Prenatal Cardiology, Polish Mother Memorial Hospital Research Institute, Lodz, Poland.
Faculty of Health Sciences, The State University of Applied Sciences in Plock, Plock, Poland.
Ultrasound Obstet Gynecol. 2018 Apr;51(4):531-536. doi: 10.1002/uog.17469.
Prenatal congenital heart disease classification systems distinguish between critical dextro-transposition of the great arteries (d-TGA) with restriction of the foramen ovale (FO) (which requires a Rashkind procedure within the first 24 h following delivery) and d-TGA for which surgery is planned (after prostaglandin perfusion or Rashkind procedure later than 24 h after delivery). However, current prenatal diagnostic criteria for postnatal FO restriction in d-TGA are inadequate, resulting in a high false-negative rate. We aimed to identify echocardiographic features to predict the urgent need for Rashkind procedure.
We identified retrospectively 98 patients with singleton pregnancy diagnosed prenatally with fetal d-TGA at two European centers from 2006 to 2013. Two groups were compared: (1) those in whom the Rashkind procedure was performed within the first 24 h postnatally; and (2) those who did not undergo a Rashkind procedure before cardiac surgery. Exclusion criteria were: (1) no fetal echocardiography within 3 weeks prior to delivery (n = 18); (2) delivery before 37 weeks of gestation (n = 6); (3) improper or lack of measurement of pulmonary vein maximum flow velocity (n = 10); (4) lack of neonatal follow-up data (n = 9); (5) Rashkind procedure performed more than 24 h after delivery (n = 4).
Fifty-one patients met the inclusion criteria: 29 who underwent the Rashkind procedure and 22 who did not. There were no differences between these two study groups in terms of maternal age, gestational age at time of fetal echocardiography, fetal biometric measurements, estimated fetal weight, rate of Cesarean delivery, newborn weight or Apgar score at 1 min. There were also no differences during prenatal life between the two groups in terms of fetal cardiac size (heart area/chest area ratio), rate of disproportion between left and right ventricle, FO diameter and maximum velocity of flow through the FO. However, the pulmonary vein maximum velocity was significantly higher in the group requiring a Rashkind procedure (47.62 ± 7.48 vs 32.21 ± 5.47 cm/s; P < 0.001). The cut-off value of 41 cm/s provided maximum specificity (100%) and positive predictive value (100%) at only a slight cost of sensitivity (82%) and NPV (86%). The prenatal appearance of the FO also differed between the groups, the FO valve being flat in 52% of those requiring a Rashkind procedure.
In fetuses with d-TGA, prenatal sonographic findings of increased pulmonary venous blood flow and flattened FO valve were associated with the need for a Rashkind procedure within the first 24 h postnatally; these echocardiographic features could be used to predict prenatally a need for the procedure following delivery. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
产前先天性心脏病分类系统区分严重右旋性大动脉转位（d-TGA）伴卵圆孔限制（FO）（这需要在分娩后 24 小时内进行 Rashkind 手术）和计划手术治疗的 d-TGA（前列腺素灌注或分娩后 24 小时后进行 Rashkind 手术）。然而，目前用于预测 d-TGA 出生后 FO 限制的产前诊断标准不足，导致假阴性率高。我们旨在确定超声心动图特征，以预测 Rashkind 手术的迫切需要。
我们回顾性地在两家欧洲中心从 2006 年到 2013 年，对 98 例在产前诊断为胎儿 d-TGA 的单胎妊娠患者进行了研究。将这两组进行比较：（1）在出生后 24 小时内进行 Rashkind 手术的患者；（2）在心脏手术前未进行 Rashkind 手术的患者。排除标准为：（1）分娩前 3 周内无胎儿超声心动图（n=18）；（2）分娩孕周<37 周（n=6）；（3）肺动脉最大流速（PV）的测量不当或缺失（n=10）；（4）新生儿随访资料缺失（n=9）；（5）Rashkind 手术在分娩后 24 小时以上进行（n=4）。
51 例患者符合纳入标准：行 Rashkind 手术 29 例，未行手术 22 例。两组患者的母亲年龄、胎儿超声心动图时的胎龄、胎儿生物测量值、估计胎儿体重、剖宫产率、新生儿体重或 1 分钟 Apgar 评分均无差异。在产前生活中，两组之间的胎儿心脏大小（心脏面积/胸廓面积比）、左心室和右心室之间的比例、FO 直径和 FO 内最大血流速度也没有差异。然而，需要 Rashkind 手术的组的肺静脉最大速度明显更高（47.62±7.48 vs 32.21±5.47 cm/s；P<0.001）。41cm/s 的截断值提供了最大的特异性（100%）和阳性预测值（100%），而敏感性（82%）和阴性预测值（86%）的代价很小。FO 的产前外观也在两组之间不同，需要 Rashkind 手术的患者中，FO 瓣呈扁平状占 52%。
在 d-TGA 胎儿中，产前超声心动图发现肺静脉血流增加和 FO 瓣变平与出生后 24 小时内需要 Rashkind 手术有关；这些超声心动图特征可用于预测分娩后需要该手术。版权所有©2017 ISUOG。由 John Wiley & Sons Ltd 出版。
