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Guseh S, Tworetzky W. Transforming congenital heart disease management: Advances in fetal cardiac interventions. Prenat Diagn 2024; 44:733-738. [PMID: 38768017 DOI: 10.1002/pd.6592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 05/03/2024] [Accepted: 05/06/2024] [Indexed: 05/22/2024]
Abstract
This review addresses the transformative advancements in fetal cardiac interventions (FCI) for congenital heart diseases (CHD), with a particular focus on aortic stenosis with evolving hypoplastic left heart syndrome, pulmonary atresia with an intact ventricular septum, and HLHS with an intact atrial septum (HLHS-IAS). We outline the specific FCI techniques employed, the refined criteria for selecting appropriate fetal and maternal candidates, and the promising yet varied outcomes associated with these procedures. Procedural strategies and clinical decision-making are examined as we take into account the fetal pathophysiology and the benefits and risks of early intervention. We highlight the role of multidisciplinary teams in improving technical success and managing immediate procedural complications, which have led to significant improvements in procedural outcomes. Additionally, the review discusses the long-term outcomes, challenges, and future research directions in FCI, emphasizing the necessity for continuous innovation and collaboration across specialties to advance the management of CHD. The integration of new technologies and research findings holds the promise of further enhancing FCI success rates and patient outcomes.
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Affiliation(s)
- Stephanie Guseh
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
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Samples S, Gandhi R, Woo J, Patel A. Ethical Considerations in Fetal Cardiology. J Cardiovasc Dev Dis 2024; 11:172. [PMID: 38921672 PMCID: PMC11204861 DOI: 10.3390/jcdd11060172] [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: 05/29/2024] [Accepted: 05/30/2024] [Indexed: 06/27/2024] Open
Abstract
Fetal cardiology has evolved over the last 40 years and changed the timing of diagnosis and counseling of congenital heart disease, decision-making, planning for treatment at birth, and predicting future surgery from the postnatal to the prenatal period. Ethical issues in fetal cardiology transect multiple aspects of biomedical ethics including improvement in prenatal detection and diagnostic capabilities, access to equitable comprehensive care that preserves a pregnant person's right to make decisions, access to all reproductive options, informed consent, complexity in shared decision-making, and appropriate use of fetal cardiac interventions. This paper first reviews the literature and then provides an ethical analysis of accurate and timely diagnosis, equitable delivery of care, prenatal counseling and shared decision-making, and innovation through in utero intervention.
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Affiliation(s)
- Stefani Samples
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Rupali Gandhi
- Division of Pediatric Cardiology, Advocate Christ Children’s Hospital, Oak Lawn, IL 60453, USA
- Section of Cardiology, Department of Pediatrics, Comer Children’s Hospital, University of Chicago, Chicago, IL 60637, USA
| | - Joyce Woo
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Angira Patel
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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Callahan R, Friedman KG, Tworetzky W, Esch JJ, Sleeper LA, Lu M, Mizrahi-Arnaud A, Brusseau R, Lafranchi T, Wilkins-Haug LE, Guseh SH, Benson CB, Frates MC, Keochakian M, Porras D. Technical Success and Serious Adverse Events for Fetal Aortic Valvuloplasty in a Large 20-Year Cohort. JACC. ADVANCES 2024; 3:100835. [PMID: 38938833 PMCID: PMC11198497 DOI: 10.1016/j.jacadv.2024.100835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 10/02/2023] [Accepted: 10/27/2023] [Indexed: 06/29/2024]
Abstract
Background FAV is offered to fetuses with severe aortic valve stenosis and evolving hypoplastic left heart syndrome. An inferential analysis of TS and SAE in a large series has not been reported. Objectives The purpose of this study was to determine factors associated with fetal aortic valvuloplasty (FAV) technical success (TS) and serious adverse events (SAEs). Methods Retrospective, single-center, cohort analysis of attempted FAV from March 1, 2000, to December 31, 2020. The primary outcome was the TS of FAV, and the secondary outcome was the presence of an SAE. Results A total of 165 FAVs were attempted in 163 patients with a median gestational age of 24.6 weeks (IQR: 22.9-27.1 weeks). FAV TS was 85% (141/165) and was higher in the 2010 to 2020 era (94% [85/90] vs 75% [56/75]; P < 0.001). Pre-FAV echocardiographic left ventricle (LV) long axis dimension z-score >-0.10 (P < 0.001) and higher LV ejection fraction (P = 0.037) were independently associated with a higher odds of TS. There were 117 SAEs in 67 attempted FAVs (41%), 13 of which were fetal deaths (7.9%). By classification and regression tree analysis, gestational age <21 weeks or in older fetuses, a procedure time of ≥39.6 minutes was associated with higher SAE rate. In the multivariable logistic regression model correcting for gestational age, fetuses with an LV end-diastolic volume <4.09 mL had an age-adjusted OR of 4.71 (95% CI: 1.67-13.29; P = 0.004) for experiencing an SAE. Conclusions TS of FAV has improved over time, and failure is associated with smaller fetal left heart sizes. SAEs are common and are associated with smaller left hearts and longer procedure times.
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Affiliation(s)
- Ryan Callahan
- Department of Pediatrics, Children’s Hospital of Philadelphia, and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kevin G. Friedman
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jesse J. Esch
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Lynn A. Sleeper
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Minmin Lu
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Arielle Mizrahi-Arnaud
- Department of Anesthesia, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Roland Brusseau
- Department of Anesthesia, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Terra Lafranchi
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Louise E. Wilkins-Haug
- Department of Obstetrics and Gynecology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Stephanie H. Guseh
- Department of Obstetrics and Gynecology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Carol B. Benson
- Department of Radiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Mary C. Frates
- Department of Radiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Mirjam Keochakian
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Diego Porras
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Deren O, Aykan HH, Ozyuncu O, Aypar E, Cagan M, Ozen O, Karagoz T. Fetal cardiac interventions: First-year experience of a tertiary referral center in Turkey. J Obstet Gynaecol Res 2023. [PMID: 37004995 DOI: 10.1111/jog.15649] [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: 11/23/2022] [Accepted: 03/22/2023] [Indexed: 04/04/2023]
Abstract
AIM To present the first-year experience of fetal cardiac interventions (FCIs) in a tertiary referral hospital and to evaluate the outcomes. METHODS This retrospective study consisted of four pregnant women who underwent fetal pulmonary or aortic balloon valvuloplasty between November 2020 and June 2021. The procedures were performed with a percutaneous cardiac puncture under the ultrasonography guidance. Gestational age at intervention, procedural success, complications, and perinatal outcomes were evaluated. Procedural complications defined as fetal bradyarrhythmia requiring treatment, pericardial effusion requiring drainage, balloon rupture, and fetal death. The procedure was considered technically successful if the valve was dilated with a balloon catheter. Ultimately successful procedure was defined as the discharge of infants alive with biventricular circulation. RESULTS A total of 5 FCIs attempted between 26 + 3 and 28 + 2 gestational weeks. While the procedure was technically successful in 2 cases with pulmonary stenosis, both attempts were unsuccessful in the fetus with pulmonary atresia. Although the procedure was technically successful in the patient with critical aortic stenosis, it ultimately failed. No fetal death occurred in our series and there were no procedure-related significant maternal complications. However, three interventions were complicated by fetal bradycardia and pericardial effusion necessitating treatment, and balloon rupture cropped up in one case. CONCLUSION FCIs may lead to improving the likelihood of a biventricular outcome for selected fetuses. Careful selection of patients and centralization of experience are essential for obtaining favorable outcomes. Operators should be aware of procedural complications. Improved procedural techniques with a lower complication rate will be achieved through advanced medical technology and special balloon catheters.
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Affiliation(s)
- Ozgur Deren
- Division of Perinatology, Department of Obstetrics and Gynecology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Hayrettin Hakan Aykan
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
- Life Support Center, Hacettepe University, Ankara, Turkey
| | - Ozgur Ozyuncu
- Division of Perinatology, Department of Obstetrics and Gynecology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ebru Aypar
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Murat Cagan
- Division of Perinatology, Department of Obstetrics and Gynecology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ozge Ozen
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Tevfik Karagoz
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Advances in the Prenatal Management of Fetal Cardiac Disease. CHILDREN 2022; 9:children9060812. [PMID: 35740749 PMCID: PMC9222001 DOI: 10.3390/children9060812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/09/2022] [Accepted: 05/11/2022] [Indexed: 11/16/2022]
Abstract
Advances in the field have improved the prenatal management of cardiovascular diseases over the past few decades; however, there remains considerable challenges in the approach towards patient selection as well as the applicability of available therapies. This review aims to discuss the current knowledge, outcomes and challenges for prenatal intervention for congenital heart disease.
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