Antenatal Risk of Coarctation for newborns at Hartford Hospital (ARCH) Pathway: A Predictor of Postnatal Management Strategy

Abstract

Background: The diagnosis of coarctation of the aorta (CoA) prior to birth can be challenging due to the physiologic changes during postnatal transition. Prenatal risk stratification can standarize postnatal management and improve outcome. CT Children’s Fetal Cardiology created the Antenatal Risk of CoA in Hartford (ARCH) clinical pathway defining four distinct postnatal order sets based on degree of suspicion for ductal dependency on fetal evaluation: low, low-moderate, moderate-high, and high risk. This study aims to evaluate safety and efficacy of the ARCH pathway in neonates with suspected CoA. Study Design: This study was a single-center, retrospective chart review evaluating maternal-infant dyads with findings concerning for CoA between July 2004 and July 2021, before and after ARCH pathway implementation. Neonates were evaluated for the presence or absence of critical CoA and postnatal clinical data were collected. Statistical analysis was performed using chi square and Fisher’s exact test. Results: There were 108 maternal-infant dyads studied, comprising 53 non-pathway patients and 55 ARCH-pathway participants. Thirty-three neonates had critical CoA, comprising 23 non-pathway and 10 ARCH-pathway subjects. Patients categorized in the high-risk group were highly associated with critical CoA (P= 0.003). Non-pathway neonates with CoA demonstrated higher likelihood of hospital transfer compared to ARCH-pathway neonates (56.5% vs 10.0%, P = 0.021). NICU admission, prostaglandin administration, and intubation were not significantly different between before and after ARCH implementation (P <0.05). More echocardiograms were performed in ARCH-pathway neonates without CoA than their non-pathway counterparts (1.586 vs 2.133, P = 0.049). Conclusion: The ARCH pathway is a safe, reliable prenatal risk stratification system to help guide management of patients with critical CoA. These results identify effective targets of modification to the pathway to reduce resource utilization without compromising safety.