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Arch watch: current approaches and opportunities for improvement

Journal of Perinatology volume 44, pages 325–332 (2024)Cite this article

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Abstract

Coarctation of the aorta (CoA) is a ductus arteriosus (DA)-dependent form of congenital heart disease (CHD) characterized by narrowing in the region of the aortic isthmus. CoA is a challenging diagnosis to make prenatally and is the critical cardiac lesion most likely to go undetected on the pulse oximetry-based newborn critical CHD screen. When undetected CoA causes obstruction to blood flow, life-threatening cardiovascular collapse may result, with a high burden of morbidity and mortality. Hemodynamic monitoring practices during DA closure (known as an “arch watch”) vary across institutions and existing tools are often insensitive to developing arch obstruction. Novel measures of tissue oxygenation and oxygen deprivation may improve sensitivity and specificity for identifying evolving hemodynamic compromise in the newborn with CoA. We explore the benefits and limitations of existing and new tools to monitor the physiological changes of the aorta as the DA closes in infants at risk of CoA.

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Fig. 1: Postnatal evolution of aortic arch anatomy with ductal restriction and closure.
Fig. 2: Mechanism of blood pressure detection using oscillometry.
Fig. 3: Photoplethysmography waveform features potentially evaluable during the arch watch.
Fig. 4: Cardiac intensive care unit arch watch protocol.

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Acknowledgements

We thank Kai-ou Tang, M.A. for her illustration of Figs. 1–3. All figures used with permission from the Cardiac ICU Manual from Boston Children’s Hospital.

Funding

T32 HD 098061, American Academy of Pediatrics Marshall Klaus Perinatal Research Award, Boston Children’s Hospital Translational Research Program Pilot Grant

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Authors and Affiliations

  1. Division of Newborn Medicine, Department of Pediatrics, Boston Children’s Hospital, Boston, MA, USA

    Alyssa R. Thomas & Philip T. Levy

  2. Department of Pediatrics, Harvard Medical School, Boston, MA, USA

    Alyssa R. Thomas, Philip T. Levy, Francesca Sperotto, Eleonore Valencia, Kevin Friedman & John N. Kheir

  3. Department of Cardiology, Boston Children’s Hospital, Boston, MA, USA

    Francesca Sperotto, Eleonore Valencia, Kevin Friedman & John N. Kheir

  4. Department of Nursing, Boston Children’s Hospital, Boston, MA, USA

    Nancy Braudis

  5. Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA, USA

    James A. DiNardo

  6. Department of Anaesthesia, Harvard Medical School, Boston, MA, USA

    James A. DiNardo

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The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. AT and JK conceptualized the manuscript. AT, PL, FS, NB, EV, JD, and KF all contributed to the first draft, performed literature review, and revised subsequent drafts. All authors have approved the submitted manuscript and have agreed to be accountable for the contents.

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Correspondence to Alyssa R. Thomas.

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Thomas, A.R., Levy, P.T., Sperotto, F. et al. Arch watch: current approaches and opportunities for improvement. J Perinatol 44, 325–332 (2024). https://doi.org/10.1038/s41372-023-01854-7

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