Transhepatic Ultrasound-Guided Cardiac Catheterization in the Fetal Lamb

Abstract

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.

Fetal Cardiocentesis: A Review of Indications, Risks, Applications and Technique

“…Unfortunately, perinatal and infant mortality have remained frequent thus far. Though all human fetal cardiac interventions thus far have been performed by transventricular cardiocentesis, an alternative approach utilizing a transhepatic cannulation of the infradiaphragmatic portion of the inferior vena cava has recently been reported in pregnant ewes [39] . Vascular access was obtained in 10 of 10 sheep fetuses, allowing cardiac catheterization of all four cardiac chambers, atrial and ventricular pacing in 6 fetuses and ballooning of the pulmonary valve in 9 of 10 fetuses.…”

Fetal trans-apical stent delivery into the pulmonary artery: prospects for prenatal heart-valve implantation

“…Based on advanced fetal-imaging techniques, there is an increasing interest in performing prenatal cardiac interventions, in particular in severe anatomic cardiac obstructions, such as pulmonary or aortic-valve stenosis [1][2][3][4][5]. Both lesions can induce irreversible ventricular malformation and dysfunction as well as hypoplasia of the adjacent great arteries, leading to severe cardiac malformation and decompensation [1,4].…”

“…Therefore, the relief of obstructive malformations, such as heart-valve stenoses, using interventional procedures has been suggested to promote functional recovery of the affected ventricle [4,6,7]. The principal feasibility of fetal cardiac interventions has been proven in both, in selected human fetuses 4] as well as in various experimental animal models involving minimally invasive fetoscopic-as well as catheter-based approaches [2,3,8,9]. In humans, successful fetal cardiac catheterization and balloon valvuloplasty by ultrasound-guided direct puncture of the obstructed ventricle have been reported by several groups [1,4,7,[10][11][12][13].…”

Re: In‐utero intervention for hypoplastic left heart syndrome: for which fetus and for what?

“…The substantial mortality rate, together with the relatively high failure rate associated with this procedure, should encourage perinatologists to reconsider the direct transthoracic approach. Other approaches mimicking the Seldinger-derived technique might be used to overcome these technical pitfalls 3,4 …”