Impact of prospective measurement of outflow tracts in prediction of coarctation of the aorta

Abstract

Objectives Prenatal diagnosis of coarctation of the aorta (CoA) is associated with reduced mortality and morbidity, however, accurate prenatal prediction remains challenging. To date, studies have used retrospective measurements of the outflow tracts to evaluate their potential to predict CoA. Our primary objective was to evaluate prospectively acquired measurements of the outflow tracts in fetuses with prenatally suspected CoA. A secondary aim was to report the postnatal prevalence of bicuspid aortic valve in this cohort. Methods Pregnancies with suspicion of isolated CoA and with a minimum of 6 months' postnatal follow‐up available were identified from the cardiac database of a tertiary fetal cardiology center in the UK, between January 2002 and December 2017. Measurement of the aortic valve, pulmonary valve, distal transverse aortic arch (DTAA) and arterial duct (AD) diameters were undertaken routinely in fetuses with suspected CoA during the study period. Z‐scores were computed using published reference ranges based on > 7000 fetuses from our own unit. Results Of 149 pregnancies with prenatally suspected CoA included in the study, CoA was confirmed within 6 months after birth in 77/149 (51.7%) cases. DTAA diameter Z‐score and the Z‐score of second‐trimester DTAA/AD diameter ratio were smaller in fetuses with postnatally confirmed CoA than those in false‐positive cases (–2.8 vs –1.9; P = 0.039 and –3.13 vs –2.61; P = 0.005, respectively). Multiple regression analysis demonstrated that the Z‐scores of DTAA and AD diameters were the only significant predictors of postnatal CoA (P = 0.001). Bicuspid aortic valve was identified in 30% of the false‐positive cases. Conclusions Measurement of DTAA and AD diameter Z‐scores can be used to ascertain risk for postnatal CoA in a selected cohort. The high incidence of bicuspid aortic valve in false‐positive cases merits further study with respect to both etiology and longer‐term significance. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Application of a Global Multiparameter Scoring System for the Prenatal Prediction of Coarctation of the Aorta

“…However, as in our series, other studies did not observe differences for functional parameters (flow at the aortic arch and FO) between CoAo and no CoAo fetuses [18,20,24]. We also did not find differences for PLSVC according to postanal outcome (CoAo vs. no CoAo), similarly to other groups [18,22,24,25,33]. Nevertheless, Morgan et al [20] found more cases of PLSVC in fetuses with CoAo compared to normal cases, although in the multivariate analysis, it was not statistically significant.…”

“…Recent studies have proposed some morphological and functional fetal echocardiographic parameters, and even multiparameter scoring systems in order to improve the prenatal prediction of the likelihood of postnatal confirmation of CoAo [18][19][20][21][22][23][24][25][30][31][32][33]. The current study is the largest to prospectively assess the capability of a multiparameter scoring system to predict CoAo in fetuses with ventricular and great vessel disproportion with right dominance.…”

“…Table 4 summarizes the echocardiographic variables and multiparameter scores proposed by several groups for prenatal prediction of CoAo [18][19][20][21][22][23][24][25][30][31][32][33]. Our global score includes three cardiac parameters (Z-score of the AAo and of the aortic isthmus in the 3VT view, and the PV/AV ratio), and GA at diagnosis.…”

“…The positive predictive value of this cardiac asymmetry varies from 60% to 86% in the second trimester and decreases to 10-41% in the third trimester [1,7,11,13,14], because this finding could appear in fetuses without CoAo in late pregnancy [15]. Consequently, more than 50-60% of cases with a prenatal suspected CoAo are not confirmed after birth, but they are recommended to be delivered at tertiary hospitals [7,[16][17][18][19][20][21][22][23][24][25][26]. An improvement in survival, morbidity, and perioperative conditions when the CoAo is prenatally diagnosed by enabling planned delivery in an adequate center and the early prevention of a ductus arteriosus (DA) constriction has been reported [27,28].…”

“…Previous studies have described some morphologic and functional cardiac parameters that could be useful to obtain a better prenatal prediction of CoAo [21,[29][30][31]. In addition, over the last few years, several multiparameter scoring systems to differentiate between subjects with and without CoAo have been published [18][19][20][21][22][23][24][25]30,32,33]. However, there are few groups that have applied these scores to clinical practice to distinguish fetuses with and without CoAo.…”