How Small Is Too Small? The Challenge of Accurate Prenatal and Postnatal Detection of Coarctation of the Aorta.

Abstract

Diagnostic Conundrum: The Challenge of Diagnosing Coarctation of the AortaWith improved imaging in foetal echocardiography, many types of congenital heart diseases can be detected prenatally allowing for care coordination and improved outcomes.1Houshmandi M.M. Eckersley L. Fruitman D. et al.Fetal diagnosis is associated with improved perioperative condition of neonates requiring surgical intervention for coarctation.Pediatr Cardiol. 2021; 42: 1504-1511Crossref PubMed Scopus (6) Google Scholar, 2Thakur V. Dutil N. Schwartz S.M. Jaeggi E. Impact of prenatal diagnosis on the management and early outcome of critical duct-dependent cardiac lesions.Cardiol Young. 2018; 28: 548-553Crossref PubMed Scopus (19) Google Scholar, 3Brown K.L. Ridout D.A. Hoskote A. et al.Delayed diagnosis of congenital heart disease worsens preoperative condition and outcome of surgery in neonates.Heart. 2006; 92: 1298Crossref PubMed Scopus (212) Google Scholar Despite this significant improvement, prenatal diagnosis and postnatal confirmation of coarctation of the aorta remain challenging. Coarctation of the aorta is defined as a narrowing of the descending aorta, typically in the isthmus region where the ductus arteriosus inserts. Identifying coarctation of the aorta is critical as a missed diagnosis can lead to cardiac dysfunction, cardiogenic shock, adverse outcomes, and mortality.4Słodki M. Rizzo G. Augustyniak A. et al.Retrospective cohort study of prenatally and postnatally diagnosed coarctation of the aorta (CoA): prenatal diagnosis improve neonatal outcome in severe CoA.J Matern Fetal Neonatal Med. 2018; 33: 1-5PubMed Google Scholar,5Franklin O. Burch M. Manning N. et al.Prenatal diagnosis of coarctation of the aorta improves survival and reduces morbidity.Heart. 2002; 87: 67Crossref PubMed Scopus (304) Google Scholar Unfortunately, coarctation of the aorta remains a diagnosis with a significant number of neonates who received postnatal diagnosis compared with other cardiac lesions.2Thakur V. Dutil N. Schwartz S.M. Jaeggi E. Impact of prenatal diagnosis on the management and early outcome of critical duct-dependent cardiac lesions.Cardiol Young. 2018; 28: 548-553Crossref PubMed Scopus (19) Google Scholar To avoid these complications, there has been increased emphasis for improved screening on obstetric ultrasounds, so a foetus with a suspicion of coarctation is flagged for a prenatal cardiac assessment.Accurate diagnosis of coarctation prenatally allows for appropriate delivery management and timely surgical intervention. However, prenatal diagnosis carries a significant risk of false-positive diagnosis leading to unnecessary hospitalization, delayed feeding, increased parental anxiety, and increased cost around unnecessary medical care. Current false-positive rates are estimated to be as high as 40%-60%.6Arya B. Maskatia S.A. Coarctation of the aorta: prenatal assessment, postnatal management and neonatal outcomes.Semin Perinatol. 2022; 46: 151584Crossref PubMed Scopus (1) Google Scholar The degree of prenatal aortic arch narrowing falls on a spectrum and the key conundrum is ascertaining whether the narrowing will lead to inadequate systemic perfusion after ductus arteriosus closure postnatally. A common feature of coarctation prenatally includes size discrepancy between the right and left ventricles (RVs/LVs), with a smaller LV. However, the normal foetal heart will exhibit different degrees of RV/LV size discrepancy as the pregnancy progresses that make it difficult to use an indicator of coarctation. In addition, conditions such as intrauterine growth restriction can also cause changes in ductal and arch flow patterns adding further complexity to prenatal diagnosis. For these reasons, prenatal diagnosis carries with it significant risk of false-positive diagnosis.Postnatal evaluation can include echocardiography, cross-sectional imaging, or angiography. However, true coarctation may only become apparent as foetal physiology transitions to a neonatal circulation and the arterial duct closes. Course of management becomes clear if patients develop discrepancy of blood pressure in the right arm and leg and signs of decreased perfusion with duct closure. Coarctation of the aorta thus remains in many ways a clinical diagnosis, which can only be confirmed once the ductal arch is sufficiently small to cause clinical signs of arch obstruction. An ongoing challenge in management of this lesion is to find postnatal diagnostic parameters that flag neonates soon after birth so unnecessary care is minimized and surgical management is expedited.Wutthiagate et al.’s Evaluation of Novel Echocardiographic Parameters to Detect CoarctationIn this issue of the Canadian Journal of Cardiology (Pediatric and Congenital Heart Disease), Wutthigate et al.7Wutthigate P. Simoneau J. Renaud C. Altit G. Early echocardiography predicts intervention need in antenatal suspicion of coarctation of the aorta.CJC Pediatric Congenit Hear Dis. 2022; 1: 167-173Abstract Full Text Full Text PDF Google Scholar explore different echocardiographic parameters to improve identification of neonates who eventually required surgical management of coarctation after prenatal suspicion. Wutthigate et al. completed a single-centre, retrospective study consisting of 51 neonates with prenatal suspicion of coarctation. The first postnatal echocardiogram performed on the first day of life was analysed for various 2D echo measurements, strain analysis, and its association with the need for neonatal aortic coarctation repair. Specifically, they used speckle tracking in echocardiography to evaluate the end diastolic area of the RV (RV EDA), the LV (LV EDA), and the ratio of the EDA between the 2 ventricles (RV/LV EDA). Forty neonates were found to have normal aortic arches, whereas 11 neonates were confirmed with a true coarctation (22% true-positive rate), and values for these parameters were compared between groups. The authors showed that the RV/LV EDA ratio and the LV end-systolic eccentricity index were also associated with surgical repair for coarctation of the aorta. Specifically, an RV/LV EDA ratio greater than 1.3 conferred a high specificity and sensitivity for association with surgical repair for coarctation of the aorta. The study attempts to show that this echocardiographic parameter can be of benefit in earlier detection of neonates with true coarctation.Strengths, Limitations, and Applications of the Current StudyThis study addresses an important dilemma of discriminating neonates who require surgical intervention. Strengths in methodology include blinding of echo readers to patient outcomes as well as measures of inter-rater agreement. In addition, their study explores application of echocardiogram analysis methods of speckle tracking to expand strain analysis experience in neonates. They identified new parameters that may aid in confirming coarctation requiring neonatal surgery. The appeal of the RV/LV EDA is in its simplicity, accessibility, and its quantitative nature of RV/LV size discrepancy assessment.Although the study shows some benefit in using these parameters, several limitations are inherent to a retrospective, single-centre study that the authors discussed thoughtfully. Of the 51 neonates suspected to have coarctation on prenatal foetal echocardiography, only 11 patients required intervention. There may be several factors at play of which a small study size may augment. Specifically, both groups had their first foetal echocardiogram in the third trimester when coarctation of the aorta may be more challenging to diagnosis due to expected RV/LV size discrepancy, ductal morphology changes, and flow pattern changes in the aorta and ductus arteriosus. Secondly, of the 40 neonates with normal echocardiograms, only 15 were started on prostaglandin, indicating some heterogeneity within this group. Of the 40 neonates with normal echocardiograms, most (n = 25, 63%) were deemed “low risk” enough for coarctation such that prostaglandin was not initiated at birth and perhaps did not require the same level of neonatal intensive care unit monitoring. Like many of the studies on this topic, the main limitation is that due to the retrospective design, the measurements are reviewed in a study of association, not a study of prediction. Larger, prospective studies are required to establish utility of these markers in predicting the presence of true coarctation. In practice, these proposed echocardiographic parameters need to be interpreted in the context of other imaging findings and with clinical findings such as blood pressure gradients and pulse changes with ductal closure.The utility of these novel parameters for risk stratification of coarctation also needs to be taken into the context of the evolving literature around detection of coarctation of the aorta in the prenatal and perinatal period. Several parameters have been proposed to help discriminate coarctation in the neonate with an open ductus arteriosus. The measurements that have been proposed to have some discerning ability involve arch dimensions or descriptors of hypoplasia of left-sided structures such as the aortic and mitral valve (MV).8Matsui H. Mellander M. Roughton M. Jicinska H. Gardiner H.M. Morphological and physiological predictors of fetal aortic coarctation.Circulation. 2008; 118: 1793-1801Crossref PubMed Scopus (107) Google Scholar,9Morgan C.T. Mueller B. Thakur V. et al.Improving prenatal diagnosis of coarctation of the aorta.Can J Cardiol. 2019; 35: 453-461Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar In addition, several studies show that the carotid-subclavian artery index (distal transverse arch diameter divided by the distance between the left common carotid and left subclavian arteries) can help distinguishing definitive diagnosis of coarctation.10Dodge-Khatami A. Ott S. Bernardo S.D. Berger F. Carotid-subclavian artery index: new echocardiographic index to detect coarctation in neonates and infants.Ann Thorac Surg. 2005; 80: 1652-1657Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 11Peng D.M. Punn R. Maeda K. Tierney E.S.S. Diagnosing neonatal aortic coarctation in the setting of patent ductus arteriosus.Ann Thorac Surg. 2016; 101: 1005-1010Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 12Mivelaz Y. Bernardo S.D. Meijboom E.J. Sekarski N. Validation of two echocardiographic indexes to improve the diagnosis of complex coarctations.Eur J Cardiothorac Surg. 2008; 34: 1051-1056Crossref PubMed Scopus (13) Google Scholar Similarly, other proposed parameters for definitive diagnosis of coarctation are transverse arch measurements, isthmus measurements, and the distal arch index (distance between the left common carotid and left subclavian artery/diameter of the distal arch).13Vigneswaran T.V. Zidere V. Chivers S. et al.Impact of prospective measurement of outflow tracts in prediction of coarctation of the aorta.Ultrasound Obstet Gynecol. 2020; 56: 850-856Crossref PubMed Scopus (11) Google Scholar A few studies have investigated strain as a potential tool for aiding in detection of neonatal coarctation, though this study is the first to identify neonatal RV strain parameters associated with the need for coarctation repair. LV global longitudinal strain was found to be significantly lower in neonates with true coarctation.14Séguéla P.E. Thomas-Chabaneix J. Jalal Z. et al.Toward the integration of global longitudinal strain analysis in the assessment of neonatal aortic coarctation? A preliminary study.Arch Cardiovasc Dis. 2018; 111: 722-729Crossref PubMed Scopus (2) Google Scholar,15Gozar L. Mărginean C. Paler A.C. et al.Speckle-tracking global longitudinal and regional strain analysis in neonates with coarctation of aorta: a case-control study.J Clin Med. 2021; 10: 4579Crossref PubMed Scopus (0) Google Scholar Although these different variables were shown to be different between neonates with true coarctation vs those who were suspected to have the condition but confirmed to have normal aortic arches postnatally, a clear set of parameters have yet to emerge as the accepted guideline to differentiate the 2 groups.Resource utilization was analysed to quantify the burden of potential coarctation. Like Wutthigate et al., Hede et al.16Hede S.V. DeVore G. Satou G. Sklansky M. Neonatal management of prenatally suspected coarctation of the aorta.Prenatal Diag. 2020; 40: 942-948Crossref PubMed Scopus (4) Google Scholar found that neonates with suspicious of neonatal coarctation but no definitive coarctation had delayed feeding, unnecessary hospital stays, frequent unnecessary echocardiograms, and delayed maternal bonding. However, a detailed cost analysis should in addition review the cost of relocation and cost of accommodation that may be incurred with changing location of delivery. The study authors review the significant cost of monitoring a neonate in a tertiary care centre neonatal intensive care unit and discuss the need for better detection of true coarctation to minimize the need for expensive tertiary centre care. Although postnatal echocardiographic parameters may eventually help detect a true coarctation, they do not minimize the need to deliver in a tertiary care centre. Improved foetal diagnosis will decrease the number of foetuses that require this monitoring and would help decrease the cost of care related to monitoring foetuses with a false-positive diagnosis. Of additional value would be the potential decrease in parental anxiety by eliminating the significant number of false-positive cases. In addition, accurate prenatal diagnosis improved postnatal well-being and survival.2Thakur V. Dutil N. Schwartz S.M. Jaeggi E. Impact of prenatal diagnosis on the management and early outcome of critical duct-dependent cardiac lesions.Cardiol Young. 2018; 28: 548-553Crossref PubMed Scopus (19) Google Scholar Prenatal detection allowed for lower doses of prostaglandin, earlier admission to a tertiary care centre, less need for mechanical ventilation, and less preoperative cardiac arrest.2Thakur V. Dutil N. Schwartz S.M. Jaeggi E. Impact of prenatal diagnosis on the management and early outcome of critical duct-dependent cardiac lesions.Cardiol Young. 2018; 28: 548-553Crossref PubMed Scopus (19) Google ScholarFuture Directions in Optimizing Care of Patients With Suspected CoarctationAlthough the study by Wutthigate et al. make important steps in identifying additional echo parameters to improve the diagnosis of coarctation, these measurements will need to be validated for predicting coarctation of the aorta. In addition, postnatal diagnosis does not decrease the unnecessary admission to tertiary centre care of neonates with a prenatal false-positive diagnosis. Many studies have looked at improving prenatal diagnosis of coarctation using foetal echocardiogram parameters.17Familiari A. Morlando M. Khalil A. et al.Risk factors for coarctation of the aorta on prenatal ultrasound.Circulation. 2017; 135: 772-785Crossref PubMed Scopus (67) Google Scholar The most significant parameters again centre on arch dimensions and markers of left-sided hypoplasia. The isthmus and ascending aorta z-scores and isthmus to duct ratios,18Beattie M. Peyvandi S. Ganesan S. Moon-Grady A. Toward improving the fetal diagnosis of coarctation of the aorta.Pediatr Cardiol. 2017; 38: 344-352Crossref PubMed Scopus (28) Google Scholar peak Doppler velocity in the ascending aorta, younger gestational age at the time of diagnosis,9Morgan C.T. Mueller B. Thakur V. et al.Improving prenatal diagnosis of coarctation of the aorta.Can J Cardiol. 2019; 35: 453-461Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar and different aortic arch angle measurements19Arya B. Bhat A. Vernon M. Conwell J. Lewin M. Utility of novel fetal echocardiographic morphometric measures of the aortic arch in the diagnosis of neonatal coarctation of the aorta.Prenatal Diag. 2016; 36: 127-134Crossref PubMed Scopus (34) Google Scholar have all been shown to be relevant in the diagnosis of this lesion. Applications of strain to foetal assessments of coarctation have also been attempted. DeVore et al.20DeVore G.R. Jone P.N. Satou G. Sklansky M. Cuneo B.F. Aortic coarctation: a comprehensive analysis of shape, size, and contractility of the fetal heart.Fetal Diagn Ther. 2020; 47: 429-439Crossref PubMed Scopus (15) Google Scholar used speckle tracking methods to show that foetuses with coarctation had ventricles that were more spherical compared with normal controls. In addition, the study also evaluated LV longitudinal strain and transverse contractility and found both to be decreased in foetuses with coarctation.20DeVore G.R. Jone P.N. Satou G. Sklansky M. Cuneo B.F. Aortic coarctation: a comprehensive analysis of shape, size, and contractility of the fetal heart.Fetal Diagn Ther. 2020; 47: 429-439Crossref PubMed Scopus (15) Google Scholar Although each of these studies has shown some differences in these measurements between foetuses with coarctation and those with normal hearts, other studies have also performed multivariable analysis to synthesize this information. A recent systematic review identified several studies that used multiparametric models for identification of neonatal coarctation that included variables such as MV diameter, MV/tricuspid valve ratio, and various measurements of isthmus, duct, arch diameter, and angle.17Familiari A. Morlando M. Khalil A. et al.Risk factors for coarctation of the aorta on prenatal ultrasound.Circulation. 2017; 135: 772-785Crossref PubMed Scopus (67) Google Scholar Power et al.21Power A. Nettel-Aguirre A. Fruitman D. Fetal right ventricular prominence: associated postnatal abnormalities and coarctation clinical prediction tool.Pediatr Cardiol. 2017; 38: 1471-1477Crossref PubMed Scopus (0) Google Scholar showed that a clinical tool using gestational age, RV mid cavity dimension, and isthmus z-score had high sensitivity for definitive coarctation of the aorta. The challenge in applying these analyses remains that most of these studies are retrospective and single institutional studies, which makes obtaining enough patients for valid multivariable analysis difficult. Future studies should focus on optimizing and validating a scoring or prediction tool to identify which foetuses will develop coarctation postnatally with prospective multi-institutional data.ConclusionIn conclusion, to better discern neonates with coarctation and improve care, a multipronged approach is needed. The study by Wutthigate et al. adds the insight of an additional neonatal echocardiographic and strain parameter that may be useful in distinguishing neonates who will eventually require coarctation repair vs potential candidates for transfer to a lower acuity unit. Postnatal assessment however does not decrease the need for hospital admission to a tertiary care centre. Prenatally, better detection of true coarctation will minimize the challenges and cost associated with the false-positive diagnosis of this lesion. Future directions include using clinical and echocardiographic data from a prospective registry of foetuses with suspicion of coarctation to construct a multivariable clinical aid tool. Diagnostic Conundrum: The Challenge of Diagnosing Coarctation of the AortaWith improved imaging in foetal echocardiography, many types of congenital heart diseases can be detected prenatally allowing for care coordination and improved outcomes.1Houshmandi M.M. Eckersley L. Fruitman D. et al.Fetal diagnosis is associated with improved perioperative condition of neonates requiring surgical intervention for coarctation.Pediatr Cardiol. 2021; 42: 1504-1511Crossref PubMed Scopus (6) Google Scholar, 2Thakur V. Dutil N. Schwartz S.M. Jaeggi E. Impact of prenatal diagnosis on the management and early outcome of critical duct-dependent cardiac lesions.Cardiol Young. 2018; 28: 548-553Crossref PubMed Scopus (19) Google Scholar, 3Brown K.L. Ridout D.A. Hoskote A. et al.Delayed diagnosis of congenital heart disease worsens preoperative condition and outcome of surgery in neonates.Heart. 2006; 92: 1298Crossref PubMed Scopus (212) Google Scholar Despite this significant improvement, prenatal diagnosis and postnatal confirmation of coarctation of the aorta remain challenging. Coarctation of the aorta is defined as a narrowing of the descending aorta, typically in the isthmus region where the ductus arteriosus inserts. Identifying coarctation of the aorta is critical as a missed diagnosis can lead to cardiac dysfunction, cardiogenic shock, adverse outcomes, and mortality.4Słodki M. Rizzo G. Augustyniak A. et al.Retrospective cohort study of prenatally and postnatally diagnosed coarctation of the aorta (CoA): prenatal diagnosis improve neonatal outcome in severe CoA.J Matern Fetal Neonatal Med. 2018; 33: 1-5PubMed Google Scholar,5Franklin O. Burch M. Manning N. et al.Prenatal diagnosis of coarctation of the aorta improves survival and reduces morbidity.Heart. 2002; 87: 67Crossref PubMed Scopus (304) Google Scholar Unfortunately, coarctation of the aorta remains a diagnosis with a significant number of neonates who received postnatal diagnosis compared with other cardiac lesions.2Thakur V. Dutil N. Schwartz S.M. Jaeggi E. Impact of prenatal diagnosis on the management and early outcome of critical duct-dependent cardiac lesions.Cardiol Young. 2018; 28: 548-553Crossref PubMed Scopus (19) Google Scholar To avoid these complications, there has been increased emphasis for improved screening on obstetric ultrasounds, so a foetus with a suspicion of coarctation is flagged for a prenatal cardiac assessment.Accurate diagnosis of coarctation prenatally allows for appropriate delivery management and timely surgical intervention. However, prenatal diagnosis carries a significant risk of false-positive diagnosis leading to unnecessary hospitalization, delayed feeding, increased parental anxiety, and increased cost around unnecessary medical care. Current false-positive rates are estimated to be as high as 40%-60%.6Arya B. Maskatia S.A. Coarctation of the aorta: prenatal assessment, postnatal management and neonatal outcomes.Semin Perinatol. 2022; 46: 151584Crossref PubMed Scopus (1) Google Scholar The degree of prenatal aortic arch narrowing falls on a spectrum and the key conundrum is ascertaining whether the narrowing will lead to inadequate systemic perfusion after ductus arteriosus closure postnatally. A common feature of coarctation prenatally includes size discrepancy between the right and left ventricles (RVs/LVs), with a smaller LV. However, the normal foetal heart will exhibit different degrees of RV/LV size discrepancy as the pregnancy progresses that make it difficult to use an indicator of coarctation. In addition, conditions such as intrauterine growth restriction can also cause changes in ductal and arch flow patterns adding further complexity to prenatal diagnosis. For these reasons, prenatal diagnosis carries with it significant risk of false-positive diagnosis.Postnatal evaluation can include echocardiography, cross-sectional imaging, or angiography. However, true coarctation may only become apparent as foetal physiology transitions to a neonatal circulation and the arterial duct closes. Course of management becomes clear if patients develop discrepancy of blood pressure in the right arm and leg and signs of decreased perfusion with duct closure. Coarctation of the aorta thus remains in many ways a clinical diagnosis, which can only be confirmed once the ductal arch is sufficiently small to cause clinical signs of arch obstruction. An ongoing challenge in management of this lesion is to find postnatal diagnostic parameters that flag neonates soon after birth so unnecessary care is minimized and surgical management is expedited. With improved imaging in foetal echocardiography, many types of congenital heart diseases can be detected prenatally allowing for care coordination and improved outcomes.1Houshmandi M.M. Eckersley L. Fruitman D. et al.Fetal diagnosis is associated with improved perioperative condition of neonates requiring surgical intervention for coarctation.Pediatr Cardiol. 2021; 42: 1504-1511Crossref PubMed Scopus (6) Google Scholar, 2Thakur V. Dutil N. Schwartz S.M. Jaeggi E. Impact of prenatal diagnosis on the management and early outcome of critical duct-dependent cardiac lesions.Cardiol Young. 2018; 28: 548-553Crossref PubMed Scopus (19) Google Scholar, 3Brown K.L. Ridout D.A. Hoskote A. et al.Delayed diagnosis of congenital heart disease worsens preoperative condition and outcome of surgery in neonates.Heart. 2006; 92: 1298Crossref PubMed Scopus (212) Google Scholar Despite this significant improvement, prenatal diagnosis and postnatal confirmation of coarctation of the aorta remain challenging. Coarctation of the aorta is defined as a narrowing of the descending aorta, typically in the isthmus region where the ductus arteriosus inserts. Identifying coarctation of the aorta is critical as a missed diagnosis can lead to cardiac dysfunction, cardiogenic shock, adverse outcomes, and mortality.4Słodki M. Rizzo G. Augustyniak A. et al.Retrospective cohort study of prenatally and postnatally diagnosed coarctation of the aorta (CoA): prenatal diagnosis improve neonatal outcome in severe CoA.J Matern Fetal Neonatal Med. 2018; 33: 1-5PubMed Google Scholar,5Franklin O. Burch M. Manning N. et al.Prenatal diagnosis of coarctation of the aorta improves survival and reduces morbidity.Heart. 2002; 87: 67Crossref PubMed Scopus (304) Google Scholar Unfortunately, coarctation of the aorta remains a diagnosis with a significant number of neonates who received postnatal diagnosis compared with other cardiac lesions.2Thakur V. Dutil N. Schwartz S.M. Jaeggi E. Impact of prenatal diagnosis on the management and early outcome of critical duct-dependent cardiac lesions.Cardiol Young. 2018; 28: 548-553Crossref PubMed Scopus (19) Google Scholar To avoid these complications, there has been increased emphasis for improved screening on obstetric ultrasounds, so a foetus with a suspicion of coarctation is flagged for a prenatal cardiac assessment. Accurate diagnosis of coarctation prenatally allows for appropriate delivery management and timely surgical intervention. However, prenatal diagnosis carries a significant risk of false-positive diagnosis leading to unnecessary hospitalization, delayed feeding, increased parental anxiety, and increased cost around unnecessary medical care. Current false-positive rates are estimated to be as high as 40%-60%.6Arya B. Maskatia S.A. Coarctation of the aorta: prenatal assessment, postnatal management and neonatal outcomes.Semin Perinatol. 2022; 46: 151584Crossref PubMed Scopus (1) Google Scholar The degree of prenatal aortic arch narrowing falls on a spectrum and the key conundrum is ascertaining whether the narrowing will lead to inadequate systemic perfusion after ductus arteriosus closure postnatally. A common feature of coarctation prenatally includes size discrepancy between the right and left ventricles (RVs/LVs), with a smaller LV. However, the normal foetal heart will exhibit different degrees of RV/LV size discrepancy as the pregnancy progresses that make it difficult to use an indicator of coarctation. In addition, conditions such as intrauterine growth restriction can also cause changes in ductal and arch flow patterns adding further complexity to prenatal diagnosis. For these reasons, prenatal diagnosis carries with it significant risk of false-positive diagnosis. Postnatal evaluation can include echocardiography, cross-sectional imaging, or angiography. However, true coarctation may only become apparent as foetal physiology transitions to a neonatal circulation and the arterial duct closes. Course of management becomes clear if patients develop discrepancy of blood pressure in the right arm and leg and signs of decreased perfusion with duct closure. Coarctation of the aorta thus remains in many ways a clinical diagnosis, which can only be confirmed once the ductal arch is sufficiently small to cause clinical signs of arch obstruction. An ongoing challenge in management of this lesion is to find postnatal diagnostic parameters that flag neonates soon after birth so unnecessary care is minimized and surgical management is expedited. Wutthiagate et al.’s Evaluation of Novel Echocardiographic Parameters to Detect CoarctationIn this issue of the Canadian Journal of Cardiology (Pediatric and Congenital Heart Disease), Wutthigate et al.7Wutthigate P. Simoneau J. Renaud C. Altit G. Early echocardiography predicts intervention need in antenatal suspicion of coarctation of the aorta.CJC Pediatric Congenit Hear Dis. 2022; 1: 167-173Abstract Full Text Full Text PDF Google Scholar explore different echocardiographic parameters to improve identification of neonates who eventually required surgical management of coarctation after prenatal suspicion. Wutthigate et al. completed a single-centre, retrospective study consisting of 51 neonates with prenatal suspicion of coarctation. The first postnatal echocardiogram performed on the first day of life was analysed for various 2D echo measurements, strain analysis, and its association with the need for neonatal aortic coarctation repair. Specifically, they used speckle tracking in echocardiography to evaluate the end diastolic area of the RV (RV EDA), the LV (LV EDA), and the ratio of the EDA between the 2 ventricles (RV/LV EDA). Forty neonates were found to have normal aortic arches, whereas 11 neonates were confirmed with a true coarctation (22% true-positive rate), and values for these parameters were compared between groups. The authors showed that the RV/LV EDA ratio and the LV end-systolic eccentricity index were also associated with surgical repair for coarctation of the aorta. Specifically, an RV/LV EDA ratio greater than 1.3 conferred