Perinatal management of critical aortic valve stenosis diagnosed by fetal echocardiography

Prenatal therapy of non-immunologic hydrops fetalis caused by severe aortic stenosis

Congenital aortic stenosis is a rare cause of congestive heart failure and hydrops fetalis. This report describes a case of prenatally diagnosed critical aortic stenosis and endocardial fibroelastosis leading to a severe hydrops fetalis at 27 weeks of gestation. Successful transplacental digitalization was performed and all signs of hydrops resolved within 2 weeks. The pregnancy continued with normal development of the fetus and birth was induced at 39 weeks of gestation. After an uneventful vaginal birth, the child was transferred for cardiac catheterization, and balloon dilation of the aortic valve was performed successfully. Follow up at the age of 2 years showed only mild left ventricular cardiac hypertrophy, a moderate elevated pressure gradient of 50 mmHg at the aortic valve and mild aortic and mitral regurgitation. No further interventions were necessary at this point.

Left ventricular dysfunction in the fetus: relation to aortic valve anomalies and endocardial fibroelastosis

OBJECTIVE

To examine the relation between a characteristic form of left ventricular dysfunction in the fetus and abnormalities of the aortic valve and endocardial fibroelastosis of the left ventricle.

DESIGN

A retrospective study to examine the correlation between echocardiographic findings in the fetus and postnatal or necropsy findings.

SETTING

Tertiary referral centre for fetal echocardiography.

PATIENTS

Thirty fetuses showing a characteristic echocardiographic picture of left ventricular dysfunction.

MAIN OUTCOME MEASURES

The relation between the prenatal echocardiographic features and the postnatal and necropsy findings.

RESULTS

At presentation the size of the left ventricular cavity was normal or enlarged in all cases. The measurements of the orifice of the aortic root and mitral valve were either normal or small for the gestational age. The echocardiographic diagnosis made at presentation was critical aortic stenosis in all cases. At necropsy or postnatal examination the aortic valve was dysplastic and stenotic in 15 cases and the left ventricle had become hypoplastic in one of these. Aortic atresia was present in seven patients, three of whom had a hypoplastic left ventricle. In six patients the aortic valve was bicuspid although not obstructive. One of these patients had hypoplasia of the aortic arch and one had a hypoplastic left ventricle but in the remaining four patients endocardial fibroelastosis of the left ventricle was the only abnormality found. No follow up information was available in two. Of 26 patients for whom there was postmortem information, 24 had evidence of some degree of endocardial fibroelastosis of the left ventricle. Sequential observations showed that five cases developed into the hypoplastic left heart syndrome.

CONCLUSIONS

This type of left ventricular dysfunction in the fetus is the result of an overlap of diseases, including primary left ventricular endocardial fibroelastosis, critical aortic stenosis, and the hypoplastic left heart syndrome.

Prenatal diagnosis of aortic atresia by colour Doppler flow mapping

A case of aortic atresia with insufficiency of mitral valve diagnosed prenatally at 33 weeks of gestation is presented. An accurate diagnosis of this fetal cardiovascular malformation was possible by application of Doppler colour flow mapping, which demonstrated (a) the absence of forward flow in the hypoplastic ascending aorta, (b) reverse flow of blood from the ductus arteriosus into the severely hypoplastic ascending aorta in the late systole, (c) pansystolic mitral valve regurgitation, and (d) absent flow across the foramen ovale as a result of premature closure of the foramen ovale.