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Does a prenatal diagnosis of congenital heart disease alter short-term outcome?
J A Copel1, A S Tan, C S Kleinman
1Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, CT 06520-8063, USA.
Insights
Prenatal diagnosis of congenital heart disease (CHD) did not improve overall survival or reduce hospitalization costs. However, it showed improved survival and lower costs for fetuses requiring biventricular repair.
Area of Science:
- Pediatric Cardiology
- Fetal Medicine
- Congenital Anomalies
Background:
- Congenital heart disease (CHD) is the most common fatal congenital anomaly in the first year of life.
- Fetal echocardiography enables in utero diagnosis of CHD, but its clinical benefits remain unevaluated.
- This study assesses the impact of prenatal diagnosis on neonatal outcomes for CHD.
Purpose of the Study:
- To evaluate the benefits of prenatal diagnosis of congenital heart disease (CHD).
- To compare hospitalization costs, length of stay, and survival rates between neonates with and without prenatal CHD diagnosis.
- To examine outcomes in specific subgroups: univentricular management, biventricular repair candidates, and ductal-dependent lesions.
Main Methods:
- A cohort analysis of neonates with CHD, excluding those with other life-threatening conditions.
- Group I: Neonates diagnosed with CHD prenatally and delivered at Yale-New Haven Hospital.
- Group II: Neonates diagnosed with CHD postnatally, delivered or transferred to the same hospital.
- Primary outcomes: initial hospitalization costs, length of hospitalization, and survival to discharge.
Main Results:
- Overall, prenatal diagnosis did not significantly improve hospitalization length, cost, or survival rates.
- For neonates requiring biventricular repair, prenatal diagnosis was associated with better survival (96% vs. 76%) and lower hospitalization costs.
- The prenatal diagnosis group showed a higher proportion of single ventricle physiology, with increased surgery rates (86% vs. 56%).
Conclusions:
- Prenatal diagnosis of CHD does not universally lead to improved outcomes or cost savings.
- Benefits were observed in specific subgroups, notably improved survival and reduced costs for fetuses amenable to biventricular repair.
- The higher rate of single ventricle cases in the prenatal group, potentially influenced by termination decisions, impacts overall outcome interpretation.
Abstract:
Congenital heart disease (CHD) is the most common fatal congenital anomaly in the first year after birth. Fetal echocardiography has become accepted as a method of diagnosing CHD in utero, but the benefits of prenatal diagnosis have not been evaluated. We performed a cohort analysis of neonates with CHD in the absence of other life-threatening conditions. One group (I) consisted of neonates who had been diagnosed as fetuses to have CHD and who were delivered at Yale-New Haven Hospital. The other group (II) consisted of neonates who were not diagnosed to have CHD until after birth, and were either delivered at, or transferred to, the same hospital. Costs of initial hospitalization, length of hospitalization, and survival to discharge home with the parents were primary outcome measures. Our primary hypothesis was that all outcome measures would be improved by prenatal diagnosis. We also examined secondary hypotheses that these same measures would be improved among selected subgroups, including those requiring univentricular management, those amenable to biventricular repair, those with ductal dependent lesions, and those requiring any surgery during the primary admission. From January 1, 1991 to June 30, 1996 we identified 45 antenatal cases and 54 postnatal cases of CHD that met the study entry criteria. The median length (+/- SE) of initial hospitalization was 16 +/- 3.8 days in group I, and 11 +/- 3.8 days in group II (p < 0.08). The median cost of initial hospitalization was $57,678 +/- 12,340 vs. $53,604 +/- 7249 (not significant). Eighty percent of group I survived to hospital discharge compared with 67% of group II (p = 0.14). There was no difference in survival among those requiring univentricular management (64 vs. 44%), but costs and length of hospitalization were greater in group I, regardless of whether or not surgery was performed postnatally. Surgery was undertaken more often among the prenatal diagnosis group with univentricular hearts (86 vs. 56%, p < 0.05). Among those fetuses amenable to biventricular repair, survival was better (96 vs. 76%, p < 0.05) and the cost of hospitalization was lower ($30,277 +/- 16,869 vs. $64,616 +/- 9441, p = 0.06) in the prenatal diagnosis group. Prenatal diagnosis of CHD does not result in the expected savings in cost, length of hospitalization or survival in the overall group of patients. The prenatal diagnosis group showed a skew towards single ventricle physiology. Within that group a high rate of pregnancy termination results in a group of parents who are likely to choose postnatal surgery despite high short- and long-term mortality risks.