Fetal Cardiology Unit Research Articles

Sonographer interaction with artificial intelligence: collaboration or conflict?

Ultrasound in Obstetrics & GynecologyAccepted Articles Opinion Sonographer interaction with artificial intelligence: collaboration or conflict? T. G. Day, Corresponding Author T. G. Day [email protected] orcid.org/0000-0001-8391-7903 Department of Congenital Cardiology, Evelina London Children's Healthcare, Guy's and St Thomas' NHS Foundation Trust, London, UK Faculty of Life Sciences and Medicine, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UKCorrespondence to: Dr T. G. Day: Fetal Cardiology Unit, South Wing, St Thomas’ Hospital, Westminster Bridge Road, London, UK, E-mail: [email protected]Search for more papers by this authorJ. Matthew, J. Matthew orcid.org/0000-0003-4754-0322 Faculty of Life Sciences and Medicine, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UKSearch for more papers by this authorS. Budd, S. Budd Faculty of Life Sciences and Medicine, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UKSearch for more papers by this authorJ. V. Hajnal, J. V. Hajnal Faculty of Life Sciences and Medicine, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UKSearch for more papers by this authorJ. M. Simpson, J. M. Simpson Department of Congenital Cardiology, Evelina London Children's Healthcare, Guy's and St Thomas' NHS Foundation Trust, London, UK Faculty of Life Sciences and Medicine, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UKSearch for more papers by this authorR. Razavi, R. Razavi Department of Congenital Cardiology, Evelina London Children's Healthcare, Guy's and St Thomas' NHS Foundation Trust, London, UK Faculty of Life Sciences and Medicine, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UKSearch for more papers by this authorB. Kainz, B. Kainz Faculty of Life Sciences and Medicine, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK Department Artificial Intelligence in Biomedical Engineering, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany Department of Computing, Faculty of Engineering, Imperial College London, London, UKSearch for more papers by this author T. G. Day, Corresponding Author T. G. Day [email protected] orcid.org/0000-0001-8391-7903 Department of Congenital Cardiology, Evelina London Children's Healthcare, Guy's and St Thomas' NHS Foundation Trust, London, UK Faculty of Life Sciences and Medicine, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UKCorrespondence to: Dr T. G. Day: Fetal Cardiology Unit, South Wing, St Thomas’ Hospital, Westminster Bridge Road, London, UK, E-mail: [email protected]Search for more papers by this authorJ. Matthew, J. Matthew orcid.org/0000-0003-4754-0322 Faculty of Life Sciences and Medicine, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UKSearch for more papers by this authorS. Budd, S. Budd Faculty of Life Sciences and Medicine, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UKSearch for more papers by this authorJ. V. Hajnal, J. V. Hajnal Faculty of Life Sciences and Medicine, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UKSearch for more papers by this authorJ. M. Simpson, J. M. Simpson Department of Congenital Cardiology, Evelina London Children's Healthcare, Guy's and St Thomas' NHS Foundation Trust, London, UK Faculty of Life Sciences and Medicine, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UKSearch for more papers by this authorR. Razavi, R. Razavi Department of Congenital Cardiology, Evelina London Children's Healthcare, Guy's and St Thomas' NHS Foundation Trust, London, UK Faculty of Life Sciences and Medicine, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UKSearch for more papers by this authorB. Kainz, B. Kainz Faculty of Life Sciences and Medicine, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK Department Artificial Intelligence in Biomedical Engineering, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany Department of Computing, Faculty of Engineering, Imperial College London, London, UKSearch for more papers by this author First published: 01 May 2023 https://doi.org/10.1002/uog.26238 This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1002/uog.26238. 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Importance of Analysis of Arrhythmia Mechanism in Predicting Outcomes in Fetal Bradycardia: A Single-Centre Retrospective Study from a Dedicated Fetal Cardiology Unit in South India

AbstractFew studies have correlated the mechanism of fetal bradycardia to pregnancy outcomes. This study aimed to correlate the arrhythmia mechanism to pregnancy and early postnatal outcomes in fetal bradycardia. This was retrospective study (May 2013–November 2019). Fetuses with sustained bradycardia (heart rate ≤ 100 per minute) were included. Based on arrhythmia mechanism, patients were categorized into 4 groups:Group 1: blocked atrial ectopics, Group 2: second-degree atrioventricular block (AVB), Group 3: complete AVB and group 4: sinus bradycardia. Clinical presentation, need for transplacental therapy, pregnancy and early postnatal outcomes were analysed. A total of 36 patients were included. Mean gestational age was 26.2 ± 5.5 weeks. The most common arrhythmia mechanism was Group 3 (N = 24; 66.7%) followed by Group 2 (N = 5; 13.8%); groups 1 and 4 had 4 and 3 patients respectively. Maternal auto-antibodies were reported in 21 patients (58.3%); 19 were in Group 3. Transplacental therapy was needed in 15 (41.7%) cases; 14 were in Group 3. Live-birth was reported in 23 cases (63.9%), other outcomes included pregnancy termination (n = 7), intra-uterine death (n = 4) and lost to follow-up (n = 2). Live-births were most common in Groups 1 (100%) and 2 (80%), followed by Group 3 (54.2%). Postnatal mortality occurred in one patient (Group 2). Three patients (60%) in Group 2 had Long QT syndrome in postnatal evaluation. Eight patients (6 in group 3) needed pacemaker implantation after birth. Fetal bradycardia was associated with an overall favorable pregnancy and good early postnatal outcomes. Analysis of the arrhythmia mechanism should guide prognostication and decisions for transplacental therapy.

Is analysis of physiological late gestation ventricular-arterial disproportion futile?

Ventricular-arterial disproportion is a frequent observation in late gestation and mostly considered physiological. It is also an indirect prenatal sign for postnatal coarctation. To investigate the remnant risk for coarctation and its possible risk factors in a fetal population with physiological late gestation asymmetry. This was a monocentric, retrospective study conducted from 2014 till 2017 in a Fetal Cardiology Unit. All foetuses referred for third trimester asymmetry with pulmonary artery/aorta ratio > 1.2 were included. Annular sizes, arterial Z-scores, valve ratios, isthmus size if available and minor associated cardiac defects were analyzed. One hundred and one foetuses were referred at a mean gestational age of 33.5 SA. After foetal echocardiography, 2% (3/151) were considered at high risk for coarctation because of a hypoplastic arch and/or a small left outflow tract or isthmus. They were scheduled to deliver in a tertiary referral center. Two of these three newborns developed coarctation. In 98% of foetuses, asymmetry was considered physiological with a normally sized aortic arch without the “shelf sign”. All infants had an early ambulatory echocardiography that revealed coarctation in 7/148 cases (4.7%). There were no significant differences in mean arterial annular sizes, aortic and pulmonary Z-scores, pulmonary artery/aorta ratio, atrioventricular annular sizes, tricuspid/mitral valve ratio, presence of ventricular septal defect or left persisting superior caval vein between the two groups. Remnant risk for coarctation in a foetal population with physiological late gestation asymmetry is < 5%. Prenatal counselling can be reassuring since the majority of infants will have a normal heart. However early cardiac evaluation of these newborns remains recommended to exclude the rare event of postnatal coarctation in absence of prenatal predictive signs.

Nonimmune hydrops fetalis management from the perspective of fetal cardiologists: A single tertiary center experience from Egypt.

Despite advances in managing nonimmune hydrops fetalis (NIHF), perinatal mortality is still significant. Fetal cardiac failure eventually occurs regardless of etiology. However, no previous study has addressed NIHF from fetal cardiologists' perspective. Therefore, we evaluated etiology and management of a NIHF cohort requiring fetal cardiologist consultation in a developing country. A single-center retrospective cohort study of 70 cases with NIHF that were referred to a fetal cardiology unit over four years was performed. Demographics, etiologic diagnosis, and outcomes of the cases were assessed. Antenatal management was evaluated using cardiovascular profile score (CVPS). The most frequent diagnosis was Idiopathic hydrops 42(62.6%), followed by hydrops due to cardiac diseases 19(28.4%), and 3 dead fetuses were detected at the first fetal echocardiography. Treatment of fetal tachyarrhythmia (n = 7) had 100% success rate in terms of antenatal hydrops resolution. Digoxin was used in cases of structural heart diseases, twin- twin transfusion syndrome, and dilated cardiomyopathy with perinatal mortality occurring in all cases (n = 9). In cases of idiopathic hydrops, 14 fetuses received digoxin with intrauterine hydrops resolution in 2/14 (14%) while non-treated cases had intrauterine or early neonatal death. Nonimmune hydrops is the worst complication of diverse etiologies. Limitations in resources for advanced investigations in developing countries increase the possibility of categorizing NIHF as idiopathic. Tachyarrhythmia induced hydrops can be entirely reversed with antenatal therapy while non-tachyarrhythmia fetal cardiac disease outcomes are unfavorable regardless of therapy. On the other hand, idiopathic hydrops shows a limited potential response to digoxin in utero.

Prenatal Identification of Restrictive and Non-restrictive Ventricular Septal Defects Based on End-Systolic Flow Patterns in the Fetal Aortic Isthmus.

Fetuses with large ventricular septal defects (VSDs) must be closely monitored during the perinatal period. Intrauterine assessment of size of septal defects with bidimensional echocardiography are unreliable. The objective of the present study is to document the contribution of flow pattern analysis in the fetal aortic isthmus for prenatal identification of large non-restrictive VSDs requiring immediate postnatal attention. We conducted a cross-sectional retrospective study of Doppler recordings from patients referred to our Fetal Cardiology Unit and diagnosed with one or multiple VSDs from January 2006 to November 2015. Three groups were defined: (1) large non-restrictive VSDs (n = 11) with postnatal cardiac failure (2) small restrictive VSDs (n = 28) asymptomatic, and (3) absence of cardiac abnormality (n = 66). The Isthmic end-Systolic Index (ISI) was computed to quantify aortic isthmus flow and compared between the three groups. Fetuses with restrictive VSD and control group showed similar ISI: stable at 0.20 ± 0.01 up to 27weeks of gestation and dropping later due to the fall of end-systolic velocities in the aortic isthmus. By 35weeks, a brief end-systolic retrograde flow was present, associated with a further fall of ISI down to -0.26 ± 0.05. In contrast, ISI of fetuses with large non-restrictive VSDs were unchanged throughout gestation (0.18 ± 0.06), becoming significantly higher during the last weeks of gestation compared to the two other groups (p < 0.001). In fetuses with VSDs, the ISI measurement from the aortic isthmus Doppler flow during the second half of gestation is a reliable predictor of a large non-restrictive defect with risk of major postnatal clinical impact.

EP11.04: Experience of the first Fetal Cardiology Unit in Mexico

EP11.04: Experience of the first Fetal Cardiology Unit in Mexico

Prenatal diagnosis of congenital heart defects: experience of the first Fetal Cardiology Unit in Mexico

Objective The purpose of this article was to describe our experience with the prenatal diagnosis of CHD in patients referred to our Fetal Cardiology Unit. Methods Prospective cohort study of consecutive fetuses referred for advanced fetal echocardiography to our Fetal Cardiology Unit during a 3-year period (September 2015–September 2018). Results Totally 809 fetuses were evaluated, with 1263 fetal advanced echocardiographies performed. Suspected cardiac abnormality was the most common indication for referral (62.2%). Only 7.3% of patients had known morbidities or risk factors for CHD. Mean gestational age at first examination was 25.6 ± 6.4 weeks. A total of 528 (65.3%) fetuses were found to have a cardiac defect: 40.7% had isolated CHD while 24.6% had associated anomalies. The most common defects found were ventricular septal defects (20.3%), followed by conotruncal defects (9.7%), hypoplastic left heart syndrome (9.3%), fetal arrhythmias (8.9%), and venous anomalies (8.7%). 31.6% presented abnormal genetic studies, the most frequent being Down syndrome (23/212, 10.8%), followed by DiGeorge syndrome (11/212, 5.2%). Conclusions Prenatal screening and diagnosis of CHD in Mexico are feasible, with suspected cardiac abnormality being the main reason for referral to a specialized Fetal Cardiology Unit. Efforts must be made to make screening available to the general population in the first and second trimesters of pregnancy by fetal medicine or trained specialists, in order to identify fetal CHD and offer advanced echocardiography, genetic studies, timely fetal cardiac intervention in selected cases, and delivery in tertiary centers, to improve overall survival.

Is analysis of physiological late gestation ventricular-arterial disproportion futile?

Ventricular-arterial disproportion is a frequent observation in the third trimester and mostly considered physiological. It is also an indirect prenatal sign for postnatal coarctation. We sought to investigate the remnant risk for coarctation and its possible risk factors in a fetal population with physiological late gestation asymmetry. This was a monocentric, retrospective study conducted from 2014 till 2017 in a Fetal Cardiology Unit. All fetuses referred for third trimester asymmetry with pulmonary artery/aorta ratio > 1.2 were included. Annular sizes, arterial Z-scores, valve ratios, isthmus size if available and minor associated cardiac defects were analyzed. 151 fetuses were referred at a mean gestational age of 33.5 SA. After fetal echocardiography, 2% (3/151) were considered at high risk for coarctation because of a hypoplastic arch and/or a small left outflow tract or isthmus. They were scheduled to deliver in a tertiary referral center. Two of these 3 newborns developed coarctation. In 98% of fetuses asymmetry was considered physiological with a normally sized aortic arch without the “shelf sign”. All infants had an early ambulatory echocardiography that revealed coarctation in 7/148 cases (4.7%). There were no significant differences in mean arterial annular sizes, aortic and pulmonary Z-scores, pulmonary artery/aorta ratio, atrioventricular annular sizes, tricuspid/mitral valve ratio, presence of ventricular septal defect or left persisting superior caval vein between the two groups. Remnant risk for coarctation in a fetal population with physiological late gestation asymmetry is < 5%. Prenatal counselling can be reassuring since the majority of infants will have a normal heart. However early cardiac evaluation of these newborns remains recommended to exclude the rare event of postnatal coarctation in absence of prenatal predictive signs.

Three-dimensional visualisation of the fetal heart using prenatal MRI with motion-corrected slice-volume registration: a prospective, single-centre cohort study

SummaryBackgroundTwo-dimensional (2D) ultrasound echocardiography is the primary technique used to diagnose congenital heart disease before birth. There is, however, a longstanding need for a reliable form of secondary imaging, particularly in cases when more detailed three-dimensional (3D) vascular imaging is required, or when ultrasound windows are of poor diagnostic quality. Fetal MRI, which is well established for other organ systems, is highly susceptible to fetal movement, particularly for 3D imaging. The objective of this study was to investigate the combination of prenatal MRI with novel, motion-corrected 3D image registration software, as an adjunct to fetal echocardiography in the diagnosis of congenital heart disease.MethodsPregnant women carrying a fetus with known or suspected congenital heart disease were recruited via a tertiary fetal cardiology unit. After initial validation experiments to assess the general reliability of the approach, MRI data were acquired in 85 consecutive fetuses, as overlapping stacks of 2D images. These images were then processed with a bespoke open-source reconstruction algorithm to produce a super-resolution 3D volume of the fetal thorax. These datasets were assessed with measurement comparison with paired 2D ultrasound, structured anatomical assessment of the 2D and 3D data, and contemporaneous, archived clinical fetal MRI reports, which were compared with postnatal findings after delivery.FindingsBetween Oct 8, 2015, and June 30, 2017, 101 patients were referred for MRI, of whom 85 were eligible and had fetal MRI. The mean gestational age at the time of MRI was 32 weeks (range 24–36). High-resolution (0·50–0·75 mm isotropic) 3D datasets of the fetal thorax were generated in all 85 cases. Vascular measurements showed good overall agreement with 2D echocardiography in 51 cases with paired data (intra-class correlation coefficient 0·78, 95% CI 0·68–0·84), with fetal vascular structures more effectively visualised with 3D MRI than with uncorrected 2D MRI (657 [97%] of 680 anatomical areas identified vs 358 [53%] of 680 areas; p<0·0001). When a structure of interest was visualised in both 2D and 3D data (n=358), observers gave a higher diagnostic quality score for 3D data in 321 (90%) of cases, with 37 (10%) scores tied with 2D data, and no lower scores than for 2D data (Wilcoxon signed rank test p<0·0001). Additional anatomical features were described in ten cases, of which all were confirmed postnatally.InterpretationStandard fetal MRI with open-source image processing software is a reliable method of generating high-resolution 3D imaging of the fetal vasculature. The 3D volumes produced show good spatial agreement with ultrasound, and significantly improved visualisation and diagnostic quality compared with source 2D MRI data. This freely available combination requires minimal infrastructure, and provides safe, powerful, and highly complementary imaging of the fetal cardiovascular system.FundingWellcome Trust/EPSRC Centre for Medical Engineering, National Institute for Health Research.

Ventricular Tachycardia in a Fetus: Benign Course of a Malignant Arrhythmia.

Fetal arrhythmias constitute 10 to 20% of the total referrals to fetal cardiology unit. Ventricular tachycardia (VT) is a rare form of fetal tachyarrhythmia. This report describes the clinical presentation, diagnostic features, and successful management of VT in a fetus at 32 weeks of gestation. Transplacental therapy with sotalol resulted in the termination of tachyarrhythmia in 48 h, followed by good postnatal outcome. Fetal m-mode showing ventricular rate higher than atrial rate with atrio-ventricular dissociation is suggestive of VT. Early diagnosis and institution of transplacental therapy prior to development of hydrops seem to carry a good prognosis even in malignant fetal arrhythmias like VT.

Biventricular impact of mild to moderate fetal pulmonary valve stenosis.

To define the pattern of fetal echocardiographic changes associated with isolated pulmonary valve stenosis (PS) and to correlate the echocardiographic findings with neonatal outcome and the need for postnatal pulmonary valvuloplasty within the first 12 months postpartum. This was a prospective cohort study between January 2009 and October 2015 of 16 fetuses with isolated PS and 48 controls matched by gestational age at ultrasound examination (± 2 weeks) evaluated at the Fetal Cardiology Unit at BCNatal (Barcelona). Standard fetal ultrasound and comprehensive echocardiography, which included cardiovascular morphometric parameters, and systolic and diastolic functional and timing measurements, were performed in all cases. Baseline characteristics and perinatal outcome were retrieved from clinical records. Cases were followed up until 12 months of age, and admission to intensive care unit, days of hospitalization, need for prostaglandins and requirement for postnatal surgery were reviewed. Fetal PS cases were analyzed according to the need for postnatal pulmonary valvuloplasty. The study groups were similar in terms of baseline, fetal ultrasound and perinatal characteristics. Median gestational age at diagnosis of PS was 33.4 (range, 20.0-36.5) weeks. Most cases corresponded to mild or moderate PS; only three fetuses had reversed flow in the ductus arteriosus before delivery. Six (37.5%) newborns, including all three with reversed flow in the ductus arteriosus prenatally, required postnatal pulmonary valvuloplasty. Fetuses with PS presented with larger and more globular hearts, with increased myocardial wall thickness in the third trimester. Despite preserved right ventricular (RV) ejection fraction and systolic longitudinal motion, PS cases showed increased right cardiac output and signs of diastolic dysfunction, with higher ductus venosus pulsatility index (0.72 ± 0.32 vs 0.53 ± 0.16, P= 0.004) and tricuspid E/E' ratio (7.52 ± 3.07 vs 5.76 ± 1.79, P= 0.022). In addition, fetuses with PS displayed a compensatory increase in left ventricular (LV) radial and longitudinal motion, as shown by a higher ejection fraction (79.3 ± 8.23% vs 67.6 ± 11.3%, P= 0.003) and mitral annular-plane systolic excursion (5.94 ± 1.38 vs 5.0 ± 1.22 mm, P= 0.035). Finally, fetuses requiring postnatal pulmonary valvuloplasty showed a different pattern of echocardiographic findings from those not requiring valvuloplasty, with a significantly smaller RV and pulmonary valve diameter, reduced tricuspid annular-plane systolic excursion (5.08 ± 1.59 vs 8.07 ± 1.93 mm, P= 0.028), increased LV cardiac output (340 ± 16 vs 176 ± 44 mL/min/kg, P =0.003) and more pronounced signs of LV diastolic dysfunction (mitral E' velocity, 5.78 ± 0.90 vs 8.16 ± 1.58 cm/s, P= 0.008). Fetuses with PS present with more hypertrophic, larger and more globular hearts in the third trimester of pregnancy, associated with a higher right cardiac output and impaired biventricular relaxation. In addition, signs of increased LV contraction were observed. Our data suggest that RV and LV functional parameters could be useful for predicting the need for postnatal pulmonary valvuloplasty. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Myocardial deformation in fetuses with coarctation of the aorta: a case-control study.

To study myocardial deformation by speckle tracking echocardiography in fetuses with coarctation of the aorta (CoA) compared with gestational age-matched normal controls. This was a retrospective study of 12 fetuses with postnatally confirmed CoA and 12 gestational age-matched controls seen at a tertiary fetal cardiology unit between January 2013 and July 2014. Two-dimensional speckle tracking in standard grayscale four-chamber view of the fetal heart was performed to assess left and right myocardial deformation. Global longitudinal strain, strain rate and velocities, and regional longitudinal strain were analyzed and compared with controls. Median gestational age at echocardiography was 25 + 4 weeks. Fetuses with CoA presented with a narrower, but not shorter, left ventricle when compared with controls (mitral valve diastolic diameter, 5.90 vs 8.50 mm; P = 0.002; left ventricular diastolic length, 16.50 vs 18.50 mm; P = 0.05). Global longitudinal systolic strain (P = 0.004), systolic strain rate (P = 0.01) and diastolic strain rate (P = 0.004) of the left ventricle were significantly lower in fetuses with CoA compared with controls. Similar findings were observed for longitudinal systolic (P = 0.03) and diastolic (P = 0.01) velocities of the left ventricle. Right ventricular parameters were not different between groups. Fetuses with CoA have lower left ventricular longitudinal systolic strain, systolic strain rate and diastolic strain rate when compared with gestational age-matched control fetuses. These differences in deformation might explain, at least in part, the cardiac asymmetry observed in fetuses with CoA. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

An exploration of the potential utility of fetal cardiovascular MRI as an adjunct to fetal echocardiography.

ObjectivesFetal cardiovascular magnetic resonance imaging (MRI) offers a potential alternative to echocardiography, although in practice, its use has been limited. We sought to explore the need for additional imaging in a tertiary fetal cardiology unit and the usefulness of standard MRI sequences.MethodsCases where the diagnosis was not fully resolved using echocardiography were referred for MRI. Following a three‐plane localiser, fetal movement was assessed with a balanced steady‐state free precession (bSSFP) cine. Single‐shot fast spin echo and bSSFP sequences were used for diagnostic imaging.ResultsTwenty‐two fetal cardiac MRIs were performed over 12 months, at mean gestation of 32 weeks (26–38 weeks). The majority of referrals were for suspected vascular abnormalities (17/22), particularly involving the aortic arch (n = 10) and pulmonary vessels (n = 4). Single‐shot fast spin echo sequences produced ‘black‐blood’ images, useful for examining the extracardiac vasculature in these cases. BSSFP sequences were more useful for intracardiac structures. Real‐time SSFP allowed for dynamic assessment of structures such as cardiac masses, with enhancement patterns also allowing for tissue characterisation in these cases.ConclusionsFetal vascular abnormalities such as coarctation can be difficult to diagnose by using ultrasound. Fetal MRI may have an adjunctive role in the evaluation of the extracardiac vascular anatomy and tissue characterisation. © 2016 The Authors. Prenatal Diagnosis published by John Wiley & Sons, Ltd.

P20 Impact on mode of delivery and early neonatal outcomes following fetal diagnosis of life-threatening congenital heart disease in the north east of england

Objective To evaluate the impact of fetal diagnosis of life-threatening congenital heart disease (CHD) on mode of delivery and early neonatal outcomes. Study Design 1-year retrospective cohort study of life-threatening CHD cases at a regional fetal cardiology unit (born June 2013–June 2014). Delivery outcomes were compared with 7630 deliveries over the same period in the tertiary obstetric unit. Results Forty-eight cases were diagnosed prenatally. There were ten terminations of pregnancy (21%) and three intrauterine deaths (6%). One of IUDs was unexpected following CVS biopsy. There were 35 livebirths; with 33 born at the intended location and 2 born elsewhere. Of the 33 babies, the mean gestation 37.6 weeks, mean birth-weight 3180g and male-to-female ratio 3:1. In CHD group (N=33), only six (18%) had spontaneous onset of labour (3 were not documented). Four (12%) had elective C-section (CS). Twenty inductions of labour (IOL) were carried out. IOL was significantly commoner in the CHD group than controls (77% vs 31% p < 0.05). Out of nine non-elective C-sections, two were semi-elective due to failed inductions; six were emergencies with one case not clearly documented. Overall CS rate was not significantly higher in the CHD group than controls (39% vs 32% p = 0.46). 20% (4/20) of vaginal deliveries were instrumental. At birth, 3 babies (9%) required some airway support (IPPV) with no significance difference in spontaneous delivery or CS groups (p = 0.8). The majority (26/33, 78.8%) were transferred to cardiac surgical unit within the first 72 h of life. Of these 26 babies, two (8%) required surgery and five (19%) required emergency balloon atrial septostomy within the first 72 h. Survival of the CHD cohort was 97% at 30-days and survival to discharge was 94%. There was no difference (p = 0.75) in survival-at-hospital-discharge comparing vaginal delivery (12/13) with CS (19/20). Conclusion The rate of IOL in CHD is higher than those found in another study.1 Despite higher induction rate, the rate of CS was no different compared to controls. Mode of delivery does not seem to impact on early outcomes. In comparison to other studies,2,3 survival for this group of antenatally-diagnosed CHD patients appears acceptable. REFERENCES 1. Walsh CA, MacTiernan A, Farrell S, Mulcahy C, McMahon CJ, Franklin O, Coleman D, Mahony R, Higgins S, Carroll S, McParland P, McAuliffe FM. Mode of delivery in pregnancies complicated by major fetal congenital heart disease: a retrospective cohort study. J Perinatol. 2014 29. doi: 10.1038/jp.2014.104 2. Trento L, Pruetz JD, Ruey K, et al. Prenatal diagnosis of congenital heart disease: impact of mode of delivery on neonatal outcome. Prenatal Diagnosis 2012;32: 1250–1255 3. Levey A, Glickstein JS, Kleinman CS, et al. The impact of prenatal diagnosis of complex congenital heart disease on neonatal outcomes. Pediatr Cardiol 2010;31:587–97

Fetal Doppler Predictor of Neonatal Coarctation of the Aorta

Objective: To describe fetal quantitative Doppler predictor of neonatal Coarctation of the aorta (CoAo). Methods: We retrospectively selected all cases of prenatal CoAo suspicion between December 2012 and August 2014 at the Fetal Cardiology Unit, Ukrainian Children’s Cardiac Center, Kyiv, Ukraine. Only fetuses with suspicion of isolated CoAo and complete follow-up were included in the study. Sixty six (66) cases were analyzed. Echocardiographic parameters obtained after 32 gestational weeks were compared in true and false-positive groups. Optimal cut-off for the isthmic-ductal diastolic flow indices difference (IDDFID) was identified and the corresponding likelihood ratios used to calculate the post-test probability of CoAo in each fetus. Results: CoAo was confirmed in 44/66 cases (66.7%). After 32 weeks of gestation cut-off value of the IDDFID was ≥ 0.2. The mean post-test probabilities of CoAo were higher in fetuses with confirmed CoAo than in fetuses with false suspicion (85 vs 30%; P<0.0001).

Correlation of maternal flecainide concentrations and therapeutic effect in fetal supraventricular tachycardia.

Transplacental flecainide is an established therapy for fetal supraventricular tachycardia (SVT), but there is a paucity of data regarding the dose-response relationship. The purpose of this study was to investigate the relationship between maternal flecainide concentrations, arrhythmia control, and adverse fetal effects in fetal SVT. Fetuses with SVT treated with transplacental flecainide at our tertiary fetal cardiology unit between 1997 and 2012 were retrospectively studied. The maternal trough flecainide concentrations throughout treatment were collated, and clinical notes were reviewed to ascertain the response to therapy and fetal outcome. Thirty-three fetuses were treated at a median (range) gestation of 28 weeks (20-38 weeks). Median fetal heart rate was 250/min (range 207-316/min). One patient was lost to follow-up, and this fetus was excluded from further analysis. In total, 25 of 32 fetuses (78%) converted to sinus rhythm. Median time to conversion to sinus rhythm was 3 days (range 2-12 days). Median flecainide concentration was 460 μg/L (range 250-866 μg/L) at conversion to sinus rhythm. Flecainide concentrations were not significantly different between responders and nonresponders (P = .849). Twelve of 14 hydropic and 13 of 18 nonhydropic fetuses converted to sinus rhythm with similar flecainide concentrations (P = .316). No fetus achieved cardioversion with a maternal serum flecainide concentration <250 μg/L. No fetus died while being treated with flecainide. The clinical response to flecainide appears good, even in hydropic fetuses. Trough maternal flecainide concentrations, once therapeutic, do not predict cardioversion in the fetus with SVT. Flecainide therapy appears both safe and effective for the fetus when monitored appropriately.

Isolated ventricular septal defects in the era of advanced fetal echocardiography: risk of chromosomal anomalies and spontaneous closure rate from diagnosis to age of 1 year

To evaluate, in a cohort of 248 fetuses seen at a tertiary referral center, the frequency of isolated ventricular septal defects (VSD) among all congenital heart defects (CHD), the association with chromosomal and postnatal anomalies and the rate of spontaneous closure. This was a 6-year study on 10,800 women referred for fetal echocardiography, with 995 confirmed cases of CHD. The prevalence and characteristics of VSDs were analyzed, including follow-up until 1 year of age. Multivariate binary logistic regression analysis was performed to test the independent contribution of the ratio of the diameter of the VSD to that of the aorta (VSD/aorta ratio) (< 0.5 or ≥ 0.5) and location of VSD (perimembranous or muscular) in the prediction of spontaneous closure before the age of 1 year. Two hundred and forty-eight VSDs (24.9% of all CHDs) were diagnosed, of which 216 (87.1%) were muscular and 32 (12.9%) perimembranous. Median gestational age at diagnosis was 30.4 (range, 17-41) weeks and mean size 2.6 ± 0.77 mm. Clinically relevant chromosomal anomalies were found in one (3.1%) perimembranous VSD compared with none in 216 muscular defects (P = 0.12). Postnatal malformations were diagnosed in eight of the 211 cases (3.8%) evaluated at 12 months postpartum. Spontaneous closure occurred prenatally in 13 fetuses (5.2%) and postnatally in 151 of the 198 infants (76.3%) who had an open VSD at birth. Closure was predicted by the VSD/aorta ratio (odds ratio (OR) 0.445 (95% CI, 0.216-0.914); P < 0.03) and location (OR 0.385 (95% CI, 0.160-0.926); P < 0.03). In our fetal cardiology unit, isolated muscular VSD is today the most prevalent CHD. In contrast to the findings of postnatal studies, muscular VSDs were more common than perimembranous VSDs. Perimembranous VSDs were associated with a higher risk of chromosomal anomalies than were muscular VSDs, which had a similar risk to those of normal pregnancies. Spontaneous closure of the VSD was frequent and occurred in most cases postnatally.

The Cost-Effectiveness of Prenatal Detection for Congenital Heart Disease Using Telemedicine Screening

We estimated the longer-term cost-effectiveness of using telemedicine screening for prenatal detection of congenital heart disease (CHD). One hospital in south-east England with a telemedicine service was connected to a fetal cardiology unit in London. A UK health service perspective was adopted. Evidence on costs and outcomes for standard-risk pregnant women during the antenatal period was based on patient-level data. Extrapolation beyond the end of the study (just after delivery) was carried out for the lifetime of children born with and without CHD. Expert opinion and data from published sources was used to populate a decision model. Future costs and benefits were discounted. The main outcome was quality-adjusted life years (QALYs) and results were expressed as cost per QALY gained. Various one-way sensitivity analyses were conducted. The model showed that offering telemedicine screening by specialists to all standard-risk pregnant women was the dominant strategy (i.e. cheaper and more effective). The sensitivity analyses found that the model was robust, and that telemedicine remained the most cost-effective strategy. The study showed that it would be cost-effective to provide telemedicine examinations as part of an antenatal screening programme for all standard-risk women.

Conotruncal anomalies in the fetus: Referral patterns and pregnancy outcomes in a dedicated fetal cardiology unit in South India

Objective:To describe the referral patterns and pregnancy outcomes of fetuses with conotruncal anomalies (CTA) from a fetal cardiology unit in South India.Methods:Records of 68 women identified to have diagnosis of CTA on fetal echocardiography (mean gestational age 26.8 ± 5.9 weeks; range 17-38 weeks) during the period 2008-2011 were reviewed.Results:The most common indication for referral was suspected congenital heart disease during routine antenatal scan (89.7%). The various CTA diagnosed included Tetralogy of Fallot (TOF, 44.1%), Double outlet right ventricle (DORV, 27.9%), Transposition of great vessels (TGA, 8.8%), TOF with pulmonary atresia (TOF-PA, 8.8%), TOF absent pulmonary valve (TOF-APV, 7.4%) and truncus arteriosus (TA, 2.9%). Extra cardiac anomalies were reported in 4 fetuses (7.1%). Pregnancy outcomes included pregnancies not culminating in live-birth (54.4%), delivery at term (41.2%) with 3 patients (4.4%) being lost to follow-up. Proportion of pregnancies not culminating in live-birth lesion wise include: TOF (53.3%), DORV (52.6%), TGA (50%), TOF -APV (80%), TOF-PA (50%), and TA (50%). Twenty-four babies (35.3%) received post-natal cardiac care with 5 (7.4%) undergoing neonatal surgical procedures. Seven babies (10.3%) died in neonatal period, including 2 who underwent surgery. The accuracy of fetal echo was 96.4% for primary lesion and 67.9% for complete segmental diagnosis.Conclusions:Pre-natal diagnosis of CTA, despite a high diagnostic accuracy, prompted utilization of post-natal tertiary cardiac care in a limited proportion of patients, including those with reparable lesions. Focus in developing countries should shift towards earlier referral, improving awareness about treatment options and a comprehensive evaluation for associated anomalies.

Fetal diagnosis of congenital heart disease by telemedicine

ObjectivesThis study aimed to evaluate the feasibility, accuracy and user acceptability of performing remote fetal echocardiograms (FEs).SettingA regional fetal cardiology unit and a district general hospital (DGH).DesignA prospective study over...