Balloon Dilation of Severe Aortic Stenosis in the Fetus

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Presentation transcript:

Balloon Dilation of Severe Aortic Stenosis in the Fetus by Wayne Tworetzky, Louise Wilkins-Haug, Russell W. Jennings, Mary E. van der Velde, Audrey C. Marshall, Gerald R. Marx, Steven D. Colan, Carol B. Benson, James E. Lock, and Stanton B. Perry Circulation Volume 110(15):2125-2131 October 12, 2004 Copyright © American Heart Association, Inc. All rights reserved.

Figure 1. Ideal fetal position and cannula course. Figure 1. Ideal fetal position and cannula course. Fetal left chest is anterior, and pathway from maternal abdomen to LV apex is unobstructed. This pathway, which corresponds to cannula course, continues from LV apex to aortic valve. Wayne Tworetzky et al. Circulation. 2004;110:2125-2131 Copyright © American Heart Association, Inc. All rights reserved.

Figure 2. Ultrasound images of technically successful percutaneous in utero aortic valvuloplasty. a, LV before intervention. Figure 2. Ultrasound images of technically successful percutaneous in utero aortic valvuloplasty. a, LV before intervention. Four-chamber view demonstrating echogenic LV, apex-forming RV, and alignment of needle (arrow), LV apex (arrow), aortic valve, and ascending aorta (arrow). b, Cannula in LV. After LV puncture with cannula, LV appears smaller. Cannula can be seen as echo-bright line in LV, with its tip directed at aortic valve (arrow). c, Guidewire across aortic valve in ascending aorta (arrow). d, Balloon across valve. Correct position of balloon across aortic valve is confirmed by external measurements of catheter and by ultrasound imaging. Balloon inflation appears as movement of bright reflection along line of LV outflow track and across level of valve (arrow). Wayne Tworetzky et al. Circulation. 2004;110:2125-2131 Copyright © American Heart Association, Inc. All rights reserved.

Figure 3. LV length at time of diagnosis in 24 fetuses with severe AS that were considered candidates for in utero aortic valvuloplasty. Figure 3. LV length at time of diagnosis in 24 fetuses with severe AS that were considered candidates for in utero aortic valvuloplasty. Twenty fetuses underwent attempted in utero aortic valvuloplasty (LV length was measured in 4-chamber view from mitral valve annulus to LV apex at end diastole). Dotted lines represent 2 SD from normal for LV length in diastole. Hollow triangles represent 3 patients who had biventricular repair after birth. Wayne Tworetzky et al. Circulation. 2004;110:2125-2131 Copyright © American Heart Association, Inc. All rights reserved.

Figure 4. Ratio of LV to RV lengths between time of diagnosis of fetal AS and time of fetal intervention. Figure 4. Ratio of LV to RV lengths between time of diagnosis of fetal AS and time of fetal intervention. Wayne Tworetzky et al. Circulation. 2004;110:2125-2131 Copyright © American Heart Association, Inc. All rights reserved.

Figure 5. A, Change in dimension of left heart structures (mitral and aortic valves and ascending aorta) in fetuses that had technically successful in utero aortic valvuloplasty (gray bars) vs those with unsuccessful procedure and those that declined procedure (white bars). Figure 5. A, Change in dimension of left heart structures (mitral and aortic valves and ascending aorta) in fetuses that had technically successful in utero aortic valvuloplasty (gray bars) vs those with unsuccessful procedure and those that declined procedure (white bars). Only fetuses with pregnancies carried to near-term delivery (>33 weeks’ gestation) were included. Data reflect first and last measurements made during gestation (n=15 for data in this figure; of original 24 patients evaluated, 3 are still in utero, 3 died in utero, 1 was born prematurely, and 2 pregnancies were terminated). B, Change in LV diastolic dimensions (long axis, short axis, and cross-sectional area) of fetuses that had technically successful in utero aortic valvuloplasty (gray bars) compared with those with unsuccessful procedure and those that declined procedure (white bars). Only fetuses with pregnancies carried to near-term delivery (>33 weeks’ gestation) were included. Data reflect first and last measurements made during gestation (n=15 for data in this figure; of original 24 patients evaluated, 3 are still in utero, 3 died in utero, 1 was born prematurely, and 2 pregnancies were terminated). Wayne Tworetzky et al. Circulation. 2004;110:2125-2131 Copyright © American Heart Association, Inc. All rights reserved.

Figure 6. Flow chart showing perinatal outcomes of all 24 patients initially considered candidates for in utero aortic valvuloplasty. Figure 6. Flow chart showing perinatal outcomes of all 24 patients initially considered candidates for in utero aortic valvuloplasty. Wayne Tworetzky et al. Circulation. 2004;110:2125-2131 Copyright © American Heart Association, Inc. All rights reserved.