Fetal Heart Team in Lodz, Poland, in 2025 – cooperation between prenatal cardiologists, obstetricians, neonatologists, cardiothoracic surgeons, and paediatric cardiologists

Prenatal diagnosis

Ever since ultrasound imaging became the standard of care in obstetrics, the prenatal detection of congenital defects, including congenital heart defects (CHDs), has improved tremendously. Initially, they were done only as an examination in the 2nd trimester of pregnancy, but since the technology progressively improved, the defects can be detected as early as in the 1st trimester of pregnancy [1-4]. Accordingly, most CHDs are detected on a 1st or 2nd trimester anatomy scan. Nonetheless, the examination in the 3rd trimester of pregnancy is important as well. Some of the problems, including e.g. coarctation of the aorta or heart tumour, are mostly detected in the 3rd trimester of pregnancy [5]. Also, because most hemodynamic changes happen in the 3rd trimester, most functional abnormalities appear in the 3rd trimester of pregnancy, consequently compromising the cardiovascular efficiency [6].
Additionally, as fetal echocardiography examinations are becoming more common, the detection of fetal CHD is also increasing. Implementing a heart screening examination and its standardised protocols results in higher detection rates of CHD.
A standard ultrasound examination is usually done by obstetrician, or in some countries by an ultrasound technician, who, in case of doubt of normal anatomy in the fetus or in case of risk factors, refers the gravid for further examination in a tertiary centre to the prenatal cardiology centre, where the defect can be classified and precisely named. This is the first step in obstetrician-fetal cardiologist cooperation.
Afterwards, the fetus is closely monitored, with examinations performed on average every 3-4 weeks, and as the pregnancy gets closer to its due date, as often as every two weeks or once a week to determine fetal well-being and to predict the neonate’s condition after birth, which is one the hardest parts of the fetal cardiologist’s work (Figure 1).
Close cooperation between the obstetrician and prenatal cardiologist can result in the best possible care for the pregnant woman, taking into account both maternal pregnancy-related diseases and fetal well-being.

Perinatal period

Transport of the neonate can be a challenging task in the case of neonates with a CHD without prenatal diagnosis. Immediate help from a specialist can be required at any time, and transport of the neonate by ambulance or helicopter can delay that process. To prevent this, we recommend transport in-utero. At about 38 weeks of gestation the gravid is admitted to the hospital – a tertiary centre with access to multiple specialists. She is monitored every day up to the delivery, and during the final weeks the last echocardiography examination takes place as close to the expected due date (EDD) as possible.
That is when the most difficult part of the prenatal cardiologist’s work takes place – the classification of the CHD and prediction of the neonate’s condition. Echocardiography examinations are then done more frequently, to establish the preferable mode of delivery, and to assess whether a prostaglandin E1 (PGE1) infusion or access to a catheterisation laboratory, or even rapid cardiac surgery, will be needed. Initially, the classification of congenital heart defects developed by Respondek-Liberska [7] consisted of four groups: the most severe, critical, severe planned, and non-urgent CHD. However, Słodki [8] extended the classification by adding two additional groups. They were proposed to predict which neonates with CHD will need immediate care, as below:
I. The most severe heart defects – for example fetal heart defects with no current possibility of help after birth. The death is predicted to happen in-utero or shortly after birth. It includes hypoplastic left heart syndrome (HLHS) with closed foramen ovale (FO) or Ebstein anomaly with severe cardiomegaly.
II. Critical heart defects – possible neonate death, an intervention should be done as fast as possible in a cath lab or by cardiac surgery. For instance, HLHS and dextro-transposition of the great arteries (d-TGA) with a restrictive FO, critical aortic and pulmonary valve stenosis, HLHS with total anomalous pulmonary venous connection (TAPVC), ectopia cordis, TAPVC with restriction [9].
III. Severe planned CHD – PGE1 should be introduced after birth to prevent the neonate’s demise, planned surgical intervention in the neonate, usually on the 7th-10th day after birth. Includes ductal dependent CHD, HLHS, and d-TGA without restrictive FO and complex heart defects.
IV. Non-urgent CHD – usually neonates are asymptomatic, intervention is done in infancy (1st year of life). Includes: simple heart defects, ventricular septal defect (VSD), atrioventricular septal defect (AVSD), mild valvular defects, classical tetralogy of Fallot with mild narrowing of the right ventricular outflow tract (RVOT).
V. CHD with an extracardiac malformations (ECM), for instance with omphalocele.
VI. CHD with an extracardiac anomaly (ECA), for example with single umbilical artery (SUA).
Adequate classification, determining whether the CHD would be ductal dependent or not are crucial for the neonate’s well-being, so that the neonatologist can be prepared for what will happen in the coming days.
In addition to structural and functional analysis of the fetus, it is also important to have knowledge about fetal growth and its genetic makeup for future outcomes [10].
With all the information gained from the fetal echocardiography examination after the consultation with a fetal cardiologist, the obstetrician can plan the mode of the delivery. Congenital heart defect is not a contraindication of vaginal delivery. However, in some cases, the fetal cardiologist can predict which fetuses would require an urgent care after the delivery. As an example, patients with d-TGA and restrictive FO, who require urgent Rashkind procedure, can be identified [11, 12]. Then, the interventional cardiologist or surgeon should be aware of the plan of the delivery to have a cath lab or surgical theatre on standby for an urgent Rashkind procedure. Therefore, caesarean section is scheduled in such cases, to ensure good coordination of the procedures needed just after the delivery. In the case of less complicated CHD, d-TGA, and no restriction of FO, vaginal delivery is recommended.
In the perinatal period, regular meetings of the Fetal Team are crucial. Specialists that the fetus require – fetal cardiologist, obstetrician, neonatologist, cardiothoracic surgeon, and paediatric cardiologist – discuss the neonatal procedures to be performed after birth.

Postnatal management

After birth, the neonate is usually transferred to the intensive care unit, but in some cases to the cath lab or the operating room. In cooperation with the paediatric cardiologist, the postnatal echocardiography examination is done, to identify any changes in the heart’s haemodynamics that could have occurred in the perinatal period and would have an impact on the course of the next few days or the surgery. However, with prenatal diagnosis and good coordination, this process does not take longer than required, and the surgery can be performed as soon as possible [13-15]. Due to surgery being performed a short time after birth, postsurgical complications can be avoided, and the neonate can be discharged home in good condition usually within 28 days. Good cooperation can also result in acquiring complete data of the case, which allows for a retrospective analysis of difficult cases, for newcomers to gain experience and to avoid possible mistakes in the future, resulting in a positive impact on future cases [16].

Conclusions

Teamwork is the key in managing patients with prenatally detected and diagnosed congenital heart defects. Good prenatal planning of the delivery, transport in-utero, and coordination of all specialists in the delivery room ensure the birth of the neonate in good condition in a tertiary centre, which accelerates the time from the birth to the surgery and decreases the hospitalisation time and complications related to it.

Acknowledgments

We would like to give special thanks to head of departments that cooperate in the Fetal Team in the Polish Mother’s Memorial Hospital – Research Institute in Lodz: Prof. Ewa Gulczyńska, Dr hab. Michał Krekora, Dr hab. Mariusz Grzesiak, Dr hab. Piotr Grzelak, Prof. Katarzyna Gilis-Januszewska, Prof. Edward Malec, Prof. Tomasz Moszura, Prof. Anna Piaseczna-Piotrowska, Dr Katarzyna Fortecka-Piestrzeniewicz.

Disclosures

Ethical considerations: none.
This research received no external funding.
The authors declare no conflict of interest.

References