Gestational Age-Specific Markers Associated with Postnatal Intervention in Fetal Suspicion of Coarctation of the Aorta

Abstract

Objective Fetal diagnosis of coarctation of the aorta (CoA) is currently associated with a high false-positive rate. Many predictive markers may be gestational age (GA)-specific. We sought to establish GA-specific traditional and speckle-tracking fetal echocardiography (STE) markers predictive of true CoA in neonates with prenatal suspicion.

Study Design This is a retrospective case–control study. We compared the fetal ventricular and arch dimensions, as well as the deformation parameters by STE, of infants who required a postnatal intervention for their CoA with those who did not. Cohort was stratified based on GA before or after 30 weeks. Data extractors were masked to the outcome. The first fetal echocardiogram available was used.

Results Seventy-five newborns with a fetal echocardiography performed between October 2013 and May 2022 for an antenatal suspicion of CoA were included, of which 59 (79%) had an aortic arch with nonsignificant obstruction upon ductal closure, and 16 (21%) underwent a neonatal intervention for a confirmed CoA. Before 30 weeks' GA, the right ventricular to left ventricular (RV/LV) end-diastolic width and end-diastolic area (EDA) ratios were most associated with postnatal CoA confirmation (area under the curve [AUCs] = 0.96 and 0.92). After 30 weeks' GA, the RV/LV end-diastolic width ratio (AUC = 0.95), the Z-score for the ascending aorta (AUC = 0.93), and the LV end-diastolic width Z-score (AUC = 0.91) performed the best. A decreased RV peak longitudinal strain was observed in those who developed true CoA and performed well by receiver operating characteristic analysis after 30 weeks (AUC = 0.85). In the overall cohort, the RV/LV EDA ratio was the most sensitive predictor of CoA and identified all cases with CoA. Indeed, a cutoff > 1.24 had a specificity of 69.5% and a sensitivity of 100% (receiver operating characteristic curve with an AUC of 0.88).

Conclusion We outlined sensitive and specific fetal markers associated with postnatal CoA based on GA at suspicion.

Key Points

• Fetal ventricular disproportion predicts postnatal coarctation.

• A decreased right ventircular contraction was observed in those with coarctation.

• Fetal markers differ based on gestational age at fetal evaluation.

Keywords

coarctation of the aorta - fetal echocardiography - STE - strain - congenital heart defect - ventricular disproportion

• References

• 1 Rao PS. Coarctation of the aorta. Curr Cardiol Rep 2005; 7 (06) 425-434
• 2 Wutthigate P. et al. Early echocardiography predicts intervention need in antenatal suspicion of coarctation of the aorta. CJC Pediatr Congenit Heart Dis 2022; 1 (04) 167-173
• 3 Rudolf A. Congenital Diseases of the Heart. Chicago:: Year Book Medical Publishers;; 1974
• 4 Peng DM, Punn R, Maeda K, Selamet Tierney ES. Diagnosing neonatal aortic coarctation in the setting of patent ductus arteriosus. Ann Thorac Surg 2016; 101 (03) 1005-1010
• 5 Arya 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. Prenat Diagn 2016; 36 (02) 127-134
• 6 Sharland GK, Chan KY, Allan LD. Coarctation of the aorta: difficulties in prenatal diagnosis. Br Heart J 1994; 71 (01) 70-75
• 7 Tadic M, Kersten J, Nita N. et al. The prognostic importance of right ventricular longitudinal strain in patients with cardiomyopathies, connective tissue diseases, coronary artery disease, and congenital heart diseases. Diagnostics (Basel) 2021; 11 (06) 954
• 8 Devore GR. The use of Z-scores in the analysis of fetal cardiac dimensions. Ultrasound Obstet Gynecol 2005; 26 (06) 596-598
• 9 Schneider C, McCrindle BW, Carvalho JS, Hornberger LK, McCarthy KP, Daubeney PE. Development of Z-scores for fetal cardiac dimensions from echocardiography. Ultrasound Obstet Gynecol 2005; 26 (06) 599-605
• 10 Boston Children's Hospital. Z Score Calculator - Heart Centre - Transverse Arch vs GA by dates. Accessed July 2022 at: https://zscore.chboston.org/
• 11 Pasquini L, Mellander M, Seale A. et al. Z-scores of the fetal aortic isthmus and duct: an aid to assessing arch hypoplasia. Ultrasound Obstet Gynecol 2007; 29 (06) 628-633
• 12 Fluss R, Faraggi D, Reiser B. Estimation of the Youden Index and its associated cutoff point. Biom J 2005; 47 (04) 458-472
• 13 El Khouli RH, Macura KJ, Barker PB, Habba MR, Jacobs MA, Bluemke DA. Relationship of temporal resolution to diagnostic performance for dynamic contrast enhanced MRI of the breast. J Magn Reson Imaging 2009; 30 (05) 999-1004
• 14 Gómez-Montes E, Herraiz I, Gómez-Arriaga PI, Escribano D, Mendoza A, Galindo A. Gestational age-specific scoring systems for the prediction of coarctation of the aorta. Prenat Diagn 2014; 34 (12) 1198-1206
• 15 Gómez-Montes E, Herraiz I, Mendoza A, Escribano D, Galindo A. Prediction of coarctation of the aorta in the second half of pregnancy. Ultrasound Obstet Gynecol 2013; 41 (03) 298-305
• 16 Deiros-Bronte L, Diez-Sebastian J, Rodríguez González R, Uceda Galiano A, De La Calle M, Gutiérrez-Larraya Aguado F. Prenatal diagnosis of aortic coarctation: prediction algorithm according to gestational age. Fetal Diagn Ther 2021; 48 (11-12): 819-828
• 17 Familiari A, Morlando M, Khalil A. et al. Risk factors for coarctation of the aorta on prenatal ultrasound: a systematic review and meta-analysis. Circulation 2017; 135 (08) 772-785
• 18 Liu J, Cao H, Zhang L. et al. Incremental value of myocardial deformation in predicting postnatal coarctation of the aorta: establishment of a novel diagnostic model. J Am Soc Echocardiogr 2022; 35 (12) 1298-1310
• 19 Quartermain MD, Cohen MS, Dominguez TE, Tian Z, Donaghue DD, Rychik J. Left ventricle to right ventricle size discrepancy in the fetus: the presence of critical congenital heart disease can be reliably predicted. J Am Soc Echocardiogr 2009; 22 (11) 1296-1301
• 20 DeVore GR, Jone PN, Satou G, Sklansky M, Cuneo BF. Aortic coarctation: a comprehensive analysis of shape, size, and contractility of the fetal heart. Fetal Diagn Ther 2020; 47 (05) 429-439
• 21 Allan LD, Crawford DC, Tynan M. Evolution of coarctation of the aorta in intrauterine life. Br Heart J 1984; 52 (04) 471-473
• 22 Hornberger LK, Sanders SP, Rein AJ, Spevak PJ, Parness IA, Colan SD. Left heart obstructive lesions and left ventricular growth in the midtrimester fetus. A longitudinal study. Circulation 1995; 92 (06) 1531-1538
• 23 Miranda JO, Hunter L, Tibby S, Sharland G, Miller O, Simpson JM. Myocardial deformation in fetuses with coarctation of the aorta: a case-control study. Ultrasound Obstet Gynecol 2017; 49 (05) 623-629
• 24 DeVore GR, Haxel C, Satou G. et al. Improved detection of coarctation of the aorta using speckle-tracking analysis of fetal heart on last examination prior to delivery. Ultrasound Obstet Gynecol 2021; 57 (02) 282-291
• 25 Brooks PA, Khoo NS, Hornberger LK. Systolic and diastolic function of the fetal single left ventricle. J Am Soc Echocardiogr 2014; 27 (09) 972-977
• 26 Risum N, Ali S, Olsen NT. et al. Variability of global left ventricular deformation analysis using vendor dependent and independent two-dimensional speckle-tracking software in adults. J Am Soc Echocardiogr 2012; 25 (11) 1195-1203
• 27 Liu MY, Tacy T, Chin C, Obayashi DY, Punn R. Assessment of speckle-tracking echocardiography-derived global deformation parameters during supine exercise in children. Pediatr Cardiol 2016; 37 (03) 519-527
• 28 Costa SP, Beaver TA, Rollor JL, Vanichakarn P, Magnus PC, Palac RT. Quantification of the variability associated with repeat measurements of left ventricular two-dimensional global longitudinal strain in a real-world setting. J Am Soc Echocardiogr 2014; 27 (01) 50-54
• 29 Matsui H, Germanakis I, Kulinskaya E, Gardiner HM. Temporal and spatial performance of vector velocity imaging in the human fetal heart. Ultrasound Obstet Gynecol 2011; 37 (02) 150-157