Abstract
Objective Risk stratification of fetuses diagnosed with congenital heart disease (CHD) helps
provide a delivery plan and prepare families and medical teams on expected course
in the delivery room. Our aim was to assess the accuracy of echocardiographically
determined risk-stratification assignments in predicting postnatal cardiac outcomes
beyond the delivery room.
Study Design This was a retrospective study at a single center evaluating all fetuses with CHD
who were risk-stratified by echocardiographically determined level of care (LOC) assignment,
ranging from 1a (lowest risk) to 4 (highest risk). All data were collected from January
1, 2017, to November 1, 2021. Outcomes included any unexpected cardiac interventions
and neonatal clinical outcomes including in-hospital mortality, the need for prostaglandins
or inotropes, and defined critical illness. These outcomes were assessed for each
LOC assignment by Fisher's exact test.
Results Out of 817 patients assigned a LOC, a total of 747 fetuses were included in our final
cohort with a separate subanalysis of 70 fetuses diagnosed with coarctation of the
aorta. The sensitivity and specificity were high for all LOC levels in predicting
delivery room needs (93–100%). Higher LOC levels (3–4) had a lower positive predictive
value (66–67%) indicating a high false-positive rate. Subjects with higher LOC assignments
had a greater frequency of critical illness, hospital mortality, need for inotropes,
need for neonatal surgical or catheterization interventions, and need for prostaglandins
(p < 0.001 for all outcomes). A post-hoc analysis reviewing LOC assignments revealed
a greater tendency to over-assign LOC at higher assignments (19% for LOC 3 and 4)
compared to lower assignments (4% for LOC 1 and 2).
Conclusion Risk stratification based on fetal echocardiography can predict neonatal clinical
outcomes and acuity of postnatal management needs. However, there is greater variability
in expected clinical events and an expected degree of false positives for those with
higher LOC assignments.
Key Points
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Risk stratification utilizing fetal echocardiography can be used to predict neonatal
needs.
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Complex heart disease has lower positive predictive value in predicting postnatal
clinical needs.
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There is a tendency to over-assign risk of acute hemodynamic instability for complex
heart disease.
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False positives are expected when planning high-risk deliveries to avoid compromising
situations.
Keywords
congenital heart disease - fetal - prenatal - echocardiography
