Fetal Echocardiography Enhances Perinatal Care for Coarctation of the Aorta: Balancing Risk of Hemodynamic Compromise...

Prenatal diagnosis of coarctation of the aorta (CoA) remains challenging. Anticipated postnatal risk, level of care (LOC), was assigned using fetal echocardiography measures including mitral valve/tricuspid valve ratio, aortic valve/pulmonary valve ratio, and aortic isthmus size. Patients assigned LOC 1 (low risk, not expected to have instability within first weeks of life) underwent postnatal echocardiography in the community; patients assigned LOC 2 (moderate risk, expected stability at delivery, postnatal intervention before hospital discharge) were started on prostaglandin and transferred. We hypothesize that LOC assignment leads to minimal neonatal morbidity. Patients with prenatal suspicion of CoA (2009-2023) were studied comparing prenatal LOC with postnatal outcomes. Retrospective analyses were performed with chi-square or Fisher's exact test for categorical variables and t-test, Mann-Whitney, or Kruskal Wallis test for continuous variables. Of 199 fetuses, 182 were assigned LOC 1 and 17 LOC 2. Of patients assigned LOC 1, 6% (11/182) versus 41.2% (7/17) of patients assigned LOC 2 required CoA repair. Interestingly, over the study period, fewer patients were assigned LOC 2 despite similar frequency of patients requiring CoA repair, suggesting a practice change. There was no increase in morbidity or length of hospital stay in patients who required CoA repair assigned LOC 1 versus 2. LOC assignment for patients with suspected CoA, with a robust framework for postnatal assessment including postnatal echocardiogram at the delivery hospital, results in confidence in LOC assignment. The increase in LOC 1 assignment over time reduced prostaglandin use and unnecessary transport without increasing morbidity, even if surgery was needed.