William N. Evans, MD and Ruben J. Acherman, MD
Introduction
From pregnant mothers receiving routine obstetric care, referrals to perinatologists for those with maternal-fetal risk factors or suspected fetal cardiac problems create an opportunity for population-wide, near-universal prenatal detection of Critical Congenital Heart Disease.[1] Our quest is to take this opportunity and turn it into reality. This report provides details and data on our approach and success.
Program History and Approach
Ruben Acherman, trained at Toronto Sick Kids and previously on the faculty at the University of Southern California’s Children’s Hospital Los Angeles, and Los Angeles County Hospital, established our Fetal Cardiology Program in 2002. From the beginning of the program’s foundation, we expressly set out to avoid perinatal-care silos.[2] Rather than requesting perinatologists and obstetricians refer patients with suspected fetal heart disease to our center, we asked that referrals be to Maternal-Fetal Medicine specialists. Then, Acherman would travel to the four Southern Nevada perinatal offices and train the community’s nine fetal sonographers to perform comprehensive fetal echocardiograms under his supervision at their locations. Onsite, real-time supervision allowed for sonographer-fetal cardiologist interaction and fetal cardiologist-perinatologist face-to-face consultation. Further, we elected that perinatologists bill for the fetal echocardiograms, as their technicians performed the studies with their equipment, and Acherman billed for evaluation and management. This system persists; although, currently there are 11 Maternal-Fetal Medicine offices throughout Nevada, in five different perinatal groups with a total of 40 perinatal sonographers, all trained to perform comprehensive fetal echocardiograms, and with each diagnostic study under the supervision of a fetal cardiologist. Now, seven fetal cardiologists provide five days-a-week coverage for scheduled Maternal-Fetal-Medicine office patients, along with same-day consultations as needed. We also provide onsite, real-time Fetal Cardiology on-call services 24-7, 365 days-of the-year to all Nevada’s 12 urban hospital maternal units for urgent or emergent fetal cardiac evaluations. Following identification of significant Fetal Congenital Heart Disease, parents receive further congenital cardiovascular surgical or interventional cardiology consultation and counseling at our congenital heart center.
FIGURE 1 The five-axial fetal-cardiac screening views
In 2007, we published our program’s results for Southern Nevada.[3] Our data demonstrated a 36% prenatal detection rate for those live-born with Critical Congenital Heart Disease from mothers receiving standard obstetric care, consistent with reports from other centers at the time.[4,5] We defined Critical Congenital Heart Disease patients as those that required neonatal cardiovascular surgery, neonatal interventional cardiac catheterization, or prostaglandin before surgery or interventional catheterization. We concluded that 36% was unacceptable and that we needed to improve the program.
To read the full article, please go to the November 2019 Issue of CCT.