Influence of Hemodynamic Risk Stratification by AHA Level of Care (LoC) in Congenital Heart Disease (CHD) on Mode of Delivery and Outcome Parameters: A Single-Center Retrospective Observational Study

Background: The aim of this analysis was to clarify, the complexity of CHD in neonates, which are referred to a high-volume pediatric heart center. Does mode or place of delivery within different CHD types influence outcome parameters, such as prematurity rates, APGAR scores, birth weights, and 28-day mortality rate?

Method: Observation period for this analysis was 10 years (2011–2021). All neonates younger than 28 days with CHD and admission as inpatient were included and divided into five groups according to expected hemodynamic instability using the American Heart Association's level of care (LoC) assignment.

Results: A total of 1,210 newborns were analyzed, of which 852 fitted the inclusion criteria. Out of these, 414 children were delivered onsite (group A) and received a primary cardiac care. A total of 438 newborns were transferred from distant clinics (>20 km) and received secondary cardiac care after diagnosis (group B). The predominant LoC grades were assigned to LoC grade 1 (29.2%), and LoC 2 (43.8%). LoC class 3, 4, and P (palliative care) accounted for 27% and were not different between group A and B. No significant differences were found in mode of delivery, birth weights and APGAR scores between the different maternal delivery locations. Furthermore, no association was found linking the rate of prematurity rates. Those receiving LOC 2 having a mortality rate of 9.4%, with the highest rate of mortality of 9.6% attributes to those receiving LOC 4. The proportion of univentricular heart defects in group A at LoC 2 were 58% and only 21% in group B. CHD at Loc 3 and 4 were dominated by d-TGA in both groups at 67 vs. 62%.

Conclusion: 73% of our neonates fulfilled the LoC criteria of an increased risk for hemodynamic instability (LoC: 2–4). One-third of patients were of relevant or high risk (LoC 3–4). The absence of differences in the perinatal outcome can be substantiated by comparable studies. Children with single ventricle morphology have an increased mortality rate in LoC 2. The increased mortality rate in LoC 4 appears to be correlated with diagnosis of d-TGA with highly restrictive foramen ovale, where these patients might profit from primary cardiac care at most.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
28 January 2023