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Selvanathan T, Mabbott C, Au-Young SH, Seed M, Miller SP, Chau V. Antenatal diagnosis, neonatal brain volumes, and neurodevelopment in transposition of the great arteries. Dev Med Child Neurol 2024; 66:882-891. [PMID: 38204357 DOI: 10.1111/dmcn.15840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 11/21/2023] [Accepted: 11/30/2023] [Indexed: 01/12/2024]
Abstract
AIM To examine whether antenatal diagnosis modifies relationships between neonatal brain volumes and 18-month neurodevelopmental outcomes in children with transposition of the great arteries (TGA). METHOD In a retrospective cohort of 139 children with TGA (77 antenatally diagnosed), we obtained total brain volumes (TBVs) on pre- (n = 102) and postoperative (n = 112) magnetic resonance imaging. Eighteen-month neurodevelopmental outcomes were assessed using the Bayley Scales of Infant and Toddler Development, Third Edition. Generalized estimating equations with interaction terms were used to determine whether antenatal diagnosis modified associations between TBVs and neurodevelopmental outcomes accounting for postmenstrual age at scan, brain injury, and ventricular septal defect. RESULTS Infants with postnatal diagnosis had more preoperative hypotension (35% vs 14%, p = 0.004). The interactions between antenatal diagnosis and TBVs were significantly related to cognitive (p = 0.003) outcomes. Specifically, smaller TBVs were associated with lower cognitive scores in infants diagnosed postnatally; this association was attenuated in those diagnosed antenatally. INTERPRETATION Antenatal diagnosis modifies associations between neonatal brain volume and 18-month cognitive outcome in infants with TGA. These findings suggest that antenatal diagnosis may be neuroprotective, possibly through improved preoperative clinical status. These data highlight the need to improve antenatal diagnosis rates. WHAT THIS PAPER ADDS Antenatal diagnosis of transposition of the great arteries modified relationships between neonatal brain volume and neurodevelopment. Smaller brain volumes related to poorer cognitive scores with postnatal diagnosis only. There was more preoperative hypotension in the postnatal diagnosis group.
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Affiliation(s)
- Thiviya Selvanathan
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
- Department of Pediatrics, BC Children's Hospital Research Institute and the University of British Columbia, Vancouver, BC, Canada
| | - Connor Mabbott
- Neurosciences and Mental Health, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Stephanie H Au-Young
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
- Neurosciences and Mental Health, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Mike Seed
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
- Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Steven P Miller
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
- Department of Pediatrics, BC Children's Hospital Research Institute and the University of British Columbia, Vancouver, BC, Canada
- Neurosciences and Mental Health, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Vann Chau
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
- Neurosciences and Mental Health, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
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Gottschalk I, Walter A, Menzel T, Weber EC, Wendt S, Sreeram N, Gembruch U, Berg C, Abel JS. D-Transposition of the great arteries with restrictive foramen ovale in the fetus: the dilemma of predicting the need for postnatal urgent balloon atrial septostomy. Arch Gynecol Obstet 2024; 309:1353-1367. [PMID: 36971845 PMCID: PMC10894161 DOI: 10.1007/s00404-023-06997-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 03/01/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVE Restrictive foramen ovale (FO) in dextro-transposition of the great arteries (d-TGA) with intact ventricular septum may lead to severe life-threatening hypoxia within the first hours of life, making urgent balloon atrial septostomy (BAS) inevitable. Reliable prenatal prediction of restrictive FO is crucial in these cases. However, current prenatal echocardiographic markers show low predictive value, and prenatal prediction often fails with fatal consequences for a subset of newborns. In this study, we described our experience and aimed to identify reliable predictive markers for BAS. METHODS We included 45 fetuses with isolated d-TGA that were diagnosed and delivered between 2010 and 2022 in two large German tertiary referral centers. Inclusion criteria were the availability of former prenatal ultrasound reports, of stored echocardiographic videos and still images, which had to be obtained within the last 14 days prior to delivery and that were of sufficient quality for retrospective re-analysis. Cardiac parameters were retrospectively assessed and their predictive value was evaluated. RESULTS Among the 45 included fetuses with d-TGA, 22 neonates had restrictive FO postnatally and required urgent BAS within the first 24 h of life. In contrast, 23 neonates had normal FO anatomy, but 4 of them unexpectedly showed inadequate interatrial mixing despite their normal FO anatomy, rapidly developed hypoxia and also required urgent BAS ('bad mixer'). Overall, 26 (58%) neonates required urgent BAS, whereas 19 (42%) achieved good O2 saturation and did not undergo urgent BAS. In the former prenatal ultrasound reports, restrictive FO with subsequent urgent BAS was correctly predicted in 11 of 22 cases (50% sensitivity), whereas a normal FO anatomy was correctly predicted in 19 of 23 cases (83% specificity). After current re-analysis of the stored videos and images, we identified three highly significant markers for restrictive FO: a FO diameter < 7 mm (p < 0.01), a fixed (p = 0.035) and a hypermobile (p = 0.014) FO flap. The maximum systolic flow velocities in the pulmonary veins were also significantly increased in restrictive FO (p = 0.021), but no cut-off value to reliably predict restrictive FO could be identified. If the above markers are applied, all 22 cases with restrictive FO and all 23 cases with normal FO anatomy could correctly be predicted (100% positive predictive value). Correct prediction of urgent BAS also succeeded in all 22 cases with restrictive FO (100% PPV), but naturally failed in 4 of the 23 cases with correctly predicted normal FO ('bad mixer') (82.6% negative predictive value). CONCLUSION Precise assessment of FO size and FO flap motility allows a reliable prenatal prediction of both restrictive and normal FO anatomy postnatally. Prediction of likelihood of urgent BAS also succeeds reliably in all fetuses with restrictive FO, but identification of the small subset of fetuses that also requires urgent BAS despite their normal FO anatomy fails, because the ability of sufficient postnatal interatrial mixing cannot be predicted prenatally. Therefore, all fetuses with prenatally diagnosed d-TGA should always be delivered in a tertiary center with cardiac catheter stand-by, allowing BAS within the first 24 h after birth, regardless of their predicted FO anatomy.
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Affiliation(s)
- I Gottschalk
- Division of Prenatal Medicine, Gynecological Ultrasound and Fetal Surgery, Department of Obstetrics and Gynecology, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany.
| | - A Walter
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | - T Menzel
- Division of Prenatal Medicine, Gynecological Ultrasound and Fetal Surgery, Department of Obstetrics and Gynecology, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - E C Weber
- Division of Prenatal Medicine, Gynecological Ultrasound and Fetal Surgery, Department of Obstetrics and Gynecology, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - S Wendt
- Heartcenter, Department of Cardiac Surgery, Cardiothoracic Intensive Care and Thoracic Surgery, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - N Sreeram
- Department of Pediatric Cardiology, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - U Gembruch
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | - C Berg
- Division of Prenatal Medicine, Gynecological Ultrasound and Fetal Surgery, Department of Obstetrics and Gynecology, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - J S Abel
- Division of Prenatal Medicine, Gynecological Ultrasound and Fetal Surgery, Department of Obstetrics and Gynecology, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
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Soares C, Vieira RJ, Costa S, Moita R, Andrade M, Guimarães H. Neurodevelopment outcomes in the first 5 years of the life of children with transposition of the great arteries surgically corrected in the neonatal period: systematic review and meta-analysis. Cardiol Young 2023; 33:2471-2480. [PMID: 37965690 DOI: 10.1017/s104795112300375x] [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] [Indexed: 11/16/2023]
Abstract
OBJECTIVES In patients with transposition of the great arteries, surgical correction may achieve definitive treatment, so a thorough knowledge of the long-term outcomes, particularly neurodevelopment outcomes, is essential. Therefore, we conducted a systematic review and meta-analysis to study the neurodevelopment outcomes in the first 5 years of the life of children submitted to corrective surgery for transposition of the great arteries in the neonatal period. METHODS A total of 17 studies from 18 reports were included, assessing 809 individuals with surgically corrected transposition of the great arteries. The neurodevelopmental outcomes were assessed with the Bayley Scales of Infant and Toddler Development (BSID) and the Wechsler Intelligence Scale for Children (WISC). RESULTS Mean Mental Development Index (MDI) and Psychomotor Development Index (PDI) were within the average values from 1 to 3 years of age, although the proportion of children scoring more than 1 standard deviation below the mean in PDI, MDI, motor, and language composite scores was significantly higher than in the general population. From 4 to 5 years, mean full-scale global intelligence quotient (IQ), verbal IQ, and performance IQ scores did not differ significantly from the general population. CONCLUSION This study revealed neurodevelopment scores within the normal range at 5 years of age in children submitted to corrective surgery for transposition of the great arteries in the neonatal period. However, these early outcomes may not adequately predict long-term outcomes. Further studies are needed to identify specific risk factors and early markers of later impairment to guide the establishment of early interventions.
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Affiliation(s)
| | - Rafael José Vieira
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of Porto University, Porto, Portugal
- Centre for Health Technology and Services Research, Health Research Network (CINTESIS@RISE), Faculty of Medicine of Porto University, Porto, Portugal
| | - Sandra Costa
- Faculty of Medicine of Porto University, Porto, Portugal
- Neonatology Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Rita Moita
- Neonatology Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Mariana Andrade
- Pediatrics Department, Centro Hospitalar Universitário São João, Porto, Portugal
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Truong VT, Nguyen BP, Nguyen-Vo TH, Mazur W, Chung ES, Palmer C, Tretter JT, Alsaied T, Pham VT, Do HQ, Do PTN, Pham VN, Ha BN, Chau HN, Le TK. Application of machine learning in screening for congenital heart diseases using fetal echocardiography. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2022; 38:1007-1015. [PMID: 35192082 DOI: 10.1007/s10554-022-02566-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 02/13/2022] [Indexed: 11/05/2022]
Abstract
There is a growing body of literature supporting the utilization of machine learning (ML) to improve diagnosis and prognosis tools of cardiovascular disease. The current study was to investigate the impact that the ML framework may have on the sensitivity of predicting the presence or absence of congenital heart disease (CHD) using fetal echocardiography. A comprehensive fetal echocardiogram including 2D cardiac chamber quantification, valvar assessments, assessment of great vessel morphology, and Doppler-derived blood flow interrogation was recorded. The postnatal echocardiogram was used to ascertain the diagnosis of CHD. A random forest (RF) algorithm with a nested tenfold cross-validation was used to train models for assessing the presence of CHD. The study population was derived from a database of 3910 singleton fetuses with maternal age of 28.8 ± 5.2 years and gestational age at the time of fetal echocardiography of 22.0 weeks (IQR 21-24). The proportion of CHD was 14.1% for the studied cohort confirmed by post-natal echocardiograms. Our proposed RF-based framework provided a sensitivity of 0.85, a specificity of 0.88, a positive predictive value of 0.55 and a negative predictive value of 0.97 to detect the CHD with the mean of mean ROC curves of 0.94 and the mean of mean PR curves of 0.84. Additionally, six first features, including cardiac axis, peak velocity of blood flow across the pulmonic valve, cardiothoracic ratio, pulmonary valvar annulus diameter, right ventricular end-diastolic diameter, and aortic valvar annulus diameter, are essential features that play crucial roles in adding more predictive values to the model in detecting patients with CHD. ML using RF can provide increased sensitivity in prenatal CHD screening with very good performance. The incorporation of ML algorithms into fetal echocardiography may further standardize the assessment for CHD.
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Affiliation(s)
- Vien T Truong
- The Christ Hospital Health Network, Cincinnati, OH, USA
- The Lindner Research Center, Cincinnati, OH, USA
| | - Binh P Nguyen
- School of Mathematics and Statistics, Victoria University of Wellington, Wellington, New Zealand
| | - Thanh-Hoang Nguyen-Vo
- School of Mathematics and Statistics, Victoria University of Wellington, Wellington, New Zealand
| | | | | | | | - Justin T Tretter
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Tarek Alsaied
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Vy T Pham
- Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Huan Q Do
- Heart Institute of HCMC, Ho Chi Minh City, Vietnam
| | | | - Vinh N Pham
- Heart Center, Tam Anh General Hospital, Ho Chi Minh City, Vietnam
| | - Ban N Ha
- Heart Institute of HCMC, Ho Chi Minh City, Vietnam
| | - Hoa N Chau
- University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Tuyen K Le
- Heart Institute of HCMC, Ho Chi Minh City, Vietnam.
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Kunde F, Thomas S, Sudhakar A, Kunjikutty R, Kumar RK, Vaidyanathan B. Prenatal diagnosis and planned peripartum care improve perinatal outcome of fetuses with transposition of the great arteries and intact ventricular septum in low-resource settings. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:398-404. [PMID: 33030746 DOI: 10.1002/uog.23146] [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: 07/19/2020] [Revised: 09/25/2020] [Accepted: 09/28/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To report on the feasibility of establishing a regional prenatal referral network for critical congenital heart defects (CHDs) and its impact on perinatal outcome of fetuses with transposition of the great arteries and intact ventricular septum (TGA-IVS) in low-resource settings. METHODS This was a retrospective study of consecutive fetuses with a diagnosis of TGA-IVS between January 2011 and December 2019 in Kochi, Kerala, India. A regional network for prenatal diagnosis and referral of patients with critical CHDs was initiated in 2011. Pregnancy and early neonatal outcomes were reported. The impact of the timing of diagnosis (prenatal or after birth) on age at surgery, perinatal mortality and postoperative recovery was evaluated. RESULTS A total of 82 fetuses with TGA-IVS were included. Diagnosis typically occurred later on in gestation, at a median of 25 (interquartile range (IQR), 21-32) weeks. The majority (78.0%) of affected pregnancies resulted in live birth, most (84.4%) of which occurred in a specialist pediatric cardiac centers. Delivery in a specialist center, compared with delivery in a local maternity center, was associated with a significantly higher rate of surgical correction (98.1% vs 70.0%; P = 0.01) and overall lower neonatal mortality (3.7% vs 50%; P = 0.001). The proportion of cases undergoing arterial switch operation after prenatal diagnosis of TGA-IVS increased significantly, along with the prenatal detection rate, over the study period (2011-2015, 11.1% vs 2016-2019, 29.4%; P = 0.001). Median age at surgery was significantly lower in the prenatally diagnosed group than that in the postnatally diagnosed group (4 days (IQR, 1-23 days) vs 10 days (IQR, 1-91 days); P < 0.001). There was no significant difference in postoperative mortality (2.0% vs 3.6%; P = 0.49) between the two groups. CONCLUSIONS This study demonstrates the feasibility of creating a network for prenatal diagnosis and referral of patients with critical CHDs, such as TGA, in low-resource settings, that enables planned peripartum care in specialist pediatric cardiac centers and improved neonatal survival. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- F Kunde
- Fetal Cardiology Division, Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - S Thomas
- Fetal Cardiology Division, Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - A Sudhakar
- Fetal Cardiology Division, Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - R Kunjikutty
- Department of Obstetrics, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - R K Kumar
- Fetal Cardiology Division, Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - B Vaidyanathan
- Fetal Cardiology Division, Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
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Huisenga D, La Bastide‐Van Gemert S, Van Bergen A, Sweeney J, Hadders‐Algra M. Developmental outcomes after early surgery for complex congenital heart disease: a systematic review and meta-analysis. Dev Med Child Neurol 2021; 63:29-46. [PMID: 32149404 PMCID: PMC7754445 DOI: 10.1111/dmcn.14512] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2020] [Indexed: 01/25/2023]
Abstract
AIM (1) To systematically review the literature on developmental outcomes from infancy to adolescence of children with complex congenital heart disease (CHD) who underwent early surgery; (2) to run a meta-regression analysis on the Bayley Scales of Infant Development, Second Edition Mental Developmental Index and Psychomotor Developmental Index (PDI) of infants up to 24 months and IQs of preschool-aged children to adolescents; (3) to assess associations between perioperative risk factors and outcomes. METHOD We searched pertinent literature (January 1990 to January 2019) in PubMed, Embase, CINAHL, and PsycINFO. Selection criteria included infants with complex CHD who had primary surgery within the first 9 weeks of life. Methodological quality, including risk of bias and internal validity, were assessed. RESULTS In total, 185 papers met the inclusion criteria; the 100 with high to moderate methodological quality were analysed in detail. Substantial heterogeneity in the group with CHD and in methodology existed. The outcome of infants with single-ventricle CHD was inferior to those with two-ventricle CHD (respectively: average scores for PDI 77 and 88; intelligence scores 92 and 98). Perioperative risk factors were inconsistently associated with developmental outcomes. INTERPRETATION The literature on children undergoing surgery in early infancy suggests that infants with a single ventricle are at highest risk of adverse developmental outcomes.
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Affiliation(s)
- Darlene Huisenga
- Department of Pediatric Rehabilitation and DevelopmentAdvocate Children’s HospitalOak LawnILUSA,University of GroningenUniversity Medical Center GroningenDepartment of PaediatricsDivision of Developmental NeurologyGroningenthe Netherlands
| | - Sacha La Bastide‐Van Gemert
- University of GroningenUniversity Medical Center GroningenDepartment of EpidemiologyGroningenthe Netherlands
| | - Andrew Van Bergen
- Department of Pediatric Rehabilitation and DevelopmentAdvocate Children’s HospitalOak LawnILUSA,Advocate Children’s Heart Institute Division of Pediatric Cardiac Critical CareAdvocate Children’s HospitalOak LawnILUSA
| | - Jane Sweeney
- Pediatric Science Doctoral ProgramRocky Mountain University of Health ProfessionsProvoUTUSA
| | - Mijna Hadders‐Algra
- University of GroningenUniversity Medical Center GroningenDepartment of PaediatricsDivision of Developmental NeurologyGroningenthe Netherlands
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Bolduc ME, Dionne E, Gagnon I, Rennick JE, Majnemer A, Brossard-Racine M. Motor Impairment in Children With Congenital Heart Defects: A Systematic Review. Pediatrics 2020; 146:peds.2020-0083. [PMID: 33208496 DOI: 10.1542/peds.2020-0083] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/23/2020] [Indexed: 11/24/2022] Open
Abstract
CONTEXT With improvements in survival rates in newborns with congenital heart defects (CHDs), focus has now shifted toward enhancing neurodevelopmental outcomes across their life span. OBJECTIVE To systematically review the prevalence and extent of motor difficulties in infants, children, and adolescents with CHD requiring open-heart surgery. DATA SOURCES Data sources included Embase, Medline and the Cumulative Index to Nursing and Allied Health Literature. STUDY SELECTION Original studies published between 1997 and 2019 examining gross and/or fine motor skills in children born with a CHD requiring open-heart surgery were selected. DATA EXTRACTION The prevalence of motor impairments and mean scores on standardized motor assessments were extracted. Findings were grouped in 5 categories on the basis of the age of the children. RESULTS Forty-six original studies were included in this systematic review. The prevalence of mild to severe motor impairments (scores <-1 SD below normative data or controls) across childhood ranged from 12.3% to 68.6%, and prevalence ranged from 0% to 60.0% for severe motor impairments (<-2 SDs). Although our results suggest that the overall prevalence of motor impairments <-1 SD remains rather constant across childhood and adolescence, severe motor impairments (<-2 SDs) appear to be more prevalent in younger children. LIMITATIONS Variability in sampling and methodology between the reviewed studies is the most important limitation of this review. CONCLUSIONS The results of this review highlight that infants with CHD have an increased risk of motor impairments across infancy, childhood, and adolescence. These findings stress the importance of systematic screening or evaluation of motor skills across childhood and adolescence in children with CHD.
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Affiliation(s)
- Marie-Eve Bolduc
- School of Physical and Occupational Therapy.,Advances in Brain and Child Development Research Laboratory, The Research Institute of the McGill University Health Centre, Montreal, Canada; and
| | - Eliane Dionne
- School of Physical and Occupational Therapy.,Advances in Brain and Child Development Research Laboratory, The Research Institute of the McGill University Health Centre, Montreal, Canada; and
| | | | - Janet E Rennick
- Ingram School of Nursing, and.,Departments of Pediatrics and.,Department of Nursing, Montreal Children's Hospital, McGill University Health Centre, Montreal, Canada
| | - Annette Majnemer
- School of Physical and Occupational Therapy.,Departments of Pediatrics and.,Neurology and Neurosurgery, McGill University, Montreal, Canada
| | - Marie Brossard-Racine
- School of Physical and Occupational Therapy, .,Departments of Pediatrics and.,Neurology and Neurosurgery, McGill University, Montreal, Canada.,Advances in Brain and Child Development Research Laboratory, The Research Institute of the McGill University Health Centre, Montreal, Canada; and
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Bravo-Valenzuela NJ, Peixoto AB, Araujo Júnior E. Prenatal diagnosis of transposition of the great arteries: an updated review. Ultrasonography 2020; 39:331-339. [PMID: 32660209 PMCID: PMC7515665 DOI: 10.14366/usg.20055] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 06/08/2020] [Indexed: 11/25/2022] Open
Abstract
Simple transposition of the great arteries (TGA) is a cyanotic heart disease that accounts for 5% to 7% of all congenital heart diseases. It is commonly underdiagnosed in utero, with prenatal detection rates of less than 50%. Simple TGA is characterized by ventriculoarterial discordance, atrioventricular concordance, and a parallel relationship of TGA. The prenatal diagnosis of TGA influences postnatal outcomes and therefore requires planned delivery and perinatal management. For these reasons, it is important to identify the key ultrasound markers of TGA to improve the prenatal diagnosis and consequently provide perinatal assistance. The presence of two vessels instead of three in the three-vessel tracheal view, a parallel course of TGA, and identification of the origin of each of TGA are the key markers for diagnosing TGA. In addition to the classical ultrasound signs, other two-dimensional ultrasound markers such as an abnormal right convexity of the aorta, an I-shaped aorta, and the "boomerang sign" may also be used to diagnose TGA in the prenatal period. When accessible, an automatic approach using four-dimensional technologies such as spatio-temporal image correlation and sonographically-based volume computer-aided analysis may improve the prenatal diagnosis of TGA. This study aimed to review the ultrasound markers that can be used in the antenatal diagnosis of TGA, with a focus on the tools used by ultrasonographers, the obstetric and fetal medicine team, and perinatal cardiologists to improve the diagnosis of this condition.
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Affiliation(s)
- Nathalie Jeanne Bravo-Valenzuela
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil.,Department of Pediatrics, Pediatric Cardiology, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Alberto Borges Peixoto
- Mário Palmério University Hospital, University of Uberaba (UNIUBE), Uberaba, Brazil.,Department of Obstetrics and Gynecology, Federal University of Triângulo Mineiro (UFTM), Uberaba, Brazil
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
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Abstract
OBJECTIVE To evaluate delivery management and outcomes in fetuses prenatally diagnosed with CHD. STUDY DESIGN A retrospective cohort study was conducted on 6194 fetuses (born between 2013 and 2016), comparing prenatally diagnosed with CHD (170) to those with non-cardiac (234) and no anomalies (5790). Primary outcomes included the incidence of preterm delivery and mode of delivery. RESULTS Gestational age at delivery was significantly lower between the CHD and non-anomalous cohorts (38.6 and 39.1 weeks, respectively). Neonates with CHD had a significantly lower birth weights (p < 0.001). There was an approximately 1.5-fold increase in the rate of primary cesarean sections associated with prenatally diagnosed CHD with an odds ratio of 1.49 (95% CI 1.06-2.10). CONCLUSIONS Our study provides additional evidence that the prenatal diagnosis of CHD is associated with a lower birth weight, preterm delivery, and with an increased risk of delivery by primary cesarean section.
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O'Byrne ML, Glatz AC, Song L, Griffis HM, Millenson ME, Gillespie MJ, Dori Y, DeWitt AG, Mascio CE, Rome JJ. Association Between Variation in Preoperative Care Before Arterial Switch Operation and Outcomes in Patients With Transposition of the Great Arteries. Circulation 2019; 138:2119-2129. [PMID: 30474422 DOI: 10.1161/circulationaha.118.036145] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The arterial switch operation (ASO) is the gold standard operative correction of neonates with transposition of the great arteries and intact ventricular septum, with excellent operative survival. The associations between patient and surgeon characteristics and outcomes are well understood, but the associations between variation in preoperative care and outcomes are less well studied. METHODS A multicenter retrospective cohort study of infants undergoing neonatal ASO between January 2010 and September 2015 at hospitals contributing data to the Pediatric Health Information Systems database was performed. The association between preoperative care (timing of ASO, preoperative use of balloon atrial septostomy, prostaglandin infusion, mechanical ventilation, and vasoactive agents) and operative outcomes (mortality, length of stay, and cost) was studied with multivariable mixed-effects models. RESULTS Over the study period, 2159 neonates at 40 hospitals were evaluated. Perioperative mortality was 2.8%. Between hospitals, the use of adjuvant therapies and timing of ASO varied broadly. At the subject level, older age at ASO was associated with higher mortality risk (age >6 days: odds ratio, 1.90; 95% CI, 1.11-3.26; P=0.02), cost, and length of stay. Receipt of a balloon atrial septostomy was associated with lower mortality risk (odds ratio, 0.32; 95% CI, 0.17-0.59; P<0.001), cost, and length of stay. Later hospital median age at ASO was associated with higher odds of mortality (odds ratio, 1.15 per day; 95% CI, 1.02-1.29; P=0.03), longer length of stay ( P<0.004), and higher cost ( P<0.001). Other hospital factors were not independently associated with the outcomes of interest. CONCLUSIONS There was significant variation in preoperative care between hospitals. Some potentially modifiable aspects of perioperative care (timing of ASO and septostomy) were significantly associated with mortality, length of stay, and cost. Further research on the perioperative care of neonates is necessary to determine whether modifying practice on the basis of the observed associations translates into improved outcomes.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology (M.L.O., A.C.G., M.J.G., Y.D., J.J.R.), The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania.,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, PA (M.L.O., A.C.G., L.S., H.M.G., M.E.M.).,Leonard Davis Institute University of Pennsylvania, Philadelphia (M.L.O.).,Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania, Philadelphia (M.L.O.)
| | - Andrew C Glatz
- Division of Cardiology (M.L.O., A.C.G., M.J.G., Y.D., J.J.R.), The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania.,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, PA (M.L.O., A.C.G., L.S., H.M.G., M.E.M.)
| | - Lihai Song
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, PA (M.L.O., A.C.G., L.S., H.M.G., M.E.M.)
| | - Heather M Griffis
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, PA (M.L.O., A.C.G., L.S., H.M.G., M.E.M.)
| | - Marisa E Millenson
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, PA (M.L.O., A.C.G., L.S., H.M.G., M.E.M.)
| | - Matthew J Gillespie
- Division of Cardiology (M.L.O., A.C.G., M.J.G., Y.D., J.J.R.), The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania
| | - Yoav Dori
- Division of Cardiology (M.L.O., A.C.G., M.J.G., Y.D., J.J.R.), The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania
| | - Aaron G DeWitt
- Division of Cardiac Critical Care Medicine (A.G.D.), The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery (C.E.M.), The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania
| | - Jonathan J Rome
- Division of Cardiology (M.L.O., A.C.G., M.J.G., Y.D., J.J.R.), The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania
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11
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Sarin K, Chauhan S, Bisoi AK, Hazarika A, Malhotra N, Manek P. Use of autologous umbilical cord blood transfusion in neonates undergoing surgical correction of congenital cardiac defects: A pilot study. Ann Card Anaesth 2019; 21:270-274. [PMID: 30052213 PMCID: PMC6078044 DOI: 10.4103/aca.aca_194_17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Blood transfusion requirement during neonatal open heart surgeries is universal. Homologous blood transfusion (HBT) in pediatric cardiac surgery is used most commonly for priming of cardiopulmonary bypass (CPB) system and for postoperative transfusion. To avoid the risks associated with HBT in neonates undergoing cardiac surgery, use of autologous umbilical cord blood (AUCB) transfusion has been described. We present our experience with the use of AUCB for neonatal cardiac surgery. Designs and Methods Consecutive neonates scheduled to undergo cardiac surgery for various cardiac diseases who had a prenatal diagnosis made on the basis of a fetal echocardiography were included in this prospective observational study. After a vaginal delivery or a cesarean section, UCB was collected from the placenta in a 150-mL bag containing 5 mL of citrate-phosphate-dextrose-adenine-1 solution. The collected bag with 70-75 mL cord blood was stored at 2°C-6°C and tested for blood grouping and infections after proper labeling. The neonate's autologous cord blood was used for postcardiac surgery blood transfusion to replace postoperative blood loss. Results AUCB has been used so far at our institute in 10 neonates undergoing cardiac surgery. The donor exposure in age and type of cardiac surgery-matched controls showed that the neonates not receiving autologous cord blood had a donor exposure to 5 donors (2 packed red blood cells [PRBCs], including 1 for CPB prime and 1 for postoperative loss, 1 fresh frozen plasma, 1 cryoprecipitate, and 1 platelet concentrate) compared to 1 donor for the AUCB neonate (1 PRBC for the CPB prime). Postoperative blood loss was similar in both the groups of matched controls and study group. Values of hemoglobin, total leukocyte count, platelet counts, and blood gas parameters were also similar. Conclusions Use of AUCB for replacement of postoperative blood loss after neonatal cardiac surgery is feasible and reduces donor exposure to the neonate. Its use, however, requires a prenatal diagnosis of a cardiac defect by fetal echo and adequate logistic and psychological support from involved clinicians and the blood bank.
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Affiliation(s)
- Kunal Sarin
- Department of Cardiac Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Chauhan
- Department of Cardiac Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Akshay Kumar Bisoi
- Department of CTVS, All India Institute of Medical Sciences, New Delhi, India
| | - Anjali Hazarika
- CN Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Neena Malhotra
- Department of Gynecology and Obstetrics, All India Institute of Medical Sciences, New Delhi, India
| | - Pratik Manek
- Department of CTVS, All India Institute of Medical Sciences, New Delhi, India
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12
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Solomon RS, Sasi T, Sudhakar A, Kumar RK, Vaidyanathan B. Early Neurodevelopmental Outcomes After Corrective Cardiac Surgery In Infants. Indian Pediatr 2018. [DOI: 10.1007/s13312-018-1281-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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13
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Wolter A, Holtmann H, Kawecki A, Degenhardt J, Enzensberger C, Graupner O, Akintürk H, Yerebakan C, Khalil M, Schranz D, Axt-Fliedner R. Perinatal outcomes of congenital heart disease after emergent neonatal cardiac procedures. J Matern Fetal Neonatal Med 2017; 31:2709-2716. [PMID: 28693354 DOI: 10.1080/14767058.2017.1353970] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE We compared outcome of neonates with prenatal and post-natal diagnosis of congenital heart disease presenting in our paediatric heart centre between March 2005 and May 2015 who underwent an emergent intervention within 48 h post-partum. MATERIALS AND METHODS In 52/111 (46.8%) with emergent intervention, congenital heart disease was diagnosed prenatally, in 59/111 (53.2%) with no specialized foetal echocardiography, diagnosis was made post-natally. In 98/111 (88.2%), 30-day outcome was known. RESULTS Regarding the entire cohort, 30-day survival did not differ significantly in prenatal and post-natal diagnosis group (71.2 vs. 72.9%; p > .1). Infants with prenatal diagnosis were more likely to be born by caesarean section (59.6% vs. 33.9%, p = .01). Those with post-natal diagnosis had a higher need for intubation (32.7% vs. 52.5%; p < .05). Subgroup analysis of HLH/HLHC (hypoplastic left heart/hypoplastic left heart complex) patients revealed higher number of deaths within 30 days of life in the post-natal diagnosis group, although the difference did not reach statistical significance (5/7, 71.4% vs. 5/20, 25.0%; p = .075). CONCLUSION For newborns who require emergent neonatal cardiac procedures, our results point towards a lower death rate after prenatal diagnosis of HLH/HLHC.
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Affiliation(s)
- Aline Wolter
- a Department of OB/GYN , University Hospital UKGM, Justus-Liebig University, Division of Prenatal Medicine , Giessen , Germany
| | - Helene Holtmann
- a Department of OB/GYN , University Hospital UKGM, Justus-Liebig University, Division of Prenatal Medicine , Giessen , Germany
| | - Andreea Kawecki
- a Department of OB/GYN , University Hospital UKGM, Justus-Liebig University, Division of Prenatal Medicine , Giessen , Germany
| | - Jan Degenhardt
- a Department of OB/GYN , University Hospital UKGM, Justus-Liebig University, Division of Prenatal Medicine , Giessen , Germany
| | - Christian Enzensberger
- a Department of OB/GYN , University Hospital UKGM, Justus-Liebig University, Division of Prenatal Medicine , Giessen , Germany
| | - Oliver Graupner
- b Department of OB/GYN , University Hospital, Klinikum Rechts der Isar, Technische Universität , München , Germany
| | - Hakan Akintürk
- c Pediatric Heart Center, University Hospital UKGM, Justus-Liebig University , Division of Pediatric Heart Surgery , Giessen , Germany
| | - Can Yerebakan
- c Pediatric Heart Center, University Hospital UKGM, Justus-Liebig University , Division of Pediatric Heart Surgery , Giessen , Germany
| | - Markus Khalil
- d Pediatric Heart Center, University Hospital UKGM, Justus-Liebig University , Division of Pediatric Cardiology , Giessen , Germany
| | - Dietmar Schranz
- d Pediatric Heart Center, University Hospital UKGM, Justus-Liebig University , Division of Pediatric Cardiology , Giessen , Germany
| | - Roland Axt-Fliedner
- a Department of OB/GYN , University Hospital UKGM, Justus-Liebig University, Division of Prenatal Medicine , Giessen , Germany
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14
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Schidlow DN, Jenkins KJ, Gauvreau K, Croti UA, Giang DTC, Konda RK, Novick WM, Sandoval NF, Castañeda A. Transposition of the Great Arteries in the Developing World: Surgery and Outcomes. J Am Coll Cardiol 2017; 69:43-51. [PMID: 28057249 DOI: 10.1016/j.jacc.2016.10.051] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 09/01/2016] [Accepted: 10/04/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Little has been published regarding surgery for transposition of the great arteries (TGA) in the developing world. OBJECTIVES This study sought to identify patient characteristics, surgical interventions, institutional characteristics, risk factors for mortality, and outcomes among patients undergoing surgery for TGA in this setting. METHODS Developing world congenital heart surgical programs submitted de-identified data to a novel international collaborative database as part of a quality improvement project. We conducted a retrospective cohort study that included all cases of TGA with intact ventricular septum and TGA with ventricular septal defect performed from 2010 to 2013. Demographic, surgical, and institutional characteristics and their associations with in-hospital mortality were identified. RESULTS There were 778 TGA operations performed at 26 centers, 480 (62%) for TGA with intact ventricular septum and 298 (38%) for TGA with ventricular septal defect. Most (80%) were single-stage arterial switch operations, but 20% were atrial baffling procedures (atrial switch operation) or 2-stage repairs (pulmonary artery band followed by arterial switch operation). Age at operation was >30 days in one-half of the cases and did not vary significantly with operation type. Survival was 85% and did not significantly vary with age at operation or operation type. Preceding septostomy was infrequently reported (16%) and was not associated with surgical mortality. Mortality was associated with lower World Health Organization weight/body mass index-for-age percentile and lower institutional volume of TGA repair. CONCLUSIONS Surgical repair of TGA performed in the developing world is associated with an early survival of 85%. Type of surgical repair and age at operation varied considerably, but no associations with mortality were identified. In contrast, poor nutrition and small surgical volume were most strongly associated with mortality. Multicenter collaborative quality improvement efforts may benefit patients with TGA in the developing world.
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Affiliation(s)
- David N Schidlow
- Children's National Heart Institute, Children's National Medical Center, George Washington University, Washington, DC.
| | - Kathy J Jenkins
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Ulisses A Croti
- Hospital da Criança e Maternidade de São José do Rio Preto, São José do Rio Preto, Brazil
| | | | | | - William M Novick
- Department of Surgery, University of Tennessee Health Science Center and William Novick Global Cardiac Alliance, Memphis, Tennessee
| | | | - Aldo Castañeda
- UNICAR and the Fundación Aldo Castañeda, Guatemala City, Guatemala
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15
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Clinical guidelines for the management of patients with transposition of the great arteries with intact ventricular septum. Cardiol Young 2017; 27:530-569. [PMID: 28249633 DOI: 10.1017/s1047951117000014] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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16
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Sarris GE, Balmer C, Bonou P, Comas JV, da Cruz E, Chiara LD, Di Donato RM, Fragata J, Jokinen TE, Kirvassilis G, Lytrivi I, Milojevic M, Sharland G, Siepe M, Stein J, Büchel EV, Vouhé PR. Clinical guidelines for the management of patients with transposition of the great arteries with intact ventricular septum. Eur J Cardiothorac Surg 2017; 51:e1-e32. [DOI: 10.1093/ejcts/ezw360] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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17
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Domínguez-Manzano P, Herraiz I, Mendoza A, Aguilar JM, Escribano D, Toral B, Gómez-Montes E, Galindo A. Impact of prenatal diagnosis of transposition of the great arteries on postnatal outcome. J Matern Fetal Neonatal Med 2016; 30:2858-2863. [DOI: 10.1080/14767058.2016.1265934] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- P. Domínguez-Manzano
- Department of Pediatrics, Pediatric Heart Institute, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - I. Herraiz
- Department of Obstetrics and Gynaecology, Fetal Medicine Unit, Hospital Universitario 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | - A. Mendoza
- Department of Pediatrics, Pediatric Heart Institute, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - J. M. Aguilar
- Department of Pediatrics, Pediatric Heart Institute, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - D. Escribano
- Department of Obstetrics and Gynaecology, Fetal Medicine Unit, Hospital Universitario 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | - B. Toral
- Department of Pediatrics, Pediatric Heart Institute, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - E. Gómez-Montes
- Department of Obstetrics and Gynaecology, Fetal Medicine Unit, Hospital Universitario 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | - A. Galindo
- Department of Obstetrics and Gynaecology, Fetal Medicine Unit, Hospital Universitario 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, Spain
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18
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Lara DA, Fixler DE, Ethen MK, Canfield MA, Nembhard WN, Morris SA. Prenatal diagnosis, hospital characteristics, and mortality in transposition of the great arteries. ACTA ACUST UNITED AC 2016; 106:739-48. [PMID: 27296724 DOI: 10.1002/bdra.23525] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 04/21/2016] [Accepted: 04/28/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND The role of prenatal diagnosis in reducing neonatal mortality from transposition of the great arteries (TGA) is controversial. Factors affected by prenatal diagnosis such as proximity at birth to a cardiac surgical center (CSC) and CSC volume are associated with mortality in congenital heart disease. The purpose of the study was to determine the associations between prenatal diagnosis, distance from birthplace to a CSC, CSC TGA volume, and neonatal mortality in patients with TGA. METHODS The Texas Birth Defects Registry was queried for all live born infants with TGA from 1999 to 2007. Four hundred sixty-eight cases of TGA were included. RESULTS Forty-eight patients (10.3%) were prenatally diagnosed, and 20 patients died before age 28 days (4.3%). Neither prenatal diagnosis nor close proximity to a CSC at birth (p > 0.05) were associated with decreased mortality. Low CSC TGA volume was associated with increased mortality (p < 0.0002). Mortality at the CSCs with <5 patients per year was 9.6%; CSCs with 5 to 10 patients per year had 0% mortality, and those with >10 patients per year had 2.3% mortality. In multivariable logistic regression, only preterm birth (odds ratio, 7.05; 95% confidence interval, 4.13-12.05) and lower CSC volume (p < 0.001) were associated with neonatal mortality, although prenatal diagnosis attenuated the detrimental association of lower volume CSCs with higher mortality (p for interaction = 0.047). CONCLUSION Lower CSC TGA patient volume was associated with higher neonatal mortality. Prenatal diagnosis may improve survival in lower volume CSCs. Birth Defects Research (Part A) 106:739-748, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Diego A Lara
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas.
| | - David E Fixler
- Department of Pediatrics, UT Southwestern Medical School, Dallas, Texas
| | - Mary K Ethen
- Birth Defects Epidemiology and Surveillance Branch, Texas Department of State Health Services, Austin, Texas
| | - Mark A Canfield
- Birth Defects Epidemiology and Surveillance Branch, Texas Department of State Health Services, Austin, Texas
| | - Wendy N Nembhard
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital Research Institute, Little Rock, Arkansas
| | - Shaine A Morris
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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Peyvandi S, De Santiago V, Chakkarapani E, Chau V, Campbell A, Poskitt KJ, Xu D, Barkovich AJ, Miller S, McQuillen P. Association of Prenatal Diagnosis of Critical Congenital Heart Disease With Postnatal Brain Development and the Risk of Brain Injury. JAMA Pediatr 2016; 170:e154450. [PMID: 26902528 PMCID: PMC5083633 DOI: 10.1001/jamapediatrics.2015.4450] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE The relationship of prenatal diagnosis of critical congenital heart disease (CHD) with brain injury and brain development is unknown. Given limited improvement of CHD outcomes with prenatal diagnosis, the effect of prenatal diagnosis on brain health may reveal additional benefits. OBJECTIVE To compare the prevalence of preoperative and postoperative brain injury and the trajectory of brain development in neonates with prenatal vs postnatal diagnosis of CHD. DESIGN, SETTING, AND PARTICIPANTS Cohort study of term newborns with critical CHD recruited consecutively from 2001 to 2013 at the University of California, San Francisco and the University of British Columbia. Term newborns with critical CHD were studied with brain magnetic resonance imaging preoperatively and postoperatively to determine brain injury severity and microstructural brain development with diffusion tensor imaging by measuring fractional anisotropy and the apparent diffusion coefficient. Comparisons of magnetic resonance imaging findings and clinical variables were made between prenatal and postnatal diagnosis of critical CHD. A total of 153 patients with transposition of the great arteries and single ventricle physiology were included in this analysis. MAIN OUTCOMES AND MEASURES The presence of brain injury on the preoperative brain magnetic resonance imaging and the trajectory of postnatal brain microstructural development. RESULTS Among 153 patients (67% male), 96 had transposition of the great arteries and 57 had single ventricle physiology. The presence of brain injury was significantly higher in patients with postnatal diagnosis of critical CHD (41 of 86 [48%]) than in those with prenatal diagnosis (16 of 67 [24%]) (P = .003). Patients with prenatal diagnosis demonstrated faster brain development in white matter fractional anisotropy (rate of increase, 2.2%; 95% CI, 0.1%-4.2%; P = .04) and gray matter apparent diffusion coefficient (rate of decrease, 0.6%; 95% CI, 0.1%-1.2%; P = .02). Patients with prenatal diagnosis had lower birth weight (mean, 3184.5 g; 95% CI, 3050.3-3318.6) than those with postnatal diagnosis (mean, 3397.6 g; 95% CI, 3277.6-3517.6) (P = .02). Those with prenatal diagnosis had an earlier estimated gestational age at delivery (mean, 38.6 weeks; 95% CI, 38.2-38.9) than those with postnatal diagnosis (mean, 39.1 weeks; 95% CI, 38.8-39.5) (P = .03). CONCLUSIONS AND RELEVANCE Newborns with prenatal diagnosis of single ventricle physiology and transposition of the great arteries demonstrate less preoperative brain injury and more robust microstructural brain development than those with postnatal diagnosis. These results are likely secondary to improved cardiovascular stability. The impact of these findings on neurodevelopmental outcomes warrants further study.
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Affiliation(s)
- Shabnam Peyvandi
- Department of Pediatrics, University of California, San Francisco, Benioff Children’s Hospital, San Francisco
| | - Veronica De Santiago
- Department of Pediatrics, University of California, San Francisco, Benioff Children’s Hospital, San Francisco
| | - Elavazhagan Chakkarapani
- School of Clinical Sciences, University of Bristol and St Michael’s Hospital, Bristol, England3Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Vann Chau
- Department of Pediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Andrew Campbell
- Department of Pediatric Cardiovascular and Thoracic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kenneth J. Poskitt
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Duan Xu
- Department of Radiology, University of California, San Francisco, Benioff Children’s Hospital, San Francisco
| | - A. James Barkovich
- Department of Radiology, University of California, San Francisco, Benioff Children’s Hospital, San Francisco
| | - Steven Miller
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada4Department of Pediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Patrick McQuillen
- Department of Pediatrics, University of California, San Francisco, Benioff Children’s Hospital, San Francisco8Department of Neurology, University of California, San Francisco, Benioff Children’s Hospital, San Francisco
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Palatnik A, Gotteiner NL, Grobman WA, Cohen LS. Is the "I-Sign" in the 3-Vessel and Trachea View a Valid Tool for Prenatal Diagnosis of D-Transposition of the Great Arteries? JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:1329-1335. [PMID: 26112638 DOI: 10.7863/ultra.34.7.1329] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Prenatal diagnosis of D-transposition of the great arteries remains less frequent compared to other major congenital heart defects. In this study, we examined how often the 3-vessel and trachea view was abnormal in a large series of prenatally diagnosed cases of D-transposition of the great arteries. We found that an abnormal 3-vessel and trachea view in the shape of an "I" ("I-sign"), which represents an anteriorly displaced aorta, was present in all fetuses with D-transposition of the great arteries when a 3-vessel and trachea view was successfully obtained. Therefore we believe that the 3-vessel and trachea view can be used to reliably detect D-transposition of the great arteries during prenatal sonography.
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Affiliation(s)
- Anna Palatnik
- Departments of Obstetrics and Gynecology (A.P., W.A.G., L.S.C.) and Pediatrics (N.L.G.), Northwestern University, Feinberg School of Medicine, Chicago, Illinois USA.
| | - Nina L Gotteiner
- Departments of Obstetrics and Gynecology (A.P., W.A.G., L.S.C.) and Pediatrics (N.L.G.), Northwestern University, Feinberg School of Medicine, Chicago, Illinois USA
| | - William A Grobman
- Departments of Obstetrics and Gynecology (A.P., W.A.G., L.S.C.) and Pediatrics (N.L.G.), Northwestern University, Feinberg School of Medicine, Chicago, Illinois USA
| | - Leeber S Cohen
- Departments of Obstetrics and Gynecology (A.P., W.A.G., L.S.C.) and Pediatrics (N.L.G.), Northwestern University, Feinberg School of Medicine, Chicago, Illinois USA
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21
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Escobar-Diaz MC, Freud LR, Bueno A, Brown DW, Friedman K, Schidlow D, Emani S, del Nido P, Tworetzky W. Prenatal diagnosis of transposition of the great arteries over a 20-year period: improved but imperfect. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:678-682. [PMID: 25484180 PMCID: PMC4452393 DOI: 10.1002/uog.14751] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 11/13/2014] [Accepted: 11/24/2014] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To evaluate temporal trends in the prenatal diagnosis of transposition of the great arteries with intact ventricular septum (TGA/IVS) and its impact on neonatal morbidity and mortality. METHODS We included in this study cohort newborns with TGA/IVS who were referred for surgical management to our center over a 20-year period (1992-2011). The study period was divided into five 4-year periods and the primary outcome was rate of prenatal diagnosis. Secondary outcomes included neonatal preoperative status and perioperative survival. RESULTS Of the 340 patients with TGA/IVS, 81 (23.8%) had a prenatal diagnosis. The rate of prenatal diagnosis increased over the study period, from 6% in 1992-1995 to 41% in 2008-2011 (P < 0.001). Compared to patients with a postnatal diagnosis, balloon atrial septostomy (BAS) was performed earlier in patients with a prenatal diagnosis (0 days after delivery vs 1 day after delivery, respectively; P < 0.001) and fewer prenatally diagnosed neonates required mechanical ventilation (55.6% vs 68.0%; P = 0.03). Between patients with a prenatal or postnatal diagnosis of TGA/IVS, there were no statistically significant differences in the incidence of preoperative acidosis (16.0% vs 25.5%; P = 0.1), need for preoperative extracorporeal membrane oxygenation (2.5% vs 2.7%; P = 1.0) or mortality (one preoperative and no postoperative deaths among prenatally diagnosed patients compared with four preoperative and six postoperative deaths among postnatally diagnosed patients). CONCLUSIONS The prenatal detection rate of TGA/IVS has improved but still remains below 50%, suggesting the need for strategies to increase detection rates. The mortality rate was not statistically significantly different between prenatally and postnatally diagnosed patients, however, there were significant preoperative differences with regard to earlier BAS and fewer neonates that required mechanical ventilation. Ongoing work is required to ascertain whether prenatal diagnosis confers long-term benefits.
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Affiliation(s)
- Maria C Escobar-Diaz
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Lindsay R Freud
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Alejandra Bueno
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - David W Brown
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Kevin Friedman
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - David Schidlow
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Massachusetts
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Pedro del Nido
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Massachusetts
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Holland BJ, Myers JA, Woods CR. Prenatal diagnosis of critical congenital heart disease reduces risk of death from cardiovascular compromise prior to planned neonatal cardiac surgery: a meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:631-8. [PMID: 25904437 DOI: 10.1002/uog.14882] [Citation(s) in RCA: 167] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 04/17/2015] [Accepted: 04/19/2015] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To determine if prenatal diagnosis improves the chance that a newborn with critical congenital heart disease will survive to undergo planned cardiac surgery. METHODS A systematic review of the medical literature identified eight studies which met the following criteria: compared outcomes between newborns with prenatal and those with postnatal diagnosis of critical congenital heart disease; compared groups of patients with the same anatomical diagnosis; provided detailed information on cardiac anatomy; included detailed information on preoperative cause of death. A meta-analysis was performed to assess differences in preoperative mortality rates between newborns with prenatal diagnosis and those with postnatal diagnosis. Patients with established risk factors for increased mortality (high risk) and those whose families chose comfort care rather than cardiac surgery were excluded. RESULTS In patients with comparable anatomy, standard risk, a parental desire to treat and optimal care, newborns with a prenatal diagnosis of critical congenital heart disease were significantly less likely to die prior to planned cardiac surgery than were those with a comparable postnatal diagnosis (pooled odds ratio, 0.26; 95% CI, 0.08-0.84). CONCLUSIONS For newborns most likely to benefit from treatment for their critical congenital heart disease, because they did not have additional risk factors and their families pursued treatment, prenatal diagnosis reduced the risk of death prior to planned cardiac surgery relative to patients with a comparable postnatal diagnosis. Further study and efforts to improve prenatal diagnosis of congenital heart disease should therefore be considered.
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Affiliation(s)
- B J Holland
- Division of Pediatric Cardiology, Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY, USA
| | - J A Myers
- Child and Adolescent Health Research and Design Support Unit, Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY, USA
| | - C R Woods
- Child and Adolescent Health Research and Design Support Unit, Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY, USA
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van Velzen CL, Haak MC, Reijnders G, Rijlaarsdam MEB, Bax CJ, Pajkrt E, Hruda J, Galindo-Garre F, Bilardo CM, de Groot CJM, Blom NA, Clur SA. Prenatal detection of transposition of the great arteries reduces mortality and morbidity. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:320-325. [PMID: 25297053 DOI: 10.1002/uog.14689] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 09/30/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To evaluate the prenatal detection of transposition of the great arteries (TGA), after the introduction of a Dutch screening program in 2007, as well as the effect of prenatal detection on pre- and postsurgical mortality and morbidity. METHODS In a geographical cohort study, all infants with TGA who were born between 1 January 2002 and 1 January 2012 were included. The cases were divided into two groups: those with and those without a prenatal diagnosis. Pre- and postsurgical mortality was assessed, with a follow-up of 1 year. Presurgical morbidity was assessed in terms of cardiovascular compromise, metabolic acidosis, renal and/or hepatic dysfunction and closure of the duct before initiation of therapy. RESULTS Of all cases (n = 144), 26.4% were diagnosed prenatally, with detection rates of 15.7% and 41.0% in the first and last 5 years of the study period, respectively. First-year mortality was significantly lower in cases with a prenatal diagnosis of TGA than in those without (0.0% vs 11.4%, respectively). Presurgical mortality (4.9%) only occurred in undetected simple TGA cases. Closure of the duct before treatment, renal dysfunction and hypoxia occurred significantly more often in the group without a prenatal diagnosis. CONCLUSIONS The prenatal detection rate of TGA has increased significantly since the introduction of the screening program in 2007. Prenatal diagnosis is an important factor that contributes to survival of the infant in the first postnatal year. Furthermore, some morbidity indicators were significantly higher in the group without a prenatal diagnosis. These results justify efforts to improve prenatal screening programs.
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Affiliation(s)
- C L van Velzen
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands
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Minimizing the risk of preoperative brain injury in neonates with aortic arch obstruction. J Pediatr 2014; 165:1116-1122.e3. [PMID: 25306190 PMCID: PMC4624274 DOI: 10.1016/j.jpeds.2014.08.066] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 06/19/2014] [Accepted: 08/28/2014] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To determine whether prenatal diagnosis lowers the risk of preoperative brain injury by assessing differences in the incidence of preoperative brain injury across centers. STUDY DESIGN From 2 prospective cohorts of newborns with complex congenital heart disease studied by preoperative cerebral magnetic resonance imaging, one cohort from the University Medical Center Utrecht (UMCU) and a combined cohort from the University of California San Francisco (UCSF) and University of British Columbia (UBC), patients with aortic arch obstruction were selected and their imaging and clinical course reviewed. RESULTS Birth characteristics were comparable between UMCU (n = 33) and UCSF/UBC (n = 54). Patients had a hypoplastic aortic arch with either coarctation/interruption or hypoplastic left heart syndrome. In subjects with prenatal diagnosis, there was a significant difference in the prevalence of white matter injury (WMI) between centers (11 of 22 [50%] at UMCU vs 4 of 30 [13%] at UCSF/UBC; P < .01). Prenatal diagnosis was protective for WMI at UCSF/UBC (13% prenatal diagnoses vs 50% postnatal diagnoses; P < .01), but not at UMCU (50% vs 46%, respectively; P > .99). Differences in clinical practice between prenatally diagnosed subjects at UMCU vs UCSF/UBC included older age at surgery, less time spent in the intensive care unit, greater use of diuretics, less use of total parenteral nutrition (P < .01), and a greater incidence of infections (P = .01). In patients diagnosed postnatally, the prevalence of WMI was similar in the 2 centers (46% at UMCU vs 50% at UCSF/UBC; P > .99). Stroke prevalence was similar in the 2 centers regardless of prenatal diagnosis (prenatal diagnosis: 4.5% at Utrecht vs 6.7% at UCSF/UBC, P = .75; postnatal diagnosis: 9.1% vs 13%, respectively, P > .99). CONCLUSION Prenatal diagnosis can be protective for WMI, but this protection may be dependent on specific clinical management practices that differ across centers.
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Abstract
PURPOSE OF REVIEW Fetal cardiology is a rapidly evolving field. Imaging technology continues to advance as do approaches to in-utero interventions and care of the critically ill neonate, with even greater demand for improvement in prenatal diagnosis of congenital heart disease (CHD) and arrhythmias. RECENT FINDINGS Reviewing the advances in prenatal diagnosis of CHD in such a rapidly developing field is a broad topic. Therefore, we have chosen to focus this review of recent literature on challenges in prenatal detection of CHD, challenges in prenatal counseling, advances in fetal arrhythmia diagnosis, and potential benefits to patients with CHD who are identified prenatally. SUMMARY As methods and tools to diagnose and manage CHD and arrhythmias in utero continue to improve, future generations will hopefully see a reduction in both prenatal and neonatal morbidity and mortality. Prenatal diagnosis can and should be used to optimize location and timing of delivery and postnatal interventions.
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Pruetz JD, Carroll C, Trento LU, Chang RK, Detterich J, Miller DA, Sklansky M. Outcomes of critical congenital heart disease requiring emergent neonatal cardiac intervention. Prenat Diagn 2014; 34:1127-32. [DOI: 10.1002/pd.4438] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 05/01/2014] [Accepted: 06/16/2014] [Indexed: 11/09/2022]
Affiliation(s)
- Jay D. Pruetz
- Division of Pediatric Cardiology; Children's Hospital Los Angeles; Los Angeles CA USA
- Keck School of Medicine; University of Southern California; Los Angeles CA USA
| | - Caitlin Carroll
- Keck School of Medicine; University of Southern California; Los Angeles CA USA
| | - Luca U. Trento
- Division of Pediatric Cardiology; Kaiser Permanente; Roseville CA USA
| | - Ruey-Kang Chang
- Division of Pediatric Cardiology; Harbor-UCLA Medical Center; Torrance CA USA
| | - Jon Detterich
- Division of Pediatric Cardiology; Children's Hospital Los Angeles; Los Angeles CA USA
- Keck School of Medicine; University of Southern California; Los Angeles CA USA
| | - David A. Miller
- Keck School of Medicine; University of Southern California; Los Angeles CA USA
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Keck School of Medicine; University of Southern California; Los Angeles CA USA
| | - Mark Sklansky
- Division of Pediatric Cardiology; David Geffen School of Medicine at UCLA; Los Angeles CA USA
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Costello JM, Pasquali SK, Jacobs JP, He X, Hill KD, Cooper DS, Backer CL, Jacobs ML. Gestational age at birth and outcomes after neonatal cardiac surgery: an analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database. Circulation 2014; 129:2511-7. [PMID: 24795388 DOI: 10.1161/circulationaha.113.005864] [Citation(s) in RCA: 146] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Gestational age at birth is a potentially important modifiable risk factor in neonates with congenital heart disease. We evaluated the relationship between gestational age and outcomes in a multicenter cohort of neonates undergoing cardiac surgery, focusing on those born at early term (ie, 37-38 weeks' gestation). METHODS AND RESULTS Neonates in the Society of Thoracic Surgeons Congenital Heart Surgery Database who underwent cardiac surgery between 2010 and 2011 were included. Multivariable logistic regression was used to evaluate the association of gestational age at birth with in-hospital mortality, postoperative length of stay, and complications, adjusting for other important patient characteristics. Of 4784 included neonates (92 hospitals), 48% were born before 39 weeks' gestation, including 31% at 37 to 38 weeks. Compared with a 39.5-week gestational age reference level, birth at 37 weeks' gestational age was associated with higher in-hospital mortality, with an adjusted odds ratio (95% confidence interval) of 1.34 (1.05-1.71; P=0.02). Complication rates were higher and postoperative length of stay was significantly prolonged for those born at 37 and 38 weeks' gestation (adjusted P<0.01 for all). Late-preterm births (34-36 weeks' gestation) also had greater mortality and postoperative length of stay (adjusted P≤0.003 for all). CONCLUSIONS Birth during the early term period of 37 to 38 weeks' gestation is associated with worse outcomes after neonatal cardiac surgery. These data challenge the commonly held perception that delivery at any time during term gestation is equally safe and appropriate and question the related practice of elective delivery of fetuses with complex congenital heart disease at early term.
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Affiliation(s)
- John M Costello
- From the Divisions of Pediatric Cardiology (J.M.C.) and Cardiovascular and Thoracic Surgery (C.L.B.), Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Pediatrics and Communicable Disease, University of Michigan C. S. Mott Children's Hospital, Ann Arbor, MI (S.K.P.); Department of Surgery, All Children's Hospital and John Hopkins University, Saint Petersburg, FL (J.P.J.); Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (X.H., K.D.H.); The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH (D.S.C.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (M.L.J.).
| | - Sara K Pasquali
- From the Divisions of Pediatric Cardiology (J.M.C.) and Cardiovascular and Thoracic Surgery (C.L.B.), Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Pediatrics and Communicable Disease, University of Michigan C. S. Mott Children's Hospital, Ann Arbor, MI (S.K.P.); Department of Surgery, All Children's Hospital and John Hopkins University, Saint Petersburg, FL (J.P.J.); Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (X.H., K.D.H.); The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH (D.S.C.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (M.L.J.)
| | - Jeffrey P Jacobs
- From the Divisions of Pediatric Cardiology (J.M.C.) and Cardiovascular and Thoracic Surgery (C.L.B.), Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Pediatrics and Communicable Disease, University of Michigan C. S. Mott Children's Hospital, Ann Arbor, MI (S.K.P.); Department of Surgery, All Children's Hospital and John Hopkins University, Saint Petersburg, FL (J.P.J.); Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (X.H., K.D.H.); The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH (D.S.C.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (M.L.J.)
| | - Xia He
- From the Divisions of Pediatric Cardiology (J.M.C.) and Cardiovascular and Thoracic Surgery (C.L.B.), Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Pediatrics and Communicable Disease, University of Michigan C. S. Mott Children's Hospital, Ann Arbor, MI (S.K.P.); Department of Surgery, All Children's Hospital and John Hopkins University, Saint Petersburg, FL (J.P.J.); Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (X.H., K.D.H.); The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH (D.S.C.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (M.L.J.)
| | - Kevin D Hill
- From the Divisions of Pediatric Cardiology (J.M.C.) and Cardiovascular and Thoracic Surgery (C.L.B.), Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Pediatrics and Communicable Disease, University of Michigan C. S. Mott Children's Hospital, Ann Arbor, MI (S.K.P.); Department of Surgery, All Children's Hospital and John Hopkins University, Saint Petersburg, FL (J.P.J.); Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (X.H., K.D.H.); The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH (D.S.C.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (M.L.J.)
| | - David S Cooper
- From the Divisions of Pediatric Cardiology (J.M.C.) and Cardiovascular and Thoracic Surgery (C.L.B.), Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Pediatrics and Communicable Disease, University of Michigan C. S. Mott Children's Hospital, Ann Arbor, MI (S.K.P.); Department of Surgery, All Children's Hospital and John Hopkins University, Saint Petersburg, FL (J.P.J.); Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (X.H., K.D.H.); The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH (D.S.C.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (M.L.J.)
| | - Carl L Backer
- From the Divisions of Pediatric Cardiology (J.M.C.) and Cardiovascular and Thoracic Surgery (C.L.B.), Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Pediatrics and Communicable Disease, University of Michigan C. S. Mott Children's Hospital, Ann Arbor, MI (S.K.P.); Department of Surgery, All Children's Hospital and John Hopkins University, Saint Petersburg, FL (J.P.J.); Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (X.H., K.D.H.); The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH (D.S.C.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (M.L.J.)
| | - Marshall L Jacobs
- From the Divisions of Pediatric Cardiology (J.M.C.) and Cardiovascular and Thoracic Surgery (C.L.B.), Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Pediatrics and Communicable Disease, University of Michigan C. S. Mott Children's Hospital, Ann Arbor, MI (S.K.P.); Department of Surgery, All Children's Hospital and John Hopkins University, Saint Petersburg, FL (J.P.J.); Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (X.H., K.D.H.); The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH (D.S.C.); Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD (M.L.J.)
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Wright LK, Ehrlich A, Stauffer N, Samai C, Kogon B, Oster ME. Relation of prenatal diagnosis with one-year survival rate for infants with congenital heart disease. Am J Cardiol 2014; 113:1041-4. [PMID: 24440326 DOI: 10.1016/j.amjcard.2013.11.065] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 11/18/2013] [Accepted: 11/18/2013] [Indexed: 11/26/2022]
Abstract
Prenatal diagnosis of congenital heart defects (CHDs) is increasingly common, but it is still unclear whether it translates to improved postoperative outcomes. We performed a retrospective cohort study of all infants (aged <1 year) who underwent surgery for CHDs from 2006 to 2011 at a single institution. Primary outcomes were in-hospital and 1-year mortality rates. Secondary outcomes were readmission within 30 days of discharge, postoperative length of intensive care unit and hospital stay, unplanned reoperation, and extracorporeal membrane oxygenation use. We used chi-square analyses, Wilcoxon rank-sum tests, Kaplan-Meier survival curves, and adjusted Cox proportional hazards models to compare outcomes. Of the 1,642 patients with CHDs, 539 (33%) were diagnosed prenatally. Patients with prenatal diagnoses were of a younger age and less weight at the time of surgery, had greater Risk Adjustment for Congenital Heart Surgery scores, and were more likely to be white, to have an identified syndrome, or to be born at term. Compared with those diagnosed postnatally, those diagnosed prenatally had a significantly higher unadjusted 1-year mortality rate (11% vs 5.5%, respectively, p = 0.03). Controlling for weight, surgical severity, race, age at surgery, prematurity, and the presence or absence of genetic syndrome, patients with prenatal diagnoses had significantly greater mortality at 1 year (adjusted hazard ratio 1.5, p = 0.03), as well as significantly longer intensive care unit and hospital stays. Infants with CHDs diagnosed prenatally had worse outcomes compared with those diagnosed postnatally. Prenatal diagnosis likely captures patients with more severe phenotypes within given surgical risk categories and even within diagnoses and thus may be an important prognostic factor when counseling families.
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Bertagna F, Rakza T, Vaksmann G, Ramdane-Sebbane N, Devisme L, Storme L, Francart C, Vaast P, Houfflin-Debarge V. Transposition of the great arteries: factors influencing prenatal diagnosis. Prenat Diagn 2014; 34:534-7. [PMID: 24532355 DOI: 10.1002/pd.4343] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Revised: 02/11/2014] [Accepted: 02/11/2014] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The objective of this study is to highlight the factors that may affect prenatal diagnosis of transposition of the great arteries (TGA) in order to improve it. METHODS This is a retrospective study performed between 2004 and 2009 in the maternity units from North of France. We identified a total of 68 cases of TGA (isolated or associated with only VSD or coarctation of aorta), of which 32 (47.1%) had prenatal diagnosis (PND+) and 36 did not (PND-). Maternal characteristics and ultrasound factors were studied in relation to PND. RESULTS Maternal weight and body mass index were significantly higher in the PND- group (70.4 kg and 26.5 kg/m(2) vs 63.6 kg and 23.6 kg/m(2) , respectively). Maternal obesity (body mass index >30) was significantly more frequent in the PND- group (27.8% vs 12.5%). More than a quarter of TGA (28.1%) were diagnosed during the third trimester. CONCLUSION Obesity is the main cause of missed PND of TGA. Obese patients with suboptimal prenatal scans may benefit from reassessment of fetal cardiac anatomy and/or from referral for fetal echocardiography.
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Affiliation(s)
- F Bertagna
- Department of Obstetrics, Jeanne de Flandre Hospital, CHU Lille, Lille, France
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30
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Costello JM, McQuillen PS, Claud EC, Steinhorn RH. Prematurity and congenital heart disease. World J Pediatr Congenit Heart Surg 2013; 2:457-67. [PMID: 23803997 DOI: 10.1177/2150135111408445] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Significant advances in technology and therapy have led to dramatic improvements in the survival of preterm babies over the last 2 decades. Similarly, improvements in surgical and cardiac intensive care techniques have increased the feasibility of supporting even very small babies to the point of surgical repair, leading some to adopt an approach of early and complete surgical repair in preterm infants, with the aim of minimizing potential preoperative morbidity associated with extended medical management or surgical palliation. (1,2) However, multiple diagnostic and therapeutic challenges complicate the care of premature infants. Major errors in echocardiography are more common in neonates weighing less than 2.5 kg, (3) and the ideal timing and type of surgical intervention in premature infants remains unknown. These problems are compounded by the need for critical care practices that optimize management of immature cardiopulmonary, gastrointestinal, and neurological systems. This review will summarize some of the recent advances in neonatal and perinatal medicine, which have the potential to contribute to improved management of preterm infants with critical cardiac disease.
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Affiliation(s)
- John M Costello
- Department of Pediatrics, Children's Memorial Hospital and Northwestern University, Chicago, IL, USA
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31
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Ishii Y, Inamura N, Kawazu Y, Kayatani F, Arakawa H. 'I-shaped' sign in the upper mediastinum: a novel potential marker for antenatal diagnosis of d-transposition of the great arteries. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 41:667-671. [PMID: 23023957 DOI: 10.1002/uog.12312] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/17/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To investigate the 'I-shaped' sign as a novel echocardiographic marker for antenatal diagnosis of d-transposition of the great arteries (dTGA) in routine cardiac examination, and to compare its prevalence in fetuses with dTGA, those with other congenital heart diseases (CHDs) and those with normal structural hearts. METHODS This retrospective evaluation involved 1134 fetuses undergoing echocardiography to screen for CHD over a 4-year period. I-shaped sign was defined as the characteristic appearance of the aortic arch, resembling the letter 'I', from the most anterior to the most posterior point of the descending aorta visible in the three vessels and trachea view. The frequency of this sign was evaluated in cases with dTGA, those with other cardiac defects and those with normal cardiac structures. RESULTS CHD was diagnosed in 671 (59.1%) cases, of which 31 (4.6%) had dTGA. I-shaped sign was observed in 30/31 (96.8%) cases of dTGA, compared with 31/640 (4.8%) cases with other cardiac anomalies, which included single ventricle with pulmonary atresia or severe pulmonary stenosis, hypoplastic left heart syndrome with aortic atresia, corrected transposition of the great arteries, and double outlet right ventricle with malposition of the great arteries. I-shaped sign was detected significantly more frequently in the dTGA group compared with the normal group and with the other CHDs group (both P < 0.001) and had 96.8% sensitivity and 97.1% specificity for diagnosis of dTGA. Importantly, I-shaped sign was never observed in fetuses with structurally normal hearts. CONCLUSIONS Detection on echocardiography of an extremely long vessel with a marked I-shape should raise suspicion of cardiac anomaly, especially dTGA. This marker may therefore aid in the prenatal diagnosis of dTGA during routine ultrasound examination.
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Affiliation(s)
- Y Ishii
- Department of Pediatric Cardiology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan.
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The impact of gestational age on resource utilization after open heart surgery for congenital cardiac disease from birth to 1 year of age. Pediatr Cardiol 2013; 34:686-93. [PMID: 23086189 DOI: 10.1007/s00246-012-0528-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Accepted: 09/12/2012] [Indexed: 10/27/2022]
Abstract
The impact of gestational age on perioperative morbidity was examined using a novel construct, the resource utilization index (RUI). The medical records of subjects from birth to 1 year of age entered into a pediatric cardiothoracic surgery database from a major academic medical center between 2007 and 2011 were reviewed. The hypothesis tested was that infants born at 37-38 weeks (early-term infants) experience greater resource utilization after open heart surgery than those born at 39 completed weeks and that this association can be observed until 1 year of age. The results support the premise that resource utilization increases linearly with declining gestational age among infants at 0-12 months who undergo cardiac surgery. Five of the six variables comprising the RUI showed statistically significant linear associations with gestational age in the predicted direction. Multivariate linear regression analysis showed that gestational age was a significant predictor of an increased RUI composite. Further investigation is needed to test the concept and to expand on these findings.
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Trento LU, Pruetz JD, Chang RK, Detterich J, Sklansky MS. Prenatal diagnosis of congenital heart disease: impact of mode of delivery on neonatal outcome. Prenat Diagn 2012; 32:1250-5. [DOI: 10.1002/pd.3991] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Luca U. Trento
- Division of Pediatric Cardiology; Kaiser Permanente; Roseville; CA; USA
| | - Jay D. Pruetz
- Division of Pediatric Cardiology; Children's Hospital Los Angeles; Los Angeles; CA; USA
| | - Ruey K. Chang
- Division of Pediatric Cardiology; Harbor-UCLA Medical Center; Torrance; CA; USA
| | - Jon Detterich
- Division of Pediatric Cardiology; Children's Hospital Los Angeles; Los Angeles; CA; USA
| | - Mark S. Sklansky
- Division of Pediatric Cardiology; David Geffen School of Medicine at UCLA; Los Angeles; CA; USA
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Calderon J, Angeard N, Moutier S, Plumet MH, Jambaqué I, Bonnet D. Impact of prenatal diagnosis on neurocognitive outcomes in children with transposition of the great arteries. J Pediatr 2012; 161:94-8.e1. [PMID: 22284567 DOI: 10.1016/j.jpeds.2011.12.036] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 11/11/2011] [Accepted: 12/20/2011] [Indexed: 10/14/2022]
Abstract
OBJECTIVES To assess the effect of prenatal diagnosis of congenital heart disease on neurocognitive outcomes in children with d-transposition of the great arteries (TGA) after surgical correction. STUDY DESIGN A prospective study of children born with a TGA between 2003 and 2005 and aged 4 to 6 years was conducted. General intelligence, language, executive functions, and social cognition scores and preoperative, intraoperative, and postoperative factors were evaluated according to time of TGA diagnosis. Neurocognitive data were also compared with a control group. RESULTS Forty-five eligible patients (67% male) were examined; 29 had a prenatal diagnosis of TGA and 16 did not. All children were comparable in age, sex, and demographic variables. Diagnostic groups did not differ in preoperative, intraoperative, and postoperative variables. Preoperative acidosis was more frequent in the postnatal group (18% versus 3%). All patients had normal IQ scores, language, and verbal working memory. However, neurocognitive deficits were more prevalent and more severe in children with a postnatal-TGA. Prenatal diagnosis was associated with better outcomes in executive functions. CONCLUSIONS Prenatal diagnosis of TGA is associated with better neurocognitive outcomes. Time of diagnosis may influence the development of early complex cognitive skills such as executive functions.
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Affiliation(s)
- Johanna Calderon
- Inserm, University Paris Descartes, Sorbonne Paris Cité, Faculty of Medicine, and APHP, Necker Hospital, Paris, France
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Chock VY, Chang IJ, Reddy VM. Short-term neurodevelopmental outcomes in neonates with congenital heart disease: the era of newer surgical strategies. CONGENIT HEART DIS 2012; 7:544-50. [PMID: 22676547 DOI: 10.1111/j.1747-0803.2012.00678.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to determine neurodevelopmental outcomes up to 30 months of age in a cohort of neonates requiring surgical intervention without circulatory arrest for congenital heart disease and to correlate these outcomes with characteristics detected prior to hospital discharge. DESIGN AND SETTING An observational cohort of surviving neonates who underwent surgical intervention without circulatory arrest for congenital heart disease between 2002 and 2003 was studied at a single tertiary care institution. PATIENTS Thirty-five patients were followed from 4 to 6 months of age until 24-30 months of age. OUTCOME MEASURES Neuromotor abnormalities, use of special services, and degree of developmental delay at set intervals between 4 and 30 months of age were retrospectively obtained from clinical reports. The relationship between these outcomes and clinical characteristics prior to hospital discharge was analyzed. RESULTS Those with neuromotor abnormalities prior to discharge were likely to have persistent abnormalities in muscle strength, tone, and symmetry until 4-6 months of age, odds ratio 6 (1.3-29). By 24-30 months of age, motor abnormalities or developmental delay occurred in 10 of 20 infants (50%), but were no longer significantly associated with predischarge findings. CONCLUSIONS Infants undergoing surgical intervention for congenital heart disease are at risk for neurodevelopmental abnormalities, which may not become apparent until months after hospital discharge. Early impairment may also resolve over time. Close developmental follow-up in this high-risk cohort of patients is warranted.
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Affiliation(s)
- Valerie Y Chock
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, Calif, USA.
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Goff DA, Luan X, Gerdes M, Bernbaum J, D'Agostino JA, Rychik J, Wernovsky G, Licht DJ, Nicolson SC, Clancy RR, Spray TL, Gaynor JW. Younger gestational age is associated with worse neurodevelopmental outcomes after cardiac surgery in infancy. J Thorac Cardiovasc Surg 2012; 143:535-42. [PMID: 22340027 DOI: 10.1016/j.jtcvs.2011.11.029] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Revised: 10/17/2011] [Accepted: 11/15/2011] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Evaluate the impact of near-term delivery on neurodevelopmental (ND) outcomes in children with congenital heart disease (CHD). METHODS Secondary analysis of data from a study of genetic polymorphisms and ND outcomes after cardiac surgery in infants. The effect of gestational age (GA) as a continuous variable on ND outcomes was evaluated using general linear regression models. GA was also evaluated as a categorical variable to seek a threshold for better outcomes. ND domains tested at 4 years of age included cognition, language skills, attention, impulsivity, memory, executive function, social competence, visual-motor, and fine-motor skills. RESULTS ND outcomes and GA were available for 378 infants. Median GA was 39 weeks (range, 28-42 weeks) with 351 born at 36 weeks or more (near-term/term). In univariate analysis of the near-term/term subgroup, older GA predicted better performance for cognition, visual-motor, and fine-motor skills. After covariate adjustment, older GA predicted better performance for fine-motor skills (P = .018). Performance for cognition, language, executive function, social skills, visual-motor, and fine-motor skills was better for those born at 39 to 40 weeks of GA or more versus those born at less than 39 weeks (all P < .05). CONCLUSIONS These findings are consistent with the hypothesis that delivery before 39 to 40 weeks of GA is associated with worse outcomes in patients with CHD. Early delivery of a child with CHD is often indicated because of maternal or fetal health issues. In the absence of these concerns, these data suggest that elective (or spontaneous) delivery at 39 to 40 weeks of GA is associated with better ND outcomes.
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Affiliation(s)
- Donna A Goff
- Division of Pediatric Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
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Jegatheeswaran A, Oliveira C, Batsos C, Moon-Grady AJ, Silverman NH, Hornberger LK, Coyte P, Friedberg MK. Costs of prenatal detection of congenital heart disease. Am J Cardiol 2011; 108:1808-14. [PMID: 21907953 DOI: 10.1016/j.amjcard.2011.07.052] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 07/16/2011] [Accepted: 07/16/2011] [Indexed: 10/17/2022]
Abstract
Little information is available about the transportation costs incurred from the missed prenatal diagnosis of congenital heart disease (CHD). The objectives of the present study were to analyze the costs of emergency transportation related to the postnatal diagnosis of major CHD and to perform a cost/benefit analysis of additional training for ultrasound technicians to study the implications of improved prenatal detection rates. The 1-year costs incurred for emergency transportation of pre- and postnatally diagnosed infants with CHD in Northern California and North Western Nevada were calculated and compared. The prenatal detection rate in our cohort (n = 147) was 30.6%. Infants postnatally diagnosed were 16.5 times more likely (p <0.001) to require emergency transport. The associated emergency transportation costs were US$542,143 in total for all patients with CHD. The mean cost per patient was $389.00 versus $5,143.51 for prenatally and postnatally diagnosed infants, respectively (p <0.001). Assuming an improvement in detection rates after 1-day training for ultrasound technicians, the investment in training cost can be recouped in 1 year if the detection rate increased by 2.4% to 33%. Savings of $6,543,476 would occur within 5 years if the detection rate increased to 50%. In conclusion, CHD diagnosed postnatally results in greater costs related to emergency transportation of ill infants. Improving the prenatal detection rates through improved ultrasound technician training could result in considerable cost savings.
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Congenital heart disease infant death rates decrease as gestational age advances from 34 to 40 weeks. J Pediatr 2011; 159:761-5. [PMID: 21676411 DOI: 10.1016/j.jpeds.2011.04.020] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Revised: 03/28/2011] [Accepted: 04/18/2011] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To describe congenital heart disease death rates in infants born between 34 and 40 weeks, estimate the relationship between gestational age and congenital heart disease infant death rates, and compare congenital heart disease death rates across 1- and 2-week intervals in gestational age. STUDY DESIGN The 2000 to 2003 national linked birth/infant death cohort datasets were obtained. Congenital heart disease deaths were identified by using International Statistical Classification of Diseases, 10th Revision codes. Proportional death rates were calculated by using congenital heart disease deaths and all live births. The relationship between congenital heart disease death rates and gestational age was determined. Death rates were compared across intervals. RESULTS A total of 14.9 million records were analyzed. Congenital heart disease deaths occurred in 4736 infants (0.04%) born between 34 and 40 weeks. There was a significant, negative linear relationship between congenital heart disease death rate and gestational age (R(2) = 0.97). Comparisons across 1-week intervals varied (P = .02-.23). All 2-week intervals were statistically significant (P < .01). CONCLUSIONS Congenital heart disease death rates decrease as gestational age approaches 40 weeks. These results should be considered before elective delivery for the sole indication of prenatally diagnosed congenital heart disease.
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Kipps AK, Feuille C, Azakie A, Hoffman JIE, Tabbutt S, Brook MM, Moon-Grady AJ. Prenatal diagnosis of hypoplastic left heart syndrome in current era. Am J Cardiol 2011; 108:421-7. [PMID: 21624547 DOI: 10.1016/j.amjcard.2011.03.065] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 03/16/2011] [Accepted: 03/16/2011] [Indexed: 11/30/2022]
Abstract
We sought to evaluate the relation of a prenatal diagnosis (preDx) with morbidity and mortality during the initial hospitalization in a contemporary cohort of patients with hypoplastic left heart syndrome (HLHS). A retrospective study of patients with HLHS presenting from 1999 to 2010 was performed. Patients with genetic disorders or a gestational age <34 weeks or who had intentionally received comfort care only were excluded. Of the 81 patients meeting the study criteria, 49 had a preDx and 32 were diagnosed postnatally (postDx). Birth weight (median 3.0 vs 3.4 kg; p = 0.007) and gestational age (median 38 vs 39 weeks; p <0.001) were lower in the preDx than in the postDx patients. Preoperatively, the postDx patients were intubated more frequently (97% vs 71%, p = 0.004) and ventilated longer (median 96 vs 24 hours, p = 0.005) than the preDx patients. They also had more preoperative acidosis, multiorgan failure, tricuspid valve regurgitation, and right ventricular dysfunction. Of the 73 patients undergoing surgery, no difference in survival was seen between the preDx and postDx groups (91% vs 89%). The median duration of postoperative ventilation was 7 days and the median length of stay was 36 days for the 66 survivors, with no difference between the 2 groups. Postoperative morbidities, including chylothorax and infection, were also similar in the preDx and postDx patients. No studied preoperative factor was associated with death, duration of postoperative ventilation, or length of stay. In conclusion, our recent experience has shown that preDx of HLHS was not associated with a survival advantage, fewer postoperative complications, or shorter length of stay. Improved preoperative status was observed in the preDx patients; however, they were born earlier with a lower birthweight. What effect these factors might have on longer term morbidity remains unknown.
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Affiliation(s)
- Alaina K Kipps
- Department of Pediatrics, Division of Cardiology, University of California, San Francisco, Benioff Children's Hospital, USA.
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Punn R, Silverman NH. Fetal Predictors of Urgent Balloon Atrial Septostomy in Neonates with Complete Transposition. J Am Soc Echocardiogr 2011; 24:425-30. [DOI: 10.1016/j.echo.2010.12.020] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Indexed: 11/25/2022]
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Cohen-Overbeek TE, Tong WH, Hatzmann TR, Wilms JF, Govaerts LCP, Galjaard RJH, Steegers EAP, Hop WCJ, Wladimiroff JW, Tibboel D. Omphalocele: comparison of outcome following prenatal or postnatal diagnosis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2010; 36:687-692. [PMID: 20509138 DOI: 10.1002/uog.7698] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/18/2010] [Indexed: 05/29/2023]
Abstract
OBJECTIVES To assess the impact of prenatal compared with postnatal diagnosis on outcome for liveborn infants with an isolated or with a non-isolated omphalocele. METHODS This was a retrospective analysis of 101 prenatally and 45 postnatally diagnosed cases of omphalocele. Cases were collected from the ultrasound database of the Division of Obstetrics and Prenatal Medicine and the patient database of the Department of Pediatric Surgery. RESULTS Following confirmation at delivery or autopsy, prenatally diagnosed omphaloceles included 21 isolated cases, 44 non-isolated cases with a normal karyotype and 36 non-isolated cases with an abnormal karyotype. Of the prenatally diagnosed apparently isolated cases (n = 31), 12 (39%; 95% CI, 22-58%) revealed associated anomalies after delivery. Liveborn infants with an isolated omphalocele had significantly worse short-term morbidity following prenatal diagnosis (n = 14) compared with diagnosis at birth (n = 29), having a lower gestational age at delivery, lower Apgar scores, longer duration of ventilation and parenteral nutrition, more readmissions and a longer hospital stay. The prenatally diagnosed subset contained more infants with a giant omphalocele (9/14 vs. 3/29, P = 0.001) and liver herniation (8/14 vs. 6/29, P = 0.02). The outcome of liveborn infants with a non-isolated omphalocele diagnosed prenatally (n = 17) was not different from that of those diagnosed at birth (n = 16), except for a greater need for ventilation and parenteral nutrition in the prenatal subset. CONCLUSION When counseling patients with a prenatal diagnosis of isolated omphalocele, it is important to remember that over one third could turn out to have associated anomalies. Liveborn infants with an isolated omphalocele detected prenatally have worse short-term morbidity than do cases detected at birth. Those with non-isolated omphaloceles detected prenatally have an increased need for ventilation and parenteral nutrition compared with those detected at birth.
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Affiliation(s)
- T E Cohen-Overbeek
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, Rotterdam, The Netherlands.
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Snookes SH, Gunn JK, Eldridge BJ, Donath SM, Hunt RW, Galea MP, Shekerdemian L. A systematic review of motor and cognitive outcomes after early surgery for congenital heart disease. Pediatrics 2010; 125:e818-27. [PMID: 20231182 DOI: 10.1542/peds.2009-1959] [Citation(s) in RCA: 174] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
CONTEXT Brain injury is the most common long-term complication of congenital heart disease requiring surgery during infancy. It is clear that the youngest patients undergoing cardiac surgery, primarily neonates and young infants, are at the greatest risk for brain injury. Developmental anomalies sustained early in life have lifelong repercussions. OBJECTIVE We conducted a systematic review to examine longitudinal studies of cognitive and/or motor outcome after cardiac surgery during early infancy. METHODS Electronic searches were performed in Medline, the Cumulative Index to Nursing and Allied Health Literature (Cinahl), and Embase (1998-2008). The search strategy yielded 327 articles, of which 65 were reviewed. Eight cohorts provided prospective data regarding the cognitive and/or motor outcome of infants who had undergone surgery for congenital heart disease before 6 months of age. Two authors, Ms Snookes and Dr Gunn, independently extracted data and presented results according to 3 subgroups for age of follow-up: early development (1 to <3 years); preschool age (3-5 years); and school age (>5 to 17 years). Weighted analysis was undertaken to pool the results of studies when appropriate. RESULTS All of the identified studies reported results of the Bayley Scales of Infant Development for children younger than the age of 3. Outcome data as reported by the Bayley Scales were combined for infants assessed at 1 year of age, revealing a weighted mean Mental Development Index of 90.3 (95% confidence interval: 88.9-91.6) and Psychomotor Development Index of 78.1 (95% confidence interval: 76.4-79.7). Additional analysis was limited by a lack of data at preschool and school age. CONCLUSIONS With this review we identified a limited number of prospective studies that systematically addressed outcome in patients at the highest risk. These studies consistently revealed cognitive and motor delay in children after cardiac surgery during early infancy. Additional investigation is required to ascertain the consequences of such impairment during later childhood and into adult life.
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Affiliation(s)
- Suzanne H Snookes
- Physiotherapy Department, Royal Children's Hospital, Flemington Road, Parkville, Victoria 3052, Australia
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Abstract
Brain and heart development occur simultaneously in the human fetus. Given the depth and complexity of these shared morphogenetic programs, it is perhaps not surprising that disruption of organogenesis in one organ will impact the development of the other. Newborns with congenital heart disease show a high frequency of acquired focal brain injury on sensitive magnetic resonance imaging studies in the perioperative period. The surprisingly high incidence of white matter injury in these term newborns suggests a unique vulnerability and may be related to a delay in brain development. These abnormalities in brain development identified with MRI in newborns with congenital heart disease might reflect abnormalities in cerebral blood flow while in utero. A complete understanding of the mechanisms of white matter injury in the term newborn with congenital heart disease will require further investigation of the timing, extent, and causes of delayed fetal brain development in the presence of congenital heart disease.
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Affiliation(s)
- Patrick S McQuillen
- Department of Pediatrics, University of California, San Francisco, California, USA
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Peiris V, Singh TP, Tworetzky W, Chong EC, Gauvreau K, Brown DW. Association of Socioeconomic Position and Medical Insurance With Fetal Diagnosis of Critical Congenital Heart Disease. Circ Cardiovasc Qual Outcomes 2009; 2:354-60. [DOI: 10.1161/circoutcomes.108.802868] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Vasum Peiris
- From the Department of Cardiology (V.P., T.P.S., W.T., E.C.C., K.G., D.W.B.), Children’s Hospital Boston, and the Department of Pediatrics (V.P., T.P.S., W.T., D.W.B.), Harvard Medical School, Boston, Mass
| | - Tajinder P. Singh
- From the Department of Cardiology (V.P., T.P.S., W.T., E.C.C., K.G., D.W.B.), Children’s Hospital Boston, and the Department of Pediatrics (V.P., T.P.S., W.T., D.W.B.), Harvard Medical School, Boston, Mass
| | - Wayne Tworetzky
- From the Department of Cardiology (V.P., T.P.S., W.T., E.C.C., K.G., D.W.B.), Children’s Hospital Boston, and the Department of Pediatrics (V.P., T.P.S., W.T., D.W.B.), Harvard Medical School, Boston, Mass
| | - Erin C. Chong
- From the Department of Cardiology (V.P., T.P.S., W.T., E.C.C., K.G., D.W.B.), Children’s Hospital Boston, and the Department of Pediatrics (V.P., T.P.S., W.T., D.W.B.), Harvard Medical School, Boston, Mass
| | - Kimberlee Gauvreau
- From the Department of Cardiology (V.P., T.P.S., W.T., E.C.C., K.G., D.W.B.), Children’s Hospital Boston, and the Department of Pediatrics (V.P., T.P.S., W.T., D.W.B.), Harvard Medical School, Boston, Mass
| | - David W. Brown
- From the Department of Cardiology (V.P., T.P.S., W.T., E.C.C., K.G., D.W.B.), Children’s Hospital Boston, and the Department of Pediatrics (V.P., T.P.S., W.T., D.W.B.), Harvard Medical School, Boston, Mass
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Outcomes for patients with unbalanced atrioventricular septal defects. Pediatr Cardiol 2009; 30:431-5. [PMID: 19184173 DOI: 10.1007/s00246-008-9376-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2008] [Revised: 12/16/2008] [Accepted: 12/24/2008] [Indexed: 10/21/2022]
Abstract
Infants with an unbalanced atrioventricular septal defect (AVSD) frequently present with comorbidities that may have an impact on their medical course and outcome. This study aimed to assess outcomes and explore possible prognostic indicators for patients undergoing surgical palliation for an unbalanced AVSD. The medical records of all infants presenting to the authors' institution with an unbalanced AVSD over a 5-year period were retrospectively reviewed for assessment of outcomes and comorbidities. The study group consisted of 44 patients with an overall survival rate of 51% for the entire follow-up period. The majority of these patients (88%) underwent single-ventricle palliation, with an 83% rate of survival to initial hospital discharge and an overall long-term survival rate of 50%. The midterm outcome was significantly worse than that for a cohort of hypoplastic left heart syndrome patients undergoing single-ventricle palliation during the same period (P = 0.03). In addition, 30% of the patients required either repair or replacement of their systemic atrioventricular valve at initial palliation or during subsequent follow-up evaluation. Of the patients with an unbalanced AVSD, 75% had associated congenital anomalies. In conclusion, infants with an unbalanced AVSD are a high-risk population with diminished midterm survival compared with palliated patients who have more classic forms of hypoplastic heart syndromes. This may be due to the higher incidence of both severe atrioventricular valve regurgitation and important associated congenital anomalies.
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Licht DJ, Shera DM, Clancy RR, Wernovsky G, Montenegro LM, Nicolson SC, Zimmerman RA, Spray TL, Gaynor JW, Vossough A. Brain maturation is delayed in infants with complex congenital heart defects. J Thorac Cardiovasc Surg 2009; 137:529-36; discussion 536-7. [PMID: 19258059 DOI: 10.1016/j.jtcvs.2008.10.025] [Citation(s) in RCA: 453] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2008] [Revised: 09/23/2008] [Accepted: 10/26/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Small head circumferences and white matter injury in the form of periventricular leukomalacia have been observed in populations of infants with severe forms of congenital heart defects. This study tests the hypothesis that congenital heart defects delay in utero structural brain development. METHODS Full-term infants with hypoplastic left heart syndrome or transposition of the great arteries were prospectively evaluated with preoperative brain magnetic resonance imaging. Patients with independent risk factors for abnormal brain development (shock, end-organ injury, or intrauterine growth retardation) were excluded. Outcome measures included head circumferences and the total maturation score on magnetic resonance imaging. Total maturation score is a previously validated semiquantitative anatomic scoring system used to assess whole brain maturity. The total maturation score evaluates 4 parameters of maturity: (1) myelination, (2) cortical infolding, (3) involution of glial cell migration bands, and (4) presence of germinal matrix tissue. RESULTS The study cohort included 29 neonates with hypoplastic left heart syndrome and 13 neonates with transposition of the great arteries at a mean gestational age of 38.9 +/- 1.1 weeks. Mean head circumference was 1 standard deviation below normal. The mean total maturation score for the cohort was 10.15 +/- 0.94, significantly lower than reported normative data in infants without congenital heart defects, corresponding to a delay of 1 month in structural brain development. CONCLUSION Before surgery, term infants with hypoplastic left heart syndrome and transposition of the great arteries have brains that are smaller and structurally less mature than expected. This delay in brain development may foster susceptibility to periventricular leukomalacia in the preoperative, intraoperative, and postoperative periods.
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Affiliation(s)
- Daniel J Licht
- Divison of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
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El-Naggar WI, Keyzers M, McNamara PJ. Role of amplitude-integrated electroencephalography in neonates with cardiovascular compromise. J Crit Care 2009; 25:317-21. [PMID: 19327328 DOI: 10.1016/j.jcrc.2008.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Revised: 10/27/2008] [Accepted: 11/23/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Neonates with congenital heart disease (CHD) and persistent pulmonary hypertension of the newborn (PPHN) represent conditions with increased risk of abnormal neurologic outcome. The role of aEEG in disorders where cerebral perfusion/oxygenation is affected by cardiac or pulmonary disease is unknown. OBJECTIVE The aim of the study was to characterize amplitude-integrated electroencephalography (aEEG) traces in nonasphyxiated neonates with cardiorespiratory compromise secondary to PPHN or CHD. DESIGN/METHODS Three hundred sixty-three aEEG records (June 2004-November 2006) were reviewed to identify neonates with a diagnosis of isolated CHD or PPHN. Clinical course, critical interventions, and neurodiagnostic investigation data were collected. The aEEG traces were reviewed by a single blinded expert and classified according to background activity (normal, moderate, or severely abnormal) and presence of seizures. The frequency of abnormal aEEG in both groups and its relationship to recognized markers of abnormal neurologic outcome (electrophysiology [EP] testing and neuroimaging [ultrasound (USS), computerized tomography, and magnetic resonance imaging] was studied. RESULTS Thirty neonates (PPHN [n = 20], CHD [n = 10]) were reviewed at a mean gestation of 39.2 +/- 1.1 weeks and weight of 3,375 +/- 565 g. Neonates with PPHN had lower Apgar scores at 1-minute (P = .02) and were significantly more likely to require inotropic support (P < .001), inhaled nitric oxide (P = .001), or surfactant (P = .01). An abnormal aEEG was found in 15 (50%) babies, but rates did not differ between CHD (n = 6) and PPHN (n = 9). The rates of abnormal composite neurologic outcome (2/3 of abnormal EP, neuroimaging, or neurologic examination) were significantly higher in neonates with abnormal aEEG. An abnormal magnetic resonance imaging was seen in 4 of 5 neonates with abnormal aEEG. CONCLUSIONS The risk of abnormal aEEG is high in sick neonates with PPHN or complex CHD. Prospective evaluation of the relationship between aEEG recordings in these disorders and acute cardiorespiratory physiology, comprehensive neuroimaging, and long-term patient outcomes is needed.
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Affiliation(s)
- Walid I El-Naggar
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada M5G 1X8
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Chang RKR, Rodriguez S, Klitzner TS. Screening newborns for congenital heart disease with pulse oximetry: survey of pediatric cardiologists. Pediatr Cardiol 2009; 30:20-5. [PMID: 18654813 DOI: 10.1007/s00246-008-9270-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Revised: 05/13/2008] [Accepted: 06/30/2008] [Indexed: 11/28/2022]
Abstract
BACKGROUND Controversies exist regarding the use of pulse oximetry for routine screening of newborns. This study aimed to evaluate current practices and opinions of pediatric cardiologists in relation to newborn screening for congenital heart disease (CHD) using pulse oximetry. METHODS Email invitations were sent to 1,045 pediatric cardiologists in North America. The survey was Internet based and included multiple-choice questions. Two repeat email reminders were sent after the initial invitation. RESULTS A total of 363 responses (35%) were returned. In terms of experience, 40% of the respondents had more than 20 years, 32% had 10 to 20 years, 21% had 5 to 10 years, and 6% had less than 5 years of experience. More than 90% agreed that an early diagnosis of CHD for newborns prevents morbidity and mortality. In terms of practice, 96% reported that all newborns are examined by a clinician before discharge, 29% reported that newborns get a pulse oximetry reading, and 1.4% (n = 5) reported the use of electrocardiogram. Only 58% of respondents thought that current practice is adequate for detecting significant CHD. With regard to their experience with pulse oximetry, 26% reported "too many false-positives," 21% described it as "prone to noise and artifact," and 30% viewed it as "very operator dependent." The overall support for mandated pulse oximetry screening was 55%. The support for mandate decreased with years of experience, with 76% of the supporters having less than 5 years, 58% of those having 5 to 10 years, 53% of those having 10 to 20 years, and 51% of those having more than 20 years of experience. CONCLUSIONS Pediatric cardiologists recognize that current practice is inadequate for detecting significant CHD. Slightly more than half of the pediatric cardiologists in this study supported a mandate for pulse oximetry screening, but there were many concerns, and the support decreased with increasing years of clinical experience.
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Affiliation(s)
- Ruey-Kang R Chang
- Division of Cardiology, Department of Pediatrics, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 491, Torrance, CA 90509, USA.
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Raboisson M, Samson C, Ducreux C, Rudigoz R, Gaucherand P, Bouvagnet P, Bozio A. Impact of prenatal diagnosis of transposition of the great arteries on obstetric and early postnatal management. Eur J Obstet Gynecol Reprod Biol 2009; 142:18-22. [DOI: 10.1016/j.ejogrb.2008.09.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2007] [Revised: 07/03/2008] [Accepted: 09/04/2008] [Indexed: 11/27/2022]
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KHOO NS, VAN ESSEN P, RICHARDSON M, ROBERTSON T. Effectiveness of prenatal diagnosis of congenital heart defects in South Australia: A population analysis 1999-2003. Aust N Z J Obstet Gynaecol 2008; 48:559-63. [DOI: 10.1111/j.1479-828x.2008.00915.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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