Paediatric Cardiac Pathways

Paediatric Cardiac Pathways

Dr Lindsey Hunter

Consultant Paediatric & Fetal Cardiologist

Royal Hospital for Children

Glasgow

Background

• Congenital heart disease (CHD) the most common congenital anomaly

• 0.3 - 0.6% of live births

• Most CHD occurs in ‘low risk’ pregnancies

• Detection at the FAS scan 18-21 weeks

Neonatal MCN Meeting 2017

High Risk Indications

1. Fetal Indications- Suspicion or detection of a congenital heart defect at a routine obstetric scan.- Increased nuchal translucency measurement between 11-14 weeks gestation (> 99th percentile)- Extra-cardiac abnormality (ECA) e.g. congenital diaphragmatic hernia (CDH), exompholos major,

duodenal atresia, cystic hygroma- Fetal hydrops- Arrhythmias: ectopic beats; tachycardia or bradycardia- Abnormal karyotype e.g. Trisomy 21/18/13/XO- Multiple Pregnancy e.g. risk of TTTS

2. Maternal Indications- Use of prostaglandin synthetase inhibitors e.g. ibuprofen- Teratogenic medications e.g. lithium or anti-epileptic medications- Diabetes Mellitus or other metabolic conditions e.g. PKU- Maternal Infection e.g. parvovirus- Antibody Positive Connective Tissue Disease e.g. positive anti-Ro, anti-La antibodies

3. Other- Family history of congenital heart disease - first degree relative- Increased risk of fetal heart failure e.g. absent ductus venosus, fetal anemia, fetal tumors with

large vascular supply

Background

• Congenital heart disease (CHD) the most common congenital anomaly

• 0.3 - 0.6% of live births

• Most CHD occurs in ‘low risk’ pregnancies

• Detection at the FAS scan 18-21 weeks

• Fetal cardiology is a relatively ‘new’ speciality

• Wide variation in detection rates across the UK



UK - Antenatal Diagnosis

• Only the lesions antenatally detected and requiring surgery within the 1st

year of life

• TOP/IUD or lesions not requiring surgical intervention not included

• Introduction of Fetal Anomaly Screening Programme (FASP)

• Outflow tracts and 3VV/Tracheal View


Antenatal Cardiac Detection


V





Recommendations

• British Congenital Cardiac Association (BCCA)

• ‘All cases of suspected CHD should be referred to a fetal cardiology specialist’.

• ‘Fetal medicine specialist should make a detailed assessment of non-cardiac structures’.

• ‘Counselling needs to take into account the extent and implications of all associated abnormalities’.

• ‘The working relationship between fetal cardiology specialists and fetal medicine specialists is extremely important in the management of fetal congenital heart disease’.

• http://www.bcs.com/documents/Fetal_Cardiology_Standards_2012_final_version.pdf


http://www.bcs.com/documents/Fetal_Cardiology_Standards_2012_final_version.pdf

Aims of Fetal Cardiology Service

• Detection of the majority of cardiac abnormalities and arrhythmias• Parental Counselling

• Risk stratify lesions

• Treatment of arrhythmias

• Appropriate timing of delivery/location

• Educational support for the screening sonographers and obstetriciansNeonatal MCN Meeting 2017




Parental Perceptions

• Detailed, often complex and emotional

• Prepares parents, allow time to ask questions

• Insight, understanding and acceptance of the diagnosis

• Appropriate to beliefs and life experiences

‘Parental perception of a

cardiologist’s level of compassion

was inversely linked to the

likelihood of them seeking a second

opinion’.

‘The manner in which a diagnosis

is initially presented to a family,

the information provided, and

how the family interprets the

information are all factors that

influence parental perception and

subsequent decisions’.



Cardiac Liaison Service

• Aim to meet all families with a diagnosis of CHD

• Provide ongoing support in the postnatal period• Even for families delivering locally

• Directing families to financial or emotional support

• Support families transferred to other cardiac centres

• Supporting families in their transition from paediatrics to teenage services and adult congenital services



• Local delivery v tertiary centre

• Geography

• Transport Implications

• Duct Dependent Lesions

• Extra-cardiac abnormalities

• Risk

• Immediate intervention

• Balloon atrial septostomy

• Pacing

• Cardiac surgery

Location, Location, Location


Timing of Delivery

• Obstetricians aiming for normal delivery

• Aiming for term

• Poorer outcomes associated with prematurity and CHD

• Induction usually around 39 weeks if geographically distant

• Exceptions….

• Complete heart block or tachyarrhythmia

• Tricuspid Valve Dysplasia/Ebsteins Anomaly









J Joined Up Thinking!


• Ensure the best quality of care for our

patients

• Equality in the provision of cardiac care

• Geography should not matter!

• Communication between fetal medicine;

obstetrics; neonatology and paediatric

cardiology is essential

Thank You!

Paediatric Cardiac Pathways

Documents