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Published on: June 29, 2013
Sonographic predictors of surgery in fetal coarctation of the aorta
V Jowett1, P Aparicio, S Santhakumaran
1Institute of Reproductive and Developmental Biology, Faculty of Medicine, Imperial College at Queen Charlotte's and Chelsea Hospital, London, UK.
Insights
Prenatal diagnosis of coarctation of the aorta (CoA) can be improved using four sonographic features. These parameters help predict which fetuses require neonatal surgery, enhancing diagnostic precision.
Area of Science:
- Fetal cardiology
- Medical imaging
- Neonatal surgery
Background:
- Isolated fetal coarctation of the aorta (CoA) diagnosis has high false-positive rates.
- Retrospective studies identified sonographic features distinguishing CoA, but predictive ability for surgery is unknown.
Purpose of the Study:
- To prospectively evaluate four sonographic features for predicting neonatal surgery in fetuses diagnosed with CoA.
- To determine if isthmal diameter Z-scores (I), isthmus to duct diameter ratio (I:D), CoA shelf (Shelf), and isthmal flow disturbance (Flow) differentiate surgical cases.
Main Methods:
- Prospective cohort study of 37 fetuses diagnosed with CoA.
- Measurements of I and I:D, and recording of Shelf and Flow at first and final scans.
- Logistic regression and ANCOVA used to compare predictors and changes in measurements.
Main Results:
- 86% diagnostic accuracy at term; 81.1% of fetuses required surgery.
- Isthmal diameter Z-score < -2 at final scan was the most powerful predictor (OR, 3.6).
- Shelf identified in 66% and Flow in 50% of fetuses with CoA.
Conclusions:
- Incorporating these four sonographic parameters improves diagnostic precision for CoA.
- This approach better identifies fetuses requiring neonatal surgery compared to previous methods.
Objectives:
Isolated fetal coarctation of the aorta (CoA) has high false-positive diagnostic rates by cardiologists in tertiary centers. Isthmal diameter Z-scores (I), ratio of isthmus to duct diameters (I:D), and visualization of CoA shelf (Shelf) and isthmal flow disturbance (Flow) distinguish hypoplastic from normal aortic arches in retrospective studies, but their ability to predict a need for perinatal surgery is unknown. The aim of this study was to determine whether these four sonographic features could differentiate prenatally cases which would require neonatal surgery in a prospective cohort diagnosed with CoA by a cardiologist.
Methods:
From 83 referrals with cardiac disproportion (January 2006 to August 2010), we identified 37 consecutive fetuses diagnosed with CoA. Measurements of I and I:D were made and the presence of Shelf or Flow recorded. Sensitivity, specificity and areas under receiver-operating characteristics curves, using previously reported limits of I < - 2 and I:D < 0.74, as well as Shelf and Flow were compared at first and final scan. Associations between surgery and predictors were compared using multivariable logistic regression and changes in measurements using ANCOVA.
Results:
Among the 37 fetuses, 30 (81.1%) required surgery and two with an initial diagnosis of CoA were revised to normal following isthmal growth, giving an 86% diagnostic accuracy at term. The median age at first scan was 22.4 (range. 16.6-7.0) weeks and the median number of scans per fetus was three (range, one to five). I < - 2 at final scan was the most powerful predictor (odds ratio, 3.6 (95% CI, 0.47-27.3)). Shelf was identified in 66% and Flow in 50% of fetuses with CoA.
Conclusion:
Incorporation of these four sonographic parameters in the assessment of fetuses with suspected CoA at a tertiary center resulted in better diagnostic precision regarding which cases would require neonatal surgery than has been reported previously.
