time of tricuspid regurgitation (TR) jet (dP/dt), estimated using TR waveforms obtained during the late-gestation period (gestational age ≥ 28 weeks), were collected from patient records. dP/dt was calculated by dividing the change in estimated right ventricular pressure obtained using Bernoulli's principle by the time taken for the TR maximum velocity to change from one-third to two-thirds of its peak value. The outcome was divided into four categories: BV, single ventricular circulation, neonatal death and fetal death. Patients with BV were included in the BV group, while patients with single ventricular circulation, neonatal death or fetal death were included in the non-BV (NBV) group. RESULTS Overall, 19 and 16 patients were included in the BV and NBV groups, respectively. The median TR maximum velocity was 3.3 (range, 2.4-3.6) m/s in the BV group and 1.9 (range, 1.0-3.3) m/s in the NBV group. There were no cases of postnatal BV in fetuses with TR maximum velocity < 2.4 m/s; cases with TR maximum velocity of 2.4-3.3 m/s were observed in both BV and NBV groups. Receiver-operating-characteristics-curve analysis was performed on the 11 patients in the BV group and five patients in the NBV group with a TR maximum velocity of 2.4-3.3 m/s. dP/dt ≥ 350 mmHg/s and TR maximum velocity ≥ 2.9 m/s were identified as criteria for predicting the outcome in such cases. The performance of dP/dt ≥ 350 mmHg/s in predicting BV after birth in fetuses with TVD or Ebstein's anomaly was higher compared to that of TR maximum velocity ≥ 2.9 m/s (sensitivity, 90.9% vs 72.3% and specificity, 80.0% vs 80.0%, respectively). CONCLUSIONS In fetuses with TVD or Ebstein's anomaly, the postnatal outcome may be BV or NBV when the TR maximum velocity is 2.4-3.3 m/s. In such cases, by combining the TR maximum velocity with dP/dt ≥ 350 mmHg/s, BV after birth may be predicted with greater accuracy. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- T Ikegawa
- Department of Cardiology, Kanagawa Children's Medical Center, Kanagawa, Japan
| | - K-S Kim
- Department of Cardiology, Kanagawa Children's Medical Center, Kanagawa, Japan
| | - M Kawataki
- Department of Neonatology, Kanagawa Children's Medical Center, Kanagawa, Japan
| | - Y Ichikawa
- Department of Cardiology, Kanagawa Children's Medical Center, Kanagawa, Japan
| | - S Ono
- Department of Cardiology, Kanagawa Children's Medical Center, Kanagawa, Japan
| | - S Yanagi
- Department of Cardiology, Kanagawa Children's Medical Center, Kanagawa, Japan
| | - H Ueda
- Department of Cardiology, Kanagawa Children's Medical Center, Kanagawa, Japan
| |
Collapse
|
23
|
Abstract
Introduction: Fetal unguarded tricuspid valve orifice (UTVO) is characterized by a complete or partial absence of the tricuspid valvular tissue or sub-valvular apparatus and only case reports are available at present. We report a UTVO diagnosed by fetal autopsy. Case report: An 18-week fetus was diagnosed by prenatal ultrasound with tricuspid dysplasia with 'to-and-fro' flow across the right-sided heart. Fetal autopsy showed partial agenesis of tricuspid valve instead of valvular dysplasia. This supported a diagnosis of UTVO. Conclusion: Fetal autopsy can differentiate UTVO form other valve abnormalities. The 'to-and-fro' flow pattern across the right atrioventricular orifice could be used to differentiate UTVO from other valve dysplasias on echocardiography.
Collapse
Affiliation(s)
- Xiaoxue Zhou
- Echocardiography Medical Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Beijing, China
| | - Ye Zhang
- Echocardiography Medical Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Beijing, China
| | - Yihua He
- Echocardiography Medical Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Beijing, China
| |
Collapse
|
24
|
Fetal Echocardiographic Variables Associated with Pre-Surgical Mortality in Truncus Arteriosus: A Pilot Study. Pediatr Cardiol 2023:10.1007/s00246-023-03099-9. [PMID: 36854855 DOI: 10.1007/s00246-023-03099-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 01/10/2023] [Indexed: 03/02/2023]
Abstract
Truncus arteriosus (TA) is a rare congenital heart defect that can be prenatally detected by fetal echocardiography. However, prognostication and prenatal counseling focus primarily on surgical outcomes due to limited fetal and neonatal pre-surgical mortality data. We aimed to describe the incidence and identify predictors of pre-surgical mortality in prenatally detected TA. This two-center, retrospective cohort study included fetuses diagnosed with TA between 01/2010 and 04/2020. The primary outcome was pre-surgical mortality, defined by fetal or neonatal pre-surgical death or primary listing for transplantation prior to discharge. Univariable regression modeling, Chi-square tests, and t tests assessed for associations between prenatal clinical, demographic, and fetal echocardiographic (fetal-echo) variables and pre-surgical mortality. Of 23 pregnancies with prenatal diagnosis of TA, 4 (17%) were terminated. Of the remaining 19, pre-surgical mortality occurred in 4 (26%), including 2 (11%) fetal deaths and 2 (11%) neonatal pre-surgical deaths. No transplantation listings. Of liveborn fetuses (n = 17), 15 (88%) underwent a neonatal surgery, and 1 (6%) required ECMO. As compared to the survivors, the pre-surgical mortality group had a higher likelihood of having left ventricular dysfunction (0% vs. 40%; p = 0.01), right ventricular dysfunction (0% vs. 60%; p = 0.002), cardiovascular profile score < 7 (0% vs. 40%; p = 0.01), skin edema (0% vs. 40%; p = 0.01), and abnormal umbilical venous (UV) Doppler (0% vs. 60%; p = 0.002). The presence of truncal valve regurgitation or stenosis neared significance. In this cohort with prenatally diagnosed TA, there is significant pre-surgical mortality, including fetal death and neonatal pre-surgical death. Termination rate is also high. Fetal-echo variables associated with pre-surgical mortality in this cohort include ventricular dysfunction, low CVP, skin edema, and abnormal UV Doppler. Knowledge about prenatal risk factors for pre-surgical mortality may guide parental counseling and postnatal planning in prenatally diagnosed TA.
Collapse
|
25
|
Utility of Fetal Echocardiography with Acute Maternal Hyperoxygenation Testing in Assessment of Complex Congenital Heart Defects. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020281. [PMID: 36832410 PMCID: PMC9955335 DOI: 10.3390/children10020281] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/22/2023] [Accepted: 01/27/2023] [Indexed: 02/04/2023]
Abstract
Fetal echocardiography is an excellent tool for accurately assessing the anatomy and physiology of most congenital heart defects (CHDs). Knowledge gathered from a thorough initial fetal echocardiogram and serial assessment assists with appropriate perinatal care planning, resulting in improved postnatal outcomes. However, fetal echocardiography alone provides limited information about the status of the pulmonary vasculature, which can be abnormal in certain complex CHDs with obstructed pulmonary venous flow (hypoplastic left heart syndrome with restrictive atrial septum) or excessive pulmonary artery flow (d-transposition of the great arteries, usually with a restrictive ductus arteriosus). Fetuses with these CHDs are at high risk of developing severe hemodynamic instability with the immediate transition from prenatal to postnatal circulatory physiology at the time of birth. Adjunctive use of acute maternal hyperoxygenation (MH) testing in such cases can help determine pulmonary vascular reactivity in prenatal life and better predict the likelihood of postnatal compromise and the need for emergent intervention. This comprehensive review discusses the findings of studies describing acute MH testing in a diverse spectrum of CHDs and congenital diagnoses with pulmonary hypoplasia. We review historical perspectives, safety profile, commonly used clinical protocols, limitations, and future directions of acute MH testing. We also provide practical tips on setting up MH testing in a fetal echocardiography laboratory.
Collapse
|
26
|
Pizarro C, Bhat MA, Davis DA, Duncan D, Pelletier GJ, Baffa G. Tailored strategy to match anatomy and physiology with intervention can improve outcomes of symptomatic neonates with Ebstein anomaly. JTCVS OPEN 2022; 12:344-354. [PMID: 36590729 PMCID: PMC9801273 DOI: 10.1016/j.xjon.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 09/14/2022] [Accepted: 09/21/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE Neonatal presentation of Ebstein anomaly (EA) represents the most severe form of this condition. Despite significant advances, operative mortality remains high and management decisions represent a formidable challenge. We used a strategy aimed to match anatomy and physiology with type and time of intervention to increase survival. METHODS We performed a review of all patients with fetal or neonatal diagnosis of EA managed at a single center between 2007 and 2020. RESULTS Among 18 patients with EA, 8 underwent neonatal intervention. The most common indication included cyanosis and heart failure (8/8), end organ dysfunction (6/8), and maldistribution of cardiac output (6/8). Only 2/8 had antegrade pulmonary blood flow. Associated conditions included pulmonary regurgitation in 4/8, atrial tachyarrhythmia in 4, and a ventricular septal defect in 3. Three patients underwent initial stabilization with main pulmonary artery occlusion including bilateral pulmonary artery banding in 2. Five patients underwent biventricular repair with conversion to right ventricle exclusion in 2 cases. Three others underwent the Starnes procedure as initially planned. The median age at surgery was 10 days (range, 1-30) and median weight 2.6 kg (range, 1.9-4.0). The median duration of mechanical ventilation and intensive care unit stay were 9 days (range, 5-34) and 30 days (range, 15-100), respectively. Operative mortality was 1/8. At a median follow-up of 130 months (range, 5-146), there were no late deaths, and all survivors remain in functional class I and free of valvular reintervention. CONCLUSIONS Symptomatic neonates with EA can be effectively managed with good outcomes. Preoperative stabilization and choice of management pathway on the basis of anatomy and physiology can help reduce morbidity and mortality.
Collapse
Affiliation(s)
- Christian Pizarro
- Address for reprints: Christian Pizarro, MD, Nemours Cardiac Center, Alfred I. duPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19803.
| | | | | | | | | | | |
Collapse
|
27
|
Impact of fetal haemodynamics on surgical and neurodevelopmental outcomes in patients with Ebstein anomaly and tricuspid valve dysplasia. Cardiol Young 2022; 32:1768-1779. [PMID: 34986918 DOI: 10.1017/s1047951121004935] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To evaluate the impact of fetal haemodynamics on surgical and neurodevelopmental outcomes in severe Ebstein anomaly and tricuspid valve dysplasia. METHODS Thirty-four fetuses with Ebstein anomaly/tricuspid valve dysplasia were referred from 2013 to 2019 for fetal echocardiography and clinical management. Nineteen fetuses with Ebstein anomaly/tricuspid valve dysplasia and 30 controls underwent cardiovascular magnetic resonance to quantify the fetal blood flow and to calculate cerebral oxygen delivery (cDO2) and consumption (cVO2). The 3D steady-state free precession acquisition was used to measure fetal brain volume. Surgical outcome, brain MRI, and neurodevelopmental follow-up were reviewed. RESULTS Twenty-six fetuses were live born (76%) and survival (65%) at a mean follow-up of 4 years. Nine fetuses had a brain MRI before discharge, and all had clinically silent injuries and volume loss. At 18 months, five single-ventricle patients had a neurodevelopmental delay in cognition and language (mean percentile: 11th), with gross-motor skills more affected than fine-motor skills (mean percentiles: 4th and 34th). Fetuses with Ebstein anomaly/tricuspid valve dysplasia had smaller brains, lower combined ventricular output, ascending aorta, superior caval vien and umbilical vein flows, lower oxygen saturation in ascending aorta and superior caval vien, lower cDO2 and cVO2 (p < 0.05). Superior caval vien/combined ventricular output and descending aorta/combined ventricular output ratios were lower in fetuses with circular shunt (p < 0.05). Fetuses requiring the Starnes procedure tended to have smaller brains, lower combined ventricular output, superior caval vien, descending aorta, and umbilical vein flows. CONCLUSIONS All patients with Ebstein anomaly/tricuspid valve dysplasia are at high risk of neurodevelopmental delay and warrant follow-up. Fetal cardiovascular magnetic resonance revealed impaired brain growth with diminished cerebral blood flow and cDO2, the extenting dependent on the severity of the haemodynamic compromise.
Collapse
|
28
|
Haxel CS, Johnson JN, Hintz S, Renno MS, Ruano R, Zyblewski SC, Glickstein J, Donofrio MT. Care of the Fetus With Congenital Cardiovascular Disease: From Diagnosis to Delivery. Pediatrics 2022; 150:189887. [PMID: 36317976 DOI: 10.1542/peds.2022-056415c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The majority of congenital cardiovascular disease including structural cardiac defects, abnormalities in cardiac function, and rhythm disturbances can be identified prenatally using screening obstetrical ultrasound with referral for fetal echocardiogram when indicated. METHODS Diagnosis of congenital heart disease in the fetus should prompt assessment for extracardiac abnormalities and associated genetic abnormalities once maternal consent is obtained. Pediatric cardiologists, in conjunction with maternal-fetal medicine, neonatology, and cardiothoracic surgery subspecialists, should counsel families about the details of the congenital heart defect as well as prenatal and postnatal management. RESULTS Prenatal diagnosis often leads to increased maternal depression and anxiety; however, it decreases morbidity and mortality for many congenital heart defects by allowing clinicians the opportunity to optimize prenatal care and plan delivery based on the specific lesion. Changes in prenatal care can include more frequent assessments through the remainder of the pregnancy, maternal medication administration, or, in selected cases, in utero cardiac catheter intervention or surgical procedures to optimize postnatal outcomes. Delivery planning may include changing the location, timing or mode of delivery to ensure that the neonate is delivered in the most appropriate hospital setting with the required level of hospital staff for immediate postnatal stabilization. CONCLUSIONS Based on the specific congenital heart defect, prenatal echocardiogram assessment in late gestation can often aid in predicting the severity of postnatal instability and guide the medical or interventional level of care needed for immediate postnatal intervention to optimize the transition to postnatal circulation.
Collapse
Affiliation(s)
- Caitlin S Haxel
- The University of Vermont Children's Hospital, Burlington, Vermont
| | | | - Susan Hintz
- Stanford University, Lucille Salter Packard Children's Hospital, Palo Alto, California
| | - Markus S Renno
- University Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | | | - Julie Glickstein
- Columbia University Vagelos School of Medicine, Morgan Stanley Children's Hospital, New York, New York
| | | |
Collapse
|
29
|
Mattia D, Lindblade C, Oatman O, Prakash S, Grebe T. Novel Case of Prader–Willi Syndrome and Ebstein's Anomaly: Implications for Complex Care Management. J Pediatr Genet 2022. [DOI: 10.1055/s-0042-1757449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractWe present a patient with a complex phenotype including diagnoses of Ebstein's anomaly and Prader–Willi syndrome (PWS) as well as additional congenital anomalies and genetic variants with potential clinical effects. This is the first reported case of both diagnoses present in the same patient. The diagnosis of Ebstein's anomaly was made on prenatal ultrasound. She presented with neonatal hypotonia, feeding problems, and dysmorphic features, followed by later onset weight gain, leading to a diagnosis of PWS. Further evaluations revealed Blaschkoid hyperpigmentation, laryngeal cleft, and pigmentary retinopathy. Whole exome sequencing determined a likely pathogenic variant in alkaline phosphatase gene and several mitochondrial DNA variants. We discuss the known genetic mechanisms of PWS and compare them to the heterogenous genetic associations of Ebstein's anomaly. The standard of care treatment for PWS is growth hormone therapy, which is associated with right-sided heart failure risks. This case illustrates the need to complete the diagnostic work up in all patients, as well as the necessity of a multidisciplinary approach for optimal outcomes.
Collapse
Affiliation(s)
- Donald Mattia
- Department of General Pediatrics, Phoenix Children's Hospital, Phoenix, Arizona, United States
| | - Christopher Lindblade
- Department of Cardiology, Phoenix Children's Hospital, Phoenix, Arizona, United States
| | - Oliver Oatman
- Department of Endocrinology, Phoenix Children's Hospital, Phoenix, Arizona, United States
| | - Supraja Prakash
- Department of Genetics and Metabolism, Phoenix Children's Hospital, Phoenix, Arizona, United States
| | - Theresa Grebe
- Department of Genetics and Metabolism, Phoenix Children's Hospital, Phoenix, Arizona, United States
| |
Collapse
|
30
|
Ebstein's Anomaly: From Fetus to Adult-Literature Review and Pathway for Patient Care. Pediatr Cardiol 2022; 43:1409-1428. [PMID: 35460366 DOI: 10.1007/s00246-022-02908-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 04/04/2022] [Indexed: 10/18/2022]
Abstract
Ebstein's anomaly, first described in 1866 by Dr William Ebstein, accounts for 0.3-0.5% of congenital heart defects and represents 40% of congenital tricuspid valve abnormalities. Ebstein's anomaly affects the development of the tricuspid valve with widely varying morphology and, therefore, clinical presentation. Associated congenital cardiac lesions tend to be found more often in younger patients and may even be the reason for presentation. Presentation can vary from the most extreme form in fetal life, to asymptomatic diagnosis late in adult life. The most symptomatic patients need intensive care support in the neonatal period. This article summarizes and analyzes the literature on Ebstein's anomaly and provides a framework for the investigation, management, and follow-up of these patients, whether they present via fetal detection or late in adult life. For each age group, the clinical presentation, required diagnostic investigations, natural history, and management are described. The surgical options available for patients with Ebstein's anomaly are detailed and analyzed, starting from the initial mono-leaflet repairs to the most recent cone repair and its modifications. The review also assesses the effects of pregnancy on the Ebstein's circulation, and vice versa, the effects of Ebstein's on pregnancy outcomes. Finally, two attached appendices are provided for a structured echocardiogram protocol and key information useful for comprehensive Multi-Disciplinary Team discussion.
Collapse
|
31
|
Wen J, Guo X, Cai S, Xu D, Zhang G, Bai X. Fetal Ductus Arteriosus Premature Constriction. Int Heart J 2022; 63:722-728. [PMID: 35831144 DOI: 10.1536/ihj.21-723] [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: 11/18/2022]
Abstract
This study aimed to investigate the connections between the echocardiography indices of fetal ductus arteriosus premature constriction and newborn prognosis by analyzing 22 cases of spontaneous fetal ductus arteriosus premature constriction.An ultrasonic instrument was used to observe prenatal fetal heart state, combine clinical examination data and echocardiographic results after delivery, summarize the ultrasound manifestations and imaging characteristics, and analyze the prognosis of the fetus.In all cases, fetal ductus arteriosus premature constriction occurred in the third trimester of pregnancy (34 + 1 to 41 weeks), and no abnormality in extracardiac organs were observed. Seven neonates required respiratory support due to the accompanying severe tricuspid regurgitation. The remaining 15 neonates did not receive respiratory support, including 4 with severe tricuspid regurgitation, 5 with moderate regurgitation, and 6 with mild regurgitation. Significant differences were observed in the fetal right atrium size and tricuspid regurgitation severity between the neonatal respiratory support group and non-respiratory support group. Furthermore, there were statistical differences in the ductus arteriosus inner diameter and pulsation index between the two groups.The severity of fetal ductus arteriosus premature contraction accompanied by tricuspid regurgitation and right atrium enlargement can predict the immediate prognosis of the newborn and provide guidance for the clinical judgment of the timing of pregnancy termination.
Collapse
Affiliation(s)
- Jie Wen
- Department of Obstetrics, Women's Hospital, Medical School of Zhejiang University & Key Lab of Women's Reproductive Health Zhejiang
| | - Xuedong Guo
- Department of Obstetrics, Women's Hospital, Medical School of Zhejiang University & Key Lab of Women's Reproductive Health Zhejiang
| | - Shuping Cai
- Department of Obstetrics, Women's Hospital, Medical School of Zhejiang University & Key Lab of Women's Reproductive Health Zhejiang
| | - Dong Xu
- Department of Obstetrics, Women's Hospital, Medical School of Zhejiang University & Key Lab of Women's Reproductive Health Zhejiang
| | - Geer Zhang
- Department of Obstetrics, Women's Hospital, Medical School of Zhejiang University & Key Lab of Women's Reproductive Health Zhejiang
| | - Xiaoxia Bai
- Department of Obstetrics, Women's Hospital, Medical School of Zhejiang University & Key Lab of Women's Reproductive Health Zhejiang
| |
Collapse
|
32
|
Liu J, Cao H, Cui L, Zhang Y, Song X, Ma J, Shi J, Zhang L, Hong L, Xie M. The Association of Pulmonary Flow Characteristics With Cardiac Function in Tricuspid Valve Malformation Fetuses: Study With Two-Dimensional Speckle Tracking Echocardiography. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:1791-1805. [PMID: 34726794 DOI: 10.1002/jum.15862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/10/2021] [Accepted: 10/14/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES To explore the relationship between cardiac function and pulmonary flow characteristics in tricuspid valve malformation (TVM) fetuses by conventional and speckle tracking echocardiography. METHODS Eighty-eight TVM fetuses were retrospectively included and compared with 80 normal controls. TVM fetuses in each trimester were divided into two subgroups according to pulmonary flow characteristics: those with normal pulmonary flow (TVM-N) and those with reduced or absent pulmonary flow (TVM-R/A). Cardiac measurements, Celermajer index, and Simpson-Andrews-Sharland (SAS) score were obtained. Speckle tracking echocardiography was used to compute ventricular deformation parameters. RESULTS TVM fetuses demonstrated significantly lower global longitudinal strain (GLS) and strain rate for both ventricles than controls (all P < .05). When compared with TVM-N, left ventricular (LV) ejection fraction, LV fractional area change, right ventricular (RV) fractional area change, LVGLS, and RVGLS were significantly reduced (all P < .05), while the RV diameter Z-score, RV/LV diameter, SAS score, and Celermajer index were obviously increased in TVM-R/A in both trimesters (all P < .05). Both LVGLS and RVGLS correlated with cardiothoracic circumference ratio, RV diameter Z-score, RV/LV diameter, Celermajer index, and SAS score (all P < .01). There was a slow decline for LVGLS and RVGLS in TVM-N fetuses throughout the gestation. Conversely, these two parameters worsened rapidly in TVM-R/A group. CONCLUSIONS TVM fetuses present biventricular dysfunction by deformation analysis in the second and third trimester of pregnancy. TVM fetuses with reduced or absent pulmonary flow exhibit significantly greater impairment and more rapid deterioration of cardiac function, which may contribute to poor outcomes.
Collapse
Affiliation(s)
- Juanjuan Liu
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Haiyan Cao
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Li Cui
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yi Zhang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Xiaoyan Song
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Jing Ma
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Jiawei Shi
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Li Zhang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Liu Hong
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Mingxing Xie
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| |
Collapse
|
33
|
Powel JE, Kraus E, Reddy C, Lannaman K. Treatment of severe fetal Ebstein's anomaly with prenatal non-steroidal anti-inflammatory therapy. Fetal Diagn Ther 2022; 49:245-249. [PMID: 35728558 DOI: 10.1159/000525593] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 05/10/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Prenatally diagnosed Ebstein's anomaly with tricuspid valve dysplasia (EA/TVD) is a rare and high-risk congenital heart malformation with limited effective treatments. We report a case of severe fetal EA with hydrops treated with modest doses of non-steroidal anti-inflammatory drug (NSAID) therapy, resulting in reversal of hydrops and a favorable fetal outcome. CASE PRESENTATION Fetal heart defects included an inferiorly displaced tricuspid valve, severe tricuspid regurgitation, significantly dilated right atrium, and hypoplastic pulmonary valve with moderate regurgitation resulting in a circular shunt across the ductus arteriosus. Maternal indomethacin therapy was initiated at 31+5 weeks gestation due to the development of fetal hydrops as demonstrated by the presence of a pericardial effusion and ascites. Indomethacin therapy resulted in the desired restriction of the ductus arteriosus and resolution of fetal hydrops. Maternal therapy was transitioned to ibuprofen and serial fetal echocardiograms ensured continued ductal restriction. Delivery occurred via cesarean at 36+3 weeks. The neonate did not require immediate cardiac surgical intervention and was discharged home with close follow-up. DISCUSSION/CONCLUSION A lower dose of prenatal NSAID therapy effected successful ductal restriction and hemodynamic mitigation of the circular shunt, resulting in reversal of hydrops and avoidance of postnatal cardiac surgical intervention.
Collapse
Affiliation(s)
- Jennifer E Powel
- Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Elena Kraus
- Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Chetana Reddy
- Division of Cardiology, Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Kia Lannaman
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| |
Collapse
|
34
|
Arunamata A, Goldstein BH. Right ventricular outflow tract anomalies: Neonatal interventions and outcomes. Semin Perinatol 2022; 46:151583. [PMID: 35422353 DOI: 10.1016/j.semperi.2022.151583] [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: 11/29/2022]
Abstract
Right ventricular outflow tract (RVOT) anomalies comprise a wide spectrum of congenital heart disease, typically characterized by obstruction to flow from the right ventricle to pulmonary arteries. This review highlights important considerations surrounding management strategy as well as clinical outcomes for the neonate with RVOT anomaly, including: pulmonary atresia with intact ventricular septum, congenital pulmonary valve stenosis, tetralogy of Fallot, and Ebstein anomaly with anatomic or physiologic RVOT obstruction.
Collapse
Affiliation(s)
- Alisa Arunamata
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine.
| | - Bryan H Goldstein
- Heart Institute, UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh School of Medicine
| |
Collapse
|
35
|
Abstract
Introduction: Tricuspid valve abnormalities detected in fetal life include Ebstein anomaly and tricuspid valve dysplasia. The differentiation between these 2 entities can sometimes be challenging in the 2nd trimester fetus. We report a case of tricuspid valve dysplasia diagnosed on fetal autopsy. Case Report: A primigravida was diagnosed at 22 weeks' gestation to have Ebstein anomaly with severe tricuspid regurgitation. There was intra-uterine fetal demise. On fetal autopsy, the tricuspid valve leaflets were not apically displaced and the leaflets were nodular with rolled up edges. This supported a diagnosis of tricuspid valve dysplasia. Conclusion: The difficulties in differentiating Ebstein anomaly from tricuspid valve dysplasia due to inherent limitations in fetal imaging can be resolved by fetal autopsy. Valvular dysplasia will not have apical displacement of the valve leaflets.
Collapse
Affiliation(s)
- Sumathi Shanmugam
- Government Medical College and Hospital Pudukkottai, Pudukkottai, India
| | | | - Mani Ram Krishna
- Dr R.K. Hospital for Women and Children, Thanjavur, India.,Pediatric Cardiology, Amrita Institute of Medical Sciences, Cochin, India
| |
Collapse
|
36
|
Goncalves LF, Lindblade CL, Cornejo P, Patel MC, McLaughlin ES, Bardo DME. Contribution of fetal magnetic resonance imaging in fetuses with congenital heart disease. Pediatr Radiol 2022; 52:513-526. [PMID: 34842935 DOI: 10.1007/s00247-021-05234-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 09/18/2021] [Accepted: 10/25/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Increasing evidence supports an association among congenital heart disease (CHD), structural brain lesions on neuroimaging, and increased risk of neurodevelopmental delay and other structural anomalies. Fetal MRI has been found to be effective in demonstrating fetal structural and developmental abnormalities. OBJECTIVE To determine the contribution of fetal MRI to identifying cardiovascular and non-cardiovascular anomalies in fetuses with CHD compared to prenatal US and fetal echocardiography. MATERIALS AND METHODS We performed a retrospective study of fetuses with CHD identified by fetal echocardiography. Exams were performed on 1.5-tesla (T) or 3-T magnets using a balanced turbo field echo sequence triggered by an external electrocardiogram simulator with a fixed heart rate of 140 beats per minute (bpm). Fetal echocardiography was performed by pediatric cardiologists and detailed obstetrical US by maternal-fetal medicine specialists prior to referral to MRI. We compared the sensitivity of fetal MRI and fetal echocardiography for the diagnosis of cardiovascular anomalies, as well as the sensitivity of fetal MRI and referral US for the diagnosis of non-cardiac anomalies. We performed statistical analysis using the McNemar test. RESULTS We identified 121 anomalies in 31 fetuses. Of these, 73 (60.3%) were cardiovascular and 48 (39.7%) involved other organ systems. Fetal echocardiography was more sensitive for diagnosing cardiovascular anomalies compared to fetal MRI, but the difference was not statistically significant (85.9%, 95% confidence interval [CI] 77.8-94.0% vs. 77.5%, 95% CI 67.7-87.2%, respectively; McNemar test 2.29; P=0.13). The sensitivity of fetal MRI was higher for diagnosing extracardiac anomalies when compared to referral US (84.1%, 95% CI 73.3-94.9% vs. 31.8%, 95% CI 18.1-45.6%, respectively; McNemar test 12.9; P<0.001). The additional information provided by fetal MRI changed prognosis, counseling or management for 10/31 fetuses (32.2%), all in the group of 19 fetuses with anomalies in other organs and systems besides CHD. CONCLUSION Fetal MRI performed in a population of fetuses with CHD provided additional information that altered prognosis, counseling or management in approximately one-third of the fetuses, mainly by identifying previously unknown anomalies in other organs and systems.
Collapse
Affiliation(s)
- Luis F Goncalves
- Department of Radiology, Phoenix Children's Hospital, 1919 E. Thomas Road, Phoenix, AZ, 85016, USA.
- University of Arizona College of Medicine, Phoenix, AZ, USA.
- Department of Radiology, Creighton University, Phoenix, AZ, USA.
- Department of Radiology, Mayo Clinic, Phoenix, AZ, USA.
| | - Christopher L Lindblade
- University of Arizona College of Medicine, Phoenix, AZ, USA
- Department of Radiology, Creighton University, Phoenix, AZ, USA
- Department of Radiology, Mayo Clinic, Phoenix, AZ, USA
- Department of Cardiology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Patricia Cornejo
- Department of Radiology, Phoenix Children's Hospital, 1919 E. Thomas Road, Phoenix, AZ, 85016, USA
- University of Arizona College of Medicine, Phoenix, AZ, USA
- Department of Radiology, Creighton University, Phoenix, AZ, USA
- Department of Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Mittun C Patel
- Department of Radiology, Phoenix Children's Hospital, 1919 E. Thomas Road, Phoenix, AZ, 85016, USA
- University of Arizona College of Medicine, Phoenix, AZ, USA
- Department of Radiology, Creighton University, Phoenix, AZ, USA
- Department of Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Ericka Scheller McLaughlin
- University of Arizona College of Medicine, Phoenix, AZ, USA
- Department of Radiology, Creighton University, Phoenix, AZ, USA
- Department of Radiology, Mayo Clinic, Phoenix, AZ, USA
- Department of Cardiology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Dianna M E Bardo
- Department of Radiology, Phoenix Children's Hospital, 1919 E. Thomas Road, Phoenix, AZ, 85016, USA
- University of Arizona College of Medicine, Phoenix, AZ, USA
- Department of Radiology, Creighton University, Phoenix, AZ, USA
- Department of Radiology, Mayo Clinic, Phoenix, AZ, USA
| |
Collapse
|
37
|
Teramachi Y, Hornberger LK, Howley L, van der Velde ME, Eckersley LG. Left Ventricular Dysfunction in Neonatal Ebstein’s Anomaly and Tricuspid Valve Dysplasia. J Am Soc Echocardiogr 2022; 35:503-512.e3. [DOI: 10.1016/j.echo.2022.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 01/17/2022] [Accepted: 01/19/2022] [Indexed: 10/19/2022]
|
38
|
Congenital heart disease: pathology, natural history, and interventions. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00011-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
39
|
Congenital Tricuspid Valve Calcification Necessitating Neonatal Surgical Intervention. Ann Thorac Surg 2021; 114:e165-e167. [PMID: 34968447 DOI: 10.1016/j.athoracsur.2021.11.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/15/2021] [Accepted: 11/20/2021] [Indexed: 11/22/2022]
Abstract
We report a case of isolated idiopathic congenital tricuspid valve calcification which necessitated urgent neonatal surgical intervention. Hemodynamic analysis revealed circular shunt caused by severe tricuspid regurgitation, pulmonary regurgitation and a hypoplastic right ventricle. The patient successfully underwent tricuspid valve repair at postnatal Day 10. Although intervention for neonatal tricuspid valve is challenging, hemodynamic evaluation and early surgical intervention are necessary in patients with this rare cardiac calcification.
Collapse
|
40
|
Gill K, Arbic N, Seed M, Honjo O, Ryan G, Jaeggi E. Inadvertent irreversible closure of arterial duct following therapeutic use of transplacental indomethacin in a fetus with severe Ebstein's anomaly and circular shunt. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:940-942. [PMID: 34453368 DOI: 10.1002/uog.24758] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/19/2021] [Accepted: 08/23/2021] [Indexed: 06/13/2023]
Abstract
We report on a fetal case of Ebstein's anomaly with severe tricuspid regurgitation, functional pulmonary atresia and progressive circular shunting (CS) across a widely patent ductus arteriosus (DA) and regurgitant pulmonary valve, contributing to significant systemic hypoperfusion. To mitigate the extent of CS and allow the pregnancy to continue, maternal non-steroidal anti-inflammatory drug (NSAID) therapy with indomethacin was started at 33 + 5 weeks to induce DA constriction. Rather than achieving the desired narrowing of the DA, the treatment led to its complete closure and only minimal antegrade flow across the pulmonary valve. While closure of the DA resulted in the anticipated improvement in fetal hemodynamics, at birth, the child was at risk of severe hypoxemia and its consequences due to the lack of adequate pulmonary perfusion. Reduction and eventual discontinuation of the NSAID treatment did not result in DA reopening. Our experience illustrates the risk of unintended irreversible DA closure when NSAIDs are used to treat CS. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- K Gill
- Divisions of Cardiology and Cardiovascular Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada
- Ontario Fetal Centre, University of Toronto, Toronto, Canada
| | - N Arbic
- Divisions of Cardiology and Cardiovascular Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada
- Ontario Fetal Centre, University of Toronto, Toronto, Canada
| | - M Seed
- Divisions of Cardiology and Cardiovascular Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada
- Ontario Fetal Centre, University of Toronto, Toronto, Canada
| | - O Honjo
- Divisions of Cardiology and Cardiovascular Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada
- Ontario Fetal Centre, University of Toronto, Toronto, Canada
| | - G Ryan
- Ontario Fetal Centre, University of Toronto, Toronto, Canada
- Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - E Jaeggi
- Divisions of Cardiology and Cardiovascular Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada
- Ontario Fetal Centre, University of Toronto, Toronto, Canada
| |
Collapse
|
41
|
Cleveland JD, Starnes VA. Simple, reproducible, and consistent physiology: The argument for single-ventricle repair in critically ill neonates with Ebstein anomaly. JTCVS Tech 2021; 10:428-432. [PMID: 34977773 PMCID: PMC8689678 DOI: 10.1016/j.xjtc.2021.02.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
- John D. Cleveland
- Address for reprints: John D. Cleveland, MD, Division of Cardiac Surgery, Department of Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop #66, Los Angeles, CA 90033.
| | | |
Collapse
|
42
|
Cordisco Md A, Lozza V, Filice ME, Chiappa E. First trimester prenatal diagnosis of a severe tricuspid valve regurgitation and pulmonary valve atresia. Echocardiography 2021; 38:2119-2121. [PMID: 34747067 DOI: 10.1111/echo.15242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/21/2021] [Indexed: 11/28/2022] Open
Abstract
Early diagnosis of congenital heart defect (CHD) increased in the last two decades, following technological evolution. A recent meta-analysis (Yu, 2020), on diagnostic accuracy in ultrasound detection of major CHD in the first trimester of pregnancy, reported an overall sensitivity of 75%. Ultrasound imaging of this case refers to a tricuspid valve dysplasia with right atriomegaly and pulmonary valve atresia diagnosed in a 13-week gestational-age fetus with low risk for chromosomal abnormalities. To our knowledge, this is the first case describing such features in the first trimester. We believe the precocity and severity of onset make this a case of diagnostic interest.
Collapse
Affiliation(s)
- Adalgisa Cordisco Md
- Division of Prenatal Diagnosis, Materno Infantile Department, Azienda USL Toscana Centro, San Giovanni di Dio Hospital, Firenze, Italy
| | - Virginia Lozza
- Division of Prenatal Diagnosis, Materno Infantile Department, Azienda USL Toscana Centro, San Giovanni di Dio Hospital, Firenze, Italy
| | - Maria Elena Filice
- Division of Anatomia Patologica 2, Department of Medicina di Laboratorio, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Enrico Chiappa
- Division of Pediatric Cardiology, National Research Center - Tuscany Region Foundation "G. Monasterio", Ospedale del Cuore, Massa, Italy
| |
Collapse
|
43
|
Knott-Craig CJ, Boston US. Current surgical techniques in the management of the symptomatic neonate with severe Ebstein anomaly: Too much, too little, or just enough? JTCVS Tech 2021; 9:128-134. [PMID: 34647081 PMCID: PMC8501262 DOI: 10.1016/j.xjtc.2021.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/11/2021] [Indexed: 12/03/2022] Open
Abstract
The management of severely symptomatic neonates with Ebstein anomaly is challenging during the early neonatal period. Initial management goals should focus on mitigating a central shunt; providing respiratory mechanical support; providing an adequate but not excessive source of pulmonary blood flow; and minimizing pulmonary vascular resistance. For most patients thus stabilized, definitive repair should be prudently deferred until it is safe for a bailout bidirectional Glenn anastomosis to be added, usually at age 3 to 4 months. For those who remain critical, initial ligation of the large ductus and placing a more peripheral aortopulmonary shunt, or ligating the main pulmonary artery, should be weighed against a primary biventricular repair (Knott-Craig repair), or the Starnes' single-ventricle palliation. The Da Silva cone biventricular repair should generally be avoided during the early neonatal period. An initial Starnes' repair can be potentially converted to a biventricular repair in later infancy.
Collapse
Affiliation(s)
- Christopher J. Knott-Craig
- Address for reprints: Christopher J. Knott-Craig, MD, FACS, Division of Pediatric Cardiovascular Surgery, Le Bonheur Children's Hospital and the University of Tennessee Health Sciences Center, Suite 332 Physician office Building, 50 N Dunlap, Memphis, TN 38105.
| | - Umar S. Boston
- Division of Pediatric Cardiovascular Surgery, Le Bonheur Children's Hospital, Memphis, Tenn
- University of Tennessee Health Sciences Center, Memphis, Tenn
| |
Collapse
|
44
|
Cleveland JD, Starnes VA. Commentary: The heart of symptomatic neonatal Ebstein anomaly: Negative interventricular interaction and ventricular myopathy. JTCVS Tech 2021; 9:135-136. [PMID: 34647082 PMCID: PMC8501124 DOI: 10.1016/j.xjtc.2021.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 05/31/2021] [Accepted: 06/05/2021] [Indexed: 11/18/2022] Open
Affiliation(s)
- John D. Cleveland
- Division of Cardiac Surgery, Department of Surgery, Children's Hospital Los Angeles, Los Angeles, Calif
| | - Vaughn A. Starnes
- Division of Cardiac Surgery, Department of Surgery, Children's Hospital Los Angeles, Los Angeles, Calif
| |
Collapse
|
45
|
Hunter L, Vigneswaran TV, Pasupathy D, Callaghan N, Tenenbaum J, Zidere V, Simpson JM. Effects and side effects of maternal administration of indomethacin for fetal tricuspid valve dysplasia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:322-323. [PMID: 32939846 DOI: 10.1002/uog.23122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/30/2020] [Accepted: 09/03/2020] [Indexed: 06/11/2023]
Affiliation(s)
- L Hunter
- Department of Congenital Heart Disease, Royal Hospital for Children, Glasgow, UK
| | - T V Vigneswaran
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - D Pasupathy
- Institute of Reproduction, Westmead Clinical School, University of Sydney, Sydney, Australia
- Department of Fetal Medicine, St Thomas' Hospital, London, UK
| | - N Callaghan
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - J Tenenbaum
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - V Zidere
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - J M Simpson
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| |
Collapse
|
46
|
Weichert J, Weichert A. A 'holistic' sonographic view on congenital heart disease - How automatic reconstruction using fetal intelligent navigation echocardiography (FINE) eases the unveiling of abnormal cardiac anatomy part I: Right heart anomalies. Echocardiography 2021; 38:1430-1445. [PMID: 34232534 DOI: 10.1111/echo.15134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 04/18/2021] [Accepted: 06/01/2021] [Indexed: 11/28/2022] Open
Abstract
Attempting a comprehensive examination of the fetal heart remains challenging for unexperienced operators as it emphasizes the acquisition and documentation of sequential cross-sectional and sagittal views and inevitably results in diminished detection rates of fetuses affected by congenital heart disease. The introduction of four-dimensional spatio-temporal image correlation (4D STIC) technology facilitated a volumetric approach for thorough cardiac anatomic evaluation by the acquisition of cardiac 4D datasets. By analyzing and re-arranging of numerous frames according to their temporal event within the heart cycle, STIC allows visualization of cardiac structures as an endless cine loop sequence of a complete single cardiac cycle in motion. However, post-analysis with manipulation and repeated slicing of the volume usually requires experience and in-depth anatomic knowledge, which limits the widespread application of this advanced technique in clinical care and unfortunately leads to the underestimation of its diagnostic value to date. Fetal intelligent navigation echocardiography (FINE), a novel method that automatically generates and displays nine standard fetal echocardiographic views in normal hearts, has shown to be able to overcome these limitations. Very recent data on the detection of congenital heart defects (CHDs) using the FINE method revealed a high sensitivity and specificity of 98% and 93%, respectively. In this two-part manuscript, we focused on the performance of FINE in delineating abnormal anatomy of typical right and left heart lesions and thereby emphasized the educational potential of this technology for more than just teaching purposes. We further discussed recent findings in a pathophysiological and/or functional context.
Collapse
Affiliation(s)
- Jan Weichert
- Department of Gynecology & Obstetrics, Division of Prenatal Medicine, Campus Luebeck, University Hospital of Schleswig-Holstein, Luebeck, Schleswig-Holstein, Germany
| | - Alexander Weichert
- Elbe Center of Prenatal Medicine and Human Genetics, Hamburg, Germany.,Department of Obstetrics, Charité-Universitätsmedizin Berlin - CCM, Berlin, Germany.,Prenatal Medicine Bergmannstrasse, Berlin, Germany
| |
Collapse
|
47
|
Critical Ebstein's anomaly with circular shunt: from successful fetal therapy with non-steroidal anti-inflammatory drugs to biventricular repair using Da Silva cone technique. Cardiol Young 2021; 31:1039-1042. [PMID: 33682656 DOI: 10.1017/s1047951121000081] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report an innovative treatment strategy for fetal Ebstein's anomaly with a circular shunt. We used transplacental non-steroidal anti-inflammatory drugs, at the 29th gestational week, to constrict the ductus arteriosus avoiding fetal demise. We addressed the critical neonate with an urgent Starnes procedure. Finally, instead of following the usual single-ventricle palliation pathway after the Starnes procedure, we achieved successful two-ventricle repair with the cone technique at 5 month old.
Collapse
|
48
|
Peluso AM, Othman HF, Zahka K, Perez AL, Sammour I, Aly H. Neonatal Ebstein anomaly national outcomes from 2000 to 2018 using the National Inpatient Sample. Birth Defects Res 2021; 113:1037-1043. [PMID: 33788426 DOI: 10.1002/bdr2.1895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 02/15/2021] [Accepted: 03/21/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND The prevalence, morbidity, and mortality associated with Ebstein anomaly (EA) remains poorly characterized in neonates. EA is a rare form of congenital heart disease (CHD) with significant heterogeneity. OBJECTIVE To determine the recent, 2000-2018, prevalence, mortality, outcomes, and healthcare utilization of infants admitted at ≤28 days of life with EA in comparison to other critical congenital heart defects (CCHD) in the United States using a national data set. METHODS The National Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project (HCUP) was queried for infants admitted for any reason at ≤28 days of life with a diagnosis of EA between 2000 and 2018 using ICD-9 and 10 codes in the United States. Patient characteristics, morbidity, mortality, and healthcare utilization were evaluated for EA and compared with other CCHD. RESULTS From 2000 to 2018 a total of 68,312,952 neonatal admissions were identified, of them 4,398 neonates with isolated EA were identified, representing 7 per 100,000 neonatal admissions and 2.2% of CCHD admissions (4,398/197,881). The number of new EA cases ranged from 138 to 375 per year. In-hospital mortality was 12.3% and surgical repair occurred in 4.2% for infants with EA. There were 470 deaths without surgical repair which is 86.6% of the mortality. Arrhythmias were diagnosed in 10.6% and ECMO was used for 2.6% of neonates with EA. CONCLUSION EA is a rare form of CHD. The prevalence has remained stable over the 19 years whereas other congenital heart defects have had an increase. The mortality in neonates with EA was significantly higher than in pooled CCHD; the burden of mortality occurred in the neonates without surgical intervention.
Collapse
Affiliation(s)
- Allison M Peluso
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, Ohio, USA
| | - Hasan F Othman
- Department of Pediatrics, Michigan State University/Sparrow Health System, Lansing, Michigan, USA
| | - Kenneth Zahka
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio, USA
| | - Antonio L Perez
- Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ibrahim Sammour
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, Ohio, USA
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, Ohio, USA
| |
Collapse
|
49
|
Miyoshi T, Hosoda H, Minamino N. Significance of Atrial and Brain Natriuretic Peptide Measurements in Fetuses With Heart Failure. Front Physiol 2021; 12:654356. [PMID: 33815155 PMCID: PMC8012666 DOI: 10.3389/fphys.2021.654356] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 03/02/2021] [Indexed: 11/13/2022] Open
Abstract
Fetal heart failure is mainly caused by congenital heart defect and arrhythmia. It is difficult to appropriately diagnose the severity of fetal heart failure simply by ultrasonography because the development of a fetal heart in fetoplacental circulation and how well the fetal myocardium can adapt to postnatal cardiopulmonary circulation are challenging to assess. In adult cardiology, natriuretic peptides (NPs) are the most useful biomarker of heart failure; however, studies investigating NP levels in the fetuses and amniotic fluid are quite limited. Furthermore, little is known about their production and metabolism. This review summarized the most relevant findings on NP levels in the umbilical cord blood and amniotic fluid. The findings can then extend their use as a diagnostic biomarker of heart failure in fetuses with congenital heart defect and/or arrhythmia.
Collapse
Affiliation(s)
- Takekazu Miyoshi
- Department of Regenerative Medicine and Tissue Engineering, National Cerebral and Cardiovascular Center, Suita, Japan.,Clinical Research Center, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroshi Hosoda
- Department of Regenerative Medicine and Tissue Engineering, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Naoto Minamino
- Omics Research Center, National Cerebral and Cardiovascular Center, Suita, Japan
| |
Collapse
|
50
|
Husain SA. Commentary: The end justifies the means: Employing a "modified" strategy for Starnes palliation in a premature low birth weight infant with Ebstein anomaly. JTCVS Tech 2021; 7:214-215. [PMID: 34318251 PMCID: PMC8311903 DOI: 10.1016/j.xjtc.2021.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 02/13/2021] [Accepted: 02/22/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- S Adil Husain
- Section of Pediatric Cardiothoracic Surgery, University of Utah Health, Salt Lake City, Utah.,Heart Center, Primary Children's Hospital, Salt Lake City, Utah
| |
Collapse
|