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

Neonatal MCN Meeting 2017

Neonatal MCN Meeting 2017

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

Neonatal MCN Meeting 2017

Antenatal Cardiac Detection

Neonatal MCN Meeting 2017

V

Neonatal MCN Meeting 2017

Neonatal MCN Meeting 2017

Neonatal MCN Meeting 2017

Neonatal MCN Meeting 2017

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

Neonatal MCN Meeting 2017

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

Neonatal MCN Meeting 2017

Neonatal MCN Meeting 2017

Neonatal 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’.

Neonatal MCN Meeting 2017

Neonatal MCN Meeting 2017

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

Neonatal MCN Meeting 2017

Neonatal MCN Meeting 2017

• 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

Neonatal MCN Meeting 2017

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

Neonatal MCN Meeting 2017

Neonatal MCN Meeting 2017

Neonatal MCN Meeting 2017

Neonatal MCN Meeting 2017

Neonatal MCN Meeting 2017

Neonatal MCN Meeting 2017

Neonatal MCN Meeting 2017

Neonatal MCN Meeting 2017

J Joined Up Thinking!

Neonatal MCN Meeting 2017

• 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!