title: Risk-stratified postnatal care of newborns with congenital heart disease determined by fetal echocardiography.
abstract: BACKGROUND
  Advances in fetal echocardiography have improved recognition of congenital heart disease (CHD). Imaging protocols have been developed that predict delivery room (DR) risk and anticipated postnatal level of care (LOC). The aim of this study was to determine the utility of fetal echocardiography in the perinatal management of CHD.
  
  
  METHODS
  A retrospective analysis of fetal and postnatal records was conducted. The anticipated LOC was assigned by fetal echocardiography (LOC 1, nursery consult/outpatient follow-up; LOC 2, stable in DR with transfer to cardiac hospital; LOC 3 or 4, DR instability/urgent intervention needed). Prenatal diagnoses and LOC assignment were compared with postnatal diagnoses, treatment, and short-term outcomes.
  
  
  RESULTS
  From 2004 to 2012, 8,101 fetuses were evaluated; 7,405 were normal. Of 696 with CHD, 101 terminated, 40 died in utero, and 37 received palliative care. LOC was assigned in the remaining 518. Of 219 LOC 1, 195 (89%) had postnatal follow-up. Only two required transfer for intervention (LOC 1 sensitivity, 0.9; LOC 1 positive predictive value, 0.99). Of 260 assigned LOC 2, 229 (88%) had follow-up. Of these, 200 (87%) were transferred for surgery or intervention. The median time to admission was 195 min. Twenty-two patients (10%) assigned LOC 2 did not require intervention; however, seven (all with D-transposition of the great arteries) required catheter intervention before surgery. Hospital survival was 86% (LOC 2 sensitivity, 0.97; LOC 2 positive predictive value, 0.87). All LOC 3 and 4 patients had follow-up. Thirty-four (87%) needed urgent intervention, with 100% DR and 87% hospital survival (LOC 3 and 4 sensitivity, 0.83; LOC 3 and 4 positive predictive value, 0.87).
  
  
  CONCLUSIONS
  Fetal echocardiography enables accurate postnatal risk stratification in CHD, with the exception of D-transposition of the great arteries. LOC 1 assignment facilitated outpatient follow-up; LOC 2 assignment facilitated transfer for intervention. LOC 3 and 4 patients underwent stabilizing intervention or surgery with good short-term outcomes. Given the inability to predict need for intervention in D-transposition of the great arteries, all such patients should be assigned as LOC 3 or 4. Fetal echocardiography with LOC assignment should be used in the planning of postnatal care in CHD.
authors: Division of Cardiology, Children's National Medical Center, Washington, District of Columbia; Division of Fetal Medicine, Children's National Medical Center, Washington, District of Columbia. Electronic address: mdonofri@childrensnational.org.
authors: Mary T
authors: MT
authors: Donofrio
authors: Division of Cardiology, Children's National Medical Center, Washington, District of Columbia.
authors: Kami
authors: K
authors: Skurow-Todd
authors: Division of Cardiology, Children's National Medical Center, Washington, District of Columbia; Division of Critical Care Medicine, Children's National Medical Center, Washington, District of Columbia.
authors: John T
authors: JT
authors: Berger
authors: Department of Biostatistics, Children's National Medical Center, Washington, District of Columbia.
authors: Robert
authors: R
authors: McCarter
authors: Division of Cardiology, Children's National Medical Center, Washington, District of Columbia.
authors: Amanda
authors: A
authors: Fulgium
authors: Division of Cardiology, Children's National Medical Center, Washington, District of Columbia.
authors: Anita
authors: A
authors: Krishnan
authors: Division of Cardiology, Children's National Medical Center, Washington, District of Columbia.
authors: Craig A
authors: CA
authors: Sable
mesh_terms: D006348:Cardiac Surgical Procedures / Q000706:statistics & numerical data; D004219:District of Columbia / Q000453:epidemiology; D004452:Echocardiography / Q000706:statistics & numerical data*; D005260:Female; D006330:Heart Defects, Congenital / Q000000981:diagnostic imaging* / Q000453:epidemiology* / Q000601:surgery; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D011181:Postnatal Care / Q000706:statistics & numerical data*; D015995:Prevalence; D011379:Prognosis; D015203:Reproducibility of Results; D018570:Risk Assessment / Q000379:methods; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D016216:Ultrasonography, Prenatal / Q000706:statistics & numerical data*
keywords: Congenital heart disease; Fetal cardiology; Fetal echocardiography