Paediatric Cardiac Pathways
Transcript of Paediatric Cardiac Pathways
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Paediatric Cardiac Pathways
Dr Lindsey Hunter
Consultant Paediatric & Fetal Cardiologist
Royal Hospital for Children
Glasgow
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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
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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
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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
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Neonatal MCN Meeting 2017
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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
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Antenatal Cardiac Detection
Neonatal MCN Meeting 2017
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V
Neonatal MCN Meeting 2017
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Neonatal MCN Meeting 2017
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Neonatal MCN Meeting 2017
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Neonatal MCN Meeting 2017
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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
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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
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Neonatal MCN Meeting 2017
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Neonatal MCN Meeting 2017
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Neonatal MCN Meeting 2017
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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
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Neonatal MCN Meeting 2017
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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
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Neonatal MCN Meeting 2017
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• 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
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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
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Neonatal MCN Meeting 2017
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Neonatal MCN Meeting 2017
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Neonatal MCN Meeting 2017
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Neonatal MCN Meeting 2017
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Neonatal MCN Meeting 2017
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Neonatal MCN Meeting 2017
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Neonatal MCN Meeting 2017
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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
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Thank You!