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Samples S, Gandhi R, Woo J, Patel A. Ethical Considerations in Fetal Cardiology. J Cardiovasc Dev Dis 2024; 11:172. [PMID: 38921672 PMCID: PMC11204861 DOI: 10.3390/jcdd11060172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/29/2024] [Accepted: 05/30/2024] [Indexed: 06/27/2024] Open
Abstract
Fetal cardiology has evolved over the last 40 years and changed the timing of diagnosis and counseling of congenital heart disease, decision-making, planning for treatment at birth, and predicting future surgery from the postnatal to the prenatal period. Ethical issues in fetal cardiology transect multiple aspects of biomedical ethics including improvement in prenatal detection and diagnostic capabilities, access to equitable comprehensive care that preserves a pregnant person's right to make decisions, access to all reproductive options, informed consent, complexity in shared decision-making, and appropriate use of fetal cardiac interventions. This paper first reviews the literature and then provides an ethical analysis of accurate and timely diagnosis, equitable delivery of care, prenatal counseling and shared decision-making, and innovation through in utero intervention.
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Affiliation(s)
- Stefani Samples
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Rupali Gandhi
- Division of Pediatric Cardiology, Advocate Christ Children’s Hospital, Oak Lawn, IL 60453, USA
- Section of Cardiology, Department of Pediatrics, Comer Children’s Hospital, University of Chicago, Chicago, IL 60637, USA
| | - Joyce Woo
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Angira Patel
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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Yilmaz Furtun B, Morris SA. Catheter-Based Fetal Cardiac Interventions. J Cardiovasc Dev Dis 2024; 11:167. [PMID: 38921667 PMCID: PMC11204342 DOI: 10.3390/jcdd11060167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/20/2024] [Accepted: 05/23/2024] [Indexed: 06/27/2024] Open
Abstract
Fetal cardiac intervention (FCI) is an emerging and rapidly advancing group of interventions designed to improve outcomes for fetuses with cardiovascular disease. Currently, FCI is comprised of pharmacologic therapies (e.g., trans-placental antiarrhythmics for fetal arrhythmia), open surgical procedures (e.g., surgical resection of pericardial teratoma), and catheter-based procedures (e.g., fetal aortic valvuloplasty for aortic stenosis). This review focuses on the rationale, criteria for inclusion, technical details, and current outcomes of the three most frequently performed catheter-based FCI procedures: (1) aortic valvuloplasty for critical aortic stenosis (AS) associated with evolving hypoplastic left heart syndrome (HLHS), (2) atrial septal intervention for HLHS with severely restrictive or intact atrial septum (R/IAS), and (3) pulmonary valvuloplasty for pulmonary atresia with intact ventricular septum (PA/IVS).
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Affiliation(s)
| | - Shaine Alaine Morris
- Texas Children’s Hospital, Baylor College of Medicine, 6651 Main Street, Suite E1920, Houston, TX 77030, USA
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Callahan R, Friedman KG, Tworetzky W, Esch JJ, Sleeper LA, Lu M, Mizrahi-Arnaud A, Brusseau R, Lafranchi T, Wilkins-Haug LE, Guseh SH, Benson CB, Frates MC, Keochakian M, Porras D. Technical Success and Serious Adverse Events for Fetal Aortic Valvuloplasty in a Large 20-Year Cohort. JACC. ADVANCES 2024; 3:100835. [PMID: 38938833 PMCID: PMC11198497 DOI: 10.1016/j.jacadv.2024.100835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 10/02/2023] [Accepted: 10/27/2023] [Indexed: 06/29/2024]
Abstract
Background FAV is offered to fetuses with severe aortic valve stenosis and evolving hypoplastic left heart syndrome. An inferential analysis of TS and SAE in a large series has not been reported. Objectives The purpose of this study was to determine factors associated with fetal aortic valvuloplasty (FAV) technical success (TS) and serious adverse events (SAEs). Methods Retrospective, single-center, cohort analysis of attempted FAV from March 1, 2000, to December 31, 2020. The primary outcome was the TS of FAV, and the secondary outcome was the presence of an SAE. Results A total of 165 FAVs were attempted in 163 patients with a median gestational age of 24.6 weeks (IQR: 22.9-27.1 weeks). FAV TS was 85% (141/165) and was higher in the 2010 to 2020 era (94% [85/90] vs 75% [56/75]; P < 0.001). Pre-FAV echocardiographic left ventricle (LV) long axis dimension z-score >-0.10 (P < 0.001) and higher LV ejection fraction (P = 0.037) were independently associated with a higher odds of TS. There were 117 SAEs in 67 attempted FAVs (41%), 13 of which were fetal deaths (7.9%). By classification and regression tree analysis, gestational age <21 weeks or in older fetuses, a procedure time of ≥39.6 minutes was associated with higher SAE rate. In the multivariable logistic regression model correcting for gestational age, fetuses with an LV end-diastolic volume <4.09 mL had an age-adjusted OR of 4.71 (95% CI: 1.67-13.29; P = 0.004) for experiencing an SAE. Conclusions TS of FAV has improved over time, and failure is associated with smaller fetal left heart sizes. SAEs are common and are associated with smaller left hearts and longer procedure times.
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Affiliation(s)
- Ryan Callahan
- Department of Pediatrics, Children’s Hospital of Philadelphia, and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kevin G. Friedman
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jesse J. Esch
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Lynn A. Sleeper
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Minmin Lu
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Arielle Mizrahi-Arnaud
- Department of Anesthesia, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Roland Brusseau
- Department of Anesthesia, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Terra Lafranchi
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Louise E. Wilkins-Haug
- Department of Obstetrics and Gynecology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Stephanie H. Guseh
- Department of Obstetrics and Gynecology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Carol B. Benson
- Department of Radiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Mary C. Frates
- Department of Radiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Mirjam Keochakian
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Diego Porras
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Minimally Invasive Bimanual Fetal Surgery—A Review. CHILDREN 2022; 9:children9091377. [PMID: 36138686 PMCID: PMC9498043 DOI: 10.3390/children9091377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/22/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022]
Abstract
Background: The aim of this review is to discuss experimental and clinical techniques and interventions of fetal surgery which have been performed minimally invasively by the means of a three-port approach for the fetoscope and instruments for the left and right hand of the surgeon (bimanual minimally invasive fetal surgery). Methods: a print and electronic literature search was performed; the titles and abstracts were screened and included reports were reviewed in a two-step approach. First, reports other than minimally invasive fetal surgery were excluded, then a full text review and analysis of the reported data was performed. Results: 17 reports were included. The heterogeneity of the included reports was high. Although reports on human fetoscopic surgical procedures can be found, most of them do not pick out bimanual fetal surgery as a central theme but rather address interventions applying a fetoscope with a working channel for a laser fiber, needle or flexible instrument. Most reports were on experimentation in animal models, the human application of minimally invasive fetoscopic bimanual surgery is rare and has at best been explored for the prenatal treatment of spina bifida. Some reported bimanual fetoscopic procedures were performed on the exteriorized uterus via a maternal laparotomy and can therefore not be classified as being truly minimally invasive. Discussion: our results demonstrate that minimally invasive fetoscopic bimanual surgery is rare, even in animal models, excluding many other techniques and procedures that are loosely termed ‘minimally invasive fetal surgery’ which we suggest to better label as ‘interventions’. Thus, more research on percutaneous minimally invasive bimanual fetoscopic surgery is warranted, with the aim to reduce the maternal, uterine and fetal trauma for correction of congenital malformations.
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Hasina Z, Wang CC. Prenatal and Postnatal Therapies for Down's Syndrome and Associated Developmental Anomalies and Degenerative Deficits: A Systematic Review of Guidelines and Trials. Front Med (Lausanne) 2022; 9:910424. [PMID: 35865169 PMCID: PMC9294288 DOI: 10.3389/fmed.2022.910424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/03/2022] [Indexed: 12/04/2022] Open
Abstract
Down's syndrome (DS) is the most common genetic disorder at birth. Multiple developmental abnormalities before birth and early onset of degenerative deficits after birth are features of DS. Early treatment for the manifestations associated with DS in either prenatal or postnatal period may improve clinical outcomes. However, information available from professional bodies and to communities is very limited. We carried out a systematic review and attempted meta-analysis of clinical trials for developmental abnormalities and degenerative deficits in DS. Only 15 randomized controlled trials (RCTs) in 995 (24 days to 65 years old) individuals with DS showed some improvement in cognitive disorders, development and growth, and musculoskeletal problem. However, each trial used different parameters and methods to measure various outcomes. RCTs of prenatal interventions in fetus with DS are lacking. The efficacy and safety of specific interventions in DS are still largely unknown. Proper counseling of the potential treatment for pregnant mothers who wish to continue their pregnancy carrying fetus with DS, and to health care professionals who take care of them are not adequate nowadays.
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Affiliation(s)
- Zinnat Hasina
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Chi Chiu Wang
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- School of Biomedical Sciences, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- Chinese University of Hong Kong-Sichuan University Joint Laboratory in Reproductive Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- *Correspondence: Chi Chiu Wang
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Wada S, Ozawa K, Sago H. New challenges of fetal therapy in Japan. J Obstet Gynaecol Res 2022; 48:2100-2111. [PMID: 35676616 PMCID: PMC9544758 DOI: 10.1111/jog.15320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 05/20/2022] [Indexed: 12/01/2022]
Abstract
Aim To review new challenges of fetal therapy in Japan after the establishment of four existing fetal therapies as standard prenatal care with National Health Insurance coverage over the past 20 years. Methods Reported studies and our current research activities related to four fetal therapies newly performed in Japan were reviewed. Results Fetoscopic endoluminal tracheal occlusion (FETO) for congenital diaphragmatic hernia (CDH) aims to occlude the trachea using a detachable balloon to promote lung growth. Following the recent successful completion of an international randomized controlled trial for CDH, in which we participated, FETO is offered for severe left CDH to perform balloon insertion at 27–29 weeks and removal at 34 weeks of gestation. Fetal cystoscopy (FC) for low urinary tract obstruction was introduced to overcome the demerits of vesicoamniotic shunting. FC may provide a proper diagnosis by visual observation of the urethra and physiological treatment of the posterior urethral valve. The effectiveness of open fetal surgery for myelomeningocele (MMC), direct surgery with laparotomy and hysterotomy, for ameliorating hindbrain herniation and the motor function was demonstrated, but it was also associated with substantial maternal and fetal risks. Fetal aortic valvuloplasty (FAV), ultrasound‐guided fetal aortic balloon dilation for critical aortic stenosis with evolving hypoplastic left heart syndrome may improve left heart development and maintain biventricular circulation. Feasibility and safety studies for FC, MMC open fetal surgery, and FAV are currently ongoing. Conclusions Clinical research on FETO, FC, MMC open fetal surgery, and FAV has proceeded with careful preparations in Japan.
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Affiliation(s)
- Seiji Wada
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Katsusuke Ozawa
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Haruhiko Sago
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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Intrauterine Valvuloplasty in Severe Aortic Stenosis-A Ten Years Single Center Experience. J Clin Med 2022; 11:jcm11113058. [PMID: 35683446 PMCID: PMC9181328 DOI: 10.3390/jcm11113058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/13/2022] [Accepted: 05/27/2022] [Indexed: 02/05/2023] Open
Abstract
Objective: To assess the course and outcome of fetal aortic valvuloplasty (FAV) in fetuses with severe aortic stenosis (SAS) in a single center. Methods: All fetuses with a prenatal diagnosis of SAS with subsequent FAV were retrospectively collected in one tertiary center for fetal medicine over a period of 10 years. In the study, period fetuses with SAS were considered suitable for FAV in the presence of markedly elevated left ventricular pressures (maximum velocity of mitral regurgitation (MR Vmax) >250 cm/s and/or maximum velocity of aortic stenosis (AS Vmax) >250 cm/s), retrograde flow in the transverse aortic arch and a left ventricular length Z-score >−1. Results: In the study period 29 fetuses with AS were treated with 38 FAV. If reinterventions are included 82.7% of fetuses received a technically successful FAV. Procedure related death occurred in three (10.3%) cases, spontaneous fetal death in 2 (6.9%), and termination of pregnancy was performed in 3 cases (10.3%). Among the 21 live births (72.4%), four died in infancy. Among the remaining survivors, 8/17 (47.1%) had a biventricular outcome at the age of one year, 8/17 (47.1%) were univentricular and one infant (5.9%) is biventricular at the age of eight months. Fetuses with biventricular outcome had significantly greater left ventricular (LV) length Z-scores (p = 0.031), and lower tricuspid to mitral valve (TV/MV) ratios (p = 0.003). Conclusions: FAV has a high technical success rate and a low rate of procedure related mortality if performed in experienced hands. The success rate of biventricular circulation at the age of one year is moderate and seems to depend rather on the center’s experience and postnatal surgical strategies than solely on prenatal selection criteria. In the absence of randomized controlled trials, FAV remains an experimental intervention.
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Vorisek CN, Zurakowski D, Tamayo A, Axt-Fliedner R, Siepmann T, Friehs I. Postnatal circulation in patients with aortic stenosis undergoing fetal aortic valvuloplasty: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:576-584. [PMID: 34726817 DOI: 10.1002/uog.24807] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/23/2021] [Accepted: 10/19/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Fetal aortic valvuloplasty (FAV) has become a treatment option for critical fetal aortic stenosis (AS) with the goal of preserving biventricular circulation (BVC); however, to date, it is unclear how many patients undergoing FAV achieve BVC. The aim of this systematic review and meta-analysis was to investigate the type of postnatal circulation achieved following FAV. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. MEDLINE, EMBASE, Web of Science and the Cochrane Library were searched systematically for studies investigating postnatal circulation in patients with AS following FAV. Eligible for inclusion were original papers in the English language, published from 2000 to 2020, with at least 12 months of follow-up after birth. Review papers, abstracts, expert opinions, books, editorials and case reports were excluded. The titles and abstracts of all retrieved literature were screened, duplicates were excluded and the full texts of potentially eligible articles were obtained and assessed. The primary endpoint was type of postnatal circulation. Additional assessed outcomes included fetal death, live birth, neonatal death (NND), termination of pregnancy (TOP) and technical success of the FAV procedure. The quality of articles was assessed using the Critical Appraisal Skills Programme (CASP) tool. To estimate the overall proportion of each endpoint, meta-analysis of proportions was employed using a random-effects model. RESULTS The electronic search identified 579 studies, of which seven were considered eligible for inclusion in the systematic review and meta-analysis. A total of 266 fetuses underwent FAV with median follow-up per study from 12 months to 13.2 years. There were no maternal deaths and only one case of FAV-related maternal complication was reported. Hydrops was present in 29 (11%) patients. The pooled prevalence of BVC and univentricular circulation (UVC) among liveborn patients was 45.8% (95% CI, 39.2-52.4%) and 43.6% (95% CI, 33.9-53.8%), respectively. The pooled prevalence of technically successful FAV procedure was 82.1% (95% CI, 74.3-87.9%), of fetal death it was 16.0% (95% CI, 11.2-22.4%), of TOP 5.7% (95% CI, 2.0-15.5%), of live birth 78.8% (95% CI, 66.5-87.4%), of NND 8.7% (95% CI, 4.7-15.5%), of palliative care 4.0% (95% CI, 1.9-8.4%) and of infant death 10.3% (95% CI, 3.6-26.1%). The pooled prevalence of BVC and UVC among liveborn patients who had technically successful FAV was 51.9% (95% CI, 44.7-59.1%) and 39.8% (95% CI, 29.7-50.9%), respectively. CONCLUSIONS This study showed a BVC rate of 46% among liveborn patients with AS undergoing FAV, which improved to 52% when subjects underwent technically successful FAV. Given the lack of randomized clinical trials, results should be interpreted with caution. Currently, data do not suggest a true benefit of FAV for achieving BVC. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- C N Vorisek
- Dresden International University, Division of Health Care Sciences, Dresden, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - D Zurakowski
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Department of Anesthesia, Harvard Medical School, Boston, MA, USA
| | - A Tamayo
- Dresden International University, Division of Health Care Sciences, Dresden, Germany
- The Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | | | - T Siepmann
- Dresden International University, Division of Health Care Sciences, Dresden, Germany
- University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - I Friehs
- Dresden International University, Division of Health Care Sciences, Dresden, Germany
- Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
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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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Kohl T, Akin I, Frommberger J, Riehle N, Schranz D. Foetoscopy-assisted balloon valvuloplasty in a human foetus with disadvantageous intrauterine position: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 5:ytab293. [PMID: 34409250 PMCID: PMC8364767 DOI: 10.1093/ehjcr/ytab293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 02/19/2021] [Accepted: 07/05/2021] [Indexed: 11/25/2022]
Abstract
Background Some foetuses scheduled for balloon valvuloplasty present with unfavourable lies that render a successful procedure unlikely or impossible. In these situations, foetal posturing previously has been achieved by maternal laparotomy. As a less invasive means, we demonstrate the feasibility of a minimally invasive foetoscopic approach. Case summary Percutaneous ultrasound-guided foetal balloon valvuloplasty for severe aortic valve stenosis was attempted in a human foetus at 29 + 4 weeks of gestation under general maternofoetal anaesthesia. Unfortunately, prior to the procedure, the foetus had been observed on several occasions remaining in a dorsoanterior cephalic position. Therefore, the left ventricle could not be accessed by the conventional percutaneous ultrasound-guided approach. In order to achieve the desired foetal lie, foetoscopic assistance was employed: using a standardized foetoscopic setup, a foetoscope and two graspers, the foetus was rotated in dorsoposterior position. After this manoeuver, successful balloon valvuloplasty was achieved. Mother and foetus tolerated the procedure well and complications were not observed. Discussion Foetoscopy-assisted foetal posturing offers itself as an alternative to maternal laparotomy in foetuses presenting with a persisting disadvantageous position at the time of balloon valvuloplasty. Due to the increased risks of preterm rupture of membranes and earlier delivery posed by the foetoscopic approach, this technique may preferably be used in more mature foetuses when foetal posturing cannot be achieved by other means.
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Affiliation(s)
- Thomas Kohl
- German Center for Fetal Surgery & Minimally-Invasive Therapy (DZFT), Mannheim University Hospital (UMM), Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Ibrahim Akin
- Department of Cardiology, Mannheim University Hospital (UMM), Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Juliane Frommberger
- Department of Anesthesiology, Mannheim University Hospital (UMM), Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Nadja Riehle
- German Center for Fetal Surgery & Minimally-Invasive Therapy (DZFT), Mannheim University Hospital (UMM), Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Dietmar Schranz
- German Center for Fetal Surgery & Minimally-Invasive Therapy (DZFT), Mannheim University Hospital (UMM), Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
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11
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Beattie MJ, Friedman KG, Sleeper LA, Lu M, Drogosz M, Callahan R, Marshall AC, Prosnitz AR, Lafranchi T, Benson CB, Wilkins-Haug LE, Tworetzky W. Late gestation predictors of a postnatal biventricular circulation after fetal aortic valvuloplasty. Prenat Diagn 2021; 41:479-485. [PMID: 33462820 DOI: 10.1002/pd.5885] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 12/03/2020] [Accepted: 12/08/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Fetal aortic valvuloplasty (FAV) for severe aortic stenosis (AS) has shown promise in averting progression to hypoplastic left heart syndrome. After FAV, predicting which fetuses will achieve a biventricular (BiV) circulation after birth remains challenging. Identifying predictors of postnatal circulation on late gestation echocardiography will improve parental counseling. METHODS Liveborn patients who underwent FAV and had late gestation echocardiography available were included (2000-2017, n = 96). Multivariable logistic regression and classification and regression tree analysis were utilized to identify independent predictors of BiV circulation. RESULTS Among 96 fetuses, 50 (52.1%) had BiV circulation at the time of neonatal discharge. In multivariable analysis, independent predictors of biventricular circulation included left ventricular (LV) long axis z-score (OR 3.2, 95% CI 1.8-5.7, p < 0.001), LV ejection fraction (OR 1.3, 95% CI 1.0-1.8, p = 0.023), anterograde aortic arch flow (OR 5.0, 95% CI 1.2-20.4, p = 0.024), and bidirectional or right-to-left foramen ovale flow (OR 4.6, 95% CI 1.4-15.8, p = 0.015). CONCLUSION Several anatomic and physiologic parameters in late gestation were found to be independent predictors of BiV circulation after FAV. Identifying these predictors adds to our understanding of LV growth and hemodynamics after FAV and may improve parental counseling.
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Affiliation(s)
- Meaghan J Beattie
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Minmin Lu
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Monika Drogosz
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ryan Callahan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Audrey C Marshall
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,The Hospital for Sick Children, University of Toronto School of Medicine, Toronto, Ontario, Canada
| | - Aaron R Prosnitz
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Sanger Heart and Vascular Institute, Levine Children's Hospital, Charlotte, North Carolina, USA
| | - Terra Lafranchi
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Carol B Benson
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Louise E Wilkins-Haug
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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12
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Atiyah M, Kurdi A, Al Tuwaijry O, Al Sahari A, Al Rakaf M, Babic I, Al Habshan F, Alhalees Z, Al Najashi K. Fetal aortic valvuloplasty: first report of two cases from Saudi Arabia. J Cardiothorac Surg 2020; 15:150. [PMID: 32571360 PMCID: PMC7310221 DOI: 10.1186/s13019-020-01195-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 06/15/2020] [Indexed: 11/11/2022] Open
Abstract
Background Fetal aortic stenosis may progress to hypoplastic left heart syndrome (HLHS), which carries a poor prognosis. We report two infants with fetal aortic stenosis successfully treated with fetal aortic valvuloplasty (FAV) using balloon dilatation. Case presentation Of five fetuses with aortic stenosis fulfilling the FAV criteria of severe aortic stenosis with a left ventricular length Z-score of ≥ − 2, retrograde flow in the transverse aortic arch, left-to-right flow across the foramen ovale, monophasic mitral inflow, and significant left ventricular dysfunction, we obtained permission for FAV in two fetuses. FAV was performed successfully under echocardiographic guidance using balloon dilatation. Both fetuses survived to birth. During FAV, mild pericardial effusion developed when introducing the stylet needle in the second fetus, and this resolved within 48 h. No intraprocedural complications occurred in the first patient, and no maternal complications occurred. The first infant underwent the Ross procedure after birth and is currently 7 years old and doing well. The second patient underwent aortic and mitral valve repair with endocardial fibroelastosis resection approximately 2 weeks after birth, which temporarily addressed the mitral valve stenosis; high doses of inotropes were subsequently required. The infant died of sepsis at 2 months of age. Conclusion FAV using balloon dilatation to treat fetal aortic stenosis was successful in our two patients, with subsequent neonatal biventricular repair resulting in long-term survival in one patient and death secondary to sepsis in the second patient.
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Affiliation(s)
- Merna Atiyah
- Pediatric Cardiology Department, Prince Sultan Cardiac Center, Prince Sultan Military Medical City, As Sulimaniyah, Riyadh, 12233, Saudi Arabia.
| | - Ahmed Kurdi
- Obstetrics & Gynecology Department, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Osama Al Tuwaijry
- Obstetrics & Gynecology Department, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Atif Al Sahari
- Pediatric Cardiology Department, Prince Sultan Cardiac Center, Prince Sultan Military Medical City, As Sulimaniyah, Riyadh, 12233, Saudi Arabia
| | - Maha Al Rakaf
- Obstetrics & Gynecology Department, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Inas Babic
- Obstetrics & Gynecology Department, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Fahad Al Habshan
- King Abdul-Aziz Cardiac Center, National Guard Hospital, Riyadh, Saudi Arabia
| | - Zohair Alhalees
- Department of Cardiac Surgery, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Khalid Al Najashi
- Pediatric Cardiology Department, Prince Sultan Cardiac Center, Prince Sultan Military Medical City, As Sulimaniyah, Riyadh, 12233, Saudi Arabia
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13
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Ultrasound-Guided Percutaneous Balloon Aortic Valvuloplasty for Aortic Stenosis. J Interv Cardiol 2020; 2020:8086796. [PMID: 32256250 PMCID: PMC7102489 DOI: 10.1155/2020/8086796] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 02/18/2020] [Indexed: 11/28/2022] Open
Abstract
Percutaneous balloon aortic valvuloplasty (PBAV), which is used to treat symptomatic aortic stenosis, requires ionizing radiation and contrast agent for imaging guidance. The aim of the study is to evaluate the feasibility and effectiveness of ultrasound-guided PBAV in patients with aortic stenosis. This case series included 30 patients (14 males; mean age, 61.5 ± 4.5 years) with moderate/severe aortic stenosis treated with ultrasound-guided PBAV at the Ultrasound Department, Fuwai Hospital, Beijing, China, between January 2016 and July 2019. Cardiac function (New York Heart Association grade) was assessed before PBAV and 1 month after the procedure. Aortic peak jet velocity, aortic valve orifice area (AVA), mean transvalvular pressure gradient (MTPG), left ventricular end-diastolic diameter (LVDD), left ventricular ejection fraction (LVEF), and left ventricular end-systolic diameter (LVESD) were determined before and immediately after PBAV using Doppler echocardiography. Preprocedural cardiac function was grade I in 3 cases, grade II in 9 cases, grade III in 10 cases, and grade IV in 8 cases. Postprocedural cardiac function was grade I in 22 cases, grade II in 4 cases, and grade III in 4 cases, suggesting that cardiac function was improved by PBAV. Ultrasound-guided PBAV resulted in significant improvements (P < 0.05) in aortic peak jet velocity (3.68 ± 0.811 m/s vs. 4.79 ± 0.63 m/s), MTPG (33.77 ± 13.85 mmHg vs. 54.54 ± 13.81 mmHg), AVA (1.96 ± 0.25 cm2 vs. 0.98 ± 0.12 cm2), LVEDD (51.90 ± 3.21 mm vs. 65.60 ± 6.81 mm), LVEF (63.46 ± 11.29% vs. 56.31 ± 11.04%), and LVESD (35.50 2.62 mm vs. 45.20 ± 2.42 mm). Ultrasound-guided PBAV is feasible and achieves good short-term effects in patients with aortic stenosis.
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14
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Pickard SS, Wong JB, Bucholz EM, Newburger JW, Tworetzky W, Lafranchi T, Benson CB, Wilkins-Haug LE, Porras D, Callahan R, Friedman KG. Fetal Aortic Valvuloplasty for Evolving Hypoplastic Left Heart Syndrome: A Decision Analysis. Circ Cardiovasc Qual Outcomes 2020; 13:e006127. [PMID: 32252549 DOI: 10.1161/circoutcomes.119.006127] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Fetal aortic valvuloplasty (FAV) may prevent progression of midgestation aortic stenosis to hypoplastic left heart syndrome. However, FAV has well-established risks, and its survival benefit remains unknown. Our primary aim was to determine whether FAV for midgestation aortic stenosis increases survival from fetal diagnosis to age 6 years. METHODS AND RESULTS We performed a retrospective analysis of 143 fetuses who underwent FAV from 2000 to 2017 and a secondary analysis of the Pediatric Heart Network Single Ventricle Reconstruction trial. Using these results, we developed a decision model to estimate probability of transplant-free survival from fetal diagnosis to age 6 years and postnatal restricted mean transplant-free survival time. FAV was technically successful in 84% of 143 fetuses with fetal demise in 8%. Biventricular circulation was achieved in 50% of 111 live-born infants with successful FAV but in only 16% of the 19 patients with unsuccessful FAV. The model projected overlapping probabilities of transplant-free survival to age 6 years at 75% (95% CI, 67%-82%) with FAV versus 72% (95% CI, 61%-82%) with expectant fetal management, resulting in a restricted mean transplant-free survival time benefit of 1.2 months. When limiting analyses to the improved FAV experience since 2009 to reflect current practice, (probability of technical success [94%], fetal demise [4%], and biventricular circulation [66%]), the model projected that FAV increased the probability of survival to age 6 years to 82% (95% CI, 73%-89%). Expectant management is favored if risk of fetal demise exceeded 12% or probability of biventricular circulation fell below 26%, but FAV remained favored over plausible recent range of technical success. CONCLUSIONS Our model suggests that FAV provides a modest, medium-term survival benefit over expectant fetal management. Appropriate patient selection and low risk of fetal demise with FAV are critical factors for obtaining a survival benefit.
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Affiliation(s)
- Sarah S Pickard
- Department of Cardiology, Boston Children's Hospital, MA (S.S.P., E.M.B., J.W.N., W.T., T.L., D.P., R.C., K.G.F.).,Departments of Pediatrics (S.S.P., E.B., J.W.N., W.T., D.P., R.C., K.G.F.), Harvard Medical School, Boston, MA
| | - John B Wong
- Division of Clinical Decision Making, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA (J.B.W.)
| | - Emily M Bucholz
- Department of Cardiology, Boston Children's Hospital, MA (S.S.P., E.M.B., J.W.N., W.T., T.L., D.P., R.C., K.G.F.).,Departments of Pediatrics (S.S.P., E.B., J.W.N., W.T., D.P., R.C., K.G.F.), Harvard Medical School, Boston, MA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, MA (S.S.P., E.M.B., J.W.N., W.T., T.L., D.P., R.C., K.G.F.).,Departments of Pediatrics (S.S.P., E.B., J.W.N., W.T., D.P., R.C., K.G.F.), Harvard Medical School, Boston, MA
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children's Hospital, MA (S.S.P., E.M.B., J.W.N., W.T., T.L., D.P., R.C., K.G.F.).,Departments of Pediatrics (S.S.P., E.B., J.W.N., W.T., D.P., R.C., K.G.F.), Harvard Medical School, Boston, MA
| | - Terra Lafranchi
- Department of Cardiology, Boston Children's Hospital, MA (S.S.P., E.M.B., J.W.N., W.T., T.L., D.P., R.C., K.G.F.)
| | - Carol B Benson
- Departments of Radiology (C.B.B.), Brigham and Women's Hospital, Boston, MA
| | - Louise E Wilkins-Haug
- Obstetrics and Gynecology (L.E.W.-H.), Brigham and Women's Hospital, Boston, MA.,Obstetrics and Gynecology, (L.E.W.-H.), Harvard Medical School, Boston, MA
| | - Diego Porras
- Department of Cardiology, Boston Children's Hospital, MA (S.S.P., E.M.B., J.W.N., W.T., T.L., D.P., R.C., K.G.F.).,Departments of Pediatrics (S.S.P., E.B., J.W.N., W.T., D.P., R.C., K.G.F.), Harvard Medical School, Boston, MA
| | - Ryan Callahan
- Department of Cardiology, Boston Children's Hospital, MA (S.S.P., E.M.B., J.W.N., W.T., T.L., D.P., R.C., K.G.F.).,Departments of Pediatrics (S.S.P., E.B., J.W.N., W.T., D.P., R.C., K.G.F.), Harvard Medical School, Boston, MA
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, MA (S.S.P., E.M.B., J.W.N., W.T., T.L., D.P., R.C., K.G.F.).,Departments of Pediatrics (S.S.P., E.B., J.W.N., W.T., D.P., R.C., K.G.F.), Harvard Medical School, Boston, MA
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15
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Patel ND, Nageotte S, Ing FF, Armstrong AK, Chmait R, Detterich JA, Galindo A, Gardiner H, Grinenco S, Herberg U, Jaeggi E, Morris SA, Oepkes D, Simpson JM, Moon-Grady A, Pruetz JD. Procedural, pregnancy, and short-term outcomes after fetal aortic valvuloplasty. Catheter Cardiovasc Interv 2020; 96:626-632. [PMID: 32216096 DOI: 10.1002/ccd.28846] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 03/05/2020] [Accepted: 03/09/2020] [Indexed: 11/12/2022]
Abstract
OBJECTIVES We aimed to evaluate the effect of technical aspects of fetal aortic valvuloplasty (FAV) on procedural risks and pregnancy outcomes. BACKGROUND FAV is performed in cases of severe mid-gestation aortic stenosis with the goal of preventing hypoplastic left heart syndrome (HLHS). METHODS The International Fetal Cardiac Intervention Registry was queried for fetuses who underwent FAV from 2002 to 2018, excluding one high-volume center. RESULTS The 108 fetuses had an attempted cardiac puncture (mean gestational age [GA] 26.1 ± 3.3 weeks). 83.3% of attempted interventions were technically successful (increased forward flow/new aortic insufficiency). The interventional cannula was larger than 19 g in 70.4%. More than one cardiac puncture was performed in 25.0%. Intraprocedural complications occurred in 48.1%, including bradycardia (34.1%), pericardial (22.2%) or pleural effusion (2.7%) requiring drainage, and balloon rupture (5.6%). Death within 48 hr occurred in 16.7% of fetuses. Of the 81 patients born alive, 59 were discharged home, 34 of whom had biventricular circulation. More than one cardiac puncture was associated with higher complication rates (p < .001). Larger cannula size was associated with higher pericardial effusion rates (p = .044). On multivariate analysis, technical success (odds ratio [OR] = 10.9, 95% confidence interval [CI] = 2.2-53.5, p = .003) and later GA at intervention (OR = 1.5, 95% CI = 1.2-1.9, p = .002) were associated with increased odds of live birth. CONCLUSIONS FAV is an often successful but high-risk procedure. Multiple cardiac punctures are associated with increased complication and fetal mortality rates. Later GA at intervention and technical success were independently associated with increased odds of live birth. However, performing the procedure later in gestation may miss the window to prevent progression to HLHS.
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Affiliation(s)
- Neil D Patel
- Division of Pediatric Cardiology, Children's Hospital, University of Southern California Keck School of Medicine of USC, Los Angeles, California, USA
| | - Stephen Nageotte
- Division of Pediatric Cardiology, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine, St Louis, Missouri, USA
| | - Frank F Ing
- Divison of Pediatric Cardiology, University of California Davis Children's Hospital, Sacramento, California, USA
| | | | - Ramen Chmait
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Jon A Detterich
- Division of Pediatric Cardiology, Children's Hospital, University of Southern California Keck School of Medicine of USC, Los Angeles, California, USA.,Department of Physiology and Biophysics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Alberto Galindo
- Department of Obstetrics and Gynecology, Hospital Universitario 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Helena Gardiner
- The Fetal Center, Children's Memorial Hermann Hospital and the Department of Obstetrics and Gynecology, McGovern Medical School, UTHealth, Houston, Texas, USA
| | | | - Ulrike Herberg
- Division of Pediatric Cardiology, Children's Hospital, University of Bonn, Germany
| | - Edgar Jaeggi
- Division of Cardiology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shaine A Morris
- Division of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Anita Moon-Grady
- Division of Pediatric Cardiology, Department of Pediatrics and the Fetal Treatment Center at UCSF Benioff Children's Hospital, San Francisco, California, USA
| | - Jay D Pruetz
- Division of Pediatric Cardiology, Children's Hospital, University of Southern California Keck School of Medicine of USC, Los Angeles, California, USA
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16
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Guseh SH, Friedman KG, Wilkins-Haug LE. Fetal cardiac intervention-Perspectives from a single center. Prenat Diagn 2020; 40:415-423. [PMID: 31875330 DOI: 10.1002/pd.5631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 10/01/2019] [Accepted: 10/18/2019] [Indexed: 12/19/2022]
Abstract
Fetal cardiac intervention was first proposed in the early 1990s to impact cardiac development and survival of fetuses with fetal aortic stenosis and evolving hypoplastic left heart syndrome (HLHS). Although initial attempts of fetal aortic valvuloplasty were unsuccessful and carried a high rate of morbidity and mortality, our collaborative group at the Brigham and Women's Hospital and Boston Children's Hospital have reinvigorated the procedure using improvements in imaging, anesthesia, balloon catheters, and surgical techniques. Two decades of experience have now allowed us to document the safety of in utero intervention and to achieve a better understanding of the impact of midgestation intervention on developing HLHS. Research into underlying genetics, predictive biomarkers, and ways to incorporate stem cell technology will hopefully allow us to further refine the procedure to most benefit children with this historically lethal disease.
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Affiliation(s)
- Stephanie H Guseh
- Division of Maternal Fetal Medicine, Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Louise E Wilkins-Haug
- Division of Maternal Fetal Medicine, Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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17
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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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18
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Crystal MA, Freud LR. Fetal aortic valvuloplasty to prevent progression to hypoplastic left heart syndrome in utero. Birth Defects Res 2019; 111:389-394. [PMID: 30868768 DOI: 10.1002/bdr2.1478] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 01/30/2019] [Indexed: 12/17/2022]
Abstract
Advances in fetal echocardiography have allowed for the prenatal diagnosis of congenital heart disease and an understanding of its natural history in utero. This insight has led to the development of fetal cardiac intervention (FCI) for select defects to prevent significant morbidity or mortality postnatally. Fetal aortic valvuloplasty (FAV) may be performed to prevent progression to hypoplastic left heart syndrome, a severe form of congenital heart disease, in utero. The current review focuses on this type of FCI and discusses the history of FAV, the rationale for intervention, candidate selection, procedural technique, and outcomes to date. Finally, the importance of building a multidisciplinary team to perform FCI is addressed.
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Affiliation(s)
- Matthew A Crystal
- Department of Pediatrics, Division of Pediatric Cardiology, Columbia University Medical Center, Morgan Stanley Children's Hospital of NewYork-Presbyterian, New York, New York
| | - Lindsay R Freud
- Department of Pediatrics, Division of Pediatric Cardiology, Columbia University Medical Center, Morgan Stanley Children's Hospital of NewYork-Presbyterian, New York, New York
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19
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Friedman KG, Sleeper LA, Freud LR, Marshall AC, Godfrey ME, Drogosz M, Lafranchi T, Benson CB, Wilkins-Haug LE, Tworetzky W. Improved technical success, postnatal outcome and refined predictors of outcome for fetal aortic valvuloplasty. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:212-220. [PMID: 28543953 DOI: 10.1002/uog.17530] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 04/30/2017] [Accepted: 05/13/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Fetal aortic valvuloplasty (FAV) may prevent progression of mid-gestation aortic stenosis to hypoplastic left heart syndrome (HLHS). The aim of this study was to evaluate whether technical success and biventricular (Biv) outcome after FAV have changed from an earlier (2000-2008) to a more recent (2009-2015) era and identify pre-FAV predictors of Biv outcome. METHODS We evaluated procedural and postnatal outcomes in 123 fetuses that underwent FAV for evolving HLHS at Boston Children's Hospital between 2000 and 2015. The primary outcome measure was circulation type (Biv vs single ventricle) at the time of neonatal hospital discharge. Classification and regression tree (CART) analysis was performed to construct a stratification algorithm to predict Biv circulation based on pre-FAV fetal variables. RESULTS The FAV procedure was technically successful in 101/123 (82%) fetuses, with a higher technical success rate in the more recent era than in the earlier one (49/52 (94%) vs 52/71 (73%); P = 0.003). In liveborn patients, the incidence of Biv outcome was higher in the recent than in the earlier era, both in the entire liveborn cohort (29/49 (59%) vs 16/62 (26%); P = 0.001) and in those in whom the procedure was technically successful (27/46 (59%) vs 15/47 (32%); P = 0.007). Independent predictors of Biv outcome were higher left ventricular (LV) pressure, larger ascending aorta, better LV diastolic function and higher LV long-axis Z-score. On CART analysis, fetuses with LV pressure > 47 mmHg and ascending aorta Z-score ≥ 0.57 had a 92% probability of Biv outcome (n = 24). Those with a lower LV pressure, or mitral dimension Z-score < 0.1 and mitral valve inflow time Z-score < -2 (n = 34) were unlikely to have Biv (probability of 9%). The remainder of the patients had an intermediate (∼40-60%) likelihood of Biv circulation. CONCLUSIONS The proportion of patients achieving Biv outcome after FAV has increased, probably owing to an improved technical success rate and modified selection criteria. Fetal factors, including LV pressure, size of the ascending aorta and diastolic function, are associated with likelihood of Biv circulation after FAV. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- K G Friedman
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - L A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - L R Freud
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - A C Marshall
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - M E Godfrey
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - M Drogosz
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - T Lafranchi
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - C B Benson
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
- Department of Obstetrics and Gynecology, Harvard Medical School, Boston, MA, USA
| | - L E Wilkins-Haug
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
- Department of Obstetrics and Gynecology, Harvard Medical School, Boston, MA, USA
| | - W Tworetzky
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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20
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Sizarov A, Boudjemline Y. Valve Interventions in Utero: Understanding the Timing, Indications, and Approaches. Can J Cardiol 2017; 33:1150-1158. [DOI: 10.1016/j.cjca.2017.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 06/16/2017] [Accepted: 06/16/2017] [Indexed: 12/25/2022] Open
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21
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Araujo Júnior E, Tonni G, Chung M, Ruano R, Martins WP. Perinatal outcomes and intrauterine complications following fetal intervention for congenital heart disease: systematic review and meta-analysis of observational studies. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:426-433. [PMID: 26799734 DOI: 10.1002/uog.15867] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 01/13/2016] [Accepted: 01/18/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To assess perinatal outcomes and intrauterine complications following fetal intervention for congenital heart disease (CHD). METHODS A systematic review and meta-analysis were performed following an electronic search of PubMed and Scopus databases (last searched August 2015). Perinatal outcomes that were assessed included fetal death, live birth, preterm delivery < 37 weeks' gestation and neonatal death. Intrauterine complications that were assessed included bradycardia requiring treatment and hemopericardium requiring drainage. Estimated proportions were reported as mean (95% CI). Inconsistency was assessed using the I2 statistic. RESULTS An electronic search identified 2279 records, of which 29 studies (11 retrospective cohort and 18 case reports) were considered eligible for analysis. Fetal death after treatment of CHD by aortic valvuloplasty was reported in three studies, with a rate of 31% (95% CI, 9-60%), after pulmonary valvuloplasty in one study, with a rate of 25% (95% CI, 10-49%), after septoplasty in one study, with a rate of 14% (95% CI, 6-28%) and after pericardiocentesis and/or pericardioamniotic shunt placement in 24 studies, with a rate of 29% (95% CI, 18-41%). Bradycardia requiring treatment was reported after aortic valvuloplasty in two studies, with a rate of 52% (95% CI, 16-87%), after pulmonary valvuloplasty in one study, with a rate of 44% (95% CI, 23-67%), and after septoplasty in one study, with a rate of 27% (95% CI, 15-43%). CONCLUSIONS Current evidence on the effectiveness of prenatal intervention for CHD derives mostly from case reports and a few larger series; no study was randomized. Although the results of the meta-analysis are encouraging in terms of perinatal survival, they should be interpreted with caution when comparing with procedures performed after delivery. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- E Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine - Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil.
| | - G Tonni
- Department of Obstetrics and Gynecology, Prenatal Diagnostic Center, Guastalla Civil Hospital, AUSL Reggio Emilia, Italy
| | - M Chung
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - R Ruano
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - W P Martins
- Department of Obstetrics and Gynecology, Ribeirão Preto School of Medicine - São Paulo University (FMRP-USP), Ribeirão Preto, Brazil
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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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WIPUTRA H, LIM GL, CHIA DAK, MATTAR CNZ, BISWAS A, YAP CH. Methods for fluid dynamics simulations of human fetal cardiac chambers based on patient-specific 4D ultrasound scans. ACTA ACUST UNITED AC 2016. [DOI: 10.1299/jbse.15-00608] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Hadi WIPUTRA
- Department of Biomedical Engineering, National University of Singapore
| | - Guat Ling LIM
- Department of Obstetrics and Gynecology, Yong Loo Lin School of Medicine, National University of Singapore, National University Health Systems
| | - Dawn Ah Kiow CHIA
- Department of Obstetrics and Gynecology, Yong Loo Lin School of Medicine, National University of Singapore, National University Health Systems
| | - Citra Nurfarah Zaini MATTAR
- Department of Obstetrics and Gynecology, Yong Loo Lin School of Medicine, National University of Singapore, National University Health Systems
| | - Arijit BISWAS
- Department of Obstetrics and Gynecology, Yong Loo Lin School of Medicine, National University of Singapore, National University Health Systems
| | - Choon Hwai YAP
- Department of Biomedical Engineering, National University of Singapore
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Donofrio MT. The Power Is in the Numbers: Using Collaboration and a Data Registry to Answer Our Burning Questions Regarding Fetal Cardiac Intervention. J Am Coll Cardiol 2015. [PMID: 26205598 DOI: 10.1016/j.jacc.2015.05.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Freud LR, Moon-Grady A, Escobar-Diaz MC, Gotteiner NL, Young LT, McElhinney DB, Tworetzky W. Low rate of prenatal diagnosis among neonates with critical aortic stenosis: insight into the natural history in utero. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:326-332. [PMID: 25251721 PMCID: PMC4351121 DOI: 10.1002/uog.14667] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 08/03/2014] [Accepted: 09/12/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To better understand the natural history and spectrum of fetal aortic stenosis (AS), we aimed to (1) determine the prenatal diagnosis rate of neonates with critical AS and a biventricular (BV) outcome, and (2) describe the findings at fetal echocardiography in patients diagnosed prenatally. METHODS A multicenter, retrospective study was performed on neonates who presented with critical AS and who were discharged with a BV outcome from 2000 to 2013. The prenatal diagnosis rate was compared with that reported for hypoplastic left heart syndrome (HLHS). We reviewed fetal echocardiographic findings in patients who were diagnosed prenatally. RESULTS In only 10 (8.5%) of 117 neonates with critical AS and a BV outcome was the diagnosis made prenatally, a rate significantly lower than that for HLHS in the contemporary era (82%; P < 0.0001). Of the 10 patients diagnosed prenatally, all had developed left ventricular dysfunction by a median gestational age of 33 (range, 28-35) weeks. When present, Doppler abnormalities such as retrograde flow in the aortic arch (n = 2), monophasic mitral inflow (n = 3) and left-to-right flow across the foramen ovale (n = 8) developed late in gestation (median 33 weeks). CONCLUSION The prenatal diagnosis rate of critical AS and a BV outcome among neonates is very low, probably owing to a relatively normal four-chamber view in mid-gestation with development of significant obstruction in the third trimester. The natural history contrasts with that of severe mid-gestation AS with evolving HLHS and suggests that the gestational timing of development of significant AS has an important impact on subsequent left-heart growth in utero.
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Affiliation(s)
- Lindsay R. Freud
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School
| | - Anita Moon-Grady
- Department of Pediatrics, Division of Cardiology, Benioff Children’s Hospital, University of California-San Francisco School of Medicine
| | | | - Nina L. Gotteiner
- Department of Pediatrics, Division of Cardiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine
| | - Luciana T. Young
- Department of Pediatrics, Division of Cardiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine
| | - Doff B. McElhinney
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School
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Frommelt MA. Challenges and controversies in fetal diagnosis and treatment: hypoplastic left heart syndrome. Clin Perinatol 2014; 41:787-98. [PMID: 25459774 DOI: 10.1016/j.clp.2014.08.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Today, almost 70% of babies with hypoplastic left heart syndrome (HLHS) will survive into adulthood, although significant long-term morbidity and mortality still exists. Prenatal diagnosis of HLHS is increasingly common, allowing improved counseling, and the potential for fetal intervention if indicated. Exciting progress continues to be made in the area of fetal diagnosis and intervention, specifically catheter intervention for intact atrial septum or severe aortic stenosis. Pediatric cardiologists should be keenly aware of the flaws of staged palliation for the treatment of HLHS, and need to keep abreast of the emerging data regarding fetal diagnosis and intervention.
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Affiliation(s)
- Michele A Frommelt
- Division of Cardiology, Children's Hospital of Wisconsin, 9000 West Wisconsin Avenue, Milwaukee, WI 53201, USA.
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Affiliation(s)
- Jack Rychik
- From the Fetal Heart Program, Cardiac Center at The Children's Hospital of Philadelphia and the Division of Cardiology, Department of Pediatrics at the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Donofrio MT, Moon-Grady AJ, Hornberger LK, Copel JA, Sklansky MS, Abuhamad A, Cuneo BF, Huhta JC, Jonas RA, Krishnan A, Lacey S, Lee W, Michelfelder EC, Rempel GR, Silverman NH, Spray TL, Strasburger JF, Tworetzky W, Rychik J. Diagnosis and treatment of fetal cardiac disease: a scientific statement from the American Heart Association. Circulation 2014; 129:2183-242. [PMID: 24763516 DOI: 10.1161/01.cir.0000437597.44550.5d] [Citation(s) in RCA: 739] [Impact Index Per Article: 73.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The goal of this statement is to review available literature and to put forth a scientific statement on the current practice of fetal cardiac medicine, including the diagnosis and management of fetal cardiovascular disease. METHODS AND RESULTS A writing group appointed by the American Heart Association reviewed the available literature pertaining to topics relevant to fetal cardiac medicine, including the diagnosis of congenital heart disease and arrhythmias, assessment of cardiac function and the cardiovascular system, and available treatment options. The American College of Cardiology/American Heart Association classification of recommendations and level of evidence for practice guidelines were applied to the current practice of fetal cardiac medicine. Recommendations relating to the specifics of fetal diagnosis, including the timing of referral for study, indications for referral, and experience suggested for performance and interpretation of studies, are presented. The components of a fetal echocardiogram are described in detail, including descriptions of the assessment of cardiac anatomy, cardiac function, and rhythm. Complementary modalities for fetal cardiac assessment are reviewed, including the use of advanced ultrasound techniques, fetal magnetic resonance imaging, and fetal magnetocardiography and electrocardiography for rhythm assessment. Models for parental counseling and a discussion of parental stress and depression assessments are reviewed. Available fetal therapies, including medical management for arrhythmias or heart failure and closed or open intervention for diseases affecting the cardiovascular system such as twin-twin transfusion syndrome, lung masses, and vascular tumors, are highlighted. Catheter-based intervention strategies to prevent the progression of disease in utero are also discussed. Recommendations for delivery planning strategies for fetuses with congenital heart disease including models based on classification of disease severity and delivery room treatment will be highlighted. Outcome assessment is reviewed to show the benefit of prenatal diagnosis and management as they affect outcome for babies with congenital heart disease. CONCLUSIONS Fetal cardiac medicine has evolved considerably over the past 2 decades, predominantly in response to advances in imaging technology and innovations in therapies. The diagnosis of cardiac disease in the fetus is mostly made with ultrasound; however, new technologies, including 3- and 4-dimensional echocardiography, magnetic resonance imaging, and fetal electrocardiography and magnetocardiography, are available. Medical and interventional treatments for select diseases and strategies for delivery room care enable stabilization of high-risk fetuses and contribute to improved outcomes. This statement highlights what is currently known and recommended on the basis of evidence and experience in the rapidly advancing and highly specialized field of fetal cardiac care.
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Yap CH, Liu X, Pekkan K. Characterization of the vessel geometry, flow mechanics and wall shear stress in the great arteries of wildtype prenatal mouse. PLoS One 2014; 9:e86878. [PMID: 24475188 PMCID: PMC3903591 DOI: 10.1371/journal.pone.0086878] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 12/18/2013] [Indexed: 12/16/2022] Open
Abstract
Introduction Abnormal fluid mechanical environment in the pre-natal cardiovascular system is hypothesized to play a significant role in causing structural heart malformations. It is thus important to improve our understanding of the prenatal cardiovascular fluid mechanical environment at multiple developmental time-points and vascular morphologies. We present such a study on fetal great arteries on the wildtype mouse from embryonic day 14.5 (E14.5) to near-term (E18.5). Methods Ultrasound bio-microscopy (UBM) was used to measure blood velocity of the great arteries. Subsequently, specimens were cryo-embedded and sectioned using episcopic fluorescent image capture (EFIC) to obtain high-resolution 2D serial image stacks, which were used for 3D reconstructions and quantitative measurement of great artery and aortic arch dimensions. EFIC and UBM data were input into subject-specific computational fluid dynamics (CFD) for modeling hemodynamics. Results In normal mouse fetuses between E14.5–18.5, ultrasound imaging showed gradual but statistically significant increase in blood velocity in the aorta, pulmonary trunk (with the ductus arteriosus), and descending aorta. Measurement by EFIC imaging displayed a similar increase in cross sectional area of these vessels. However, CFD modeling showed great artery average wall shear stress and wall shear rate remain relatively constant with age and with vessel size, indicating that hemodynamic shear had a relative constancy over gestational period considered here. Conclusion Our EFIC-UBM-CFD method allowed reasonably detailed characterization of fetal mouse vascular geometry and fluid mechanics. Our results suggest that a homeostatic mechanism for restoring vascular wall shear magnitudes may exist during normal embryonic development. We speculate that this mechanism regulates the growth of the great vessels.
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Affiliation(s)
- Choon Hwai Yap
- Department of Biomedical Engineering, National University of Singapore, Singapore, Singapore
| | - Xiaoqin Liu
- Department of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Kerem Pekkan
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
- * E-mail:
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Abstract
Neonatal aortic stenosis is a complex and heterogeneous condition, defined as left ventricular outflow tract obstruction at valvular level, presenting and often requiring treatment in the first month of life. Initial presentation may be catastrophic, necessitating hemodynamic, respiratory and metabolic resuscitation. Subsequent management is focused on maintaining systemic blood flow, either via a univentricular Norwood palliation or a biventricular route, in which the effective aortic valve area is increased by balloon dilation or surgical valvotomy. In infants with aortic annular hypoplasia but adequately sized left ventricle, the Ross-Konno procedure is also an attractive option. Outcomes after biventricular management have improved in recent years as a consequence of better patient selection, perioperative management and advances in catheter technology. Exciting new developments are likely to significantly modify the natural history of this disorder, including fetal intervention for the salvage of the hypoplastic left ventricle; 3D echocardiography providing better definition of valve morphology and aiding patient selection for a surgical or catheter-based intervention; and new transcutaneous approaches, such as duel beam echo, to perforate the valve.
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Affiliation(s)
- Nigel E Drury
- Wessex Cardiothoracic Centre, Southampton University Hospitals NHS Trust, Southampton General Hospital, Southampton, Hampshire, UK.
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Abstract
OBJECTIVES Foetal aortic valvuloplasty has been proposed as a strategy to improve left heart growth and function in foetuses with severe aortic stenosis at risk of progression to hypoplastic left heart syndrome. We report our experience with this intervention. METHODS AND RESULTS Between 2005 and 2010, five foetuses with aortic stenosis and at risk of progression to hypoplastic left heart syndrome underwent ultrasound-guided percutaneous foetal aortic valvuloplasty. There were no associated maternal complications or foetal demise. In one case, the pregnancy was terminated a couple of weeks after the intervention, one foetus evolved to hypoplastic left heart syndrome, and three did not. CONCLUSIONS Foetal aortic valvuloplasty seems to be a safe and feasible procedure. It has been reported that it has the potential to prevent progression to hypoplastic left heart syndrome in selected foetuses with severe aortic stenosis. Further investigation regarding physiological and clinical aspects of this disease both prenatally and postnatally will probably allow to improve therapeutic strategies and clinical outcome.
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Abstract
Fetal congenital heart disease may progress during pregnancy and may lead to irreversible myocardial or pulmonary damage. The rationale of fetal intracardiac interventions is to change fetal hemodynamics, prevent secondary damage and improve long-term outcome at an acceptable risk for mother and fetus. This review focuses on the current experience about patient selection, risks and benefits of this technique.
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Affiliation(s)
- Gerald Tulzer
- Children's Heart Centre Linz, Department of Pediatric Cardiology, Krankenhausstrasse 26-30, A-4020 Linz, Austria.
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Abstract
The surgical repair of complex congenital heart defects frequently requires additional tissue in various forms, such as patches, conduits, and valves. These devices often require replacement over a patient's lifetime because of degeneration, calcification, or lack of growth. The main new technologies in congenital cardiac surgery aim at, on the one hand, avoiding such reoperations and, on the other hand, improving long-term outcomes of devices used to repair or replace diseased structural malformations. These technologies are: 1) new patches: CorMatrix® patches made of decellularized porcine small intestinal submucosa extracellular matrix; 2) new devices: the Melody® valve (for percutaneous pulmonary valve implantation) and tissue-engineered valved conduits (either decellularized scaffolds or polymeric scaffolds); and 3) new emerging fields, such as antenatal corrective cardiac surgery or robotically assisted congenital cardiac surgical procedures. These new technologies for structural malformation surgery are still in their infancy but certainly present great promise for the future. But the translation of these emerging technologies to routine health care and public health policy will also largely depend on economic considerations, value judgments, and political factors.
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Affiliation(s)
- David Kalfa
- Pediatric Cardiac Surgery, Columbia University, Morgan Stanley Children's Hospital of New York-Presbyterian, New York, USA
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Park MV, Fedderly RT, Frommelt PC, Frommelt MA, Pelech AN, Jaquiss RDB, Mussatto K, Tweddell JS. Leftward displacement of septum primum in hypoplastic left heart syndrome. Pediatr Cardiol 2013. [PMID: 23179423 PMCID: PMC4567036 DOI: 10.1007/s00246-012-0579-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Embryologic development of atrial septum primum antedates formation of the atrioventricular and semilunar valves. Leftward displacement of the superior attachment of septum primum (LDSP) has only been described in hypoplastic left heart syndrome (HLHS). This study reports the frequency of LDSP in HLHS and correlates LDSP with other echocardiographic features of HLHS. Preoperative echocardiograms for 72 consecutive patients with classic HLHS from 1996 to 2002 at Children's Hospital of Wisconsin were reviewed. One patient was excluded for inadequate imaging. Data for the 71 patients included the following: size, location, and Doppler gradient across the atrial septal defect (ASD); location of attachment of septum primum; size and patency of the aortic valve (AoV) annulus; size and patency of the mitral valve (MV) annulus; ascending aorta diameter (AAD); and left-ventricular end diastolic dimension (LVEDD). Patients were categorized into three groups: aortic atresia/mitral atresia (AA/MA), aortic atresia/mitral stenosis (AA/MS), and aortic stenosis/mitral stenosis (AS/MS). LDSP was seen in 46 of 71 patients (64 %). By diagnostic group, 32 of 35 patients with AA/MA had LDSP (91 %) compared with 10 of 19 AA/MS patients (53 %) and 4 of 17 AS/MS patients (24 %), p < 0.05. AoV patency was seen in 4 of 46 (9 %) patients with LDSP compared with 13 of 25 (52 %) patients with normal atrial attachment, p < 0.005. Mean left heart dimensions in infants with LDSP compared with normal attachment were as follows: AoV annulus 2.24 versus 3.83 mm, AAD 2.34 versus 4.1 mm, MV annulus 3.21 versus 6.48 mm, and LVEDD 6.38 versus 13.83 mm. By two-way analysis of variance of diagnostic category versus atrial septal attachment with interaction, MV annulus and AAD were independently predicted smaller by LDSP versus normal atrial attachment, p < 0.05. Nonsignificant factors included AoV annulus, LVEDD, ASD size, and Doppler gradient. LDSP correlates with more severe maldevelopment of the left heart in patients with HLHS. Because formation of septum primum precedes development and growth of the intracardiac valves, we speculate that LDSP may be an initiating event in the development of HLHS. In addition, prenatal identification of LDSP may help direct planning of potential in utero therapies.
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Affiliation(s)
- Matthew V. Park
- Pediatrix Medical Group, Northwest Children's Heart Care, 314 Martin Luther King Junior Way, Suite #303, Tacoma, WA 98405, USA
| | - Raymond T. Fedderly
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
| | - Peter C. Frommelt
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
| | - Michele A. Frommelt
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
| | - Andrew N. Pelech
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
| | | | - Kathleen Mussatto
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
| | - James S. Tweddell
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
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Abstract
BACKGROUND Fetal echocardiography plays a critical role in the diagnosis and management of structural, functional and rhythm-related fetal cardiovascular disease. OBJECTIVES/METHODS This article reviews the history of fetal echocardiography and the prenatal diagnosis of fetal cardiovascular disease as well as the evolution of the field of fetal cardiology. The clinical application of fetal echocardiography, including indications for referral, timing of referral and considerations in the diagnosis and serial assessment of fetal cardiovascular disease, is presented. CONCLUSIONS Newer directions in the field of fetal cardiology, including first trimester diagnoses and fetal intervention, will continue to expand its role in the evaluation and treatment of affected pregnancies in the future; however, equally as important are efforts to continue to improve prenatal detection rates.
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Affiliation(s)
- Lisa K Hornberger
- Professor of Pediatrics University of Alberta William C McKenzie Health Centre, Director of the Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics & Obstetrics, 4C2.23, 8440 112th Street, Edmonton, Alberta T6G2B7, Canada +1 780 407 3952 ; +1 780 407 3954 ;
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Bishnoi RN, Coulson JD, Ringel RE. Recent advances in interventional pediatric cardiology. Adv Pediatr 2013; 60:187-200. [PMID: 24007845 DOI: 10.1016/j.yapd.2013.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Ram N Bishnoi
- Department of Pediatric Cardiology, Johns Hopkins University School of Medicine, 1800 Orleans Street, Bloomberg Children's Center M2309, Baltimore, MD 21287, USA.
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Abstract
Fetal interventions for congenital heart disease have become important treatment modalities in the past 10 to 15 years. The basic hypothesis has been that a prenatal intervention may remodel cardiac morphology and function to such an extent that it may favorably alter the in utero natural history, resulting in improved prenatal and postnatal outcomes, including an increased likelihood of achieving biventricular circulation. This review discusses the current indications, techniques, and outcomes of fetal cardiac interventions and provides a glimpse into the future with regard to technical improvements and newer treatment modalities, such as maternal oxygenation and in utero pacemaker implantation.
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van Mieghem T, Baud D, Devlieger R, Lewi L, Ryan G, De Catte L, Deprest J. Minimally invasive fetal therapy. Best Pract Res Clin Obstet Gynaecol 2012; 26:711-25. [DOI: 10.1016/j.bpobgyn.2012.03.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 03/21/2012] [Indexed: 12/31/2022]
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Diemert A, Diehl W, Glosemeyer P, Deprest J, Hecher K. Intrauterine surgery--choices and limitations. DEUTSCHES ARZTEBLATT INTERNATIONAL 2012; 109:603-38. [PMID: 23093990 DOI: 10.3238/arztebl.2012.0603] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Accepted: 04/25/2012] [Indexed: 12/26/2022]
Abstract
BACKGROUND The past decade has seen much progress in intrauterine surgery. Randomized trials have documented the benefit of some procedures of this type for the unborn child. METHOD Selective literature review RESULTS Randomized trials have demonstrated the benefit of fetoscopic laser coagulation of placental anastomoses in twin-to-twin transfusion syndrome (TTTS) and of intrauterine surgery via hysterotomy for the repair of spina bifida. Other fetoscopic procedures have yielded promising initial results but are not yet supported by findings from randomized trials. Some intrauterine surgical procedures must still be considered experimental in view of the lack of randomized trials and the rarity of the conditions they are designed to treat. Fetoscopic laser coagulation for TTTS is by far the most common procedure in fetal surgery; TTTS arises in roughly 1 in 2500 pregnancies. The other procedures discussed in this article are performed much less often and for rarer indications. In general, intrauterine surgery is indicated only to treat conditions that would otherwise lead to intrauterine death or irreversible prenatal damage. CONCLUSION Intrauterine surgery is a rapidly developing field. Prenatal intervention by laser coagulation is indicated to treat severe TTTS, as its benefit has been shown in a randomized trial. Not enough evidence is yet available for the possible benefit of intrauterine surgery to treat myelomeningocele and congenital diaphragmatic hernia. Other indications are experimental. When an indication for intrauterine surgery exists, the parents should be informed and, depending on their wishes, referred to a center where it can be performed.
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Affiliation(s)
- Anke Diemert
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Germany
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Zhou K, Wu G, Li Y, Zhao L, Zhou R, Zhu Q, Huang X, Mu D, Hua Y. Protective effects of indomethacin and dexamethasone in a goat model with intrauterine balloon aortic valvuloplasty. J Biomed Sci 2012; 19:74. [PMID: 22889399 PMCID: PMC3438018 DOI: 10.1186/1423-0127-19-74] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2012] [Accepted: 07/31/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intrauterine balloon aortic valvuloplasty (IUBAV) has been used for critical aortic stenosis. However, it is necessary to determine the fetal impairments such as preterm birth after this approach and to find a way to prevent or reduce them. METHODS In the present study, we evaluated the therapeutic value of indomethacin (IDM) and dexamethasone (DXS) on reducing the preterm birth rate in experimental goats after IUBAV. RESULTS Our results indicated that the administration of IDM/DXS significantly reduced the rate of premature birth. IDM/DXS treatment led to preservation of myocardial ultrastructure with less damage, and amelioration of the fetal and placental circulation. Furthermore, we found that norepinephrine (NE) level was positively associated with the degree of myocardial damage. IDM/DXS administration led to a significant decrease of operation-induced increase of NE levels, which may be associated with the protective effects of IDM/DXS. Lastly, we found that the administration of IDM/DXS did not induce the risk of ductus arteriosus closure or slow down fetal growth. CONCLUSIONS Our results indicate that IDM/DXS promotes a better gestational outcome at least partially by reducing stress response during and after the operation of IUBAV in the goat model. IDM/DXS may be a useful application in human patients during IUBAV intervention.
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Affiliation(s)
- Kaiyu Zhou
- Department of Pediatric Cardiology, Second University Hospital and West China Medical School, Sichuan University, Chengdu 610041, China
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Yamamoto Y, Hornberger LK. Progression of outflow tract obstruction in the fetus. Early Hum Dev 2012; 88:279-85. [PMID: 22460060 DOI: 10.1016/j.earlhumdev.2012.02.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 02/22/2012] [Indexed: 10/28/2022]
Abstract
Fetal ventricular outflow tract obstruction (OTO) is congenital heart disease with significant potential for progression before birth as a consequence of the unique nature of the fetal circulation. The pattern of evolution depends upon the timing of development, severity of obstruction and the influence of the OTO on the fetal atrioventricular valve and myocardial function. Critical aortic (AS) or pulmonary (PS) valve stenosis, the two most common forms of fetal OTO, may be associated with progressive ventricular and great artery hypoplasia if presenting early in gestation or with normal ventricular and great artery growth if evolving later in gestation. In some affected fetuses, AS or PS may lead to the evolution of fetal heart failure. This article will review our current understanding of the natural history of fetal AS and PS, experience with fetal intervention and future directions of research.
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Affiliation(s)
- Yuka Yamamoto
- Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Women's & Children's Health Research Institute, Mazankowski Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
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Rationale for and current status of prenatal cardiac intervention. Early Hum Dev 2012; 88:287-90. [PMID: 22425038 DOI: 10.1016/j.earlhumdev.2012.02.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 02/22/2012] [Indexed: 11/21/2022]
Abstract
The idea of prenatal intervention in congenital heart defects was put forward over 20 years ago, arising from the observation that some forms of cardiac malformation progressed in severity as pregnancy advanced. The simultaneous development of minimally invasive catheter techniques in children, led to the concept of treating the foetal heart directly, in an attempt to prevent the changes which had been observed. Early efforts at prenatal valvuloplasty were largely set aside after poor results and the coincidental development of alternative, increasingly successful, postnatal surgical strategies. However, in the last 10 years or so, some centres have revived and extended the interventional techniques, with some success. The application of these techniques is limited to very few conditions, and suitable cases are relatively uncommon. Exploration of these procedures, therefore, should be limited to very few centres and the results should be closely scrutinised before this becomes an accepted management option.
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Abstract
Successful treatment of severe aortic (AS) or pulmonary valve (PS) stenosis by balloon valvuloplasty in term neonates is well-established. Sometimes, AS or PS diagnosed antenatally, progresses to severe left or right ventricular hypoplasia respectively. Successful fetal balloon valvuloplasty cannot be assumed to significantly change the natural history. In this review of premature infants, balloon valvuloplasty was used in extremely small babies. Five with severe AS (32 to 36 weeks, birth weight 1.4 to 1.9 kg) had percutaneous balloon aortic valvuloplasty during the first 10 days of life. Seven infants with severe/critical PS (28 to 36 weeks, birth weight 1.2 to 1.9 kg) had percutaneous balloon pulmonary valvuloplasty during the first 9 days of life. Two with pulmonary atresia (1.9 and 0.85 kg), underwent successful radiofrequency assisted balloon pulmonary valvuloplasty. There were no procedural deaths but one infant developed severe aortic insufficiency.
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Khan MA, Almoukirish AS, Das K, Galal MO. Hypoplastic left heart syndrome, cor triatriatum and partial anomalous pulmonary venous connection: Imaging of a very rare association. J Saudi Heart Assoc 2012; 24:137-40. [PMID: 23960683 DOI: 10.1016/j.jsha.2011.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Revised: 09/19/2011] [Accepted: 10/02/2011] [Indexed: 10/16/2022] Open
Abstract
A newborn is presented with an association of hypoplastic left heart syndrome, cor triatriatum and partial anomalous pulmonary venous connection. The diagnosis was established with echocardiography and further confirmed with computed tomography. To our knowledge the images of such an association have never been reported before.
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Ciccolo ML, Rothman A, Galindo A, Acherman RJ, Evans WN. Successful immediate newborn ross-konno and mitral valve repair following fetal aortic valvuloplasty. World J Pediatr Congenit Heart Surg 2012; 3:264-6. [PMID: 23804787 DOI: 10.1177/2150135111433471] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Perinatal management of severe mitral regurgitation (MR) and aortic stenosis (AS) is difficult; mortality is high, and there are few reports of successful postnatal biventricular repairs. We report a patient with severe MR and AS, diagnosed prenatally, that underwent a fetal aortic valvuloplasty and a successful modified Ross-Konno procedure with concomitant mitral valve repair shortly after birth.
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Affiliation(s)
- Michael L Ciccolo
- Cardiovascular Surgical Associates, 1090 E Desert Inn Road, Ste 202, Las Vegas, NV 89109, USA
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Weber B, Emmert MY, Behr L, Schoenauer R, Brokopp C, Drögemüller C, Modregger P, Stampanoni M, Vats D, Rudin M, Bürzle W, Farine M, Mazza E, Frauenfelder T, Zannettino AC, Zünd G, Kretschmar O, Falk V, Hoerstrup SP. Prenatally engineered autologous amniotic fluid stem cell-based heart valves in the fetal circulation. Biomaterials 2012; 33:4031-43. [PMID: 22421386 DOI: 10.1016/j.biomaterials.2011.11.087] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2011] [Accepted: 11/29/2011] [Indexed: 01/22/2023]
Abstract
Prenatal heart valve interventions aiming at the early and systematic correction of congenital cardiac malformations represent a promising treatment option in maternal-fetal care. However, definite fetal valve replacements require growing implants adaptive to fetal and postnatal development. The presented study investigates the fetal implantation of prenatally engineered living autologous cell-based heart valves. Autologous amniotic fluid cells (AFCs) were isolated from pregnant sheep between 122 and 128 days of gestation via transuterine sonographic sampling. Stented trileaflet heart valves were fabricated from biodegradable PGA-P4HB composite matrices (n = 9) and seeded with AFCs in vitro. Within the same intervention, tissue engineered heart valves (TEHVs) and unseeded controls were implanted orthotopically into the pulmonary position using an in-utero closed-heart hybrid approach. The transapical valve deployments were successful in all animals with acute survival of 77.8% of fetuses. TEHV in-vivo functionality was assessed using echocardiography as well as angiography. Fetuses were harvested up to 1 week after implantation representing a birth-relevant gestational age. TEHVs showed in vivo functionality with intact valvular integrity and absence of thrombus formation. The presented approach may serve as an experimental basis for future human prenatal cardiac interventions using fully biodegradable autologous cell-based living materials.
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Affiliation(s)
- Benedikt Weber
- Swiss Center for Regenerative Medicine and Clinic for Cardiovascular Surgery, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
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Feinstein JA, Benson DW, Dubin AM, Cohen MS, Maxey DM, Mahle WT, Pahl E, Villafañe J, Bhatt AB, Peng LF, Johnson BA, Marsden AL, Daniels CJ, Rudd NA, Caldarone CA, Mussatto KA, Morales DL, Ivy DD, Gaynor JW, Tweddell JS, Deal BJ, Furck AK, Rosenthal GL, Ohye RG, Ghanayem NS, Cheatham JP, Tworetzky W, Martin GR. Hypoplastic left heart syndrome: current considerations and expectations. J Am Coll Cardiol 2012; 59:S1-42. [PMID: 22192720 PMCID: PMC6110391 DOI: 10.1016/j.jacc.2011.09.022] [Citation(s) in RCA: 349] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 09/06/2011] [Accepted: 09/20/2011] [Indexed: 01/25/2023]
Abstract
In the recent era, no congenital heart defect has undergone a more dramatic change in diagnostic approach, management, and outcomes than hypoplastic left heart syndrome (HLHS). During this time, survival to the age of 5 years (including Fontan) has ranged from 50% to 69%, but current expectations are that 70% of newborns born today with HLHS may reach adulthood. Although the 3-stage treatment approach to HLHS is now well founded, there is significant variation among centers. In this white paper, we present the current state of the art in our understanding and treatment of HLHS during the stages of care: 1) pre-Stage I: fetal and neonatal assessment and management; 2) Stage I: perioperative care, interstage monitoring, and management strategies; 3) Stage II: surgeries; 4) Stage III: Fontan surgery; and 5) long-term follow-up. Issues surrounding the genetics of HLHS, developmental outcomes, and quality of life are addressed in addition to the many other considerations for caring for this group of complex patients.
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Affiliation(s)
- Jeffrey A Feinstein
- Department of Pediatrics, Stanford University School of Medicine, Lucile Salter Packard Children's Hospital, Palo Alto, California 94304, USA.
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Weber B, Emmert MY, Behr L, Brokopp C, Frauenfelder T, Kretschmar O, Falk V, Hoerstrup SP. Fetal trans-apical stent delivery into the pulmonary artery: prospects for prenatal heart-valve implantation. Eur J Cardiothorac Surg 2011; 41:398-403. [PMID: 21741853 DOI: 10.1016/j.ejcts.2011.04.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE The purpose of this study was to assess the technical feasibility of a fetal trans-apical stent delivery into the pulmonary artery using a novel hybrid-intervention technique as a possible route for prenatal minimally invasive heart-valve-implantation approaches. METHODS Pregnant Pre-Alp sheep between 122 and 128 days' gestation (n = 3) underwent a midline laparotomy. The fetus was left in utero or partially externalized and its chest was opened via a left-sided minithoracotomy. The fetal heart was cannulated and a guide wire was introduced through the ductus arteriosus into the aorta. A 14-French delivery system was then mounted onto the guide wire and advanced to the landing zone in the pulmonary artery, where the stent was deployed. The position of the stent was confirmed using echocardiography, angiography as well as computed tomography. RESULTS The trans-apical implantation was successful in all animals. However, at necropsy in one animal, the stent was found to partly occlude one of the pulmonary valvular leaflets. Bleeding at the antero-apical incision occurred in all animals but could be managed without fetal demise. No fetal cardiopulmonary bypass was performed. In all animals, contrast angiography displayed normal perfusion of the pulmonary vasculature as well as the ductus arteriosus. CONCLUSIONS Our study demonstrates the principal technical feasibility of a prenatal stent delivery into the pulmonary artery using a novel trans-apical hybrid-intervention technique. This approach demonstrates the first step towards possible future minimally invasive prenatal heart-valve-implantation procedures.
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Affiliation(s)
- Benedikt Weber
- Clinic for Cardiovascular Surgery and Department of Surgical Research, University Hospital of Zurich, Zurich, Switzerland
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Galindo A, Gutiérrez-Larraya F, de la Fuente P. Congenital heart defects in fetal life: an overview. ACTA ACUST UNITED AC 2011. [DOI: 10.3109/14722240400023578] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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