800 regional prenatal chd detection sept 2013

9/17/2013

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©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 ©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13

Lori Erickson RN, CPNP, APRN

Fetal Cardiac and Single Ventricle

Survivorship APRN

Ward Family Heart Center

Regional Prenatal Congenital

Heart Disease Detection and

Practices

©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13

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Objectives

State the categories of congenital heart

disease

Review literature of national prenatal

detection and outcomes

State the frequency of Fetal Echocardiogram

Compare national to current local and

regional detection of congenital heart

disease admitted to CMH

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Symposium Registrants Cardiac Surgery

Genetic Counseling

Maternal Fetal Medicine

Neonatology

Obstetrics

Pediatric Cardiology

Respiratory Therapy

Sonography

APRN 11%

Staff MD 10%

CGC 1%

Fellow 5%

RT 11%

RN 22%

Student 2%

US 38%


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Categories of Congenital

Heart Disease (CHD)

– d-Transposition of the Great Arteries

(d-TGA)

– Tricuspid and Pulmonary Atresia

– Hypoplastic Left Heart Syndrome (HLHS)

– Single Ventricle Anatomy

– Double Outlet Right Ventricle (DORV)

Severe/Major CHD


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Categories of CHD

Severe/Major CHD

– Truncus Arteriosus

– Total Anomalous Pulmonary Venous

Return (TAPVR)

– Critical Pulmonary Stenosis

– Aortic Arch Abnormalities

(IAA, COA, Hypoplastic arch)

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Categories of CHD

• Mild aortic stenosis

(AS)

• Moderate pulmonary

stenosis (PS)

• Non-Critical Coarctation

of the Aorta

• Large ASD

• Isolated VSD

• Small VSD

• Small PDA

• Mild Pulmonary

Stenosis (PS)

• Small or spontaneously

closing ASD

• Bicuspid aortic valve

Moderate CHD Mild CHD


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National Prenatal Detection

1-3 /100 babies are born with a Heart

defect

4-6/1000 with Moderate–Severe

Categories of CHD

In 1994, only 12.7% of CHD Detected

prenatally

(Hoffman et al, 2002 &

Friedberg et al 2009)

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Levy et al (2013)


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by Diagnosis

(Friedberg et al, 2009)

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Standardized Fetal Echo

Screening

Implemented an educational program for

sonographers including 4 chamber view

and both outflow tracts in low-risk

patients/pregnancy

Video Clips of prenatal ultrasounds

Rotating the sonographers with the

Pediatric Cardiologists Levy et al (2013)

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Positives of Prenatal Cardiac

Diagnosis Improved Morbidity with less intubation,

acidosis, or cardiovascular collapse less

likely related to ductal closure

Improved Neurocognitive outcomes in

children with d-TGA

Improved surgical outcome with HLHS

and coarctations

(Calderon et al, 2012, Franklin et al, 2002 &

Tworetzky et al, 2001 )


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Positives of Prenatal Diagnosis

Parental and Family counseling about

cardiac diagnosis with multi-disciplinary

team

Short and Long-term prognosis

Surgical planning

Co-Morbid Conditions

(Feinstein et al., 2012)

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Positives of Prenatal Cardiac

Diagnosis Social and Family Factors of CHD

Genetic Counseling

Possibility of Fetal Intervention

(Feinstein et al., 2012)


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Local Detection of Congenital

Heart Disease

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Reasons for Referral

Abnormal 4 chamber View

Abnormal RVOT View

Arrhythmia: Tachycardia, SVT, Heart

Block

Syndromes: T-21, Noonan’s, Turner’s

Multiple Gestations

Family History of CHD


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Reasons for Referral ASD or VSD

Possible HLHS

Possible HRHS

Possible TOF

Pulmonary Stenosis

“Other”

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Fetal Echocardiogram at CMH

2009 2010 2011 2012 2013

f/u 9 3 7 44 74

New 59 59 106 115 114

0

20

40

60

80

100

120

140

160

180

200 N

um

be

r o

f E

ch

os

January 2009-August 2013


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Prenatal Detection for Major Congenital

Heart Disease Regionally

January 2010 to July 2013

2010 2011 2012 2013

Prenatal Diagnosis 28.1 44.9 47 44.8

0

5

10

15

20

25

30

35

40

45

50

Pe

rce

nt

Pre

na

tlly

Dete

cte

d

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Prenatal Detection By

Diagnosis

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

2010 2011 2012 2013

Heart Block

HLHS (Stage I)

Left Sided Lesion (No VSD) VSD with Other Lesions (Truncus, IAA, COA) ASO

ASO + VSD

BT shunt for Pulmonary Blood Flow TAPVR


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Prenatal Detection of Specific

Lesions

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

2010 2011 2012 2013

Heart Block

HLHS (Stage I)


ASO + VSD


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Lesions

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

2010 2011 2012 2013

Heart Block

HLHS (Stage I)

Left Sided Lesion (No VSD)

VSD with Other Lesions (Truncus, IAA, COA)

ASO

ASO + VSD

BT shunt for Pulmonary Blood Flow

TAPVR


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Lesions

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

2010 2011 2012 2013

Heart Block

HLHS (Stage I)


ASO + VSD


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Fetal Cardiac Clinic Multi-disciplinary

Fetal Cardiology

MD

APRN

Nurse Coordinator

MFM

Social Work

Genetic Counseling


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Fetal Cardiac Clinic

Integrated Consultations

2012: 169

2013: 175 to date

Neonatology, Cardiac

Surgery, Heart Center

APRN/RN’s,

Electrophysiology, Cardiac

Interventionalists, Cardiac

Anesthesia

Genetics and SW

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Fetal Cardiac Clinic

Family support

PACT- Palliative Care

Team

Child Life

Chaplain

Tours of FHC, NICU, PICU

Ronald McDonald Support

for night before visits and

during periods of relocation


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References

List to be on Fetal Cardiology Symposium

website after conference

Education

800 regional prenatal chd detection sept 2013