Aortic valvuloplasty in the fetus: Technical characteristics of successful balloon dilation

ArticleinJournal of Pediatrics 147(4):535-9 · November 2005with24 Reads
DOI: 10.1016/j.jpeds.2005.04.055 · Source: PubMed
Abstract
To describe technical aspects of successful fetal aortic valvuloplasty, with particular attention to balloon size. We retrospectively reviewed all procedural records and echocardiograms pertaining to 26 attempts at fetal aortic valve dilation performed at a single center over a period of 4 years. We assessed the effect of valvuloplasty as determined by echocardiographic appearance at the time of intervention and in follow-up. In 20 of 26 fetuses who had technically successful aortic valve dilation (median balloon:annulus ratio=1.1), all had improved antegrade flow and 12 had at least mild regurgitation after dilation. Use of an oversized balloon was associated with the onset of moderate or severe aortic regurgitation, seen in 5 fetuses. This aortic regurgitation was well tolerated and improved through the remainder of gestation. These data imply that fetal aortic valves can be dilated safely with larger balloons than are commonly used for postnatal dilation. The observation of spontaneous improvement in postdilation aortic regurgitation further suggests that fetal valve tissue behaves uniquely.
    • Patients at our institution who underwent technically successful FAV for evolving HLHS with a BiV circulation at most recent follow-up and age C1 year were included. Technical aspects, selection criteria, and clinical outcomes after FAV have been previously published [12, 13, 16, 20, 23]. The current investigation evaluates the same cohort of patients as a recent review of clinical outcomes after FAV [23], but focuses exclusively on LV characteristics in this cohort.
    [Show abstract] [Hide abstract] 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.
    Article · May 2015
    • The valvoplasty is performed with a small coronary artery balloon over a thin, floppy guide wire. The balloon is inflated and the procedure is considered successful if there is clear evidence of increased anterograde flow across the valve and/or new aortic regurgitation by color-Doppler (Marshall et al., 2005; McElhinney et al., 2009; WilkinsHaug et al., 2006). Complications of valvoplasty in the fetus include bradycardia (50% upon needle access to the ventricle), pericardial effusion, significant iatrogenic aortic regurgitation and fetal demise.
    File · Data · Nov 2012 · Catheterization and Cardiovascular Interventions
    • The discovery of abnormal brain microstructure and metabolism shortly after birth in newborns with congenital heart disease is consistent with mounting evidence that these newborns have impaired brain development in utero, possibly related to impaired cerebral oxygen and substrate delivery prenatally.[2223] Information regarding brain maturation may be important in considering when to perform these interventions.[24]
    [Show abstract] [Hide abstract] ABSTRACT: To assess brain development and brain injury in neonates with cyanotic and acyanotic congenital heart disease (CHD). 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). 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). Newborn infants with cyanotic and acyanotic CHD are at high risk of brain injury and impaired brain maturity.
    Article · Mar 2012
    • Based on the published methods for human fetal cardiac intervention [4] [5] [6] [7] [8] and personal experience, we selected needles, wires, and catheters currently in use in the human fetus. A standard thin-walled Cook 19-gauge intravascular needle (DTN-19UT-11.5-M3,
    [Show abstract] [Hide abstract] 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.
    Full-text · Article · Mar 2010
    • The authors state that ''while cardiac catheterization by direct ventricular puncture has been described over 50 years ago, this is the first report regarding its utility for interventional procedures.'' Direct ventricular puncture has already been successfully used for aortic and pulmonary fetal valvuloplasty [2][3][4][5]. This route has also been employed for catheter-based aortic valve replacement [6,7].
    [Show abstract] [Hide abstract] ABSTRACT: No abstract is available for this article.
    Article · Jun 2009
    • The authors state that ''while cardiac catheterization by direct ventricular puncture has been described over 50 years ago, this is the first report regarding its utility for interventional procedures.'' Direct ventricular puncture has already been successfully used for aortic and pulmonary fetal valvuloplasty [2][3][4][5]. This route has also been employed for catheter-based aortic valve replacement [6,7].
    [Show abstract] [Hide abstract] ABSTRACT: No abstract is available for this article.
    Article · Jun 2009
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