Changes in left heart hemodynamics after technically successful in-utero aortic valvuloplasty.
OBJECTIVE
Severe aortic stenosis in the mid-gestation fetus can progress to hypoplastic left heart syndrome (HLHS). @ In-utero aortic valvuloplasty is an innovative therapy to promote left ventricular growth and function and potentially to prevent HLHS. This study evaluated the effects of mid-gestation fetal balloon aortic valvuloplasty on subsequent fetal left ventricular function and left heart Doppler characteristics.


METHODS
We reviewed fetuses with aortic stenosis that underwent attempted in-utero aortic valvuloplasty between 2000 and 2006. Pre-intervention and the latest post-intervention fetal echocardiograms were analyzed to characterize changes in left heart function and Doppler characteristics in utero.


RESULTS
Forty-two fetuses underwent attempted aortic valvuloplasty during the study period, 12 of which were excluded from analysis secondary to inadequate follow-up data, termination or fetal demise. Study fetuses (n = 30) underwent pre-intervention echocardiography at a median gestational age of 23 weeks, and were followed for a median of 66 +/- 23 days post-intervention. In 26 fetuses, aortic valvuloplasty was technically successful. Among these 26, left heart physiology was abnormal pre-intervention and improved or normalized after intervention in most cases: biphasic mitral inflow was present in 5/25 (20%) cases pre-intervention and in 21/23 (91%) post-intervention (P < 0.001); moderate or severe mitral regurgitation was present in 14/26 (54%) cases pre-intervention and in 5/23 (22%) post-intervention (P = 0.02); bidirectional flow across the patent foramen ovale was present in 0/26 cases pre-intervention and in 6/25 (24%) post-intervention (P = 0.01); antegrade flow in the transverse arch was present in 0/25 cases pre-intervention and in 17/26 (65%) post-intervention (P < 0.001). The left ventricular ejection fraction increased from 19 +/- 10% pre-intervention to 39 +/- 14% post-intervention (P < 0.001). These changes were not observed in control fetuses (n = 18).


CONCLUSIONS
Fetal aortic valvuloplasty, when technically successful, improves left ventricular systolic function and left heart Doppler characteristics.
Selamet Tierney
E S
ES
Department of Cardiology, Children's Hospital Boston, MA, USA.
Wald
R M
RM
McElhinney
D B
DB
Marshall
A C
AC
Benson
C B
CB
Colan
S D
SD
Marcus
E N
EN
Marx
G R
GR
Levine
J C
JC
Wilkins-Haug
L
L
Lock
J E
JE
Tworetzky
W
W
D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000196:embryology / Q000628:therapy*; D002404:Catheterization / Q000379:methods*; D015150:Echocardiography, Doppler / Q000379:methods; D005260:Female; D006330:Heart Defects, Congenital / Q000000981:diagnostic imaging / Q000503:physiopathology; D006439:Hemodynamics; D006801:Humans; D018636:Hypoplastic Left Heart Syndrome / Q000000981:diagnostic imaging / Q000196:embryology / Q000517:prevention & control*; D011247:Pregnancy; D011256:Pregnancy Outcome; D015203:Reproducibility of Results; D016216:Ultrasonography, Prenatal / Q000379:methods