A Clinical Prediction Model to Estimate the Risk for Coarctation of the Aorta in the Presence of a Patent Ductus Arteriosus

Abstract

Objective To create a model to help identify coarctation of the aorta (CoA) in neonates with a patent ductus arteriosus (PDA). Background Diagnosing CoA in the presence of a PDA may require observation until PDA closure. We created a model incorporating previously published indices to estimate the probability of neonatal CoA in the presence of a PDA. Methods A retrospective “investigation” cohort of 80 neonates was divided into two groups: (1) neonates with PDA and suspicion for CoA requiring observation to confirm the presence or absence of CoA and (2) neonates with PDA and confirmed diagnosis of either CoA or unobstructed aortic arch. Multivariable logistic regression was used to create the coarctation probability model (CPM), which calculates a neonate’s probability of CoA. The CPM was validated internally using bootstrapping and subsequently validated prospectively using a “validation” cohort of 74 neonates with PDA. Results The CPM had an area under the ROC curve of 0.96 and demonstrated good clinical significance in risk stratification of neonates with a PDA and CoA. No neonate with a CPM probability of <15% had CoA after PDA closure. We classify neonates with CPM <15% as low-risk, between 15–60% as moderate-risk, and > 60% as high-risk for CoA. Conclusion Based on our study results, we recommend measurement of the CPM in all neonates with PDA. Those with CPM <15% no longer require observation, which could decrease observation in as many as half of neonates with unobstructed aortic arch; those with CPM between 15–60% require follow up imaging while those with CPM >60% risk should be observed as inpatients until PDA closure.

Utility of novel fetal echocardiographic morphometric measures of the aortic arch in the diagnosis of neonatal coarctation of the aorta

“…The distance from the carotid artery to subclavian artery measured on neonatal echocardiogram has been shown to be useful in predicting CoA in the presence of a large DA. This is theorized to be secondary to a stretch or change in contour of the transverse to proximal DAo (including the isthmus) in patients with coarctation . Using the sagittal view of the fetal aortic arch, we found that similar contour changes exist in the fetus and could be employed for identification of CoA.…”

“…Three novel fetal echocardiographic measurements of the aortic arch were performed using a sagittal view of the aortic arch in ventricular systole. The left common carotid‐to‐left subclavian artery distance (LCSA) was measured along the outer edge of the distal transverse arch using the distal boundary of the left common carotid artery to the proximal boundary of the left subclavian artery (Figure a), as previously described in postnatal evaluation for CoA . The angle between the AAo and DAo (AAo–DAo angle) was defined as the angle created by two straight lines: One straight line was drawn proximal (above the aortic valve) to distal (just prior to the first head vessel) along the internal boundary of the Aao, and the second line was drawn distal (distal thoracic aorta) to proximal (just prior to the isthmus) along the internal boundary of the DAo (Figure b).…”

“…The left common carotid-to-left subclavian artery distance (LCSA) was measured along the outer edge of the distal transverse arch using the distal boundary of the left common carotid artery to the proximal boundary of the left subclavian artery (Figure 1a), as previously described in postnatal evaluation for CoA. 19 The angle between the AAo and DAo (AAo-DAo angle) was defined as the angle created by two straight lines: One straight line was drawn proximal (above the aortic valve) to distal (just prior to the first head vessel) along the internal boundary of the Aao, and the second line was drawn distal (distal thoracic aorta) to proximal (just prior to the isthmus) along the internal boundary of the DAo (Figure 1b). The angle between the TAo and DAo (TAo-DAo angle) was defined as the angle created by two straight lines: One straight line was drawn proximal (from the take-off of the first head vessel) to distal (to the end of the third head vessel) along the internal boundary of the Tao, and the second line was drawn along the DAo as described in the preceding texts ( Figure 1c).…”

Diagnosis, imaging and clinical management of aortic coarctation

“…Neonates with clinically significant CoA should be hospitalised for continuous administration of prostaglandin E1, to keep the PDA open 22. Patients with subtle clinical and/or diagnostic signs require close clinical and echocardiographic observation to determine whether PDA-closure results in clinically significant CoA 22.…”

“…Patients with subtle clinical and/or diagnostic signs require close clinical and echocardiographic observation to determine whether PDA-closure results in clinically significant CoA 22. Diagnosis of milder cases of CoA is important because hypertension and compensatory LV hypertrophy due to increased LV afterload may occur later in life 6…”