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Prenatal Diagnosis Influences Preoperative Status in Neonates with Congenital Heart Disease: An Analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database

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Abstract

The early postnatal course for a newborn with critical congenital heart disease (CHD) can be negatively impacted if diagnosis is delayed. Despite this, there continues to be inconsistent evidence regarding potential benefits associated with prenatal diagnosis (PND) in neonates who undergo cardiac surgery. The objective of this study was to better define the impact of a PND on pre-operative morbidity by utilizing a large clinical database. Neonates (< 30 days) undergoing heart surgery from 2010 to 2014 and entered in the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) were included. Multivariable logistic regression was used to evaluate the association between PND and a composite measure including nine major pre-operative risk factors. Co-variates were included to adjust for important patient characteristics (e.g., weight-for-age z-score, genetic syndromes, prematurity), case complexity, and center effects. Centers and patients with excess missing data for relevant co-variates were excluded. Included were 12,899 neonates undergoing surgery at 112 centers. Major pre-operative risk factors were present in 34% overall. By univariate analysis, PND was associated with a lower overall prevalence of major pre-operative risk factors. After adjusting for potential confounders, major pre-operative risk factors were less prevalent among neonates with PND compared to neonates without PND (adjusted OR 0.62, 95% CI 0.57–0.68, p < 0.001). A sensitivity analysis excluding neonates with genetic syndromes, non-cardiac anatomic abnormalities, and prematurity demonstrated similar findings (adjusted OR 0.55, 95% CI 0.49–0.61, p < 0.0001). Among neonates with CHD, prenatal diagnosis is associated with significantly lower rates of pre-operative risk factors for cardiac surgery. Further studies are needed to define association of these pre-operative benefits of a PND with longer term clinical outcomes.

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Funding

This study was funded by the Society of Thoracic Surgeons in the form of data collection and statistical analysis (no grant number available).

Author information

Authors and Affiliations

  1. Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA

    Michael D. Quartermain & David J. Goldberg

  2. Duke University Medical Center, Durham, NC, USA

    Kevin D. Hill

  3. Duke Clinical Research Institute, Durham, NC, USA

    Kevin D. Hill & Amelia S. Wallace

  4. Department of Surgery, All Children’s Hospital and Johns Hopkins University, Saint Petersburg, FL, USA

    Jeffrey P. Jacobs

  5. Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA

    Marshall L. Jacobs

  6. University of Michigan, Ann Arbor, MI, USA

    Sara K. Pasquali

  7. Northwestern University Feinberg School of Medicine, Chicago, IL, USA

    George R. Verghese

  8. Driscoll Children’s Hospital, Corpus Christi, TX, USA

    Ross M. Ungerleider

  9. Department of Pediatrics, The Children’s Hospital of Philadelphia, 34th Civic Center Blvd. Echo Lab, 3rd Floor Main Bldg, Suite 3NW110, Philadelphia, PA, 19104, USA

    Michael D. Quartermain

Authors
  1. Michael D. Quartermain
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  2. Kevin D. Hill
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  3. David J. Goldberg
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  4. Jeffrey P. Jacobs
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  5. Marshall L. Jacobs
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  6. Sara K. Pasquali
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  7. George R. Verghese
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  9. Ross M. Ungerleider
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Contributions

MDQ, KDH, and RMU conceptualized and designed the study, were involved with data analysis and interpretation, drafted the initial manuscript, and approved the final manuscript as submitted. SKP, DJG, GV, JPJ and MLJ helped conceptualize and design the study, were involved with the data analysis and interpretation, critically reviewed and revised all drafts of the manuscript, and approved the final manuscript as submitted. AW performed the statistical analysis, was involved with study design, reviewed and revised all versions of the manuscript and approved the final manuscript version as submitted.

Corresponding author

Correspondence to Michael D. Quartermain.

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Conflict of interest

Michael Quartermain, Kevin Hill, David Goldberg, Jeffery Jacobs, Marshall Jacobs, Sara Pasquali, Amelia Wallace, George Verghese, and Ross Ungerleider declares that they have no conflict of interest. David Goldberg, receives grants support from Mezzion Pharmaceutical.

Research Involving Human Participants or Animals

This article does not contain any studies with human participants or animals performed by any of the authors.

Appendix A

Appendix A

Risk Factor Definitions

Shock defined as a state of inadequate tissue perfusion. If the patient had metabolic acidosis with pH < 7.2 and/or lactate > 4 mmol/liter at the time of OR or present at any time during the admission.

Mechanical ventilation when the patient was supported with mechanical ventilation to treat cardio- respiratory failure during the hospitalization prior to the operating room.

Mechanical circulatory support included use of ventricular assist devices, extracorporeal membrane oxygenation or cardiopulmonary resuscitation for support.

Renal dysfunction is defined as oliguria with sustained urine output less than 0.5 mL per kilo per hour for 24 h and /or a rise in creatinine greater than 1.5 times upper limits for normal age, without needing dialysis (including peritoneal dialysis and/or hemodialysis) or hemofiltration.

Pre-operative neurologic deficit including stroke or seizures. Patient had any deficit of neurologic function identified by the care team during the hospitalization prior to the time of operating room entry. Seizures defined as the clinical and/or electroencephalographic recognition of epileptiform activity. Stroke confirmed by a neurologic imaging study indicating a new or previously unsuspected collection of intraventricular hemorrhage and involves an area of up to but not more than 50% of the ventricular cross-sectional area and sagittal view.

Cardiopulmonary resuscitation defined as chest compression with medications within 48 h prior to surgery.

Hepatic dysfunction is defined as dysfunction of the liver that results in hypoalbuminemia less than 2 g per DL, coagulopathy with prothrombin time greater than 1.5 times the upper limit of normal and hyperbilirubinemia greater than three times upper limits of normal. Selected if the patient developed two out of the three of these laboratory abnormalities.

Necrotizing enterocolitis treated medically or surgically. Necrotizing enterocolitis is defined as acute reduction in the supply of oxygenated blood to the small or large intestines typically results in acidosis, abdominal distention, pneumatosis and/or intestinal perforation that promotes initiation of antibiotics or exploratory laparotomy.

Coagulation disorder. The patient has evidence of a coagulopathy at the time of the operating room as manifested by PT/PTT above normal, thrombocytopenia less than 100,000 or fibrinogen split products positive greater than 10% and the coagulopathy is not secondary to medication such as heparin or warfarin.

Definitions of pre-operative factors are those currently in use in the STS Congenital Heart Surgery Database during the study period.

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Quartermain, M.D., Hill, K.D., Goldberg, D.J. et al. Prenatal Diagnosis Influences Preoperative Status in Neonates with Congenital Heart Disease: An Analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database. Pediatr Cardiol 40, 489–496 (2019). https://doi.org/10.1007/s00246-018-1995-4

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  • DOI: https://doi.org/10.1007/s00246-018-1995-4

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