1
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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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2
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Fluid Mechanical Effects of Fetal Aortic Valvuloplasty for Cases of Critical Aortic Stenosis with Evolving Hypoplastic Left Heart Syndrome. Ann Biomed Eng 2023:10.1007/s10439-023-03152-x. [PMID: 36780051 DOI: 10.1007/s10439-023-03152-x] [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: 09/28/2022] [Accepted: 01/16/2023] [Indexed: 02/14/2023]
Abstract
Fetuses with critical aortic stenosis (FAS) are at high risk of progression to HLHS by the time of birth (and are thus termed "evolving HLHS"). An in-utero catheter-based intervention, fetal aortic valvuloplasty (FAV), has shown promise as an intervention strategy to circumvent the progression, but its impact on the heart's biomechanics is not well understood. We performed patient-specific computational fluid dynamic (CFD) simulations based on 4D fetal echocardiography to assess the changes in the fluid mechanical environment in the FAS left ventricle (LV) directly before and 2 days after FAV. Echocardiograms of five FAS cases with technically successful FAV were retrospectively analysed. FAS compromised LV stroke volume and ejection fraction, but FAV rescued it significantly. Calculations to match simulations to clinical measurements showed that FAV approximately doubled aortic valve orifice area, but it remained much smaller than in healthy hearts. Diseased LVs had mildly stenotic mitral valves, which generated fast and narrow diastolic mitral inflow jet and vortex rings that remained unresolved directly after FAV. FAV further caused aortic valve damage and high-velocity regurgitation. The high-velocity aortic regurgitation jet and vortex ring caused a chaotic flow field upon impinging the apex, which drastically exacerbated the already high energy losses and poor flow energy efficiency of FAS LVs. Two days after the procedure, FAV did not alter wall shear stress (WSS) spatial patterns of diseased LV but elevated WSS magnitudes, and the poor blood turnover in pre-FAV LVs did not significantly improve directly after FAV. FAV improved FAS LV's flow function, but it also led to highly chaotic flow patterns and excessively high energy losses due to the introduction of aortic regurgitation directly after the intervention. Further studies analysing the effects several weeks after FAV are needed to understand the effects of such biomechanics on morphological development.
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3
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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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4
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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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5
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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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6
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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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7
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Sedmera D. HLHS: Power of the Chick Model. J Cardiovasc Dev Dis 2022; 9:jcdd9040113. [PMID: 35448089 PMCID: PMC9031965 DOI: 10.3390/jcdd9040113] [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: 01/30/2022] [Revised: 04/01/2022] [Accepted: 04/07/2022] [Indexed: 01/25/2023] Open
Abstract
Background: Hypoplastic left heart syndrome (HLHS) is a rare but deadly form of human congenital heart disease, most likely of diverse etiologies. Hemodynamic alterations such as those resulting from premature foramen ovale closure or aortic stenosis are among the possible pathways. Methods: The information gained from studies performed in the chick model of HLHS is reviewed. Altered hemodynamics leads to a decrease in myocyte proliferation causing hypoplasia of the left heart structures and their functional changes. Conclusions: Although the chick phenocopy of HLHS caused by left atrial ligation is certainly not representative of all the possible etiologies, it provides many useful hints regarding the plasticity of the genetically normal developing myocardium under altered hemodynamic loading leading to the HLHS phenotype, and even suggestions on some potential strategies for prenatal repair.
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Affiliation(s)
- David Sedmera
- Institute of Anatomy, First Faculty of Medicine, Charles University, 128 00 Prague, Czech Republic;
- Laboratory of Developmental Cardiology, Institute of Physiology, Czech Academy of Sciences, 142 20 Prague, Czech Republic
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8
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Avesani M, Kang SL, Jalal Z, Thambo JB, Iriart X. Renaissance of Cardiac Imaging to Assist Percutaneous Interventions in Congenital Heart Diseases:The Role of Three-Dimensional Echocardiography and Multimodality Imaging. Front Pediatr 2022; 10:894472. [PMID: 35664875 PMCID: PMC9160663 DOI: 10.3389/fped.2022.894472] [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: 03/11/2022] [Accepted: 04/12/2022] [Indexed: 11/20/2022] Open
Abstract
Percutaneous interventions have completely refashioned the management of children with congenital heart diseases (CHD) and the use of non-invasive imaging has become the gold standard to plan and guide these procedures in the modern era. We are now facing a dual challenge to improve the standard of care in low-risk patients, and to shift our strategies from the classic open chest surgery to imaging-guided percutaneous interventions in high-risk patients. Such rapid evolution of ultrasound technologies over the last 20 years have permitted the integration of transthoracic, transesophageal and intracardiac echocardiography into the interventional workflow to improve image guidance and reduce radiation burden from fluoroscopy and angiography. Specifically, miniaturization of transesophageal probe and advances in three-dimensional (3D) imaging techniques have enabled real-time 3D image guidance during complex interventional procedure, In addition, multimodality and fusion imaging techniques harness the strengths of different modalities to enhance understanding of anatomical and spatial relationship between different structures, improving communication and coordination between interventionalists and imaging specialists. In this review, we aim to provide an overview of 3D imaging modalities and multimodal fusion in procedural planning and live guidance of percutaneous interventions. At the present times, 3D imaging can no longer be considered a luxury but a routine clinical tool to improve procedural success and patient outcomes.
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Affiliation(s)
- Martina Avesani
- Department of Pediatric and Congenital Cardiology, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux, France
| | - Sok-Leng Kang
- Department of Pediatric Cardiology, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - Zakaria Jalal
- Department of Pediatric and Congenital Cardiology, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux, France.,Institut Hospitalo-Universitaire (IHU) Liryc, Electrophysiology and Heart Modeling Institute, Bordeaux University Foundation, Pessac, France
| | - Jean-Benoit Thambo
- Department of Pediatric and Congenital Cardiology, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux, France.,Institut Hospitalo-Universitaire (IHU) Liryc, Electrophysiology and Heart Modeling Institute, Bordeaux University Foundation, Pessac, France
| | - Xavier Iriart
- Department of Pediatric and Congenital Cardiology, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux, France.,Institut Hospitalo-Universitaire (IHU) Liryc, Electrophysiology and Heart Modeling Institute, Bordeaux University Foundation, Pessac, France
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9
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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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10
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Zebhi B, Lazkani M, Bark D. Calcific Aortic Stenosis-A Review on Acquired Mechanisms of the Disease and Treatments. Front Cardiovasc Med 2021; 8:734175. [PMID: 34604358 PMCID: PMC8486019 DOI: 10.3389/fcvm.2021.734175] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/18/2021] [Indexed: 11/13/2022] Open
Abstract
Calcific aortic stenosis is a progressive disease that has become more prevalent in recent decades. Despite advances in research to uncover underlying biomechanisms, and development of new generations of prosthetic valves and replacement techniques, management of calcific aortic stenosis still comes with unresolved complications. In this review, we highlight underlying molecular mechanisms of acquired aortic stenosis calcification in relation to hemodynamics, complications related to the disease, diagnostic methods, and evolving treatment practices for calcific aortic stenosis.
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Affiliation(s)
- Banafsheh Zebhi
- Department of Mechanical Engineering, Colorado State University, Fort Collins, CO, United States
| | - Mohamad Lazkani
- Medical Center of the Rockies, University of Colorado Health, Loveland, CO, United States
| | - David Bark
- Department of Pediatrics, Washington University in Saint Louis, Saint Louis, MO, United States.,Department of Biomedical Engineering, Washington University in Saint Louis, Saint Louis, MO, United States
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11
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Jha P, Feldstein VA, Revzin MV, Katz DS, Moshiri M. Role of Imaging in Obstetric Interventions: Criteria, Considerations, and Complications. Radiographics 2021; 41:1243-1264. [PMID: 34115536 DOI: 10.1148/rg.2021200163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
US has an established role in the prenatal detection of congenital and developmental disorders. Many pregnant women undergo US at 18-20 weeks of gestation for assessment of fetal anatomy and detection of structural anomalies. With advances in fetoscopy and minimally invasive procedures, in utero fetal interventions can be offered to address some of the detected structural and physiologic fetal abnormalities. Most interventions are reserved for conditions that, if left untreated, often cause in utero death or a substantially compromised neonatal outcome. US is crucial for preprocedural evaluation and planning, real-time procedural guidance, and monitoring and assessment of postprocedural complications. Percutaneous needle-based interventions include in utero transfusion, thoracentesis and placement of a thoracoamniotic shunt, vesicocentesis and placement of a vesicoamniotic shunt, and aortic valvuloplasty. Fetoscopic interventions include myelomeningocele repair and tracheal balloon occlusion for congenital diaphragmatic hernia. In rare cases, open hysterotomy may be required for repair of a myelomeningocele or resection of a sacrococcygeal teratoma. Monochorionic twin pregnancies involve specific complications such as twin-twin transfusion syndrome, which is treated with fetoscopic laser ablation of vascular connections, and twin reversed arterial perfusion sequence, which is treated with radiofrequency ablation. Finally, when extended placental support is necessary at delivery for repair of congenital high airway obstruction or resection of lung masses, ex utero intrapartum treatment can be planned. Radiologists should be aware of the congenital anomalies that are amenable to in utero interventions and, when necessary, consider referral to centers where such treatments are offered. Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. ©RSNA, 2021.
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Affiliation(s)
- Priyanka Jha
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
| | - Vickie A Feldstein
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
| | - Margarita V Revzin
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
| | - Douglas S Katz
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
| | - Mariam Moshiri
- From the Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143-0628 (P.J., V.A.F.); Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Conn (M.V.R.); Department of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K.); and Department of Radiology, University of Washington, Seattle, Wash (M.M.)
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12
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Rebizant B, Koleśnik A, Grzyb A, Chaberek K, Sękowska A, Witwicki J, Szymkiewicz-Dangel J, Dębska M. Fetal Cardiac Interventions-Are They Safe for the Mothers? J Clin Med 2021; 10:jcm10040851. [PMID: 33669554 PMCID: PMC7922873 DOI: 10.3390/jcm10040851] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/14/2021] [Accepted: 02/15/2021] [Indexed: 12/28/2022] Open
Abstract
The aim of fetal cardiac interventions (FCI), as other prenatal therapeutic procedures, is to bring benefit to the fetus. However, the safety of the mother is of utmost importance. The objective of our study was to evaluate the impact of FCI on maternal condition, course of pregnancy, and delivery. 113 mothers underwent intrauterine treatment of their fetuses with critical heart defects. 128 percutaneous ultrasound-guided FCI were performed and analyzed. The patients were divided into four groups according to the type of FCI: balloon aortic valvuloplasty (fBAV), balloon pulmonary valvuloplasty (fBPV), interatrial stent placement (IAS), and balloon atrioseptoplasty (BAS). Various factors: maternal parameters, perioperative data, and pregnancy complications, were analyzed. There was only one major complication—procedure-related placental abruption (without need for blood products transfusion). There were no cases of: procedure-related preterm prelabor rupture of membranes (pPROM), chorioamnionitis, wound infection, and anesthesia associated complications. Tocolysis was only necessary only in two cases, and it was effective in both. None of the patients required intensive care unit admission. The procedure was effective in treating polyhydramnios associated with fetal heart failure in six out of nine cases. Deliveries occurred at term in 89%, 54% were vaginal. The results showed that FCI had a negligible impact on a further course of pregnancy and delivery.
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Affiliation(s)
- Beata Rebizant
- 2nd Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland; (K.C.); (A.S.)
- Correspondence: Correspondence: (B.R.); (M.D.); Tel.: +48-508130737 (B.R.); +48-607449302 (M.D.)
| | - Adam Koleśnik
- Department of Perinatal Cardiology and Congenital Anomalies, Centre of Postgraduate Medical Education, US Clinic Agatowa, 03-680 Warsaw, Poland; (A.K.); (A.G.); (J.S.-D.)
- Cardiovascular Interventions Laboratory, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland
- Department of Descriptive and Clinical Anatomy, Medical University of Warsaw, 02-004 Warsaw, Poland
| | - Agnieszka Grzyb
- Department of Perinatal Cardiology and Congenital Anomalies, Centre of Postgraduate Medical Education, US Clinic Agatowa, 03-680 Warsaw, Poland; (A.K.); (A.G.); (J.S.-D.)
- Department of Cardiology, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland
| | - Katarzyna Chaberek
- 2nd Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland; (K.C.); (A.S.)
| | - Agnieszka Sękowska
- 2nd Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland; (K.C.); (A.S.)
- Pain Clinic, Department of Anesthesiology and Intensive Care, Centre of Postgraduate Medical Education, 00-416 Warsaw, Poland
| | - Jacek Witwicki
- Department of Neonatology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland;
| | - Joanna Szymkiewicz-Dangel
- Department of Perinatal Cardiology and Congenital Anomalies, Centre of Postgraduate Medical Education, US Clinic Agatowa, 03-680 Warsaw, Poland; (A.K.); (A.G.); (J.S.-D.)
| | - Marzena Dębska
- 2nd Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland; (K.C.); (A.S.)
- Department of Gynecologic Oncology and Obstetrics, Centre of Postgraduate Medical Education, 00-416 Warsaw, Poland
- Correspondence: Correspondence: (B.R.); (M.D.); Tel.: +48-508130737 (B.R.); +48-607449302 (M.D.)
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13
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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: 3] [Impact Index Per Article: 1.0] [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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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: 16] [Impact Index Per Article: 4.0] [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: 11] [Impact Index Per Article: 2.8] [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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Fetal cardiac interventions: Where do we stand? Arch Cardiovasc Dis 2020; 113:121-128. [PMID: 32113817 DOI: 10.1016/j.acvd.2019.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/11/2019] [Accepted: 06/12/2019] [Indexed: 11/21/2022]
Abstract
Fetal cardiac intervention (FCI) is a novel and evolving technique that allows for in utero treatment of a subset of congenital heart disease. This review describes the rationale, selection criteria, technical features, and current outcomes for the three most commonly performed FCI: fetal aortic stenosis with evolving hypoplastic left heart syndrome (HLHS); HLHS with intact or restrictive atrial septum; and pulmonary atresia with intact ventricular septum, with concern for worsening right ventricular (RV) hypoplasia.
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17
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Strainic J, Armstrong A. Fetal Cardiac Intervention: a Review of the Current Literature. CURRENT PEDIATRICS REPORTS 2020. [DOI: 10.1007/s40124-020-00209-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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18
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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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19
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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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20
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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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21
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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: 58] [Impact Index Per Article: 9.7] [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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22
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Abstract
Fetal cardiac abnormalities are some of the commonest congenital disorders seen in prenatal life. They can be anatomical or functional and can develop de novo or as a consequence of either maternal or fetal disease. Untreated, morbidity and mortality rates are high for hypoplastic left heart disorders and for some fetal tachy and bradyarrhythmias. Optimum management strategies are often not clear because of the lack of knowledge about the precise natural history of some of these conditions. Prenatal therapy ranges from invasive fetal cardiac intervention to maternal administration of drugs for transplacental transfer to the fetus. This comprehensive review covers many fetal cardiac disorders and various prenatal therapeutic options that are available.
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Affiliation(s)
- Sailesh Kumar
- a Mater Research Institute / University of Queensland , Brisbane , Australia.,b Mater Centre for Maternal Fetal Medicine , Mater Mothers' Hospital , Brisbane , Australia.,c Faculty of Medicine , the University of Queensland , Brisbane , Australia
| | - Jade Lodge
- b Mater Centre for Maternal Fetal Medicine , Mater Mothers' Hospital , Brisbane , Australia
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Prosnitz AR, Drogosz M, Marshall AC, Wilkins-Haug LE, Benson CB, Sleeper LA, Tworetzky W, Friedman KG. Early hemodynamic changes after fetal aortic stenosis valvuloplasty predict biventricular circulation at birth. Prenat Diagn 2018; 38:286-292. [PMID: 29436717 DOI: 10.1002/pd.5232] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/14/2017] [Accepted: 02/03/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To describe the early hemodynamic changes after fetal aortic valvuloplasty (FAV) for evolving hypoplastic left heart syndrome due to mid-gestational aortic stenosis and to assess whether these early changes predict biventricular (BiV) circulation at neonatal discharge. METHOD We retrospectively reviewed all technically successful FAV cases resulting in live birth between 2000 and 2015 (n = 93, 45% BiV circulation at neonatal discharge). Paired testing methods were used to compare pre-intervention and post-intervention measures of left ventricular hemodynamics. Logistic regression was used to determine whether these changes were predictive of post-natal outcome. RESULTS Measures of left heart physiology were markedly abnormal pre-FAV and improved significantly post-FAV. No subjects had systolic antegrade transverse aortic arch flow pre-FAV and 65% of subjects had antegrade flow post-FAV. The number of subjects with abnormal left-to-right patent foramen ovale flow decreased, and the number with biphasic mitral valve inflow increased. The median left ventricular ejection fraction improved after intervention. Amongst the pre-post changes, gaining partially or exclusively antegrade systolic arch flow was the most significant independent predictor of BiV circulation (OR 9.80 and 19.83, respectively, both P < 0.001). CONCLUSION Technically successful FAV is associated with immediate improvements in left heart physiology that are predictive of BiV circulation at neonatal discharge.
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Affiliation(s)
- Aaron R Prosnitz
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Monika Drogosz
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Audrey C Marshall
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Louise E Wilkins-Haug
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Carol B Benson
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Abstract
PURPOSE OF REVIEW This article discusses the rationale, patient selection, technical aspects, and outcomes of percutaneous, ultrasound-guided fetal cardiac intervention (FCI) for structural congenital heart disease. RECENT FINDINGS FCI is most commonly performed for three forms of congenital heart disease: severe aortic stenosis with evolving hypoplastic left heart syndrome (HLHS), pulmonary atresia with intact ventricular septum and evolving hypoplastic right heart syndrome, and HLHS with intact or highly restrictive atrial septum. For severe aortic stenosis and pulmonary atresia with intact ventricular septum, the goal of intervention is to alter the natural history such that a biventricular circulation may be achieved postnatally. A growing number of patients have achieved a biventricular circulation; however, patient selection and postnatal management strategy are essential for success. HLHS with intact or highly restrictive atrial septum is one of the most lethal forms of congenital heart disease, and the goal of FCI is to improve survival. Although the creation of an atrial communication in utero is technically feasible and may permit greater stability in the immediate postnatal period, significant improvements in survival have not yet been reported. SUMMARY FCI is an evolving form of treatment for congenital heart disease that holds promise for select patients. Critical evaluation of both short and long-term outcomes is warranted.
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Left Ventricular Remodeling and Function in Children with Biventricular Circulation After Fetal Aortic Valvuloplasty. Pediatr Cardiol 2015; 36:1502-9. [PMID: 25972285 PMCID: PMC7001762 DOI: 10.1007/s00246-015-1193-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 05/06/2015] [Indexed: 10/23/2022]
Abstract
Fetal aortic valvuloplasty (FAV) has shown promise in averting the progression of fetal aortic stenosis to hypoplastic left-heart syndrome. Altered loading conditions due to valvar disease, intrinsic endomyocardial abnormalities, and procedures that alter endomyocardial mechanics may place patients with biventricular circulation (BiV) after FAV at risk of abnormal LV remodeling and function. Using the most recent echo data on BiV patients after technically successful FAV (n = 34), we evaluated LV remodeling pattern, risk factors for pathologic LV remodeling, and the association between LV remodeling pattern and LV function. Median age at follow-up was 4.7 years (range 1.0-12.5). Cardiac interventions were common. At latest follow-up, no patient had hypoplastic LV. Nineteen patients (55 %) had dilated LV, and five (16 %) patients had severely dilated LV. LV remodeling patterns were as follows: 12 (35 %) normal ventricle, 11 (32 %) mixed hypertrophy, 8 (24 %) eccentric hypertrophy or remodeling, and 3 (9 %) concentric hypertrophy. Univariate factors associated with pathologic LV remodeling were long-standing AR, ≥2 cardiac interventions, EFE resection, and aortic or mitral regurgitation ≥ moderate at most recent follow-up. In multivariate analysis, only long-standing AR fraction remained associated with pathologic remodeling. Pathologic LV remodeling was associated with depressed ejection fraction, lower septal E´, and higher E/E´. Pathologic LV remodeling, primarily eccentric or mixed hypertrophy, is common in BiV patients after FAV and is related to LV loading conditions imposed by valvar disease. Pathologic remodeling is associated with both systolic and diastolic dysfunction in this population.
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Ide T, Miyoshi T, Kitano M, Kurosaki KI, Yoshimatsu J. Fetal critical aortic stenosis with natural improvement of hydrops fetalis due to spontaneous relief of severe restrictive atrial communication. J Obstet Gynaecol Res 2015; 41:1137-40. [DOI: 10.1111/jog.12681] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 12/25/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Tetsuya Ide
- Department of Perinatology and Gynecology; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Takekazu Miyoshi
- Department of Perinatology and Gynecology; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Masataka Kitano
- Department of Pediatric Cardiology; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Ken-ichi Kurosaki
- Department of Pediatric Cardiology; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Jun Yoshimatsu
- Department of Perinatology and Gynecology; National Cerebral and Cardiovascular Center; Osaka Japan
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Freud LR, McElhinney DB, Marshall AC, Marx GR, Friedman KG, del Nido PJ, Emani SM, Lafranchi T, Silva V, Wilkins-Haug LE, Benson CB, Lock JE, Tworetzky W. Fetal aortic valvuloplasty for evolving hypoplastic left heart syndrome: postnatal outcomes of the first 100 patients. Circulation 2014; 130:638-45. [PMID: 25052401 DOI: 10.1161/circulationaha.114.009032] [Citation(s) in RCA: 122] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Fetal aortic valvuloplasty can be performed for severe midgestation aortic stenosis in an attempt to prevent progression to hypoplastic left heart syndrome (HLHS). A subset of patients has achieved a biventricular (BV) circulation after fetal aortic valvuloplasty. The postnatal outcomes and survival of the BV patients, in comparison with those managed as HLHS, have not been reported. METHODS AND RESULTS We included 100 patients who underwent fetal aortic valvuloplasty for severe midgestation aortic stenosis with evolving HLHS from March 2000 to January 2013. Patients were categorized based on postnatal management as BV or HLHS. Clinical records were reviewed. Eighty-eight fetuses were live-born, and 38 had a BV circulation (31 from birth, 7 converted after initial univentricular palliation). Left-sided structures, namely aortic and mitral valve sizes and left ventricular volume, were significantly larger in the BV group at the time of birth (P<0.01). After a median follow-up of 5.4 years, freedom from cardiac death among all BV patients was 96±4% at 5 years and 84±12% at 10 years, which was better than HLHS patients (log-rank P=0.04). There was no cardiac mortality in patients with a BV circulation from birth. All but 1 of the BV patients required postnatal intervention; 42% underwent aortic or mitral valve replacement. On the most recent echocardiogram, the median left ventricular end-diastolic volume z score was +1.7 (range, -1.3 to +8.2), and 80% had normal ejection fraction. CONCLUSIONS Short- and intermediate-term survival among patients who underwent fetal aortic valvuloplasty and achieved a BV circulation postnatally is encouraging. However, morbidity still exists, and ongoing assessment is warranted.
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Affiliation(s)
- Lindsay R Freud
- From the Departments of Cardiology (L.R.F., D.B.M., A.C.M., G.R.M., K.G.F., T.L., J.E.L., W.T.) and Cardiac Surgery (P.J.d.N., S.M.E.), Boston Children's Hospital, Boston, MA; and the Departments of Obstetrics and Gynecology (V.S., L.E.W.-H.) and Radiology (C.B.B.), Brigham and Women's Hospital; Harvard Medical School, Boston, MA.
| | - Doff B McElhinney
- From the Departments of Cardiology (L.R.F., D.B.M., A.C.M., G.R.M., K.G.F., T.L., J.E.L., W.T.) and Cardiac Surgery (P.J.d.N., S.M.E.), Boston Children's Hospital, Boston, MA; and the Departments of Obstetrics and Gynecology (V.S., L.E.W.-H.) and Radiology (C.B.B.), Brigham and Women's Hospital; Harvard Medical School, Boston, MA
| | - Audrey C Marshall
- From the Departments of Cardiology (L.R.F., D.B.M., A.C.M., G.R.M., K.G.F., T.L., J.E.L., W.T.) and Cardiac Surgery (P.J.d.N., S.M.E.), Boston Children's Hospital, Boston, MA; and the Departments of Obstetrics and Gynecology (V.S., L.E.W.-H.) and Radiology (C.B.B.), Brigham and Women's Hospital; Harvard Medical School, Boston, MA
| | - Gerald R Marx
- From the Departments of Cardiology (L.R.F., D.B.M., A.C.M., G.R.M., K.G.F., T.L., J.E.L., W.T.) and Cardiac Surgery (P.J.d.N., S.M.E.), Boston Children's Hospital, Boston, MA; and the Departments of Obstetrics and Gynecology (V.S., L.E.W.-H.) and Radiology (C.B.B.), Brigham and Women's Hospital; Harvard Medical School, Boston, MA
| | - Kevin G Friedman
- From the Departments of Cardiology (L.R.F., D.B.M., A.C.M., G.R.M., K.G.F., T.L., J.E.L., W.T.) and Cardiac Surgery (P.J.d.N., S.M.E.), Boston Children's Hospital, Boston, MA; and the Departments of Obstetrics and Gynecology (V.S., L.E.W.-H.) and Radiology (C.B.B.), Brigham and Women's Hospital; Harvard Medical School, Boston, MA
| | - Pedro J del Nido
- From the Departments of Cardiology (L.R.F., D.B.M., A.C.M., G.R.M., K.G.F., T.L., J.E.L., W.T.) and Cardiac Surgery (P.J.d.N., S.M.E.), Boston Children's Hospital, Boston, MA; and the Departments of Obstetrics and Gynecology (V.S., L.E.W.-H.) and Radiology (C.B.B.), Brigham and Women's Hospital; Harvard Medical School, Boston, MA
| | - Sitaram M Emani
- From the Departments of Cardiology (L.R.F., D.B.M., A.C.M., G.R.M., K.G.F., T.L., J.E.L., W.T.) and Cardiac Surgery (P.J.d.N., S.M.E.), Boston Children's Hospital, Boston, MA; and the Departments of Obstetrics and Gynecology (V.S., L.E.W.-H.) and Radiology (C.B.B.), Brigham and Women's Hospital; Harvard Medical School, Boston, MA
| | - Terra Lafranchi
- From the Departments of Cardiology (L.R.F., D.B.M., A.C.M., G.R.M., K.G.F., T.L., J.E.L., W.T.) and Cardiac Surgery (P.J.d.N., S.M.E.), Boston Children's Hospital, Boston, MA; and the Departments of Obstetrics and Gynecology (V.S., L.E.W.-H.) and Radiology (C.B.B.), Brigham and Women's Hospital; Harvard Medical School, Boston, MA
| | - Virginia Silva
- From the Departments of Cardiology (L.R.F., D.B.M., A.C.M., G.R.M., K.G.F., T.L., J.E.L., W.T.) and Cardiac Surgery (P.J.d.N., S.M.E.), Boston Children's Hospital, Boston, MA; and the Departments of Obstetrics and Gynecology (V.S., L.E.W.-H.) and Radiology (C.B.B.), Brigham and Women's Hospital; Harvard Medical School, Boston, MA
| | - Louise E Wilkins-Haug
- From the Departments of Cardiology (L.R.F., D.B.M., A.C.M., G.R.M., K.G.F., T.L., J.E.L., W.T.) and Cardiac Surgery (P.J.d.N., S.M.E.), Boston Children's Hospital, Boston, MA; and the Departments of Obstetrics and Gynecology (V.S., L.E.W.-H.) and Radiology (C.B.B.), Brigham and Women's Hospital; Harvard Medical School, Boston, MA
| | - Carol B Benson
- From the Departments of Cardiology (L.R.F., D.B.M., A.C.M., G.R.M., K.G.F., T.L., J.E.L., W.T.) and Cardiac Surgery (P.J.d.N., S.M.E.), Boston Children's Hospital, Boston, MA; and the Departments of Obstetrics and Gynecology (V.S., L.E.W.-H.) and Radiology (C.B.B.), Brigham and Women's Hospital; Harvard Medical School, Boston, MA
| | - James E Lock
- From the Departments of Cardiology (L.R.F., D.B.M., A.C.M., G.R.M., K.G.F., T.L., J.E.L., W.T.) and Cardiac Surgery (P.J.d.N., S.M.E.), Boston Children's Hospital, Boston, MA; and the Departments of Obstetrics and Gynecology (V.S., L.E.W.-H.) and Radiology (C.B.B.), Brigham and Women's Hospital; Harvard Medical School, Boston, MA
| | - Wayne Tworetzky
- From the Departments of Cardiology (L.R.F., D.B.M., A.C.M., G.R.M., K.G.F., T.L., J.E.L., W.T.) and Cardiac Surgery (P.J.d.N., S.M.E.), Boston Children's Hospital, Boston, MA; and the Departments of Obstetrics and Gynecology (V.S., L.E.W.-H.) and Radiology (C.B.B.), Brigham and Women's Hospital; Harvard Medical School, Boston, MA
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Friedman KG, Schidlow D, Freud L, Escobar-Diaz M, Tworetzky W. Left ventricular diastolic function and characteristics in fetal aortic stenosis. Am J Cardiol 2014; 114:122-7. [PMID: 24819899 DOI: 10.1016/j.amjcard.2014.04.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 04/09/2014] [Accepted: 04/09/2014] [Indexed: 12/29/2022]
Abstract
Fetal aortic balloon valvuloplasty (FAV) has shown promise in averting progression of midgestation aortic stenosis (AS) to hypoplastic left heart syndrome in a subset of patients. Patients who achieve biventricular circulation after FAV frequently have left ventricular (LV) diastolic dysfunction (DD). This study evaluates DD in fetuses with AS by comparing echocardiographic indices of LV diastolic function in fetuses underwent FAV (n = 20) with controls (n = 40) and evaluates for LV factors associated with DD in patients with FAV. We also compared pre-FAV and post-FAV DD variables (n = 16). Median gestational age (24 weeks, range 18 to 29 weeks) and fetal heart rate were similar between FAV and controls. Compared with controls, patients with FAV had universally abnormal LV diastolic parameters including fused mitral inflow E and A waves (p = 0.008), higher E velocity (p <0.001), shorter mitral inflow time (p = 0.001), lower LV lateral annulus E' (p <0.001), septal E' (p = 0.003), and higher E/E' (p <0.001) than controls. Patients with FAV had abnormal right ventricular mechanics with higher tricuspid inflow E velocity (p <0.001) and shorter tricuspid inflow time (p = 0.03). Worse LV diastolic function (lower LV E') was associated with higher endocardial fibroelastosis grade (r = 0.74, p <0.001), large LV volume (r = 0.55, p = 0.013), and sphericity (r = 0.58, p = 0.009) and with lower LV pressure by mitral regurgitation jet (r = -0.68, p <0.001). Post-FAV, fewer patients had fused mitral inflow E and A than pre-FAV (p = 0.05) and septal E' was higher (=0.04). In conclusion, fetuses with midgestation AS have evidence of marked DD. Worse DD is associated with larger, more spherical LV, with more extensive endocardial fibroelastosis and lower LV pressure.
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Zhou J, Zhou Q, Zhang M, Zeng S, Peng Q, Tian L. Echocardiographic follow-up and pregnancy outcome of fetuses with cardiac asymmetry at 18-22 weeks of gestation. Prenat Diagn 2014; 34:900-7. [PMID: 24760774 DOI: 10.1002/pd.4391] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 04/17/2014] [Accepted: 04/17/2014] [Indexed: 11/07/2022]
Affiliation(s)
- Jiawei Zhou
- Department of Ultrasonography, The Second Xiangya Hospital; Central South University; No.139 Middle Renmin Road Changsha Hunan 410011 China
| | - Qichang Zhou
- Department of Ultrasonography, The Second Xiangya Hospital; Central South University; No.139 Middle Renmin Road Changsha Hunan 410011 China
| | - Ming Zhang
- Department of Ultrasonography, The Second Xiangya Hospital; Central South University; No.139 Middle Renmin Road Changsha Hunan 410011 China
| | - Shi Zeng
- Department of Ultrasonography, The Second Xiangya Hospital; Central South University; No.139 Middle Renmin Road Changsha Hunan 410011 China
| | - Qinghai Peng
- Department of Ultrasonography, The Second Xiangya Hospital; Central South University; No.139 Middle Renmin Road Changsha Hunan 410011 China
| | - Leiqi Tian
- Department of Ultrasonography, The Second Xiangya Hospital; Central South University; No.139 Middle Renmin Road Changsha Hunan 410011 China
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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: 704] [Impact Index Per Article: 70.4] [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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Cole CR, Yutzey KE, Brar AK, Goessling LS, Van Vickle-Chavez SJ, Cunningham MW, Eghtesady P. Congenital heart disease linked to maternal autoimmunity against cardiac myosin. THE JOURNAL OF IMMUNOLOGY 2014; 192:4074-82. [PMID: 24670798 DOI: 10.4049/jimmunol.1301264] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Structural congenital heart disease (CHD) has not previously been linked to autoimmunity. In our study, we developed an autoimmune model of structural CHD that resembles hypoplastic left heart syndrome (HLHS), a life-threatening CHD primarily affecting the left ventricle. Because cardiac myosin (CM) is a dominant autoantigen in autoimmune heart disease, we hypothesized that immunization with CM might lead to transplacental passage of maternal autoantibodies and a prenatal HLHS phenotype in exposed fetuses. Elevated anti-CM autoantibodies in maternal and fetal sera, as well as IgG reactivity in fetal myocardium, were correlated with structural CHD that included diminished left ventricular cavity dimensions in the affected progeny. Further, fetuses that developed a marked HLHS phenotype had elevated serum titers of anti-β-adrenergic receptor Abs, as well as increased protein kinase A activity, suggesting a potential mechanism for the observed pathological changes. Our maternal-fetal model presents a new concept linking autoimmunity against CM and cardiomyocyte proliferation with cardinal features of HLHS. To our knowledge, this report shows the first evidence in support of a novel immune-mediated mechanism for pathogenesis of structural CHD that may have implications in its future diagnosis and treatment.
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Affiliation(s)
- Charles R Cole
- Division of Molecular Cardiovascular Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229
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Pedra SRFF, Peralta CFA, Crema L, Jatene IB, da Costa RN, Pedra CAC. Fetal interventions for congenital heart disease in Brazil. Pediatr Cardiol 2014; 35:399-405. [PMID: 24030590 DOI: 10.1007/s00246-013-0792-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 08/28/2013] [Indexed: 10/26/2022]
Abstract
Fetal interventions have been performed for some congenital heart diseases. However, these procedures have not gained wide acceptance due to concerns about their efficacy and safety. The aim of this study was to report on a preliminary experience with fetal cardiac interventions in Brazil. Twenty-two cardiac interventions were performed in 21 fetuses. Thirteen fetuses had critical aortic stenosis (CAS), 4 had hypoplastic left heart syndrome (HLHS) and intact interatrial septum or small patent foramen ovale, 1 had pulmonary atresia with intact ventricular septum (IVS), and 3 had critical pulmonary stenosis (CPS). The main outcome variables evaluated were technical success and procedural complications as well as pregnancy and postnatal outcomes. Success was achieved in 20 of 22 procedures (91%) with 1 failed aortic and 1 failed pulmonary valvuloplasties. There was 1 fetal death. No maternal complications occurred. One patient with CAS, severe mitral regurgitation, and hydrops died postnatally within 5 months of age. All patients with HLHS and restrictive atrial septum died after interventional or surgical procedures and prolonged hospitalizations. All patients with CPS/IVS survived and achieved a biventricular (BV) circulation after neonatal valvuloplasty and ductal stenting. A BV circulation was achieved in 4 of 8 patients with CAS and evolving HLHS (one still in utero), including 2 with initial borderline left ventricles (LV) in whom surgical LV overhaul was performed at 9 months of age. In this preliminary experience, the feasibility of fetal cardiac interventions and their outcomes were similar to those previously reported.
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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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Abstract
Objective: To assess brain development and brain injury in neonates with cyanotic and acyanotic congenital heart disease (CHD). Methods: The study included 52 term infants with CHD who were divided into two groups: Cyanotic (n=21) and acyanotic (n=31). Fifteen healthy neonates of matched age and sex were enrolled in the study as controls. Three-dimensional proton magnetic resonance spectroscopic imaging and diffusion tensor imaging were used to assess brain development and injury. We calculated the ratio of N-acetylaspartate (NAA) to choline (which increases with maturation), average diffusivity (which decreases with maturation), fractional anisotropy of white matter (which increases with maturation), and the ratio of lactate to choline (which increases with brain injury). Results: As compared with control neonates, those with CHD had significant decrease in NAA/choline ratio (P<0.001), significant increase in lactate/choline ratio (P<0.0001), significant increase in average diffusivity (P<0.0001), and significant decrease of white matter fractional anisotropy (P<0.001). Neonates with cyanotic CHD had significant less brain development and more brain injury than those with acyanotic CHD (P<0.05). Conclusions: Newborn infants with cyanotic and acyanotic CHD are at high risk of brain injury and impaired brain maturity.
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Affiliation(s)
- Moustafa M Abdel Raheem
- Department of Pediatrics, Faculty of Medicine, Minia University, Minia, Egypt, Department of Pediatrics, College of Medicine, King Khalid University, Abha, Saudi Arabia
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Van Aerschot I, Rosenblatt J, Boudjemline Y. Fetal cardiac interventions: myths and facts. Arch Cardiovasc Dis 2012; 105:366-72. [PMID: 22800721 DOI: 10.1016/j.acvd.2012.01.011] [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: 12/23/2011] [Revised: 01/20/2012] [Accepted: 01/22/2012] [Indexed: 11/24/2022]
Abstract
An early, primary, in utero cardiac abnormality may prevent normal heart development and cause irreversible secondary structural changes. The idea of foetal cardiac intervention stems from this understanding and focuses on antenatal intervention targeting the primary abnormality to allow normal flow and haemodynamics and thus normal heart development. Crucial aspects of foetal vascular access, varying foetal lie and structural complexity make it very hard to set procedural standards. The procedures are complex and are associated with significant maternal and foetal morbidity and mortality. The high risk-benefit ratio clearly explains the investigational nature of such therapies. With the development of minimally invasive techniques and continued animal experiments, foetal interventional therapy may see a low rate of morbidity and mortality, improving the prognosis of newborns with congenital heart disease previously considered incurable.
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Affiliation(s)
- Isabelle Van Aerschot
- Centre de référence malformations cardiaques congénitales complexes-M3C, hôpital Necker-Enfants-Malades, cardiologie pédiatrique, assistance publique des hôpitaux de Paris, 149, rue de Sèvres, 75015 Paris cedex, France
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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: 347] [Impact Index Per Article: 28.9] [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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Friedman KG, Margossian R, Graham DA, Harrild DM, Emani SM, Wilkins-Haug LE, McElhinney DB, Tworetzky W. Postnatal left ventricular diastolic function after fetal aortic valvuloplasty. Am J Cardiol 2011; 108:556-60. [PMID: 21624551 DOI: 10.1016/j.amjcard.2011.03.085] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 03/22/2011] [Accepted: 03/22/2011] [Indexed: 12/22/2022]
Abstract
Fetal aortic balloon valvuloplasty (FAV) has shown promise in altering in utero progression of aortic stenosis to hypoplastic left heart syndrome. In patients who achieve a biventricular circulation after FAV, left ventricular (LV) compliance may be impaired. Echocardiographic indexes of diastolic function were compared between patients with biventricular circulation after FAV, congenital aortic stenosis (AS), and age-matched controls. In the neonatal period, patients with FAV had similar LV, aortic, and mitral valve dimensions but more evidence of endocardial fibroelastosis than patients with AS. Patients with FAV underwent more postnatal cardiac interventions than patients with AS (p = 0.007). Mitral annular early diastolic tissue velocity (E') was lower in patients with FAV and those with AS and controls in the neonatal period and over follow-up (p <0.001). Septal E' was similar among all 3 groups in the neonatal period. In follow-up patients, with FAV had lower septal E' than patients with AS or controls (p <0.001). Early mitral inflow velocity/E' was higher in patients with FAV as neonates and at follow-up (p <0.001). Mitral inflow pulse-wave Doppler-derived indexes of diastolic function were similar between groups. In conclusion, echocardiographic evidence of LV diastolic dysfunction is common in patients with biventricular circulation after FAV and persists in short-term follow-up. LV diastolic dysfunction in this unique population may have important implications on long-term risk of left atrial and subsequent pulmonary hypertension.
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Arzt W, Tulzer G. Fetal surgery for cardiac lesions. Prenat Diagn 2011; 31:695-8. [PMID: 21671460 DOI: 10.1002/pd.2810] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 05/18/2011] [Indexed: 11/12/2022]
Abstract
Intrauterine dilation of critical fetal aortic stenosis (AS) and pulmonary stenosis or atresia has the potential to change the natural course of these congenital heart defects preventing progression to a single ventricle circulation. This article reviews the world experience in fetal cardiac interventions. In carefully selected cases, fetal cardiac surgery can reverse end-stage heart failure and can provide biventricular outcome postnatally in about two thirds of the cases with successful interventions.
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Affiliation(s)
- Wolfgang Arzt
- Department of Prenatal Medicine, Women's and Children's Hospital Linz, Linz, Austria.
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Arzt W, Wertaschnigg D, Veit I, Klement F, Gitter R, Tulzer G. Intrauterine aortic valvuloplasty in fetuses with critical aortic stenosis: experience and results of 24 procedures. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 37:689-695. [PMID: 21229549 DOI: 10.1002/uog.8927] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/20/2010] [Indexed: 05/30/2023]
Abstract
OBJECTIVE Valvuloplasty of the fetal aortic valve has the potential to prevent progression of critical aortic stenosis (AS) to hypoplastic left heart syndrome (HLHS). The aim of the study was to assess 24 aortic valvuloplasties regarding indications, success rate, procedure-related risks and outcome. METHODS Between January 2001 and December 2009 we performed 24 aortic valvuloplasties in 23 fetuses with critical AS at a median gestational age of 26 + 4 (range, 21 + 3 to 32 + 5) weeks by a transabdominal ultrasound-guided approach. Four fetuses had hydrops as a late sign of heart failure. RESULTS In 16/24 procedures (66.7%) corresponding to 16/23 fetuses (69.6%) the procedures were technically successful, with one intrauterine death in this group. After an initial learning curve, success rate improved to 78.6% (11 of the last 14 interventions were successful). In 10 out of the 15 (66.7%) successfully-treated and liveborn fetuses a biventricular circulation could be achieved postnatally. All four fetuses with hydrops had successful interventions, hydrops disappearing within 5 weeks. In 8/24 interventions (33.3%) the aortic valve could not be treated successfully, with intrauterine fetal death in two of these cases. In one fetus a repeat procedure was successful. All surviving fetuses with unsuccessful (n = 5) or no (n = 5) procedure performed developed HLHS until delivery. CONCLUSIONS Fetal aortic valvuloplasty could be performed successfully in selected fetuses with critical AS and evolving HLHS, with a biventricular outcome in two thirds of the patients. Safety and success rate were dependent on patient selection and the level of experience of the whole interventional team. In fetuses with AS and hydrops, aortic valvuloplasty could reverse end-stage heart failure and hydrops and ensure fetal survival.
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Affiliation(s)
- W Arzt
- Department of Prenatal Medicine, Women's and Children's Hospital Linz, Linz, Austria.
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Coceani F, Menciassi A, Murzi B. Antenatal corrective cardiac surgery: An emerging area for technological innovation. MINIM INVASIV THER 2011; 19:170-6. [PMID: 20367502 DOI: 10.3109/13645701003644368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The possibility of intervening in utero on certain cardiac malformations with the intent to prevent secondary major alterations in structure and function is becoming a reality. Central to progress in this area is the development of instrumentation specifically designed for minimally invasive cardiac surgery in the fetus. The present review introduces a novel set of devices for interventional cardiology, based on current knowledge and prior experience, and highlights their prospective application. In meeting this objective, particular importance is assigned to the synergic contribution of diverse disciplines, both medical and nonmedical.
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Abstract
The severity of fetal heart disease progresses during gestation and may lead to significant in utero or postnatal morbidity and mortality. Fetal echocardiography allows us to detect heart disease early enough in pregnancy to perform fetal cardiac intervention that may change the natural history of some diseases. The principal aims are the prevention of hydrops due to congenital heart disease, recruitment of hypoplastic ventricles, remodeling of the fetal pulmonary vascular bed, or creation of a two-ventricular circulation after birth without risk to the mother. The initial fetal interventions for valvuloplasty and atrial septostomy showed a high mortality and did not achieve significant change in the final outcome of patients. Nevertheless, some technique modifications have improved the outcome of these patients, making fetal cardiac intervention a promising treatment for congenital heart disease. Conversely, different assessment tools for selection of the correct patient have been studied in some series to improve the success of these procedures and thus the survival odds. We believe that percutaneous procedures with local anesthesia are preferable.
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Affiliation(s)
- Regina Viesca
- Department of Pediatrics and Obstetrics/Gynecology, USF Daicoff-Andrews Chair in Perinatal Cardiology, 140 7th Avenue S, CRI-4007, St. Petersburg, FL 33701, USA
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Sedmera D. Factors in ventricular and atrioventricular valve growth: An embryologist's perspective. PROGRESS IN PEDIATRIC CARDIOLOGY 2010. [DOI: 10.1016/j.ppedcard.2010.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Emery SP, Kreutzer J, McCaffrey FM, Sherman FS, Simhan HN, Keller BB. The learning curve for a fetal cardiac intervention team. Minim Invasive Surg 2010; 2010:674185. [PMID: 22091354 PMCID: PMC3196156 DOI: 10.1155/2010/674185] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Accepted: 01/18/2010] [Indexed: 12/20/2022] Open
Abstract
Objectives. Multiple technical difficulties are encountered when a multidisciplinary team of subspecialists begins a minimally-invasive fetal cardiac interventional program. We describe the learning curve. Study Design. Ten pregnant sheep underwent ultrasound-guided balloon valvuloplasty of the aortic valve. Team members and their roles remained constant through the trial. The time between needle insertion and entrance of the left ventricle at the aortic root was recorded. F-test was used to assess significance (P ≤ .05). Results. The time required to accurately position the needle tip at the aortic root decreased significantly over the course of the trial, from 12 minutes with the first attempt to one minute with the last (P = .003). Conclusion. A significant learning curve is encountered when a multidisciplinary team begins a minimally-invasive fetal cardiac intervention program. However, technical proficiency can be achieved with practice. Institutions interested in developing such a program should consider practice in an animal model before proceeding to the human fetus.
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Affiliation(s)
- Stephen P. Emery
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | | | | | - Fredrick S. Sherman
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
- The Children's Hospital of Pittsburgh of UPMC, 15224, USA
| | - Hyagriv N. Simhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
- The Department of Pediatric Cardiology, The Magee-Womens Research Institute, 15213, USA
| | - Bradley B. Keller
- The Division of Pediatric Heart Research Cardiovascular Innovation Institute, University of Louisville, KY 40202, USA
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McElhinney DB, Benson CB, Brown DW, Wilkins-Haug LE, Marshall AC, Zaccagnini L, Tworetzky W. Cerebral blood flow characteristics and biometry in fetuses undergoing prenatal intervention for aortic stenosis with evolving hypoplastic left heart syndrome. ULTRASOUND IN MEDICINE & BIOLOGY 2010; 36:29-37. [PMID: 19931971 PMCID: PMC4230573 DOI: 10.1016/j.ultrasmedbio.2009.09.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Revised: 07/29/2009] [Accepted: 07/29/2009] [Indexed: 05/28/2023]
Abstract
Children with hypoplastic left heart syndrome (HLHS) are at risk for neurodevelopmental dysfunction; prenatal factors may play a role in this predilection. Cerebral blood flow profiles are abnormal in fetuses with HLHS, raising the possibility that cerebral hemodynamics in utero may be related to neurodevelopmental abnormalities. Prenatal aortic valvuloplasty for fetal aortic stenosis with evolving HLHS is technically feasible and improves left heart hemodynamics. This study aimed to assess the effects of prenatal intervention on cerebral blood flow profiles and head circumference in fetuses with evolving HLHS. Seventy fetuses underwent prenatal aortic valvuloplasty for evolving HLHS (median 23 weeks gestation). Among 46 fetuses that had successful valvuloplasty and available data, middle cerebral artery (MCA) pulsatility (PI) and resistive (RI) indices were abnormal (Z-scores -1.7+/-1.1 and -2.2+/-1.4, p<0.001). Early post-valvuloplasty (n=33) and at late gestation follow-up (n=28), MCA PI and RI Z-scores remained low with no difference from pre- or early postintervention. Fetal head circumference was normal, as were umbilical artery PI and RI Z-scores. Cerebral blood flow characteristics are abnormal in mid-gestation fetuses with evolving HLHS, suggesting low cerebral vascular impedance. The mechanisms and significance of these abnormalities are unknown. Prenatal aortic valvuloplasty did not have a major impact on these indices. (E-mail: doff.mcelhinney@cardio.chboston.org).
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Affiliation(s)
- Doff B McElhinney
- Department of Cardiology, Children's Hospital Boston, and Pediatrics, Harvard Medical School, Boston, MA, USA.
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Hasan BS, Keane JF, Tworetzky W, Lock JE, Marshall AC. Postnatal angiographic appearance of left ventricular myocardium in fetal patients with aortic stenosis having in-utero aortic valvuloplasty. Am J Cardiol 2009; 104:1271-5. [PMID: 19840575 DOI: 10.1016/j.amjcard.2009.06.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2009] [Revised: 06/16/2009] [Accepted: 06/16/2009] [Indexed: 11/28/2022]
Abstract
Fetal aortic valvuloplasty (FAV) is performed on the basis of the hypothesis that aortic stenosis leads to the impairment of left ventricular (LV) filling and growth. Given that most fetuses fail to exhibit normalization of LV growth even after successful FAV, better understanding of the associated LV myocardial pathology is indicated. Postnatal angiography was reviewed retrospectively for all patients who (1) underwent FAV for severe aortic stenosis and (2) had well-opacified LV angiograms before any surgical intervention from 2000 to 2007. The angiographic appearance of the LV myocardium was described as either smooth or trabeculated in a total of 6 anatomic segments in 2 projections (anteroposterior and lateral). Twenty-four infants who underwent FAV had angiographic images appropriate for review. Of these, 4 (17%) had uniformly smooth LV myocardium, whereas 20 (83%) had deep trabeculations of > or =1 LV myocardial segment. Half of the infants (n = 13) had extensive trabeculations with the involvement of > or =4 segments. In all cases, the septal segments were smooth. In conclusion, patients after FAV have angiographically abnormal left ventricles, commonly involving extensive trabeculations of the free wall, but without septal involvement.
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Affiliation(s)
- Babar Sultan Hasan
- Department of Cardiology, Children's Hospital Boston, Massachusetts, USA.
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Rand L, Caughey AB. The challenges of caring for twins discordant for anomalies. J Perinatol 2009; 29:653-4. [PMID: 19784000 DOI: 10.1038/jp.2009.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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McElhinney DB, Marshall AC, Wilkins-Haug LE, Brown DW, Benson CB, Silva V, Marx GR, Mizrahi-Arnaud A, Lock JE, Tworetzky W. Predictors of technical success and postnatal biventricular outcome after in utero aortic valvuloplasty for aortic stenosis with evolving hypoplastic left heart syndrome. Circulation 2009; 120:1482-90. [PMID: 19786635 DOI: 10.1161/circulationaha.109.848994] [Citation(s) in RCA: 225] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aortic stenosis in the midgestation fetus with a normal-sized or dilated left ventricle predictably progresses to hypoplastic left heart syndrome when associated with certain physiological findings. Prenatal balloon aortic valvuloplasty may improve left heart growth and function, possibly preventing evolution to hypoplastic left heart syndrome. METHODS AND RESULTS Between March 2000 and October 2008, 70 fetuses underwent attempted aortic valvuloplasty for critical aortic stenosis with evolving hypoplastic left heart syndrome. We analyzed this experience to determine factors associated with procedural and postnatal outcome. The median gestational age at intervention was 23 weeks. The procedure was technically successful in 52 fetuses (74%). Relative to 21 untreated comparison fetuses, subsequent prenatal growth of the aortic and mitral valves, but not the left ventricle, was improved after intervention. Nine pregnancies (13%) did not reach a viable term or preterm birth. Seventeen patients had a biventricular circulation postnatally, 15 from birth. Larger left heart structures and higher left ventricular pressure at the time of intervention were associated with biventricular outcome. A multivariable threshold scoring system was able to discriminate fetuses with a biventricular outcome with 100% sensitivity and modest positive predictive value. CONCLUSIONS Technically successful aortic valvuloplasty alters left heart valvar growth in fetuses with aortic stenosis and evolving hypoplastic left heart syndrome and, in a subset of cases, appeared to contribute to a biventricular outcome after birth. Fetal aortic valvuloplasty carries a risk of fetal demise. Fetuses undergoing in utero aortic valvuloplasty with an unfavorable multivariable threshold score at the time of intervention are very unlikely to achieve a biventricular circulation postnatally.
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Affiliation(s)
- Doff B McElhinney
- Department of Cardiology, Children's Hospital, Boston, MA 02115, USA.
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Tworetzky W, McElhinney DB, Marx GR, Benson CB, Brusseau R, Morash D, Wilkins-Haug LE, Lock JE, Marshall AC. In utero valvuloplasty for pulmonary atresia with hypoplastic right ventricle: techniques and outcomes. Pediatrics 2009; 124:e510-8. [PMID: 19706566 PMCID: PMC4235279 DOI: 10.1542/peds.2008-2014] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Prenatal intervention for fetuses with pulmonary atresia with an intact ventricular septum (PA/IVS) has the potential to alter right heart physiologic features in utero, facilitating right heart growth and improving the prospect of a biventricular outcome after birth. METHODS Since 2002, we have considered prenatal intervention for fetal PA/IVS in patients with (1) membranous pulmonary atresia, with identifiable pulmonary valve (PV) leaflets or membrane; (2) an intact or highly restrictive ventricular septum; and (3) right heart hypoplasia, with a tricuspid valve annulus z score of -2 or below and an identifiable but small right ventricle. Intervention was performed through direct cardiac puncture under ultrasound guidance, with percutaneous access or access through a limited laparotomy. RESULTS Ten fetuses underwent attempted balloon dilation of the PV in utero. The first 4 procedures were technically unsuccessful, and the most-recent 6 were technically successful. Compared with control fetuses with PA/IVS who did not undergo prenatal intervention and had univentricular outcomes after birth, the tricuspid valve annulus, right ventricle length, and PV annulus grew significantly more from midgestation to late gestation in the 6 fetuses who underwent successful interventions. CONCLUSIONS In utero perforation and dilation of the PV in midgestation fetuses with PA/IVS is technically feasible and may be associated with improved right heart growth and postnatal outcomes for fetuses with moderate right heart hypoplasia in midgestation. There is an important learning curve for this procedure, and much remains to be learned about the selection of appropriate fetuses for prenatal intervention.
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Affiliation(s)
- Wayne Tworetzky
- Department of Cardiology, Children's Hospital, Boston, MA 02115, USA.
| | - Doff B. McElhinney
- Department of Cardiology, Children’s Hospital Boston, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Gerald R. Marx
- Department of Cardiology, Children’s Hospital Boston, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Carol B. Benson
- Department of Radiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Roland Brusseau
- Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital Boston and Harvard Medical School, Boston, Massachusetts
| | - Donna Morash
- Department of Surgery, Children’s Hospital Boston and Harvard Medical School, Boston, Massachusetts
| | - Louise E. Wilkins-Haug
- Department of Obstetrics and Gynecology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - James E. Lock
- Department of Cardiology, Children’s Hospital Boston, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Audrey C. Marshall
- Department of Cardiology, Children’s Hospital Boston, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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