title: Creation of an atrial septal defect in utero for fetuses with hypoplastic left heart syndrome and intact or highly restrictive atrial septum.
abstract: BACKGROUND
  Infants born with hypoplastic left heart syndrome and an intact or highly restrictive atrial septum face a neonatal mortality of at least 48% despite early postnatal left atrial decompression and palliative surgery. Prenatal left atrial decompression has been suggested as a means of improving these outcomes. This study reports the feasibility of fetal catheterization to create an interatrial communication and describes technical considerations.
  
  
  RESULTS
  Seven fetuses at 26 to 34 weeks' gestation with hypoplastic left heart syndrome and intact or highly restrictive atrial septum underwent attempted prenatal intervention. Under ultrasound guidance, the atrial septum was approached with a needle introduced percutaneously from the maternal abdominal surface. In 6 of 7 fetuses, the atrial septum was successfully perforated, with balloon dilation of this iatrogenic defect resulting in a small but persistent interatrial communication. There were no maternal complications. One fetus died after the procedure. The remaining fetuses were liveborn at term, although 4 died as neonates.
  
  
  CONCLUSIONS
  Ultrasound-guided fetal atrial septoplasty consisting of septal puncture and balloon dilation is feasible and can be performed percutaneously to minimize maternal risk. Although we have not demonstrated any positive clinical impact to date, it is our hope that further technical evolution will ultimately enable prenatal left atrial decompression and improvement of outcomes in fetuses with hypoplastic left heart syndrome and intact atrial septum.
authors.affiliation: Department of Cardiology, Children's Hospital and Pediatrics, Harvard Medical School, 300 Longwood Ave, Boston, Mass 02115, USA. Audrey.marshall@cardio.chboston.org
authors.forename: Audrey C
authors.initials: AC
authors.lastname: Marshall
authors.forename: Mary E
authors.initials: ME
authors.lastname: van der Velde
authors.forename: Wayne
authors.initials: W
authors.lastname: Tworetzky
authors.forename: Carlen A
authors.initials: CA
authors.lastname: Gomez
authors.forename: Louise
authors.initials: L
authors.lastname: Wilkins-Haug
authors.forename: Carol B
authors.initials: CB
authors.lastname: Benson
authors.forename: Russell W
authors.initials: RW
authors.lastname: Jennings
authors.forename: James E
authors.initials: JE
authors.lastname: Lock
mesh_terms: D006328:Cardiac Catheterization / Q000295:instrumentation; D005260:Female; D005318:Fetal Heart / Q000000981:diagnostic imaging; D006344:Heart Septal Defects, Atrial / Q000000981:diagnostic imaging / Q000628:therapy*; D006801:Humans; D018636:Hypoplastic Left Heart Syndrome / Q000000981:diagnostic imaging / Q000628:therapy*; D011247:Pregnancy; D016216:Ultrasonography, Prenatal