title: Percutaneous fetal cardiac catheterization technique for stenting the foramen ovale in a midgestation lamb model.
abstract: BACKGROUND
  Intact or highly restricted intra-atrial septum can be reliably diagnosed in the human fetus as early as 22 to 24 weeks of gestation. Fetal interventions targeting the atrial septum have used a direct approach through the atrial wall. Here, we report stenting of the foramen ovale with a large, open-cell stent via percutaneous access through the fetal hepatic vein in a sheep model.
  
  
  RESULTS
  In 5 fetal sheep of 109 to 111 days of gestation (term, 147 days), the fetal hepatic vein was punctured percutaneously under ultrasound guidance and a 13.3-cm 14-gauge intravenous catheter was inserted. After catheterization of the inferior vena cava, right atrium, foramen ovale, and left atrium with a guidewire and 1.8F to 2.6F tapered catheter, a self-expandable, 8×12-mm flexible open-cell stent was positioned in an unrestricted foramen ovale. Flow and fetal well-being were documented for 45 minutes after the procedure. Access to the left atrium was achieved in all 5 animals and all survived. In 4 animals, the stent was successfully positioned in the foramen ovale. One fetus was born at term and euthanized on day 3: postmortem examination confirmed the patency of the stent. The other 3 fetuses were well after being monitored by ultrasound for 45 minutes. In 1 animal, the stent dislodged immediately after release obstructing the mitral valve. This fetus developed ascites and was euthanized after 4 days.
  
  
  CONCLUSIONS
  It is feasible to safely advance a large diameter, self-expandable, open-cell design stent into the fetal atrial septum via a percutaneous access route through the fetal hepatic vein.
authors.affiliation: From The Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash University, Melbourne, Victoria, Australia (A.E., A.V., I.N., N.B., S.M., F.Y.W.); Perinatal Services (A.E., M.T., S.M.), Fetal Cardiac Unit (A.E., M.T., S.M.), Department of Pathology (Y.C.), and Monash Newborn (F.Y.W.), Monash Medical Centre, Melbourne, Victoria, Australia; Department of Paediatrics, Monash University, Melbourne, Victoria, Australia (A.V., F.Y.W.); and Pediatric Heart Center, Justus-Liebig University, Giessen, Germany (A.V., D.S.).
authors.forename: Andrew
authors.initials: A
authors.lastname: Edwards
authors.affiliation: From The Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash University, Melbourne, Victoria, Australia (A.E., A.V., I.N., N.B., S.M., F.Y.W.); Perinatal Services (A.E., M.T., S.M.), Fetal Cardiac Unit (A.E., M.T., S.M.), Department of Pathology (Y.C.), and Monash Newborn (F.Y.W.), Monash Medical Centre, Melbourne, Victoria, Australia; Department of Paediatrics, Monash University, Melbourne, Victoria, Australia (A.V., F.Y.W.); and Pediatric Heart Center, Justus-Liebig University, Giessen, Germany (A.V., D.S.).
authors.forename: Alex
authors.initials: A
authors.lastname: Veldman
authors.affiliation: From The Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash University, Melbourne, Victoria, Australia (A.E., A.V., I.N., N.B., S.M., F.Y.W.); Perinatal Services (A.E., M.T., S.M.), Fetal Cardiac Unit (A.E., M.T., S.M.), Department of Pathology (Y.C.), and Monash Newborn (F.Y.W.), Monash Medical Centre, Melbourne, Victoria, Australia; Department of Paediatrics, Monash University, Melbourne, Victoria, Australia (A.V., F.Y.W.); and Pediatric Heart Center, Justus-Liebig University, Giessen, Germany (A.V., D.S.).
authors.forename: Ilias
authors.initials: I
authors.lastname: Nitsos
authors.affiliation: From The Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash University, Melbourne, Victoria, Australia (A.E., A.V., I.N., N.B., S.M., F.Y.W.); Perinatal Services (A.E., M.T., S.M.), Fetal Cardiac Unit (A.E., M.T., S.M.), Department of Pathology (Y.C.), and Monash Newborn (F.Y.W.), Monash Medical Centre, Melbourne, Victoria, Australia; Department of Paediatrics, Monash University, Melbourne, Victoria, Australia (A.V., F.Y.W.); and Pediatric Heart Center, Justus-Liebig University, Giessen, Germany (A.V., D.S.).
authors.forename: Yuen
authors.initials: Y
authors.lastname: Chan
authors.affiliation: From The Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash University, Melbourne, Victoria, Australia (A.E., A.V., I.N., N.B., S.M., F.Y.W.); Perinatal Services (A.E., M.T., S.M.), Fetal Cardiac Unit (A.E., M.T., S.M.), Department of Pathology (Y.C.), and Monash Newborn (F.Y.W.), Monash Medical Centre, Melbourne, Victoria, Australia; Department of Paediatrics, Monash University, Melbourne, Victoria, Australia (A.V., F.Y.W.); and Pediatric Heart Center, Justus-Liebig University, Giessen, Germany (A.V., D.S.).
authors.forename: Nadine
authors.initials: N
authors.lastname: Brew
authors.affiliation: From The Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash University, Melbourne, Victoria, Australia (A.E., A.V., I.N., N.B., S.M., F.Y.W.); Perinatal Services (A.E., M.T., S.M.), Fetal Cardiac Unit (A.E., M.T., S.M.), Department of Pathology (Y.C.), and Monash Newborn (F.Y.W.), Monash Medical Centre, Melbourne, Victoria, Australia; Department of Paediatrics, Monash University, Melbourne, Victoria, Australia (A.V., F.Y.W.); and Pediatric Heart Center, Justus-Liebig University, Giessen, Germany (A.V., D.S.).
authors.forename: Mark
authors.initials: M
authors.lastname: Teoh
authors.affiliation: From The Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash University, Melbourne, Victoria, Australia (A.E., A.V., I.N., N.B., S.M., F.Y.W.); Perinatal Services (A.E., M.T., S.M.), Fetal Cardiac Unit (A.E., M.T., S.M.), Department of Pathology (Y.C.), and Monash Newborn (F.Y.W.), Monash Medical Centre, Melbourne, Victoria, Australia; Department of Paediatrics, Monash University, Melbourne, Victoria, Australia (A.V., F.Y.W.); and Pediatric Heart Center, Justus-Liebig University, Giessen, Germany (A.V., D.S.).
authors.forename: Samuel
authors.initials: S
authors.lastname: Menahem
authors.affiliation: From The Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash University, Melbourne, Victoria, Australia (A.E., A.V., I.N., N.B., S.M., F.Y.W.); Perinatal Services (A.E., M.T., S.M.), Fetal Cardiac Unit (A.E., M.T., S.M.), Department of Pathology (Y.C.), and Monash Newborn (F.Y.W.), Monash Medical Centre, Melbourne, Victoria, Australia; Department of Paediatrics, Monash University, Melbourne, Victoria, Australia (A.V., F.Y.W.); and Pediatric Heart Center, Justus-Liebig University, Giessen, Germany (A.V., D.S.).
authors.forename: Dietmar
authors.initials: D
authors.lastname: Schranz
authors.affiliation: From The Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash University, Melbourne, Victoria, Australia (A.E., A.V., I.N., N.B., S.M., F.Y.W.); Perinatal Services (A.E., M.T., S.M.), Fetal Cardiac Unit (A.E., M.T., S.M.), Department of Pathology (Y.C.), and Monash Newborn (F.Y.W.), Monash Medical Centre, Melbourne, Victoria, Australia; Department of Paediatrics, Monash University, Melbourne, Victoria, Australia (A.V., F.Y.W.); and Pediatric Heart Center, Justus-Liebig University, Giessen, Germany (A.V., D.S.). flora.wong@monash.edu.
authors.forename: Flora Y
authors.initials: FY
authors.lastname: Wong
mesh_terms: D000818:Animals; D006328:Cardiac Catheterization / Q000379:methods*; D005318:Fetal Heart / Q000601:surgery*; D054085:Foramen Ovale / Q000601:surgery*; D018636:Hypoplastic Left Heart Syndrome / Q000601:surgery; D023421:Models, Animal; D012756:Sheep; D015607:Stents
keywords: atrial septum; cardiac catheterization; fetal heart; foramen ovale; hypoplastic left heart syndrome; stent