Dudley and Schneider
Prenatal detection of congenital heart disease: the case for improved training DJ Dudley,a D Schneiderb a
Department of Obstetrics and Gynecology and,
b
Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
Linked article: This is a mini commentary on CL van Velzen et al., pp.400–407 in this issue. To view this article visit http://dx.doi.org/10.1111/1471-0528.13274. Published Online 6 March 2015. van Velzen et al. report on a national programme to improve the detection of fetal cardiac anomalies in the Netherlands. The authors found a significant improvement in the detection of such abnormalities, from 36% prior to organised screening to 60% afterwards. They accomplished this by training sonographers in a standardized approach and then examining them according to criteria set by the Fetal Medicine Foundation. The investigators were able to significantly improve detection across all abnormalities. Remarkably, they diagnosed greater than 90% of hypoplastic left heart syndrome, other univentricular heart defects, and complex heart defects with atrial isomerism. Although there was improved detection of other abnormalities, only a handful was detected greater than 50% of the time. Certainly some of these abnormalities, such as venous and aortic arch anomalies, are often not detected by even skilled paediatric cardiologists. Yet the results, although impressive, indicate that more work needs to be done to improve overall detection rates for fetal cardiac abnormalities. In a way the results are disappointing, and one wonders what can be done to improve performance.
408
The investigators demonstrated that improved training, with universal standards and testing to confirm competence, works. Ultrasound technology will continue to improve, and perhaps 3D cardiac imaging will improve prenatal diagnosis; however, this will require more experience and expertise, so the sonographer and obstetrician will require further training. Not surprisingly, the complex lesions (hypoplastic left heart syndrome, single ventricle variants, and heterotaxy variants) were easily diagnosed, as these abnormalities should be readily detected on a four-chamber view. We know that just learning to visualise outflow tracts increases the diagnosis of congenital heart disease significantly compared with the fourchamber view only (Oggel et al. Ultrasound Obstet Gynecol 2006;28: 779–84). Of greatest importance is the conclusion that the education of sonographers and obstetricians is key to continued improvement. But why are we still missing common heart defects? Perhaps because those performing the screening sonography may not have an appreciation of the incidence of common congenital heart disease and the importance of early diagnosis. As a
result, they may not have developed the baseline skills and motivation to take the extra few moments to obtain the views necessary for these diagnoses. Newer imaging modalities are unlikely to replace ultrasound for fetal cardiac imaging. The ready availability, relatively low cost, and established safety of sonography are compelling. Magnetic resonance imaging (MRI) has been increasingly used for postnatal cardiac imaging of congenital heart disease, but echocardiography remains the preferred diagnostic tool. Surgery is often performed based only on echocardiography, whereas catheterisation, computerised tomography, and MRI are used only when echocardiography results are uncertain. The overall detection rate will probably never be better than 60– 70%. Fetal cardiac development is too subtle and some anomalies are so small that they will continue to defy detection prenatally; however, the work by Van Velzen and colleagues demonstrates that detection rates can improve on a national scale, but work remains to be done to improve these even more.
Disclosure of interests Neither author has any conflict of interest. &
ª 2015 Royal College of Obstetricians and Gynaecologists
Prenatal detection of congenital heart disease: the case for improved training DJ Dudley,a D Schneiderb a
Department of Obstetrics and Gynecology and,
b
Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
Linked article: This is a mini commentary on CL van Velzen et al., pp.400–407 in this issue. To view this article visit http://dx.doi.org/10.1111/1471-0528.13274. Published Online 6 March 2015. van Velzen et al. report on a national programme to improve the detection of fetal cardiac anomalies in the Netherlands. The authors found a significant improvement in the detection of such abnormalities, from 36% prior to organised screening to 60% afterwards. They accomplished this by training sonographers in a standardized approach and then examining them according to criteria set by the Fetal Medicine Foundation. The investigators were able to significantly improve detection across all abnormalities. Remarkably, they diagnosed greater than 90% of hypoplastic left heart syndrome, other univentricular heart defects, and complex heart defects with atrial isomerism. Although there was improved detection of other abnormalities, only a handful was detected greater than 50% of the time. Certainly some of these abnormalities, such as venous and aortic arch anomalies, are often not detected by even skilled paediatric cardiologists. Yet the results, although impressive, indicate that more work needs to be done to improve overall detection rates for fetal cardiac abnormalities. In a way the results are disappointing, and one wonders what can be done to improve performance.
408
The investigators demonstrated that improved training, with universal standards and testing to confirm competence, works. Ultrasound technology will continue to improve, and perhaps 3D cardiac imaging will improve prenatal diagnosis; however, this will require more experience and expertise, so the sonographer and obstetrician will require further training. Not surprisingly, the complex lesions (hypoplastic left heart syndrome, single ventricle variants, and heterotaxy variants) were easily diagnosed, as these abnormalities should be readily detected on a four-chamber view. We know that just learning to visualise outflow tracts increases the diagnosis of congenital heart disease significantly compared with the fourchamber view only (Oggel et al. Ultrasound Obstet Gynecol 2006;28: 779–84). Of greatest importance is the conclusion that the education of sonographers and obstetricians is key to continued improvement. But why are we still missing common heart defects? Perhaps because those performing the screening sonography may not have an appreciation of the incidence of common congenital heart disease and the importance of early diagnosis. As a
result, they may not have developed the baseline skills and motivation to take the extra few moments to obtain the views necessary for these diagnoses. Newer imaging modalities are unlikely to replace ultrasound for fetal cardiac imaging. The ready availability, relatively low cost, and established safety of sonography are compelling. Magnetic resonance imaging (MRI) has been increasingly used for postnatal cardiac imaging of congenital heart disease, but echocardiography remains the preferred diagnostic tool. Surgery is often performed based only on echocardiography, whereas catheterisation, computerised tomography, and MRI are used only when echocardiography results are uncertain. The overall detection rate will probably never be better than 60– 70%. Fetal cardiac development is too subtle and some anomalies are so small that they will continue to defy detection prenatally; however, the work by Van Velzen and colleagues demonstrates that detection rates can improve on a national scale, but work remains to be done to improve these even more.
Disclosure of interests Neither author has any conflict of interest. &
ª 2015 Royal College of Obstetricians and Gynaecologists
