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Yilmaz Furtun B, Morris SA. Catheter-Based Fetal Cardiac Interventions. J Cardiovasc Dev Dis 2024; 11:167. [PMID: 38921667 PMCID: PMC11204342 DOI: 10.3390/jcdd11060167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/20/2024] [Accepted: 05/23/2024] [Indexed: 06/27/2024] Open
Abstract
Fetal cardiac intervention (FCI) is an emerging and rapidly advancing group of interventions designed to improve outcomes for fetuses with cardiovascular disease. Currently, FCI is comprised of pharmacologic therapies (e.g., trans-placental antiarrhythmics for fetal arrhythmia), open surgical procedures (e.g., surgical resection of pericardial teratoma), and catheter-based procedures (e.g., fetal aortic valvuloplasty for aortic stenosis). This review focuses on the rationale, criteria for inclusion, technical details, and current outcomes of the three most frequently performed catheter-based FCI procedures: (1) aortic valvuloplasty for critical aortic stenosis (AS) associated with evolving hypoplastic left heart syndrome (HLHS), (2) atrial septal intervention for HLHS with severely restrictive or intact atrial septum (R/IAS), and (3) pulmonary valvuloplasty for pulmonary atresia with intact ventricular septum (PA/IVS).
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Affiliation(s)
| | - Shaine Alaine Morris
- Texas Children’s Hospital, Baylor College of Medicine, 6651 Main Street, Suite E1920, Houston, TX 77030, USA
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2
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Dütemeyer V, Schaible T, Badr DA, Cordier AG, Weis M, Perez-Ortiz A, Carriere D, Cannie MM, Vuckovic A, Persico N, Cavallaro G, Benachi A, Jani JC. Fetoscopic endoluminal tracheal occlusion vs expectant management for fetuses with severe left-sided congenital diaphragmatic hernia. Am J Obstet Gynecol MFM 2024; 6:101248. [PMID: 38070678 DOI: 10.1016/j.ajogmf.2023.101248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/14/2023] [Accepted: 12/02/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND The treatment of fetuses with a congenital diaphragmatic hernia is challenging, but there is evidence that fetoscopic endoluminal tracheal occlusion has a benefit over expectant care. In addition, standardization and expertism have a great impact on survival and are probably crucial in centers that rely on expectant management with extracorporeal membrane oxygenation after birth. OBJECTIVE This study aimed to examine the survival and morbidity rates of fetuses with a severe isolated left-sided congenital diaphragmatic hernia who underwent fetoscopic endoluminal tracheal occlusion vs expectant management in high-volume centers. STUDY DESIGN This was a multicenter, retrospective study that included all consecutive fetuses with severe isolated left-sided congenital diaphragmatic hernia who were expectantly managed in a German center or who underwent fetoscopic endoluminal tracheal occlusion in 3 other European centers (Belgium, France, and Italy). Severe congenital diaphragmatic hernia was defined as having an observed to expected total fetal lung volume ≤35% with intrathoracic position of the liver diagnosed with magnetic resonance imaging. All magnetic resonance images were centralized, and lung volumes were measured by 2 experienced operators who were blinded to the pre- and postnatal data. Multiple logistic regression analyses were performed to examine the effect of the management strategy in the 2 groups on the short- and long-term outcomes. RESULTS A total of 147 patients who were managed expectantly and 47 patients who underwent fetoscopic endoluminal tracheal occlusion were analyzed. Fetuses who were managed expectantly had lower observed to expected total fetal lung volumes (20.6%±7.5% vs 23.7%±6.8%; P=.013), higher gestational age at delivery (median weeks of gestation, 37.4; interquartile range, 36.6-38.00 vs 35.1; interquartile range, 33.1-37.2; P<.001), and more frequent use of extracorporeal membrane oxygenation (55.8% vs 4.3%; P<.001) than the fetuses who underwent fetoscopic endoluminal tracheal occlusion. The survival rates at discharge and at 2 years of age in the expectant management group were higher than the survival rates of the fetoscopic endoluminal tracheal occlusion group (74.3% vs 44.7%; P=.001 and 72.8% vs 42.5%; P=.001, respectively). After adjustment for maternal age, gestational age at birth, observed to expected total fetal lung volume, and birth weight Z-score, the odds ratios were 4.65 (95% confidence interval, 1.9-11.9; P=.001) and 4.37 (95% confidence interval, 1.8-11.0; P=.001), respectively. CONCLUSION Fetuses with a severe isolated left-sided congenital diaphragmatic hernia had a higher survival rate when treated in an experienced center in Germany with antenatal expectant management and frequent use of extracorporeal membrane oxygenation during the postnatal period than fetuses who were treated with fetoscopic endoluminal tracheal occlusion in 3 centers in Belgium, France, and Italy.
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Affiliation(s)
- Vivien Dütemeyer
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium (Drs Dütemeyer, Badr, and Jani); Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany (Drs Dütemeyer)
| | - Thomas Schaible
- Department of Neonatology, Universitätsklinikum Mannheim, Mannheim, Germany (Drs Schaible and Perez-Ortiz)
| | - Dominique A Badr
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium (Drs Dütemeyer, Badr, and Jani)
| | - Anne-Gael Cordier
- Department of Obstetrics and Gynecology, Hospital Antoine Béclère, Université Paris Saclay, Clamart, France (Drs Cordier and Benachi)
| | - Meike Weis
- Department of Radiology, Universitätsklinikum Mannheim, Mannheim, Germany (Dr Weis)
| | - Alba Perez-Ortiz
- Department of Neonatology, Universitätsklinikum Mannheim, Mannheim, Germany (Drs Schaible and Perez-Ortiz)
| | - Diane Carriere
- Service de Réanimation Pédiatrique, Hôpital Bicêtre- AP-HP, Université Paris Saclay, Le Kremlin Bicêtre, France (Dr Carriere)
| | - Mieke M Cannie
- Department of Radiology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium (Dr Cannie)
| | - Aline Vuckovic
- Neonatal Intensive Care Unit, Queen Fabiola Children's Hospital-ULB, Brussels, Belgium (Dr Vuckovic)
| | - Nicola Persico
- Fetal Medicine and Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy (Dr Persico); Department of Clinical Science and Community Health, University of Milan, Milan, Italy (Dr Persico)
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy (Dr Cavallaro)
| | - Alexandra Benachi
- Department of Obstetrics and Gynecology, Hospital Antoine Béclère, Université Paris Saclay, Clamart, France (Drs Cordier and Benachi)
| | - Jacques C Jani
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium (Drs Dütemeyer, Badr, and Jani).
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Krispin E, Didier R, Shaniker SA, Duffy CR, Hecht J, Shamshirsaz AA. Diagnostic fetoscopy: important resource for prenatal assessment. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:282-283. [PMID: 37676469 DOI: 10.1002/uog.27469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/15/2023] [Accepted: 08/18/2023] [Indexed: 09/08/2023]
Affiliation(s)
- E Krispin
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - R Didier
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - S A Shaniker
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - C R Duffy
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - J Hecht
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - A A Shamshirsaz
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Bano S, Casella A, Vasconcelos F, Qayyum A, Benzinou A, Mazher M, Meriaudeau F, Lena C, Cintorrino IA, De Paolis GR, Biagioli J, Grechishnikova D, Jiao J, Bai B, Qiao Y, Bhattarai B, Gaire RR, Subedi R, Vazquez E, Płotka S, Lisowska A, Sitek A, Attilakos G, Wimalasundera R, David AL, Paladini D, Deprest J, De Momi E, Mattos LS, Moccia S, Stoyanov D. Placental vessel segmentation and registration in fetoscopy: Literature review and MICCAI FetReg2021 challenge findings. Med Image Anal 2024; 92:103066. [PMID: 38141453 PMCID: PMC11162867 DOI: 10.1016/j.media.2023.103066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 11/27/2023] [Accepted: 12/19/2023] [Indexed: 12/25/2023]
Abstract
Fetoscopy laser photocoagulation is a widely adopted procedure for treating Twin-to-Twin Transfusion Syndrome (TTTS). The procedure involves photocoagulation pathological anastomoses to restore a physiological blood exchange among twins. The procedure is particularly challenging, from the surgeon's side, due to the limited field of view, poor manoeuvrability of the fetoscope, poor visibility due to amniotic fluid turbidity, and variability in illumination. These challenges may lead to increased surgery time and incomplete ablation of pathological anastomoses, resulting in persistent TTTS. Computer-assisted intervention (CAI) can provide TTTS surgeons with decision support and context awareness by identifying key structures in the scene and expanding the fetoscopic field of view through video mosaicking. Research in this domain has been hampered by the lack of high-quality data to design, develop and test CAI algorithms. Through the Fetoscopic Placental Vessel Segmentation and Registration (FetReg2021) challenge, which was organized as part of the MICCAI2021 Endoscopic Vision (EndoVis) challenge, we released the first large-scale multi-center TTTS dataset for the development of generalized and robust semantic segmentation and video mosaicking algorithms with a focus on creating drift-free mosaics from long duration fetoscopy videos. For this challenge, we released a dataset of 2060 images, pixel-annotated for vessels, tool, fetus and background classes, from 18 in-vivo TTTS fetoscopy procedures and 18 short video clips of an average length of 411 frames for developing placental scene segmentation and frame registration for mosaicking techniques. Seven teams participated in this challenge and their model performance was assessed on an unseen test dataset of 658 pixel-annotated images from 6 fetoscopic procedures and 6 short clips. For the segmentation task, overall baseline performed was the top performing (aggregated mIoU of 0.6763) and was the best on the vessel class (mIoU of 0.5817) while team RREB was the best on the tool (mIoU of 0.6335) and fetus (mIoU of 0.5178) classes. For the registration task, overall the baseline performed better than team SANO with an overall mean 5-frame SSIM of 0.9348. Qualitatively, it was observed that team SANO performed better in planar scenarios, while baseline was better in non-planner scenarios. The detailed analysis showed that no single team outperformed on all 6 test fetoscopic videos. The challenge provided an opportunity to create generalized solutions for fetoscopic scene understanding and mosaicking. In this paper, we present the findings of the FetReg2021 challenge, alongside reporting a detailed literature review for CAI in TTTS fetoscopy. Through this challenge, its analysis and the release of multi-center fetoscopic data, we provide a benchmark for future research in this field.
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Affiliation(s)
- Sophia Bano
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS) and Department of Computer Science, University College London, UK.
| | - Alessandro Casella
- Department of Advanced Robotics, Istituto Italiano di Tecnologia, Italy; Department of Electronics, Information and Bioengineering, Politecnico di Milano, Italy
| | - Francisco Vasconcelos
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS) and Department of Computer Science, University College London, UK
| | | | | | - Moona Mazher
- Department of Computer Engineering and Mathematics, University Rovira i Virgili, Spain
| | | | - Chiara Lena
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Italy
| | | | - Gaia Romana De Paolis
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Italy
| | - Jessica Biagioli
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Italy
| | | | | | - Bizhe Bai
- Medical Computer Vision and Robotics Group, Department of Mathematical and Computational Sciences, University of Toronto, Canada
| | - Yanyan Qiao
- Shanghai MicroPort MedBot (Group) Co., Ltd, China
| | - Binod Bhattarai
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS) and Department of Computer Science, University College London, UK
| | | | - Ronast Subedi
- NepAL Applied Mathematics and Informatics Institute for Research, Nepal
| | | | - Szymon Płotka
- Sano Center for Computational Medicine, Poland; Quantitative Healthcare Analysis Group, Informatics Institute, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Arkadiusz Sitek
- Sano Center for Computational Medicine, Poland; Center for Advanced Medical Computing and Simulation, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - George Attilakos
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospital, UK; EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, UK
| | - Ruwan Wimalasundera
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospital, UK; EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, UK
| | - Anna L David
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospital, UK; EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, UK; Department of Development and Regeneration, University Hospital Leuven, Belgium
| | - Dario Paladini
- Department of Fetal and Perinatal Medicine, Istituto "Giannina Gaslini", Italy
| | - Jan Deprest
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, UK; Department of Development and Regeneration, University Hospital Leuven, Belgium
| | - Elena De Momi
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Italy
| | - Leonardo S Mattos
- Department of Advanced Robotics, Istituto Italiano di Tecnologia, Italy
| | - Sara Moccia
- The BioRobotics Institute and Department of Excellence in Robotics and AI, Scuola Superiore Sant'Anna, Italy
| | - Danail Stoyanov
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS) and Department of Computer Science, University College London, UK
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Casella A, Lena C, Moccia S, Paladini D, De Momi E, Mattos LS. Toward a navigation framework for fetoscopy. Int J Comput Assist Radiol Surg 2023; 18:2349-2356. [PMID: 37587389 PMCID: PMC10632301 DOI: 10.1007/s11548-023-02974-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 05/23/2023] [Indexed: 08/18/2023]
Abstract
PURPOSE Fetoscopic laser photocoagulation of placental anastomoses is the most effective treatment for twin-to-twin transfusion syndrome (TTTS). A robust mosaic of placenta and its vascular network could support surgeons' exploration of the placenta by enlarging the fetoscope field-of-view. In this work, we propose a learning-based framework for field-of-view expansion from intra-operative video frames. METHODS While current state of the art for fetoscopic mosaicking builds upon the registration of anatomical landmarks which may not always be visible, our framework relies on learning-based features and keypoints, as well as robust transformer-based image-feature matching, without requiring any anatomical priors. We further address the problem of occlusion recovery and frame relocalization, relying on the computed features and their descriptors. RESULTS Experiments were conducted on 10 in-vivo TTTS videos from two different fetal surgery centers. The proposed framework was compared with several state-of-the-art approaches, achieving higher [Formula: see text] on 7 out of 10 videos and a success rate of [Formula: see text] in occlusion recovery. CONCLUSION This work introduces a learning-based framework for placental mosaicking with occlusion recovery from intra-operative videos using a keypoint-based strategy and features. The proposed framework can compute the placental panorama and recover even in case of camera tracking loss where other methods fail. The results suggest that the proposed framework has large potential to pave the way to creating a surgical navigation system for TTTS by providing robust field-of-view expansion.
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Affiliation(s)
- Alessandro Casella
- Department of Advanced Robotics, Istituto Italiano di Tecnologia, Genoa, Italy.
- Department of Electronic, Information and Bioengineering, Politecnico di Milano, Milan, Italy.
| | - Chiara Lena
- Department of Electronic, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Sara Moccia
- Department of Excellence in Robotics and AI, The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Dario Paladini
- Department of Fetal and Perinatal Medicine, Istituto Giannina Gaslini, Genoa, Italy
| | - Elena De Momi
- Department of Electronic, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Leonardo S Mattos
- Department of Advanced Robotics, Istituto Italiano di Tecnologia, Genoa, Italy
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Mikulski MF, Well A, Beckerman Z, Fraser CD, Bebbington MW, Moise KJ. Open and endoscopic fetal myelomeningocele surgeries display similar in-hospital safety profiles in a large, multi-institutional database. Am J Obstet Gynecol MFM 2023; 5:100854. [PMID: 36587805 DOI: 10.1016/j.ajogmf.2022.100854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Open intrauterine fetal myelomeningocele repair has demonstrated decreased ventriculoperitoneal shunting and improved motor outcomes despite maternal and fetal risks. Few data directly compare the safety of open vs endoscopic approaches. OBJECTIVE This study aimed to analyze in-hospital maternal and fetal outcomes of pregnant patients undergoing open vs endoscopic fetal myelomeningocele repair using a large, multi-center database. STUDY DESIGN This was a review of the Pediatric Health Information System database from October 1, 2015, to December 31, 2021. All patients who underwent open or endoscopic fetal myelomeningocele repair according to the International Classification of Diseases, Tenth Revision, were identified. Demographics, gestational age, and outcomes were analyzed. Descriptive and univariate statistics were used. RESULTS A total of 378 pregnant patients underwent fetal myelomeningocele repair. The approach was endoscopic in 143 cases (37.8%) and open in 235 cases (62.2%). Overall postprocedural outcomes included no maternal in-hospital mortalities or intensive care unit admissions, a median length of stay of 4 days (interquartile range, 4-5), 14 cases (3.7%) of surgical and postoperative complications, 6 cases (1.6%) of intrauterine infections, 12 cases (3.2%) of obstetrical complications (including preterm premature rupture of membranes), 3 cases (0.8%) of intrauterine fetal demise, and 16 cases (4.2%) of preterm delivery. Compared with an open approach, the endoscopic approach occurred at a later gestational age (25 weeks [interquartile range, 24-25] vs 24 weeks [interquartile range, 24-25]; P<.001) and had an increased rate of intrauterine infection (6 [4.2%] cases vs 0 [0%] case; P=.002). There was no difference between approaches in the rates of surgical complications, obstetrical complications, intrauterine fetal demise, or preterm deliveries. CONCLUSION Compared with an open approach, endoscopic fetal myelomeningocele repair displays a comparable rate of fetal complications, including intrauterine fetal demise and preterm delivery, and a similar in-hospital maternal safety profile despite an association with increased intrauterine infection.
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Affiliation(s)
- Matthew F Mikulski
- Departments of Surgery and Perioperative Care (Drs Mikulski, Well, Beckerman, and Fraser).
| | - Andrew Well
- Departments of Surgery and Perioperative Care (Drs Mikulski, Well, Beckerman, and Fraser)
| | - Ziv Beckerman
- Departments of Surgery and Perioperative Care (Drs Mikulski, Well, Beckerman, and Fraser); Department of Surgery, Duke University School of Medicine, Durham NC (Dr Beckerman)
| | - Charles D Fraser
- Departments of Surgery and Perioperative Care (Drs Mikulski, Well, Beckerman, and Fraser)
| | - Michael W Bebbington
- Women's Health (Drs Bebbington and Moise), The University of Texas at Austin Dell Medical School, Austin, TX
| | - Kenneth J Moise
- Women's Health (Drs Bebbington and Moise), The University of Texas at Austin Dell Medical School, Austin, TX
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Meuwese RT, Versteeg EM, van Drongelen J, de Hoog D, Bouwhuis D, Vandenbussche FP, van Kuppevelt TH, Daamen WF. A collagen plug with shape memory to seal iatrogenic fetal membrane defects after fetoscopic surgery. Bioact Mater 2023; 20:463-471. [PMID: 35800408 PMCID: PMC9249610 DOI: 10.1016/j.bioactmat.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 05/20/2022] [Accepted: 06/12/2022] [Indexed: 12/04/2022] Open
Abstract
Iatrogenic preterm premature rupture of fetal membranes (iPPROM) after fetal surgery remains a strong trigger for premature birth. As fetal membrane defects do not heal spontaneously and amniotic fluid leakage and chorioamniotic membrane separation may occur, we developed a biocompatible, fetoscopically-applicable collagen plug with shape memory to prevent leakage. This plug expands directly upon employment and seals fetal membranes, hence preventing amniotic fluid leakage and potentially iPPROM. Lyophilized type I collagen plugs were given shape memory and crimped to fit through a fetoscopic cannula (Ø 3 mm). Expansion of the plug was examined in phosphate buffered saline (PBS). Its sealing capacity was studied ex vivo using human fetal membranes, and in situ in a porcine bladder model. The crimped plug with shape memory expanded and tripled in diameter within 1 min when placed into PBS, whereas a crimped plug without shape memory did not. In both human fetal membranes and porcine bladder, the plug expanded in the defect, secured itself and sealed the defect without membrane rupture. In conclusion, collagen plugs with shape memory are promising as medical device for rapid sealing of fetoscopic defects in fetal membranes at the endoscopic entry point. Shape memory can be given to collagen plugs to rapidly expand in aqueous fluids. Within 1 min in aqueous fluid, collagen plugs with shape memory triple in diameter. Collagen plugs with shape memory show potency to seal fetal membrane defects.
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8
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Olutoye OO, Joyeux L, King A, Belfort MA, Lee TC, Keswani SG. Minimally Invasive Fetal Surgery and the Next Frontier. Neoreviews 2023; 24:e67-e83. [PMID: 36720693 DOI: 10.1542/neo.24-2-e67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Most patients with congenital anomalies do not require prenatal intervention. Furthermore, many congenital anomalies requiring surgical intervention are treated adequately after birth. However, there is a subset of patients with congenital anomalies who will die before birth, shortly after birth, or experience severe postnatal complications without fetal surgery. Fetal surgery is unique in that an operation is performed on the fetus as well as the pregnant woman who does not receive any direct benefit from the surgery but rather lends herself to risks, such as hemorrhage, abruption, and preterm labor. The maternal risks involved with fetal surgery have limited the extent to which fetal interventions may be performed but have, in turn, led to technical innovations that have significantly advanced the field. This review will examine congenital abnormalities that can be treated with minimally invasive fetal surgery and introduce the next frontier of prenatal management of fetal surgical pathology.
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Affiliation(s)
- Oluyinka O Olutoye
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Luc Joyeux
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Michael A Belfort
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Timothy C Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Sundeep G Keswani
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
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Danzer E, Rintoul NE, van Meurs KP, Deprest J. Prenatal management of congenital diaphragmatic hernia. Semin Fetal Neonatal Med 2022; 27:101406. [PMID: 36456433 DOI: 10.1016/j.siny.2022.101406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Recently, two randomized controlled, prospective trials, the Tracheal Occlusion to Accelerate Lung Growth (TOTAL) trials, reported the outcomes on fetal endoluminal tracheal occlusion (FETO) for isolated left congenital diaphragmatic hernia (CDH). FETO significantly improved outcomes for severe hypoplasia. The effect in moderate cases, where the balloon was inserted later in pregnancy, did not reach significance. In a pooled analysis investigating the effect of the heterogeneity of the treatment effect by the time point of occlusion and severity, the difference may be explained by a difference in the duration of occlusion. Nevertheless, FETO carries a significant risk of preterm birth. The primary objective of this review is to provide an overview of the rationale for fetal intervention in CDH and the results of the randomized trials. The secondary objective is to discuss the technical aspects of FETO. Finally, recent developments of potential alternative fetal approaches will be highlighted.
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Affiliation(s)
- Enrico Danzer
- Stanford University School of Medicine and Lucile Packard Children's Hospital, Division of Neonatal and Developmental Medicine, Palo Alto, CA, USA; Division of Pediatric Surgery, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA.
| | - Natalie E Rintoul
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment and Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Krisa P van Meurs
- Stanford University School of Medicine and Lucile Packard Children's Hospital, Division of Neonatal and Developmental Medicine, Palo Alto, CA, USA
| | - Jan Deprest
- Academic Department Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium; Center for Surgical Technologies, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium; Department of Obstetrics and Gynecology, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium; Institute of Women's Health, University College London Hospitals, London, United Kingdom
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10
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The Rearing of Maternal-Fetal Surgery: The Maturation of a Field from Conception to Adulthood. Clin Perinatol 2022; 49:799-810. [PMID: 36328599 DOI: 10.1016/j.clp.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Maternal-fetal surgery is fraught with inherent controversy from within the medical community and general public. Despite these challenges, the field of maternal-fetal surgery evolved into an international enterprise. Carefully nurtured by pioneers with foresight and resilience, the field navigated ethical dilemmas with rigorous scientific methodology, collaboration, transparency, and accordance. These central pillars are consistent throughout the brief but momentous history of maternal-fetal surgery, serving as the catalyst for its success. The maturation of fetal intervention is an exemplar of technological innovation propelling clinical innovation, as well as a celebration of mastering the delicate balance between caution and optimism.
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Pechriggl E, Blumer M, Tubbs RS, Olewnik Ł, Konschake M, Fortélny R, Stofferin H, Honis HR, Quinones S, Maranillo E, Sanudo J. Embryology of the Abdominal Wall and Associated Malformations—A Review. Front Surg 2022; 9:891896. [PMID: 35874129 PMCID: PMC9300894 DOI: 10.3389/fsurg.2022.891896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/10/2022] [Indexed: 12/12/2022] Open
Abstract
In humans, the incidence of congenital defects of the intraembryonic celom and its associated structures has increased over recent decades. Surgical treatment of abdominal and diaphragmatic malformations resulting in congenital hernia requires deep knowledge of ventral body closure and the separation of the primary body cavities during embryogenesis. The correct development of both structures requires the coordinated and fine-tuned synergy of different anlagen, including a set of molecules governing those processes. They have mainly been investigated in a range of vertebrate species (e.g., mouse, birds, and fish), but studies of embryogenesis in humans are rather rare because samples are seldom available. Therefore, we have to deal with a large body of conflicting data concerning the formation of the abdominal wall and the etiology of diaphragmatic defects. This review summarizes the current state of knowledge and focuses on the histological and molecular events leading to the establishment of the abdominal and thoracic cavities in several vertebrate species. In chronological order, we start with the onset of gastrulation, continue with the establishment of the three-dimensional body shape, and end with the partition of body cavities. We also discuss well-known human etiologies.
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Affiliation(s)
- Elisabeth Pechriggl
- Institute of Clinical and Functional Anatomy, Medical University of Innsbruck (MUI), Innsbruck, Austria
| | - Michael Blumer
- Institute of Clinical and Functional Anatomy, Medical University of Innsbruck (MUI), Innsbruck, Austria
| | - R. Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, United States
- Department of Neurology, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, United States
- Department of Anatomical Sciences, St. George’s University, St. George’s, Grenada, West Indies
- Department of Structural & Cellular Biology, Tulane University School of Medicine, New Orleans, LA, United States
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, United States
- Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, LA, United States
- University of Queensland, Brisbane, Australia
| | - Łukasz Olewnik
- Department of Anatomical Dissection and Donation, Medical University of Lodz, Lodz, Poland
| | - Marko Konschake
- Institute of Clinical and Functional Anatomy, Medical University of Innsbruck (MUI), Innsbruck, Austria
- Correspondence: Marko Konschake
| | - René Fortélny
- Department of General, Visceral, and Oncological Surgery, Wilhelminenspital, Vienna, Austria
| | - Hannes Stofferin
- Institute of Clinical and Functional Anatomy, Medical University of Innsbruck (MUI), Innsbruck, Austria
| | - Hanne Rose Honis
- Institute of Clinical and Functional Anatomy, Medical University of Innsbruck (MUI), Innsbruck, Austria
| | - Sara Quinones
- Department of Anatomy and Embryology, School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Eva Maranillo
- Department of Anatomy and Embryology, School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - José Sanudo
- Department of Anatomy and Embryology, School of Medicine, Complutense University of Madrid, Madrid, Spain
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Deng J, Papageorghiou AT, Xie M. From dotted lines to fetal cardiology: the pioneering contribution of Xin-Fang Wang (1934-2021). ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:574-575. [PMID: 35195308 DOI: 10.1002/uog.24881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 02/14/2022] [Indexed: 06/14/2023]
Affiliation(s)
- J Deng
- Barts Heart Centre & University College London, London, UK
| | - A T Papageorghiou
- Founder Member, ISUOG China Task Force
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | - M Xie
- Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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13
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Cochius - den Otter S, Deprest JA, Storme L, Greenough A, Tibboel D. Challenges and Pitfalls: Performing Clinical Trials in Patients With Congenital Diaphragmatic Hernia. Front Pediatr 2022; 10:852843. [PMID: 35498783 PMCID: PMC9051320 DOI: 10.3389/fped.2022.852843] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/08/2022] [Indexed: 11/17/2022] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a rare developmental defect of the lungs and diaphragm, with substantial morbidity and mortality. Although internationally established treatment guidelines have been developed, most recommendations are still expert opinions. Trials in patients with CDH, more in particular randomized controlled trials, are rare. Only three multicenter trials in patients with CDH have been completed, which focused on fetoscopic tracheal occlusion and ventilation mode. Another four are currently recruiting, two with a focus on perinatal transition and two on the treatment of pulmonary hypertension. Herein, we discuss major challenges and pitfalls when performing a clinical trial in infants with CDH. It is essential to select the correct intervention and dose, select the appropriate population of CDH patients, and also define a relevant endpoint that allows a realistic duration and sample size. New statistical approaches might increase the feasibility of randomized controlled trials in patients with CDH. One should also timely perform the trial when there is still equipoise. But above all, awareness of policymakers for the relevance of investigator-initiated trials is essential for future clinical research in this rare disease.
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Affiliation(s)
- Suzan Cochius - den Otter
- Intensive Care and Department of Pediatric Surgery, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Jan A. Deprest
- Department of Obstetrics and Gynaecology, University Hospitals KU Leuven, Leuven, Belgium
- Academic Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Institute for Women's Health, University College London, London, United Kingdom
| | - Laurent Storme
- Metrics-Perinatal Environment and Health, University of Lille, Lille, France
- Department of Neonatology, Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
- Center of Rare Disease Congenital Diaphragmatic Hernia, Jeanne de Flandre Hospital, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Anne Greenough
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, United Kingdom
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
- The Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London, United Kingdom
- NIHR Biomedical Centre, Guy's and St Thomas NHS Foundation Trust and King's College London, London, United Kingdom
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC University Medical Center, Rotterdam, Netherlands
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Fulati A, Uto K, Iwanaga M, Watanabe M, Ebara M. Smart Shape-Memory Polymeric String for the Contraction of Blood Vessels in Fetal Surgery of Sacrococcygeal Teratoma. Adv Healthc Mater 2022; 11:e2200050. [PMID: 35385611 DOI: 10.1002/adhm.202200050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/01/2022] [Indexed: 12/19/2022]
Abstract
Shape-memory polymers (SMPs) are promising materials in numerous emerging biomedical applications owing to their unique shape-memory characteristics. However, simultaneous realization of high strength, toughness, stretchability while maintaining high shape fixity (Rf ) and shape recovery ratio (Rr ) remains a challenge that hinders their practical applications. Herein, a novel shape-memory polymeric string (SMP string) that is ultra-stretchable (up to 1570%), strong (up to 345 MPa), tough (up to 237.9 MJ m-3 ), and highly recoverable (Rf averagely above 99.5%, Rr averagely above 99.1%) through a facile approach fabricated solely by tetra-branched poly(ε-caprolactone) (PCL) is reported. Notably, the shape-memory contraction force (up to 7.97 N) of this SMP string is customizable with the manipulation of their energy storage capacity by adjusting the string thickness and stretchability. In addition, this SMP string displays a controllable shape-memory response time and demonstrates excellent shape-memory-induced contraction effect against both rigid silicone tubes and porcine carotids. This novel SMP string is envisioned to be applied in the contraction of blood vessels and resolves the difficulties in the restriction of blood flow in minimally invasive surgeries such as fetoscopic surgery of sacrococcygeal teratoma (SCT).
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Affiliation(s)
- Ailifeire Fulati
- Research Center for Functional Materials National Institute for Materials Science Tsukuba 3050044 Japan
- Graduate School of Science and Technology University of Tsukuba Tsukuba 3058577 Japan
| | - Koichiro Uto
- Research Center for Functional Materials National Institute for Materials Science Tsukuba 3050044 Japan
| | - Masanobu Iwanaga
- Research Center for Functional Materials National Institute for Materials Science Tsukuba 3050044 Japan
| | - Miho Watanabe
- Department of Pediatric Surgery Graduate School of Medicine Osaka University Osaka 5650871 Japan
| | - Mitsuhiro Ebara
- Research Center for Functional Materials National Institute for Materials Science Tsukuba 3050044 Japan
- Graduate School of Science and Technology University of Tsukuba Tsukuba 3058577 Japan
- Graduate School of Advanced Engineering Tokyo University of Science Tokyo 1258585 Japan
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Filho J, Xavier J, Nunes L. An Alternative Digital Image Correlation-Based Experimental Approach to Estimate Fracture Parameters in Fibrous Soft Materials. MATERIALS 2022; 15:ma15072413. [PMID: 35407748 PMCID: PMC8999918 DOI: 10.3390/ma15072413] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 03/22/2022] [Accepted: 03/23/2022] [Indexed: 11/16/2022]
Abstract
One of the main challenges in experimental fracture mechanics is to correctly estimate fracture parameters of a nonhomogeneous and nonlinear material under large deformation. The crack tip detection is strongly affected by fibers at crack tip, leading to inaccurate measures. To overcome this limitation, a novel methodology based on the Digital Image Correlation (DIC) method for crack tip detection of fibrous soft composites is proposed in this work. The unidirectional composite was manufactured using a matrix of polydimethylsiloxane reinforced with a single layer of extensible cotton knit fabric. For two different fiber orientations, the crack growth (da), Crack Tip Opening Displacement (CTOD) and Crack Tip Opening Angle (CTOA) were determined using pure shear specimens under mode I fracture. A consistent estimation of fracture parameters was obtained. The location of the crack tip position during the fracture test using the DIC-based methodology was validated against a visual inspection approach. Results indicated that the DIC-based methodology is easily replicable, precise and robust.
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Affiliation(s)
- João Filho
- Laboratory of Opto-Mechanics (LOM), Department of Mechanical Engineering (PGMEC-TEM), Universidade Federal Fluminense (UFF), Rua Passo da Pátria, 156, Bloco E, Sala 210, Rio de Janeiro 24210-240, Brazil;
- Correspondence: (J.F.); (J.X.)
| | - José Xavier
- Research and Development Unit for Mechanical and Industrial Engineering (UNIDEMI), Department of Mechanical and Industrial Engineering, NOVA School of Science and Technology, NOVA University Lisbon, 2825-149 Lisbon, Portugal
- Correspondence: (J.F.); (J.X.)
| | - Luiz Nunes
- Laboratory of Opto-Mechanics (LOM), Department of Mechanical Engineering (PGMEC-TEM), Universidade Federal Fluminense (UFF), Rua Passo da Pátria, 156, Bloco E, Sala 210, Rio de Janeiro 24210-240, Brazil;
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16
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Russo F, Benachi A, Gratacos E, Zani A, Keijzer R, Partridge E, Sananes N, De Coppi P, Aertsen M, Nicolaides KH, Deprest J. Antenatal Management of Congenital Diaphragmatic Hernia: what's next ? Prenat Diagn 2022; 42:291-300. [PMID: 35199368 DOI: 10.1002/pd.6120] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/19/2022] [Accepted: 02/20/2022] [Indexed: 11/07/2022]
Abstract
Congenital diaphragmatic hernia (CDH) can be diagnosed in the prenatal period and its severity can be measured by fetal imaging. There is now level I evidence that, in selected cases, Fetoscopic Endoluminal Tracheal Occlusion (FETO) increases survival to discharge from the neonatal unit as well as the risk for prematurity. Both effects are dependent on the time point of tracheal occlusion. FETO may also lead to iatrogenic death when done in unexperienced centres. The implementation of the findings from our clinical studies, may also vary based on local conditions. These may be different in terms of available skill set, access to fetal therapy, as well as outcome based on local neonatal management. We encourage prior benchmarking of local outcomes with optimal postnatal management, based on large enough numbers and using identical criteria as in the recent trials. We propose to work further on prenatal prediction methods, and the improvement of fetal intervention. In this manuscript, we describe a research agenda from a fetal medicine perspective. This research should be in parallel with innovation in neonatal and pediatric (surgical) management of this condition. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Francesca Russo
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven and Clinical Department of Obstetrics and Gynaecology, UZ Leuven, Leuven, Belgium
| | - Alexandra Benachi
- Department of Obstetrics and Gynaecology, Hospital Antoine Béclère, Université Paris Saclay, Clamart, France
| | | | - Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Richard Keijzer
- Department of Pediatric Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Emily Partridge
- Department of Pediatric Surgery, Children's Hospital of Philadelphia, PA, USA
| | - Nicolas Sananes
- Department Obstetrics and Gynaecology, University Hospitals Strasbourg, Strasbourg, France
| | | | - Michael Aertsen
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | | | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven and Clinical Department of Obstetrics and Gynaecology, UZ Leuven, Leuven, Belgium.,Institute of Women's Health, University College London, London, United Kingdom
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17
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BÜYÜKFIRAT E, DEMİR A, DÖRTERLER ME, GÜNENDİ T. Etiology and Mortality Investigation in Neonates that Underwent Surgery. KONURALP TIP DERGISI 2022. [DOI: 10.18521/ktd.1024822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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18
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Deprest J, Flake A. How should fetal surgery for congenital diaphragmatic hernia be implemented in the post-TOTAL trial era: a discussion . Prenat Diagn 2022; 42:301-309. [PMID: 35032132 DOI: 10.1002/pd.6091] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/08/2022] [Accepted: 01/10/2022] [Indexed: 11/07/2022]
Abstract
Following prenatal diagnosis of congenital diaphragmatic hernia, severity can be predicted based on the presence of associated abnormalities, and in isolated cases, on lung size and position of the liver. Severe hypoplasia is defined by a contralateral lung size < 25% on ultrasound; moderate hypoplasia is when that lung measures between 25 and 45% of the normal. In fetuses with predicted poor postnatal outcome a procedure that reverses pulmonary hypoplasia may be considered. In uncontrolled studies, fetoscopic endoluminal tracheal occlusion (FETO) improved neonatal outcome. Recently, two randomized controlled trials compared the neonatal and infant outcomes in fetuses with isolated CDH (www.totaltrial.eu). In severe cases, FETO was carried out at 27+0 -29+6 weeks' gestation (referred to as "early") and in moderate at 30+0 -31+6 weeks ("late"). Survival to discharge from the neonatal intensive care unit increased by 25% (95%-CI:+6 - +46; P=.0091) and 13% (-1 - +28; P=.059), in fetuses with severe and moderate cases, respectively. Following FETO gestational age at delivery was on average 3.2 (2.3-4.1) weeks earlier following early and 1.7 (1.1 - 2.3) following late FETO. Here the strengths and weaknesses of the TOTAL trials and their translation to the clinic are debated. Discussants are the lead for the trial (JD) and a colleague (AF) not involved. The discussant notes that the observed survival, both in treated and expectantly managed fetuses, was overall less than what is reported by some high volume centers, particularly in North America. Additional criticisms are the potential effects of prematurity on the long term, the inclusion of low-volume centers, and the potential of FETO for severe iatrogenic complications. Therefore results may not be generalizable. The discussants concluded that although FETO may have its value it remains a procedure with a high risk for prematurity and it can be lethal when the balloon cannot be removed prior to delivery. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven and Clinical Department of Obstetrics and Gynaecology, UZ Leuven, Leuven, Belgium
| | - Alan Flake
- Department of Pediatric Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Gonser M, Vonzun L, Kandler L, Ochsenbein-Kölble N. Fetal circulatory redistribution during open spina bifida repair: can loss or reversal of end-diastolic umbilical artery flow be avoided? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:130-131. [PMID: 34985819 DOI: 10.1002/uog.24822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/02/2021] [Indexed: 06/14/2023]
Affiliation(s)
- M Gonser
- Prenatal Medicine & Sonography, Wiesbaden, Germany
- Department of Obstetrics and Prenatal Medicine, Helios-HSK Kliniken Wiesbaden, Wiesbaden, Germany
| | - L Vonzun
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - L Kandler
- University of Zurich, Zurich, Switzerland
- Department of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - N Ochsenbein-Kölble
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
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20
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Avilla-Royo E, Ochsenbein-Kölble N, Vonzun L, Ehrbar M. Biomaterial-based treatments for the prevention of preterm birth after iatrogenic rupture of the fetal membranes. Biomater Sci 2022; 10:3695-3715. [DOI: 10.1039/d2bm00401a] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Minimally invasive interventions to ameliorate or correct fetal abnormalities are becoming a clinical reality. However, the iatrogenic premature preterm rupture of the fetal membranes (FMs) (iPPROM), which may result in...
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Joyeux L, Belfort MA, De Coppi P, Basurto D, Valenzuela I, King A, De Catte L, Shamshirsaz AA, Deprest J, Keswani SG. Complex gastroschisis: a new indication for fetal surgery? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:804-812. [PMID: 34468062 DOI: 10.1002/uog.24759] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/16/2021] [Accepted: 08/19/2021] [Indexed: 06/13/2023]
Abstract
Gastroschisis (GS) is a congenital abdominal wall defect, in which the bowel eviscerates from the abdominal cavity. It is a non-lethal isolated anomaly and its pathogenesis is hypothesized to occur as a result of two hits: primary rupture of the 'physiological' umbilical hernia (congenital anomaly) followed by progressive damage of the eviscerated bowel (secondary injury). The second hit is thought to be caused by a combination of mesenteric ischemia from constriction in the abdominal wall defect and prolonged amniotic fluid exposure with resultant inflammatory damage, which eventually leads to bowel dysfunction and complications. GS can be classified as either simple or complex, with the latter being complicated by a combination of intestinal atresia, stenosis, perforation, volvulus and/or necrosis. Complex GS requires multiple neonatal surgeries and is associated with significantly greater postnatal morbidity and mortality than is simple GS. The intrauterine reduction of the eviscerated bowel before irreversible damage occurs and subsequent defect closure may diminish or potentially prevent the bowel damage and other fetal and neonatal complications associated with this condition. Serial prenatal amnioexchange has been studied in cases with GS as a potential intervention but never adopted because of its unproven benefit in terms of survival and bowel and lung function. We believe that recent advances in prenatal diagnosis and fetoscopic surgery justify reconsideration of the antenatal management of complex GS under the rubric of the criteria for fetal surgery established by the International Fetal Medicine and Surgery Society (IFMSS). Herein, we discuss how conditions for fetoscopic repair of complex GS might be favorable according to the IFMSS criteria, including an established natural history, an accurate prenatal diagnosis, absence of fully effective perinatal treatment due to prolonged need for neonatal intensive care, experimental evidence for fetoscopic repair and maternal and fetal safety of fetoscopy in expert fetal centers. Finally, we propose a research agenda that will help overcome barriers to progress and provide a pathway toward clinical implementation. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- L Joyeux
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Woman and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
- Department of Pediatric Surgery, Queen Fabiola Children's University Hospital, Brussels, Belgium
- Michael E. DeBakey Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - M A Belfort
- Michael E. DeBakey Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- Department of Obstetrics and Gynecology, Division Maternal-Fetal Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- Texas Children's Fetal Center, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - P De Coppi
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Woman and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
- Specialist Neonatal and Paediatric Surgery Unit and NIHR Biomedical Research Center, Great Ormond Street Hospital, and Great Ormond Street Institute of Child Health, University College London, London, UK
| | - D Basurto
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Woman and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
| | - I Valenzuela
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - A King
- Michael E. DeBakey Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- Texas Children's Fetal Center, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - L De Catte
- Department of Obstetrics and Gynecology, Division Woman and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
| | - A A Shamshirsaz
- Michael E. DeBakey Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- Department of Obstetrics and Gynecology, Division Maternal-Fetal Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- Texas Children's Fetal Center, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - J Deprest
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Woman and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
- Institute of Women's Health, University College London Hospitals, London, UK
| | - S G Keswani
- Michael E. DeBakey Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- Texas Children's Fetal Center, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
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22
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Devroe S, Van der Veeken L, Bleeser T, Van der Merwe J, Meeusen R, Van de Velde M, Deprest J, Rex S. The effect of xenon on fetal neurodevelopment following maternal sevoflurane anesthesia and laparotomy in rabbits. Neurotoxicol Teratol 2021; 87:106994. [PMID: 33961970 DOI: 10.1016/j.ntt.2021.106994] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 04/29/2021] [Accepted: 04/29/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND There is concern that maternal anesthesia during pregnancy impairs brain development of the human fetus. Xenon is neuroprotective in pre-clinical models of anesthesia-induced neurotoxicity in neonates. It is not known if xenon also protects the developing fetal brain when administered in addition to maternal sevoflurane-anesthesia during pregnancy. OBJECTIVE To investigate the effects of sevoflurane and xenon on neurobehaviour and neurodevelopment of the offspring in a pregnant rabbit model. METHODS Pregnant rabbits on post-conception day 28 (term = 31d) underwent two hours of general anesthesia with 1 minimum alveolar concentration (MAC) of sevoflurane in 30% oxygen (n = 17) or 1 MAC sevoflurane plus 50-60 % xenon in 30% oxygen (n = 10) during a standardized laparotomy while receiving physiological monitoring. A sham-group (n = 11) underwent monitoring alone for two hours. At term, the rabbits were delivered by caesarean section. On the first postnatal day, neonatal rabbits underwent neurobehavioral assessment using a validated test battery. Following euthanasia, the brains were harvested for neurohistological analysis. A mixed effects-model was used for statistical analysis. RESULTS Maternal cardiopulmonary parameters during anesthesia were within the reference range. Fetal survival rates were significantly higher in the sham-group as compared to the sevoflurane-group and the fetal brain/body weight ratio was significantly lower in the sevoflurane-group as compared with the sham- and xenon-group. Pups antenatally exposed to anesthesia had significantly lower motor and sensory neurobehavioral scores when compared to the sham-group (mean ± SD; sevo: 22.70 ± 3.50 vs. sevo+xenon: 22.74 ± 3.15 vs. sham: 24.37 ± 1.59; overall p = 0.003; sevo: 14.98 ± 3.00 vs. sevo+xenon: 14.80 ± 2.83 vs. sham: 16.43 ± 2.63; overall p = 0.006; respectively). Neuron density, neuronal proliferation and synaptic density were reduced in multiple brain regions of the exposed neonates. The co-administration of xenon had no measurable neuroprotective effects in this model. CONCLUSIONS In rabbits, sevoflurane anesthesia for a standardized laparotomy during pregnancy resulted in impaired neonatal neurobehavior and a decreased neuron count in several regions of the neonatal rabbit brain. Co-administration of xenon did not prevent this effect.
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Affiliation(s)
- Sarah Devroe
- Department of Anesthesiology, University Hospitals of the KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Lennart Van der Veeken
- Department of Obstetrics and Gynecology, University Hospitals of the KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Tom Bleeser
- Department of Anesthesiology, University Hospitals of the KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Johannes Van der Merwe
- Department of Obstetrics and Gynecology, University Hospitals of the KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Roselien Meeusen
- Department of Anesthesiology, University Hospitals of the KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Marc Van de Velde
- Department of Anesthesiology, University Hospitals of the KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Jan Deprest
- Department of Obstetrics and Gynecology, University Hospitals of the KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Institute for Women's Health, University College London, London, UK; King's College University, BMEIS School, Interventional Image Computing, London, UK.
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals of the KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
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23
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Fung ACH, Kan ASY, Chung PH, Shek NWM, Chan IHY, Wong KKY. Antenatal counselling of congenital surgical anomalies: A decade of experience in a local tertiary centre. J Paediatr Child Health 2021; 57:710-714. [PMID: 33400340 DOI: 10.1111/jpc.15321] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/27/2020] [Accepted: 12/08/2020] [Indexed: 11/28/2022]
Abstract
AIM This study reviewed the experience of a tertiary paediatric surgery and obstetric centre on prenatal counselling of congenital surgical anomalies and to explore the role of paediatric surgeons on perinatal outcomes of antenatally detected anomalies. METHODS A retrospective analysis of all antenatal consultations and subsequent medical records after birth were performed between 2009 and 2018. Data including timing of consultations, gestations at birth, birthweight, impact on obstetrics management, neonatal mortality and need of surgery were included. RESULTS A total of 256 fetuses were diagnosed to have congenital surgical anomalies on antenatal ultrasound. The most common were urogenital (31%) and thoracic (30%) anomalies. Twelve of the 256 (4.7%) had multiple anomalies. The mean gestation at referral was 23 ± 5 weeks. The majority (85.4%) were born at term. Mode and timing of delivery was altered in 7% of patients. Four received fetal intervention after surgical consultation. Termination of pregnancy rate was 5.4% (n = 14). Neonatal death was reported in 7.8% of the cohort. CONCLUSION Congenital surgical anomalies had a significant impact on perinatal outcome as well as morbidity in later infancy and childhood. A multidisciplinary approach in managing pregnancy with these anomalies should be implemented. Combined-specialty consultations and counselling deliver valuable information for parents.
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Affiliation(s)
| | - Anita Sik Yau Kan
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, Hong Kong, China
| | - Patrick Hy Chung
- Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Noel Wing Man Shek
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, Hong Kong, China
| | - Ivy Hau Yee Chan
- Department of Surgery, The University of Hong Kong, Hong Kong, China
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24
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Evans LL, Harrison MR. Modern fetal surgery-a historical review of the happenings that shaped modern fetal surgery and its practices. Transl Pediatr 2021; 10:1401-1417. [PMID: 34189101 PMCID: PMC8192985 DOI: 10.21037/tp-20-114] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The history of fetal surgery is one of constant evolution. Over the last 50 years, fetal surgery has progressed from a mere idea to an internationally respected innovative field of surgery. This article aims to provide a historical review of how the enterprise of maternal-fetal surgery came to be its modern version. This review is less focused on the history of specific therapies for a relatively small number of conditions, and more on how the whole field of maternal-fetal surgery evolved. The various internal and external influences that steered the field's evolution are discussed in chronologic order. Since the start of modern fetal surgery in the 1980s, large paradigm shifts have characterized the growth of the field as a whole. Innovative interventions are now based on physiologic manipulation as opposed to simple anatomic repair, fetoscopy has become the more frequently preferred surgical approach, and rigorous scientific evaluation with randomized controlled trials is now the standard expected by the community. In a very similar fashion to when the field first began in the early 1980s, recently community's leaders have risen to protect the integrity of maternal-fetal surgery by publishing ethical guidelines for innovation and clinical practice. This incredible history of innovation, rigorous science and ethical contemplation is the foundation on which modern maternal-fetal surgery rests.
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Affiliation(s)
- Lauren L Evans
- Department of Surgery, Division of Pediatric Surgery, University of California, San Francisco, CA, USA
| | - Michael R Harrison
- Department of Surgery, Division of Pediatric Surgery, University of California, San Francisco, CA, USA
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25
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Wood CL, Zuk J, Rollins MD, Silveira LJ, Feiner JR, Zaretsky M, Chatterjee D. Anesthesia for Maternal-Fetal Interventions: A Survey of Fetal Therapy Centers in the North American Fetal Therapy Network. Fetal Diagn Ther 2021; 48:361-371. [PMID: 33827094 DOI: 10.1159/000514897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 01/31/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION A wide range of fetal interventions are performed across fetal therapy centers (FTCs). We hypothesized that there is significant variability in anesthesia staffing and anesthetic techniques. METHODS We conducted an online survey of anesthesiology directors at every FTC within the North American Fetal Therapy Network (NAFTNet). The survey included details of fetal interventions performed in 2018, anesthesia staffing models, anesthetic techniques, fetal monitoring, and postoperative management. RESULTS There was a 92% response rate. Most FTCs are located within an adult hospital and employ a small team of anesthesiologists. There is heterogeneity when evaluating anesthesiology fellowship training and staffing, indicating there is a multidisciplinary specialty team-based approach even within anesthesiology. Minimally invasive fetal interventions were the most commonly performed. The majority of FTCs also performed ex utero intrapartum treatment (EXIT) and open mid-gestation procedures under general anesthesia (GA). Compared to FTCs only performing minimally invasive procedures, FTCs performing open fetal procedures were more likely to have a pediatric surgeon as director and performed more minimally invasive procedures. CONCLUSIONS There is considerable variability in anesthesia staffing, caseload, and anesthetic techniques among FTCs in NAFTNet. Most FTCs used maternal sedation for minimally invasive procedures and GA for EXIT and open fetal surgeries.
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Affiliation(s)
- Cristina L Wood
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jeannie Zuk
- Department of Surgery, Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Mark D Rollins
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Lori J Silveira
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - John R Feiner
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Michael Zaretsky
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Colorado Fetal Care Center, Aurora, Colorado, USA
| | - Debnath Chatterjee
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
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26
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Anesthesia for Maternal-Fetal Interventions: A Consensus Statement From the American Society of Anesthesiologists Committees on Obstetric and Pediatric Anesthesiology and the North American Fetal Therapy Network. Anesth Analg 2021; 132:1164-1173. [PMID: 33048913 DOI: 10.1213/ane.0000000000005177] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Maternal-fetal surgery is a rapidly evolving specialty, and significant progress has been made over the last 3 decades. A wide range of maternal-fetal interventions are being performed at different stages of pregnancy across multiple fetal therapy centers worldwide, and the anesthetic technique has evolved over the years. The American Society of Anesthesiologists (ASA) recognizes the important role of the anesthesiologist in the multidisciplinary approach to these maternal-fetal interventions and convened a collaborative workgroup with representatives from the ASA Committees of Obstetric and Pediatric Anesthesia and the Board of Directors of the North American Fetal Therapy Network. This consensus statement describes the comprehensive preoperative evaluation, intraoperative anesthetic management, and postoperative care for the different types of maternal-fetal interventions.
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27
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Basurto D, Sananès N, Bleeser T, Valenzuela I, De Leon N, Joyeux L, Verbeken E, Vergote S, Van Der Veeken L, Russo FM, Deprest J. Safety and efficacy of smart tracheal occlusion device in diaphragmatic hernia lamb model. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:105-112. [PMID: 33012007 PMCID: PMC7613565 DOI: 10.1002/uog.23135] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/15/2020] [Accepted: 09/18/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To investigate the efficacy and safety of the 'smart' tracheal occlusion (Smart-TO) device in fetal lambs with diaphragmatic hernia (DH). METHODS DH was created in fetal lambs on gestational day 70 (term, 145 days). Fetuses were allocated to either pregnancy continuation until term (DH group) or fetoscopic endoluminal tracheal occlusion (TO), performed using the Smart-TO balloon on gestational day 97 (DH + TO group). On gestational day 116, the presence of the balloon was confirmed on ultrasound, then the ewe was walked around a 3.0-Tesla magnetic resonance scanner for balloon deflation, which was confirmed by ultrasound immediately afterwards. At term, euthanasia was performed and the fetus retrieved. Efficacy of occlusion was assessed by the lung-to-body-weight ratio (LBWR) and lung morphometry. Safety parameters included tracheal side effects assessed by morphometry and balloon location after deflation. The unoccluded DH lambs served as a comparator. RESULTS Six fetuses were included in the DH group and seven in the DH + TO group. All balloons deflated successfully and were expelled spontaneously from the airways. In the DH + TO group, in comparison to controls, the LBWR at birth was significantly higher (1.90 (interquartile range (IQR), 1.43-2.55) vs 1.07 (IQR, 0.93-1.46); P = 0.005), while on lung morphometry, the alveolar size was significantly increased (mean linear intercept, 47.5 (IQR, 45.6-48.1) vs 41.9 (IQR, 38.8-46.1) μm; P = 0.03); whereas airway complexity was lower (mean terminal bronchiolar density, 1.56 (IQR, 1.0-1.81) vs 2.23 (IQR, 2.14-2.40) br/mm2 ; P = 0.005). Tracheal changes on histology were minimal in both groups, but more noticeable in fetal lambs that underwent TO than in unoccluded lambs (tracheal score, 2 (IQR, 1-3) vs 0 (0-1); P = 0.03). CONCLUSIONS In fetal lambs with DH, TO using the Smart-TO balloon is effective and safe. Occlusion can be reversed non-invasively and the deflated intact balloon expelled spontaneously from the fetal upper airways. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- D. Basurto
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - N. Sananès
- INSERM 1121 Biomaterials and Bioengineering, Strasbourg University, Strasbourg, France
- Department of Maternal-Fetal Medicine, Strasbourg University Hospital, Strasbourg, France
| | - T. Bleeser
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - I. Valenzuela
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - N. De Leon
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - L. Joyeux
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - E. Verbeken
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - S. Vergote
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - L. Van Der Veeken
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - F. M. Russo
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - J. Deprest
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Institute for Women’s Health, University College London, London, UK
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Chitty LS, Ghidini A, Deprest J, Van Mieghem T, Levy B, Hui L, Bianchi DW. Right or wrong? Looking through the retrospectoscope to analyse predictions made a decade ago in prenatal diagnosis and fetal surgery. Prenat Diagn 2020; 40:1627-1635. [PMID: 33231306 DOI: 10.1002/pd.5870] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 11/21/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Lyn S Chitty
- North Thames Genomic Laboratory Hub, Great Ormond Street NHS Foundation Trust, London, UK.,UCL Great Ormond Street Institute of Child Health, London, UK
| | - Alessandro Ghidini
- Department of Obstetrics and Gynecology, Georgetown University Hospital, Washington, DC.,Antenatal Testing Center, Inova Alexandria Hospital, Alexandria, VA
| | - Jan Deprest
- Department of Obstetrics and Gynaecology, University of Leuven, Leuven, Belgium and the Institute for Women's Health, UCL, London
| | - Tim Van Mieghem
- Fetal Medicine Unit and Ontario Fetal Centre, Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Brynn Levy
- Division of Personalized Genomic Medicine, Columbia University Medical Center & the New York Presbyterian Hospital, New York, New York, USA
| | - Lisa Hui
- Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia.,Mercy Hospital for Women, Heidelberg, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia.,The Northern Hospital, Epping, Victoria, Australia
| | - Diana W Bianchi
- Division of Prenatal Genomics and Fetal Therapy, Medical Genomics and Metabolic Genetics Branch, National Human Genome Institute, National Human Genome Institute, National Institutes of Health, Bethesda, Maryland, USA
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29
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Sharma D, Tsibizova VI. Current perspective and scope of fetal therapy: part 1. J Matern Fetal Neonatal Med 2020; 35:3783-3811. [PMID: 33135508 DOI: 10.1080/14767058.2020.1839880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Fetal therapy term has been described for any therapeutic intervention either invasive or noninvasive for the purpose of correcting or treating any fetal malformation or condition. Fetal therapy is a rapidly evolving specialty and has gained pace in last two decades and now fetal intervention is being tried in many malformations with rate of success varying with the type of different fetal conditions. The advances in imaging techniques have allowed fetal medicine persons to make earlier and accurate diagnosis of numerous fetal anomalies. Still many fetal anomalies are managed postnatally because the fetal outcomes have not changed significantly with the use of fetal therapy and this approach avoids unnecessary maternal risk secondary to inutero intervention. The short-term maternal risk associated with fetal surgery includes preterm labor, premature rupture of membranes, uterine wall bleeding, chorioamniotic separation, placental abruption, chorioamnionitis, and anesthesia risk. Whereas, maternal long-term complications include risk of infertility, uterine rupture, and need for cesarean section in future pregnancies. The decision for invasive fetal therapy should be taken after discussion with parents about the various aspects like postnatal fetal outcome without fetal intervention, possible outcome if the fetal intervention is done, available postnatal intervention for the fetal condition, and possible short-term and long-term maternal complications. The center where fetal intervention is done should have facility of multi-disciplinary team to manage both maternal and fetal complications. The major issues in the development of fetal surgery include selection of patient for intervention, crafting effective fetal surgical skills, requirement of regular fetal and uterine monitoring, effective tocolysis, and minimizing fetal and maternal fetal risks. This review will cover the surgical or invasive aspect of fetal therapy with available evidence and will highlight the progress made in the management of fetal malformations in last two decades.
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Affiliation(s)
- Deepak Sharma
- Department of Neonatology, National Institute of Medical Science, Jaipur, India
| | - Valentina I Tsibizova
- Almazov National Medical Research Centre, Health Ministry of Russian Federation, Saint Petersburg, Russia
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30
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Perrone EE, Galganski LA, Tarantal AF, Olstad KJ, Treadwell MC, Berman DR, Jarboe MD, Mychaliska GB, Farmer DL. Fetal Surgery in the Primate 4.0: A New Technique 30 Years Later. Fetal Diagn Ther 2020; 48:43-49. [PMID: 33108788 DOI: 10.1159/000511355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 09/02/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Open fetal surgery requires a hemostatic hysterotomy that minimizes membrane separation. For over 30 years, the standard of care for hysterotomy in the gravid uterus has been the AutoSuture Premium Poly CS*-57 stapler. OBJECTIVE In this study, we sought to test the feasibility of hysterotomy in a rhesus monkey model with the Harmonic ACE®+7 Shears. METHODS A gravid rhesus monkey underwent midgestation hysterotomy at approximately 90 days of gestation (2nd trimester; term = 165 ± 10 days) using the Harmonic ACE®+7 Shears. A two-layer uterine closure was completed and the dam was monitored by ultrasound intermittently throughout the pregnancy. At 58 days after hysterotomy (near term), a final surgery was performed to evaluate the uterus and hysterotomy site. RESULTS A 3.5-cm hysterotomy was completed in 2 min 7 s. The opening was hemostatic and the membranes were sealed. Immediately after closure and throughout the pregnancy, ultrasound revealed intact membranes without separation and normal amniotic fluid levels. At term, the scar was well healed without signs of thinning or dehiscence. CONCLUSIONS The Harmonic ACE®+7 Shears produced a hemostatic midgestation hysterotomy with membrane sealing in the rhesus monkey model. Importantly, healing was acceptable.
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Affiliation(s)
- Erin E Perrone
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA, .,Fetal Diagnosis and Treatment Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA,
| | - Laura A Galganski
- Department of Surgery, UC Davis Children's Hospital, University of California, Davis, Sacramento, California, USA
| | - Alice F Tarantal
- Departments of Pediatrics and Cell Biology and Human Anatomy, School of Medicine, and California National Primate Research Center, University of California, Davis, California, USA
| | - Katie J Olstad
- Laboratory Animal Pathology, California National Primate Research Center, University of California, Davis, California, USA
| | - Marjorie C Treadwell
- Fetal Diagnosis and Treatment Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, C.S. Mott Children's Hospital and Von Voigtlander Women's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Deborah R Berman
- Fetal Diagnosis and Treatment Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, C.S. Mott Children's Hospital and Von Voigtlander Women's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Marcus D Jarboe
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Fetal Diagnosis and Treatment Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - George B Mychaliska
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Fetal Diagnosis and Treatment Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Diana L Farmer
- Department of Surgery, UC Davis Children's Hospital, University of California, Davis, Sacramento, California, USA.,Fetal Care and Treatment Center, University of California, Davis, Davis, California, USA
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Luks FI, Collins S, Xia J, Cao SA, Rios M. Combination of volume-rendering 3D surface modeling and medical illustration to capture the living fetus. Prenat Diagn 2020; 41:79-88. [PMID: 33058179 DOI: 10.1002/pd.5844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 09/21/2020] [Accepted: 10/11/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE A good medical illustration renders essential aspects of a procedure or condition faithfully, yet idealizes it enough to make it widely applicable. Unfortunately, the live fetus is generally hidden from sight, and illustrating it relies either on autopsy material or manipulated newborn images. High-definition volume rendering of diagnostic imaging data can represent hidden conditions with an almost lifelike realism but is limited by the resolution and artifacts of the data capture. We have combined both approaches to enhance the accuracy and didactic value of illustrations of fetal conditions. METHODS Three examples, of increasing complexity, are presented to demonstrate the creation of medical illustrations of the fetus based on semiautomatic computerized posthoc manipulation of diagnostic images. RESULTS The end product utilizes the diagnostic accuracy of ultrasound and magnetic resonance imaging of the fetuses and the spatial manipulation of 3D models to create a lifelike, accurate and informative image of the fetal anomalies. CONCLUSION Volume-rendering and 3D surface modeling can be combined with medical illustration to create realistic and informative images of the developing fetus, using a level of detail that is tailored to the intended audience.
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Affiliation(s)
- Francois I Luks
- Division of Pediatric Surgery, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA.,Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Scott Collins
- Department of Diagnostic Imaging, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jimmy Xia
- Brown University, Providence, Rhode Island, USA
| | - Shiliang Alice Cao
- Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Matthew Rios
- Rhode Island School of Design, Providence, Rhode Island, USA
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32
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Deprest J. Prenatal treatment of severe congenital diaphragmatic hernia: there is still medical equipoise. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:493-497. [PMID: 33001496 DOI: 10.1002/uog.22182] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/08/2020] [Accepted: 06/26/2020] [Indexed: 06/11/2023]
Affiliation(s)
- J Deprest
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Academic Department Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Institute for Woman's Health, University College London, London, UK
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33
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Basurto D, Sananès N, Verbeken E, Sharma D, Corno E, Valenzuela I, Van der Veeken L, Favre R, Russo FM, Deprest J. New device permitting non-invasive reversal of fetal endoscopic tracheal occlusion: ex-vivo and in-vivo study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:522-531. [PMID: 32602968 DOI: 10.1002/uog.22132] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/05/2020] [Accepted: 06/19/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE One of the drawbacks of fetal endoscopic tracheal occlusion (FETO) for congenital diaphragmatic hernia is the need for a second invasive intervention to re-establish airway patency. The 'Smart-TO' device is a new balloon for FETO that deflates spontaneously when placed in a strong magnetic field, therefore overcoming the need for a second procedure. The safety and efficacy of this device have not yet been demonstrated. The aim of this study was to investigate the reversibility, local side effects and occlusiveness of the Smart-TO balloon, both in a simulated in-utero environment and in the fetal lamb model. METHODS First, the reversibility of tracheal occlusion by the Smart-TO balloon was tested in a high-fidelity simulator. Following videoscopic tracheoscopic balloon insertion, the fetal mannequin was placed within a 1-L water-filled balloon to mimic the amniotic cavity. This was held by an operator in front of their abdomen, and different fetal and maternal positions were simulated to mimic the most common clinical scenarios. Following exposure to the magnetic field generated by a 1.5-T magnetic resonance (MR) machine, deflation of the Smart-TO balloon was assessed by tracheoscopy. In cases of failed deflation, the mannequin was reinserted into a water-filled balloon for additional MR exposure, up to a maximum of three times. Secondly, reversibility, occlusiveness and local effects of the Smart-TO balloon were tested in vivo in fetal lambs. Tracheal occlusion was performed in fetal lambs on gestational day 95 (term, 145 days), either using the balloon currently used in clinical practice (Goldbal2) (n = 5) or the Smart-TO balloon (n = 5). On gestational day 116, the presence of the balloon was assessed by tracheoscopy. Deflation was performed by puncture (Goldbal2) or MR exposure (Smart-TO). Six unoccluded fetal lambs served as controls. Following euthanasia, the lung-to-body-weight ratio (LBWR), lung morphometry and tracheal circumference were assessed. Local tracheal changes were measured using a hierarchical histologic scoring system. RESULTS Ex vivo, Smart-TO balloon deflation occurred after a single MR exposure in 100% of cases in a maternal standing position with the mannequin at a height of 95 cm (n = 32), 55 cm (n = 8) or 125 cm (n = 8), as well as when the maternal position was 'lying on a stretcher' (n = 8). Three out of eight (37.5%) balloons failed to deflate at first exposure when the maternal position was 'sitting in a wheelchair'. Of these, two balloons deflated after a second MR exposure, but one balloon remained inflated after a third exposure. In vivo, all Smart-TO balloons deflated successfully. The LBWR in fetal lambs with tracheal occlusion by a Smart-TO balloon was significantly higher than that in unoccluded controls, and was comparable with that in the Goldbal2 group. There were no differences in lung morphometry and tracheal circumference between the two balloon types. Tracheal histology showed minimal changes for both balloons. CONCLUSIONS In a simulated in-utero environment, the Smart-TO balloon was effectively deflated by exposure of the fetus in different positions to the magnetic field of a 1.5-T MR system. There was only one failure, which occurred when the mother was sitting in a wheelchair. In healthy fetal lambs, the Smart-TO balloon is as occlusive as the clinical standard Goldbal2 system and has only limited local side effects. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- D Basurto
- My FetUZ Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - N Sananès
- INSERM 1121 'Biomaterials and Bioengineering', Strasbourg University, Strasbourg, France
- Department of Maternal Fetal Medicine, Strasbourg University Hospital, Strasbourg, France
| | - E Verbeken
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - D Sharma
- My FetUZ Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - E Corno
- My FetUZ Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - I Valenzuela
- My FetUZ Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - L Van der Veeken
- My FetUZ Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - R Favre
- Department of Maternal Fetal Medicine, Strasbourg University Hospital, Strasbourg, France
| | - F M Russo
- My FetUZ Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - J Deprest
- My FetUZ Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Institute for Women's Health, University College London, London, UK
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Valenzuela I, van der Merwe J, De Catte L, Devlieger R, Deprest J, Lewi L. Foetal therapies and their influence on preterm birth. Semin Immunopathol 2020; 42:501-514. [PMID: 32785752 DOI: 10.1007/s00281-020-00811-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/26/2020] [Indexed: 12/12/2022]
Abstract
Foetal therapy aims to improve perinatal survival or to prevent severe long-term handicap. Foetal medicine opens a new territory by treating the foetus as a patient. The mother has nothing to gain in terms of health benefits, yet she is inherently also undergoing treatment. In utero foetal interventions can be divided into ultrasound-guided minimally invasive procedures, fetoscopic procedures and open hysterotomy procedures, which carry an inherent risk of ruptured membranes and preterm birth. In this review, we summarise the conditions that may benefit from foetal therapy and review the current therapies on offer, each with their associated risk of ruptured membrane and preterm birth. We also look into some risk limiting and preventative strategies to mitigate these complications.
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Affiliation(s)
- Ignacio Valenzuela
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium
| | - Johannes van der Merwe
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Luc De Catte
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Roland Devlieger
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium.,Institute for Women's Health, University College London, London, United Kingdom
| | - Liesbeth Lewi
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium. .,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium.
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Fetal therapy for congenital hydrocephalus-where we came from and where we are going. Childs Nerv Syst 2020; 36:1697-1712. [PMID: 32601902 DOI: 10.1007/s00381-020-04738-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 06/10/2020] [Indexed: 10/24/2022]
Abstract
Despite unfavorable outcomes during the early experience with in utero intervention for congenital hydrocephalus, improvements in prenatal diagnosis, patient selection, and fetal surgery techniques have led to a renewed interest in fetal intervention for congenital hydrocephalus. Research studies and clinical evidence shows that postnatal cerebrospinal fluid diversion to release intraventricular pressure and cerebral mantle compression usually arrives late to avoid irreversible brain damage. Make sense to decompress those lateral ventricles as soon as possible during the intrauterine life when hydrocephalus is antenatally detected. We present a historical review of research in animal models as well as clinical experience in the last decades, traveling until the last years when some research fetal therapy groups have made significant progress in recapitulating the prenatal intervention for fetuses with congenital obstructive hydrocephalus.
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36
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Fetal cardiac interventions: Where do we stand? Arch Cardiovasc Dis 2020; 113:121-128. [PMID: 32113817 DOI: 10.1016/j.acvd.2019.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/11/2019] [Accepted: 06/12/2019] [Indexed: 11/21/2022]
Abstract
Fetal cardiac intervention (FCI) is a novel and evolving technique that allows for in utero treatment of a subset of congenital heart disease. This review describes the rationale, selection criteria, technical features, and current outcomes for the three most commonly performed FCI: fetal aortic stenosis with evolving hypoplastic left heart syndrome (HLHS); HLHS with intact or restrictive atrial septum; and pulmonary atresia with intact ventricular septum, with concern for worsening right ventricular (RV) hypoplasia.
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Gao K, He S, Kumar P, Farmer D, Zhou J, Wang A. Clonal isolation of endothelial colony-forming cells from early gestation chorionic villi of human placenta for fetal tissue regeneration. World J Stem Cells 2020; 12:123-138. [PMID: 32184937 PMCID: PMC7062038 DOI: 10.4252/wjsc.v12.i2.123] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 12/03/2019] [Accepted: 12/23/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endothelial colony-forming cells (ECFCs) have been implicated in the process of vascularization, which includes vasculogenesis and angiogenesis. Vasculogenesis is a de novo formation of blood vessels, and is an essential physiological process that occurs during embryonic development and tissue regeneration. Angiogenesis is the growth of new capillaries from pre-existing blood vessels, which is observed both prenatally and postnatally. The placenta is an organ composed of a variety of fetal-derived cells, including ECFCs, and therefore has significant potential as a source of fetal ECFCs for tissue engineering.
AIM To investigate the possibility of isolating clonal ECFCs from human early gestation chorionic villi (CV-ECFCs) of the placenta, and assess their potential for tissue engineering.
METHODS The early gestation chorionic villus tissue was dissociated by enzyme digestion. Cells expressing CD31 were selected using magnetic-activated cell sorting, and plated in endothelial-specific growth medium. After 2-3 wks in culture, colonies displaying cobblestone-like morphology were manually picked using cloning cylinders. We characterized CV-ECFCs by flow cytometry, immunophenotyping, tube formation assay, and Dil-Ac-LDL uptake assay. Viral transduction of CV-ECFCs was performed using a Luciferase/tdTomato-containing lentiviral vector, and transduction efficiency was tested by fluorescent microscopy and flow cytometry. Compatibility of CV-ECFCs with a delivery vehicle was determined using an FDA approved, small intestinal submucosa extracellular matrix scaffold.
RESULTS After four passages in 6-8 wks of culture, we obtained a total number of 1.8 × 107 CV-ECFCs using 100 mg of early gestational chorionic villus tissue. Immunophenotypic analyses by flow cytometry demonstrated that CV-ECFCs highly expressed the endothelial markers CD31, CD144, CD146, CD105, CD309, only partially expressed CD34, and did not express CD45 and CD90. CV-ECFCs were capable of acetylated low-density lipoprotein uptake and tube formation, similar to cord blood-derived ECFCs (CB-ECFCs). CV-ECFCs can be transduced with a Luciferase/tdTomato-containing lentiviral vector at a transduction efficiency of 85.1%. Seeding CV-ECFCs on a small intestinal submucosa extracellular matrix scaffold confirmed that CV-ECFCs were compatible with the biomaterial scaffold.
CONCLUSION In summary, we established a magnetic sorting-assisted clonal isolation approach to derive CV-ECFCs. A substantial number of CV-ECFCs can be obtained within a short time frame, representing a promising novel source of ECFCs for fetal treatments.
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Affiliation(s)
- Kewa Gao
- Department of Burns and Plastic Surgery, The Third Xiangya Hospital of Central South University, Changsha 410013, Hunan Province, China
- Surgical Bioengineering Laboratory, Department of Surgery, University of California Davis, Sacramento, CA 95817, United States
- Institute for Pediatric Regenerative Medicine, Shriners Hospitals for Children, Sacramento, CA 95817, United States
| | - Siqi He
- Department of Burns and Plastic Surgery, The Third Xiangya Hospital of Central South University, Changsha 410013, Hunan Province, China
- Surgical Bioengineering Laboratory, Department of Surgery, University of California Davis, Sacramento, CA 95817, United States
- Institute for Pediatric Regenerative Medicine, Shriners Hospitals for Children, Sacramento, CA 95817, United States
| | - Priyadarsini Kumar
- Surgical Bioengineering Laboratory, Department of Surgery, University of California Davis, Sacramento, CA 95817, United States
- Institute for Pediatric Regenerative Medicine, Shriners Hospitals for Children, Sacramento, CA 95817, United States
| | - Diana Farmer
- Surgical Bioengineering Laboratory, Department of Surgery, University of California Davis, Sacramento, CA 95817, United States
- Institute for Pediatric Regenerative Medicine, Shriners Hospitals for Children, Sacramento, CA 95817, United States
| | - Jianda Zhou
- Department of Burns and Plastic Surgery, The Third Xiangya Hospital of Central South University, Changsha 410013, Hunan Province, China
| | - Aijun Wang
- Surgical Bioengineering Laboratory, Department of Surgery, University of California Davis, Sacramento, CA 95817, United States
- Institute for Pediatric Regenerative Medicine, Shriners Hospitals for Children, Sacramento, CA 95817, United States
- Department of Biomedical Engineering, University of California Davis, Davis, CA 95817, United States
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Hao D, Ma B, He C, Liu R, Farmer DL, Lam KS, Wang A. Surface modification of polymeric electrospun scaffolds via a potent and high-affinity integrin α4β1 ligand improved the adhesion, spreading and survival of human chorionic villus-derived mesenchymal stem cells: a new insight for fetal tissue engineering. J Mater Chem B 2020; 8:1649-1659. [PMID: 32011618 PMCID: PMC7353926 DOI: 10.1039/c9tb02309g] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Cell-biomaterial interactions are primarily governed by cell adhesion, which arises from the binding of cellular integrins to the extracellular matrix (ECM). Integrins drive the assembly of focal contacts that serve as mechanotransducers and signaling nexuses for stem cells, for example integrin α4β1 plays pivotal roles in regulating mesenchymal stem cell (MSC) homing, adhesion, migration and differentiation. The strategy to control the integrin-mediated cell adhesion to bioinspired, ECM-mimicking materials is essential to regulate cell functions and tissue regeneration. Previously, using one-bead one-compound (OBOC) combinatorial technology, we discovered that LLP2A was a high-affinity peptidomimetic ligand (IC50 = 2 pM) against integrin α4β1. In this study, we identified that LLP2A had a strong binding to human early gestation chorionic villi-derived MSCs (CV-MSCs) via integrin α4β1. To improve CV-MSC seeding, expansion and delivery for regenerative applications, we constructed artificial scaffolds simulating the structure of the native ECM by immobilizing LLP2A onto the scaffold surface as cell adhesion sites. LLP2A modification significantly enhanced CV-MSC adhesion, spreading and viability on the polymeric scaffolds via regulating signaling pathways including phosphorylation of focal adhesion kinase (FAK), and AKT, NF-kB and Caspase 9. In addition, we also demonstrated that LLP2A had strong binding to MSCs of other sources, such as bone marrow-derived mesenchymal stem cells (BM-MSCs) and adipose tissue-derived mesenchymal stem cells (AT-MSCs). Therefore, LLP2A and its derivatives not only hold great promise for improving CV-MSC-mediated treatment of fetal diseases, but they can also be widely applied to functionalize various biological and medical materials, which are in need of MSC recruitment, enrichment and survival, for regenerative medicine applications.
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Affiliation(s)
- Dake Hao
- Department of Surgery, School of Medicine, University of California Davis, Sacramento, CA 95817, USA. and Institute for Pediatric Regenerative Medicine, Shriners Hospitals for Children, Sacramento, CA 95817, USA
| | - Bowen Ma
- Department of Surgery, School of Medicine, University of California Davis, Sacramento, CA 95817, USA.
| | - Chuanchao He
- Department of Surgery, School of Medicine, University of California Davis, Sacramento, CA 95817, USA.
| | - Ruiwu Liu
- Department of Biochemistry and Molecular Medicine, School of Medicine, University of California Davis, Sacramento, CA 95817, USA
| | - Diana L Farmer
- Department of Surgery, School of Medicine, University of California Davis, Sacramento, CA 95817, USA. and Institute for Pediatric Regenerative Medicine, Shriners Hospitals for Children, Sacramento, CA 95817, USA
| | - Kit S Lam
- Department of Biochemistry and Molecular Medicine, School of Medicine, University of California Davis, Sacramento, CA 95817, USA
| | - Aijun Wang
- Department of Surgery, School of Medicine, University of California Davis, Sacramento, CA 95817, USA. and Institute for Pediatric Regenerative Medicine, Shriners Hospitals for Children, Sacramento, CA 95817, USA and Department of Biomedical Engineering, University of California Davis, Davis, CA 95616, USA
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Fetal therapies as standard prenatal care in Japan. Obstet Gynecol Sci 2020; 63:108-116. [PMID: 32206649 PMCID: PMC7073354 DOI: 10.5468/ogs.2020.63.2.108] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 08/25/2019] [Accepted: 09/09/2019] [Indexed: 11/09/2022] Open
Abstract
With recent advances in fetal medicine, various attempts have been made to save fetuses facing perinatal death or devastating consequences despite optimal management after birth. The concept of the fetus as a patient has been established through the application of in utero treatments. This paper reviews fetal therapies in order to highlight the role of perinatal medicine as standard prenatal care. Fetal therapies consist of medical therapy, percutaneous ultrasound-guided surgery, fetoscopic surgery, and open fetal surgery. In the 1980s, with advances in ultrasound imaging, percutaneous ultrasound-guided surgeries such as vesicoamniotic shunting for lower urinary tract obstruction and thoracoamniotic shunting (TAS) for fetal hydrothorax (FHT) were started. In the 1990s, fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS) was introduced, and later, a fetoscopic approach for congenital diaphragmatic hernia was also established. The revival of open fetal surgery, introduced in the 1980s by pediatric surgeons, began in the 2010s after a successful clinical study for myelomeningocele. Although many fetal therapies are still considered experimental, some have proven effective, such as FLS for TTTS, TAS for primary FHT, and radiofrequency ablation (RFA) for twin reversed arterial perfusion (TRAP) sequence. These three fetal therapies have been approved for coverage by Japan National Health Insurance as a result of clinical studies performed in Japan. FLS for TTTS, TAS for primary FHT, and RFA for TRAP sequence have become standard prenatal care approaches in Japan. These three minimally invasive fetal therapies will help improve the perinatal outcomes of fetuses with these disorders.
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Hypoxic Preconditioning Enhances Survival and Proangiogenic Capacity of Human First Trimester Chorionic Villus-Derived Mesenchymal Stem Cells for Fetal Tissue Engineering. Stem Cells Int 2019; 2019:9695239. [PMID: 31781252 PMCID: PMC6874947 DOI: 10.1155/2019/9695239] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/23/2019] [Accepted: 09/04/2019] [Indexed: 12/19/2022] Open
Abstract
Prenatal stem cell-based regenerative therapies have progressed substantially and have been demonstrated as effective treatment options for fetal diseases that were previously deemed untreatable. Due to immunoregulatory properties, self-renewal capacity, and multilineage potential, autologous human placental chorionic villus-derived mesenchymal stromal cells (CV-MSCs) are an attractive cell source for fetal regenerative therapies. However, as a general issue for MSC transplantation, the poor survival and engraftment is a major challenge of the application of MSCs. Particularly for the fetal transplantation of CV-MSCs in the naturally hypoxic fetal environment, improving the survival and engraftment of CV-MSCs is critically important. Hypoxic preconditioning (HP) is an effective priming approach to protect stem cells from ischemic damage. In this study, we developed an optimal HP protocol to enhance the survival and proangiogenic capacity of CV-MSCs for improving clinical outcomes in fetal applications. Total cell number, DNA quantification, nuclear area test, and cell viability test showed HP significantly protected CV-MSCs from ischemic damage. Flow cytometry analysis confirmed HP did not alter the immunophenotype of CV-MSCs. Caspase-3, MTS, and Western blot analysis showed HP significantly reduced the apoptosis of CV-MSCs under ischemic stimulus via the activation of the AKT signaling pathway that was related to cell survival. ELISA results showed HP significantly enhanced the secretion of vascular endothelial growth factor (VEGF) and hepatocyte growth factor (HGF) by CV-MSCs under an ischemic stimulus. We also found that the environmental nutrition level was critical for the release of brain-derived neurotrophic factor (BDNF). The angiogenesis assay results showed HP-primed CV-MSCs could significantly enhance endothelial cell (EC) proliferation, migration, and tube formation. Consequently, HP is a promising strategy to increase the tolerance of CV-MSCs to ischemia and improve their therapeutic efficacy in fetal clinical applications.
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Wang G, Zuluaga MA, Li W, Pratt R, Patel PA, Aertsen M, Doel T, David AL, Deprest J, Ourselin S, Vercauteren T. DeepIGeoS: A Deep Interactive Geodesic Framework for Medical Image Segmentation. IEEE TRANSACTIONS ON PATTERN ANALYSIS AND MACHINE INTELLIGENCE 2019; 41:1559-1572. [PMID: 29993532 PMCID: PMC6594450 DOI: 10.1109/tpami.2018.2840695] [Citation(s) in RCA: 148] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/17/2018] [Accepted: 05/22/2018] [Indexed: 05/20/2023]
Abstract
Accurate medical image segmentation is essential for diagnosis, surgical planning and many other applications. Convolutional Neural Networks (CNNs) have become the state-of-the-art automatic segmentation methods. However, fully automatic results may still need to be refined to become accurate and robust enough for clinical use. We propose a deep learning-based interactive segmentation method to improve the results obtained by an automatic CNN and to reduce user interactions during refinement for higher accuracy. We use one CNN to obtain an initial automatic segmentation, on which user interactions are added to indicate mis-segmentations. Another CNN takes as input the user interactions with the initial segmentation and gives a refined result. We propose to combine user interactions with CNNs through geodesic distance transforms, and propose a resolution-preserving network that gives a better dense prediction. In addition, we integrate user interactions as hard constraints into a back-propagatable Conditional Random Field. We validated the proposed framework in the context of 2D placenta segmentation from fetal MRI and 3D brain tumor segmentation from FLAIR images. Experimental results show our method achieves a large improvement from automatic CNNs, and obtains comparable and even higher accuracy with fewer user interventions and less time compared with traditional interactive methods.
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Affiliation(s)
- Guotai Wang
- Translational Imaging Group, Wellcome EPSRC Centre for Interventional and Surgical Sciences (WEISS)University College LondonLondonWC1E 6BTUnited Kingdom
| | - Maria A. Zuluaga
- Translational Imaging Group, Wellcome EPSRC Centre for Interventional and Surgical Sciences (WEISS)University College LondonLondonWC1E 6BTUnited Kingdom
| | - Wenqi Li
- Translational Imaging Group, Wellcome EPSRC Centre for Interventional and Surgical Sciences (WEISS)University College LondonLondonWC1E 6BTUnited Kingdom
| | - Rosalind Pratt
- Translational Imaging Group, Wellcome EPSRC Centre for Interventional and Surgical Sciences (WEISS)University College LondonLondonWC1E 6BTUnited Kingdom
- Institute for Women's HealthUniversity College LondonLondonWC1E 6BTUnited Kingdom
| | - Premal A. Patel
- Translational Imaging Group, Wellcome EPSRC Centre for Interventional and Surgical Sciences (WEISS)University College LondonLondonWC1E 6BTUnited Kingdom
| | - Michael Aertsen
- Department of RadiologyUniversity Hospitals KU LeuvenLeuven3000Belgium
| | - Tom Doel
- Translational Imaging Group, Wellcome EPSRC Centre for Interventional and Surgical Sciences (WEISS)University College LondonLondonWC1E 6BTUnited Kingdom
| | - Anna L. David
- Institute for Women's HealthUniversity College LondonLondonWC1E 6BTUnited Kingdom
| | - Jan Deprest
- Department of ObstetricsUniversity Hospitals KU LeuvenLeuven3000Belgium
| | - Sébastien Ourselin
- Translational Imaging Group, Wellcome EPSRC Centre for Interventional and Surgical Sciences (WEISS)University College LondonLondonWC1E 6BTUnited Kingdom
| | - Tom Vercauteren
- Translational Imaging Group, Wellcome EPSRC Centre for Interventional and Surgical Sciences (WEISS)University College LondonLondonWC1E 6BTUnited Kingdom
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Riggan KA, Collura CA, Pittock ST, Ruano R, Whitford KJ, Allyse M. Ethical considerations of maternal-fetal intervention in a twin pregnancy discordant for anomalies. J Matern Fetal Neonatal Med 2019; 34:1312-1317. [PMID: 31189438 DOI: 10.1080/14767058.2019.1631793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Recent evidence suggests prenatal fetoscopic tracheal occlusion (FETO) may improve the survival and long-term morbidity of neonates with congenital diaphragmatic hernia, yet little guidance exists in the medical literature as to the ethical permissibility of performing a maternal-fetal surgical intervention in a twin pregnancy discordant for a structural abnormality. CASE Here, we present a case of a twin pregnancy with an unaffected twin (Twin A) and a twin diagnosed with severe congenital diaphragmatic hernia (Twin B). A proposed fetoscopic tracheal occlusion (FETO) procedure may improve the likelihood of survival and postnatal outcome of Twin B; however, balloon placement may also initiate very preterm birth at 28 weeks of gestation. The Fetal Ethics Advisory Board was asked to provide guidance on the permissibility of FETO in this pregnancy. DISCUSSION A literature review identified one brief mention of FETO in a 34-week dichorionic twin pregnancy in the medical literature, which resulted in the rupture of fetal membranes in the sac of the nonsurgical twin. Only one paper specifically addressed the question of whether it would be ethically permissible to subject a healthy twin to the risks of maternal-fetal surgery for the benefit of a compromised twin, finding that any risk to the unaffected twin would be an ethical contraindication. We offer our own analysis of moral weight and risk/benefit considerations of this proposed intervention, and present our findings on the circumstances in which it may be ethically permissible to perform a maternal-fetal intervention in a twin pregnancy. CONCLUSION While FETO was not ethically advisable in this pregnancy, we find that in limited circumstances, certain maternal-fetal surgical interventions may be ethically permissible in a twin pregnancy discordant for a structural abnormality if the risks to the unaffected twin are minimal and the procedure would improve the likelihood of survival and postnatal outcome of a critically compromised co-twin.
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Affiliation(s)
- Kirsten A Riggan
- Biomedical Ethics Research Program, Mayo Clinic Rochester, Rochester, MN, USA
| | - Christopher A Collura
- Division of Neonatal Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Siobhan T Pittock
- Division of Pediatric Endocrinology and Metabolism, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rodrigo Ruano
- Division of Maternal and Fetal Medicine, Department of Obstetrics & Gynecology, Mayo Clinic, Rochester, MN, USA
| | - Kevin J Whitford
- Department of Internal Medicine, Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Megan Allyse
- Biomedical Ethics Research Program, Mayo Clinic Rochester, Rochester, MN, USA.,Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
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Sacco A, Van der Veeken L, Bagshaw E, Ferguson C, Van Mieghem T, David AL, Deprest J. Maternal complications following open and fetoscopic fetal surgery: A systematic review and meta-analysis. Prenat Diagn 2019; 39:251-268. [PMID: 30703262 PMCID: PMC6492015 DOI: 10.1002/pd.5421] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To establish maternal complication rates for fetoscopic or open fetal surgery. METHODS We conducted a systematic literature review for studies of fetoscopic or open fetal surgery performed since 1990, recording maternal complications during fetal surgery, the remainder of pregnancy, delivery, and after the index pregnancy. RESULTS One hundred sixty-six studies were included, reporting outcomes for open fetal (n = 1193 patients) and fetoscopic surgery (n = 9403 patients). No maternal deaths were reported. The risk of any maternal complication in the index pregnancy was 20.9% (95%CI, 15.22-27.13) for open fetal and 6.2% (95%CI, 4.93-7.49) for fetoscopic surgery. For severe maternal complications (grades III to V Clavien-Dindo classification of surgical complications), the risk was 4.5% (95% CI 3.24-5.98) for open fetal and 1.7% (95% CI, 1.19-2.20) for fetoscopic surgery. In subsequent pregnancies, open fetal surgery increased the risk of preterm birth but not uterine dehiscence or rupture. Nearly one quarter of reviewed studies (n = 175, 23.3%) was excluded for failing to report the presence or absence of maternal complications. CONCLUSIONS Maternal complications occur in 6.2% fetoscopic and 20.9% open fetal surgeries, with serious maternal complications in 1.7% fetoscopic and 4.5% open procedures. Reporting of maternal complications is variable. To properly quantify maternal risks, outcomes should be reported consistently across all fetal surgery studies.
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Affiliation(s)
- Adalina Sacco
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Lennart Van der Veeken
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
| | - Emma Bagshaw
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Catherine Ferguson
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Tim Van Mieghem
- Department of Obstetrics and GynaecologyMount Sinai Hospital and University of TorontoTorontoOntarioCanada
| | - Anna L. David
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- National Institute for Health ResearchUniversity College London Hospitals Biomedical Research CentreLondonUK
| | - Jan Deprest
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- Clinical Department Obstetrics and GynaecologyUniversity Hospitals LeuvenLeuvenBelgium
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44
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Abstract
Fracture toughness characterizes the ability of a material to maintain a certain level of strength despite the presence of a macroscopic crack. Understanding this tolerance for defects in soft collagenous tissues (SCT) has high relevance for assessing the risks of fracture after cutting, perforation or suturing. Here we investigate the peculiar toughening mechanisms of SCT through dedicated experiments and multi-scale simulations, showing that classical concepts of fracture mechanics are inadequate to quantify and explain the high defect tolerance of these materials. Our results demonstrate that SCT strength is only modestly reduced by defects as large as several millimeters. This defect tolerance is achieved despite a very narrow process zone at the crack tip and even for a network of brittle fibrils. The fracture mechanics concept of tearing energy fails in predicting failure at such defects, and its magnitude is shown to depend on the chemical potential of the liquid environment.
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Basurto D, Russo FM, Van der Veeken L, Van der Merwe J, Hooper S, Benachi A, De Bie F, Gomez O, Deprest J. Prenatal diagnosis and management of congenital diaphragmatic hernia. Best Pract Res Clin Obstet Gynaecol 2019; 58:93-106. [PMID: 30772144 DOI: 10.1016/j.bpobgyn.2018.12.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 12/31/2018] [Indexed: 12/13/2022]
Abstract
Congenital diaphragmatic hernia is characterized by failed closure of the diaphragm, thereby allowing abdominal viscera to herniate into the thoracic cavity and subsequently interfering with normal lung development. At birth, pulmonary hypoplasia leads to respiratory insufficiency and persistent pulmonary hypertension (PHT), that is lethal in up to 32% of patients. In isolated cases, the outcome may be predicted prenatally by medical imaging and advanced genetic testing. In those fetuses with a predicted poor outcome, fetoscopic endoluminal tracheal occlusion may be offered. This procedure is currently being evaluated in a global randomized clinical trial (www.TOTALtrial.eu). We are currently investigating alternative strategies including transplacental sildenafil administration to reduce the occurrence of persistent PHT.
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Affiliation(s)
- David Basurto
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Belgium
| | - Francesca Maria Russo
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Belgium; Clinical Department of Obstetrics & Gynaecology, KU Leuven, Leuven, Belgium
| | - Lennart Van der Veeken
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Belgium; Clinical Department of Obstetrics & Gynaecology, KU Leuven, Leuven, Belgium
| | - Johannes Van der Merwe
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Belgium; Clinical Department of Obstetrics & Gynaecology, KU Leuven, Leuven, Belgium
| | - Stuart Hooper
- The Ritchie Centre, Hudson Institute of Medical Research and Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Alexandra Benachi
- Obstetrics and Gynaecology Department, Centre de Référence Maladie Rare: Hernie de Coupole Diaphragmatique, Hôpital Antoine Béclère, Université Paris Sud, AP-HP, Clamart, France; European Reference Network on Rare and Inherited Congenital Anomalies "ERNICA"
| | - Felix De Bie
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Belgium
| | - Olga Gomez
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Fetal I+D Fetal Medicine Research Center, Institut Clinic de Ginecologia, Obstetricia I Neonatologia, IDIBAPS, CIBER-ER, University of Barcelona, Spain
| | - Jan Deprest
- Academic Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Belgium; Clinical Department of Obstetrics & Gynaecology, KU Leuven, Leuven, Belgium; Institute for Women's Health, University College London, London, UK; European Reference Network on Rare and Inherited Congenital Anomalies "ERNICA".
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46
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Baba JS, McKnight TE, Ericson MN, Johnson A, Moise KJ, Evans BM. Characterization of a reversible thermally-actuated polymer-valve: A potential dynamic treatment for congenital diaphragmatic hernia. PLoS One 2018; 13:e0209855. [PMID: 30589888 PMCID: PMC6307748 DOI: 10.1371/journal.pone.0209855] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 12/12/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) is a fetal defect comprising an incomplete diaphragm and the herniation of abdominal organs into the chest cavity that interfere with fetal pulmonary development. Though the most promising treatment for CDH is via interventional fetoscopic tracheal occlusion (TO) surgery in-utero, it has produced mixed results due to the static nature of the inserted occlusion. We hypothesize that a suitable noninvasively-actuatable, cyclic-release tracheal occlusion device can be developed to enable dynamic tracheal occlusion (dTO) implementation. OBJECTIVE To conduct an in-vitro proof-of-concept investigation of the construction of thermo-responsive polymer valves designed for targeted activation within a physiologically realizable temperature range as a first step towards potential development of a noninvasively-actuatable implantable device to facilitate dynamic tracheal occlusion (dTO) therapy. METHODS Six thermo-responsive polymer valves, with a critical solution temperature slightly higher than normal physiological body temperature of 37°C, were fabricated using a copolymer of n-isopropylacrylamide (NIPAM) and dimethylacrylamide (DMAA). Three of the valves underwent ethylene oxide (EtO) sterilization while the other three served as controls for EtO-processing compatibility testing. Thermal response actuation of the valves and their steady-state flow performances were evaluated using water and caprine amniotic fluid. RESULTS All six valves consisting of 0.3-mole fraction of DMAA were tested for thermal actuation of caprine amniotic fluid flow at temperatures ranging from 30-44°C. They all exhibited initiation of valve actuation opening at ~40°C with full completion at ~44°C. The overall average coefficient of variation (CV) for the day-to-day flow performance of the valves tested was less than 12%. Based on a Student t-test, there was no significant difference in the operational characteristics for the EtO processed versus the non-EtO processed valves tested. CONCLUSIONS We successfully fabricated and demonstrated physiological realizable temperature range operation of thermo-responsive polymer valves in-vitro and their suitability for standard EtO sterilization processing, a prerequisite for future in-vivo surgical implantation testing.
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Affiliation(s)
- Justin S. Baba
- Electrical and Electronics Systems Research Division, Oak Ridge National Laboratory, Oak Ridge, Tennessee, United States of America
- Biophotonics Center, Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Timothy E. McKnight
- Electrical and Electronics Systems Research Division, Oak Ridge National Laboratory, Oak Ridge, Tennessee, United States of America
| | - M. Nance Ericson
- Electrical and Electronics Systems Research Division, Oak Ridge National Laboratory, Oak Ridge, Tennessee, United States of America
| | - Anthony Johnson
- Department of Obstetrics, Gynecology, Baylor College of Medicine, Houston, Texas, United States of America
| | - Kenneth J. Moise
- Department of Obstetrics, Gynecology, Baylor College of Medicine, Houston, Texas, United States of America
| | - Boyd M. Evans
- Electrical and Electronics Systems Research Division, Oak Ridge National Laboratory, Oak Ridge, Tennessee, United States of America
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47
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Sacco A, Simpson L, Deprest J, David AL. A study to assess global availability of fetal surgery for myelomeningocele. Prenat Diagn 2018; 38:1020-1027. [PMID: 30378145 DOI: 10.1002/pd.5383] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 09/23/2018] [Accepted: 10/23/2018] [Indexed: 11/08/2022]
Abstract
AIM To establish the provision of fetal surgery for myelomeningocele (MMC) worldwide. METHODS Through the International Society for Prenatal Diagnosis (ISPD) Fetal Therapy Special Interest Group and the North American Fetal Therapy Network (NAFTNet), fetal therapy centres were surveyed (September 2017-June 2018) regarding availability of fetal MMC surgical repair, patient inclusion criteria, repair techniques, number of cases, and outcome reporting. Responses were summarised on an interactive map on the ISPD website. RESULTS Forty-four of 59 centres responded (74.6%) of which 34 centres (77.1%) currently offered fetal surgery for MMC and seven centres (15.9%) were awaiting a first case after service set up. Patient inclusion criteria were similar and based on the Management of Myelomeningocele (MOMS) trial. Five centres (14.7%) operated beyond 26 weeks' gestational age, outside the MOMS criteria. Open fetal surgery was provided in 23 centres (67.6%), fetoscopic surgery only in five (14.7%), and six centres offered both types (17.6%). Neurosurgical closure was similar for open surgery but highly variable in fetoscopy surgery. The median number of cases per centre was 21 (range 1-253). CONCLUSIONS Fetal surgery for MMC is now offered globally. Two thirds of centres offer open repair via hysterotomy using criteria based on the MOMS trial.
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Affiliation(s)
- Adalina Sacco
- Institute for Women's Health, University College London, London, UK
| | - Lynn Simpson
- Maternal Fetal Medicine division, Columbia University Medical Center, Manhattan, NY, USA
| | - Jan Deprest
- Institute for Women's Health, University College London, London, UK.,Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, Leuven, Belgium
| | - Anna L David
- Institute for Women's Health, University College London, London, UK.,Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, Leuven, Belgium.,NIHR University College London Hospitals Biomedical Research Centre, London, UK
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48
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Abstract
Fetal surgery corrects severe congenital anomalies in utero to prevent their severe consequences on fetal development. The significant risk of open fetal operations to the pregnant mother has driven innovation toward minimally invasive procedures that decrease the risks inherent to hysterotomy. In this article, we discuss the basic principles of minimally invasive fetal surgery, the general history of its development, specific conditions and procedures used to treat them, and the future of the field.
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Affiliation(s)
- Claire E Graves
- Department of Surgery, University of California, San Francisco, 550 16th Street 5th Floor UCSF Mail Stop 0570, San Francisco, CA 94158-2549, USA
| | - Michael R Harrison
- University of California, San Francisco, 550 16th Street 5th Floor UCSF Mail Stop 0570, San Francisco, CA 94158-2549, USA
| | - Benjamin E Padilla
- Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, 550 16th Street 5th Floor UCSF Mail Stop 0570, San Francisco, CA 94158-2549, USA.
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49
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N-terminal pro-B-type natriuretic peptide in amniotic fluid of fetuses with known or suspected cardiac load. PLoS One 2017; 12:e0177253. [PMID: 28545116 PMCID: PMC5436674 DOI: 10.1371/journal.pone.0177253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 04/25/2017] [Indexed: 12/14/2022] Open
Abstract
Background Myocardial dysfunction occurs in a variety of fetal disorders. Findings from adult cardiology, where n-terminal pro-B-type natriuretic peptide (nt-proBNP) is an established biomarker of left ventricular dysfunction have been extended to fetal life. Since fetal blood sampling is technically challenging we investigated amniotic fluid nt-proBNP for its suitability to diagnose fetal myocardial dysfunction. Methods Ultrasound, Doppler examination and echocardiography was applied to classify cases and controls. Amniotic fluid nt-proBNP to amniotic fluid total protein ratio was calculated and compared to the gestational age-dependent reference intervals. In a subset of cases, fetal and maternal plasma nt-proBNP levels were determined. Results Specimen from 391 fetuses could be analyzed (171 cases, 220 controls). There was a high correlation between amniotic fluid and fetal blood nt-proBNP levels (r = 0.441 for cases; r = 0.515 for controls), whereas no correlation could be detected between maternal and fetal (blood and amniotic fluid) nt-proBNP concentrations. Specificity and positive likelihood ratio of amniotic fluid nt-proBNP to amniotic fluid total protein ratio were high (0.97 and 4.3, respectively). Conclusion Amniotic fluid nt-proBNP measurement allows diagnostic confirmation of fetal myocardial dysfunction. It may serve as a useful adjunct in addition and correlation to existing tests of myocardial function, particularly in the context of invasive fetal therapy, where access to the amniotic cavity is part of the procedure.
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50
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Enzensberger C, Achterberg F, Graupner O, Wolter A, Herrmann J, Axt-Fliedner R. Wall-motion tracking in fetal echocardiography-Influence of frame rate on longitudinal strain analysis assessed by two-dimensional speckle tracking. Echocardiography 2017; 34:898-905. [DOI: 10.1111/echo.13542] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Christian Enzensberger
- Division of Prenatal Medicine; Department of OB/GYN; University Hospital UKGM; Justus-Liebig University; Giessen Germany
| | - Friederike Achterberg
- Division of Prenatal Medicine; Department of OB/GYN; University Hospital UKGM; Justus-Liebig University; Giessen Germany
| | - Oliver Graupner
- Department of OB/GYN; University Hospital, Technical University; Munich Germany
| | - Aline Wolter
- Division of Prenatal Medicine; Department of OB/GYN; University Hospital UKGM; Justus-Liebig University; Giessen Germany
| | | | - Roland Axt-Fliedner
- Division of Prenatal Medicine; Department of OB/GYN; University Hospital UKGM; Justus-Liebig University; Giessen Germany
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