1
|
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.
Collapse
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
| |
Collapse
|
2
|
Sizarov A, Boudjemline Y. Valve Interventions in Utero: Understanding the Timing, Indications, and Approaches. Can J Cardiol 2017; 33:1150-1158. [DOI: 10.1016/j.cjca.2017.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 06/16/2017] [Accepted: 06/16/2017] [Indexed: 12/25/2022] Open
|
3
|
Watanabe M, Rollins AM, Polo-Parada L, Ma P, Gu S, Jenkins MW. Probing the Electrophysiology of the Developing Heart. J Cardiovasc Dev Dis 2016; 3:jcdd3010010. [PMID: 29367561 PMCID: PMC5715694 DOI: 10.3390/jcdd3010010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 03/08/2016] [Accepted: 03/10/2016] [Indexed: 12/14/2022] Open
Abstract
Many diseases that result in dysfunction and dysmorphology of the heart originate in the embryo. However, the embryonic heart presents a challenging subject for study: especially challenging is its electrophysiology. Electrophysiological maturation of the embryonic heart without disturbing its physiological function requires the creation and deployment of novel technologies along with the use of classical techniques on a range of animal models. Each tool has its strengths and limitations and has contributed to making key discoveries to expand our understanding of cardiac development. Further progress in understanding the mechanisms that regulate the normal and abnormal development of the electrophysiology of the heart requires integration of this functional information with the more extensively elucidated structural and molecular changes.
Collapse
Affiliation(s)
- Michiko Watanabe
- Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA.
- Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH 44106, USA.
| | - Andrew M Rollins
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH 44106, USA.
| | - Luis Polo-Parada
- Department of Medical Pharmacology and Physiology, University of Missouri, Columbia, MO 65201, USA.
- Dalton Cardiovascular Research Center, University of Missouri, Columbia, MO 65201, USA.
| | - Pei Ma
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH 44106, USA.
| | - Shi Gu
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH 44106, USA.
| | - Michael W Jenkins
- Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA.
- Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH 44106, USA.
| |
Collapse
|
4
|
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.
Collapse
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
| | | | | |
Collapse
|
5
|
Weber B, Emmert MY, Behr L, Schoenauer R, Brokopp C, Drögemüller C, Modregger P, Stampanoni M, Vats D, Rudin M, Bürzle W, Farine M, Mazza E, Frauenfelder T, Zannettino AC, Zünd G, Kretschmar O, Falk V, Hoerstrup SP. Prenatally engineered autologous amniotic fluid stem cell-based heart valves in the fetal circulation. Biomaterials 2012; 33:4031-43. [PMID: 22421386 DOI: 10.1016/j.biomaterials.2011.11.087] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2011] [Accepted: 11/29/2011] [Indexed: 01/22/2023]
Abstract
Prenatal heart valve interventions aiming at the early and systematic correction of congenital cardiac malformations represent a promising treatment option in maternal-fetal care. However, definite fetal valve replacements require growing implants adaptive to fetal and postnatal development. The presented study investigates the fetal implantation of prenatally engineered living autologous cell-based heart valves. Autologous amniotic fluid cells (AFCs) were isolated from pregnant sheep between 122 and 128 days of gestation via transuterine sonographic sampling. Stented trileaflet heart valves were fabricated from biodegradable PGA-P4HB composite matrices (n = 9) and seeded with AFCs in vitro. Within the same intervention, tissue engineered heart valves (TEHVs) and unseeded controls were implanted orthotopically into the pulmonary position using an in-utero closed-heart hybrid approach. The transapical valve deployments were successful in all animals with acute survival of 77.8% of fetuses. TEHV in-vivo functionality was assessed using echocardiography as well as angiography. Fetuses were harvested up to 1 week after implantation representing a birth-relevant gestational age. TEHVs showed in vivo functionality with intact valvular integrity and absence of thrombus formation. The presented approach may serve as an experimental basis for future human prenatal cardiac interventions using fully biodegradable autologous cell-based living materials.
Collapse
Affiliation(s)
- Benedikt Weber
- Swiss Center for Regenerative Medicine and Clinic for Cardiovascular Surgery, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
6
|
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: 339] [Impact Index Per Article: 28.3] [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.
Collapse
Affiliation(s)
- Jeffrey A Feinstein
- Department of Pediatrics, Stanford University School of Medicine, Lucile Salter Packard Children's Hospital, Palo Alto, California 94304, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Weber B, Emmert MY, Behr L, Brokopp C, Frauenfelder T, Kretschmar O, Falk V, Hoerstrup SP. Fetal trans-apical stent delivery into the pulmonary artery: prospects for prenatal heart-valve implantation. Eur J Cardiothorac Surg 2011; 41:398-403. [PMID: 21741853 DOI: 10.1016/j.ejcts.2011.04.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE The purpose of this study was to assess the technical feasibility of a fetal trans-apical stent delivery into the pulmonary artery using a novel hybrid-intervention technique as a possible route for prenatal minimally invasive heart-valve-implantation approaches. METHODS Pregnant Pre-Alp sheep between 122 and 128 days' gestation (n = 3) underwent a midline laparotomy. The fetus was left in utero or partially externalized and its chest was opened via a left-sided minithoracotomy. The fetal heart was cannulated and a guide wire was introduced through the ductus arteriosus into the aorta. A 14-French delivery system was then mounted onto the guide wire and advanced to the landing zone in the pulmonary artery, where the stent was deployed. The position of the stent was confirmed using echocardiography, angiography as well as computed tomography. RESULTS The trans-apical implantation was successful in all animals. However, at necropsy in one animal, the stent was found to partly occlude one of the pulmonary valvular leaflets. Bleeding at the antero-apical incision occurred in all animals but could be managed without fetal demise. No fetal cardiopulmonary bypass was performed. In all animals, contrast angiography displayed normal perfusion of the pulmonary vasculature as well as the ductus arteriosus. CONCLUSIONS Our study demonstrates the principal technical feasibility of a prenatal stent delivery into the pulmonary artery using a novel trans-apical hybrid-intervention technique. This approach demonstrates the first step towards possible future minimally invasive prenatal heart-valve-implantation procedures.
Collapse
Affiliation(s)
- Benedikt Weber
- Clinic for Cardiovascular Surgery and Department of Surgical Research, University Hospital of Zurich, Zurich, Switzerland
| | | | | | | | | | | | | | | |
Collapse
|
8
|
Hua Y, Yang S, Zhou K, Guo N, Zhu Q, Zhou R, Mu D, Jiang X. Impact of intrauterine balloon aortic valvuloplasty on gestational outcome in a fetal goat model. Fetal Diagn Ther 2011; 30:100-7. [PMID: 21464555 DOI: 10.1159/000324503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Accepted: 01/17/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Intrauterine balloon aortic valvuloplasty (IUBAV) has been used to correct critical aortic valve stenosis. Evaluation of the intervention-related risk is necessary. The purpose of this study was to establish an experimental goat model for ultrasound-guided IUBAV intervention and investigate the immediate and long-term effects of IUBAV on the fetus, gestational outcome and mother's safety. STUDY DESIGN Fifteen pregnant goats with twin gestation in the 2nd and 3rd trimester were anesthetized to establish the surgical procedure. One fetus of the twins received IUBAV intervention, the other served as a control. The data were collected at three time points: immediately before and after IUBAV, and 24 h after birth. Critical organs including the heart, brain, lung and liver from the fetuses/newborns were collected after IUBAV or 24 h after birth. RESULTS IUBAV intervention immediately induced a significant decrease of pH and Ca(2+), as well as an increase of blood glucose and lactic acid levels (p < 0.05). IUBAV also caused an increase in stress hormones (epinephrine 1-fold, norepinephrine 4-fold, and cortisol 1-fold; p < 0.05). Following the operation, all of the mother goats recovered, but in 60% (6/10) preterm delivery occurred. Neither pathological changes in fetal critical organs nor a significant difference in metabolism or growth parameters were detected between IUBAV and control kids. CONCLUSIONS Ultrasound-guided IUBAV intervention induced a strong but transient stress response in the operated fetus, which did not result in irreversible histological changes in the fetus or the mother, but may disrupt the continuation of normal gestation in the long term. Preterm delivery is the major risk in this goat IUBAV model.
Collapse
Affiliation(s)
- Yimin Hua
- Department of Pediatric Cardiology, West China Second University Hospital, and West China Medical School, Sichuan University, Chengdu, China.
| | | | | | | | | | | | | | | |
Collapse
|
9
|
Hering R, Hoeft A, Putensen C, Tchatcheva K, Stressig R, Gembruch U, Kohl T. Maternal haemodynamics and lung water content during percutaneous fetoscopic interventions under general anaesthesia. Br J Anaesth 2009; 102:523-7. [DOI: 10.1093/bja/aep016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
10
|
|
11
|
Schmidt D, Mol A, Odermatt B, Neuenschwander S, Breymann C, Gössi M, Genoni M, Zund G, Hoerstrup SP. Engineering of Biologically Active Living Heart Valve Leaflets Using Human Umbilical Cord–Derived Progenitor Cells. ACTA ACUST UNITED AC 2006; 12:3223-32. [PMID: 17518636 DOI: 10.1089/ten.2006.12.3223] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This study demonstrates the engineering of biologically active heart valve leaflets using prenatally available human umbilical cord-derived progenitor cells as the only cell source. Wharton's Jelly-derived cells and umbilical cord blood-derived endothelial progenitor cells were subsequently seeded on biodegradable scaffolds and cultured in a biomimetic system under biochemical or mechanical stimulation or both. Depending on the stimulation, leaflets showed mature layered tissue formation with functional endothelia and extracellular matrix production comparable with that of native tissues. This demonstrates the feasibility of heart valve leaflet fabrication from prenatal umbilical cord-derived progenitor cells as a further step in overcoming the lack of living autologous replacements with growth and regeneration potential for the repair of congenital malformation.
Collapse
Affiliation(s)
- Dörthe Schmidt
- Department of Surgical Research and Clinic for Cardiovascular Surgery, University Hospital and University of Zurich, Zurich, Switzerland
| | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Wilkins-Haug LE, Tworetzky W, Benson CB, Marshall AC, Jennings RW, Lock JE. Factors affecting technical success of fetal aortic valve dilation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2006; 28:47-52. [PMID: 16795115 DOI: 10.1002/uog.2732] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
OBJECTIVE We have reported previously that valve dilation enhances growth of cardiac structures and may prevent hypoplastic left heart syndrome (HLHS) in fetuses with critical aortic stenosis. We aimed to investigate maternal/fetal factors which may affect the technical success of fetal valvuloplasty, and to describe perinatal complications of the procedure. METHODS This was a descriptive series of 22 fetuses diagnosed with critical aortic stenosis developing into HLHS which underwent intervention by valvuloplasty. Initially this was attempted using a percutaneous approach; reassessment after our first five attempts, only one of which was successful, led to the introduction of the option of laparotomy. Technical success was defined as balloon inflation across the aortic annulus and a broader jet through the aortic valve as assessed by Doppler. Data collected included body mass index, demographic variables, ultrasound findings and postprocedure interventions. RESULTS Technical success increased significantly if maternal laparotomy was an option (83.3% vs. 20.0%, P = 0.017). Laparotomy was performed in 66.6% (12/18) of cases. There was a learning curve that showed an increase in success rate and decrease in need for laparotomy over the 3-year study period. Neither the need for laparotomy nor the chances of technical success were predictable by gestational age, body mass index or placental location. Tocolysis was limited to perioperative prophylaxis; one woman experienced wound infection and fluid overload. Postoperatively, three fetuses died and two delivered prematurely, 2 and 7 weeks after intervention. CONCLUSION Fetal aortic valvuloplasty can be performed with technical success, with low fetal loss rate and few maternal complications. While the need for laparotomy cannot be predicted, having it available as an option improves the technical success rate.
Collapse
Affiliation(s)
- L E Wilkins-Haug
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Boston, MA 02115, USA.
| | | | | | | | | | | |
Collapse
|
13
|
Kohl T, Hering R, Van de Vondel P, Tchatcheva K, Berg C, Bartmann P, Heep A, Franz A, Müller A, Gembruch U. Analysis of the stepwise clinical introduction of experimental percutaneous fetoscopic surgical techniques for upcoming minimally invasive fetal cardiac interventions. Surg Endosc 2006; 20:1134-43. [PMID: 16763924 DOI: 10.1007/s00464-005-0662-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2005] [Accepted: 01/28/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study assessed the feasibility and safety of surgical techniques developed in sheep for fetoscopic fetal cardiac interventions during three selected less complex procedures for noncardiac fetal conditions in humans. On the basis of this assessment, the implications for the clinical introduction of minimally invasive fetoscopic fetal cardiac interventions in the near future are discussed. METHODS The authors performed 16 percutaneous fetoscopic procedures in 13 human fetuses at between 19 + 2 and 34 + 6 weeks of gestation, then analyzed various parameters of surgical relevance for minimally invasive fetoscopic fetal cardiac interventions. Each of the three noncardiac malformations posed typical surgical challenges that will be critical for the technical success of minimally invasive fetoscopic cardiac interventions. RESULTS Overall technical success was achieved in 14 of the 16 procedures. Percutaneous fetoscopic surgery did not result in any untoward effects and was well tolerated by all but two pregnant women: one with bleeding complication and one with mild postoperative pulmonary edema. No fetal complications or injuries from the various percutaneous fetoscopic surgical approaches were observed. CONCLUSIONS The author's experience with surgical techniques introduced for percutaneous fetoscopic fetal cardiac intervention in selected noncardiac fetal lesions has led them to believe the time has come for the clinical introduction of fetoscopic fetal cardiac interventions. After an adequate learning curve supervised by committees of human research, the overall outcome and quality of postnatal life for the unborn patients ultimately will determine whether fetoscopic or other fetal cardiac interventions will be better therapeutic alternatives to currently available postnatal procedures.
Collapse
Affiliation(s)
- T Kohl
- German Center for Fetal Surgery and Minimally Invasive Therapy, Department of Obstetrics & Prenatal Medicine, University of Bonn Medical School, 53105, Bonn, Germany.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Wilkins-Haug LE, Benson CB, Tworetzky W, Marshall AC, Jennings RW, Lock JE. In-utero intervention for hypoplastic left heart syndrome--a perinatologist's perspective. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2005; 26:481-6. [PMID: 16184508 DOI: 10.1002/uog.2595] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
|
15
|
Abstract
This article focuses on the current status of in utero catheter interventions for congenital heart disease. The discussion of fetal interventions for cardiac defects briefly reviews the evolution of approaches to congenital heart disease and issues surrounding the prenatal detection of cardiac defects, the rationale for fetal intervention, and optional candidates for the procedures. Finally, the technical aspects and procedural considerations are reviewed.
Collapse
Affiliation(s)
- Wayne Tworetzky
- Department of Pediatrics, Children's Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
| | | |
Collapse
|
16
|
Kohl T, Reckers J, Strümper D, Grosse Hartlage M, Gogarten W, Gembruch U, Vogt J, Van Aken H, Scheld HH, Paulus W, Rickert CH. Amniotic air insufflation during minimally invasive fetoscopic fetal cardiac interventions is safe for the fetal brain in sheep. J Thorac Cardiovasc Surg 2004; 128:467-71. [PMID: 15354110 DOI: 10.1016/j.jtcvs.2004.01.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Amniotic air insufflation during experimental fetoscopic fetal cardiac interventions greatly improves the visualization of intra-amniotic contents. The purpose of this study was to assess any histologically discernible effects from this approach on the fetal brain after short-term studies and long-term survival in sheep. METHODS Thirty pregnant ewes between 80 and 110 days of gestation underwent amniotic air insufflation during various fetoscopic fetal cardiac interventions. After 18 short-term and 12 long-term studies, the brains of the operated fetuses and-if available-their unoperated siblings were examined for hemorrhage, embolism, infarctions, inflammatory changes, and abnormal cortical maturation. RESULTS Amniotic air insufflation during minimally invasive fetoscopic fetal cardiac interventions did not result in any histologically discernible damage to the brain in short-term and long-term studies in any but 2 sibling sheep. In the 2 affected siblings, a small area of chronic cortical frontal lobe infarction was observed after long-term survival. CONCLUSIONS Amniotic air insufflation during minimally invasive percutaneous fetoscopic fetal cardiac interventions is safe for the fetal brain and does not compromise maternal hemodynamics in sheep. These findings encourage further investigation of the role this technique might play during fetoscopic fetal cardiac interventions in humans.
Collapse
Affiliation(s)
- Thomas Kohl
- Division of Obstetrics & Prenatal Medicine, University Hospital of Bonn, Bonn, Germany.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Abstract
PURPOSE OF REVIEW Since the early 1990s, advances in endoscopic equipment and the commercial availability of micro-catheters, mini-balloons, tiny laser fibers and other ingenious tools have set the trend toward the development of minimally invasive fetoscopic surgical techniques for the treatment of some congenital malformations that progress in severity over the course of gestation and may destroy entire organ systems of the unborn. The purpose of this review is to provide a state-of-the-art overview of these new procedures for the anesthesiologist. RECENT FINDINGS Procedures like diagnostic fetoscopies, laser coagulation of inter-twin placental vascular connections in twin-twin transfusion syndrome, fetal tracheal balloon occlusion in diaphragmatic hernia, laser perforation of posterior urethral valves, vocal cord division in congenital high-airway obstruction syndrome and most recently even coverage of spina bifida aperta can be performed entirely percutaneously using minimally invasive fetoscopic techniques. Careful selection of anesthetic methods and intensive maternal monitoring by the anesthesiology team are paramount to the success of these procedures, particularly in hemodynamically unstable fetuses or procedures that employ gas insufflation of the amniotic cavity. SUMMARY An increasing spectrum of congenital malformations can be treated by fetoscopic surgery. Compared to open fetal surgery, fetoscopic surgery results in significantly less maternal trauma. Like the open procedures, the efficacy of the fetoscopic procedures to improve fetal outcome over postnatal treatment strategies will have to be assessed in further studies under close supervision of committees for human research.
Collapse
Affiliation(s)
- Thomas Kohl
- German Center for Fetal Surgery and Minimally-Invasive Therapy, Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany.
| |
Collapse
|
18
|
Abstract
Rapid advances in graphics computing and micro-engineering have offered new techniques for prenatal cardiac imaging. Some of them can be non-invasively applied to both clinical and laboratory settings, including dynamic three-dimensional echocardiography, myocardial Doppler imaging, harmonic ultrasound imaging, and B-flow sonography. With clinical constraints, a few others have been mainly used in laboratories, such as endoscopic ultrasound, magnetic resonance imaging and biomicroscopy. Appropriate use and co-use of these new tools will not only provide unique information for better clinical assessment of fetal cardiac disease but also offer new ways to improved understanding of cardiovascular development and pathogenesis.
Collapse
Affiliation(s)
- Jing Deng
- Department of Medical Physics and Bioengineering, University College London, UK.
| | | |
Collapse
|
19
|
Abstract
Fetal cardiac interventions are relatively new and promising therapeutic options for modifying CHD in utero. Techniques for safe access to the fetus must be improved and patient selection criteria must be developed. Most important is early detection and referral of all patients who have CHD, enabling improved outcomes for infants. Finally, it should be stressed that performing successful fetal cardiac interventions requires multidisciplinary collaboration between perinatologists, cardiologists, fetal surgeons, and anesthesiologists. Each discipline has specific skills for providing safe access to the fetus, performing the procedure, and providing perioperative care.
Collapse
Affiliation(s)
- Wayne Tworetzky
- Department of Cardiology, Children's Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
| | | |
Collapse
|
20
|
Meyer-Wittkopf M. Interventional fetal cardiac therapy -- possible perspectives and current shortcomings. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2002; 20:527-531. [PMID: 12493038 DOI: 10.1046/j.1469-0705.2002.00858.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
|
21
|
Kohl T, Hartlage MG, Westphal M, Kienitz D, Aryee S, Achenbach S, Buller T, Kossobutzki C, Gogarten W, Vogt J, Scheld HH, Van Aken H, Gembruch U. Intra-amniotic multimodal fetal echocardiography in sheep: a novel imaging approach during fetoscopic interventions and for assessment of high-risk pregnancies in which conventional imaging methods fail. ULTRASOUND IN MEDICINE & BIOLOGY 2002; 28:731-736. [PMID: 12113785 DOI: 10.1016/s0301-5629(02)00521-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
During fetoscopic interventions, intraesophageal placement of intravascular ultrasound (US) catheters for fetal hemodynamic monitoring may result in esophageal injury in very small fetuses. Moreover, conventional fetal imaging by the transvaginal or transabdominal routes may be impossible in some high-risk pregnancies. The purpose of our study in sheep was to assess the potential of a phased-array intravascular US catheter for intra-amniotic fetal echocardiography. The catheter was percutaneously inserted into the amniotic cavity in seven pregnant ewes at between 78 to 98 days of gestation and permitted high-quality 2-D imaging of the fetal heart and multimodal Doppler assessment of fetal cardiovascular flows. Fetoscopic examination of intra-amniotic contents after intra-amniotic imaging was finished did not display any injury to intra-amniotic contents. The intra-amniotic imaging approach may provide an effective alternative in humans for monitoring during fetoscopic interventions, and to assess fetal anatomy and hemodynamics in high-risk pregnancies when sufficient images cannot be obtained by conventional routes.
Collapse
Affiliation(s)
- Thomas Kohl
- Department of Obstetrics & Prenatal Medicine, University of Bonn, Bonn, Germany.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Gardiner HM. Fetal echocardiography: 20 years of progress. HEART (BRITISH CARDIAC SOCIETY) 2001. [PMID: 11709530 DOI: 10.1136/heart.86] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- H M Gardiner
- Division of Paediatrics, Faculty of Medicine, Imperial College School of Science, Royal Brompton and Harefield Hospital, London SW3 6NP, UK.
| |
Collapse
|
23
|
Affiliation(s)
- H M Gardiner
- Division of Paediatrics, Faculty of Medicine, Imperial College School of Science, Royal Brompton and Harefield Hospital, London SW3 6NP, UK.
| |
Collapse
|
24
|
|
25
|
Pulmonary atresia with intact ventricular septum (PA/IVS): diagnostic and interventional cardiac catheterization in the neonate. PROGRESS IN PEDIATRIC CARDIOLOGY 2001. [DOI: 10.1016/s1058-9813(01)00104-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
26
|
Abstract
A systematic approach to examination of the fetal heart will enhance the detection of structural cardiac abnormalities and will enable an accurate diagnosis of congenital heart disease to be made. Once an abnormality has been detected appropriate counselling must be provided and adequate support given to the parents. Associated extracardiac abnormalities should be sought for, and plans for the remainder of pregnancy, delivery and postnatal management should be made using a team approach. In cases resulting in termination of pregnancy, permission for autopsy should be sought to confirm the ultrasound diagnosis. Although in-utero therapy is available for some forms of fetal arrhythmia and a few limited cases of structural heart disease, this should be conducted in tertiary centres.
Collapse
Affiliation(s)
- G Sharland
- Department of Congenital Heart Disease, Fetal Cardiology, 15th Floor Guy's Tower, Guy's Hospital, St. Thomas Street, London SE1 9RT, UK
| |
Collapse
|
27
|
Abstract
Pediatric cardiac intensive care has emerged as a distinct clinical entity to meet the unique needs of pediatric patients with congenital and acquired heart disease. This new subspecialty demands expertise and experience in the pediatric subspecialties of cardiology, intensive care, cardiac surgery, cardiac anesthesia, neonatology, and others. Ten recent developments will have an impact on pediatric cardiac intensive care for the coming decades: 1) emergence of new patient populations; 2) new clinical methodologies in the treatment of pulmonary hypertension; 3) innovations in techniques of respiratory support; 4) expanding research of single ventricle physiology; 5) advances in the treatment of heart failure; 6) improved noninvasive imaging; 7) new directions in interventional cardiac catheterization; 8) new techniques in pediatric cardiac surgery; 9) use of computer technology and intensive care monitoring; and 10) appreciation for global economics of intensive care. Finally, a multidisciplinary approach with a team esprit de corps remains vital to a successful pediatric cardiac intensive care program.
Collapse
Affiliation(s)
- A C Chang
- Pediatric Cardiac Intensive Care Program, Miami Children's Hospital, Florida 33155-4069, USA.
| |
Collapse
|
28
|
Kohl T, Sharland G, Allan LD, Gembruch U, Chaoui R, Lopes LM, Zielinsky P, Huhta J, Silverman NH. World experience of percutaneous ultrasound-guided balloon valvuloplasty in human fetuses with severe aortic valve obstruction. Am J Cardiol 2000; 85:1230-3. [PMID: 10802006 DOI: 10.1016/s0002-9149(00)00733-5] [Citation(s) in RCA: 212] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Prenatal alleviation of severe fetal aortic valve obstructions by percutaneous ultrasound-guided balloon valvuloplasty has been performed to improve the fate of affected fetuses. The purpose of this study was to analyze the current world experience of these procedures in human fetuses. Data from 12 human fetuses were available for analysis. The mean gestational age at intervention was 29.2 weeks (range 27 to 33). The mean time period between initial presentation and intervention was 3.3 weeks (range 3 days to 9 weeks). Technically successful balloon valvuloplasties were achieved in 7 fetuses, none of whom had an atretic valve. Only 1 of these fetuses remains alive today. Of the 5 remaining technical failures, 1 patient with severe aortic stenosis underwent successful postnatal intervention and remains alive. Six patients who survived prenatal intervention died from cardiac dysfunction or at surgery in the first days or weeks after delivery. Four fetuses died early within 24 hours after the procedure, 1 from a bleeding complication, 2 from persistent bradycardias, and 1 at valvotomy after emergency delivery. Thus, the early clinical experience of percutaneous ultrasound-guided fetal balloon valvuloplasty in human fetuses with severe aortic valve obstruction has been poor due to selection of severe cases, technical problems during the procedure, and high postnatal operative mortality in fetuses who survived gestation. Improved patient selection and technical modifications in interventional methods may hold promise to improve outcome in future cases.
Collapse
Affiliation(s)
- T Kohl
- Division of Pediatric Cardiology, University of Münster Medical School, Germany.
| | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Kohl T, Suda K, Reckers J, Scheld HH, Vogt J, Silverman NH. Fetal transesophageal echocardiography utilizing a 10-F, 10-MHz intravascular ultrasound catheter--comparison with conventional maternal transabdominal fetal echocardiography in sheep. ULTRASOUND IN MEDICINE & BIOLOGY 1999; 25:939-946. [PMID: 10461722 DOI: 10.1016/s0301-5629(99)00037-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
The purpose of our study in fetal sheep was to assess the measurement agreement between fetal transesophageal echocardiography (FTEE) and conventional maternal transabdominal echocardiography (CMTFE) by the Bland-Altman method. We performed our study in 11 fetal sheep between 95-103 days of gestation (term = 145 days). FTEE was performed by imaging the fetal heart in horizontal planes utilizing a 10-F, 10-MHz intravascular ultrasound catheter. CMTFE was carried out using a 5.0-MHz phased-array transducer replicating the FTEE imaging planes. We found close agreement between FTEE and CMTFE measurements of great vessel and cardiac valvar dimensions. Conversely, the variability between both techniques for measuring ventricular dimensions was inadequate. We conclude that FTEE permits measurement of great vessel and cardiac valve dimensions with high agreement with CMTFE measurements. This finding strengthens the applicability of FTEE as a monitoring tool during experimental open or fetoscopic fetal cardiac interventions.
Collapse
Affiliation(s)
- T Kohl
- Division of Pediatric Cardiology, University of California, San Francisco, USA.
| | | | | | | | | | | |
Collapse
|
30
|
Maeno YV, Boutin C, Hornberger LK, McCrindle BW, Cavallé-Garrido T, Gladman G, Smallhorn JF. Prenatal diagnosis of right ventricular outflow tract obstruction with intact ventricular septum, and detection of ventriculocoronary connections. Heart 1999; 81:661-8. [PMID: 10336930 PMCID: PMC1729057 DOI: 10.1136/hrt.81.6.661] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To determine the accuracy of prenatal diagnosis of pulmonary atresia and intact ventricular septum (PAIVS), and pulmonary stenosis, including prenatal detection of ventriculocoronary connections, to evaluate heart size during the prenatal period, and to evaluate the outcome. DESIGN AND PATIENTS Medical records of 20 cases with prenatally diagnosed PAIVS and pulmonary stenosis were reviewed retrospectively. Prenatal and postnatal echocardiography were also reviewed and dimensions of the ventricles and vessels were measured retrespectively. RESULTS Of 20 prenatal diagnoses (15 PAIVS and five pulmonary stenosis), 16 were confirmed as correct. One critical pulmonary stenosis case had been diagnosed as PAIVS prenatally; three had no confirmation. Eight pregnancies were terminated, three had no active treatment, and nine were treated; all survived. Of 13 assessed with ventriculocoronary connections prenatally, seven were diagnosed correctly (four with, three without ventriculocoronary connections), but one was falsely positive; five had no confirmation. The more prominent hypoplasia of the main pulmonary artery and the tricuspid valve annulus, and the sigmoid shape of the ductus arteriosus, seemed to be associated with the presence of ventriculocoronary connections. CONCLUSIONS Current prenatal echocardiography can accurately diagnose right ventricular outflow tract obstruction and ventriculocoronary connections. Prenatal detection of this constellation of abnormalities aids in family counselling and decisions on postnatal management.
Collapse
Affiliation(s)
- Y V Maeno
- Fetal Treatment Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | |
Collapse
|
31
|
Abstract
Pulmonary atresia with intact ventricular septum (PA/IVS) is a spectrum of diseases with varying severity of right ventricle hypoplasia and potential for biventricular, univentricular, or hybrid repairs. Pessimistic outcome measures for PA/IVS may give way to optimism with the refinement of early diagnosis and early intervention to encourage right ventricle flow and optimize growth. To this end, PA/IVS has become a focus of innovative interventions (e.g., fetal surgery) and new catheter-based and surgical techniques.
Collapse
Affiliation(s)
- D P Bichell
- Department of Cardiovascular Surgery, Children's Hospital, Boston, MA 02115, USA
| |
Collapse
|