title: Transhepatic ultrasound-guided cardiac catheterization in the fetal lamb: a new approach for cardiac interventions in fetuses.
abstract: BACKGROUND
  Percutaneous transventricular and fetoscopic umbilical catheterization have been applied to animal and human fetuses. These methods have a high rate of failure and complications. Here, we propose an alternative route for anterograde echocardiography-guided cardiac catheterization through a transhepatic approach of the intra-abdominal vessels in the fetal lamb.
  
  
  RESULTS
  After exteriorization of the uterus in 12 pregnant ewes between 118 to 122 days' gestation, a 4F sheath mounted over a 1.2-mm needle was placed into the intra-abdominal portion of the umbilical vein (n=2) and into the subdiaphragmatic portion of the inferior vena cava via a transhepatic approach (n=10) under ultrasound guidance. In the first 2 animals using a transumbilical approach, it was impossible to reach the heart through the ductus venosus. In the next 10 animals, using a conventional technique, echocardiography-guided catheterization of the 4 chambers was performed in the all fetuses, atrial or ventricular pacing in 6 fetuses, and ballooning of the pulmonary valve in 9 of 10 fetuses. Among the 10 fetuses catheterized through the transhepatic approach, 2 were euthanized immediately after the procedure to evaluate intraperitoneal bleeding (23 and 29 mL, respectively), and 3 died after the procedure (1 of major bleeding and 2 deaths related to balloon catheter manipulation). Finally, 5 were delivered vaginally after an uneventful pregnancy, and autopsy at day 5 did not show significant liver, vascular, or cardiac injury.
  
  
  CONCLUSIONS
  Echocardiography-guided fetal cardiac catheterization through a transhepatic approach is feasible and provides an interesting alternative approach for human fetal cardiac interventions.
authors.affiliation: Service de Gynécologie-Obstétrique, Hôpital Rothschild, Assistance Publique Hôpitaux de Paris, Paris, France.
authors.forename: Jean-Marie
authors.initials: JM
authors.lastname: Jouannic
authors.forename: Younes
authors.initials: Y
authors.lastname: Boudjemline
authors.forename: Jean-Louis
authors.initials: JL
authors.lastname: Benifla
authors.forename: Damien
authors.initials: D
authors.lastname: Bonnet
mesh_terms: D000818:Animals; D016063:Blood Loss, Surgical; D006328:Cardiac Catheterization / Q000379:methods*; D004452:Echocardiography / Q000379:methods; D005260:Female; D005313:Fetal Death / Q000209:etiology; D005318:Fetal Heart / Q000473:pathology*; D006330:Heart Defects, Congenital / Q000473:pathology; D007431:Intraoperative Complications; D008099:Liver / Q000000981:diagnostic imaging*; D011183:Postoperative Complications; D011247:Pregnancy; D012756:Sheep; D014471:Umbilical Veins / Q000601:surgery; D014682:Vena Cava, Inferior / Q000601:surgery