Diagnostic accuracy of prenatal ultrasound in coarctation of aorta: systematic review and individual participant data meta‐analysis

Abstract

Objectiveto determine the diagnostic accuracy of prenatal ultrasound (US) in detecting coarctation of aorta (CoA).Methodsan individual participant data meta‐analysis was performed to report the strength of association and diagnostic accuracy of different US signs in detecting CoA prenatally. MEDLINE, Embase, and CINAHL were searched from January 2000 until November 2021. Individual participant‐level data was obtained by two leading teams. PRISMA‐IPD and PRISMA‐DTA guidelines were used for abstracting data and the QUADAS‐2 tool for assessing quality and applicability. The reference standard was CoA diagnosed after birth defined as narrowing of the aortic arch. The index test included the most commonly evaluated parameters on US both in B‐Mode and Doppler. Summary estimates of sensitivity, specificity, diagnostic odds ratio (DOR), and likelihood ratios were computed using hierarchical summary receiver–operating characteristics.ResultsThe initial search yielded 72 studies of which 25 met the inclusion criteria (evaluation of fetuses with suspected CoA considered as isolated cardiac and/or great vessels disproportion with right dominance on US assessment). Seventeen studies (640 fetuses) were included. At random effect logistic regression analysis, tricuspid/mitral valve ratio > 1.4 and >1.6, aortic isthmus/arterial duct ratio <0.7, hypoplastic arch (all p<0.001), aortic isthmus z‐score <2 at sagittal (p=0.003) and 3‐vessel view (p<0.001), pulmonary artery/ascending aorta ratio (p=0.048), bidirectional flow at the foramen ovale (p=0.012) and redundant foramen ovale (p=0.037) were independently associated with CoA. Regarding diagnostic accuracy, tricuspid/mitral valve ratio >1.4 had a sensitivity of 72.6% (95%CI, 48.2‐88.3), a specificity of 65.4% (95%CI, 46.9‐80.2), and a DOR of 5.02 (95%CI, 1.82‐13.9). The respective sensitivity/specificity figures for pulmonary artery/ascending aorta ratio >1.4, aortic isthmus z‐score <‐2 at sagittal and aortic isthmus at 3‐vessel views were 75.0% (95%CI, 61.1‐86.0)/39.7% (95%CI, 27.0‐53.4), 47.8% (95%CI, 14.6‐83.0)/87.6% (95%CI, 27.3‐99.3) and 74.1% (95%CI, 58.0‐85.6)/62.0% (95%CI, 41.6‐78.9). Hypoplastic arch had a sensitivity of 70.0% (95%CI, 42.0‐88.6), a specificity of 91.3 (95%CI, 78.6‐96.8), and a DOR of 24.9 (95%CI, 6.18‐100). Continuous parameters were independently associated with CoA (all, p<0.001) but all had low‐moderate diagnostic yield, same as multivariate models.ConclusionsSeveral prenatal ultrasound parameters are associated with an increased risk for postnatal CoA. However, diagnostic accuracy is only moderate, even when combined.This article is protected by copyright. All rights reserved.

Prenatal Diagnosis of Congenital Heart Disease: The Crucial Role of Perinatal and Delivery Planning

“…Prediction of the presence or severity of aortic arch coarctation is challenging prenatally due to the presence of the ductus arteriosus, with its true severity often becoming evident only after the ductal constriction. Several studies have evaluated the utility of fetal echocardiographic findings in the prediction of postnatal coarctation, such as ventricular size discrepancy [19], aortic isthmus hypoplasia using gestational age-specific Z scores [20,21], increased distance between left common carotid to left subclavian branches, aortic arch curvature [22], and retrograde flow in the aortic isthmus [23]. However, none of these individual markers had high sensitivity and specificity for accurate coarctation prediction, and multi-parametric models integrating different fetal echocardiographic variables were proposed after a metanalysis study [24].…”

“…However, none of these individual markers had high sensitivity and specificity for accurate coarctation prediction, and multi-parametric models integrating different fetal echocardiographic variables were proposed after a metanalysis study [24]. A more recent metanalysis study [21] again showed that although several prenatal ultrasound parameters can be associated with coarctation, their diagnostic accuracy is only moderate, even when parameters were used in combination. It has been reported that risk-based delivery and perinatal care planning in suspected coarctation can reduce unnecessary medical interventions [25].…”

Differential diagnosis in disproportion in four‐chamber view in fetus in late pregnancy—Challenging dilemma

“…2,3,17,21 Positive predictive value is rising in combination with disproportion in three vessel view but is still not satisfying for many researchers. 15,18 Proper interpretation and diagnosis of CoA during fetal life, rise with experience of the sonographer. Competency in visualizing ductal and aortic arch in sagittal view is helpful with no doubt but is difficult to achieve and sometimes not possible because of the position of the fetus.…”

“…The disproportion between aorta (A) and pulmonary artery (PA) in 3VV should be no more than 2 mm, or the index between them should be less than 1.5. [15][16][17][18] The differential may rise between second and third trimester, and it concerns 4CH and 3VV. 19 Disproportion, like other echocardiography findings in third trimester such as: trivial/mild tricuspid regurgitation or aneurysm of septum primum could be a result of the physiologic alteration.…”