Clinical utility of repeat fetal echocardiography in congenital heart disease.

OBJECTIVES: We aimed to investigate the utility of repeat fetal echocardiograms (FE) after a diagnosis of structural congenital heart disease (CHD) was made on the initial FE. We evaluated how often changes in management and counseling occurred based on subsequent FE findings and sought to determine which types of CHD were more likely to have changes in management and/or counseling based on repeat FE.

METHODS: We performed a retrospective review of all patients who presented to our center between January 2012 to January 2019 and had more than one FE performed for structural CHD. We reviewed consult notes to determine whether management or counseling had changed based on findings at follow up visits. Management variables included: a change in location or mode of delivery, plan for atrial septostomy, prostaglandin initiation, umbilical line placement, and planned admission location (nursery versus neonatal intensive care unit). We defined a counseling change as any of the above changes in management as well as any meaningful refinements in the cardiac diagnosis that led to a change in overall prognosis or future management. Initial diagnoses were grouped into anatomically/hemodynamically relevant subgroups and Fisher's exact test was used to assess the relationship between initial diagnosis and change in management. Post-hoc pairwise comparisons were performed using a Dunnett-Adjusted multiple comparison test.

RESULTS: Between January, 2012, and January, 2019, 267 patients had 534 follow up FE performed for structural CHD. The overall frequency of a management change based on a repeat FE was 41/267 (15.4%) patients. A change in management was associated with the diagnosis made at the initial visit (p<0.001). Management changed most frequently for pulmonary valve abnormalities/non critical pulmonary stenosis (4/11, 36.4%), followed by balanced atrioventricular canal defects (AVC) (5/17, 29.4%), and left ventricular outflow tract obstruction/aortic valve abnormality/coarctation/interrupted aortic arch (19/68, 27.9%). No management changes occurred for fetuses diagnosed with ventricular septal defects, or truncus arteriosus. Compared to those with VSDs, management was significantly more likely to be changed in fetuses with AVC (p=0.025) and obstructive left heart lesions (p=0.002), and right heart lesions reached near-significance (p=0.05). The frequency of a counseling change based on a repeat FE was 108/267 (40.4%). Counseling changed most frequently for pulmonary valve abnormalities/non critical pulmonary stenosis (8/11 72.7%) and hypoplastic left heart syndrome/critical aortic stenosis (5/9 55.6%).

CONCLUSIONS: The clinical utility of follow-up FE is associated with the type of CHD diagnosed. Follow-up FE led to changes in management in several types of CHD, most commonly in right and left outflow obstructive lesions and AVC. In developing programmatic protocols for frequency of FE reassessments, the type of CHD should be a major determinant. Additional studies are required to reach a consensus for how often serial FE should be performed for each type of CHD. This article is protected by copyright. All rights reserved.