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. Author manuscript; available in PMC: 2015 Jun 3.
Published in final edited form as: Ultrasound Obstet Gynecol. 2015 Apr 30;45(6):678–682. doi: 10.1002/uog.14751

Prenatal Diagnosis of Transposition of the Great Arteries over a 20-Year Period: Improved but Imperfect

Maria C Escobar-Diaz *,‡, Lindsay R Freud *,‡, Alejandra Bueno *,‡, David W Brown *,‡, Kevin Friedman *,‡, David Schidlow *,‡, Sitaram Emani †,§, Pedro del Nido †,§, Wayne Tworetzky *,‡
PMCID: PMC4452393  NIHMSID: NIHMS651027  PMID: 25484180

Abstract

Objective

To evaluate temporal trends in prenatal diagnosis of transposition of the great arteries with intact ventricular septum (TGA/IVS) and its impact on neonatal morbidity and mortality.

Methods

Newborns with TGA/IVS referred for surgical management to our center over a 20-year period (1992 – 2011) were included. The study time was divided into 5 four-year periods, and the primary outcome was rate of prenatal diagnosis. Secondary outcomes included neonatal pre-operative status and perioperative survival.

Results

Of the 340 patients, 81 (24%) had a prenatal diagnosis. Prenatal diagnosis increased over the study period from 6% to 41% (p<0.001). Prenatally diagnosed patients underwent a balloon atrial septostomy (BAS) earlier than postnatally diagnosed patients (0 vs. 1 day, p<0.001) and fewer required mechanical ventilation (56% vs. 69%, p=0.03). There were no statistically significant differences in pre-operative acidosis (16% vs. 26%, p=0.1) and need for preoperative ECMO (2% vs. 3%, p=1.0). There was also no significant mortality difference (1 pre-operative and no post-operative deaths among prenatally diagnosed patients, as compared to 4 pre-operative and 6 post-operative deaths among postnatally diagnosed patients).

Conclusion

The prenatal detection rate of TGA/IVS has improved but still remains below 50%, suggesting the need for strategies to increase detection rates. The mortality rate was not statistically different between pre- and postnatally diagnosed patients; however, there were significant pre-operative differences with regard to earlier BAS and less mechanical ventilation. Ongoing study is required to elucidate whether prenatal diagnosis confers long-term benefit.

Keywords: Prenatal diagnosis, transposition of the great arteries, outflow tract view, survival, metabolic acidosis

INTRODUCTION

Despite advances in prenatal ultrasound screening, the detection rate of major congenital heart defects (CHD) remains low, with recent reports demonstrating fewer than 50% of live born patients with CHD diagnosed in utero1–5. The importance of prenatal detection of CHD is to enhance perinatal decision making and delivery planning and to provide for optimal management of the often unique transitional physiology6. Delays in diagnosis and treatment of critical CHD can lead to rapid hemodynamic compromise, significant morbidity, and even death.

Transposition of the great arteries with intact ventricular septum (TGA/IVS), despite being a serious and relatively common form of critical CHD with an incidence of 3 per 10,000 live births7, has been shown to have a low rate of prenatal diagnosis, ranging from 10% in the United States to 50–70% in Europe2, 8–10. The historical recommendations of ultrasound screening for CHD included a four-chamber view (4CV) without incorporation of the outflow tract view (OTV), precluding the prenatal diagnosis of TGA/IVS11, 12 due to its normal appearance in the 4CV. Incorporation of the OTV only became a formal recommendation by prenatal ultrasound societies in 201313–15.

There are limited data on trends in the rate of prenatal diagnosis of TGA/IVS and its impact on perinatal outcomes2, 3, 16. Therefore, we performed a retrospective study on patients with TGA/IVS who presented to a single center over a 20-year period to assess 1) the temporal trends in prenatal diagnosis rate; and 2) whether prenatal diagnosis impacted neonatal morbidity or mortality.

METHODS

We included patients with d-looped TGA/IVS who presented at <1 month of age to Boston Children’s Hospital over a 20-year period from January 1992 to December 2011. Only patients within our natural catchment area, i.e., the New England region of the United States, were included. Patients with more complex variations of d-looped TGA, such as those with ventricular septal defects or significant outflow tract obstruction, and patients with l-looped (or congenitally corrected) TGA were excluded. Patients with major non-cardiac anomalies and genetic diagnoses were also excluded in order to study a homogenous patient population and prevent overestimation of the prenatal diagnosis rate due to significant associated findings.

Our population of patients with TGA/IVS was divided into two cohorts based on whether they were prenatally or postnatally diagnosed. Temporally, the study was divided into five 4-year periods in order to compare the rate of prenatal diagnosis, pre-operative morbidity and mortality, and surgical survival among eras.

The primary outcome was rate of prenatal diagnosis among the eras. Secondary outcomes included neonatal pre-operative status and peri-operative survival between the pre- and postnatally diagnosed patients.

Specific pre-operative variables investigated were weight and gestational age at birth, age at admission, prostaglandin therapy, requirement for mechanical ventilation, presence of metabolic acidosis (lowest pre-operative pH, defined categorically as pH < 7.1), need for balloon atrial septostomy (BAS) and/or extracorporeal membrane oxygenation (ECMO), and pre-operative survival. Pregnancy related variables for those prenatally diagnosed included maternal and gestational age at time of diagnosis. Peri-operative variables included age at surgery, need for post-operative ECMO, length of intensive care unit (ICU) stay, total length of stay, and post-operative survival.

Data analysis

Values shown are number (percent) for categorical variables, and median (range) for continuous variables. The Cochran-Armitage test was used to analyze the trends in rate of prenatal diagnosis. Comparisons between pre- and postnatally diagnosed patients were performed with Fisher’s exact test for categorical variables and the Wilcoxon rank- sum test for continuous variables. Values of p < 0.05 were considered statistically significant.

RESULTS

The study population included 340 patients with TGA/IVS. During the 20-year study period, 81 patients (24%) were prenatally diagnosed. The rate of prenatal diagnosis increased from 6% during the first 4-year period (1992–1995) to 41% in the most recent period (2008–2011) (p<0.001) (Figure 1). Of those with a prenatal diagnosis, the first fetal echocardiogram at our institution was performed at a median gestational age of 22.5 weeks (17–38). The median maternal age at diagnosis was 31 years (14–41). Table 1 displays the demographic characteristics of the cohort.

Figure 1.

Figure 1

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Trends in prenatal diagnosis of transposition of the great arteries (1992–2011), Cochran-Armitage test was used to analyze the trends in rate of prenatal diagnosis.

Table 1.

Demographic characteristics of the pre- and postnatally diagnosed patients.

Prenatal group (n=81) Postnatal group (n=259) p value
Gender (male) 56 (69%) 182 (70%) 0.89
Gestational age at diagnosis (weeks) 24.7 – –
Maternal age at diagnosis (years) 31 – –
Gestational age at birth (weeks) 38.3 (31–41) 38.8 (31–42) <0.001
Birth weight (kg) 3.3 (1.5–4.7) 3.4 (0.8–4.9) 0.36
Age at admission (days) 0 (0–0) 1 (0–21) <0.001
Admitted on day of birth 81 (100%) 120 (46%) <0.001
Prostaglandin therapy 71 (88%) 218 (84%) 0.48
Mechanical ventilation 45 (56%) 176 (69%) 0.03
Metabolic acidosis 13 (16%) 66 (26%) 0.10
BAS 74 (91%) 228 (88%) 0.43
Age at BAS (days) 0 (0–2) 1 (0–21) <0.001
Preoperative ECMO 2 (2%) 7 (3%) 1.0
Preoperative mortality 1 (1%) 4 (2%) 1.0
Age at surgery (days) 4 (1–10) 5 (0–23) 0.14
Postoperative mortality 0 (0%) 6/255 (2%) 0.34
Postoperative ECMO 0 (0%) 2/255 (1%) 1.0
Postoperative ICU stay (days) 5 (0–54) 4 (0–246) 0.15
Total hospital stay (days) 14 (0–62) 11 (0–247) <0.001
Overall mortality 1 (1%) 10 (4%) 0.47
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BAS: Balloon atrial septostomy; ECMO: Extracorporeal membrane oxygenation; ICU: Intensive care unit.

Values are presented as frequency (%) or median (range).

Among prenatally diagnosed patients, 95% (n=77) were born at an obstetric unit adjacent to our cardiac center. In contrast, only 5% (14/259) of postnatally diagnosed patients were born at an obstetric unit adjacent to our center (p<0.001). Although postnatally diagnosed patients were born later (38.8 vs. 38.3 weeks of gestation for prenatally diagnosed patients, p<0.001), both pre- and postnatally diagnosed patients were born at a median gestational age > 38 weeks. There were no differences in weight at birth. Patients in the postnatal diagnosis group were admitted to our cardiac center at a median of 1 day later than those in the prenatal group (0 vs.1 day, p<0.001).

Pre-operative Status

Table 1 displays the pre- and post-operative findings of the patients. Prenatally diagnosed patients were less likely to require mechanical ventilation (56% vs. 69%, p<0.05) and had a BAS performed earlier (0 vs.1 day, p<0.001). Fewer prenatally diagnosed patients (16%) were acidotic as compared to postnatally diagnosed patients (26%); however, this difference was not statistically significant using the threshold value of pH < 7.1. Pre-operative ECMO in the prenatal diagnosis group was utilized for intractable pulmonary hypertension in 1 patient and following hepatic vein rupture during BAS in another patient. This latter patient with the BAS complication was the only pre-operative death in the prenatal diagnosis group. There were 7 patients in the postnatal group who required pre-operative ECMO: 6 for intractable pulmonary hypertension and biventricular dysfunction, and 1 after resuscitation during transport. Four neonates in the postnatally diagnosed cohort died pre-operatively, all of whom were transferred from remote hospitals. Causes of death included profound hypoxemia (n=1), biventricular dysfunction (n=2), and complication from an air embolism during BAS (n=1). Given the overall low event rate, however, there were no significant differences with regard to pre-operative ECMO or mortality between the pre-and postnatally diagnosed groups.

Post-operative Status

As demonstrated in Table 1, the arterial switch operation was performed at a median of 4 days in both groups. There was no statistically significant difference between the need for ECMO post-operatively nor in the length of ICU stay. Post-operative mortality remained the same throughout the study period at 1.8% (6/335). There were no post-operative deaths among the prenatally diagnosed patients. Despite the 6 post-operative deaths among the postnatally diagnosed patients, this finding was not statistically significant (0 vs. 2.3%, p=0.34).

Overall Mortality

In total, 11 out of 340 patients (3.2%) died: 5 pre-operatively and 6 post-operatively. The mortality decreased from 5.5 % in 1992–1995 to 3 % in 2008–2011; however, this difference was not statistically significant (p=0.16). In addition, there was no significant difference in overall mortality between the pre-and postnatally diagnosed patients. All patients in the postnatal group that died (10/259, 3.8%) were born remote from our hospital. When patients who died from complications from BAS were excluded, there remained no significant difference in mortality (0 vs. 9, p=0.12).

DISCUSSION

We performed this study to investigate the trends in prenatal diagnosis of TGA/IVS over a 20-year period and the influence of prenatal diagnosis on outcome. The prenatal diagnosis rate of TGA/IVS increased significantly over the 20 years of our study, from 6% to 41%; however, the rate of prenatal diagnosis remained low. There was no significant difference in neonatal mortality between pre- and postnatally diagnosed patients, but prenatally diagnosed patients had earlier BAS and were less likely to require mechanical ventilation.

While the quality of the ultrasound images may have improved over the period of our study9, 17, we speculate that the greatest improvement in prenatal detection emerged from increased utilization of the OTV among physicians and sonographers. Prior studies have demonstrated improvements in the detection rates of CHD, in general, and TGA/IVS, in particular, by 20 to 30% after introducing the OTV into the screening protocol18–21. Commensurate with these findings, recommendations from various prenatal ultrasound societies have evolved. For example, in 2011, the International Society of Ultrasound in Obstetrics and Gynecology stated that the OTV was optional “if technically feasible”22. In 2013, the OTV became an integral part of the fetal cardiac screening examination13 in concordance with guidelines from the American Institute of Ultrasound in Medicine and the World Association of Perinatal Medicine14, 15. With universal recommendations for incorporation of the OTV now in place, we have to direct our efforts towards education, consistent performance, and accurate interpretation of the OTV to improve prenatal detection of critical CHD, including TGA/IVS.

Over the past several decades, the benefits of prenatal diagnosis of CHD have been demonstrated23, 24. For example, prenatally diagnosed patients with major CHD have earlier hospital admission and cardiac surgery. In addition, they have lower pre-operative morbidity with regard to mechanical ventilation and metabolic acidosis8, 24–27. In our study, we found that prenatally diagnosed patients had significantly earlier admission to the hospital and earlier BAS, which may have allowed for less significant hypoxemia and improved hemodynamics. In addition, they were less likely to require mechanical ventilation pre-operatively. Our study did not, however, demonstrate a significant difference in pre-operative acidosis. This may have been due to the lack of availability of outside hospital records demonstrating the lowest pH and/or the use of a threshold value of 7.1. Finally, our study noted a slightly lower median gestational age at birth among prenatally diagnosed patients; however, the median of both groups was >38 weeks. While our affiliated maternity centers formerly offered induction of labor or caesarean section at 37 weeks gestation (covering most of the time period of our study), recent literature28, 29 has changed our practice to 39 weeks to optimize both planning and outcomes for neonates undergoing congenital heart surgery.

Although there were more deaths among the postnatally diagnosed patients as compared to the prenatally diagnosed patients in our study, the difference was not statistically significant. The lack of significant difference likely reflects our overall low mortality of 3%, which is similar to that reported from other centers in the current era30. In contrast, when a population-based study of TGA patients was performed in France from 1988–1997, the overall mortality was 11%, and prenatally diagnosed patients were found to have both lower morbidity and mortality31. In the current era, greater availability of postnatal echocardiographic diagnosis also leads to earlier initiation of prostaglandin therapy and prompt transfer to a cardiac center with expertise in neonatal resuscitation. Importantly, this was not a population-based study. We only analyzed patients who arrived to our center, thereby excluding the most critically ill patient who may have died prior to transfer or even diagnosis, as has recently been demonstrated in a study examining the impact of prenatal diagnosis of hypoplastic left heart syndrome32. In our study, all postnatally diagnosed patients who died were born remote from our cardiac center.

While neonatal mortality may be obscured by the reasons noted above, the potential neurologic injury incurred with severe hypoxemia and/or acidosis among postnatally diagnosed patients may produce lasting effects, particularly on later neuro-developmental outcomes26, 33, 34. It has been reported that although cognitive, fine, and gross motor development outcomes are similar between pre- and postnatally diagnosed patients with TGA/IVS at 1 year of age25, neurocognitive defects among prenatally diagnosed patients with TGA/IVS at 4 to 6 years of age are less prevalent and less severe than in patients who are postnatally diagnosed26. Certainly, the long-term effects of prenatal diagnosis on functional and neurodevelopmental outcomes, among others, remain active areas of on-going investigation.

This was a retrospective, single-center study with several limitations. First, our rate of prenatal diagnosis may not be generalizable to other regions where access to prenatal care is different. However, given our aim to study trends over time, it was important to focus on a single catchment area for the present investigation. Significant changes in access to prenatal care did not occur throughout the time period of our study, with >80% of women receiving adequate prenatal care35. However, changes in referral indications were difficult to assess, largely due to poor documentation in the earlier years of the study period. We did not have access to the obstetric ultrasounds of the postnatally diagnosed patients to know if a difference in ultrasound technique, i.e. lack of incorporation of the OTV, was directly responsible for the delay in their diagnosis. Finally, as mentioned previously, this was not a population-based study. Therefore, we were unable to account for deaths prior to arrival at our hospital and to investigate the early neonatal courses of postnatally diagnosed patients born at remote institutions to discern the greatest degree of acidosis.

Conclusion

We found that the prenatal detection rate of TGA/IVS has improved over the past 20 years but still remains low for an important form of critical CHD. Recognition of our poor prenatal detection of this disease is paramount to improving education for both the performance and interpretation of the OTV during routine screening. Although this study did not detect a difference in mortality between pre- and postnatally diagnosed patients, prenatal diagnosis may confer long-term benefits by minimizing pre-operative morbidity.

Acknowledgments

Dr. Escobar-Diaz is supported by a grant from “Fundacio La Caixa”, Barcelona, Spain. Drs. Freud is supported by the National Institutes of Health (T32-HLHL007572) and the Kenrose Kitchen Foundation. Dr. Schidlow is supported by the National Institutes of Health (T32-HL007572).

References

  • 1.Oster ME, Kim CH, Kusano AS, Cragan JD, Dressler P, Hales AR, Mahle WT, Correa A. A population-based study of the association of prenatal diagnosis with survival rate for infants with congenital heart defects. Am J Cardiol. 2014;113(6):1036–1040. doi: 10.1016/j.amjcard.2013.11.066. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Khoshnood B, De Vigan C, Vodovar V, Goujard J, Lhomme A, Bonnet D, Goffinet F. Trends in prenatal diagnosis, pregnancy termination, and perinatal mortality of newborns with congenital heart disease in France, 1983–2000: a population-based evaluation. Pediatrics. 2005;115(1):95–101. doi: 10.1542/peds.2004-0516. [DOI] [PubMed] [Google Scholar]
  • 3.Marek J, Tomek V, Skovranek J, Povysilova V, Samanek M. Prenatal ultrasound screening of congenital heart disease in an unselected national population: a 21-year experience. Heart. 2011;97(2):124–130. doi: 10.1136/hrt.2010.206623. [DOI] [PubMed] [Google Scholar]
  • 4.Trines J, Fruitman D, Zuo KJ, Smallhorn JF, Hornberger LK, Mackie AS. Effectiveness of prenatal screening for congenital heart disease: assessment in a jurisdiction with universal access to health care. Can J Cardiol. 2013;29(7):879–885. doi: 10.1016/j.cjca.2013.04.028. [DOI] [PubMed] [Google Scholar]
  • 5.Gardiner HM, Kovacevic A, van der Heijden LB, Pfeiffer PW, Franklin RC, Gibbs JL, Averiss IE, Larovere JM. Prenatal screening for major congenital heart disease: assessing performance by combining national cardiac audit with maternity data. Heart. 2014 Mar;100(5):375–8. doi: 10.1136/heartjnl-2013-304640. [DOI] [PubMed] [Google Scholar]
  • 6.Rudolph AM. Aortopulmonary transposition in the fetus: speculation on pathophysiology and therapy. Pediatr Res. 2007;61(3):375–380. doi: 10.1203/pdr.0b013e318030d5b9. [DOI] [PubMed] [Google Scholar]
  • 7.Hoffman JI, Kaplan S. The incidence of congenital heart disease. J Am Coll Cardiol. 2002;39(12):1890–1900. doi: 10.1016/s0735-1097(02)01886-7. [DOI] [PubMed] [Google Scholar]
  • 8.Raboisson MJ, Samson C, Ducreux C, Rudigoz RC, Gaucherand P, Bouvagnet P, Bozio A. Impact of prenatal diagnosis of transposition of the great arteries on obstetric and early postnatal management. Eur J Obstet Gynecol Reprod Biol. 2009;142(1):18–22. doi: 10.1016/j.ejogrb.2008.09.001. [DOI] [PubMed] [Google Scholar]
  • 9.Bertagna F, Rakza T, Vaksmann G, Ramdane-Sebbane N, Devisme L, Storme L, Francart C, Vaast P, Houfflin-Debarge V. Transposition of the great arteries: factors influencing prenatal diagnosis. Prenat Diagn. 2014;34(6):534–537. doi: 10.1002/pd.4343. [DOI] [PubMed] [Google Scholar]
  • 10.Blyth M, Howe D, Gnanapragasam J, Wellesley D. The hidden mortality of transposition of the great arteries and survival advantage provided by prenatal diagnosis. BJOG. 2008;115(9):1096–1100. doi: 10.1111/j.1471-0528.2008.01793.x. [DOI] [PubMed] [Google Scholar]
  • 11.Cardiac screening examination of the fetus: guidelines for performing the ‘basic’ and ‘extended basic’ cardiac scan. Ultrasound Obstet Gynecol. 2006;27(1):107–113. doi: 10.1002/uog.2677. [DOI] [PubMed] [Google Scholar]
  • 12.Lee W. Performance of the basic fetal cardiac ultrasound examination. J Ultrasound Med. 1998;17(9):601–607. doi: 10.7863/jum.1998.17.9.601. [DOI] [PubMed] [Google Scholar]
  • 13.International Society of Ultrasound in O, Gynecology. Carvalho JS, Allan LD, Chaoui R, Copel JA, et al. ISUOG Practice Guidelines (updated): sonographic screening examination of the fetal heart. Ultrasound Obstet Gynecol. 2013;41(3):348–359. doi: 10.1002/uog.12403. [DOI] [PubMed] [Google Scholar]
  • 14.Wood D, Respondek-Liberska M, Puerto B, Weiner S, World Association of Perinatal Medicine Ultrasonography Working G Perinatal echocardiography: protocols for evaluating the fetal and neonatal heart. J Perinat Med. 2009;37(1):5–11. doi: 10.1515/JPM.2009.022. [DOI] [PubMed] [Google Scholar]
  • 15.American Institute of Ultrasound in M. AIUM practice guideline for the performance of obstetric ultrasound examinations. J Ultrasound Med. 2013;32(6):1083–1101. doi: 10.7863/ultra.32.6.1083. [DOI] [PubMed] [Google Scholar]
  • 16.Montana E, Khoury MJ, Cragan JD, Sharma S, Dhar P, Fyfe D. Trends and outcomes after prenatal diagnosis of congenital cardiac malformations by fetal echocardiography in a well defined birth population, Atlanta, Georgia, 1990–1994. J Am Coll Cardiol. 1996;28(7):1805–1809. doi: 10.1016/S0735-1097(96)00381-6. [DOI] [PubMed] [Google Scholar]
  • 17.Tegnander E, Eik-Nes SH. The examiner’s ultrasound experience has a significant impact on the detection rate of congenital heart defects at the second-trimester fetal examination. Ultrasound Obstet Gynecol. 2006;28(1):8–14. doi: 10.1002/uog.2804. [DOI] [PubMed] [Google Scholar]
  • 18.Sklansky MS, Berman DP, Pruetz JD, Chang RK. Prenatal screening for major congenital heart disease: superiority of outflow tracts over the 4-chamber view. J Ultrasound Med. 2009;28(7):889–899. doi: 10.7863/jum.2009.28.7.889. [DOI] [PubMed] [Google Scholar]
  • 19.Carvalho JS, Mavrides E, Shinebourne EA, Campbell S, Thilaganathan B. Improving the effectiveness of routine prenatal screening for major congenital heart defects. Heart. 2002;88(4):387–391. doi: 10.1136/heart.88.4.387. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Ogge G, Gaglioti P, Maccanti S, Faggiano F, Todros T. Prenatal screening for congenital heart disease with four-chamber and outflow-tract views: a multicenter study. Ultrasound Obstet Gynecol. 2006;28(6):779–784. doi: 10.1002/uog.3830. [DOI] [PubMed] [Google Scholar]
  • 21.Levy DJ, Pretorius DH, Rothman A, Gonzales M, Rao C, Nunes ME, Bendelstein J, Mehalek K, Thomas A, Nehlsen C, Ehr J, Burchette RJ, Sklansky MS. Improved prenatal detection of congenital heart disease in an integrated health care system. Pediatr Cardiol. 2013;34(3):670–679. doi: 10.1007/s00246-012-0526-y. [DOI] [PubMed] [Google Scholar]
  • 22.Salomon LJ, Alfirevic Z, Berghella V, Bilardo C, Hernandez-Andrade E, Johnsen SL, Kalache K, Leung KY, Malinger G, Munoz H, Prefumo F, Toi A, Lee W. Practice guidelines for performance of the routine mid-trimester fetal ultrasound scan. Ultrasound Obstet Gynecol. 2011;37(1):116–126. doi: 10.1002/uog.8831. [DOI] [PubMed] [Google Scholar]
  • 23.Tworetzky W, McElhinney DB, Reddy VM, Brook MM, Hanley FL, Silverman NH. Improved surgical outcome after fetal diagnosis of hypoplastic left heart syndrome. Circulation. 2001;103(9):1269–1273. doi: 10.1161/01.cir.103.9.1269. [DOI] [PubMed] [Google Scholar]
  • 24.Fuchs IB, Muller H, Abdul-Khaliq H, Harder T, Dudenhausen JW, Henrich W. Immediate and long-term outcomes in children with prenatal diagnosis of selected isolated congenital heart defects. Ultrasound Obstet Gynecol. 2007;29(1):38–43. doi: 10.1002/uog.3900. [DOI] [PubMed] [Google Scholar]
  • 25.Bartlett JM, Wypij D, Bellinger DC, Rappaport LA, Heffner LJ, Jonas RA, Newburger JW. Effect of prenatal diagnosis on outcomes in D-transposition of the great arteries. Pediatrics. 2004;113(4):e335–340. doi: 10.1542/peds.113.4.e335. [DOI] [PubMed] [Google Scholar]
  • 26.Calderon J, Angeard N, Moutier S, Plumet M-H, Jambaqué I, Bonnet D. Impact of Prenatal Diagnosis on Neurocognitive Outcomes in Children with Transposition of the Great Arteries. J Pediatr. 2012;161(1):94–98.e91. doi: 10.1016/j.jpeds.2011.12.036. [DOI] [PubMed] [Google Scholar]
  • 27.Levey A, Glickstein JS, Kleinman CS, Levasseur SM, Chen J, Gersony WM, Williams IA. The impact of prenatal diagnosis of complex congenital heart disease on neonatal outcomes. Pediatr Cardiol. 2010;31(5):587–597. doi: 10.1007/s00246-010-9648-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Costello JM, Pasquali SK, Jacobs JP, He X, Hill KD, Cooper DS, Backer CL, Jacobs ML. Gestational age at birth and outcomes after neonatal cardiac surgery: an analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database. Circulation. 129(24):2511–2517. doi: 10.1161/CIRCULATIONAHA.113.005864. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Costello JM, Polito A, Brown DW, McElrath TF, Graham DA, Thiagarajan RR, Bacha EA, Allan CK, Cohen JN, Laussen PC. Birth before 39 weeks’ gestation is associated with worse outcomes in neonates with heart disease. Pediatrics. 2010;126(2):277–284. doi: 10.1542/peds.2009-3640. [DOI] [PubMed] [Google Scholar]
  • 30.Villafane J, Lantin-Hermoso MR, Bhatt AB, Tweddell JS, Geva T, Nathan M, Elliott MJ, Vetter VL, Paridon SM, Kochilas L, Jenkins KJ, Beekman RH, 3rd, Wernovsky G, Towbin JA. D-transposition of the great arteries: the current era of the arterial switch operation. J Am Coll Cardiol. 2014;64(5):498–511. doi: 10.1016/j.jacc.2014.06.1150. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Bonnet D, Coltri A, Butera G, Fermont L, Le Bidois J, Kachaner J, Sidi D. Detection of transposition of the great arteries in fetuses reduces neonatal morbidity and mortality. Circulation. 1999;99(7):916–918. doi: 10.1161/01.cir.99.7.916. [DOI] [PubMed] [Google Scholar]
  • 32.Morris SA, Ethen MK, Penny DJ, Canfield MA, Minard CG, Fixler DE, Newbhard WN. Prenatal Diagnosis, Birth Location, Surgical Center, and Neonatal Mortality in Infants With Hypoplastic Left Heart Syndrome. Circulation. 2014;129(3):285–292. doi: 10.1161/CIRCULATIONAHA.113.003711. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Donofrio MT, Duplessis AJ, Limperopoulos C. Impact of congenital heart disease on fetal brain development and injury. Curr Opin Pediatr. 2011;23(5):502–511. doi: 10.1097/MOP.0b013e32834aa583. [DOI] [PubMed] [Google Scholar]
  • 34.Khalil A, Suff N, Thilaganathan B, Hurrell A, Cooper D, Carvalho JS. Brain abnormalities and neurodevelopmental delay in congenital heart disease: systematic review and meta-analysis. Ultrasound Obstet Gynecol. 2014;43(1):14–24. doi: 10.1002/uog.12526. [DOI] [PubMed] [Google Scholar]
  • 35.Massachusetts Births 2010 report. Mass.Gov; cited 2014. Available from: http://www.mass.gov/eohhs/docs/dph/research-epi/birth-report-2010.pdfSimilar.

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