Prenatal detection of critical cardiac outflow tract anomalies remains suboptimal despite revised obstetrical imaging guidelines. A study evaluated the prenatal detection rate of critical outflow tract anomalies before and after updated AIUM guidelines in 2013 which emphasized outflow tract imaging. Overall, prenatal diagnosis occurred in 55% of infants with critical anomalies. Prenatal detection rates were similar before (52%) and after (61%) the guidelines and did not significantly improve. Despite guidelines highlighting importance of outflow tract views, referrals and prenatal diagnosis of critical anomalies like transposition of the great arteries and tetralogy of fallot remain low. Increased education of obstetric sonographers is needed to improve prenatal detection of critical outflow
Fetal echocardiographic measures to improve the prenatal diagnosis of coarcta...gisa_legal
This study aimed to identify fetal echocardiographic measures that can accurately predict postnatal coarctation of the aorta (CoA). The study retrospectively reviewed 13 cases of prenatal CoA diagnosis confirmed postnatally, 14 cases of prenatal CoA diagnosis with normal postnatal arches, and 30 controls. Measurements of the aorta, head vessels, and ventricles were made on available fetal echocardiograms. Linear mixed effects models found significant differences in the true CoA group for smaller distal transverse arch diameter, smaller distal transverse arch to head vessel index, and longer head vessel distances. The head vessel to arch index trend also differentiated true CoAs from false positives. Fetal echocardiographic
Fetal echocardiographic parameters and surgical outcomes in congenital left s...gisa_legal
This study evaluated fetal echocardiographic parameters in 68 fetuses with suspected left-sided cardiac lesions to determine predictors of neonatal intervention and surgical outcome (biventricular repair vs single-ventricle palliation). Smaller measurements of left heart structures including the left ventricle, mitral valve, aortic valve and ascending aorta as well as abnormal Doppler findings were associated with needing neonatal intervention or single-ventricle palliation. A right ventricle to left ventricle length ratio over 1.28 had the strongest association with single-ventricle palliation, identifying 76% of such cases with 96% specificity. Fetal echocardiography may help predict postnatal management for fetuses with
Prenatal diagnosis of critical congenital heart disease was associated with better preoperative outcomes compared to postnatal diagnosis. Neonates with a prenatal diagnosis had no deaths or cardiac arrests before surgery, were admitted to the cardiac center earlier, and were less likely to require preoperative ventilation or medications. Prenatal diagnosis may improve outcomes by allowing for planned delivery at a hospital near the cardiac center and earlier treatment interventions.
This document discusses the history and current state of prenatal diagnosis of congenital heart disease. It notes that while fetal cardiac evaluation was initially confined to high-risk pregnancies, four chamber view scanning became standard in the late 1980s, allowing detection of 60% of major heart defects. Extending scans to include the great arteries can detect over 90% of defects. However, detection rates vary widely in practice due to differing policies, guidelines, and scanning skills between locations. The ideal would be a universal anatomical scan at 18-20 weeks. Improvements in prenatal diagnosis could significantly impact pediatric cardiology by reducing complex heart defects and improving outcomes for children born with defects.
The document reviews 25 studies that assess medication errors in pediatric patients during prescribing, dispensing, and drug administration processes. The studies found that the combined medication error rate was highest for prescribing errors (17.5%) and administration errors (20.9%), while the rate was lowest for dispensing errors (6.5%). The review concludes that medication errors are common in healthcare systems and that the medication process is prone to errors, especially during prescribing and administration.
Prenatal diagnosis of critical congenital heart disease reduces risk of death...gisa_legal
This meta-analysis examined outcomes for newborns with critical congenital heart disease who received prenatal vs postnatal diagnoses. It analyzed data from 8 studies including 1,373 total patients. When excluding patients who were high risk or received comfort care, newborns with prenatal diagnoses were significantly less likely to die before planned cardiac surgery than those with postnatal diagnoses (pooled odds ratio 0.26). Specifically, of the 1,316 cases deemed standard risk and planned for surgery, preoperative death occurred in 0.7% with prenatal diagnosis vs 3.0% with postnatal diagnosis. The study concludes that for newborns most likely to benefit from treatment, prenatal diagnosis can reduce the risk of death prior to
This document summarizes the outcomes of an emerging pediatric cardiac surgery program's experience with surgical palliation of hypoplastic left heart syndrome (HLHS) and related anomalies between 2010-2014. The program achieved an overall hospital survival rate of 81% by utilizing different surgical strategies including the Norwood procedure, hybrid procedure, and salvage hybrid-bridge-to-Norwood procedure based on individual patient factors. Cardiac comorbidities such as obstructed pulmonary venous return influenced the choice to use a hybrid or salvage strategy. The program's flexible approach and matching of surgical strategy to patient characteristics helped achieve outcomes comparable to benchmark data, despite being a new program.
This document presents the 2012 World Heart Federation criteria for echocardiographic diagnosis of rheumatic heart disease. An international panel of experts developed evidence-based guidelines to standardize the identification of rheumatic heart disease using echocardiography. The guidelines define three categories - 'definite RHD', 'borderline RHD', and 'normal'. Criteria for 'definite RHD' include pathological mitral or aortic regurgitation accompanied by specific morphological changes to the valves. 'Borderline RHD' includes minor abnormalities that do not meet criteria for 'definite RHD'. The standardized criteria aim to allow consistent identification of rheumatic heart disease globally to facilitate screening and secondary prophylaxis programs.
Fetal echocardiographic measures to improve the prenatal diagnosis of coarcta...gisa_legal
This study aimed to identify fetal echocardiographic measures that can accurately predict postnatal coarctation of the aorta (CoA). The study retrospectively reviewed 13 cases of prenatal CoA diagnosis confirmed postnatally, 14 cases of prenatal CoA diagnosis with normal postnatal arches, and 30 controls. Measurements of the aorta, head vessels, and ventricles were made on available fetal echocardiograms. Linear mixed effects models found significant differences in the true CoA group for smaller distal transverse arch diameter, smaller distal transverse arch to head vessel index, and longer head vessel distances. The head vessel to arch index trend also differentiated true CoAs from false positives. Fetal echocardiographic
Fetal echocardiographic parameters and surgical outcomes in congenital left s...gisa_legal
This study evaluated fetal echocardiographic parameters in 68 fetuses with suspected left-sided cardiac lesions to determine predictors of neonatal intervention and surgical outcome (biventricular repair vs single-ventricle palliation). Smaller measurements of left heart structures including the left ventricle, mitral valve, aortic valve and ascending aorta as well as abnormal Doppler findings were associated with needing neonatal intervention or single-ventricle palliation. A right ventricle to left ventricle length ratio over 1.28 had the strongest association with single-ventricle palliation, identifying 76% of such cases with 96% specificity. Fetal echocardiography may help predict postnatal management for fetuses with
Prenatal diagnosis of critical congenital heart disease was associated with better preoperative outcomes compared to postnatal diagnosis. Neonates with a prenatal diagnosis had no deaths or cardiac arrests before surgery, were admitted to the cardiac center earlier, and were less likely to require preoperative ventilation or medications. Prenatal diagnosis may improve outcomes by allowing for planned delivery at a hospital near the cardiac center and earlier treatment interventions.
This document discusses the history and current state of prenatal diagnosis of congenital heart disease. It notes that while fetal cardiac evaluation was initially confined to high-risk pregnancies, four chamber view scanning became standard in the late 1980s, allowing detection of 60% of major heart defects. Extending scans to include the great arteries can detect over 90% of defects. However, detection rates vary widely in practice due to differing policies, guidelines, and scanning skills between locations. The ideal would be a universal anatomical scan at 18-20 weeks. Improvements in prenatal diagnosis could significantly impact pediatric cardiology by reducing complex heart defects and improving outcomes for children born with defects.
The document reviews 25 studies that assess medication errors in pediatric patients during prescribing, dispensing, and drug administration processes. The studies found that the combined medication error rate was highest for prescribing errors (17.5%) and administration errors (20.9%), while the rate was lowest for dispensing errors (6.5%). The review concludes that medication errors are common in healthcare systems and that the medication process is prone to errors, especially during prescribing and administration.
Prenatal diagnosis of critical congenital heart disease reduces risk of death...gisa_legal
This meta-analysis examined outcomes for newborns with critical congenital heart disease who received prenatal vs postnatal diagnoses. It analyzed data from 8 studies including 1,373 total patients. When excluding patients who were high risk or received comfort care, newborns with prenatal diagnoses were significantly less likely to die before planned cardiac surgery than those with postnatal diagnoses (pooled odds ratio 0.26). Specifically, of the 1,316 cases deemed standard risk and planned for surgery, preoperative death occurred in 0.7% with prenatal diagnosis vs 3.0% with postnatal diagnosis. The study concludes that for newborns most likely to benefit from treatment, prenatal diagnosis can reduce the risk of death prior to
This document summarizes the outcomes of an emerging pediatric cardiac surgery program's experience with surgical palliation of hypoplastic left heart syndrome (HLHS) and related anomalies between 2010-2014. The program achieved an overall hospital survival rate of 81% by utilizing different surgical strategies including the Norwood procedure, hybrid procedure, and salvage hybrid-bridge-to-Norwood procedure based on individual patient factors. Cardiac comorbidities such as obstructed pulmonary venous return influenced the choice to use a hybrid or salvage strategy. The program's flexible approach and matching of surgical strategy to patient characteristics helped achieve outcomes comparable to benchmark data, despite being a new program.
This document presents the 2012 World Heart Federation criteria for echocardiographic diagnosis of rheumatic heart disease. An international panel of experts developed evidence-based guidelines to standardize the identification of rheumatic heart disease using echocardiography. The guidelines define three categories - 'definite RHD', 'borderline RHD', and 'normal'. Criteria for 'definite RHD' include pathological mitral or aortic regurgitation accompanied by specific morphological changes to the valves. 'Borderline RHD' includes minor abnormalities that do not meet criteria for 'definite RHD'. The standardized criteria aim to allow consistent identification of rheumatic heart disease globally to facilitate screening and secondary prophylaxis programs.
This document discusses acute rheumatic fever (ARF) and rheumatic heart disease (RHD) in resource-limited settings. It presents a case study of a 12-year-old girl diagnosed with ARF in The Gambia. Key challenges in diagnosis and management of ARF and RHD in these settings include limited access to investigations like echocardiography and lack of specialists. The Jones criteria for diagnosing ARF may be too insensitive for high-prevalence areas. Management involves bed rest, antibiotics, aspirin, and follow-up care, though access can be limited. RHD is a major cause of heart disease worldwide and often presents with severe disease due to limited care access.
Circulation 2015-criterios de jones reviewgisa_legal
This document revises the Jones criteria for diagnosing acute rheumatic fever to better align with current evidence and international guidelines. It recognizes that acute rheumatic fever remains a serious health problem globally. The revisions define high-risk populations, acknowledge variability in clinical presentation among these groups, and include Doppler echocardiography as a tool for diagnosing cardiac involvement even without overt symptoms. This represents the first major revision to the Jones criteria by the American Heart Association in over 20 years and applies their classification system for recommendations and evidence levels.
Pulmonary outflow tract obstruction in fetuses with complexgisa_legal
This study aimed to identify prenatal echocardiographic markers that could predict which fetuses with right ventricular outflow tract obstruction and complex congenital heart disease would require neonatal intervention. The study reviewed prenatal echocardiograms and neonatal outcomes of 52 fetuses. It found that fetuses who required neonatal intervention had significantly lower pulmonary valve Z-scores and smaller pulmonary valve to aortic valve diameter ratios. Classifying ductus arteriosus flow direction as abnormal was highly sensitive and specific for predicting need for intervention. Analysis of the pulmonary outflow tract and ductus arteriosus flow can help identify fetuses likely to require postnatal support of pulmonary blood flow.
This study aimed to determine which combination of cardiac parameters best predicts postnatal coarctation of the aorta (CoAo) in fetuses with cardiac asymmetry. The study analyzed 85 liveborn fetuses with isolated cardiac asymmetry and complete postnatal follow-up. CoAo was confirmed in 41/85 neonates (48%). Logistic regression identified four parameters that best predicted CoAo: gestational age at diagnosis, Z-scores of the ascending aorta and aortic isthmus diameters, and the pulmonary valve/aortic valve diameter ratio. Combining these parameters allowed calculation of individual post-test probabilities for CoAo, improving prediction compared to individual parameters alone.
- The document describes the results of a study analyzing the reasons for over 2000 pediatric cardiology consultations at a tertiary academic hospital over 12 months.
- The most common reasons for consultation were murmurs (18.5%), evaluation of cardiac function (12.7%), and arrhythmias (12.7%).
- For murmurs, the most common diagnoses were patent ductus arteriosus, ventricular septal defects, innocent murmurs, and pulmonary branch murmurs of infancy. Evaluation of function was often for oncologic diseases and congenital heart disease. Most arrhythmias were supraventricular in origin.
This study examined outcomes for fetuses diagnosed prenatally with absent pulmonary valve syndrome (APV), dividing them into two groups - those with APV associated with tetralogy of Fallot (TOF/APV), and those without an underlying heart defect and either an intact ventricular septum or small ventricular septal defect (APV/IVS). There were no fetal deaths in either group. Survival to birth was 71% for TOF/APV and 83% for APV/IVS, with 80% survival among those born alive for both groups. However, transplantation-free survival was only 20% for APV/IVS due to single-ventricle physiology strongly predicting heart transplantation. Left ventricular
This study analyzed 1,474 cases of congenital heart disease (CHD) identified between 1997-2007 in Utah to evaluate prenatal detection rates and barriers. The main findings were:
1) CHD was only detected prenatally in 39% of cases, and the detection rate did not improve over the 10-year study period.
2) While 97% of mothers received at least one prenatal ultrasound, the ultrasound failed to detect CHD in 61% of cases.
3) Factors associated with increased odds of prenatal detection included a family history of CHD, presence of extracardiac defects, and ultrasound performed at a high-risk clinic rather than a general clinic. Defect
Detecção pré natal de cc resultado de programa preliminargisa_legal
This study evaluated the effectiveness of a national prenatal screening program for congenital heart disease (CHD) introduced in the Netherlands in 2007. The study found that the overall prenatal detection rate of severe CHD increased from 35.8% before the screening program to 59.7% after. Some specific types of CHD saw even larger increases, such as hypoplastic left heart syndrome which increased from 54.1% to 97.6% detection. Additionally, late referrals after 24 weeks gestation decreased by 24.3% following the screening program. This is the largest study to investigate prenatal detection rates of severe CHD in an unselected population, and found the screening program led to remarkably high detection compared to
The expert panel developed comprehensive, evidence-based guidelines to assist pediatric care providers in promoting cardiovascular health and managing risk factors from infancy to young adulthood. The guidelines address both the prevention of risk factor development and the management of existing risk factors to prevent future cardiovascular disease. The evidence review considered a broad range of questions on risk factor development, progression, and management extending from birth to age 21. While randomized controlled trials were limited, the review included relevant epidemiological studies. The panel's recommendations are presented in a cardiovascular health schedule by age to guide risk factor screening and treatment. The full report cites over 1000 studies and is available online.
This study aimed to establish a complete set of reference ranges for 18 parameters routinely measured during perinatal autopsies in Australia. The study reviewed 1116 autopsy reports from a hospital between 2001-2006. Reference ranges including means, standard deviations, and percentiles were produced for each parameter by gestational age from 12 to 42 weeks. The reference ranges account for the mixed immigrant population in Australia and will be valuable for perinatal pathologists.
1) The study investigated perinatal outcomes for 312 fetuses diagnosed prenatally with single-ventricle heart defects between 1995-2008.
2) Most common diagnoses were hypoplastic left heart syndrome (HLHS) for dominant right ventricle and tricuspid atresia for dominant left ventricle.
3) Prenatal outcomes included 31% elective termination of pregnancy, 4% spontaneous fetal demise, 4% lost to follow up, and 61% born alive. Postnatal outcomes varied by diagnosis, with lower survival for high risk HLHS.
This study compared long-term outcomes of children randomized to balloon angioplasty (BA) or surgery for treatment of native coarctation of the aorta (CoA) during childhood. Of the original 36 subjects, 21 returned for evaluation 10-12 years later. Resting blood pressure, exercise performance, and magnetic resonance imaging results were similar between groups. However, BA was associated with a higher rate of aneurysm formation (35% vs 0%) and greater differences in blood pressure between legs during exercise compared to surgery. Only 50% of BA subjects remained free of aneurysms or need for repeat procedures, compared to 87.5% of surgery subjects. The risk of complications was higher with BA than surgery as a long
FIBRILACION AURICULAR EN URGENCIAS THE After Studyjasar
- The study derived and validated a complex model and simplified model to predict 30-day mortality for patients presenting to the emergency department with atrial fibrillation.
- The complex model considered age, vital signs, laboratory results, comorbidities, bleeding risk, and secondary diagnoses, achieving c-statistics of 0.88-0.87.
- The simplified 6-variable TrOPs-BAC model included troponin result, other diagnosis, pulmonary disease, bleeding risk, age over 75, and congestive heart failure, with c-statistics of 0.81 in both cohorts.
This systematic review and meta-analysis examined the prevalence of abnormalities associated with persistent left superior vena cava (PLSVC) detected on prenatal ultrasound. The main findings were:
1) Associated intra-cardiac and extra-cardiac anomalies were detected at the initial scan in 56.6% and 37.8% of cases, respectively.
2) Chromosomal abnormalities occurred in 12.5% of all PLSVC cases and 7% of isolated PLSVC cases.
3) Additional intra-cardiac and extra-cardiac anomalies missed on initial ultrasound but detected after birth occurred in 2.4% and 6.7% of isolated PLSVC cases, respectively.
4) Co
Diagnosis and treatment of fetal cardiac disease aha 2014gisa_legal
This scientific statement from the American Heart Association reviews the current practice of fetal cardiac medicine. It discusses advances in prenatal diagnosis of heart conditions using ultrasound and other imaging technologies. The statement also addresses evaluation of cardiac function, rhythm, and the cardiovascular system in the fetus. It presents recommendations on the performance and interpretation of prenatal diagnostic studies. Additionally, the statement outlines available prenatal treatment options for certain conditions and strategies for delivery planning and counseling parents on outcomes.
Prediction for rashkind procedure in fetuses with d tgvbgisa_legal
This study aimed to identify prenatal echocardiographic features that predict the need for a Rashkind procedure within 24 hours of birth in fetuses with dextro-transposition of the great arteries (d-TGA). The study retrospectively analyzed 51 fetuses with d-TGA, comparing those who did (n=29) and did not (n=22) require the Rashkind procedure. While most parameters did not differ between groups, fetuses requiring the procedure had significantly higher pulmonary venous maximum velocities and were more likely to have a flattened foramen ovale valve seen on prenatal ultrasound. These findings may help predict which fetuses will need urgent postnatal intervention.
This study aimed to identify prenatal ultrasound features that can predict whether fetuses diagnosed with dextro-transposition of the great arteries (d-TGA) will require a Rashkind procedure within the first 24 hours after birth. The study compared 51 fetuses who did require the procedure to 22 who did not. Two features were found to be associated with needing the procedure: increased maximum velocity of blood flow in the pulmonary veins, and a flattened appearance of the foramen ovale valve on prenatal ultrasound. These features may help predict which fetuses will need urgent postnatal intervention.
1) The document describes a study comparing early prenatal diagnosis of fetal tetralogy of Fallot (fTOF) between 12-17 weeks gestation to diagnosis after 17 weeks.
2) It found that while detailed assessment of cardiac anatomy was possible in most early cases, referral indications and pregnancy outcomes differed significantly between early and later diagnosis groups.
3) Specifically, early diagnosis was usually due to extracardiac abnormalities, and resulted in termination 80% of the time, compared to 33% termination for later diagnoses usually due to suspected cardiac abnormalities on routine ultrasound.
Diagnosis of tetralogy of fallot and its variants in thegisa_legal
Fetal tetralogy of Fallot (fTOF) can be diagnosed in the late first and early second trimesters of pregnancy using fetal echocardiography. This study reviewed 10 cases of fTOF diagnosed between 12-17 weeks gestation and compared them to 25 cases diagnosed after 17 weeks. Key findings included: 1) Detailed cardiac anatomy was possible in most early cases, though visualization was sometimes limited; 2) Referrals for early cases often involved extracardiac anomalies while later cases were usually for suspected cardiac issues; 3) Pregnancy termination was more common for early diagnoses (80%) versus later diagnoses (33%).
Fetal interventions for congenital heart disease in brazilgisa_legal
In this preliminary study from Brazil, fetal cardiac interventions were performed in 21 fetuses with congenital heart defects. The interventions included aortic valvuloplasty for critical aortic stenosis, atrial septoplasty for hypoplastic left heart syndrome, and pulmonary valvuloplasty for pulmonary atresia or stenosis. The procedures had a 91% technical success rate, with one fetal death. Postnatal outcomes varied, with some patients achieving biventricular circulation and others requiring univentricular palliation or dying. This early experience demonstrated feasibility and outcomes similar to previous reports, though safety and efficacy require further study.
This multicenter study characterized patients with anomalous left coronary artery from the pulmonary artery (ALCAPA) who underwent repair after 1 year of age. Of 248 ALCAPA patients, 71 (29%) underwent repair at age 1 year or older. These older patients were more likely to present with cardiac arrest but less likely to have left ventricular dysfunction or mitral regurgitation compared to infants. Postoperatively, most older patients showed good recovery of left ventricular function and size, though chronic mitral regurgitation and arrhythmias remained common. Survival rates were excellent, with only 1 operative death and no late deaths among this older cohort.
Detecção pré natal de cc resultado de programa preliminargisa_legal
This study evaluated the effectiveness of a national prenatal screening program for congenital heart disease (CHD) introduced in the Netherlands in 2007. The study found that the overall prenatal detection rate of severe CHD increased from 35.8% before the screening program to 59.7% after. Some specific types of CHD saw even larger increases, such as hypoplastic left heart syndrome which increased from 54.1% to 97.6% detection. Additionally, late referrals after 24 weeks gestation decreased by 24.3% following the screening program. This is the largest study to investigate prenatal detection rates of severe CHD in an unselected population, and found the screening program led to remarkably high detection compared to
This document discusses acute rheumatic fever (ARF) and rheumatic heart disease (RHD) in resource-limited settings. It presents a case study of a 12-year-old girl diagnosed with ARF in The Gambia. Key challenges in diagnosis and management of ARF and RHD in these settings include limited access to investigations like echocardiography and lack of specialists. The Jones criteria for diagnosing ARF may be too insensitive for high-prevalence areas. Management involves bed rest, antibiotics, aspirin, and follow-up care, though access can be limited. RHD is a major cause of heart disease worldwide and often presents with severe disease due to limited care access.
Circulation 2015-criterios de jones reviewgisa_legal
This document revises the Jones criteria for diagnosing acute rheumatic fever to better align with current evidence and international guidelines. It recognizes that acute rheumatic fever remains a serious health problem globally. The revisions define high-risk populations, acknowledge variability in clinical presentation among these groups, and include Doppler echocardiography as a tool for diagnosing cardiac involvement even without overt symptoms. This represents the first major revision to the Jones criteria by the American Heart Association in over 20 years and applies their classification system for recommendations and evidence levels.
Pulmonary outflow tract obstruction in fetuses with complexgisa_legal
This study aimed to identify prenatal echocardiographic markers that could predict which fetuses with right ventricular outflow tract obstruction and complex congenital heart disease would require neonatal intervention. The study reviewed prenatal echocardiograms and neonatal outcomes of 52 fetuses. It found that fetuses who required neonatal intervention had significantly lower pulmonary valve Z-scores and smaller pulmonary valve to aortic valve diameter ratios. Classifying ductus arteriosus flow direction as abnormal was highly sensitive and specific for predicting need for intervention. Analysis of the pulmonary outflow tract and ductus arteriosus flow can help identify fetuses likely to require postnatal support of pulmonary blood flow.
This study aimed to determine which combination of cardiac parameters best predicts postnatal coarctation of the aorta (CoAo) in fetuses with cardiac asymmetry. The study analyzed 85 liveborn fetuses with isolated cardiac asymmetry and complete postnatal follow-up. CoAo was confirmed in 41/85 neonates (48%). Logistic regression identified four parameters that best predicted CoAo: gestational age at diagnosis, Z-scores of the ascending aorta and aortic isthmus diameters, and the pulmonary valve/aortic valve diameter ratio. Combining these parameters allowed calculation of individual post-test probabilities for CoAo, improving prediction compared to individual parameters alone.
- The document describes the results of a study analyzing the reasons for over 2000 pediatric cardiology consultations at a tertiary academic hospital over 12 months.
- The most common reasons for consultation were murmurs (18.5%), evaluation of cardiac function (12.7%), and arrhythmias (12.7%).
- For murmurs, the most common diagnoses were patent ductus arteriosus, ventricular septal defects, innocent murmurs, and pulmonary branch murmurs of infancy. Evaluation of function was often for oncologic diseases and congenital heart disease. Most arrhythmias were supraventricular in origin.
This study examined outcomes for fetuses diagnosed prenatally with absent pulmonary valve syndrome (APV), dividing them into two groups - those with APV associated with tetralogy of Fallot (TOF/APV), and those without an underlying heart defect and either an intact ventricular septum or small ventricular septal defect (APV/IVS). There were no fetal deaths in either group. Survival to birth was 71% for TOF/APV and 83% for APV/IVS, with 80% survival among those born alive for both groups. However, transplantation-free survival was only 20% for APV/IVS due to single-ventricle physiology strongly predicting heart transplantation. Left ventricular
This study analyzed 1,474 cases of congenital heart disease (CHD) identified between 1997-2007 in Utah to evaluate prenatal detection rates and barriers. The main findings were:
1) CHD was only detected prenatally in 39% of cases, and the detection rate did not improve over the 10-year study period.
2) While 97% of mothers received at least one prenatal ultrasound, the ultrasound failed to detect CHD in 61% of cases.
3) Factors associated with increased odds of prenatal detection included a family history of CHD, presence of extracardiac defects, and ultrasound performed at a high-risk clinic rather than a general clinic. Defect
Detecção pré natal de cc resultado de programa preliminargisa_legal
This study evaluated the effectiveness of a national prenatal screening program for congenital heart disease (CHD) introduced in the Netherlands in 2007. The study found that the overall prenatal detection rate of severe CHD increased from 35.8% before the screening program to 59.7% after. Some specific types of CHD saw even larger increases, such as hypoplastic left heart syndrome which increased from 54.1% to 97.6% detection. Additionally, late referrals after 24 weeks gestation decreased by 24.3% following the screening program. This is the largest study to investigate prenatal detection rates of severe CHD in an unselected population, and found the screening program led to remarkably high detection compared to
The expert panel developed comprehensive, evidence-based guidelines to assist pediatric care providers in promoting cardiovascular health and managing risk factors from infancy to young adulthood. The guidelines address both the prevention of risk factor development and the management of existing risk factors to prevent future cardiovascular disease. The evidence review considered a broad range of questions on risk factor development, progression, and management extending from birth to age 21. While randomized controlled trials were limited, the review included relevant epidemiological studies. The panel's recommendations are presented in a cardiovascular health schedule by age to guide risk factor screening and treatment. The full report cites over 1000 studies and is available online.
This study aimed to establish a complete set of reference ranges for 18 parameters routinely measured during perinatal autopsies in Australia. The study reviewed 1116 autopsy reports from a hospital between 2001-2006. Reference ranges including means, standard deviations, and percentiles were produced for each parameter by gestational age from 12 to 42 weeks. The reference ranges account for the mixed immigrant population in Australia and will be valuable for perinatal pathologists.
1) The study investigated perinatal outcomes for 312 fetuses diagnosed prenatally with single-ventricle heart defects between 1995-2008.
2) Most common diagnoses were hypoplastic left heart syndrome (HLHS) for dominant right ventricle and tricuspid atresia for dominant left ventricle.
3) Prenatal outcomes included 31% elective termination of pregnancy, 4% spontaneous fetal demise, 4% lost to follow up, and 61% born alive. Postnatal outcomes varied by diagnosis, with lower survival for high risk HLHS.
This study compared long-term outcomes of children randomized to balloon angioplasty (BA) or surgery for treatment of native coarctation of the aorta (CoA) during childhood. Of the original 36 subjects, 21 returned for evaluation 10-12 years later. Resting blood pressure, exercise performance, and magnetic resonance imaging results were similar between groups. However, BA was associated with a higher rate of aneurysm formation (35% vs 0%) and greater differences in blood pressure between legs during exercise compared to surgery. Only 50% of BA subjects remained free of aneurysms or need for repeat procedures, compared to 87.5% of surgery subjects. The risk of complications was higher with BA than surgery as a long
FIBRILACION AURICULAR EN URGENCIAS THE After Studyjasar
- The study derived and validated a complex model and simplified model to predict 30-day mortality for patients presenting to the emergency department with atrial fibrillation.
- The complex model considered age, vital signs, laboratory results, comorbidities, bleeding risk, and secondary diagnoses, achieving c-statistics of 0.88-0.87.
- The simplified 6-variable TrOPs-BAC model included troponin result, other diagnosis, pulmonary disease, bleeding risk, age over 75, and congestive heart failure, with c-statistics of 0.81 in both cohorts.
This systematic review and meta-analysis examined the prevalence of abnormalities associated with persistent left superior vena cava (PLSVC) detected on prenatal ultrasound. The main findings were:
1) Associated intra-cardiac and extra-cardiac anomalies were detected at the initial scan in 56.6% and 37.8% of cases, respectively.
2) Chromosomal abnormalities occurred in 12.5% of all PLSVC cases and 7% of isolated PLSVC cases.
3) Additional intra-cardiac and extra-cardiac anomalies missed on initial ultrasound but detected after birth occurred in 2.4% and 6.7% of isolated PLSVC cases, respectively.
4) Co
Diagnosis and treatment of fetal cardiac disease aha 2014gisa_legal
This scientific statement from the American Heart Association reviews the current practice of fetal cardiac medicine. It discusses advances in prenatal diagnosis of heart conditions using ultrasound and other imaging technologies. The statement also addresses evaluation of cardiac function, rhythm, and the cardiovascular system in the fetus. It presents recommendations on the performance and interpretation of prenatal diagnostic studies. Additionally, the statement outlines available prenatal treatment options for certain conditions and strategies for delivery planning and counseling parents on outcomes.
Prediction for rashkind procedure in fetuses with d tgvbgisa_legal
This study aimed to identify prenatal echocardiographic features that predict the need for a Rashkind procedure within 24 hours of birth in fetuses with dextro-transposition of the great arteries (d-TGA). The study retrospectively analyzed 51 fetuses with d-TGA, comparing those who did (n=29) and did not (n=22) require the Rashkind procedure. While most parameters did not differ between groups, fetuses requiring the procedure had significantly higher pulmonary venous maximum velocities and were more likely to have a flattened foramen ovale valve seen on prenatal ultrasound. These findings may help predict which fetuses will need urgent postnatal intervention.
This study aimed to identify prenatal ultrasound features that can predict whether fetuses diagnosed with dextro-transposition of the great arteries (d-TGA) will require a Rashkind procedure within the first 24 hours after birth. The study compared 51 fetuses who did require the procedure to 22 who did not. Two features were found to be associated with needing the procedure: increased maximum velocity of blood flow in the pulmonary veins, and a flattened appearance of the foramen ovale valve on prenatal ultrasound. These features may help predict which fetuses will need urgent postnatal intervention.
1) The document describes a study comparing early prenatal diagnosis of fetal tetralogy of Fallot (fTOF) between 12-17 weeks gestation to diagnosis after 17 weeks.
2) It found that while detailed assessment of cardiac anatomy was possible in most early cases, referral indications and pregnancy outcomes differed significantly between early and later diagnosis groups.
3) Specifically, early diagnosis was usually due to extracardiac abnormalities, and resulted in termination 80% of the time, compared to 33% termination for later diagnoses usually due to suspected cardiac abnormalities on routine ultrasound.
Diagnosis of tetralogy of fallot and its variants in thegisa_legal
Fetal tetralogy of Fallot (fTOF) can be diagnosed in the late first and early second trimesters of pregnancy using fetal echocardiography. This study reviewed 10 cases of fTOF diagnosed between 12-17 weeks gestation and compared them to 25 cases diagnosed after 17 weeks. Key findings included: 1) Detailed cardiac anatomy was possible in most early cases, though visualization was sometimes limited; 2) Referrals for early cases often involved extracardiac anomalies while later cases were usually for suspected cardiac issues; 3) Pregnancy termination was more common for early diagnoses (80%) versus later diagnoses (33%).
Fetal interventions for congenital heart disease in brazilgisa_legal
In this preliminary study from Brazil, fetal cardiac interventions were performed in 21 fetuses with congenital heart defects. The interventions included aortic valvuloplasty for critical aortic stenosis, atrial septoplasty for hypoplastic left heart syndrome, and pulmonary valvuloplasty for pulmonary atresia or stenosis. The procedures had a 91% technical success rate, with one fetal death. Postnatal outcomes varied, with some patients achieving biventricular circulation and others requiring univentricular palliation or dying. This early experience demonstrated feasibility and outcomes similar to previous reports, though safety and efficacy require further study.
This multicenter study characterized patients with anomalous left coronary artery from the pulmonary artery (ALCAPA) who underwent repair after 1 year of age. Of 248 ALCAPA patients, 71 (29%) underwent repair at age 1 year or older. These older patients were more likely to present with cardiac arrest but less likely to have left ventricular dysfunction or mitral regurgitation compared to infants. Postoperatively, most older patients showed good recovery of left ventricular function and size, though chronic mitral regurgitation and arrhythmias remained common. Survival rates were excellent, with only 1 operative death and no late deaths among this older cohort.
Detecção pré natal de cc resultado de programa preliminargisa_legal
This study evaluated the effectiveness of a national prenatal screening program for congenital heart disease (CHD) introduced in the Netherlands in 2007. The study found that the overall prenatal detection rate of severe CHD increased from 35.8% before the screening program to 59.7% after. Some specific types of CHD saw even larger increases, such as hypoplastic left heart syndrome which increased from 54.1% to 97.6% detection. Additionally, late referrals after 24 weeks gestation decreased by 24.3% following the screening program. This is the largest study to investigate prenatal detection rates of severe CHD in an unselected population, and found the screening program led to remarkably high detection compared to
Detecção pré natal de cc resultado de programa preliminargisa_legal
This study evaluated the effectiveness of a national prenatal screening program for congenital heart disease (CHD) introduced in the Netherlands in 2007. The study found that the overall prenatal detection rate of severe CHD increased from 35.8% before the screening program to 59.7% after. Some specific types of CHD saw even larger increases, such as hypoplastic left heart syndrome which increased from 54.1% to 97.6% detection. Additionally, late referrals after 24 weeks gestation decreased by 24.3% following the screening program. This is the largest study to investigate prenatal detection rates of severe CHD in an unselected population, and found the screening program led to remarkably high detection compared to
Journal of perinatology fetal cardiology changing the definition of critica...gisa_legal
1) The document discusses different classification systems for critical congenital heart disease (CHD) in fetuses and newborns that require urgent intervention within the first 24 hours of life.
2) It describes the most common types of critical CHD, including hypoplastic left heart syndrome (HLHS) with a restricted or closed atrial septum, total anomalous pulmonary venous return with obstruction, and transposition of the great arteries with a restrictive atrial septum.
3) For HLHS, certain Doppler ultrasound parameters measured late in pregnancy, such as a pulmonary vein flow velocity time integral ratio below 3, can help identify fetuses needing emergency intervention immediately after birth to improve survival rates.
Stratified Management of Cardiac Surgery for Structural Heart Disease during ...semualkaira
We study pregnancy outcomes of cardiac surgery
under cardiopulmonary bypass (CPB) at different stages and discuss stratified management of cardiac surgery under CPB in pregnant women with structural heart disease (SHD) from pre-pregnancy counseling through postpartum management.
Stratified Management of Cardiac Surgery for Structural Heart Disease during ...semualkaira
: We study pregnancy outcomes of cardiac surgery
under cardiopulmonary bypass (CPB) at different stages and discuss stratified management of cardiac surgery under CPB in pregnant women with structural heart disease (SHD) from pre-pregnancy counseling through postpartum management.
This study examined echocardiographic predictors of perinatal mortality in fetuses diagnosed with Ebstein's anomaly or tricuspid valve dysplasia. The study reviewed 21 fetuses between 2000-2008. Smaller right atrial size and absence of hydrops were associated with improved survival. Analysis of left ventricular function showed non-survivors had shorter combined contraction and relaxation times, though ejection times did not differ. Overall perinatal survival was 75% and survival to 3 months was 57-50% depending on whether terminations were included.
This study examined the impact of prenatal diagnosis via fetal echocardiography on outcomes for neonates with critical congenital heart defects (CHD) requiring intervention within the first month of life. The study compared outcomes between neonates who were diagnosed prenatally (n=29) versus postnatally (n=71). Key findings included that neonates diagnosed prenatally presented at birth in better condition, with a mean age of presentation of 0 days compared to 10 days for those diagnosed postnatally. Prenatal diagnosis also facilitated delivery at a tertiary care center for 34.5% of cases and improved preoperative stabilization. However, there were no significant differences found in postoperative outcomes between the two groups.
Ann pediatrcard eco fetal no diag precocegisa_legal
This study examined the impact of prenatal diagnosis via fetal echocardiography on neonatal outcomes for critical congenital heart defects. The study compared outcomes for 29 neonates diagnosed prenatally via fetal echocardiography to 71 diagnosed postnatally. Prenatal diagnosis resulted in planned deliveries at tertiary care centers for 10/29 babies and allowed for prompt postnatal stabilization. Prenatal diagnosis was associated with shorter time to presentation, better preoperative stabilization including use of prostaglandin, and improved pH and mortality rates compared to postnatal diagnosis. Fetal echocardiography facilitated improved counseling and management planning, leading to reduced morbidity and mortality.
Fetal echocardiography provides several advantages for diagnosing and managing congenital heart disease:
1) It allows for counseling of parents on prognosis and treatment options, including the possibility of termination of pregnancy for major defects or chromosomal anomalies.
2) In some cases, it enables life-saving procedures to be performed on the mother or fetus before or during pregnancy.
3) It facilitates delivery planning at a specialized medical center near pediatric cardiac surgery.
Screening for heart defects in the first trimesterTony Terrones
This document discusses two studies on screening for heart defects in the first trimester of pregnancy. The first study measured cardiac axis in 100 pregnancies between 11-14 weeks and found an abnormal axis in 4 cases that were later diagnosed with congenital heart disease. However, the study excluded women with high BMI and nearly 20% required additional imaging, calling into question its applicability for widespread screening. The second study found measuring ductus venosus pulsatility index could help predict heart defects, but obtaining a clear measurement may be difficult and half of postnatally diagnosed cases were missed prenatally. The document concludes that while identifying high-risk cases early is important, screening also needs to allow for timely diagnostic imaging and accurate diagnosis
Prenatal diagnosis of critical congenital heart disease reduces risk of death...gisa_legal
This meta-analysis examined outcomes for newborns with critical congenital heart disease who received prenatal vs postnatal diagnoses. It analyzed data from 8 studies including 1,373 total patients. When excluding patients who were high risk or received comfort care, newborns with prenatal diagnoses were significantly less likely to die before planned cardiac surgery than those with postnatal diagnoses (pooled odds ratio 0.26). Specifically, of the 1,316 cases deemed standard risk and planned for surgery, preoperative death occurred in 0.7% with prenatal diagnosis vs 3.0% with postnatal diagnosis. The study concludes that for newborns most likely to benefit from treatment, prenatal diagnosis can reduce the risk of death prior to
ISUOG consensus statement: what constitutes a fetal echocardiogram?Tony Terrones
This document presents a consensus statement from an expert panel that defines what constitutes a fetal echocardiogram. A fetal echocardiogram involves a thorough examination of standard cardiac views using ultrasound and Doppler techniques to assess cardiac structure, function, connections, and blood flow. It should be performed by specialists with training in fetal cardiac imaging when indications such as increased risk of congenital heart disease or abnormal screening results are present.
This document describes a study conducted at a children's heart center examining alternative surgical strategies for high-risk neonates and infants with congenital heart defects and significant co-morbidities. The study analyzed 442 cardiac surgeries performed between 2010-2013. It found that alternative bi-ventricular and uni-ventricular strategies minimized mortality but were associated with prolonged intubation, ICU stay, and hospitalization compared to standard strategies. Major pre-operative risk factors and lower weight significantly correlated with worse outcomes. The study concludes that flexible surgical approaches allowed survival of high-risk patients, though at the cost of increased resource utilization.
The study analyzed 201 preterm neonates treated medically or surgically for a patent ductus arteriosus (PDA). The mean PDA diameter was significantly larger in patients where medical treatment failed compared to those where it succeeded. An index of PDA diameter squared divided by birth weight below 9 mm2/kg correctly predicted successful medical closure in 87.5% of patients, while an index above 9 mm2/kg correctly predicted medication failure in 41.5% of patients. Respiration time was significantly longer before PDA closure in patients where medication failed compared to those where it succeeded, but similar after closure between groups. Larger PDA size and lower birth weight make medical treatment more likely to fail.
This study evaluated the effects of prenatal corticosteroid treatment on 56 fetuses diagnosed with isolated congenital atrioventricular block (CAVB) in the Netherlands between 2003-2013. The study found no differences in outcomes between fetuses treated with dexamethasone (n=14) and those receiving expectant management (n=42). Specifically, there were no differences in rates of AV block progression, survival to birth, pacemaker implantation, or development of dilated cardiomyopathy. However, fetuses treated with dexamethasone demonstrated more in utero growth restriction. The data provide no evidence to support routine prenatal corticosteroid treatment for isolated CAVB.
This study evaluated 70 patients with oral clefts to describe their clinical, electrocardiographic, and echocardiographic cardiovascular findings. Sixty percent of patients were male, and most had cleft lip and palate. Forty-four percent had comorbidities. Family history of risk for metabolic syndrome was present in 49% of patients, and one patient was diagnosed with rheumatic heart disease. Electrocardiograms found one case of atrioventricular block, and echocardiograms were abnormal in 36% of patients, including 5 cases of mitral valve prolapse. The findings indicate patients with oral clefts may be prone to acquired heart disease, so cardiovascular follow-up is necessary.
Similar to Prenatal detection of critical cardiac outflow tract anomalies (20)
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2. 2 | SUN et al.
1 | INTRODUCTION
Congenital heart disease (CHD) is the most common congenital
anomaly, accounting for approximately 1% of live births.1
About one
in four infants with CHD have critical CHD requiring timely inter-
vention after birth to prevent significant morbidity or mortality.2
Prenatal diagnosis of critical CHD by fetal echocardiogram (ECHO)
leads to appropriate fetal cardiac care, delivery, and postnatal man-
agement in a pediatric cardiac center.3
Most referrals for fetal ECHO
and subsequent accurate prenatal diagnosis of CHD rely primarily on
abnormality detection on screening obstetrical anatomic ultrasound,
as many cases of CHD occur in otherwise low‐risk pregnancies.4,5
Until recently, obstetric anatomic ultrasound guidelines for
cardiac evaluation mandated only a four‐chamber view, with
“views of the outflow tracts attempted as part of the cardiac
screening.”6
Critical CHD that can be missed by imaging only the
four‐chamber view (Figure 1A) include outflow tract anomalies
such as D‐transposition of the great arteries (TGA) (Figure 1B and
C), congenitally corrected‐TGA (cc‐TGA), tetralogy of Fallot (TOF),
double outlet right ventricle (DORV), pulmonary atresia with intact
ventricular septum (PA/IVS), truncus arteriosus, pulmonary steno-
sis, and aortic stenosis. Many of these defects require surgical or
cardiac catheterization intervention within the first few months
of life and usually prior to discharge after delivery. In this study,
we defined critical CHD as a cardiac defect requiring cardiac cath-
eterization and/or surgical procedure(s) in the first 3 months of
life, with a focus on outflow tract anomalies. Studies have demon-
strated the ability of fetal ECHO to predict the need for urgent
postnatal intervention,7‒9
as well as improved neonatal outcomes
with prenatal diagnosis.10‒12
With evidence supporting the value
of ventricular outflow tract imaging,13
in June 2013, the American
Institute of Ultrasound in Medicine (in conjunction with the
American College of Radiology, American College of Obstetricians
and Gynecologists, and the Society of Radiologists in Ultrasound)
updated its obstetrical ultrasound guidelines to include evaluation
of the ventricular outflow tracts.14
2 | OBJECTIVE
As the San Diego region’s only pediatric cardiac and cardiovascular
surgery center, all neonates with critical CHD potentially requir-
ing interventional management are cared for at Rady Children’s
Hospital. The primary objective of this retrospective study was
to evaluate the prenatal detection rate of critical outflow tract
anomalies in neonates at Rady Children’s Hospital with critical
outflow tract CHD before and after theoretical implementation
of the 2013 updated obstetrical imaging guidelines. Ideally, the
majority of neonates with critical outflow tract CHD should have
been detected by prenatal ventricular outflow tract imaging on
obstetrical ultrasound.
3 | METHODS
3.1 | Study design
Infants with critical CHD requiring cardiac catheterization and/
or surgical procedure(s) in the first 3 months of life were retro-
spectively identified through Rady Children’s Hospital cardiac and
electronic medical record databases. Infants were subdivided into
two time frames; the pre‐guideline time frame consisted of infants
requiring procedures between June 2010 and May 2013, while
the post‐guideline time frame consisted of infants requiring pro-
cedures between January 2015 and June 2016. The timeframe be-
tween June 2013 and December 2014 was specifically excluded
to allow for theoretical time necessary for obstetrical providers to
FI G U R E 1 (A) Normal appearing cardiac four‐chamber view with abnormal parallel, (B) right ventricular, and (C) left ventricular outflow
tracts in a fetus with D‐transposition of the great arteries. Abbreviations: RV, right ventricle; LV, left ventricle; RA, right atrium; LA, left
atrium; Ao, aorta; PA, pulmonary artery
3. | 3SUN et al.
implement the recommended guidelines into daily practice. Actual
implementation of outflow tract imaging per the new guidelines
was at the discretion of individual obstetrical practices; there
is currently no universal training of all obstetrical sonographers
given the large number of practices in San Diego county.
Infants with the following cardiac outflow tract anomalies
identifiable by outflow tract imaging were included: D‐TGA, cc‐
TGA, TOF, DORV, PA/IVS, truncus arteriosus, pulmonary stenosis,
and aortic stenosis. Although cc‐TGA should also be detectable
by the four‐chamber view, cc‐TGA was included in this study, as
it may be unrealistic to expect the general obstetrical screening
sonographer the nuance of differentiating the morphologic right
versus left ventricle. Those with other forms of CHD potentially
diagnosable by the four‐chamber view were excluded (ie atrio-
ventricular canal defects or single ventricle lesions such as hypo-
plastic right or left heart syndrome). Isolated aortic coarctation
without aortic valve stenosis was also excluded as it is not reliably
expected to be diagnosed prenatally. Rady Children’s Hospital
also serves as the primary referral center for infants with CHD
from Hawaii and the Pacific Islands; out‐of‐state patients were
excluded. The study was approved by the Institutional Review
Boards of Rady Children’s Hospital and University of California,
San Diego.
3.2 | Statistical analysis
Interval variables were expressed as mean standard deviation or
median (range). Categorical variables were counted and expressed as
frequencies or percentages. Due to the non‐normality of most of our
continuous study outcomes, the Mann‐Whitney U test was used as
a robust rank‐based statistic to determine if there was a significant
difference between pre‐guidelines and post‐guidelines or prenatal
and postnatal diagnosis groups. Due to some small expected cell
counts, Fisher’s exact test was used to compare categorical variables
across groups. A p value less than .05 was considered statistically
significant. All analyses were performed using the latest version of R
software (version 3.3.2).
4 | RESULTS
All but one of the mothers in each time frame had reportedly re-
ceived standard prenatal care. There was no association between
maternal race or type of health insurance and prenatal versus post-
natal diagnosis (P = .99 and .41, respectively) (Table 1).
Overall, prenatal diagnosis occurred in 55% of infants with crit-
ical outflow tract anomalies. Prenatal diagnosis occurred at a mean
age of 26.7 ± 4.8 weeks gestational age. Postnatal diagnosis of a
critical outflow tract anomaly was mostly made on day of life 1 or 2
(range 1–71 d) (Table 2). The most common clinical findings leading
to postnatal diagnosis of CHD were hypoxemia, murmur, or failed
pulse oximetry screening. Seven percent of patients (11 of 153 new-
borns) were discharged prior to diagnosis; none of these patients had
ductal dependent lesions. Of the three most common defects, pre-
natal diagnosis occurred in 54% of D‐TGA, 63% of TOF, and 80% of
DORV patients (Figure 2).
Fifty percent of the infants required transfer from the delivery
hospital to our institution; the other infants were born at our ad-
joining women’s hospital. Sixty‐three percent had ductal dependent
lesions for systemic or pulmonary blood flow. Most infants (86%)
required intervention prior to hospital discharge. Three infants died
without procedural intervention due to withdrawal of care. The
first cardiac intervention occurred at a median age of 6 days (range
0–88 d), with 51 infants undergoing only cardiac catheterization, 69
infants undergoing only surgical palliation/repair, and 33 infants un-
dergoing both catheterization followed by surgical palliation/repair
within the first 3 months.
4.1 | Prenatal versus postnatal diagnosis
Prenatally diagnosed infants had a statistically significant slightly ear-
lier gestational age at birth (37.7 ± 2.4 wk vs. 37.9 ± 3.4 wk in post-
natally diagnosed infants, P = .03). Prenatally diagnosed infants had
statistically lower birth weights (2.97 ± 0.69 kg vs. 3.18 ± 0.64 kg,
P = .02) and 5‐minute Apgar scores (7.9 ± 1.6 vs. 8.4 ± 0.9, P = .01).
There was a higher frequency of ductal dependent lesions in those
Prenatal diagnosis
n = 86 (%)
Postnatal diagnosis
n = 70 (%) p value
Maternal race .99
White 34 (40%) 28 (40%)
Hispanic 32 (37%) 26 (37%)
Asian 10 (12%) 7 (10%)
African American 3 (3%) 3 (4%)
American Indian 0 1 (1%)
Hawaiian 1 (1%) 0
Unknown/not reported 6 (7%) 5 (7%)
Maternal insurance type .41
Private 53 (62%) 38 (54%)
Public 33 (38%) 32 (46%)
TA B LE 1 Maternal demographics, by
timing of diagnosis
4. 4 | SUN et al.
prenatally diagnosed (73% vs. 50% postnatally diagnosed, P = .004).
There was no significant difference in degree of pre‐intervention
lactic acidosis, need for pre‐intervention inotropic support, or num-
ber of days to first intervention (Table 2).
4.2 | Pre‐guidelines vs. post‐guidelines
Pre‐guideline revision, between June 2010 and May 2013, 102 of
424 infants with critical CHD had outflow tract anomalies poten-
tially identifiable by outflow tract imaging which required cardiac
catheterization or surgery within the first 3 months of life. Prenatal
diagnosis occurred in 52% of the pre‐guidelines group. Post‐guide-
lines, between January 2015 and June 2016, 54 of 176 infants with
critical CHD had outflow tract anomalies which required cardiac
catheterization or surgery within the first 3 months of life. Prenatal
diagnosis occurred in 61% of the post‐guidelines group, not sig-
nificantly different than the prenatal detection rate pre‐guide-
lines (P = .31) (Table 3 and Figure 3). The types of cardiac outflow
tract anomalies pre‐guidelines versus post‐guidelines were similar
(Table 3 and Figure 4). The timing of diagnosis was also not signifi-
cantly different based on type of cardiac defect pre‐guidelines vs.
post‐guidelines (Table 4 and Figure 5).
5 | DISCUSSION
Screening for congenital anomalies should occur during routine
anatomic obstetrical ultrasound examination at approximately
18‐20 weeks gestational age in all pregnancies.14
The most com-
mon congenital anomaly is CHD, affecting approximately 1% of live
Prenatal
diagnosis n = 84
Postnatal diagnosis
n = 65 p value
Timing of diagnosis Gestational age
26.7 ± 4.8 wk
Day of life 1 (1−71) n/a
Gestational age at birth (weeks) 37.7 ± 2.4 37.9 ± 3.4 .03
Birth weight (kg) 2.97 ± 0.69 3.18 ± 0.64 .02
Apgar score
1 min of life 6.9 ± 2.1 7.2 ± 1.9 .47
5 min of life 7.9 ± 1.6 8.4 ± 0.9 .01
Genetic syndrome and/or extracardiac
anomaly
28 (33%) 14 (20%) .10
Ductal dependent 63 (73%) 35 (50%) .004
Highest pre‐intervention lactate 3.07 ± 2.05 4.30 ± 4.48 .08
Pre‐intervention inotropic support 21 (26%) 17 (26%) .99
Timing of first Intervention (day of life) 6 (0−88) 5 (0−84) .19
Continuous data are reported as mean ± SD or median (range), as appropriate, and categorical data
are reported as count (percentage).
TA B LE 2 Patient characteristics, by
timing of diagnosis
FI G U R E 2 Overall cardiac diagnoses
and timing of diagnosis
010203040
NumberofinfantsAortic
Stenosis
D
−TG
A
D
O
R
V
PA/IVS
Pulm
onary
Stenosis
TO
F
Truncus
Arteriosus
cc−TG
A
Cardiac Diagnoses and Timing of Diagnosis
Postnatal Diagnosis Prenatal Diagnosis
5. | 5SUN et al.
infants.1
Of these, approximately 25% have critical CHD requir-
ing timely intervention to prevent significant infant morbidity or
mortality.2
Although a multitude of maternal and/or fetal factors can prompt
referrals for fetal ECHO to evaluate for the presence (or absence)
of prenatal CHD,4
most CHD occurs in pregnancies without mater-
nal or fetal risk factors.5
Referrals for fetal ECHO in these partic-
ular cases rely solely on the identification of cardiac abnormalities
on screening obstetrical ultrasound. Studies have shown that less
experienced obstetric sonographers have lower detection rates of
cardiac abnormalities on screening ultrasound.15
In the mid‐1990s,
a single major referral center in New South Wales showed that ob-
stetrics screening detected only 6.7% of ventricular outflow tract
anomalies prenatally.16
In 1992, a study at a single obstetrics center
in the US also demonstrated significant limitations to the four‐cham-
ber view, with only 63% of all CHD detected, while the detection
rate increased to 83% when ventricular outflow tract imaging was
included.13
Outflow tract imaging is practically feasible when incor-
porated into a standard screening protocol.17
Despite increased awareness and education, prenatal detection
of various forms of CHD remains low,18,19
with outflow tract anom-
alies historically lower than for other types of critical CHD (such
as single ventricle lesions).20
Contemporary studies have shown
a wide range of prenatal diagnosis rates for conotruncal anoma-
lies (Table 5).21‒28
Many outflow tract anomalies can appear nor-
mal when visualizing only the four‐chamber view (Figure 1A). The
ability of obstetric anatomic ultrasound to identify outflow tract
anomalies increases substantially when ventricular outflow tract
imaging supplements the more traditional four‐chamber view.18,19,29
In June 2013, the American Institute of Ultrasound in Medicine
officially recognized the importance of imaging ventricular outflow
tracts by updating its guidelines on obstetric anatomic ultrasound
to include this critical outflow tract view into its basic cardiac ex-
amination.14
These guidelines (developed in conjunction with the
American College of Radiology, American College of Obstetricians
and Gynecologists, and the Society of Radiologists in Ultrasound)
are the standard of care reference for obstetric practices in the
United States. The International Society of Ultrasound in Obstetrics
TA B LE 3 Patient characteristics, by time frame
Pre‐guidelines n = 102 (%) Post‐guidelines n = 54 (%) p value
Timing of diagnosis .31
Prenatal diagnosis 53 (52%) 33 (61%)
Postnatal diagnosis 49 (48%) 21 (39%)
Type of cardiac defect .97
D‐TGA 26 (26%) 13 (24%)
TOF 19 (18%) 14 (26%)
DORV 17 (16%) 9 (17%)
Pulmonary stenosis 15 (15%) 6 (11%)
Truncus arteriosus 10 (10%) 5 (9%)
Aortic stenosis 8 (8%) 4 (7%)
PA/IVS 6 (6%) 2 (4%)
CC‐TGA 1 (1%) 1 (2%)
Prenatal care (if postnatal diagnosis) .52
Yes 48 (98%) 20 (95%)
No 1 (2%) 1 (5%)
Gestational age (weeks) 38 ± 2.3 37.4 ± 3.8 .31
Birth weight (kg) 3.1 ± 0.7 3 ± 0.7 .33
FIGURE 3 Timing of diagnosis: pre‐guidelines versus
post‐guidelines
6. 6 | SUN et al.
and Gynecology also published similar guidelines to include outflow
tract views.30
Fetal ECHO performed by fetal/pediatric cardiac sonographers
with interpretation by fetal/pediatric cardiologists provide a more
accurate prenatal cardiac diagnosis31,32
as compared to obstetri-
cal ultrasound. Fetal ECHO accurately detects simple and complex
CHD,3
such as outflow tract anomalies,33‒35
and allows for directed
prenatal parental counseling as well as delivery management in an
appropriate setting.36
The most common outflow tract anomalies,
such as TOF, d‐TGA, DORV with pulmonary stenosis, or DORV with
malposed great arteries, can cause significant cyanosis and hypoxia
after birth leading to poor neonatal outcomes if not appropriately
treated in a timely manner; the long‐term survival rates are high if
appropriately treated. Prenatal detection with timely post‐delivery
access to cardiac medical and surgical management improves mor-
tality rates and outcomes.12,35,37,38
The overall prenatal detection rate of 55% in this study remains
low in the modern era of specialty medicine capable of prenatally
diagnosing and managing critical cardiac outflow tract anomalies.
Despite the official revised obstetrical ultrasound guidelines, this
study shows no significant difference in the prenatal diagnosis rate
of these critical outflow tract anomalies following guideline revision.
The limitation stems primarily from lack of obstetrical identification
of abnormalities—presumably from inadequate imaging of the ven-
tricular outflow tracts on routine anatomic screening ultrasounds.
This study supports the need for more resources dedicated to ed-
ucating obstetrical sonographers and practitioners in optimizing
imaging of ventricular outflow tracts and/or encouraging referrals
for fetal echocardiograms if unable to confidently confirm normal
outflow tracts.
In this study, prenatally diagnosed infants had a statistically sig-
nificant earlier gestational age at birth, although the majority were
still born at or near term. We speculate that prenatally detected CHD
placed these pregnancies into a higher risk category and may have
prompted increased pregnancy and fetal monitoring and a lower
threshold for induction or delivery. Prenatally diagnosed infants also
had slightly lower birth weights and 5‐minute Apgar scores, which may
have been related to their earlier gestational age at birth. The majority
of infants had ductal dependent lesions and/or required intervention
prior to hospital discharge, indicating high risk for hemodynamic com-
promise if not diagnosed and treated in an expeditious manner.
No differences were seen in pre‐operative lactic acidosis,
need for inotropic support, or number of days to first proce-
dure between the prenatal and postnatal diagnosis groups. The
FI G U R E 4 Cardiac diagnoses: pre‐guidelines and post‐guidelines
Pre‐guideline %
(# prenatal diagnosis/total)
Post‐guideline %
(# prenatal diagnosis/total) p value
D‐TGA 50% (13/26) 61% (8/13) .73
TOF 58% (11/19) 71% (10/14) .48
DORV 76% (13/17) 88% (8/9) .62
Pulmonary stenosis 27% (4/15) 50% (3/6) .35
Truncus arteriosus 50% (5/10) 40% (2/5) .99
Aortic stenosis 50% (4/8) 0% (0/4) .21
PA/IVS 33% (2/6) 50% (1/2) .99
TA B LE 4 Prenatal detection rate of
cardiac diagnoses, by time frame
7. | 7SUN et al.
FI G U R E 5 Timing of diagnosis by
cardiac diagnoses: (A) Pre‐Guidelines and
(B) Post‐Guidelines
0510152025
NumberofinfantsAortic
Stenosis
D
−TG
A
D
O
R
V
PA/IVS
Pulm
onary
Stenosis
TO
F
Truncus
Arteriosus
cc−TG
A
Pre−Guidelines
Postnatal Diagnosis Prenatal Diagnosis
051015
NumberofinfantsAortic
Stenosis
D
−TG
A
D
O
R
V
PA/IVS
Pulm
onary
Stenosis
TO
F
Truncus
Arteriosus
cc−TG
A
Post−Guidelines
Postnatal Diagnosis Prenatal Diagnosis
A
B
TA B LE 5 Prenatal diagnosis rates of conotruncal anomalies from recent studies
Location Author Years Number of patients Prenatal diagnosis rate (%)
D‐TGA Texas Lara 1999−2007 468 10
Czech Republic Marek 2000−2006 223 25
Netherlands van Velzen 2002−2012 172 36
Paris Khoshnood 2005−2008 85 70
Belgium De Groote 2006−2014 79 24
TOF Czech Republic Marek 2000−2006 142 37
Netherlands van Velzen 2002−2012 111 30
Paris Khoshnood 2005−2008 60 68
Belgium De Groote 2006−2014 117 23
Truncus arteriosus Boston Swanson 1992−2007 136 32
Czech Republic Marek 2000−2006 47 80
Netherlands van Velzen 2002−2012 46 62
PA/IVS Italy Tuo 1993−2009 60 60
Czech Republic Marek 2000−2006 88 68
cc‐TGA Toronto Wan 1999−2006 54 29
8. 8 | SUN et al.
heterogeneous nature of cardiac diagnoses in the two groups lim-
ited the power to detect statistical differences and draw conclu-
sions between pre‐intervention course between the prenatal and
postnatal diagnosis groups. Prenatal diagnosis of critical CHD has
been shown to decrease preoperative mortality in other studies.12
6 | LIMITATIONS
Given the large number of hospitals delivering infants in San Diego
county, infants with postnatal diagnosis of critical CHD that did not
survive to admission to our hospital were not able to be identified, as
it was outside the scope of our study. Theoretically, the addition of
these infants would further decrease the prenatal detection rate in
both timeframes.
This study did not aim to encompass all critical CHD, only those
detectable by outflow tract imaging. Other critical CHD, such as sin-
gle ventricle lesions and isolated aortic arch anomalies, were spe-
cifically excluded as the authors aimed to highlight the importance
of obstetric screening ultrasounds incorporating adequate outflow
tract imaging.
7 | CONCLUSIONS
Despite revised obstetrical guidelines highlighting the importance
of outflow tract imaging, referrals and prenatal diagnosis of these
types of critical CHD remain suboptimal. Education of obstetri-
cal sonographers and practitioners who perform fetal anatomic
screening is vital to increase referrals for fetal cardiac evalu-
ation and optimize prenatal detection of critical outflow tract
anomalies.
ACKNOWLEDGMENTS
The project was partially supported by the National Institutes of
Health, Grant UL1TR001442 of CTSA funding. The content is solely
the responsibility of the authors and does not necessarily represent
the official views of the National Institutes of Health.
DISCLOSURE STATEMENT
The authors report no conflicts of interest.
AUTHOR CONTRIBUTIONS
All authors have read and approved the final version of the
manuscript.
Concept/Design, Data collection/interpretation, Drafting/revision
of article: Sun
Statistics: Proudfoot
Critical revision of article: McCandless
ORCID
Heather Y. Sun http://orcid.org/0000-0001-9309-3565
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How to cite this article: Sun HY, Proudfoot JA, McCandless
RT. Prenatal detection of critical cardiac outflow tract
anomalies remains suboptimal despite revised obstetrical
imaging guidelines. Congenital Heart Disease. 2018;00:1–9.
https://doi.org/10.1111/chd.12648