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Grinenco S, Aiello HA, Meller CH, Lucini V, Nápoli N, Trentacoste L, Córdoba A, Saenz Tejeira M, Osuna JM, Barretta J, Villa AB, Marantz P, Otaño L. Fetal aortic valvuloplasty as the first step in a complex therapeutic strategy. Prenat Diagn 2024; 44:739-746. [PMID: 38666896 DOI: 10.1002/pd.6579] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/02/2024] [Accepted: 04/11/2024] [Indexed: 06/17/2024]
Abstract
BACKGROUND Fetal aortic valvuloplasty (FAV) is proposed to prevent hypoplastic left heart syndrome due to fetal critical aortic stenosis. OBJECTIVE to report our experience on FAV as the first step in a complex therapeutic strategy. METHOD Series of patients with FAV over an 18-year period. RESULTS 27 FAVs were performed in 26 fetuses, with technical success in 82% (22/27) and periprocedural fetal demise in 22% (6/27), decreasing to 15% in the second half-cohort. Loss to follow-up was due to birth or postnatal therapy in other centers (5) and termination of pregnancy (1), A normal-sized LV at birth was observed in 46% (6/13), 4 neonates underwent aortic valvuloplasty and 2 cardiac surgeries, with 5/6 achieving biventricular circulation at 28 days, and 3 transplant-free survival at mid-term follow-up. The 7/13 born with a borderline LV underwent LV rehabilitation strategy, with survival at 28 days in 4/7 and at mid-term in 3: one with biventricular circulation, one with a ventricle-and-a-half repair, and one lost to follow-up. CONCLUSION FAV was feasible in most cases, with no maternal complications, and biventricular circulation at 28 days in ∼40% of survivors. After FAV, a diverse range of postnatal cardiac interventions are performed, reflecting the challenging innovation in current cardiovascular therapy.
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Affiliation(s)
- Sofía Grinenco
- Pediatric Cardiology Service, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
| | - Horacio Antonio Aiello
- Maternal-Fetal Medicine Unit, Obstetrics Service, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
| | - César Hernán Meller
- Maternal-Fetal Medicine Unit, Obstetrics Service, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
| | - Victorio Lucini
- Hemodinamics Service, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
| | - Natalia Nápoli
- Pediatric Cardiology Service, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
| | - Luis Trentacoste
- Hemodinamics Service, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
| | - Antonela Córdoba
- Pediatric Cardiology Service, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
| | - Mercedes Saenz Tejeira
- Pediatric Cardiology Service, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
| | - Juan Manuel Osuna
- Pediatric Cardiovascular Surgery Service, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
| | - Jorge Barretta
- Pediatric Cardiovascular Surgery Service, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
| | - Alejandra Beatriz Villa
- Pediatric Cardiology Service, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
| | - Pablo Marantz
- Pediatric Cardiology Service, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
| | - Lucas Otaño
- Maternal-Fetal Medicine Unit, Obstetrics Service, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
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2
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Guseh S, Tworetzky W. Transforming congenital heart disease management: Advances in fetal cardiac interventions. Prenat Diagn 2024; 44:733-738. [PMID: 38768017 DOI: 10.1002/pd.6592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 05/03/2024] [Accepted: 05/06/2024] [Indexed: 05/22/2024]
Abstract
This review addresses the transformative advancements in fetal cardiac interventions (FCI) for congenital heart diseases (CHD), with a particular focus on aortic stenosis with evolving hypoplastic left heart syndrome, pulmonary atresia with an intact ventricular septum, and HLHS with an intact atrial septum (HLHS-IAS). We outline the specific FCI techniques employed, the refined criteria for selecting appropriate fetal and maternal candidates, and the promising yet varied outcomes associated with these procedures. Procedural strategies and clinical decision-making are examined as we take into account the fetal pathophysiology and the benefits and risks of early intervention. We highlight the role of multidisciplinary teams in improving technical success and managing immediate procedural complications, which have led to significant improvements in procedural outcomes. Additionally, the review discusses the long-term outcomes, challenges, and future research directions in FCI, emphasizing the necessity for continuous innovation and collaboration across specialties to advance the management of CHD. The integration of new technologies and research findings holds the promise of further enhancing FCI success rates and patient outcomes.
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Affiliation(s)
- Stephanie Guseh
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
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3
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Green L, Chan WX, Tulzer A, Tulzer G, Yap CH. Myocardial biomechanical effects of fetal aortic valvuloplasty. Biomech Model Mechanobiol 2024:10.1007/s10237-024-01848-0. [PMID: 38683446 DOI: 10.1007/s10237-024-01848-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 04/07/2024] [Indexed: 05/01/2024]
Abstract
Fetal critical aortic stenosis with evolving hypoplastic left heart syndrome (CAS-eHLHS) can progress to a univentricular (UV) birth malformation. Catheter-based fetal aortic valvuloplasty (FAV) can resolve stenosis and reduce the likelihood of malformation progression. However, we have limited understanding of the biomechanical impact of FAV and subsequent LV responses. Therefore, we performed image-based finite element (FE) modeling of 4 CAS-eHLHS fetal hearts, by performing iterative simulations to match image-based characteristics and then back-computing physiological parameters. We used pre-FAV simulations to conduct virtual FAV (vFAV) and compared pre-FAV and post-FAV simulations. vFAV simulations generally enabled partial restoration of several physiological features toward healthy levels, including increased stroke volume and myocardial strains, reduced aortic valve (AV) and mitral valve regurgitation (MVr) velocities, reduced LV and LA pressures, and reduced peak myofiber stress. FAV often leads to aortic valve regurgitation (AVr). Our simulations showed that AVr could compromise LV and LA depressurization but it could also significantly increase stroke volume and myocardial deformational stimuli. Post-FAV scans and simulations showed FAV enabled only partial reduction of the AV dissipative coefficient. Furthermore, LV contractility and peripheral vascular resistance could change in response to FAV, preventing decreases in AV velocity and LV pressure, compared with what would be anticipated from stenosis relief. This suggested that case-specific post-FAV modeling is required to fully capture cardiac functionality. Overall, image-based FE modeling could provide mechanistic details of the effects of FAV, but computational prediction of acute outcomes was difficult due to a patient-dependent physiological response to FAV.
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Affiliation(s)
- Laura Green
- Department of Biomedical Engineering, Imperial College London, L2 Bessemer Building, South Kensington Campus, London, SW7 2AZ, UK
| | - Wei Xuan Chan
- Department of Biomedical Engineering, Imperial College London, L2 Bessemer Building, South Kensington Campus, London, SW7 2AZ, UK
- BHF Centre of Research Excellence, Imperial College London, London, UK
| | - Andreas Tulzer
- Department of Pediatric Cardiology, Children's Heart Center Linz, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - Gerald Tulzer
- Department of Pediatric Cardiology, Children's Heart Center Linz, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - Choon Hwai Yap
- Department of Biomedical Engineering, Imperial College London, L2 Bessemer Building, South Kensington Campus, London, SW7 2AZ, UK.
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4
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Okpaise OO, Tonni G, Werner H, Araujo Júnior E, Lopes J, Ruano R. Three-dimensional real and virtual models in fetal surgery: a real vision. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:303-311. [PMID: 36565438 DOI: 10.1002/uog.26148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 11/30/2022] [Accepted: 12/14/2022] [Indexed: 06/17/2023]
Affiliation(s)
- O O Okpaise
- Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - G Tonni
- Prenatal Diagnostic Centre, Department of Obstetrics and Neonatology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), AUSL Reggio Emilia, Reggio Emilia, Italy
| | - H Werner
- Biodesign Lab DASA/PUC-Rio, Rio de Janeiro, Brazil
| | - E Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
- Medical School, Municipal University of São Caetano do Sul (USCS), Bela Vista Campus, São Paulo, Brazil
| | - J Lopes
- Biodesign Lab DASA/PUC-Rio, Rio de Janeiro, Brazil
- Institute for Pure and Applied Mathematics, Rio de Janeiro, Brazil
| | - R Ruano
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of Miami, Miller School of Medicine, Miami, FL, USA
- Maternal-Fetal-Children Service of Excellence, Americas Group, United Health Care Brazil, São Paulo, Brazil
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5
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Reitz JG, Meier JM, Berg C, Weber EC, Gembruch U, Wolter A, Sterzbecher V, Bedei I, Axt-Fliedner R. Two-dimensional speckle tracking echocardiography in fetuses with critical aortic stenosis before and after fetal aortic valvuloplasty. Arch Gynecol Obstet 2024:10.1007/s00404-024-07376-7. [PMID: 38363396 DOI: 10.1007/s00404-024-07376-7] [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: 12/05/2023] [Accepted: 01/02/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Critical aortic stenosis (AS) in fetuses may progress to hypoplastic left heart syndrome (HLHS) with need for postnatal single ventricular (SV) palliation. Fetal aortic valvuloplasty (FAV) is performed to achieve postnatal biventricular (BV) circulation. However, the impact of FAV on fetal myocardial function is difficult to measure. Prediction of postnatal circulatory status and, therefore, counseling is challenging. METHODS Retrospective study of fetuses with critical AS who underwent FAV. Global Longitudinal Peak Systolic Strain (GLPSS) of the left ventricle (LV) and right ventricle (RV) were retrospectively analyzed before and after intervention. Fisher's Exact Test and Mann-Whitney-U Test were used for univariant statistical analysis. RESULTS 23 fetuses with critical AS were included. After intervention fetuses demonstrated more negative LV-GLPSS mean values post- vs. pre-intervention (- 5.36% vs. - 1.57%; p < 0.05). RV-GLPSS was decreased in all fetuses, there was no peri-interventional change. 20 fetuses were born alive. Postnatally, 10 had BV and 10 SV circulation. Improved post-interventional LV-GLPSS strain values correlated with BV outcome (p < 0.05). Pre-interventional continuous LV-GLPSS values correlated with postnatal SV vs. BV outcome (p < 0.05). CONCLUSION In some fetuses, LV myocardial function assessed by speckle tracking echocardiography (STE) improves after FAV. Improved post-interventional LV-GLPSS correlates with biventricular postnatal outcome. Furthermore, pre-interventional LV- and RV-GLPSS correlate with postnatal outcome. Further studies are needed to asses, if pre-interventional STE parameters might predict which fetuses will benefit from FAV with postnatal BV circulation.
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Affiliation(s)
- Justus G Reitz
- Department of Cardiovascular Surgery, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
| | - Johanna M Meier
- Division of Prenatal Medicine, Department of Obstetrics and Gynecology, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
| | - Christoph Berg
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Bonn, Germany
| | - Eva C Weber
- Department of Obstetrics and Gynecology, University Hospital Cologne, Cologne, Germany
| | - Ulrich Gembruch
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Bonn, Germany
| | - Aline Wolter
- Division of Prenatal Medicine, Department of Obstetrics and Gynecology, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
| | - Vanessa Sterzbecher
- Division of Prenatal Medicine, Department of Obstetrics and Gynecology, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
| | - Ivonne Bedei
- Division of Prenatal Medicine, Department of Obstetrics and Gynecology, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
| | - Roland Axt-Fliedner
- Division of Prenatal Medicine, Department of Obstetrics and Gynecology, University Hospital Giessen, Justus-Liebig University, Giessen, Germany.
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Yagi H, Xu X, Gabriel GC, Lo C. Molecular Pathways and Animal Models of Hypoplastic Left Heart Syndrome. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1441:947-961. [PMID: 38884763 DOI: 10.1007/978-3-031-44087-8_61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Hypoplastic left heart syndrome (HLHS) is a severe congenital heart disease (CHD) with underdevelopment of left-sided heart structures. While previously uniformly fatal, surgical advances now provide highly effective palliation that allows most HLHS patients to survive their critical CHD. Nevertheless, there remains high morbidity and mortality with high risk of heart failure. As hemodynamic compromise from restricted aortic blood flow has been suggested to underlie the poor LV growth, this suggests the possibility of prenatal fetal intervention to recover LV growth. As such interventions have yielded ambiguous results, the optimization of therapy will require more mechanistic insights into the developmental etiology for HLHS. Clinical studies have shown high heritability for HLHS, with an oligogenic etiology indicated in conjunction with genetic heterogeneity. This is corroborated with the recent recovery of mutant mice with HLHS. With availability-induced pluripotent stem cell (iPSC)-derived cardiomyocytes from HLHS mice and patients, new insights have emerged into the cellular and molecular etiology for the LV hypoplasia in HLHS. Cell proliferation defects were observed in conjunction with metaphase arrest and the disturbance of Hippo-YAP signaling. The left-sided restriction of the ventricular hypoplasia may result from epigenetic perturbation of pathways regulating left-right patterning. These findings suggest new avenues for fetal interventions with therapies using existing drugs that target the Hippo-YAP pathway and/or modulate epigenetic regulation.
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Affiliation(s)
- Hisato Yagi
- Department of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Xinxiu Xu
- Department of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - George C Gabriel
- Department of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Cecilia Lo
- Department of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Salciccioli KB, Zachariah JP. Coarctation of the Aorta: Modern Paradigms Across the Lifespan. Hypertension 2023; 80:1970-1979. [PMID: 37476999 PMCID: PMC10530495 DOI: 10.1161/hypertensionaha.123.19454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
While coarctation of the aorta varies greatly in both severity and age at presentation, all patients are at increased risk of hypertension both before and after repair. Despite advances in knowledge about genetic etiologies, pathophysiologic mechanisms, and optimal repair strategies, patients with repaired coarctation of the aorta remain at increased risk of acquired cardiovascular disease. The aims of this review are to describe the management of coarctation of the aorta at all ages before and after repair, highlight pathophysiologic mechanisms of hypertension, and review long-term follow-up considerations.
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Affiliation(s)
- Katherine B Salciccioli
- Section of Pediatric Cardiology, Departments of Internal Medicine and Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston TX USA
| | - Justin P Zachariah
- Section of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston TX USA
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Paul EA, Cohen J, Geiger MK. Cardiac problems in the fetus: a review for pediatric providers. Curr Opin Pediatr 2023; 35:523-530. [PMID: 37466056 DOI: 10.1097/mop.0000000000001274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
PURPOSE OF REVIEW The aim of this study was to provide pediatric providers with a review of the diagnosis and management of fetal cardiac disease in the current era. RECENT FINDINGS Prenatal detection of congenital heart disease (CHD) has improved but is still imperfect. In experienced hands, fetal echocardiography can detect severe CHD as early as the first trimester and a majority of more subtle conditions in the second and third trimesters. Beyond detection, a prenatal diagnosis allows for lesion-specific counseling for families as well as for development of a multidisciplinary perinatal management plan, which may involve in-utero treatment. Given the diversity of cardiac diagnoses and the rarity of some, collaborative multicenter fetal cardiac research has gained momentum in recent years. SUMMARY Accurate diagnosis of fetal cardiac disease allows for appropriate counseling, pregnancy and delivery planning, and optimization of immediate neonatal care. There is potential for improving fetal CHD detection rates. Fetal interventions are available for certain conditions, and fetal and pediatric cardiac centers have developed management plans specific to the expected postnatal physiology.
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Affiliation(s)
- Erin A Paul
- Division of Pediatric Cardiology, Mount Sinai Kravis Children's Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Lifesaving Treatments for the Tiniest Patients-A Narrative Description of Old and New Minimally Invasive Approaches in the Arena of Fetal Surgery. CHILDREN (BASEL, SWITZERLAND) 2022; 10:children10010067. [PMID: 36670618 PMCID: PMC9856479 DOI: 10.3390/children10010067] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 12/14/2022] [Accepted: 12/21/2022] [Indexed: 12/31/2022]
Abstract
Fetal surgery has become a lifesaving reality for hundreds of fetuses each year. The development of a formidable spectrum of safe and effective minimally invasive techniques for fetal interventions since the early 1990s until today has led to an increasing acceptance of novel procedures by both patients and health care providers. From his vast personal experience of more than 20 years as one of the pioneers at the forefront of clinical minimally invasive fetal surgery, the author describes and comments on old and new minimally invasive approaches, highlighting their lifesaving or quality-of-life-improving potential. He provides easy-to-use practical information on how to perform partial amniotic carbon dioxide insufflation (PACI), how to assess lung function in fetuses with pulmonary hypoplasia, how to deal with giant CPAMS, how to insert shunts into fetuses with LUTO and hydrothorax when conventional devices are not available, and how to resuscitate a fetus during fetal cardiac intervention. Furthermore, the author proposes a curriculum for future fetal surgeons, solicits for the centralization of patients, for adequate maternal counseling, for adequate pain management and adequate hygienic conditions during interventions, and last but not least for starting the process of academic recognition of the matured field as an independent specialty. These steps will allow more affected expectant women and their unborn children to gain access to modern minimally invasive fetal surgery and therapy. The opportunity to treat more patients at dedicated centers will also result in more opportunities for the research of rare diseases and conditions, promising even better pre- and postnatal care in the future.
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10
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Asrani PP, Gellis LA, Schidlow D, Callahan R, Porras D, Wilkins‐Haug L, Guseh S, Tworetzky W, Friedman KG. Technically Successful Fetal Aortic Valvuloplasty Acutely improves Left Heart Output. Prenat Diagn 2022; 42:1466-1470. [DOI: 10.1002/pd.6240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/30/2022] [Accepted: 09/03/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Priyanka P. Asrani
- From the Departments of Cardiology Children\'s Hospital Boston Boston United States
- Brigham and Women’s Hospital; and the Departments of Pediatrics and Obstetrics and Gynecology Boston United States
| | - Laura A. Gellis
- From the Departments of Cardiology Children\'s Hospital Boston Boston United States
- Brigham and Women’s Hospital; and the Departments of Pediatrics and Obstetrics and Gynecology Boston United States
| | - David Schidlow
- From the Departments of Cardiology Children\'s Hospital Boston Boston United States
- Brigham and Women’s Hospital; and the Departments of Pediatrics and Obstetrics and Gynecology Boston United States
| | - Ryan Callahan
- From the Departments of Cardiology Children\'s Hospital Boston Boston United States
- Brigham and Women’s Hospital; and the Departments of Pediatrics and Obstetrics and Gynecology Boston United States
| | - Diego Porras
- From the Departments of Cardiology Children\'s Hospital Boston Boston United States
- Brigham and Women’s Hospital; and the Departments of Pediatrics and Obstetrics and Gynecology Boston United States
| | - Louise Wilkins‐Haug
- Department of Obstetrics and Gynecology Boston Children’s Hospital New York United States
- Harvard Medical School Boston MA United States
| | - Stephanie Guseh
- Department of Obstetrics and Gynecology Boston Children’s Hospital New York United States
- Harvard Medical School Boston MA United States
| | - Wayne Tworetzky
- From the Departments of Cardiology Children\'s Hospital Boston Boston United States
- Brigham and Women’s Hospital; and the Departments of Pediatrics and Obstetrics and Gynecology Boston United States
| | - Kevin G. Friedman
- From the Departments of Cardiology Children\'s Hospital Boston Boston United States
- Brigham and Women’s Hospital; and the Departments of Pediatrics and Obstetrics and Gynecology Boston United States
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11
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Bradford VR, Tworetzky W, Callahan R, Wilkins-Haug LE, Benson CB, Porras D, Guseh SH, Lu M, Sleeper LA, Gellis L, Friedman KG. Hemodynamic and Anatomic Changes after Fetal Aortic Valvuloplasty are associated with Procedural Success and Postnatal Biventricular Circulation. Prenat Diagn 2022; 42:1312-1322. [PMID: 35924422 DOI: 10.1002/pd.6216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/08/2022] [Accepted: 07/13/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND There are minimal data characterizing the trajectory of left heart growth and hemodynamics following fetal aortic valvuloplasty (FAV). METHODS This retrospective study included patients who underwent FAV between 2000 and 2019 with echocardiograms performed pre-FAV, immediately post-FAV, and in late gestation. RESULTS Of 118 fetuses undergoing FAV, 106 (90%) underwent technically successful FAV, of which 55 (52%) had biventricular circulation. Technically successful FAV was associated with improved aortic valve growth (p<0.001), sustained antegrade aortic arch (AoA) flow (p=0.02), improved mitral valve inflow pattern (p=0.002), and favorable patent foramen ovale (PFO) flow pattern (p=0.004) from pre-FAV to late gestation. Compared to patients with univentricular outcome, patients with biventricular outcome had less decrement in size of the left ventricle (LV) (p<0.001) and aortic valve (p=0.005), as well more physiologic PFO flow (p<0.001) and antegrade AoA flow (p<0.001) from pre-FAV to late gestation. In multivariable analysis, echocardiographic predictors of biventricular outcome were less decline in LV end diastolic dimension (p<0.001), improved PFO flow (p=0.004), and sustained antegrade AoA flow (p=0.002) from pre-FAV to late gestation. CONCLUSION Stabilization of left heart growth and improved hemodynamics following successful FAV through late gestation are associated with postnatal biventricular circulation. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Victoria R Bradford
- Cardiology, Boston CObstetrics and Gynecology andhildren's Hospital, Departments of, Boston, MA, USA.,Pediatrics, Boston, MA, USA
| | - Wayne Tworetzky
- Cardiology, Boston CObstetrics and Gynecology andhildren's Hospital, Departments of, Boston, MA, USA.,Pediatrics, Boston, MA, USA
| | - Ryan Callahan
- Cardiology, Boston CObstetrics and Gynecology andhildren's Hospital, Departments of, Boston, MA, USA.,Pediatrics, Boston, MA, USA
| | - Louise E Wilkins-Haug
- Obstetrics and Gynecology and, Boston, MA, USA.,Obstetrics and Gynecology and, Boston, MA, USA
| | - Carol B Benson
- Radiology, Brigham and Women's Hospital, Department of, Boston, MA, USA.,Radiology, Harvard Medical School, Boston, MA, USA
| | - Diego Porras
- Cardiology, Boston CObstetrics and Gynecology andhildren's Hospital, Departments of, Boston, MA, USA.,Pediatrics, Boston, MA, USA
| | - Stephanie H Guseh
- Obstetrics and Gynecology and, Boston, MA, USA.,Obstetrics and Gynecology and, Boston, MA, USA
| | - Minmin Lu
- Cardiology, Boston CObstetrics and Gynecology andhildren's Hospital, Departments of, Boston, MA, USA
| | - Lynn A Sleeper
- Cardiology, Boston CObstetrics and Gynecology andhildren's Hospital, Departments of, Boston, MA, USA.,Pediatrics, Boston, MA, USA
| | - Laura Gellis
- Cardiology, Boston CObstetrics and Gynecology andhildren's Hospital, Departments of, Boston, MA, USA.,Pediatrics, Boston, MA, USA
| | - Kevin G Friedman
- Cardiology, Boston CObstetrics and Gynecology andhildren's Hospital, Departments of, Boston, MA, USA.,Pediatrics, Boston, MA, USA
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12
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Corroenne R, Malekzadeh-Milani SG, Bonnet D, Stos B, Ville Y, Stirnemann J. [Fetal aortic valvuloplasty in critical aortic stenosis: indication, technique and postnatal outcomes]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2022; 50:553-558. [PMID: 35537664 DOI: 10.1016/j.gofs.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 04/24/2022] [Accepted: 04/25/2022] [Indexed: 06/14/2023]
Abstract
Aortic stenosis is a complex heart disease that involves the aortic valve and the left ventricle. Impairment of the left ventricle, abnormalities in its size, systolic and diastolic function determine the postnatal outcomes in the same way as the aortic valve. In the most severe forms, the left ventricle cannot provide systemic circulation at birth and the physiology is that of hypoplastic left heart syndrome. Fetal aortic valvuloplasty has been developed in the 90s to prevent in utero progression of aortic stenosis to hypoplastic left heart syndrome. In the present article, the most recently reported data about indications, procedure details and postnatal outcomes were reviewed.
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Affiliation(s)
- Romain Corroenne
- Maternité et médecine fœtale, hôpital Necker enfants malades, AP-HP, 149, rue de Sèvres, 75015 Paris, France; EA7328, Université de Paris, Institut Imagine, France
| | | | - Damien Bonnet
- M3C-Necker, Hôpital Necker-Enfants malades, AP-HP, Université de Paris, 149, rue de Sèvres, 75015 Paris, France
| | - Bertrand Stos
- M3C-Necker, Hôpital Necker-Enfants malades, AP-HP, Université de Paris, 149, rue de Sèvres, 75015 Paris, France; UE3C, Paris, France
| | - Yves Ville
- Maternité et médecine fœtale, hôpital Necker enfants malades, AP-HP, 149, rue de Sèvres, 75015 Paris, France; EA7328, Université de Paris, Institut Imagine, France
| | - Julien Stirnemann
- Maternité et médecine fœtale, hôpital Necker enfants malades, AP-HP, 149, rue de Sèvres, 75015 Paris, France; EA7328, Université de Paris, Institut Imagine, France.
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13
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Wong HS, Wiputra H, Tulzer A, Tulzer G, Yap CH. Fluid Mechanics of Fetal Left Ventricle During Aortic Stenosis with Evolving Hypoplastic Left Heart Syndrome. Ann Biomed Eng 2022; 50:1158-1172. [PMID: 35731342 PMCID: PMC9363377 DOI: 10.1007/s10439-022-02990-5] [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: 01/19/2022] [Accepted: 06/05/2022] [Indexed: 11/28/2022]
Abstract
In cases of fetal aortic stenosis and evolving Hypoplastic Left Heart Syndrome (feHLHS), aortic stenosis is associated with specific abnormalities such as retrograde or bidirectional systolic transverse arch flow. Many cases progressed to hypoplastic left heart syndrome (HLHS) malformation at birth, but fetal aortic valvuloplasty can prevent the progression in many cases. Since both disease and intervention involve drastic changes to the biomechanical environment, in-vivo biomechanics likely play a role in inducing and preventing disease progression. However, the fluid mechanics of feHLHS is not well-characterized. Here, we conduct patient-specific echocardiography-based flow simulations of normal and feHLHS left ventricles (LV), to understand the essential fluid dynamics distinction between the two cohorts. We found high variability across feHLHS cases, but also the following unifying features. Firstly, feHLHS diastole mitral inflow was in the form of a narrowed and fast jet that impinged onto the apical region, rather than a wide and gentle inflow in normal LVs. This was likely due to a malformed mitral valve with impaired opening dynamics. This altered inflow caused elevated vorticity dynamics and wall shear stresses (WSS) and reduced oscillatory shear index at the apical zone rather than mid-ventricle. Secondly, feHLHS LV also featured elevated systolic and diastolic energy losses, intraventricular pressure gradients, and vortex formation numbers, suggesting energy inefficiency of flow and additional burden on the LV. Thirdly, feHLHS LV had poor blood turnover, suggesting a hypoxic environment, which could be associated with endocardial fibroelastosis that is often observed in these patients.
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Affiliation(s)
- Hong Shen Wong
- Department of Bioengineering, Imperial College London, London, UK
| | - Hadi Wiputra
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, USA
| | - Andreas Tulzer
- Department of Pediatric Cardiology, Children's Heart Center Linz, Kepler University Hospital, Linz, Austria
| | - Gerald Tulzer
- Department of Pediatric Cardiology, Children's Heart Center Linz, Kepler University Hospital, Linz, Austria
| | - Choon Hwai Yap
- Department of Bioengineering, Imperial College London, London, UK.
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14
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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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15
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Flow-Mediated Factors in the Pathogenesis of Hypoplastic Left Heart Syndrome. J Cardiovasc Dev Dis 2022; 9:jcdd9050154. [PMID: 35621865 PMCID: PMC9144087 DOI: 10.3390/jcdd9050154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/01/2022] [Accepted: 05/06/2022] [Indexed: 12/03/2022] Open
Abstract
Hypoplastic left heart syndrome (HLHS) is a life-threatening congenital heart disease that is characterized by severe underdevelopment of left heart structures. Currently, there is no cure, and affected individuals require surgical palliation or cardiac transplantation to survive. Despite these resource-intensive measures, only about half of individuals reach adulthood, often with significant comorbidities such as liver disease and neurodevelopmental disorders. A major barrier in developing effective treatments is that the etiology of HLHS is largely unknown. Here, we discuss how intracardiac blood flow disturbances are an important causal factor in the pathogenesis of impaired left heart growth. Specifically, we highlight results from a recently developed mouse model in which surgically reducing blood flow through the mitral valve after cardiogenesis led to the development of HLHS. In addition, we discuss the role of interventional procedures that are based on improving blood flow through the left heart, such as fetal aortic valvuloplasty. Lastly, using the surgically-induced mouse model, we suggest investigations that can be undertaken to identify the currently unknown biological pathways in left heart growth failure and their associated therapeutic targets.
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16
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Tulzer A, Arzt W, Gitter R, Sames‐Dolzer E, Kreuzer M, Mair R, Tulzer G. Valvuloplasty in 103 fetuses with critical aortic stenosis: outcome and new predictors for postnatal circulation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:633-641. [PMID: 34605096 PMCID: PMC9324970 DOI: 10.1002/uog.24792] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 09/21/2021] [Accepted: 09/23/2021] [Indexed: 05/28/2023]
Abstract
OBJECTIVES To review our experience with fetal aortic valvuloplasty (FAV) in fetuses with critical aortic stenosis (CAS) and evolving hypoplastic left heart syndrome (eHLHS), including short- and medium-term postnatal outcome, and to refine selection criteria for FAV by identifying preprocedural predictors of biventricular (BV) outcome. METHODS This was a retrospective review of all fetuses with CAS and eHLHS undergoing FAV at our center between December 2001 and September 2020. Echocardiograms and patient charts were analyzed for pre-FAV ventricular and valvular dimensions and hemodynamics and for postnatal procedures and outcomes. The primary endpoints were type of circulation 28 days after birth and at 1 year of age. Classification and regression-tree analysis was performed to investigate the predictive capacity of pre-FAV parameters for BV circulation at 1 year of age. RESULTS During the study period, 103 fetuses underwent 125 FAVs at our center, of which 87.4% had a technically successful procedure. Technical success per fetus was higher in the more recent period (from 2014) than in the earlier period (96.2% (51/53) vs 78.0% (39/50); P = 0.0068). Eighty fetuses were liveborn after successful intervention and received further treatment. BV outcome at 1 year of age was achieved in 55% of liveborn patients in our cohort after successful FAV, which is significantly higher than the BV-outcome rate (23.7%) in a previously published natural history cohort fulfilling the same criteria for eHLHS (P = 0.0015). Decision-tree analysis based on the ratio of right to left ventricular (RV/LV) length combined with LV pressure (mitral valve regurgitation maximum velocity (MR-Vmax)) had a sensitivity of 96.97% and a specificity of 94.44% for predicting BV outcome without signs of pulmonary arterial hypertension at 1 year of age. The highest probability for a BV outcome was reached for fetuses with a pre-FAV RV/LV length ratio of < 1.094 (96.4%) and for those fetuses with a RV/LV length ratio ≥ 1.094 to < 1.135 combined with a MR-Vmax of ≥ 3.14 m/s (100%). CONCLUSIONS FAV could be performed with high success rates and an acceptable risk with improving results after a learning curve. Pre-FAV RV/LV length ratio combined with LV pressure estimates were able to predict a successful BV outcome at 1 year of age with high sensitivity and specificity. © 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)
- A. Tulzer
- Children's Heart Center Linz, Department of Pediatric CardiologyKepler University Hospital, Medical Faculty of the Johannes Kepler UniversityLinzAustria
| | - W. Arzt
- Institute of Prenatal Medicine, Kepler University Hospital, Medical Faculty of the Johannes Kepler UniversityLinzAustria
| | - R. Gitter
- Children's Heart Center Linz, Department of Pediatric CardiologyKepler University Hospital, Medical Faculty of the Johannes Kepler UniversityLinzAustria
| | - E. Sames‐Dolzer
- Children's Heart Center Linz, Department of Pediatric Cardiac SurgeryKepler University Hospital, Medical Faculty of the Johannes Kepler UniversityLinzAustria
| | - M. Kreuzer
- Children's Heart Center Linz, Department of Pediatric Cardiac SurgeryKepler University Hospital, Medical Faculty of the Johannes Kepler UniversityLinzAustria
| | - R. Mair
- Children's Heart Center Linz, Department of Pediatric Cardiac SurgeryKepler University Hospital, Medical Faculty of the Johannes Kepler UniversityLinzAustria
| | - G. Tulzer
- Children's Heart Center Linz, Department of Pediatric CardiologyKepler University Hospital, Medical Faculty of the Johannes Kepler UniversityLinzAustria
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17
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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: 0] [Impact Index Per Article: 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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18
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Deficient Myocardial Organization and Pathological Fibrosis in Fetal Aortic Stenosis-Association of Prenatal Ultrasound with Postmortem Histology. J Cardiovasc Dev Dis 2021; 8:jcdd8100121. [PMID: 34677190 PMCID: PMC8540431 DOI: 10.3390/jcdd8100121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/17/2021] [Accepted: 09/23/2021] [Indexed: 01/08/2023] Open
Abstract
In fetal aortic stenosis (AS), it remains challenging to predict left ventricular development over the course of pregnancy. Myocardial organization, differentiation and fibrosis could be potential biomarkers relevant for biventricular outcome. We present four cases of fetal AS with varying degrees of severity and associate myocardial deformation on fetal ultrasound with postmortem histopathological characteristics. During routine fetal echocardiography, speckle tracking recordings of the cardiac four-chamber view were performed to assess myocardial strain as parameter for myocardial deformation. After pregnancy termination, postmortem cardiac specimens were examined using immunohistochemical labeling (IHC) of key markers for myocardial organization, differentiation and fibrosis and compared to normal fetal hearts. Two cases with critical AS presented extremely decreased left ventricular (LV) strain on fetal ultrasound. IHC showed overt endocardial fibro-elastosis, which correlated with pathological fibrosis patterns in the myocardium and extremely disturbed cardiomyocyte organization. The LV in severe AS showed mildly reduced myocardial strain and less severe disorganization of the cardiomyocytes. In conclusion, the degree of reduction in myocardial deformation corresponded with high extent to the amount of pathological fibrosis patterns and cardiomyocyte disorganization. Myocardial deformation on fetal ultrasound seems to hold promise as a potential biomarker for left ventricular structural damage in AS.
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19
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Corno AF. Introduction to the series: pre-natal diagnosis in congenital heart defects. Transl Pediatr 2021; 10:2144-2147. [PMID: 34584886 PMCID: PMC8429873 DOI: 10.21037/tp-20-140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/05/2020] [Indexed: 11/06/2022] Open
Affiliation(s)
- Antonio F Corno
- Research Professor, Houston Children's Heart Institute, Memorial Hermann Children's Hospital, University Texas Health, McGovern Medical School, Houston, Texas, USA
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20
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Computational Modeling of Blood Flow Hemodynamics for Biomechanical Investigation of Cardiac Development and Disease. J Cardiovasc Dev Dis 2021; 8:jcdd8020014. [PMID: 33572675 PMCID: PMC7912127 DOI: 10.3390/jcdd8020014] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 01/16/2021] [Accepted: 01/21/2021] [Indexed: 12/11/2022] Open
Abstract
The heart is the first functional organ in a developing embryo. Cardiac development continues throughout developmental stages while the heart goes through a serious of drastic morphological changes. Previous animal experiments as well as clinical observations showed that disturbed hemodynamics interfere with the development of the heart and leads to the formation of a variety of defects in heart valves, heart chambers, and blood vessels, suggesting that hemodynamics is a governing factor for cardiogenesis, and disturbed hemodynamics is an important source of congenital heart defects. Therefore, there is an interest to image and quantify the flowing blood through a developing heart. Flow measurement in embryonic fetal heart can be performed using advanced techniques such as magnetic resonance imaging (MRI) or echocardiography. Computational fluid dynamics (CFD) modeling is another approach especially useful when the other imaging modalities are not available and in-depth flow assessment is needed. The approach is based on numerically solving relevant physical equations to approximate the flow hemodynamics and tissue behavior. This approach is becoming widely adapted to simulate cardiac flows during the embryonic development. While there are few studies for human fetal cardiac flows, many groups used zebrafish and chicken embryos as useful models for elucidating normal and diseased cardiogenesis. In this paper, we explain the major steps to generate CFD models for simulating cardiac hemodynamics in vivo and summarize the latest findings on chicken and zebrafish embryos as well as human fetal hearts.
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21
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O'Byrne ML, Peyvandi S. Decisions, Decisions, Decisions…: A Novel Approach Helps Evaluate Potential Benefit of Fetal Aortic Valvuloplasty. Circ Cardiovasc Qual Outcomes 2020; 13:e006636. [PMID: 32252550 DOI: 10.1161/circoutcomes.120.006636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology and Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Department of Pediatrics, Leonard Davis Institute, and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, (M.L.O.)
| | - Shabnam Peyvandi
- Division of Cardiology, Departments of Pediatrics and Epidemiology & Biostatistics, UCSF Benioff Children's Hospital, San Francisco, CA (S.P.)
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