Chandrasekar Hamsika, Maskatia Shiraz A, Beattie Meaghan J, Kaplinski Michelle A, Punn Rajesh, Reddy Charitha D, Jensen Alexandria, Tacy Theresa A
Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Palo Alto, California.
Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Palo Alto, California.
J Am Soc Echocardiogr. 2025 Jun 4. doi: 10.1016/j.echo.2025.05.017.
Neonates with dextro-transposition of the great arteries (d-TGA) require adequate mixing at the atrial level. Without this, they experience severe cyanosis, necessitating balloon atrial septostomy (BAS). Multiple studies have identified various fetal echocardiogram (FE) findings as risk factors for postnatal BAS. The predictive value of these findings remains poor in clinical use.
We aimed to determine the relationship between interrater reliability (IRR) of FE BAS predictors and postnatal BAS, as well as postnatal markers of hypoxia/hypoxemia. We hypothesized that poor IRR may contribute to limited FE predictive value.
We identified d-TGA pregnancies followed at our institution between 2012 and 2022, excluding fetuses with large ventricular septal defects and pregnancies terminated or lost to follow-up. Two groups of 3 independent readers blinded to BAS outcome assessed 7 FE predictors: peak pulmonary vein Doppler velocity >41 cm/sec, reverse flow in patent ductus arteriosus (PDA), restrictive PDA, restrictive patent foramen ovale (PFO), bidirectional PFO flow, flat septum primum, and hypermobile septum primum. Interrater reliability was determined with the S metric. Clinical information before BAS was collected to evaluate postnatal physiology. A multivariable logistic regression was used to determine significant associations between FE findings and postnatal BAS. Multivariable linear regressions were also used to determine significant associations between FE findings and indicators of hypoxia/hypoxemia.
Fifty-two fetuses were included, of whom 25 (48%) underwent BAS. Fetal echocardiograms were performed at a mean gestational age of 34.02 weeks (SD = 2.14 weeks). Interrater reliability was lowest for PFO flow direction and highest for restrictive PDA, likely due to its rarity. The remainder of FE predictors had either moderate or substantial IRR. Five FE characteristics could be included in the regression analysis, and none were significantly associated with odds of BAS, postnatal pH, or postnatal oxygen saturation. Reverse PDA flow was statistically significantly associated with lower postnatal pre-BAS paO.
Our results demonstrate substantial but not excellent IRR for current FE BAS predictors. There was no significant association between these predictors and postnatal BAS or postnatal hypoxia/hypoxemia in d-TGA patients, except for reverse PDA flow and lower postnatal paO. Additional work is needed to identify more reliable FE predictors of postnatal d-TGA physiology.
患有大动脉右位转位（d-TGA）的新生儿需要在心房水平进行充分混合。否则，他们会出现严重的紫绀，需要进行球囊房间隔造口术（BAS）。多项研究已将各种胎儿超声心动图（FE）检查结果确定为出生后BAS的危险因素。这些检查结果在临床应用中的预测价值仍然较差。
我们旨在确定FE BAS预测指标的评分者间可靠性（IRR）与出生后BAS以及缺氧/低氧血症的出生后标志物之间的关系。我们假设较差的IRR可能导致FE预测价值有限。
我们确定了2012年至2022年在我们机构随访的d-TGA妊娠病例，排除患有大型室间隔缺损的胎儿以及终止妊娠或失访的妊娠病例。两组3名对BAS结果不知情的独立读者评估了7项FE预测指标：肺静脉峰值多普勒速度>41 cm/秒、动脉导管未闭（PDA）逆流、限制性PDA、限制性卵圆孔未闭（PFO）、双向PFO血流、原发隔扁平、原发隔活动过度。用S指标确定评分者间可靠性。收集BAS前的临床信息以评估出生后生理学情况。采用多变量逻辑回归确定FE检查结果与出生后BAS之间的显著关联。还采用多变量线性回归确定FE检查结果与缺氧/低氧血症指标之间的显著关联。
纳入52例胎儿，其中25例（48%）接受了BAS。胎儿超声心动图检查的平均孕周为34.02周（标准差=2.14周）。PFO血流方向的评分者间可靠性最低，限制性PDA的评分者间可靠性最高，这可能是因为其罕见。其余FE预测指标的IRR为中等或较高。回归分析可纳入5项FE特征，且无一项与BAS几率、出生后pH值或出生后氧饱和度显著相关。PDA逆流与出生后BAS前较低的动脉血氧分压（paO）在统计学上显著相关。
我们的结果表明，目前FE BAS预测指标的IRR较高但并非极佳。除了PDA逆流与出生后较低的paO外，这些预测指标与d-TGA患者出生后BAS或出生后缺氧/低氧血症之间无显著关联。需要开展更多工作以确定出生后d-TGA生理学更可靠的FE预测指标。
