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Cited by 33Congenital Heart Disease StudiesPrenatal Screening and DiagnosticsCongenital heart defects research

The effect of the introduction of the three‐vessel view on the detection rate of transposition of the great arteries and tetralogy of Fallot

Open access
Everwijn, Sheila M.P., van Nisselrooij, Amber E.L., Rozendaal, Lieke, Clur, Sally‐Ann B., Pajkrt, Eva, Hruda, Jaroslav, Linskens, Ingeborg H., van Lith, Jan M. +2 more·2018·Prenatal Diagnosis
DOI 10.1002/pd.5347
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Abstract

Objectives: The aim of this study was to analyze the annual detection rate (DR) of transposition of the great arteries (TGA) and tetrology of Fallot (ToF), after the introduction of the three‐vessel view as a mandatory plane in 2012. Methods: All registered TGA and ToF cases were retrospectively extracted from our registry between 2007 and 2016. We compared the DR in a 10‐year period, before 2011, with the DR of TGA and ToF after 2012. Results: In the period before 2012, 23 of the 52 TGA cases were prenatally detected (44.2%), compared with 42 of the 51 cases (82.4%) after 2012. For ToF, the DRs increased from 28 of 64 cases (43.8%) to 42 of 62 cases (67.7%) in the aforementioned periods. The increase in DRs for both defects was statistically significant (P ≤ 0.001 and P ≤ 0.05). Conclusions: In this nationally organized prenatal screening program with a quality monitoring system and a uniform protocol, DRs of 82.4% for TGA and 67.7% for ToF were reached after the introduction of the three‐vessel view as a mandatory item. The three‐vessel view significantly contributes to the detection of these conotruncal anomalies.

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Written from the paper’s full text.

TL;DR

After the three-vessel view (3VV) became mandatory in the Dutch national screening program in 2012, prenatal detection of transposition of the great arteries (TGA) rose from 44.2% to 82.4%, and tetralogy of Fallot/double-outlet right ventricle Fallot-type (ToF/DORV-ToF) rose from 43.9% to 67.7%. The authors conclude that the 3VV significantly contributes to detection of these conotruncal anomalies.

Key findings

  • TGA prenatal detection increased from 23/52 (44.2%) in 2007–2011 to 42/51 (82.4%) in 2012–2016, an increase of 38.2% (P = 0.000057).
  • ToF/DORV-ToF prenatal detection increased from 28/64 (43.9%) to 42/62 (67.7%), an increase of 23.8% (P = 0.00673; table reports P = 0.007).
  • Isolated ToF detection increased significantly from 14/47 (30%) to 31/50 (62%) (P = 0.001), while nonisolated ToF detection remained stable at 14/17 (82%) vs 11/12 (92%) (P = 0.62).
  • Mortality < 1 year did not significantly decrease for TGA or ToF; in TGA, the authors judged that at least four of eight deaths could have been preventable with a prenatal diagnosis.

Methods

  • Retrospective study using the PRECOR registry, including all TGA and ToF/DORV-ToF cases with a normal four-chamber view from three university medical centers in the North-West Netherlands; neonates born May 1, 2007–April 30, 2017, corresponding to anomaly scans from January 2007–December 2016.
  • Compared prenatal detection in 2007–2011 vs 2012–2016, after the 3VV was added as a mandatory item to the standard anomaly scan in January 2012.
  • Used frequencies/percentages, chi-square tests, independent-samples t tests, and SPSS version 24; P < 0.05 was considered statistically significant.

Limitations

  • The paper states the study is observational and retrospective, and that a study comparing geographical regions with different screening protocols would be more ideal; it also notes the effect could be attributed to increased experience, though the sudden TGA effect opposes that hypothesis.
  • The authors state that the presented data are too small to prove the help of the “Leiden line” training tool.
  • Evident from the text: the study is from a single regional/national registry without a concurrent control group, and mortality analyses had small numbers, limiting statistical power.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1002/pd.5347

Cites

22 of 22 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 22 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    In the period 2007-2011, 28 of 64 ToF/DORV-ToF cases (43.9%) were prenatally detected.

    “In the first period (2007-2011), a prenatal diagnosis of ToF/DORV-ToF cases was found in 28 of 64 (43.9%).”
    • Also stated in: § Abstract · plain
      “For ToF, the DRs increased from 28 of 64 cases (43.8%) to 42 of 62 cases (67.7%) in the aforementioned periods.”
    Quote in the paperSubstantial claim
  • Findingown data

    In the period 2007-2011, 23 of 52 TGA cases (44.2%) were prenatally detected.

    “In the period before 2012, 23 of the 52 TGA cases were prenatally detected (44.2%), compared with 42 of the 51 cases (82.4%) after 2012.”
    • Also stated in: § 3 | RESULTS · plain
      “In the first period (2007-2011), a prenatal diagnosis of TGA was identified in 23 of 52 (44.2%) cases, as was reported before.7”
    Quote in the paperSubstantial claim
  • Findingown data

    In the period 2012-2016, 42 of 62 ToF/DORV-ToF cases (67.7%) were prenatally detected.

    “In the second period (2012-2016), after the introduction of the 3VV, ToF/ DORV-ToF was prenatally diagnosed in 42 of 62 cases (67.7%).”
    • Also stated in: § Abstract · plain
      “42 of 62 cases (67.7%)”
    Quote in the paperSubstantial claim
  • Findingown data

    In the period 2012-2016, 42 of 51 TGA cases (82.4%) were prenatally detected.

    “compared with 42 of the 51 cases (82.4%) after 2012.”
    Quote in the paperSubstantial claim
  • Findingreasoning

    Mortality rates <1 year did not significantly decrease for both TGA and ToF.

    “Mortality rates < 1 year did not significantly decrease for both TGA and ToF.”
    Quote in the paperSubstantial claim
  • May combine two claims. 17
  • Classified as probably not a substantial claim. 15

  • May combine two claims.

    Findingown data

    The increase in ToF/DORV-ToF detection rate from 43.9% to 67.7% (23.8 percentage points) was statistically significant (P=0.00673).

    “The increase of 23.8% was statistically significant (P = 0.00673) (Table 2).”
    • Also stated in: § Abstract · plain
      “The increase in DRs for both defects was statistically significant (P ≤ 0.001 and P ≤ 0.05).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The increase in TGA detection rate from 44.2% to 82.4% (38.2 percentage points) was statistically significant (P=0.000057).

    “The increase of 38.2% (Table 1) was statistically significant (P = 0.000057).”
    • Also stated in: § Abstract · plain
      “The increase in DRs for both defects was statistically significant (P ≤ 0.001 and P ≤ 0.05).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In TGA, the relatively high mortality in the second period was caused by one death in the detected group due to abnormal coronary artery anatomy, and a relatively high mortality rate in the undetected group (33%).

    “In TGA, the relatively high mortality in the second period was caused by one death in the detected group due to abnormal coronary artery anatomy, and a relatively high mortality rate in the undetected group (33%).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The increase in detection rate of ToF/DORV-ToF after 2011 was more gradual than that of TGA, in which the increase was abrupt.

    “The increase of the detection rate of ToF/DORV-ToF after 2011 was more gradual than that of the TGA cases, in which the increase was abrupt.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The uptake for the standard anomaly scan is 95%.

    “The uptake for the SAS is 95%, with the remaining proportion of women receiving an anomaly scan in a center for prenatal diagnosis because of an increased risk for fetal anomalies.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisenone given

    Both TGA and ToF generally present with a normal four-chamber view, which may explain the low detection rate of these defects.

    “Both TGA and ToF generally present with a normal four-chamber view, which may explain the low DR of these defects.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    The effect of guideline changes in obstetrical ultrasound on detection rate in regional cohorts is only reported once and only for TGA.

    “The effect of guideline changes in obstetrical ultrasound on DR in regional cohorts is only reported once and only for TGA.6”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [6]

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    In this nationally organized prenatal screening program with a quality monitoring system and a uniform protocol, DRs of 82.4% for TGA and 67.7% for ToF were reached after the introduction of the three-vessel view as a mandatory item.

    “In this nationally organized prenatal screening program with a quality monitoring system and a uniform protocol, DRs of 82.4% for TGA and 67.7% for ToF were reached after the introduction of the three-vessel view as a mandatory item.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The three-vessel view became a mandatory item in the Dutch national standard anomaly scan protocol on January 1, 2012.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    In PRECOR, the prevalence of severe CHD is 2.3 per 1000 live births, which corresponds with earlier reported prevalence and is a strong indicator of the completeness of the registry.

    “In PRECOR, the prevalence of severe CHD, defined as heart defects needing surgery or a therapeutic intervention in the first year of life, is 2.3 of 1000 live births, which corresponds with earlier reported prevalence of CHD.The encountered prevalence in the registry is a strong indicator of the completeness of this registry.1”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [1] source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Data were cross-checked with neonatal mortality registries, heart catheterization registries, and emergency admission charts to prevent missing any CHD cases.

    “We cross-checked the data with neonatal mortality registries, heart catheterization registries, and emergency admission charts to prevent missing any CHD cases.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The national screening program is continuously monitored by audits including biannual image analysis of the ultrasonographers.

    “The national screening program is continuously monitored by audits including biannual image analysis of the ultrasonographers.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductnone given

    The study was observational and retrospective.

    “A limitation of this study is the observational retrospective character.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    The absence of an effect on mortality in TGA cases in this cohort was unexpected.

    “The absence of an effect on mortality in TGA cases in this cohort was unexpected.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    A possible explanation for the less profound and more gradual increase in ToF is that the encountered abnormalities in the 3VV can be subtle in ToF.

    “A possible explanation could be that the encountered abnormalities in the 3VV can be subtle in ToF (Figure 1C).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

    Interpretationreasoning

    The complex geometric anatomy with its crossing outflow tracts could explain the difficulty in the examination.

    “The complex geometric anatomy with its crossing outflow tracts could explain the difficulty in the examination.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Although prenatal detection did not result in lower mortality in this cohort owing to lack of statistical power, other studies showed a positive effect on mortality and neurological outcome.

    “Although prenatal detection did not result in lower mortality in this cohort owing to lack of statistical power, other studies showed a positive effect on mortality 7 and, even more importantly, a beneficial effect on neurological outcome, 11 underlining the importance of a prenatal diagnosis of TGA.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [7] source

      Not checked in the free run.

    • cites [11] source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    Our detection rate of 82% in TGA is among the highest reported in literature, but 18% was still missed with considerable morbidity and mortality in these cases.

    “Our DR of 82% in TGA is among the highest reported in literature, but 18% was still missed with considerable morbidity and mortality in these cases.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    Despite the effort of ultrasonographers, detection rates in a screening setting are unlikely to equal those of tertiary referral centers, which may be explained by a lack of advanced knowledge of normal cardiac anatomy and low exposure to pathology.

    “Despite the effort of the ultrasonographers, DRs in a screening setting are unlikely to equal those of tertiary referral centers, which may be explained by a lack of advanced knowledge of normal cardiac anatomy and, most importantly, low exposure to pathology.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    The described effect in this study could be attributed to increased experience as well.

    “The described effect in this study could therefore be attributed to increased experience as well.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The assessment of the fetal heart is perceived as the most difficult part of the standard anomaly scan.

    “The assessment of the fetal heart is perceived as the most difficult part of the SAS.22”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [22] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Previously described screening programs looking at regional cohorts show persistently low detection rates of 40% to 50% for all CHDs combined, with very low detection rates for conotruncal anomalies like TGA and ToF in the majority of programs.

    “Previously described screening programs looking at regional cohorts show persistently low DRs of 40% to 50% for all CHDs combined, with very low DRs for conotruncal anomalies like TGA and ToF in the majority of programs.1”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [1] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In ToF, the configuration of the vessels is relatively normal, and the size of the pulmonary trunk in fetal life can be normal to only slightly decreased.

    “The configuration of the vessels is relatively normal in ToF, and the size of the pulmonary trunk in fetal life can be normal to only slightly decreased.17”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [17] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    Our study is the first to investigate the effect of the nongradual implementation of a single plane to the screening protocol on detection rates.

    “To our knowledge, our study is the first to investigate the effect of the nongradual implementation of a single plane to the screening protocol on DRs.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Ravi et al reported comparable detection rate for TGA only, with a gradual improvement following guideline changes.

    “Recently, Ravi et al 6 reported comparable DR for TGA only, with a gradual improvement following guideline changes.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [6]

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    The introduction of the 3VV in screening programs in addition to the four-chamber view could lead to a prenatal detection of 82% of TGA and 68% of ToF.

    “The introduction of the 3VV in screening programs in addition to the four-chamber view could lead to a prenatal detection of 82% of TGA and 68% of ToF.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The three-vessel view became a mandatory item in the Dutch national standard anomaly scan protocol on January 1, 2012.
    • Rests on an assumption: No other mandatory planes were added, or no other significant changes were made to the SAS protocol during the studied period.

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    The sudden effect on TGA detection rates opposes the hypothesis that the effect is due to increased experience.

    “The sudden effect on TGA-DRs, however, opposes to that hypothesis in our opinion.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Our data show the strength of the 3VV in itself on TGA detection and that detection rates for TGA change immediately after the introduction of 3VV in a centrally organized screening program.

    “Our study differs from Ravi et al as our data show the strength of the 3VV in itself on TGA detection and the fact that the DRs for TGA change immediately after the introduction of 3VV in a centrally organized screening program.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The three-vessel view became a mandatory item in the Dutch national standard anomaly scan protocol on January 1, 2012.
    • Rests on an assumption: No other mandatory planes were added, or no other significant changes were made to the SAS protocol during the studied period.
27 of 27

  • The paper relies on this without support.

    The three-vessel view became a mandatory item in the Dutch national standard anomaly scan protocol on January 1, 2012.

    “Starting January 1, 2012, the 3VV became mandatory in the national guideline of the standard anomaly scan (SAS).”

  • The paper relies on this without support.

    No other mandatory planes were added, or no other significant changes were made to the SAS protocol during the studied period.

    “No other mandatory planes were added, or no other significant changes were made to the SAS protocol during the studied period.”

  • The authors state this as an assumption.

    The TGA cases that died would have received immediate postnatal care to maintain mixing of deoxygenated and oxygenated blood.

    “Assuming that these cases would have received immediate postnatal care, to maintain mixing of deoxygenated and oxygenated blood, at least four of the eight deaths could have been preventable with a prenatal diagnosis.”
3 of 3

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Cites

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Research works printed but not linked: 1

  1. Ravi P, 2017, Population trends in prenatal detection of transposition of great arteries: impact of obstetrical screening ultrasound guidelines, Ultras Obstetr Ggynecol : Official J Int Soc Ultras Obstetrics Gynecol

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Authors
Everwijn, S. M. P., van Nisselrooij, A. E. L., Rozendaal, L., Clur, S. B., Pajkrt, E., Hruda, J., Linskens, I. H., van Lith, J. M., Blom, N. A., & Haak, M. C.
Affiliations
  • Leiden University Medical Center (NL)
  • Department of Obstetrics and Fetal Medicine Leiden University Medical Center Leiden The Netherlands
  • Amsterdam UMC Location University of Amsterdam (NL)
  • Amsterdam UMC Location Vrije Universiteit Amsterdam (NL)
Corresponding author
Everwijn, Sheila M.P.
ORCID
Venue
Prenatal Diagnosis
Publisher
Wiley
Published
2018-09-11
Volume
38
Issue
12
Pages
951-957
ISSN
  • 0197-3851 (ISSN-L)
  • 1097-0223
DOI
10.1002/pd.5347
OpenAlex
W2888699170
Cited by
33
References
22
Citations by year
2026: 3 · 2025: 2 · 2024: 7 · 2023: 7 · 2022: 6 · 2021: 2 · 2020: 3 · 2019: 3
FWCI
1.56
Type
journal article
Language
en
Open access
Licence
Locations
  • Prenatal Diagnosis (publishedVersion)
  • PubMed (publishedVersion)
  • Pure Amsterdam UMC (submittedVersion, other-oa)
  • Data Archiving and Networked Services (DANS) (submittedVersion)
  • Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
  • Leiden Repository (Leiden University) (submittedVersion)
  • Amsterdam UMC (VU Amsterdam) - Institutional Repository (submittedVersion)
Topics
  • Health Sciences › Medicine › Epidemiology › Congenital Heart Disease Studies
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Prenatal Screening and Diagnostics
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Biology › Congenital heart defects research
Keywords
transposition of the great arteries, tetralogy of Fallot, three-vessel view, prenatal ultrasound screening, conotruncal anomalies, detection rate, quality monitoring
MeSH terms
Clinical Protocols, Echocardiography, Female, Fetal Diseases, Humans, Infant, Newborn, Male, Netherlands, Pregnancy, Prenatal Diagnosis, Registries, Tetralogy of Fallot, Transposition of Great Vessels, Ultrasonography, Prenatal

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