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DALLAS, May 17, 2021 – Detection of a critical heart defect before birth (congenital heart defects) is less likely when a mother lives in a rural area, lives in a neighborhood of low socioeconomic status, or is Hispanic, according to one new study published today in the American Heart Association’s flagship journal, Circulation.
Diagnosing a heart defect before birth reduces infant mortality rates, increases access to prompt medical treatment, improves neurodevelopmental outcomes, and decreases the risk of brain injury to the infant after birth.
“The benefits of prenatal diagnosis of heart defects have been recognized for years, but prenatal detection occurs in less than 60% of cases of congenital heart disease in many parts of the United States,” said the study’s first author. , Anita Krishnan, MD, associate professor of pediatrics. and Associate Director of Echocardiography at Children’s National Hospital in Washington, DC
“This is one of the largest studies to define specific populations at risk for missed prenatal screening and diagnosis of congenital heart disease,†she said. “With these conditions, minutes can make a difference, and prenatal planning can improve care before, during and after birth.
Researchers evaluated data on more than 1,800 infants from 21 heart centers in the United States and Canada to determine whether there is a relationship between prenatal detection of large artery transposition and hypoplastic left heart syndrome and socio-economic, racial / ethnic and geographic factors.
Congenital heart defects are heart conditions that are present at birth. According to Heart Disease and Stroke Statistics – 2021 update from the American Heart Association, approximately 40,000 infants are expected to be affected by congenital heart defects each year in the United States. At least 18 distinct types of congenital heart defects are recognized, with many additional anatomical variations.
The transposition of the large arteries occurs when the two main arteries leaving the heart are reversed and account for 2.6% of congenital heart defects. Hypoplastic left heart syndrome involves an underdeveloped left side of the heart and accounts for about 0.3% of defects.
The study focused on clinical data from fetuses and infants with an initial assessment between 2012 and 2016 at a participating facility in the Fetal Heart Society, a nonprofit, multi-center research collaboration whose mission is to advance the field of fetal cardiovascular care and science. . Researchers defined prenatal detection as a fetal echocardiogram – a test that uses high-frequency sound waves, or ultrasound, to visualize the structures and function of the fetal heart. Patients are referred for fetal echocardiograms for a variety of maternal or fetal conditions as directed by the American Institute of Ultrasound in Medicine, or if an abnormality is suspected on a second trimester ultrasound examination. Most cases are referred because of suspected heart disease and not for one of the routine indications for fetal echocardiography, Krishnan explained.
Hypoplastic left heart syndrome can be identified by echocardiographic imaging of the four chambers of the heart; However, detection of large artery transposition requires additional views on prenatal ultrasound screening and may be more difficult to detect prenatally than hypoplastic left heart syndrome, the authors noted.
Socio-economic and residential information was taken from federal census data for mothers, and the distance to a heart center was derived from the address of the mother at the time of her first visit for prenatal screening. For American patients, neighborhood socioeconomic status was measured in quartiles taking into account median household income; median household value; neighborhood percentage of high school graduates; percentage of neighborhood college graduates; percentage of neighborhood residents in managerial, managerial or professional specialty positions; and the percentage of households receiving rental income.
In Canadian patients – all from Alberta and Ontario – socioeconomic status was calculated from 22 variables related to cultural identities, environmental pollutants, studies of environmental injustice, and a deprivation index, which is a marker of social inequalities in health. These factors were then converted to be comparable to US quartiles.
The study found that about 92% of cases of hypoplastic left heart syndrome and 58% of cases of large artery transposition were diagnosed before birth. However, significant socioeconomic, racial, and ethnic differences emerged among women diagnosed with fetal major artery transposition.
“Mothers who lived in poorer neighborhoods were up to 22% less likely to receive a prenatal diagnosis of large artery transposition than mothers who lived in richer neighborhoods,†Krishnan said. “While the results were not completely surprising and resonated with clinical experience, the strength of the associations was surprising.”
Other results include:
Hispanic ethnicity in the United States was associated with a 15% lower probability of prenatal detection of large artery transposition compared to non-Hispanic mothers, and living in rural areas was associated with a probability of detection. prenatal transposition of the large arteries compared to mothers who lived in more urban areas.
Among patients in Canada, only a longer distance to a heart center was associated with lower prenatal detection rates of hypoplastic left heart syndrome – those who drove more than 135 miles for treatment were 24% less likely to ” have a transposition of the major arteries detected.
Lower socioeconomic status was associated with an approximately four week delay in the diagnosis of prenatal congenital heart disease in pregnant women in the United States and Canada.
The standards of care for congenital heart disease are similar in both countries, but some associations were different in the United States compared to Canada, where health care is publicly funded and available to all Canadian citizens or permanent residents. without financial limitation. “This suggests that factors related to different health care delivery systems may also play a role in screening and diagnosis rates,†Krishnan said.
“While prenatal detection rates for congenital heart disease are lower than they should be across the board, there are striking socio-demographic and geographic disparities,†she said. “Strengthening relationships between cardiology and surgery centers and the populations identified in this study, through awareness raising and possibly telemedicine, could improve prenatal detection rates within these communities.
“Telehealth links with the tertiary care center can improve speed of detection as well as overall detection rates, but it is probably not the only solution,†continued Krishnan. “In-person collaboration or consultation is also required. A study is underway to determine if there are socio-economic barriers to participating in telemedicine and the Internet, and our center is currently piloting work in rural Maryland. To successfully implement telemedicine, one must invest in equipment, educate ultrasound technologists and set up the security infrastructure to make telemedicine easier to achieve. “
The study created a new registry of data variables that had not been possible using hospital databases that typically do not include antenatal care information linking maternal and pediatric records. One important limitation is that the study only included patients who received care at one of 21 participating fetal heart centers.
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The co-authors are Marni B. Jacobs, Ph.D .; Shaine A. Morris, MD, MPH; Shabnam Peyvandi, MD; Aarti H. Bhat, MD; Anjali Chelliah, MD; Joanne S. Chiu, MD; Bettina F. Cuneo, MD; Grace Freire, MD; Lisa K. Hornberger, MD; Lisa Howley, MD; Nazia Husain, MD; Catherine Ikemba, MD; Ann Kavanaugh-McHugh, MD; Shelby Kutty, MD, Ph.D., MHCM; Caroline Lee, MD; Keila N. Lopez, MD, MPH; Angela McBrien, MD; Erik C. Michelfelder, MD; Nelangi M. Pinto, MD; Rachel Schwartz, MD; Kenan WD Stern, MD; Carolyn Taylor, MD; Varsha Thakur, MD; Wayne Tworetzky, MD; Carol Wittlieb-Weber, MD; Kristal Woldu, MD; and Mary T. Donofrio, MD
The study was funded by the National Institute on Minority Health and Health Disparities of the National Institutes of Health, the Children’s National Heart Institute Cardiology Patient Research Fund, and the Fetal Heart Society.
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