Hemodynamic Risk Stratification in Fetuses with Congenital Heart Defects—When Is a Delivery at a Heart Center Advisable?

Background: The prenatal diagnosis of a congenital heart defect (CHD) leads via optimization of peripartal management to a significantly improved prognosis of neonates with CHD. Which fetuses really benefit from a delivery at a cardiac center in cases of limited capacity and when should this be recommended? The aim of this study was to analyze the exactly of prenatal echocardiographic diagnosis with the postnatal diagnosis and when an emergency intervention was really necessary in our collective.

Methods: Observation period for this analysis was 10 years (2011–2021). All neonates younger 28 days with CHD and admission as inpatient were included and divided into five groups according to expected hemodynamic instability using the American Heart Association's Level of Care (LoC) Assignment. We assessed the presence of a prenatal echocardiographic diagnosis, its accuracy and the need for emergency intervention in our study population.

Results: Total of 1,210 newborns were analyzed, of which 825 fitted the inclusion criteria. Out of these, 397 children were delivered onsite (group A) and received a primary cardiac care. In total, 428 newborns were transferred from distant clinics (>20 km) and received secondary cardiac care after diagnosis (group B). The predominant LoC grades were assigned to LoC grade 1 (27,8%), and LoC 2 (46,1%). LoC class 3, 4, and P (palliative care) accounted for 26% and were not different between group A and B. A prenatal diagnosis was present in 430 cases (54%). In addition, 88% (n = 379) of these agreed with the postnatal ultrasound diagnosis. 92% of the children born locally had a prenatal diagnosis. In the group of fetuses delivered outside from our center, only 19% had a prenatal diagnosis. Emergency intervention (Rashkind procedure, balloon valvuloplasty) was highest in LoC class 4 with 83% (n = 95 of 125), followed by LoC3, LoC2, and LoC1 with 18% (n = 15 of 87), 13% (n = 45 of 382), and 13% (n = 17 of 194), respectively.

Conclusion: In total, 73% of our neonates fulfilled the LoC criteria of an increased risk for hemodynamic instability (LoC 2–4). One-third of a relevant or high risk (LoC 3–4). A significant percentage of the fetuses delivered at our center had a prenatal diagnosis that was consistent with the postnatal diagnosis in almost 90% of cases. As expected, emergency intervention was required in 9 out of 10 cases in LoC4. Therefore, fetuses in LoC4 (HLHS with RAS or IAS TGA with RAS or IAS, obstructed TAPVR, severe Ebstein’s anomaly or TOF/APV with hydrops) especially benefit of a delivery at a heart center.

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Artikel online veröffentlicht:
13. Februar 2024