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

Fontan circulation has improved life expectancy for infants born with complex heart disease over the last 50 years but has also resulted in significant morbidity

The prognosis for infants born with complex heart disease improved dramatically with the introduction of the Fontan circulation 50 years ago. With today's carefully designed and staged operations to a Fontan circulation, life expectancy has increased and most children will survive into adult life. The Fontan circulation entails an unphysiological circulation with high risk for multiple organ system dysfunction. Neurodevelopmental disabilities with adverse psychosocial effects are prevalent. The Fontan circulation may eventually fail and necessitate heart transplantation. CONCLUSION: Fifty years development of the Fontan circulation to today's staged surgical procedures has improved survival but also revealed the burden of a high morbidity for a growing number of patients.

Ethical issues after pre-natal diagnosis

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

Impacts of prenatal diagnosis of congenital heart diseases on outcomes

Prenatal diagnosis of congenital heart diseases (CHD) is increasingly performed in developed countries. Still, the current impacts of prenatal diagnosis on fetal and neonatal outcomes remains unclear or contradictory. We will review here the different consequences of prenatal screening and of fetal echocardiography on different categories of outcomes. Increasing detection may lead to a reduced birth incidence of severe complex CHD through a high rate of termination of pregnancy but this trend is not universal. Conversely, one of the main impacts of prenatal diagnosis is to optimize perinatal care and to improve hard outcomes such as mortality. Indeed, decrease of neonatal mortality is inconsistently observed in transposition of the great arteries and is not shown in other defects. The reduction of perinatal morbidity is a new end-point to scrutinize but how to examine this impact is controversial in the neonatal period. The influence of the reduction of neonatal distress may modify neurodevelopmental outcomes and quality of survival. The risk stratification after a prenatal diagnosis of CHD helps to optimize the timing, mode, and site of management with the aim to improve outcomes. The anticipated care is tailored according to the type of CHD and expected initial physiology. However, the imprecision of prenatal diagnosis even in expert centers hampers this logical outcome. Prediction of the type of repair is theoretically possible but remains challenging in defects such as double outlet right ventricles or pulmonary atresia with ventricular septal defect. The cost of prenatal diagnosis or of its absence is still a matter of debate and policies have to be tailored to regional health systems. Finally, the impact on parents and siblings is a rarely explored outcome. Screening and echography of fetal heart are currently performed in developed countries but it is still too early to talk about fetal cardiology.