Fetal pulmonary valvuloplasty for critical pulmonary stenosis or atresia with intact septum

Tulzer, Gerald; Arzt, W; Franklin, Rodney C. G.; Loughna, Pamela; Mair, Rudolf; Gardiner, Helena M.

doi:10.1016/s0140-6736(02)11531-5

Cited by 191 publications

(104 citation statements)

References 4 publications

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“…All interventions were performed under ultrasound guidance as described previously8, 14 and under general anesthesia of the mother without separate fetal analgesia. The fetal RV was punctured with a 16‐, 18‐ or 19‐gauge needle (Cook® Medical Systems, Limerick, Ireland).…”

Section: Methodsmentioning

confidence: 99%

“…Therefore, prenatal treatment could be a unique opportunity to take advantage of a better ventricular growth than that achievable postnatally. A few case reports and small case series have shown that fetal pulmonary valvuloplasty is technically feasible and associated with continued growth of RV structures8, 9, 10, 11, 12, 13. The International Fetal Cardiac Intervention Registry reported 16 fetal pulmonary valvuloplasties, of which 11 procedures were successful and resulted in seven liveborn patients, five of which were discharged with a biventricular circulation.…”

Section: Introductionmentioning

confidence: 99%

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Immediate effects and outcome of in‐utero pulmonary valvuloplasty in fetuses with pulmonary atresia with intact ventricular septum or critical pulmonary stenosis

Tulzer

Arzt

Gitter

et al. 2018

Ultrasound in Obstet & Gyne

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ObjectiveTo assess the immediate effects of fetal pulmonary valvuloplasty on right ventricular (RV) size and function as well as in‐utero RV growth and postnatal outcome.MethodsPatients with pulmonary atresia with intact ventricular septum (PAIVS) or critical pulmonary stenosis (CPS) who underwent fetal pulmonary valvuloplasty at our center between October 2000 and July 2017 were included. Echocardiographic data obtained before and after the procedure were analyzed retrospectively (median interval after intervention, 1 (range, 1–3) days) for ventricular and valvular dimensions and ratios, RV filling time (duration of tricuspid valve (TV) inflow/cardiac cycle length), TV velocity time integral (TV‐VTI) × heart rate (HR) and tricuspid regurgitation (TR) velocity. Longitudinal data were collected from only those fetuses followed up in our center. Outcome was assessed using the scoring system as described by Roman et al. for non‐biventricular outcome.ResultsThirty‐five pulmonary valvuloplasties were performed in our institution on 23 fetuses with PAIVS (n = 15) or CPS (n = 8). Median gestational age at intervention was 28 + 4 (range, 23 + 6 to 32 + 1) weeks. No fetal death occurred. Immediately after successful intervention, RV/left ventricular length (RV/LV) ratio (P ≤ 0.0001), TV/mitral valve annular diameter (TV/MV) ratio (P ≤ 0.001), RV filling time (P ≤ 0.00001) and TV‐VTI × HR (P ≤ 0.001) increased significantly and TR velocity (P ≤ 0.001) decreased significantly. In fetuses followed longitudinally to delivery (n = 5), RV/LV and TV/MV ratios improved further or remained constant until birth. Fetuses with unsuccessful intervention (n = 2) became univentricular, all others had either a biventricular (n = 15), one‐and‐a‐half ventricular (n = 3) or still undetermined (n = 3) outcome. Five of nine fetuses with a predicted non‐biventricular outcome, in which the procedure was successful, became biventricular, while two of nine had an undetermined circulation.ConclusionIn selected fetuses with PAIVS or CPS, in‐utero pulmonary valvuloplasty led immediately to larger RV caused by reduced afterload and increased filling, thus improving the likelihood of biventricular outcome even in fetuses with a predicted non‐biventricular circulation. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

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Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Immediate effects and outcome of in‐utero pulmonary valvuloplasty in fetuses with pulmonary atresia with intact ventricular septum or critical pulmonary stenosis

Tulzer

Arzt

Gitter

et al. 2018

Ultrasound in Obstet & Gyne

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“…Due to the recognition that the growth of fetal cardiovascular structures correlates with antegrade blood flow and mechanical loading conditions, intrauterine aortic balloon valvuloplasty has emerged as a useful therapy for the fetus recognized to have aortic valve stenosis associated with reduce left ventricular function (Makikallio et al, 2006;Tierney et al, 2007;Tulzer et al, 2002). Successful fetal aortic valvuloplasty increases LVOT antegrade flow, is associated with both left ventricular and aortic arch growth, and has prevented the development of HLHS in some patients (Tometzki et al, 1999).…”

Section: Discussionmentioning

confidence: 99%

In vitro hemodynamic investigation of the embryonic aortic arch at late gestation

Pekkan

Dasi

Nourparvar

et al. 2008

Journal of Biomechanics

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This study focuses on the dynamic flow through the fetal aortic arch driven by the concurrent action of right and left ventricles. We created a parametric pulsatile computational fluid dynamics (CFD) model of the fetal aortic junction with physiologic vessel geometries. To gain a better biophysical understanding an in vitro experimental fetal flow loop for flow visualization was constructed for identical CFD conditions. CFD and in vitro experimental results were comparable.Swirling flow during the acceleration phase of the cardiac cycle and unidirectional flow following mid-deceleration phase were observed in pulmonary arteries (PA), head-neck vessels, and descending aorta. Right-to-left (oxygenated) blood flowed through the ductus arteriosus (DA) posterior relative to the antegrade left ventricular outflow tract (LVOT) stream and resembled jet flow. LVOT and right ventricular outflow tract flow mixing had not completed until ~3.5 descending aorta diameters downstream of the DA insertion into the aortic arch. Normal arch model flow patterns were then compared to flow patterns of four common congenital heart malformations that include aortic arch anomalies. Weak oscillatory reversing flow through the DA junction was observed only for the Tetralogy of Fallot configuration. Pulmonary Atresia and Hypoplastic Left Heart Syndrome configurations demonstrated complex, abnormal flow patterns in the PAs and head-neck vessels. Aortic Coarctation resulted in large scale recirculating flow in the aortic arch proximal to the DA. Intravascular flow patterns spatially correlated with abnormal vascular structures consistent with the paradigm that abnormal intravascular flow patterns associated with congenital heart disease influence vascular growth and function.

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“…[5][6][7] By preventing the pathophysiology that leads to development of ventricular hypoplasia or congestive heart failure, antenatal aortic or pulmonary balloon valvuloplasty may improve the outcome of fetuses with severe aortic or pulmonary valve stenosis. 8,9 However, despite theoretical advantages, the human experience is still limited, and the results of the in utero treatment of such stenotic lesions have been disappointing, with a low rate of success and efficacy in terms of restoration of normal function and anatomy and a high rate of complications. 8 …”

Section: Rationale Of Fetus Interventionmentioning

confidence: 99%

“…Although encouraging, the human experience is still limited, and the transventricular, percutaneous ultrasound-guided balloon valvuloplasty has been associated with several technical problems, as illustrated by the high failure rate and the fetal mortality rate after cardiac intervention. 8,9 Because some problems might be related to the vascular access, some authors have investigated alternative approaches to the fetal heart. In particular, a fetoscopic approach that allows direct puncture of the umbilical arteries has been proposed, with the major aim of allowing retrograde cardiac catheterization.…”

mentioning

confidence: 99%

Transhepatic Ultrasound-Guided Cardiac Catheterization in the Fetal Lamb

et al. 2005

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Background-Percutaneous transventricular and fetoscopic umbilical catheterization have been applied to animal and human fetuses. These methods have a high rate of failure and complications. Here, we propose an alternative route for anterograde echocardiography-guided cardiac catheterization through a transhepatic approach of the intra-abdominal vessels in the fetal lamb. Methods and Results-After exteriorization of the uterus in 12 pregnant ewes between 118 to 122 days' gestation, a 4F sheath mounted over a 1.2-mm needle was placed into the intra-abdominal portion of the umbilical vein (nϭ2) and into the subdiaphragmatic portion of the inferior vena cava via a transhepatic approach (nϭ10) under ultrasound guidance. In the first 2 animals using a transumbilical approach, it was impossible to reach the heart through the ductus venosus.In the next 10 animals, using a conventional technique, echocardiography-guided catheterization of the 4 chambers was performed in the all fetuses, atrial or ventricular pacing in 6 fetuses, and ballooning of the pulmonary valve in 9 of 10 fetuses. Among the 10 fetuses catheterized through the transhepatic approach, 2 were euthanized immediately after the procedure to evaluate intraperitoneal bleeding (23 and 29 mL, respectively), and 3 died after the procedure (1 of major bleeding and 2 deaths related to balloon catheter manipulation). Finally, 5 were delivered vaginally after an uneventful pregnancy, and autopsy at day 5 did not show significant liver, vascular, or cardiac injury. Conclusions-Echocardiography-guided fetal cardiac catheterization through a transhepatic approach is feasible and provides an interesting alternative approach for human fetal cardiac interventions.

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Fetal pulmonary valvuloplasty for critical pulmonary stenosis or atresia with intact septum

Cited by 191 publications

References 4 publications

Immediate effects and outcome of in‐utero pulmonary valvuloplasty in fetuses with pulmonary atresia with intact ventricular septum or critical pulmonary stenosis

Immediate effects and outcome of in‐utero pulmonary valvuloplasty in fetuses with pulmonary atresia with intact ventricular septum or critical pulmonary stenosis

In vitro hemodynamic investigation of the embryonic aortic arch at late gestation

Transhepatic Ultrasound-Guided Cardiac Catheterization in the Fetal Lamb

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