Kardiale Interventionen bei Feten

Abstract

Fetal cardiac interventions are being performed with growing success by a minimally invasive percutaneous and transthoracic approach. The primary aim of these interventions is to minimise postnatal morbidity and mortality, rarely also to achieve intrauterine survival. Valvuloplasty in utero for severe aortic stenosis is performed in order to achieve sufficient growth of the left ventricle and to make a later biventricular repair possible. In rare cases with hydrops secondary to massive left ventricular dilatation and mitral insufficiency it is used as a salvage therapy. Premature obstruction of the foramen ovale can be treated by balloon atrioseptoplasty or stenting of the atrial septum with the aim to attain a decompression of the left atrium and consequently of the pulmonary veins. This might reduce the extent of pulmonary hypertension and the resulting vascular and parenchymal changes in affected infants. Intrauterine valvuloplasty of a highly stenotic pulmonary valve or a pulmonary atresia with intact ventricular septum in order to prevent hypoplasia of the right ventricle and to enable postnatal biventricular repair is only rarely justified. Currently these intrauterine cardiac interventions are limited to a small group of fetuses with cardiac defects. However, with enhanced imaging modalities and equipment and with growing experience, fetal cardiac interventions are likely to increase in the next years.

Indications and methods for intrauterine intervention in the surgical correction of cardiac malformations

“…Заболевания бывают несовместимыми с жизнью, а бывают такими, которые могут привести к пожизненной инвалидности. Комплексная задача оказания медицинской помощи заключается в ранней диагностике и лечении данной патологии [2][3][4]. Существует большая группа аномалий развития плода, в том числе и пороки развития сердца, которые вызывают необратимые нарушения, затрудняющие хирургическую коррекцию после рождения ребенка.…”

“…С высокой долей вероятности врожденные пороки сердечно-сосудистой системы можно обнаружить на 16-й неделе беременности, а на 21-22-й неделе практически в 100% случаев можно идентифицировать тип врожденного порока [20][21][22][23]. Осуществить внутриутробную коррекцию возможно преимущественно на 22-32-й неделе в зависимости от вида порока [4,10,24,25].…”

The Diagnostics of Fetal Heart Defects in the First and Early Second Trimester – Early Fetal Echocardiography

“…Both pre-operative morbidity as well as mortality can be significantly reduced for some major heart defects, as this has been well established for the transposition of the large arteries, the hypoplastic left heart and the coarctatio aortae (aortic coarctation) [4]. Furthermore, it appears that, in some situations, fetuses with severe outflow tract anomalies benefit from interventions controlled by intrauterine ultrasound (balloon dilatation of a semilunar valve; opening of a closed or highly restrictive foramen ovale), thereby preventing the rapid development towards the hypoplastic ventricle during pregnancy and so the possibility of a univentricular repair can be reduced or intervention can have a life-saving effect in cases of hydrops [5].…”

“…This is particularly the case for the frequent, small ventricular septal defects in the trabecular and outlet part of the interventricular septum; the interventricular shunts for these defects, which lead to their discovery in the second trimester [43,44], are not currently detectable using colour Doppler. Other heart defects change cardiac structures as the pregnancy progresses further, meaning that they are detectable in the four-chamber view; this is particularly true for aortic and pulmonary valve obstructions, which are present in the first trimester and can also be detected through colour Doppler, but which could lead to abnormalities in the ventricle (myocardial hypertrophy, dilatation, hypoplasia, endocardial fibroelastosis) as the pregnancy progresses, depending on the severity of the obstruction [5,8,45]. The changes are similar in those leading to a narrow left ventricle and right heart dominance in the event of a severe obstruction in the first trimester in the context of aortic coarctation, with a normal four-chamber view potentially being seen until birth in the case of light obstruction [46].…”