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Qasim A, Morris SA, Belfort MA, Qureshi AM. Current Understanding of Indications, Technical Aspects and Outcomes of Fetal Cardiac Interventions. Interv Cardiol Clin 2024; 13:319-331. [PMID: 38839166 DOI: 10.1016/j.iccl.2024.03.005] [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] [Indexed: 06/07/2024]
Abstract
With the improvement in the detection of congenital heart disease in fetal life, fetal cardiac interventions are pushing the envelope in hopes of either altering the natural history of disease or improving survival in certain high-risk lesions. These interventions include fetal aortic valvuloplasty for evolving hypoplastic left heart syndrome, fetal atrial septoplasty with or without atrial septal stenting for hypoplastic left heart syndrome and variants with intact or severely restrictive atrial septum, and fetal pulmonary valvuloplasty for severe pulmonary stenosis or pulmonary atresia with intact ventricular septum. This review discusses their indications, technical aspects, and outcomes based on available literature.
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Affiliation(s)
- Amna Qasim
- Department of Cardiology, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Shaine A Morris
- The Lillie Frank Abercrombie Division of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine
| | - Athar M Qureshi
- CE Mullins Cardiac Catheterization Laboratories, The Lillie Frank Abercrombie Division of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Internal Medicine/Cardiology, Baylor St. Luke's Medical Center, 6651 Main Street, E 1920, Houston, TX 77030, USA.
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2
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Mustafa HJ, Aghajani F, Jawwad M, Shah N, Abuhamad A, Khalil A. Fetal cardiac intervention in hypoplastic left heart syndrome with intact or restrictive atrial septum, systematic review, and meta-analysis. Prenat Diagn 2024; 44:747-757. [PMID: 37596875 DOI: 10.1002/pd.6420] [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: 05/07/2023] [Revised: 08/02/2023] [Accepted: 08/06/2023] [Indexed: 08/20/2023]
Abstract
To investigate outcomes of fetuses with hypoplastic left heart syndrome (HLHS) with an intact or restrictive atrial septum (I/RAS) managed expectantly or with fetal atrial septal intervention (FASI PubMed, Scopus, and Web of Science were searched systematically from inception until April 2023. Outcomes were classified by those who had FASI and those who had expectant management (EM). To estimate the overall proportion of each endpoint, a meta-analysis of proportions was employed using a random-effects model. Heterogeneity was assessed using the I2 value. Thirty-two studies reporting on 746 fetuses with HLHS and I/RAS met our inclusion criteria. Eleven studies (123 fetuses) were in the FASI group and 21 studies (623 fetuses) were in the EM group. Among the 123 FASI cases, 107 (87%) were reported to be technically successful. The mean gestational age (GA) at diagnosis was comparable between the groups (26.2 weeks FASI vs. 24.4 weeks EM group). The mean GA at FASI was 30.4 weeks (95% CI 28.5, 32.5). The mean GA at delivery was also comparable (37.7 weeks FASI vs. 38.1 weeks EM group). Neonatal outcomes, including live birth, neonatal death, and survival to hospital discharge pooled proportions, were also comparable between groups (live birth: 92% (95% CI 64, 99) FASI versus 93% (95% CI 79, 98) in EM, neonatal death: 32% (95% CI 11, 65) FASI versus 30% (95% CI 21, 41) EM, survival to hospital discharge: 37% (95% CI 25, 52) FASI versus 52% (95% CI 42, 61) EM). Age at neonatal death was higher in the FASI group (mean: 17 days FASI vs. 7.2 days EM group). There was a lower rate of postnatal atrial restrictive septum in the FASI group 38% (95% CI 17, 63) compared to the EM group 88% (95% CI 57, 98). Our review shows variations across centers in the selection criteria and techniques used for FASI. Although survival including livebirth, neonatal death, and survival to hospital discharge did not differ between groups, the procedure may translate into a less restrictive septum at birth. Future multicenter studies are needed to better identify the subset of cases that might have improved outcomes, use standardized definitions, unified techniques, utilize core outcome set, and assess long-term benefits.
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Affiliation(s)
- Hiba J Mustafa
- Division of Maternal-Fetal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
- The Fetal Center at Riley Children's and Indiana University Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Faezeh Aghajani
- BCNatal Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Universitat de Barcelona, Barcelona, Spain
| | - Mohammad Jawwad
- Department of Medicine and Surgery, Dow University of Health Sciences, Karachi, Pakistan
| | - Nensi Shah
- Department of Internal Medicine, College of Medical Sciences, Bharatpur, Nepal
| | - Alfred Abuhamad
- Division of Maternal-Fetal Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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3
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Yilmaz Furtun B, Morris SA. Catheter-Based Fetal Cardiac Interventions. J Cardiovasc Dev Dis 2024; 11:167. [PMID: 38921667 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)
- Betul Yilmaz Furtun
- Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, Suite E1920, Houston, TX 77030, USA
| | - Shaine Alaine Morris
- Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, Suite E1920, Houston, TX 77030, USA
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Klein JH, Donofrio MT. Untangling the Complex Associations between Socioeconomic and Demographic Characteristics and Prenatal Detection and Outcomes in Congenital Heart Disease. J Cardiovasc Dev Dis 2024; 11:155. [PMID: 38786977 PMCID: PMC11122600 DOI: 10.3390/jcdd11050155] [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: 04/15/2024] [Revised: 05/02/2024] [Accepted: 05/12/2024] [Indexed: 05/25/2024] Open
Abstract
Recent literature has established a strong foundation examining the associations between socioeconomic/demographic characteristics and outcomes for congenital heart disease. These associations are found beginning in fetal life and influence rates of prenatal detection, access to timely and appropriate delivery room and neonatal interventions, and surgical and other early childhood outcomes. This review takes a broad look at the existing literature and identifies gaps in the current body of research, particularly as it pertains to disparities in the prenatal detection of congenital heart disease within the United States. It also proposes further research and interventions to address these health disparities.
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Vollbrecht TM, Bissell MM, Kording F, Geipel A, Isaak A, Strizek BS, Hart C, Barker AJ, Luetkens JA. Fetal Cardiac MRI Using Doppler US Gating: Emerging Technology and Clinical Implications. Radiol Cardiothorac Imaging 2024; 6:e230182. [PMID: 38602469 PMCID: PMC11056758 DOI: 10.1148/ryct.230182] [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: 07/06/2023] [Revised: 02/13/2024] [Accepted: 02/27/2024] [Indexed: 04/12/2024]
Abstract
Fetal cardiac MRI using Doppler US gating is an emerging technique to support prenatal diagnosis of congenital heart disease and other cardiovascular abnormalities. Analogous to postnatal electrocardiographically gated cardiac MRI, this technique enables directly gated MRI of the fetal heart throughout the cardiac cycle, allowing for immediate data reconstruction and review of image quality. This review outlines the technical principles and challenges of cardiac MRI with Doppler US gating, such as loss of gating signal due to fetal movement. A practical workflow of patient preparation for the use of Doppler US-gated fetal cardiac MRI in clinical routine is provided. Currently applied MRI sequences (ie, cine or four-dimensional flow imaging), with special consideration of technical adaptations to the fetal heart, are summarized. The authors provide a literature review on the clinical benefits of Doppler US-gated fetal cardiac MRI for gaining additional diagnostic information on cardiovascular malformations and fetal hemodynamics. Finally, future perspectives of Doppler US-gated fetal cardiac MRI and further technical developments to reduce acquisition times and eliminate sources of artifacts are discussed. Keywords: MR Fetal, Ultrasound Doppler, Cardiac, Heart, Congenital, Obstetrics, Fetus Supplemental material is available for this article. © RSNA, 2024.
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Affiliation(s)
- Thomas M. Vollbrecht
- From the Department of Diagnostic and Interventional Radiology,
University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany (T.M.V., A.I.,
C.H., J.A.L.); Quantitative Imaging Laboratory Bonn (QILaB), University Hospital
Bonn, Bonn, Germany (T.M.V., A.I., C.H., J.A.L.); Department of Biomedical
Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine,
University of Leeds, Leeds, United Kingdom (M.M.B.); Northh Medical, Hamburg,
Germany (F.K.); Departments of Obstetrics and Prenatal Medicine (A.G., B.S.S.)
and Pediatric Cardiology (C.H.), University Hospital Bonn, Bonn, Germany;
Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora,
Colo (A.J.B.); Department of Pediatric Radiology, Children’s Hospital
Colorado, Aurora, Colo (A.J.B.)
| | - Malenka M. Bissell
- From the Department of Diagnostic and Interventional Radiology,
University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany (T.M.V., A.I.,
C.H., J.A.L.); Quantitative Imaging Laboratory Bonn (QILaB), University Hospital
Bonn, Bonn, Germany (T.M.V., A.I., C.H., J.A.L.); Department of Biomedical
Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine,
University of Leeds, Leeds, United Kingdom (M.M.B.); Northh Medical, Hamburg,
Germany (F.K.); Departments of Obstetrics and Prenatal Medicine (A.G., B.S.S.)
and Pediatric Cardiology (C.H.), University Hospital Bonn, Bonn, Germany;
Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora,
Colo (A.J.B.); Department of Pediatric Radiology, Children’s Hospital
Colorado, Aurora, Colo (A.J.B.)
| | - Fabian Kording
- From the Department of Diagnostic and Interventional Radiology,
University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany (T.M.V., A.I.,
C.H., J.A.L.); Quantitative Imaging Laboratory Bonn (QILaB), University Hospital
Bonn, Bonn, Germany (T.M.V., A.I., C.H., J.A.L.); Department of Biomedical
Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine,
University of Leeds, Leeds, United Kingdom (M.M.B.); Northh Medical, Hamburg,
Germany (F.K.); Departments of Obstetrics and Prenatal Medicine (A.G., B.S.S.)
and Pediatric Cardiology (C.H.), University Hospital Bonn, Bonn, Germany;
Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora,
Colo (A.J.B.); Department of Pediatric Radiology, Children’s Hospital
Colorado, Aurora, Colo (A.J.B.)
| | - Annegret Geipel
- From the Department of Diagnostic and Interventional Radiology,
University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany (T.M.V., A.I.,
C.H., J.A.L.); Quantitative Imaging Laboratory Bonn (QILaB), University Hospital
Bonn, Bonn, Germany (T.M.V., A.I., C.H., J.A.L.); Department of Biomedical
Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine,
University of Leeds, Leeds, United Kingdom (M.M.B.); Northh Medical, Hamburg,
Germany (F.K.); Departments of Obstetrics and Prenatal Medicine (A.G., B.S.S.)
and Pediatric Cardiology (C.H.), University Hospital Bonn, Bonn, Germany;
Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora,
Colo (A.J.B.); Department of Pediatric Radiology, Children’s Hospital
Colorado, Aurora, Colo (A.J.B.)
| | - Alexander Isaak
- From the Department of Diagnostic and Interventional Radiology,
University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany (T.M.V., A.I.,
C.H., J.A.L.); Quantitative Imaging Laboratory Bonn (QILaB), University Hospital
Bonn, Bonn, Germany (T.M.V., A.I., C.H., J.A.L.); Department of Biomedical
Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine,
University of Leeds, Leeds, United Kingdom (M.M.B.); Northh Medical, Hamburg,
Germany (F.K.); Departments of Obstetrics and Prenatal Medicine (A.G., B.S.S.)
and Pediatric Cardiology (C.H.), University Hospital Bonn, Bonn, Germany;
Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora,
Colo (A.J.B.); Department of Pediatric Radiology, Children’s Hospital
Colorado, Aurora, Colo (A.J.B.)
| | - Brigitte S. Strizek
- From the Department of Diagnostic and Interventional Radiology,
University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany (T.M.V., A.I.,
C.H., J.A.L.); Quantitative Imaging Laboratory Bonn (QILaB), University Hospital
Bonn, Bonn, Germany (T.M.V., A.I., C.H., J.A.L.); Department of Biomedical
Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine,
University of Leeds, Leeds, United Kingdom (M.M.B.); Northh Medical, Hamburg,
Germany (F.K.); Departments of Obstetrics and Prenatal Medicine (A.G., B.S.S.)
and Pediatric Cardiology (C.H.), University Hospital Bonn, Bonn, Germany;
Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora,
Colo (A.J.B.); Department of Pediatric Radiology, Children’s Hospital
Colorado, Aurora, Colo (A.J.B.)
| | - Christopher Hart
- From the Department of Diagnostic and Interventional Radiology,
University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany (T.M.V., A.I.,
C.H., J.A.L.); Quantitative Imaging Laboratory Bonn (QILaB), University Hospital
Bonn, Bonn, Germany (T.M.V., A.I., C.H., J.A.L.); Department of Biomedical
Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine,
University of Leeds, Leeds, United Kingdom (M.M.B.); Northh Medical, Hamburg,
Germany (F.K.); Departments of Obstetrics and Prenatal Medicine (A.G., B.S.S.)
and Pediatric Cardiology (C.H.), University Hospital Bonn, Bonn, Germany;
Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora,
Colo (A.J.B.); Department of Pediatric Radiology, Children’s Hospital
Colorado, Aurora, Colo (A.J.B.)
| | - Alex J. Barker
- From the Department of Diagnostic and Interventional Radiology,
University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany (T.M.V., A.I.,
C.H., J.A.L.); Quantitative Imaging Laboratory Bonn (QILaB), University Hospital
Bonn, Bonn, Germany (T.M.V., A.I., C.H., J.A.L.); Department of Biomedical
Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine,
University of Leeds, Leeds, United Kingdom (M.M.B.); Northh Medical, Hamburg,
Germany (F.K.); Departments of Obstetrics and Prenatal Medicine (A.G., B.S.S.)
and Pediatric Cardiology (C.H.), University Hospital Bonn, Bonn, Germany;
Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora,
Colo (A.J.B.); Department of Pediatric Radiology, Children’s Hospital
Colorado, Aurora, Colo (A.J.B.)
| | - Julian A. Luetkens
- From the Department of Diagnostic and Interventional Radiology,
University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany (T.M.V., A.I.,
C.H., J.A.L.); Quantitative Imaging Laboratory Bonn (QILaB), University Hospital
Bonn, Bonn, Germany (T.M.V., A.I., C.H., J.A.L.); Department of Biomedical
Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine,
University of Leeds, Leeds, United Kingdom (M.M.B.); Northh Medical, Hamburg,
Germany (F.K.); Departments of Obstetrics and Prenatal Medicine (A.G., B.S.S.)
and Pediatric Cardiology (C.H.), University Hospital Bonn, Bonn, Germany;
Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora,
Colo (A.J.B.); Department of Pediatric Radiology, Children’s Hospital
Colorado, Aurora, Colo (A.J.B.)
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6
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Ricketts RM, Refakis CA, DiNardo JA. Commentary on the 2023 Guidelines and Recommendations for Performance of the Fetal Echocardiogram: An Update From the American Society of Echocardiography. J Cardiothorac Vasc Anesth 2023; 37:2431-2434. [PMID: 37775344 DOI: 10.1053/j.jvca.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 09/04/2023] [Indexed: 10/01/2023]
Affiliation(s)
- Robert M Ricketts
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA.
| | - Christian A Refakis
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - James A DiNardo
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
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7
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Reuter MS, Sokolowski DJ, Javier Diaz-Mejia J, Keunen J, de Vrijer B, Chan C, Wang L, Ryan G, Chiasson DA, Ketela T, Scherer SW, Wilson MD, Jaeggi E, Chaturvedi RR. Decreased left heart flow in fetal lambs causes left heart hypoplasia and pro-fibrotic tissue remodeling. Commun Biol 2023; 6:770. [PMID: 37481629 PMCID: PMC10363152 DOI: 10.1038/s42003-023-05132-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/11/2023] [Indexed: 07/24/2023] Open
Abstract
Low blood flow through the fetal left heart is often conjectured as an etiology for hypoplastic left heart syndrome (HLHS). To investigate if a decrease in left heart flow results in growth failure, we generate left ventricular inflow obstruction (LVIO) in mid-gestation fetal lambs by implanting coils in their left atrium using an ultrasound-guided percutaneous technique. Significant LVIO recapitulates important clinical features of HLHS: decreased antegrade aortic valve flow, compensatory retrograde perfusion of the brain and ascending aorta (AAo) from the arterial duct, severe left heart hypoplasia, a non-apex forming LV, and a thickened endocardial layer. The hypoplastic AAo have miRNA-gene pairs annotating to cell proliferation that are inversely differentially expressed by bulk RNA-seq. Single-nucleus RNA-seq of the hypoplastic LV myocardium shows an increase in fibroblasts with a reciprocal decrease in cardiomyocyte nuclei proportions. Fibroblasts, cardiomyocytes and endothelial cells from hypoplastic myocardium have increased expression of extracellular matrix component or fibrosis genes with dysregulated fibroblast growth factor signaling. Hence, a severe sustained ( ~ 1/3 gestation) reduction in fetal left heart flow is sufficient to cause left heart hypoplasia. This is accompanied by changes in cellular composition and gene expression consistent with a pro-fibrotic environment and aberrant induction of mesenchymal programs.
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Affiliation(s)
- Miriam S Reuter
- CGEn, The Hospital for Sick Children, Toronto, ON, Canada
- The Centre for Applied Genomics, The Hospital for Sick Children, Toronto, ON, Canada
- Genetics and Genome Biology, SickKids Research Institute, Toronto, ON, Canada
| | - Dustin J Sokolowski
- Genetics and Genome Biology, SickKids Research Institute, Toronto, ON, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | - J Javier Diaz-Mejia
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Johannes Keunen
- Ontario Fetal Centre, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Obstetrics & Gynaecology, University of Toronto, Toronto, ON, Canada
| | - Barbra de Vrijer
- Department of Obstetrics & Gynaecology, Western University, London, ON, Canada
- Children's Health Research Institute, London, ON, Canada
- London Health Sciences Centre, Victoria Hospital, London, ON, Canada
| | - Cadia Chan
- Genetics and Genome Biology, SickKids Research Institute, Toronto, ON, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | - Liangxi Wang
- Genetics and Genome Biology, SickKids Research Institute, Toronto, ON, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | - Greg Ryan
- Ontario Fetal Centre, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Obstetrics & Gynaecology, University of Toronto, Toronto, ON, Canada
| | - David A Chiasson
- Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Troy Ketela
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Stephen W Scherer
- The Centre for Applied Genomics, The Hospital for Sick Children, Toronto, ON, Canada
- Genetics and Genome Biology, SickKids Research Institute, Toronto, ON, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
- McLaughlin Centre, University of Toronto, Toronto, ON, Canada
| | - Michael D Wilson
- Genetics and Genome Biology, SickKids Research Institute, Toronto, ON, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | - Edgar Jaeggi
- Ontario Fetal Centre, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, ON, Canada
- Labatt Family Heart Centre, Division of Cardiology, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Rajiv R Chaturvedi
- Ontario Fetal Centre, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, ON, Canada.
- Labatt Family Heart Centre, Division of Cardiology, The Hospital for Sick Children, Toronto, ON, Canada.
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
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Ramcharan T, Quintero DB, Stickley J, Poole E, Miller P, Desai T, Harris M, Kilby MD, Stumper O, Khan N, Barron DJ, Seale AN. Medium-term Outcome of Prenatally Diagnosed Hypoplastic Left-Heart Syndrome and Impact of a Restrictive Atrial Septum Diagnosed in-utero. Pediatr Cardiol 2023:10.1007/s00246-023-03184-z. [PMID: 37219587 DOI: 10.1007/s00246-023-03184-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/12/2023] [Indexed: 05/24/2023]
Abstract
OBJECTIVE Surgical outcome data differs from overall outcomes of prenatally diagnosed fetuses with hypoplastic left heart syndrome (HLHS). Our aim was to describe outcome of prenatally diagnosed fetuses with this anomaly. METHODS Retrospective review of prenatally diagnosed classical HLHS at a tertiary hospital over a 13-year period, estimated due dates 01/08/2006 to 31/12/2019. HLHS-variants and ventricular disproportion were excluded. RESULTS 203 fetuses were identified with outcome information available for 201. There were extra-cardiac abnormalities in 8% (16/203), with genetic variants in 14% of those tested (17/122). There were 55 (27%) terminations of pregnancy, 5 (2%) intrauterine deaths and 10 (5%) babies had prenatally planned compassionate care. There was intention to treat (ITT) in the remaining 131/201(65%). Of these, there were 8 neonatal deaths before intervention, two patients had surgery in other centers. Of the other 121 patients, Norwood procedure performed in 113 (93%), initial hybrid in 7 (6%), and 1 had palliative coarctation stenting. Survival for the ITT group from birth at 6-months, 1-year and 5-years was 70%, 65%, 62% respectively. Altogether of the initial 201 prenatally diagnosed fetuses, 80 patients (40%) are currently alive. A restrictive atrial septum (RAS) is an important sub-category associated with death, HR 2.61, 95%CI 1.34-5.05, p = 0.005, with only 5/29 patients still alive. CONCLUSION Medium-term outcomes of prenatally diagnosed HLHS have improved however it should be noted that almost 40% do not get to surgical palliation, which is vital to those doing fetal counselling. There remains significant mortality particularly in fetuses with in-utero diagnosed RAS.
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Affiliation(s)
- Tristan Ramcharan
- Heart Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Diana B Quintero
- Heart Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - John Stickley
- Heart Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Esther Poole
- Heart Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Paul Miller
- Heart Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Tarak Desai
- Heart Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Michael Harris
- Heart Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Mark D Kilby
- Fetal Medicine Centre, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Medical Genomics Research Group, Granta Park, Illumina, Cambridge, UK
| | - Oliver Stumper
- Heart Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Natasha Khan
- Heart Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - David J Barron
- Heart Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Anna N Seale
- Heart Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.
- Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK.
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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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10
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Moerdijk AS, Claessens NH, van Ooijen IM, van Ooij P, Alderliesten T, Grotenhuis HB, Benders MJNL, Bohte AE, Breur JMPJ, Charisopoulou D, Clur SA, Cornette JMJ, Fejzic Z, Franssen MTM, Frerich S, Geerdink LM, Go ATJI, Gommers S, Helbing WA, Hirsch A, Holtackers RJ, Klein WM, Krings GJ, Lamb HJ, Nijman M, Pajkrt E, Planken RN, Schrauben EM, Steenhuis TJ, ter Heide H, Vanagt WYR, van Beynum IM, van Gaalen MD, van Iperen GG, van Schuppen J, Willems TP, Witters I. Fetal MRI of the heart and brain in congenital heart disease. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:59-68. [PMID: 36343660 DOI: 10.1016/s2352-4642(22)00249-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 08/12/2022] [Accepted: 08/22/2022] [Indexed: 11/06/2022]
Abstract
Antenatal assessment of congenital heart disease and associated anomalies by ultrasound has improved perinatal care. Fetal cardiovascular MRI and fetal brain MRI are rapidly evolving for fetal diagnostic testing of congenital heart disease. We give an overview on the use of fetal cardiovascular MRI and fetal brain MRI in congenital heart disease, focusing on the current applications and diagnostic yield of structural and functional imaging during pregnancy. Fetal cardiovascular MRI in congenital heart disease is a promising supplementary imaging method to echocardiography for the diagnosis of antenatal congenital heart disease in weeks 30-40 of pregnancy. Concomitant fetal brain MRI is superior to brain ultrasound to show the complex relationship between fetal haemodynamics in congenital heart disease and brain development.
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Affiliation(s)
- Anouk S Moerdijk
- Department of Pediatric Cardiology, Division of Pediatrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Nathalie Hp Claessens
- Department of Pediatric Cardiology, Division of Pediatrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands; Department of Neonatology, Division of Woman and Baby, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Inge M van Ooijen
- Department of Neonatology, Division of Woman and Baby, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Pim van Ooij
- Department of Pediatric Cardiology, Division of Pediatrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Thomas Alderliesten
- Department of Pediatric Cardiology, Division of Pediatrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands; Department of Neonatology, Division of Woman and Baby, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Heynric B Grotenhuis
- Department of Pediatric Cardiology, Division of Pediatrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands.
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11
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The Evolution and Developing Importance of Fetal Magnetic Resonance Imaging in the Diagnosis of Congenital Cardiac Anomalies: A Systematic Review. J Clin Med 2022; 11:jcm11237027. [PMID: 36498602 PMCID: PMC9738414 DOI: 10.3390/jcm11237027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/21/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
Magnetic Resonance Imaging (MRI) is a reliable method, with a complementary role to Ultrasound (US) Echocardiography, that can be used to fully comprehend and precisely diagnose congenital cardiac malformations. Besides the anatomical study of the fetal cardiovascular system, it allows us to study the function of the fetal heart, remaining, at the same time, a safe adjunct to the classic fetal echocardiography. MRI also allows for the investigation of cardiac and placental diseases by providing information about hematocrit, oxygen saturation, and blood flow in fetal vessels. It is crucial for fetal medicine specialists and pediatric cardiologists to closely follow the advances of fetal cardiac MRI in order to provide the best possible care. In this review, we summarize the advance in techniques and their practical utility to date.
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12
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Yan C. Is combined use of radiofrequency ablation and balloon dilation the future of interatrial communications? Expert Rev Cardiovasc Ther 2022; 20:895-903. [PMID: 36329641 DOI: 10.1080/14779072.2022.2144233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Personalized and stable interatrial communication is an important palliative therapy for patients with heart failure. However, this remains a technically challenging task. AREAS COVERED In the past decades, substantial advancements in atrial septostomy for the creation of controllable and durable interatrial communication have been made, and numerous novel devices and techniques are in various stages of development. In this review, we discuss the evolving indications for atrial septostomy, current approaches with or without device implantation, and indicators for optimal interatrial communication. The combined use of radiofrequency ablation and balloon dilation (CURB) is an individualized management approach based on underlying hemodynamics, which demonstrates unique advantages in creating a sufficient interatrial communication with satisfactory stability. The advantages and disadvantages of this implant-free procedure are analyzed and its clinical prospects are assessed. EXPERT OPINION With ready availability, high safety, and efficacy, CURB is a promising procedure for creating personalized and stable interatrial communication without device implantation. Further research is required to simplify the procedure, screen optimal reference parameters for personalized therapy, and evaluate the long-term outcome in a large population of patients.
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Affiliation(s)
- Chaowu Yan
- Department of Structural Heart Disease, Fuwai Hospital, 100037, Beijing, China
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13
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The role of ultrasound and MRI in diagnosing of obstetrics cardiac disorders: A systematic review. JOURNAL OF RADIATION RESEARCH AND APPLIED SCIENCES 2022. [DOI: 10.1016/j.jrras.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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14
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Wald R, Mertens L. Hypoplastic Left Heart Syndrome Across the Lifespan: Clinical Considerations for Care of the Fetus, Child, and Adult. Can J Cardiol 2022; 38:930-945. [PMID: 35568266 DOI: 10.1016/j.cjca.2022.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 04/22/2022] [Accepted: 04/24/2022] [Indexed: 12/14/2022] Open
Abstract
Hypoplastic left heart syndrome (HLHS) is the most common anatomic lesion in children born with single ventricle physiology and is characterized by the presence of a dominant right ventricle and a hypoplastic left ventricle along with small left-sided heart structures. Diagnostic subgroups of HLHS reflect the extent of inflow and outflow obstruction at the aortic and mitral valves, specifically stenosis or atresia. If left unpalliated, HLHS is a uniformly fatal lesion in infancy. Following introduction of the Norwood operation, early survival has steadily improved over the past four decades, mirroring advances in operative and peri-operative management as well as reflecting refinements in patient surveillance and interstage clinical care. Notably, survival following staged palliation has increased from 0% to a 5-year survival of 60-65% for children in some centres. Despite the prevalence of HLHS in childhood with relatively favourable surgical outcomes in contemporary series, this cohort is only now reaching early adult life and longer-term outcomes have yet to be elucidated. In this article we focus on contemporary clinical management strategies for patients with HLHS across the lifespan, from fetal to adult life. Nomenclature and diagnostic considerations are discussed and current literature pertaining to putative genetic etiologies is reviewed. The spectrum of fetal and pediatric interventional strategies, both percutaneous and surgical, are described. Clinical, patient-reported and neurodevelopmental outcomes of HLHS are delineated. Finally, note is made of current areas of clinical uncertainty and suggested directions for future research are highlighted.
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Affiliation(s)
- Rachel Wald
- Labatt Family Heart Centre, Division of Cardiology, Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Division of Cardiology, University Health Network, Department of Medicine,University of Toronto, Toronto, Ontario, Canada
| | - Luc Mertens
- Labatt Family Heart Centre, Division of Cardiology, Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Division of Cardiology, University Health Network, Department of Medicine,University of Toronto, Toronto, Ontario, Canada
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15
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Surgical Strategies in Single Ventricle Management of Neonates and Infants. Can J Cardiol 2022; 38:909-920. [PMID: 35513174 DOI: 10.1016/j.cjca.2022.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 12/17/2022] Open
Abstract
No area of congenital heart disease has undergone greater change and innovation than Single Ventricle management over the past 20 years. Surgical and catheter lab interventions have transformed outcomes such that in some subgroups more than 80% of these patients can survive into adulthood. Driven by parallel development in diagnostic imaging and cardiac intensive care, surgical management is focused on the neonatal period as the key time to creating a balanced circulation and limiting pulmonary blood-flow. Different configurations of the circulation including new types of surgical shunts and the role of 'hybrid' circulations provide greater options and better physiology. This overview will focus on these changes in surgical management and timing but also look at the exciting areas of regenerative therapies to improve ventricular function, and the concept of ventricular rehabilitation to achieve biventricular circulations in certain groups of patients. The importance of early (neonatal) intervention and multidisciplinary approach to management is emphasised, as well as looking beyond simply survival but also improving neurodevelopmental outcomes.
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16
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Generali T, Hermuzi A, Sajnach-Menke M, Johnson A, Crossland DS, O'Sullivan JJ, Nassar M, Hasan A, De Rita F. Evolving Approach in Hypoplastic Left Heart Syndrome With Restrictive and Intact Septum. World J Pediatr Congenit Heart Surg 2022; 13:311-320. [PMID: 35446214 DOI: 10.1177/21501351211073614] [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] [Indexed: 11/15/2022]
Abstract
Background: Hypoplastic left heart syndrome (HLHS) with either intact atrial septum (IS) or highly restrictive interatrial communication (HRIC) is associated with poor survival. Immediate postpartum access to cardiac therapy and timely left atrial decompression (LAD) are paramount to a successful outcome. We describe herein our evolving approach to LAD and report interstage and longer-term results. Methods: We retrospectively identified neonates with HLHS IS/HRIC requiring LAD between 2005 and 2019. All babies had prenatal/postnatal echocardiography. Our LAD strategy evolved over time from attempt at transcatheter balloon atrial septostomy (BAS) to surgical septectomy with inflow occlusion, to hybrid trans-atrial stent implantation. Results: Twelve neonates required LAD at a median time of 14 (0.5-31) hours after birth. Five patients underwent BAS that proved successful in 2 cases. Of the 3 unsuccessful cases, 2 required extra-corporeal membrane oxygenation (ECMO) support and died subsequently; one underwent hybrid trans-atrial stent implantation. Of the remaining 7 patients, 3 underwent surgical septectomy with inflow-occlusion and 4 underwent hybrid trans-atrial stent implantations. Overall, 8 patients survived LAD and reached Norwood palliation. Three of the 8 required ECMO postoperatively. There was no hospital mortality after Norwood stage 1 palliation and interstage survival was 100%. Six patients successfully underwent Glenn shunt (superior cavopulmonary anastomosis) and 5 have completed total cavopulmonary connection. Conclusions: Our experience suggests that prompt postnatal LAD can be safely achieved with careful multidisciplinary planning and accurate antenatal diagnosis. In our hands, hybrid trans-atrial septal stent insertion appears to be a safe approach which combines the versatility of transcatheter techniques together with the effectiveness of surgical control.
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Affiliation(s)
- Tommaso Generali
- 105565Department of Congenital Cardiac Surgery and Pediatric Cardiology, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Antony Hermuzi
- 105565Department of Congenital Cardiac Surgery and Pediatric Cardiology, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Magdalena Sajnach-Menke
- 105565Department of Congenital Cardiac Surgery and Pediatric Cardiology, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Anna Johnson
- 105565Department of Congenital Cardiac Surgery and Pediatric Cardiology, Freeman Hospital, Newcastle Upon Tyne, UK
| | - David S Crossland
- 105565Department of Congenital Cardiac Surgery and Pediatric Cardiology, Freeman Hospital, Newcastle Upon Tyne, UK
| | - John J O'Sullivan
- 105565Department of Congenital Cardiac Surgery and Pediatric Cardiology, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Mohamed Nassar
- 105565Department of Congenital Cardiac Surgery and Pediatric Cardiology, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Asif Hasan
- 105565Department of Congenital Cardiac Surgery and Pediatric Cardiology, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Fabrizio De Rita
- 105565Department of Congenital Cardiac Surgery and Pediatric Cardiology, Freeman Hospital, Newcastle Upon Tyne, UK
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17
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Freud LR, Seed M. Prenatal Diagnosis and Management of Single Ventricle Heart Disease. Can J Cardiol 2022; 38:897-908. [DOI: 10.1016/j.cjca.2022.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 03/27/2022] [Accepted: 04/04/2022] [Indexed: 12/18/2022] Open
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18
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Tulzer A, Huhta JC, Hochpoechler J, Holzer K, Karas T, Kielmayer D, Tulzer G. Hypoplastic Left Heart Syndrome: Is There a Role for Fetal Therapy? Front Pediatr 2022; 10:944813. [PMID: 35874565 PMCID: PMC9304816 DOI: 10.3389/fped.2022.944813] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 06/22/2022] [Indexed: 12/03/2022] Open
Abstract
During fetal life some cardiac defects may lead to diminished left heart growth and to the evolution of a form of hypoplastic left heart syndrome (HLHS). In fetuses with an established HLHS, severe restriction or premature closure of the atrial septum leads to left atrial hypertension and remodeling of the pulmonary vasculature, severely worsening an already poor prognosis. Fetal therapy, including invasive fetal cardiac interventions and non-invasive maternal hyperoxygenation, have been introduced to prevent a possible progression of left heart hypoplasia, improve postnatal outcome, or secure fetal survival. The aim of this review is to cover patient selection and possible hemodynamic effects of fetal cardiac procedures and maternal hyperoxygenation in fetuses with an evolving or established hypoplastic left heart syndrome.
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Affiliation(s)
- Andreas Tulzer
- Children's Heart Center Linz, Department of Pediatric Cardiology, Kepler University Hospital, Linz, Austria.,Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - James C Huhta
- Perinatal Cardiology, St. Joseph Hospital, Tampa, FL, United States
| | - Julian Hochpoechler
- Children's Heart Center Linz, Department of Pediatric Cardiology, Kepler University Hospital, Linz, Austria
| | - Kathrin Holzer
- Children's Heart Center Linz, Department of Pediatric Cardiology, Kepler University Hospital, Linz, Austria
| | - Thomas Karas
- Children's Heart Center Linz, Department of Pediatric Cardiology, Kepler University Hospital, Linz, Austria
| | - David Kielmayer
- Children's Heart Center Linz, Department of Pediatric Cardiology, Kepler University Hospital, Linz, Austria
| | - Gerald Tulzer
- Children's Heart Center Linz, Department of Pediatric Cardiology, Kepler University Hospital, Linz, Austria
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19
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Fetal cardiovascular magnetic resonance imaging. Pediatr Radiol 2020; 50:1881-1894. [PMID: 33252756 DOI: 10.1007/s00247-020-04902-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 09/23/2020] [Accepted: 11/02/2020] [Indexed: 12/11/2022]
Abstract
Fetal cardiovascular MRI is showing promise as a clinical diagnostic tool in the setting of congenital heart disease when the cardiac anatomy is unresolved by US or when complementary quantitative data on blood flow, oxygen saturation and hematocrit are required to aid in management. Compared with postnatal cardiovascular MRI, prenatal cardiovascular MRI still has some technical limitations. However, ongoing technical advances continue to improve the robustness and usability of fetal cardiovascular MRI. In this review, we provide an overview of the state of the art of fetal cardiovascular MRI and summarize the current focus of clinical application for this versatile technique.
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20
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Risk stratification of patients with hypoplastic left heart syndrome and intact atrial septum using fetal MRI and echocardiography. Cardiol Young 2020; 30:790-798. [PMID: 32406345 DOI: 10.1017/s1047951120001006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Despite prenatal diagnosis, prenatal intervention, and immediate postnatal intervention, patients with hypoplastic left heart syndrome and intact or highly restrictive atrial septum have the highest risk for mortality. Charts for all infants diagnosed with hypoplastic left heart syndrome from 2009 to 2017 were retrospectively reviewed and compared, including pulmonary vein Doppler patterns on fetal echocardiogram and evidence of pulmonary lymphangiectasia on fetal MRI. Of the 81 newborns with hypoplastic left heart syndrome, we defined two groups. Group 1 patients had an adequate atrial septal communication (n = 69), while Group 2 met criteria for intact/restrictive septum (n = 12). No patient in Group 1 had a type C pulmonary vein Doppler pattern, while no patient in Group 2 had a type A pulmonary vein Doppler pattern. The two patients with pulmonary lymphangiectasia had type C pulmonary vein Doppler pattern and an intact atrial septum and did not survive. Survival to discharge for Group 1 was 83% compared to 58% for Group 2 (p = 0.116). Survival to stage 2 palliation was 71% for Group 1 compared to 50% for Group 2 (p = 0.186). Only 4 of the initial 12 patients from Group 2 are alive, which is an overall survival of 33%. Our experience supports previous evidence that fetal echocardiography can identify those patients with the greatest likelihood for postnatal intervention as well as those at highest risk for mortality. Fetal MRI is a novel imaging modality that may help providers separate patients at highest risk for mortality, regardless of pulmonary vein Doppler pattern.
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21
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Schneider K, Hahn E, Statile C, Hirsch R, Khoury PR, Cnota J, Divanovic A. Pulmonary venous Doppler patterns and midterm outcomes in fetuses with left-sided obstructive lesions and restrictive atrial septum. Prenat Diagn 2020; 40:776-784. [PMID: 32176365 DOI: 10.1002/pd.5682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/29/2020] [Accepted: 03/04/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To compare length of stay of the initial neonatal hospitalization and mortality across multiple stages of surgical palliation for infants with left-sided obstructive lesions and severely restrictive or intact atrial septum (I/RAS). METHODS Retrospective cohort study of patients prenatally diagnosed with left-sided obstructive lesions and I/RAS, defined by fetal pulmonary venous Dopplers. RESULTS We identified 76 fetal patients with 59 live born intending to pursue intervention. Those with I/RAS had longer durations of mechanical ventilation (P = .031) but no difference in intensive care unit or total length of stay. Survival to discharge from neonatal hospitalization was 41.7% in the I/RAS group and 80.7% in the unrestrictive group (P = .001). There was a higher proportion of deaths between stage 1 and stage 2 in the I/RAS group - 5/9 (55.6%) vs 9/50 (18%) in the unrestrictive group (P = .027). Beyond stage 2 palliation there was trend toward a difference in overall mortality (66.7% in I/RAS vs 35.7% in unrestrictive, P = .05) but no statistically significant difference in transplant-free survival (33.3% in I/RAS vs 53.5% in unrestrictive, P = .11). CONCLUSION The survival disadvantage conferred by prenatally diagnosed severe atrial septal restriction is most pronounced in the neonatal and early infancy period, with no detectable difference in late midterm transplant-free survival in our cohort.
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Affiliation(s)
- Kristin Schneider
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Eunice Hahn
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Christopher Statile
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Russel Hirsch
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Philip R Khoury
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - James Cnota
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Allison Divanovic
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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22
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Tulzer A, Arzt W, Prandstetter C, Tulzer G. Atrial septum stenting in a foetus with hypoplastic left heart syndrome and restrictive foramen ovale: an alternative to emergency atrioseptectomy in the newborn-a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-4. [PMID: 32128498 PMCID: PMC7047067 DOI: 10.1093/ehjcr/ytaa005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 09/27/2019] [Accepted: 01/08/2020] [Indexed: 11/24/2022]
Abstract
Background In patients with hypoplastic left heart syndrome (HLHS) premature closure or restriction of the interatrial communication causes severe cyanosis directly after birth with rapid deterioration in clinical state. An ex-utero intrapartum treatment (EXIT) procedure, extracorporal membrane oxygenation (ECMO), and emergency interventional cardiac catheterization or cardiac surgery has to be anticipated and prepared. We report the first case performing foetal atrial septum stenting in such a patient directly before birth to enable uncomplicated interatrial shunting postnatally. Case summary A 31-year-old pregnant woman was referred to our centre for further evaluation of the foetus due to HLHS. In the follow-up study before birth severe restriction of the foramen ovale with increased retrograde flow in the pulmonary veins [0.33 ratio antegrade/retrograde time velocity integral (TVI)] was detected. After careful consideration foetal atrial septum stenting was performed at 38 + 3 weeks of gestation. At 39 + 2 weeks of gestation the baby was born by caesarean section followed by an uncomplicated postnatal adaption. On the 7th day of life a Norwood procedure was performed and the baby was discharged on the 63rd postoperative day. Discussion Evaluation of the interatrial communication in foetuses with HLHS should be done carefully just before birth. In the case of severe restriction or closure of the foramen ovale atrial septum stenting just before birth can be considered as an alternative treatment to an EXIT procedure, ECMO, or emergency atrioseptectomy on bypass. However, a very experienced team of paediatric cardiologists and perinatologists with expertise in foetal cardiac interventions is needed to perform this technical difficult procedure.
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Affiliation(s)
- Andreas Tulzer
- Department of Pediatric Cardiology, Children's Heart Center Linz, Kepler University Hospital, Krankenhausstrasse 26-30, 4020 Linz, Austria
| | - Wolfgang Arzt
- Institute of Prenatal Medicine, Kepler University Hospital, Krankenhausstrasse 26-30, 4020 Linz, Austria
| | - Christoph Prandstetter
- Department of Pediatric Cardiology, Children's Heart Center Linz, Kepler University Hospital, Krankenhausstrasse 26-30, 4020 Linz, Austria
| | - Gerald Tulzer
- Department of Pediatric Cardiology, Children's Heart Center Linz, Kepler University Hospital, Krankenhausstrasse 26-30, 4020 Linz, Austria
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23
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Kang SL, Jaeggi E, Ryan G, Chaturvedi RR. An Overview of Contemporary Outcomes in Fetal Cardiac Intervention: A Case for High-Volume Superspecialization? Pediatr Cardiol 2020; 41:479-485. [PMID: 32198586 DOI: 10.1007/s00246-020-02294-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 01/17/2020] [Indexed: 01/04/2023]
Abstract
Fetal cardiac interventions (FCI) offer the opportunity to rescue a fetus at risk of intrauterine death, or more ambitiously to alter disease progression. Most of these fetuses require multiple additional postnatal procedures, and it is difficult to disentangle the effect of the fetal procedure from that of the postnatal management sequence. The true clinical impact of FCI may only be discernible in large-volume institutions that can commit to a standardized postnatal approach and have sufficient case volume to overcome their FCI learning curve.
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Affiliation(s)
- Sok-Leng Kang
- Division of Cardiology, Labatt Heart Centre, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
| | - Edgar Jaeggi
- Division of Cardiology, Labatt Heart Centre, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
| | - Greg Ryan
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Mt Sinai Hospital, Toronto, ON, M5G 1X5, Canada
| | - Rajiv R Chaturvedi
- Division of Cardiology, Labatt Heart Centre, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada. .,Fetal Medicine Unit, Department of Obstetrics and Gynecology, Mt Sinai Hospital, Toronto, ON, M5G 1X5, Canada.
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24
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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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25
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Strainic J, Armstrong A. Fetal Cardiac Intervention: a Review of the Current Literature. CURRENT PEDIATRICS REPORTS 2020. [DOI: 10.1007/s40124-020-00209-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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26
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Creation of high position fetal balloon atrial septoplasty for hypoplastic left heart syndrome and highly restrictive atrial septum: A case report and literature review. J Interv Med 2020; 3:55-57. [PMID: 34805908 PMCID: PMC8562168 DOI: 10.1016/j.jimed.2020.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Fetal balloon atrial septoplasty (BAS) is performed through the restrictive foramen ovale in fetal cases with established hypoplastic left heart syndrome (HLHS) and an intact or highly restrictive atrial septum (RAS). Methods In the current report, we present a case of high position BAS in a fetus with HLHS/RAS. Results Echocardiography confirmed an adequate atrial opening above the foramen ovale and fetal pleural effusion resolved spontaneously 1 day after the procedure. Conclusion To the best of our knowledge, the creation of a high position hole in the thinner part of the atrial septum, instead of the restrictive tiny hole, has not been reported in fetal cases with HLHS/RAS.
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Marini D, Xu J, Sun L, Jaeggi E, Seed M. Current and future role of fetal cardiovascular MRI in the setting of fetal cardiac interventions. Prenat Diagn 2019; 40:71-83. [PMID: 31834624 DOI: 10.1002/pd.5626] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 11/01/2019] [Accepted: 11/04/2019] [Indexed: 12/11/2022]
Abstract
Over recent years, technical developments resulting in the feasibility of fetal cardiovascular magnetic resonance (CMR) have provided a new diagnostic tool for studying the human fetal heart and circulation. During the same period, we have witnessed the arrival of several minimally invasive fetal cardiac interventions (FCI) as a possible form of treatment in selected congenital heart diseases (CHDs). The role of fetal CMR in the planning and monitoring of FCI is not yet clear. Indeed, high-quality fetal CMR is not available or routinely offered at most centers caring for patients with prenatally detected CHD. However, in theory, fetal CMR could have much to offer in the setting of FCI by providing complementary anatomic and physiologic information relating to the specific intervention under consideration. Similarly, fetal CMR may be useful as an alternative imaging modality when ultrasound is hampered by technical limitations, for example, in the setting of oligohydramnios and in late gestation. In this review, we summarize current experience of the use of fetal CMR in the diagnosis and monitoring of fetuses with cardiopathies in the setting of a range of invasive in utero cardiac and vascular interventions and medical treatments and speculate about future directions for this versatile imaging medium.
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Affiliation(s)
- Davide Marini
- Division of Pediatric Cardiology, Department of Pediatrics, University of Toronto and Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jiawei Xu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Toronto and Hospital for Sick Children, Toronto, Ontario, Canada
| | - Liqun Sun
- Division of Pediatric Cardiology, Department of Pediatrics, University of Toronto and Hospital for Sick Children, Toronto, Ontario, Canada
| | - Edgar Jaeggi
- Division of Pediatric Cardiology, Department of Pediatrics, University of Toronto and Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mike Seed
- Division of Pediatric Cardiology, Department of Pediatrics, University of Toronto and Hospital for Sick Children, Toronto, Ontario, Canada
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Mallmann MR, Herberg U, Gottschalk I, Strizek B, Hellmund A, Geipel A, Breuer J, Gembruch U, Berg C. Fetal Cardiac Intervention in Critical Aortic Stenosis with Severe Mitral Regurgitation, Severe Left Atrial Enlargement, and Restrictive Foramen Ovale. Fetal Diagn Ther 2019; 47:440-447. [PMID: 31593939 DOI: 10.1159/000502840] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 08/21/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess the intrauterine course and outcome of fetal cardiac intervention (FCI) in fetuses with critical aortic stenosis (CAS), severe mitral regurgitation (MR), severe left atrial dilatation (LAD), and restrictive foramen ovale (RFO) or intact atrial septum. METHODS All fetuses with a prenatal diagnosis of CAS, severe MR, severe LAD, and RFO were retrospectively collected in one tertiary center for fetal medicine over a period of 10 years. Video recordings, pre- and postnatal charts were reviewed for cardiac and extracardiac anomalies, intrauterine course, and postnatal outcome. RESULTS Nineteen fetuses with CAS, severe MR, severe LAD, and RFO were diagnosed in the study period. In 5 cases, FCI was not considered as the parents either opted for expectative management or for termination. In the remaining 14 fetuses, 21 FCI were performed: 14 balloon valvuloplasties, 2 atrioseptostomies, and 5 fetal atrial stent insertions. Seven of 14 fetuses (50%) had fetal hydrops, 5 of 14 fetuses (36%) presented with intact atrial septum. Procedure-related death occurred in 5 fetuses after aortic valvuloplasty or concomitant atrioseptostomy but in none after fetal atrial stenting. Due to progressive hydrops, two terminations of pregnancy were performed. Among the 7 live births, 3 died in the neonatal period. The remaining 4 received single ventricle palliation, 2 following fetal aortic valvuloplasty and 2 after fetal atrial stent insertion. CONCLUSIONS CAS with severe MR, severe LAD, and RFO has a high overall mortality even in cases undergoing intrauterine intervention. Parameters that accurately predict the intrauterine and postnatal outcome have yet to be defined.
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Affiliation(s)
- Michael R Mallmann
- Division of Prenatal Medicine and Gynecologic Sonography, University of Cologne, Cologne, Germany,
| | - Ulrike Herberg
- Department of Pediatric Cardiology, University of Bonn, Bonn, Germany
| | - Ingo Gottschalk
- Division of Prenatal Medicine and Gynecologic Sonography, University of Cologne, Cologne, Germany
| | - Brigitte Strizek
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | - Astrid Hellmund
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | - Annegret Geipel
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | - Johannes Breuer
- Department of Pediatric Cardiology, University of Bonn, Bonn, Germany
| | - Ulrich Gembruch
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | - Christoph Berg
- Division of Prenatal Medicine and Gynecologic Sonography, University of Cologne, Cologne, Germany.,Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
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Marini D, van Amerom J, Saini BS, Sun L, Seed M. MR imaging of the fetal heart. J Magn Reson Imaging 2019; 51:1030-1044. [PMID: 31190452 DOI: 10.1002/jmri.26815] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/20/2019] [Accepted: 05/21/2019] [Indexed: 12/11/2022] Open
Abstract
In the last decade, technological advances have enabled the acquisition of high spatial and temporal resolution cardiac magnetic resonance imaging (MRI) in the fetus. Fetal cardiac MRI has emerged as an alternative to ultrasound, which may be helpful to confirm a diagnosis of congenital heart disease when ultrasound assessment is hampered, for example in late gestation or in the setting of oligohydramnios. MRI also provides unique physiologic information, including vessel blood flow, oxygen saturation and hematocrit, which may be helpful to investigate cardiac and placental diseases. In this review, we summarize some of the main techniques and significant advances in the field to date. Level of Evidence: 5 Technical Efficacy: Stage 5 J. Magn. Reson. Imaging 2020;51:1030-1044.
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Affiliation(s)
- Davide Marini
- Division of Pediatric Cardiology, Department of Pediatrics, University of Toronto and Hospital for Sick Children, Toronto, ON, Canada
| | - Joshua van Amerom
- Division of Pediatric Cardiology, Department of Pediatrics, University of Toronto and Hospital for Sick Children, Toronto, ON, Canada
| | - Brahmdeep S Saini
- Division of Pediatric Cardiology, Department of Pediatrics, University of Toronto and Hospital for Sick Children, Toronto, ON, Canada
| | - Liqun Sun
- Division of Pediatric Cardiology, Department of Pediatrics, University of Toronto and Hospital for Sick Children, Toronto, ON, Canada
| | - Mike Seed
- Division of Pediatric Cardiology, Department of Pediatrics, University of Toronto and Hospital for Sick Children, Toronto, ON, Canada
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30
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Pedra SRFF, Zielinsky P, Binotto CN, Martins CN, Fonseca ESVBD, Guimarães ICB, Corrêa IVDS, Pedrosa KLM, Lopes LM, Nicoloso LHS, Barberato MFA, Zamith MM. Brazilian Fetal Cardiology Guidelines - 2019. Arq Bras Cardiol 2019; 112:600-648. [PMID: 31188968 PMCID: PMC6555576 DOI: 10.5935/abc.20190075] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Simone R F Fontes Pedra
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brazil.,Hospital do Coração (HCor), São Paulo, SP - Brazil
| | - Paulo Zielinsky
- Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS - Brazil
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Said SM, Qureshi MY, Taggart NW, Anderson HN, O'Leary PW, Cetta F, Alrahmani L, Cofer SA, Segura LG, Pike RB, Sharpe EE, Derleth DP, Nemergut ME, Van Dorn CS, Gleich SJ, Rose CH, Collura CA, Ruano R. Innovative 2-Step Management Strategy Utilizing EXIT Procedure for a Fetus With Hypoplastic Left Heart Syndrome and Intact Atrial Septum. Mayo Clin Proc 2019; 94:356-361. [PMID: 30711131 DOI: 10.1016/j.mayocp.2018.08.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 06/17/2018] [Accepted: 08/08/2018] [Indexed: 11/23/2022]
Abstract
Hypoplastic left heart syndrome (HLHS) with intact atrial septum (HLHS-IAS) carries a high risk of mortality and affects about 6% of all patients with HLHS. Fetal interventions, postnatal transcatheter interventions, and postnatal surgical resection have all been used, but the mortality risk continues to be high in this subgroup of patients. We describe a novel, sequential approach to manage HLHS-IAS and progressive fetal hydrops. A 28-year-old, gravida 4 para 2 mother was referred to Mayo Clinic for fetal HLHS. Fetal echocardiography at 28 weeks of gestation demonstrated HLHS-IAS with progressive fetal hydrops. The atrial septum was thick and muscular with no interatrial communication. Ultrasound-guided fetal atrial septostomy was performed with successful creation of a small atrial communication. However, fetal echocardiogram at 33 weeks of gestation showed recurrence of a pleural effusion and restriction of the atrial septum. We proceeded with an Ex uteroIntrapartum Treatment (EXIT) delivery and open atrial septectomy. This was performed successfully, and the infant was stabilized in the intensive care unit. The infant required venoarterial extracorporeal membrane oxygenator support on day of life 1. The patient later developed hemorrhagic complications, leading to his demise on day of life 9. This is the first reported case of an EXIT procedure and open atrial septectomy performed without cardiopulmonary bypass for an open-heart operation and provides a promising alternative strategy for the management of HLHS-IAS in select cases.
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Affiliation(s)
- Sameh M Said
- Department of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, MN
| | | | - Nathaniel W Taggart
- Division of Pediatric Cardiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Heather N Anderson
- Division of Pediatric Cardiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Patrick W O'Leary
- Division of Pediatric Cardiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Frank Cetta
- Division of Pediatric Cardiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Layan Alrahmani
- Division of Obstetrics and Maternal Fetal Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Shelagh A Cofer
- Division of Pediatric Otorhinolaryngology, Mayo Clinic College of Medicine, Rochester, MN
| | - Leal G Segura
- Division of Pediatric Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Roxann B Pike
- Division of Cardiovascular Anesthesia, Mayo Clinic College of Medicine, Rochester, MN
| | - Emily E Sharpe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Douglas P Derleth
- Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Michael E Nemergut
- Division of Pediatric Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Charlotte S Van Dorn
- Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Stephen J Gleich
- Division of Pediatric Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN
| | - Carl H Rose
- Division of Obstetrics and Maternal Fetal Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | | | - Rodrigo Ruano
- Division of Obstetrics and Maternal Fetal Medicine, Mayo Clinic College of Medicine, Rochester, MN.
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Buffie AW, Belfort MA, Shamshirsaz AA, Justino H, Qureshi AM, Ayres NA, Morris SA, Espinoza J. Two- and Four-dimensional Ultrasonography of an Interatrial Stent in a Fetus With Hypoplastic Left Heart Syndrome. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:549-551. [PMID: 30058144 DOI: 10.1002/jum.14718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/18/2018] [Accepted: 05/22/2018] [Indexed: 06/08/2023]
Affiliation(s)
| | - Michael A Belfort
- Division of Maternal-Fetal Medicine Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Alireza A Shamshirsaz
- Division of Maternal-Fetal Medicine Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Henri Justino
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Athar M Qureshi
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Nancy A Ayres
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Shaine A Morris
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Jimmy Espinoza
- Division of Maternal-Fetal Medicine Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
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Fetal Intracardiac Hemodynamic Measurements Using Pressure Guidewire During Fetal Atrial Septal Stent Placement. JACC Cardiovasc Interv 2019; 12:e25-e26. [PMID: 30660455 DOI: 10.1016/j.jcin.2018.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 11/21/2018] [Accepted: 11/27/2018] [Indexed: 11/23/2022]
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Schidlow DN, Freud L, Friedman K, Tworetzky W. Fetal interventions for structural heart disease. Echocardiography 2018; 34:1834-1841. [PMID: 29287139 DOI: 10.1111/echo.13667] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Fetal cardiac intervention (FCI) offers the potential to alter in utero anatomy and physiology. For aortic stenosis with evolving hypoplastic left heart syndrome and pulmonary atresia with intact ventricular septum with evolving hypoplastic right heart syndrome, FCI may result in maintenance of a biventricular circulation, thus avoiding single-ventricle palliation and its attendant complications. In the case of hypoplastic left heart syndrome with intact atrial septum, FCI may ameliorate in utero pathophysiology and portend a more favorable postnatal prognosis. In all cases, a detailed fetal echocardiographic assessment to identify the appropriate FCI candidate is essential. This article reviews the three aforementioned lesions for which FCI can be considered. The pathophysiology and rationale for intervention, echocardiographic assessment, patient selection criteria, and outcomes for each lesion will be reviewed. A primary focus will be the echocardiographic evaluation of each lesion.
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Affiliation(s)
- David N Schidlow
- Children's National Heart Institute, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Lindsay Freud
- Division of Pediatric Cardiology, Columbia University Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Kevin Friedman
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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35
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Hunter LE, Seale AN. EDUCATIONAL SERIES IN CONGENITAL HEART DISEASE: Prenatal diagnosis of congenital heart disease. Echo Res Pract 2018; 5:R81-R100. [PMID: 30012852 PMCID: PMC6107762 DOI: 10.1530/erp-18-0027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 07/16/2018] [Indexed: 12/31/2022] Open
Abstract
This review article will guide the reader through the background of prenatal screening for congenital heart disease. The reader will be given insight into the normal screening views, common abnormalities, risk stratification of lesions and also recent advances in prenatal cardiology.
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Affiliation(s)
- Lindsey E Hunter
- Department of Paediatric Cardiology, Royal Hospital for Children, Glasgow, UK
| | - Anna N Seale
- Department of Paediatric Cardiology, Birmingham Children’s Hospital, Birmingham, UK
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36
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Gellis L, Drogosz M, Lu M, Sleeper LA, Cheng H, Allan C, Marshall AC, Tworetzky W, Friedman KG. Echocardiographic predictors of neonatal illness severity in fetuses with critical left heart obstruction with intact or restrictive atrial septum. Prenat Diagn 2018; 38:788-794. [PMID: 29956347 DOI: 10.1002/pd.5322] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 06/20/2018] [Accepted: 06/21/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND Neonates with critical left heart obstruction and intact atrial septum (IAS) or restrictive atrial septum (RAS) are at risk for hypoxia within hours of birth and remain a group at high risk for mortality. METHODS Prenatally diagnosed fetuses with critical left heart obstruction and IAS or RAS with follow-up from January 1, 2005, to February 14, 2017, were included. Primary outcome was a composite measure of severe neonatal illness (pH < 7.15, venous pH < 7.10, bicarbonate < 16 mmol/L, lactic acid > 5 mmol/L, or median oxygen saturation < 60% within 2 hours of birth). RESULTS Of 68 live born fetuses, 52 (76.5%) had hypoplastic left heart syndrome, 14 (20.5%) had critical aortic stenosis, and two (3%) had complex anatomy with mitral stenosis/atresia. There were 27 (39.7%) fetuses with IAS and 41 (60.3%) with RAS. Severe neonatal illness was present in 36 (52.9%). The strongest discriminators for severe neonatal illness were a pulmonary vein A:R VTI ≤ 2.7 (P < 0.001, AUC 0.93) and larger pulmonary vein diameter (P = 0.025, AUC 0.77). A:R VTI ≤ 2.7 predicted death or transplant (log-rank P = 0.03). CONCLUSIONS In neonates with hypoplastic left heart syndrome and IAS or RAS, A:R VTI ≤ 2.7 is predictive of severe neonatal instability. This threshold can help guide resource planning, delivery management, and improve fetal intervention criteria.
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Affiliation(s)
- Laura Gellis
- Department of Cardiology, Children's Hospital Boston, Boston, Massachusetts, US.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, US
| | - Monika Drogosz
- Department of Cardiology, Children's Hospital Boston, Boston, Massachusetts, US
| | - Minmin Lu
- Department of Cardiology, Children's Hospital Boston, Boston, Massachusetts, US
| | - Lynn A Sleeper
- Department of Cardiology, Children's Hospital Boston, Boston, Massachusetts, US.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, US
| | - Henry Cheng
- Department of Cardiology, Children's Hospital Boston, Boston, Massachusetts, US.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, US
| | - Catherine Allan
- Department of Cardiology, Children's Hospital Boston, Boston, Massachusetts, US.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, US
| | - Audrey C Marshall
- Department of Pediatrics Division of Cardiology, Department of Pediatrics, Tufts Medical Center, Boston, Massachusetts, US
| | - Wayne Tworetzky
- Department of Cardiology, Children's Hospital Boston, Boston, Massachusetts, US.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, US
| | - Kevin G Friedman
- Department of Cardiology, Children's Hospital Boston, Boston, Massachusetts, US.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, US
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Abstract
Fetal cardiac abnormalities are some of the commonest congenital disorders seen in prenatal life. They can be anatomical or functional and can develop de novo or as a consequence of either maternal or fetal disease. Untreated, morbidity and mortality rates are high for hypoplastic left heart disorders and for some fetal tachy and bradyarrhythmias. Optimum management strategies are often not clear because of the lack of knowledge about the precise natural history of some of these conditions. Prenatal therapy ranges from invasive fetal cardiac intervention to maternal administration of drugs for transplacental transfer to the fetus. This comprehensive review covers many fetal cardiac disorders and various prenatal therapeutic options that are available.
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Affiliation(s)
- Sailesh Kumar
- a Mater Research Institute / University of Queensland , Brisbane , Australia.,b Mater Centre for Maternal Fetal Medicine , Mater Mothers' Hospital , Brisbane , Australia.,c Faculty of Medicine , the University of Queensland , Brisbane , Australia
| | - Jade Lodge
- b Mater Centre for Maternal Fetal Medicine , Mater Mothers' Hospital , Brisbane , Australia
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38
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A potentially curative fetal intervention for hypoplastic left heart syndrome. Med Hypotheses 2018; 110:132-137. [PMID: 29317056 DOI: 10.1016/j.mehy.2017.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 11/26/2017] [Accepted: 12/01/2017] [Indexed: 11/21/2022]
Abstract
Hypoplastic left heart syndrome (HLHS) encapsulates a spectrum of complex congenital cardiovascular malformations involving varying degrees of underdevelopment of the left-sided heart structures. However, despite improved survival rates since the introduction of staged surgical reconstruction, treatment options for HLHS remain palliative rather than curative. A major limiting factor in the development of definitive curative therapy for HLHS is an incomplete understanding of its pathogenesis. Currently, the aetiology HLHS is best conceptualised by the 'flow theory' of cardiogenesis, which states that normal cardiac development is reliant on the interrelationship of normal flow patterns of blood through the developing heart, and appropriate growth of the cardiac valves and myocardium. Thus, congenital cardiac malformations, such as HLHS, are thought to arise when these two processes are incorrectly coupled in utero. The rationale for the hypothesis proposed herein rests upon the flow theory of cardiogenesis. Morphological studies of HLHS indicate that, although underdeveloped, all left-sided cardiac structures are present and anatomically correct. Further, of the various structural abnormalities that can occur within the spectrum of HLHS, the presence of a ventricular septal defect (VSD) is rare. The rarity of a VSD within the morphological spectrum of HLHS suggests the syndrome may not develop in the presence of a functionally significant VSD. Presumably, the presence of a functional VSD establishes a communication between the two ventricles during cardiac development, and preserves the normal pressure-flow-dependent growth of the left ventricular (LV) myocardium, despite inflow/outflow valve defects. It is proposed that surgical creation of a VSD in utero will 'rescue' the LV of hearts with left-sided valvular deformities that render them susceptible to the development of HLHS later in gestation. In evaluating this hypothesis, potential techniques for surgical creation of a VSD in utero are offered. These techniques are based on already established catheter-based in utero interventions, and conventional postnatal percutaneous procedures for VSD creation. Further discussion is also offered on techniques to avoid, and manage, potential complications (i.e. conduction system damage) of the proposed technique(s). Finally, if VSD creation in utero is indeed practically feasible, and successfully establishes the hypothesised hemodynamic and myocardial growth normalisation within the abnormally developing LV, the clinical implications are profound. This procedure may hold a potential cure for almost every sub-type of HLHS.
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Mainzer G, Goreczny S, Morgan GJ, Qureshi S, Krasemann T, Dryzek P, Moll JA, Moszura T, Rosenthal E. Stenting of the inter-atrial septum in infants and small children: Indications, techniques and outcomes. Catheter Cardiovasc Interv 2018; 91:1294-1300. [DOI: 10.1002/ccd.27462] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 11/04/2017] [Accepted: 11/29/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Gur Mainzer
- Department of Paediatric Cardiology; Evelina London Children's Hospital, Guy's and St. Thomas' Hospital; London United Kingdom
- Paediatric Cardiology Unit, Padeh-Poriya Medical Center; Tiberias Israel
| | - Sebastian Goreczny
- Cardiology Department; Polish Mother's Memorial Hospital, Research Institute; Lodz Poland
| | - Gareth J. Morgan
- Department of Paediatric Cardiology; Evelina London Children's Hospital, Guy's and St. Thomas' Hospital; London United Kingdom
- Department of Congenital Cardiology; University of Colorado; Denver Colorado
| | - Shakeel Qureshi
- Department of Paediatric Cardiology; Evelina London Children's Hospital, Guy's and St. Thomas' Hospital; London United Kingdom
| | - Thomas Krasemann
- Department of Paediatric Cardiology; Evelina London Children's Hospital, Guy's and St. Thomas' Hospital; London United Kingdom
- Department of Pediatric Cardiology; Erasmus Medical Centre; Rotterdam Netherlands
| | - Pawel Dryzek
- Cardiology Department; Polish Mother's Memorial Hospital, Research Institute; Lodz Poland
| | - Jadwiga A Moll
- Cardiology Department; Polish Mother's Memorial Hospital, Research Institute; Lodz Poland
| | - Tomasz Moszura
- Cardiology Department; Polish Mother's Memorial Hospital, Research Institute; Lodz Poland
| | - Eric Rosenthal
- Department of Paediatric Cardiology; Evelina London Children's Hospital, Guy's and St. Thomas' Hospital; London United Kingdom
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40
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Bravo-Valenzuela NJ, Peixoto AB, Araujo Júnior E. Prenatal diagnosis of congenital heart disease: A review of current knowledge. Indian Heart J 2017; 70:150-164. [PMID: 29455772 PMCID: PMC5903017 DOI: 10.1016/j.ihj.2017.12.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 12/10/2017] [Accepted: 12/13/2017] [Indexed: 01/16/2023] Open
Abstract
This article reviews important features to improve the diagnosis of congenital heart disease (CHD) by applying ultrasound in prenatal cardiac screening. As low and high-risk pregnancies for CHD are subject to routine obstetric ultrasound, the diagnosis of structural heart defects represents a challenge that involves a team of specialists and subspecialists on fetal ultrasonography. In this review, the images highlight normal anatomy of the heart as well as pathologic cases consistent with cardiac malposition and isomerism, septal defects, pulmonary stenosis/atresia, aortic malformations, hypoplastic left ventricle, conotruncal anomalies, tricuspid dysplasia, and Ebstein’s anomaly, and univentricular heart, among other congenital cardiovascular defects. Anatomical details of most CHD in fetuses were provided by two-dimensional (2D) ultrasound with higher quality imaging, enhancing diagnostic accuracy in a variety of CHD. Moreover, the accuracy of the cardiac defects in obstetrics ultrasound improves the outcome of most CHD, providing planned delivery, aided genetic counseling, and perinatal management.
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Affiliation(s)
| | - Alberto Borges Peixoto
- Department of Obstetrics, Paulista School of Medicine - Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil; Mário Palmério University Hospital, University of Uberaba (UNIUBE), Uberaba, MG, Brazil
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine - Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil.
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Intrauterine therapy for structural congenital heart disease: Contemporary results and Canadian experience. Trends Cardiovasc Med 2016; 26:639-46. [DOI: 10.1016/j.tcm.2016.04.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Revised: 04/09/2016] [Accepted: 04/19/2016] [Indexed: 11/19/2022]
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Sonographic Pulmonary Abnormalities in Fetuses With Hypoplastic Left Heart Syndrome and Intact Atrial Septum Undergoing Attempted Atrial Septostomy In Utero. Ultrasound Q 2016; 33:82-85. [PMID: 27575842 DOI: 10.1097/ruq.0000000000000247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Fetuses with hypoplastic left heart syndrome (HLHS) and intact atrial septum are a particular subset of HLHS neonates with high perinatal mortality. The reported mortality in these patients is 50% to 70%, even with prenatal diagnosis. Prenatal left atrial and pulmonary venous hypertension results in abnormal pulmonary vascular and parenchymal development. The goal of this study was to compare the sonographic appearance of the lungs in fetuses with HLHS/intact atrial septum to neonatal outcome and/or pathology in cases where in utero intervention was performed to open the atrial septum. We found that lung inhomogeneity on ultrasound corresponded to peripheral lymphatic dilatation at autopsy and was associated with a dismal prognosis even when in utero intervention was successful.
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Abstract
BACKGROUND Hypoplastic left heart syndrome (HLHS) is an etiologically multifactorial congenital heart disease affecting one in 5,000 newborns. Thirty years ago there were no treatment options for this pathology and the natural course of the disease led to death, usually within the first weeks of life. Recently surgical palliative techniques have been developed allowing for a five-year survival in more than half the cases. MATERIALS AND METHODS We reviewed literature available on HLHS, specifically its anatomy, embryology and pathophysiology, and treatment. The Pubmed and ClinicalKey databases were searched using the key words hypoplastic left heart syndrome, foetal aortic valvuloplasty, foetal septoplasty, Norwood procedure, bidirectional Glenn procedure, Fontan procedure, hybrid procedure. The relevant literature was reviewed and included in the article. We reported a case from Children's Clinical University Hospital, Riga, to illustrate treatment tactics in Latvia. RESULTS There are three possible directions for therapy in newborns with HLHS: orthotopic heart transplantation, staged surgical palliation and palliative non-surgical treatment or comfort care. Another treatment mode - foetal therapy - has arisen. Staged palliation and full Fontan circulation is a temporary solution, however, the only means for survival until heart transplantation. Fifty to 70% of patients who have gone through all three stages of palliation live to the age of five years. CONCLUSIONS The superior mode of treatment is not yet clear and the management must be based on each individual case, the experience of each clinic, as well as the financial aspects and will of the patient's parents.
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Affiliation(s)
| | | | - Ingūna Lubaua
- Riga Stradiņš University, Riga, Latvia.,Department of Cardiology and Cardio Surgery, Children's Clinical University Hospital, Riga, Latvia
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Yuan SM, Humuruola G. Fetal cardiac interventions: clinical and experimental research. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2016; 12:99-107. [PMID: 27279868 PMCID: PMC4882381 DOI: 10.5114/aic.2016.59359] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 10/04/2015] [Indexed: 11/17/2022] Open
Abstract
Fetal cardiac interventions for congenital heart diseases may alleviate heart dysfunction, prevent them evolving into hypoplastic left heart syndrome, achieve biventricular outcome and improve fetal survival. Candidates for clinical fetal cardiac interventions are now restricted to cases of critical aortic valve stenosis with evolving hypoplastic left heart syndrome, pulmonary atresia with an intact ventricular septum and evolving hypoplastic right heart syndrome, and hypoplastic left heart syndrome with an intact or highly restrictive atrial septum as well as fetal heart block. The therapeutic options are advocated as prenatal aortic valvuloplasty, pulmonary valvuloplasty, creation of interatrial communication and fetal cardiac pacing. Experimental research on fetal cardiac intervention involves technical modifications of catheter-based cardiac clinical interventions and open fetal cardiac bypass that cannot be applied in human fetuses for the time being. Clinical fetal cardiac interventions are plausible for midgestation fetuses with the above-mentioned congenital heart defects. The technical success, biventricular outcome and fetal survival are continuously being improved in the conditions of the sophisticated multidisciplinary team, equipment, techniques and postnatal care. Experimental research is laying the foundations and may open new fields for catheter-based clinical techniques. In the present article, the clinical therapeutic options and experimental fetal cardiac interventions are described.
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Affiliation(s)
- Shi-Min Yuan
- The First Hospital of Putian, Teaching Hospital, Fujian Medical University, Putian, Fujian Province, China
| | - Gulimila Humuruola
- People's Hospital of Jimunai, Altay Prefecture, Xinjiang Uygur Autonomous Region, China
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Hermuzi A, McBrien A, De Rita F, McCheyne A, Griselli M, O'Sullivan JJ, Hasan A, Crossland DS. Hybrid transatrial stent insertion for left atrial decompression in hypoplastic left heart syndrome with intact atrial septum. Catheter Cardiovasc Interv 2016; 87:109-16. [PMID: 26268147 DOI: 10.1002/ccd.26115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 07/05/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To describe a novel strategy for the management of infants with hypoplastic left heart syndrome (HLHS) and intact atrial septum. Antenatally diagnosed infants are delivered in cardiac theatre and immediate left atrial decompression (LAD) using hybrid transatrial stent insertion (HTSI) via sternotomy is carried out. BACKGROUND HLHS with intact atrial septum is a condition incompatible with life following placental separation. Despite a number of reported strategies the survival of these infants remains much worse than those born with an adequate atrial communication. Immediate postnatal LAD is mandatory to allow consideration of active treatment. METHODS Single institution retrospective review of intention to carry out HTSI for LAD in infants with an antenatal diagnosis of HLHS intact atrial septum. RESULTS Two patients were delivered by planned caesarean section and transferred immediately to the prepared team in the adjacent cardiothoracic theatre. Birth weights were 3.2 Kg and 2.96 Kg. Clinical condition was poor with mean arterial PaO2 2.8kPa intubated with 100% inspired oxygen. HTSI was performed using premounted 7 × 17 mm stents (Visi-Pro™, eV3 Endovascular, Plymouth, MN). Mean arterial PaO2 improved to 6.2 kPa. Mean time from surgical incision to LAD was 26 min. Bilateral pulmonary artery bands (BPAB) were then placed. No procedural complications occurred and both patients underwent subsequent surgical stage 1 Norwood at 6 and 10 days. CONCLUSIONS In this high-risk anatomical substrate, careful planning from accurate fetal diagnosis underpins the success of initial management. This early experience suggests that HTSI offers rapid and successful postnatal LAD with no procedural morbidity facilitating successful subsequent palliation. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Antony Hermuzi
- Department of Congenital Cardiology, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Angela McBrien
- Department of Congenital Cardiology, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Fabrizio De Rita
- Department of Congenital Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Alan McCheyne
- Department of Cardiothoracic Anaesthesia, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Massimo Griselli
- Department of Congenital Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - John J O'Sullivan
- Department of Congenital Cardiology, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Asif Hasan
- Department of Congenital Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - David S Crossland
- Department of Congenital Cardiology, Freeman Hospital, Newcastle upon Tyne, United Kingdom
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Moon-Grady AJ, Morris SA, Belfort M, Chmait R, Dangel J, Devlieger R, Emery S, Frommelt M, Galindo A, Gelehrter S, Gembruch U, Grinenco S, Habli M, Herberg U, Jaeggi E, Kilby M, Kontopoulos E, Marantz P, Miller O, Otaño L, Pedra C, Pedra S, Pruetz J, Quintero R, Ryan G, Sharland G, Simpson J, Vlastos E, Tworetzky W, Wilkins-Haug L, Oepkes D. International Fetal Cardiac Intervention Registry: A Worldwide Collaborative Description and Preliminary Outcomes. J Am Coll Cardiol 2015. [PMID: 26205597 DOI: 10.1016/j.jacc.2015.05.037] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Invasive fetal cardiac intervention (FCI) has been reported in single-institution series, promoting technical and physiologic success. OBJECTIVES This study describes the creation of an international registry of cases presenting for FCI, intended to compile technical and outcome data from a multicenter cohort. METHODS For this initial analysis, the entire database of the International Fetal Cardiac Intervention Registry (IFCIR) was queried for details of diagnoses, procedures, and outcomes. Maternal-fetal dyads from January 2001 through June 2014 were included. RESULTS Eighteen institutions submitted data by data harvest. Of 370 cases entered, 245 underwent FCI: 100 aortic valvuloplasties from a previous single-center report (excluded from additional reporting here), an additional 86 aortic and 16 pulmonary valvuloplasties, 37 atrial septal cases, and 6 unclassified cases. FCI did not appear to affect overall survival to hospital discharge. Among live-born infants with a fetal diagnosis of aortic stenosis/evolving hypoplastic left heart syndrome, more than twice as many were discharged with biventricular circulation after successful FCI versus those meeting institutional criteria but without any or successful FCI (42.8% vs. 19.4%, respectively). When fetal deaths were counted as treatment failures, the percentages were similar: biventricular circulation at discharge was 31.3% versus 18.5% for those discharged with univentricular palliation. Survival to discharge for live-born fetuses with atrial restriction was similar to that of those undergoing technically successful versus unsuccessful FCI (63.6% vs. 46.7%, respectively), although criteria for diagnosis were nonuniform. CONCLUSIONS We describe the contents of the IFCIR and present post-natal data to suggest potential benefit to fetal therapy among pregnancies considered for possible intervention and support proposals for additional work.
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Affiliation(s)
| | | | | | - Ramen Chmait
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Joanna Dangel
- Perinatal Cardiology Clinic, Medical University of Warsaw, Warsaw, Poland
| | | | - Stephen Emery
- Magee Women's Hospital of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Alberto Galindo
- Hospital Universitario 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Sarah Gelehrter
- C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | | | - Sofia Grinenco
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | | | - Edgar Jaeggi
- Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mark Kilby
- University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | | | - Pablo Marantz
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Owen Miller
- Evelina London Children's Hospital, London, United Kingdom
| | - Lucas Otaño
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | | | - Jay Pruetz
- Children's Hospital of Los Angeles, Los Angeles, California
| | - Ruben Quintero
- University of Miami Miller School of Medicine, Miami, Florida
| | - Greg Ryan
- Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - John Simpson
- Evelina London Children's Hospital, London, United Kingdom
| | - Emanuel Vlastos
- SSM Cardinal Glennon Children's Medical Center, St. Louis, Missouri
| | | | | | - Dick Oepkes
- Leiden University Medical Center, Leiden, the Netherlands
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Arai S, Fujii Y, Kotani Y, Kuroko Y, Kasahara S, Sano S. Surgical outcome of hypoplastic left heart syndrome with intact atrial septum. Asian Cardiovasc Thorac Ann 2015; 23:1034-8. [DOI: 10.1177/0218492315606581] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The surgical outcomes of hypoplastic left heart syndrome with intact atrial septum remains very poor in spite of the introduction of prenatal diagnosis before the Norwood operation. The hybrid operation consisting of bilateral pulmonary artery banding and balloon atrioseptectomy is one of the treatment strategies to potentially improve this patient population, however, the long-term outcomes are unknown. Methods Six consecutive patients with hypoplastic left heart syndrome with intact atrial septum, who underwent the hybrid operation between October 2006 and July 2014, were retrospectively reviewed. Hypoplastic left heart syndrome with highly restrictive atrial communication was excluded. Results Three patients died after the hybrid operation, due to sepsis, cerebral bleeding, and heart failure. Three patients underwent the modified Norwood operation. One of these died due to severe hypoxia while awaiting the bidirectional Glenn operation. The others underwent a bidirectional Glenn operation and subsequent Fontan completion but died due to lung dysfunction and sudden hemoptysis. Conclusions The hybrid operation for hypoplastic left heart syndrome with intact atrial septum may have improved the neonatal outcome and Fontan completion rate in this extremely high-risk group of patients, but the long-term outcome remains dismal. Considering the late mortality related to pulmonary complications, aggressive fetal intervention to create a nonrestrictive atrial septal communication to promote normal development of the pulmonary vessels may be the last resort to improve the long-term outcome.
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Affiliation(s)
- Sadahiko Arai
- Okayama University Hospital, Department of Cardiovascular Surgery, Okayama, Japan
| | - Yasuhiro Fujii
- Okayama University Hospital, Department of Cardiovascular Surgery, Okayama, Japan
| | - Yasuhiro Kotani
- Okayama University Hospital, Department of Cardiovascular Surgery, Okayama, Japan
| | - Yosuke Kuroko
- Okayama University Hospital, Department of Cardiovascular Surgery, Okayama, Japan
| | - Shingo Kasahara
- Okayama University Hospital, Department of Cardiovascular Surgery, Okayama, Japan
| | - Shunji Sano
- Okayama University Hospital, Department of Cardiovascular Surgery, Okayama, Japan
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Yuan SM. Fetal cardiac interventions: an update of therapeutic options. Braz J Cardiovasc Surg 2015; 29:388-95. [PMID: 25372914 PMCID: PMC4412330 DOI: 10.5935/1678-9741.20140099] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 07/24/2014] [Indexed: 11/20/2022] Open
Abstract
Objective This article aims to present updated therapeutic options for fetal congenital
heart diseases. Methods Data source for the present study was based on comprehensive literature retrieval
on fetal cardiac interventions in terms of indications, technical approaches and
clinical outcomes. Results About 5% of fetal congenital heart diseases are critical and timely intrauterine
intervention may alleviate heart function. Candidates for fetal cardiac
interventions are limited. These candidates may include critical aortic valve
stenosis with evolving hypoplastic left heart syndrome, pulmonary atresia with an
intact ventricular septum and evolving hypoplastic right heart syndrome, and
hypoplastic left heart syndrome with an intact or highly restrictive atrial septum
as well as fetal heart block. The advocated option are prenatal aortic
valvuloplasty, pulmonary valvuloplasty, creation of atrial communication and fetal
cardiac pacing. Conclusion Fetal cardiac interventions are feasible at midgestation with gradually improved
technical success and fetal/postnatal survival due mainly to a well-trained
multidisciplinary team, sophisticated equipment and better postnatal care.
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Affiliation(s)
- Shi-Min Yuan
- Teaching Hospital, Fujian Medical University, Putian, China
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49
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MRI shows limited mixing between systemic and pulmonary circulations in foetal transposition of the great arteries: a potential cause of in utero pulmonary vascular disease. Cardiol Young 2015; 25:737-44. [PMID: 24932863 PMCID: PMC4411741 DOI: 10.1017/s1047951114000870] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To investigate the relationship between foetal haemodynamics and postnatal clinical presentation in patients with transposition of the great arteries using phase-contrast cardiovascular magnetic resonance. BACKGROUND A severe and irreversible form of persistent pulmonary hypertension of the newborn occurs in up to 5% of patients with transposition and remains an important cause of morbidity and mortality in these infants. Restriction at the foramen ovale and ductus arteriosus has been identified as a risk factor for the development of pulmonary hypertension, and this can now be studied with magnetic resonance imaging using a new technique called metric optimised gating. METHODS Blood flow was measured in the major vessels of four foetuses with transposition with intact ventricular septum (gestational age range: 35-38 weeks) and compared with values from 12 normal foetuses (median gestational age: 37 weeks; range: 34-40 weeks). RESULTS We found significantly reduced flows in the ductus arteriosus (p<0.01) and foramen ovale (p=0.03) and increased combined ventricular output (p=0.01), ascending aortic (p=0.001), descending aortic (p=0.03), umbilical vein (p=0.03), and aorto-pulmonary collateral (p<0.001) flows in foetuses with transposition compared with normals. The foetus with the lowest foramen ovale shunt and highest aorto-pulmonary collateral flow developed fatal pulmonary vascular disease. CONCLUSIONS We found limited mixing between the systemic and pulmonary circulations in a small group of late-gestation foetuses with transposition. We propose that the resulting hypoxia of the pulmonary circulation could be the driver behind increased aorto-pulmonary collateral flow and contribute to the development of pulmonary vascular disease in some foetuses with transposition.
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50
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Peng E, Howley L, Cromblehome TM, Jaggers J. Ex-utero intrapartum treatment as a novel bridging strategy to surgery in hypoplastic left heart syndrome with intact atrial septum—cross-circulation revisited. J Thorac Cardiovasc Surg 2015; 149:935-7. [DOI: 10.1016/j.jtcvs.2014.11.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 11/12/2014] [Accepted: 11/19/2014] [Indexed: 11/30/2022]
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