Detection of fetal cardiac anomalies: cost‐effectiveness of increased number of cardiac views

Abstract

Objective To compare the recommended three‐view fetal heart screening method to detect major congenital heart disease (CHD) with more elaborate screening strategies to determine the cost‐effective strategy in unselected (low‐risk) pregnancies. Methods A decision‐analytic model was designed to compare four screening strategies to identify fetuses with major CHD in a theoretical cohort of 4 000 000 births in the USA. The four strategies were: (1) three views: four‐chamber view (4CV) and views of the left (LVOT) and right (RVOT) ventricular outflow tracts; (2) five views: 4CV, LVOT, RVOT and longitudinal views of the ductal arch and aortic arch; (3) five axial views: 4CV, LVOT, RVOT, three‐vessel (3V) view and three‐vessels‐and‐trachea view; and (4) six views: 4CV, LVOT, RVOT and 3V views and longitudinal views of the ductal arch and aortic arch. Outcomes related to neonatal mortality and neurodevelopmental disability were evaluated. The analysis was performed from a healthcare‐system perspective, with a cost‐effectiveness willingness‐to‐pay threshold set at $100 000 per quality‐adjusted life year (QALY). Baseline analysis, one‐way sensitivity analysis and Monte‐Carlo simulation were performed. Results In our baseline model, screening with five axial views was the optimal strategy, detecting 3520 more CHDs, and resulting in 259 fewer children with neurodevelopmental disability, 40 fewer neonatal deaths and only slightly higher costs, compared with screening with the currently recommended three views. Screening with six views was more effective, but also cost considerably more, compared with screening with five axial views, and had an incremental cost of $490 023/QALY, which was over the willingness‐to‐pay threshold. The five‐view strategy was dominated by the other three strategies, i.e. it was more costly and less effective in comparison. The data were robust when tested with Monte‐Carlo and one‐way sensitivity analysis. Conclusion Although current guidelines recommend a minimum of three views for detecting CHD during the mid‐trimester anatomy scan, screening with five axial views is a cost‐effective strategy that may lead to improved outcome compared with three‐view screening. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

A “holistic” sonographic view on congenital heart disease: How automatic reconstruction using fetal intelligent navigation echocardiography eases unveiling of abnormal cardiac anatomy part II—Left heart anomalies

“…The most commonly missed severe CHDs are conotruncal lesions, such as transposition of the great arteries, tetralogy of Fallot, double outlet right ventricle or truncus arteriosus, since the four‐chamber view may be falsely reassuring in the majority of these cases 89 . The addition of more standard views has been shown to increase the detection rate of CHDs, as this increase may yield valuable information on most left and right‐sided cardiac lesions and is cost‐effective according to recent data 90,91 …”

“…89 The addition of more standard views has been shown to increase the detection rate of CHDs, as this increase may yield valuable information on most left and rightsided cardiac lesions and is cost-effective according to recent data. 90,91 According to the results from a very recent national survey of physicians, the main barriers preventing effective cardiac screening were knowledge of CHD screening guidelines and minimal volumes of cardiac scans. 92 Detailed characterization of fetal cardiac function in normal and abnormal fetal hearts is feasible and well described using conventional 2D US.…”

Impact of maternal obesity on fetal cardiac screening: which follow‐up strategy is cost‐effective?

“…These societies recommend assessing a minimum of three heart views: the four‐chamber view and views of the left and right ventricular outflow tracts. Instead of using just these three views, we used five axial views, including also the three‐vessel (3V) view and three‐vessels‐and‐trachea (3VT) view (Figure 2), because we found previously that this strategy was cost‐effective when performing fetal heart screening 30 .…”

Expert-level prenatal detection of complex congenital heart disease from screening ultrasound using deep learning

“…A fetal survey (fetal screening ultrasound) is recommended for every pregnancy worldwide 10,11 in the second trimester and generally includes five clinically recommended cardiac views ( Figure 1a ) that together could allow clinicians to diagnose up to 90% of complex CHD 12,13 . In practice, however, detection is often as low as 30% 1,14,15 , even where ultrasound is universal 10,11,15 .…”