Structural Cardiovascular Malformations Management,Complex Heart Lesions

4th Pediatric Infectious Diseases Conference

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Fetal Echocardiography and Antenatal Management of CHD

FETAL ECHOCARDIOGRAPHY AND ANTENATAL MANAGEMENT OF CONGENITAL HEART DISEASES

Related topics

Fetal Echocardiography Importance

Fetal Arrhythmias Management

Dr. Sumitra V, Dr.S.S.Prabhu,
Dr.N.J. Burkule
Division of Cardiology,
Department of Pediatrics,
B.J.Wadia Children's Hospital.

Management of various groups of structural cardiovascular malformations detected in antenatal period (Table II and III):

Atrioventricular Septal defect: This is the commonest of the serious structural abnormality seen on fetal echocardiography. Down's syndrome is commonly associated and other complex cardiac lesions include left atrial Isomerism, complete heart block and non-immune hydrops. There is no left to right shunt in utero because of similar pressure in both atria and both ventricles. There is a potential risk of diminution of blood flow to ascending aorta and progressive coarctation of aorta as the gestation advances. Thus the management strategies in most patients with these defects is to advice a normal delivery as surgical repair is easier in larger patients. The prognosis is poor if compounded by chromosomal anomalies and other cardiac and non-cardiac anomalies where therapeutic termination of pregnancy may be offered.
Hypoplastic Left and right heart syndrome:The second most frequent lesion detected in most series is hypoplastic heart syndrome. Progressive ventricular hypertrophy, endocardial fibroelastosis of the obstructed ventricle leading to cardiac failure and fetal loss usually occur consequently. Certain centers in developed countries offer intervention by means of catheter dilation in an attempt to arrest the progressive obstruction to ventricular outflow but with limited success(4). In our setting, the best option given to the potential parents would be to offer medical termination of pregnancy to the group with hypoplastic left heart syndrome. In the hypoplastic right heart, the pregnancy is continued, with advise to deliver these fetuses in an institution offering specialized and intensive perinatal care and starting prostaglandin infusion immediately after birth to keep the ductus patent. Early surgical intervention and staged palliative repair is offered postnatally.
Tricuspid regurgitation with or without associated Tricuspid dysplasia:It is not uncommon to find mild to moderate tricuspid regurgitation on fetal echocardiography, but most of them are benign and secondary to high pulmonary pressures. The follow up of these fetuses in neonatal period generally show regression of right ventricular hypertrophy and tricuspid regurgitation. It is important to distinguish these from the structurally abnormal and dysplastic tricuspid valve conditions like Ebstein's where the right ventricular cavity is small with associated severe tricuspid regurgitation. Most of these fetuses have additionally severe hydrops, heart failure or complete heart block with a high incidence of fetal loss or neonatal deaths.
Conotruncal anomalies: Transposition of Great Vessels, Double Outlet Right Ventricles, Tetralogy of Fallot and its variants and persistent Truncus Arteriosus These group of lesions are compatible with normal fetal development and survival. In most lesions, early corrective surgery can be offered postnatally with fair prognosis and a decreased morbidity and mortality. Associated cardiac, non-cardiac lesions and chromosomal anomalies have to be ruled out. Transposition of Great Vessels with intact ventricular septum need prostaglandin infusion in neonatal period to keep the ductus arteriosus patent.
Univentricular Hearts: These complex forms of cardiac defects are usually associated with fetal losses due to nonimmune hydrops. In most cases normal delivery is advocated with staged univentricular repair in the postnatal period.

Table (II)-Protocol for management of Cardio-Vascular anomalies detected in fetus

Cardiovascular Malformations in Antenatal period - Figure 1

Table (III)-Complex Heart lesions - Management

Cardiovascular Malformations in Antenatal period - Figure 2

Next : Fetal Arrhythmias Management

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