Recent trends in indications of fetal echocardiography and postnatal outcomes in fetuses diagnosed as congenital heart disease

Rhythm abnormalities among hospitalised children in Lagos: a case series

Arrhythmias refer to disturbances in heart rate or rhythm which leads to heart rates that are abnormally fast, slow or irregular. Rhythm abnormalities may be common among Nigerian children but there are only a few reports. The current write up is a clinical review of eight patients in various age groups including neonates, infants and older children. It is presented to highlight the different forms of arrhythmias that can occur in children, with varying underlying aetiology, thus, stressing the need for early recognition of arrhythmias in children, appropriate early intervention and challenges involved in their care.

Impact of prenatally diagnosed congenital heart defects on outcomes and management

Fetal echocardiogram aids in prenatal identification of neonates at high risk for congenital heart defects (CHD). Prenatal detection rates for CHD have increased with improved ultrasound technology, the use of the early fetal echocardiography, and standardization of the performance of the fetal echocardiogram. Accurate prenatal detection of CHD, particularly complex CHD, is an important contributor to improved survival rates for patients with CHD. Early detection allows for families to choose whether or not to continue with pregnancy, referral to pediatric cardiology specialists for patient education, and delivery planning. Better psychosocial supports are needed for families with CHD.

Impact of the expanded examination of fetal heart to the prenatal diagnosis of congenital heart diseases

Objective:

In the present study, for which reasons fetal cardiac evaluation was requested from our pediatric cardiology clinic, the effects of routine fetal cardiac evaluation in obstetric ultrasonography (USG) on the detection of congenital heart disease (CHD) and the distribution of intrauterine diagnosis of CHD according to pregnancy risk profiles were retrospectively analyzed.

Materials and Methods:

Fetal echocardiography reports which containing the nineteen-month period were retrospectively examined. We performed a fetal echocardiography for all pregnant women who were referred to pediatric cardiology clinic after detail obstetric USG screening. The pregnancies were categorized into two groups based on the risk of CHD: Low-risk and high-risk groups. Detected congenital cardiac structural malformations were classified as complex, moderate, and mild according to perinatal mortality risk.

Results:

Of the 736 pregnancies, 22 were twin, and fetal cardiac evaluation was performed in 758 fetuses. There were 341 (46.3%) pregnancies in the high-risk group and 395 (53.6%) pregnancies in the low-risk group. The most common reason for fetal cardiac evaluation request was inability to adequately visualize the fetal heart (36.1%), while suspected fetal cardiac abnormality was the second most common cause (21.3%). Number of fetuses detected with cardiac abnormalities was 80 (23.5%) among high-risk pregnancies, and 20 (5%) among low-risk pregnancies. The most common type of malformation was simple cardiac abnormalities (6%) followed by complex lesions (4.1%). The most common cardiac abnormality was ventricular septal defect comprised of 18 cases (2.4%) while the most common complex cardiac abnormality was pulmonary atresia (1.2%). The rate of consistency was 40.1% between obstetricians and pediatric cardiologist in terms of the diagnosis of the congenital cardiac malformations.

Conclusion:

Routine evaluation of the fetal heart by means of obstetric USG, including four chambers, outflow tracts’ and three vessel views, would allow for diagnosing congenital cardiac malformations to a large extent during the intrauterine period.

Fetal Echocardiography Indications and Lack of Association between Abnormal Exams and Advanced Maternal Age: A Cross-Sectional Study - Fetal Abnormal Echocardiography

OBJECTIVE

 To analyze the most frequent referrals for fetal echocardiography, including advanced maternal age and its association with abnormal results.

METHODS

 We included all pregnant women referred to perform fetal echocardiography (gestational age 22-32 weeks) in 2 health centers in Rio de Janeiro, from June 2015 to June 2016. Advanced maternal age was considered when age was > 35 years at the time of delivery). Referral reasons and results were recorded, according to the Brazilian Fetal Cardiology Statement. Crude and adjusted prevalence ratios were calculated (Poisson regression). We considered p < 0.05 as significant.

RESULTS

 A total of 1,221 tests were analyzed. Abnormal fetal echocardiography was observed in 14.82% of the cases. The most frequent abnormalities were interventricular septal defect (6.39%), septal hypertrophy (3.35%) and atrioventricular septal defect (1.14%). Routine exams were performed in 559 women, 289 were referred for advanced maternal age and 373 were referred according to the Brazilian Fetal Cardiology Statement criteria. An obstetric ultrasound suggesting fetal cardiac abnormality, maternal diabetes, increased nuchal translucency, and obstetric ultrasound suggesting a noncardiac abnormality were strongly associated with an abnormal fetal echocardiography. Abnormal results were not more frequent in women with advanced maternal age when compared with the rest of the study group.

CONCLUSIONS

 It was observed that routine exams and advanced maternal age referrals were very frequent. Those exams were not associated to fetal echocardiography abnormalities. In this scenario, when the obstetric ultrasound suggests a fetal cardiac abnormality, the fetal echocardiography probably is abnormal. Therefore, obstetric ultrasound is a good screening method.

Discrepancy Between Pre- and Postnatal Diagnoses of Congenital Heart Disease and Impact on Neonatal Clinical Course - A Retrospective Study at a Japanese Tertiary Institution

BACKGROUND

Congenital heart disease (CHD) is often diagnosed prenatally using fetal echocardiography, but few studies have evaluated the accuracy of these fetal cardiac diagnoses in detail. We investigated the discrepancy between pre- and postnatal diagnoses of CHD and the impact of discrepant diagnoses.Methods and Results:This retrospective study at a tertiary institution included data from the medical records of 207 neonates with prenatally diagnosed CHD admitted to the cardiac neonatal intensive care unit between January 2011 and December 2016. Pre- and postnatal diagnoses of CHD differed in 12% of neonates. Coarctation of the aorta and ventricular septal defects were the most frequent causes of discrepant diagnosis. Unexpected treatments were added to 38% of discrepant diagnostic cases. However, discrepant diagnoses did not adversely affect the clinical course. The 9% of the 207 neonates who required invasive intervention within 24 h of delivery were accurately diagnosed prenatally.

CONCLUSIONS

Pre- and postnatal diagnoses differed in only a few neonates, with differences not adversely affecting the clinical course. Neonates who required invasive intervention immediately after delivery were accurately diagnosed prenatally. Prenatal diagnosis thus seems to contribute to improved prognosis in neonates with CHD.

Early Growth Trajectory of Infants With Simple Congenital Heart Disease and Complex Congenital Heart Disease Undergoing Cardiac Repair: A Prospective Cohort Study in China

BACKGROUND

We aimed to evaluate the growth trajectory of infants with congenital heart disease (CHD) and to analyze the effects of disease classification on their growth trajectory.

METHODS

A prospective cohort of infants with CHD was enrolled and divided into 2 groups: simple CHD (SC) and complex CHD (CC) groups. All patients were followed up for 6 months after CHD surgery. Weight for age (WAZ), length for age (LAZ), weight for length (WLZ), and head circumference for age were compared between the 2 groups using mixed-effects linear regression.

RESULT

Between September 2018 and November 2019, 801 patients had data collected. The z-score trend decreased (e.g., ΔWAZ: 1.29±1.44) and then increased (e.g., ΔWAZ: 1.06±1.13), and all z-scores were below 0 from birth to 6 months postoperatively. Mixed-effects linear regression models indicated that the postoperative WAZ and WLZ scores of the CC group were lower than those of the SC group after adjustment (WAZ: β = -0.72; 95% confidence interval [CI], -1.37 to -0.07; P = .03) (WLZ: β = -0.93, 95% CI, -1.67 to -0.19; P = .01). The models also showed an interaction effect between disease classification and preoperative growth status on infant growth outcome (WAZ: interaction β = -0.48; 95% CI, -0.88 to -0.07; P = .02) (WLZ: interaction β = -0.36; 95% CI, -0.60 to -0.12; P = .004) (LAZ: interaction β = -0.29; 95% CI, -0.56 to -0.02; P = .04).

CONCLUSIONS

Compared with SC children, CC children have deficits in their early growth trajectories. The type of disease and preoperative growth status synergistically affect the early postoperative growth trajectory.

Behavior of fetal longitudinal myocardial fibers assessed by speckle tracking to obtain strain and strain rate values for low-risk pregnancies

Objective To analyze the behavior of fetal longitudinal myocardial fibers assessed by speckle tracking (STE) after fetal viability. Methods A cross-sectional study was performed in 156 women with normal singleton pregnancies from 22 to 31 weeks of gestation. Strain (S) and strain rate (SR) values were measured in both ventricles during the fetal cardiac cycle. The population was divided into five gestational age groups based on 2-week intervals. The correlations of maternal variables with the S and SR variables and intra-observer analysis were performed. Results There was a significant difference in the S and SR values of the left ventricle (LV) among the gestational age groups (P = 0.007). Significantly higher S and SR values were observed in early age groups demonstrating reductions in LV S and SR values at 26 weeks, followed by stabilization. For the right ventricle (RV), there was no significant difference between gestational age groups. Significant intra-observer agreement was observed for S values of the RV (P = 0.008) and LV (P = 0.0004) and SR values of the RV (P = 0.0001) and LV (P = 0.015). Conclusion Decreases in the S and SR values of the LV occurred after 26 weeks, followed by stabilization. No significant difference was observed in the S or SR value of the RV among the gestational age groups, and no significant association of any maternal variable evaluated with S and SR values was observed. Significant intra-observer agreement was obtained among the results.

Sensitivity, specificity, and accuracy of fetal echocardiography for high-risk pregnancies in a tertiary center in Egypt

BACKGROUND

Advances in fetal echocardiography training among pediatric cardiologists have led to substantial improvements in prenatal detection of congenital heart diseases (CHDs). Nevertheless, diagnostic accuracy varies among centers. Moreover, this subspecialty continues to evolve in developing countries, with limited studies assessing fetal echocardiography sensitivity, specificity, and accuracy in developing countries such as Egypt.

SUBJECT AND METHODS

High-risk pregnancies referred for fetal echocardiography from January 2011 to January 2019 were analyzed retrospectively. All of the cases included had one of the high-risk indications for fetal echocardiography. Maternal age and gestational age at the prenatal diagnosis were determined, and detailed fetal and neonatal echocardiograms were documented. The results of fetal and postnatal echocardiography were compared to assess the sensitivity, specificity, and accuracy of fetal echocardiography. A minor lesion was defined when no postnatal intervention was needed and a major anomaly when postnatal cardiac therapy, surgery, or intervention was required.

RESULTS

Out of 615 pregnant patients referred, comparisons between fetal and neonatal echocardiography were possible in 458 fetuses, with 157 patients excluded from the study. The mean maternal age in the study was 26.97±5.871 years and the mean gestational age at referral was 27.24±5.407 weeks. The most common indication for prenatal echocardiography in this cohort was a family history of CHD (142; 31%) followed by nonimmune hydrops (97; 21.18%) and abnormal obstetrical ultrasound screening (64; 13.97%). We had three false-positive minor diagnoses and four false-negative cases with only one requiring intervention. Prenatal diagnosis in this study was accurate in 98.47% of cases. The sensitivity, specificity, and accuracy of fetal echocardiography in the current work were 97.03%, 99.07%, and 98.47, respectively.

CONCLUSION

Fetal echocardiography is considered a highly sensitive specific tool for prenatal detection of congenital heart diseases in high-risk pregnancies even in developing countries. However, minor fetal cardiac disorders are challenging to diagnose and family counseling should emphasize the difficulty of excluding or confirming such lesions.

The Effect of Multidisciplinary Approach on the Birth Rate of Fetuses with Prenatally Diagnosed Congenital Heart Disease

BACKGROUND

This study aimed to determine the effect of a multidisciplinary approach on the birth rate of fetuses with prenatally diagnosed congenital heart diseases (CHDs).

METHODS

Among the fetuses of 724 gravidas who underwent fetal echocardiography in Samsung Medical Center from January 2013 to June 2017, 463 fetuses with normal cardiac structure, arrhythmia or simple left-to-right shunt were excluded, and the remaining 261 were included in the study. The subjects were subdivided into groups based on whether they were consulted multidisciplinarily, that is, consulted simultaneously by pediatric cardiologists, obstetricians and pediatric cardiac surgeons or not. They were also categorized based on the initial fetal echocardiogram results.

RESULTS

Among the fetuses in the multidisciplinary group, 64.5% of the fetuses were given birth to, and the proportion was not different from that in the non-multidisciplinary group (68.6%, P = 0.48). The delivery rate in the multidisciplinary consultation group were 69.2% in the transposition of the great arteries group, 63.6% in the tetralogy of Fallot group, 68.8% in the pulmonary atresia or interrupted aortic arch group, 62.5% in the coarctation of aorta group, 60.0% in the atrioventricular septal defect group, 70.0% in the functional single ventricle group, and 55.6% in the hypoplastic left heart syndrome group; there were no significant differences between the 10 echocardiogram groups. However, when the subjects were categorized into Fontan repair group and biventricular repair group, the Fontan repair group showed a significant increase in the likelihood of delivery when a multidisciplinary approach was taken (P = 0.035).

CONCLUSION

When a fetus was diagnosed with a CHD where Fontan repair should be considered, a multidisciplinary approach resulted in increased possibility of delivery.

Echocardiography in children with Down syndrome

Congenital heart disease is a common problem in children with Down syndrome (DS). Echocardiography plays an important role in the detection of both structural and functional abnormalities in this group of patients. Fetal echocardiography can help in the early recognition of DS by detecting soft markers of DS, but its main role is to define the exact nature of the suspected cardiac problem in the fetus. Postnatal echocardiography is mandatory in the first month of life for all neonates with DS. It is also indicated before any cardiac surgery and for serial follow-up after cardiac surgery. In this article, we discuss the types and mechanism of cardiac abnormalities in DS children and the role of both fetal and postnatal echocardiography in the detection of these abnormalities.

Echocardiography in children with Down syndrome

Congenital heart disease is a common problem in children with Down syndrome (DS). Echocardiography plays an important role in the detection of both structural and functional abnormalities in this group of patients. Fetal echocardiography can help in the early recognition of DS by detecting soft markers of DS, but its main role is to define the exact nature of the suspected cardiac problem in the fetus. Postnatal echocardiography is mandatory in the first month of life for all neonates with DS. It is also indicated before any cardiac surgery and for serial follow-up after cardiac surgery. In this article, we discuss the types and mechanism of cardiac abnormalities in DS children and the role of both fetal and postnatal echocardiography in the detection of these abnormalities.

Sonographic markers for early diagnosis of fetal malformations

Fetal malformations are very frequent in industrialized countries. Although advanced maternal age may affect pregnancy outcome adversely, 80%-90% of fetal malformations occur in the absence of a specific risk factor for parents. The only effective approach for prenatal screening is currently represented by an ultrasound scan. However, ultrasound methods present two important limitations: the substantial absence of quantitative parameters and the dependence on the sonographer experience. In recent years, together with the improvement in transducer technology, quantitative and objective sonographic markers highly predictive of fetal malformations have been developed. These markers can be detected at early gestation (11-14 wk) and generally are not pathological in themselves but have an increased incidence in abnormal fetuses. Thus, prenatal ultrasonography during the second trimester of gestation provides a “genetic sonogram”, including, for instance, nuchal translucency, short humeral length, echogenic bowel, echogenic intracardiac focus and choroid plexus cyst, that is used to identify morphological features of fetal Down’s syndrome with a potential sensitivity of more than 90%. Other specific and sensitive markers can be seen in the case of cardiac defects and skeletal anomalies. In the future, sonographic markers could limit even more the use of invasive and dangerous techniques of prenatal diagnosis (amniocentesis, etc.).