Fetal aortic valvuloplasty procedures: experience from Hospital Italiano de Buenos Aires
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1 International Fetal Medicine and Surgery Society Sedona, Arizona May 13-18, 2011 Fetal aortic valvuloplasty procedures: experience from Hospital Italiano de Buenos Aires Otaño L 1, Aiello H 1, Peña G 2,, Trentacoste L 2, Granja M 2, Izbizky G 1, Marantz P 1,2 (1)Fetal Medicine Unit, (2) División of Pediatric Cardiolgy, Lucas Otaño Unidad de Medicina Fetal Unidad de Diagnóstico y Tratamiento Fetal
2 Introduction Fetal cardiac interventions are in a clinical experimental phase. The 3 most frequent interventions are: 1. Aortic balloon valvuloplasty for critical aortic stenosis 2. Atrial septostomy for highly restrictive or intact atrial septum in HLHS 3. Pulmonary valvuloplasty for pulmonary atresia and hypoplastic rigth ventricule.
3 Introduction Natural hystory of severe aortic estenosis 22 weeks 33 weeks RV LV RV LV Editorial: In-utero intervention for hypoplastic left heart syndrome a perinatologist s perspective. LE Wilkins-Haug Ultrasound Obstet Gynecol 2005;26:481-6
4 Introduction Fetal aortic valvuloplasty Tworetzky W et al. Circulation 2004;110: US guided Percutaneous Maternal epidural Fetal position Fetal paralysis & analgesisa 19-18G needle in guidewire Valvuloplastic baloon smaller than the aortic annulus
5 Tworetzky W et al. Circulation 2004;110:
6 Introduction Procedure complications Technical failure Severe bradycardia Pericardial effusion Cardiac tamponade Thrombosis LV Rupture of the balloon Missed fragment of balloon Fetal death PPROM & Preterm delivery Maternal respiratory compromise
7 Objective To describe the experience in fetal aortic valvuloplasty procedures from a single center.
8 Methods Fetuses with severe aortic stenosis considered to be at risk of progression to hypoplastic left ventricule that underwent percutaneous ultrasoundguided fetal aortic valvuloplasty (PUG- FAV) in our Unit were included.
9 Single pregnancy Selection criteria Aortic stenosis at weeks No other anomalies. Normal karyotype Severe LV disfunction LV length not <2SD below the mean for GA at Dx Left to right flow at the foramen ovale Retrograde flow in the TAA Normal appearing mitral valve No maternal contraindication
10 Results 5 fetuses underwent PUG-FAV under maternal regional anesthesia between 20 and 30 weeks. After achieving an appropriate position, fetal paralysis and analgesia were performed. 1/5 case underwent a TOP 2 weeks after the procedure In the other 4 cases, there were not fetal losses, PPROM or premature delivery. There was not maternal morbidity.
11 # G A Needle Attempt # Proced time Complications Technic success Delivery None 38 wks 3125 grs Severe bradycardia, resolved with norepinephrine TOP 23 wks None 37 wks 1980 grs None 38 wks 2740 grs Pericardial effusion (autolimited) Pleural effusion Rupture of balloon Subcutaneous edema (thorax & head) 39 wks 2970
12 # G A Needle Attempt # Proced time Complications Technic success Delivery None 38 wks 3125 grs Severe bradycardia, resolved with norepinephrine TOP 23 wks None 37 wks 1980 grs None 38 wks 2740 grs Pericardial effusion (autolimited) Pleural effusion Rupture of balloon Subcutaneous edema (thorax & head) 39 wks 2970
13 # G A Needle Attempt # Proced time Complications Technic success Delivery None 38 wks 3125 grs Severe bradycardia, resolved with norepinephrine TOP 23 wks None 37 wks 1980 grs None 38 wks 2740 grs Pericardial effusion (autolimited) Pleural effusion Rupture of balloon Subcutaneous edema (thorax & head) 39 wks 2970
14 # G A Needle Attempt # Proced time Complications Technic success Delivery None 38 wks 3125 grs Severe bradycardia, resolved with norepinephrine TOP 23 wks None 37 wks 1980 grs None 38 wks 2740 grs Pericardial effusion (autolimited) Pleural effusion Rupture of balloon Subcutaneous edema (thorax & head) 39 wks 2970
15 # G A Needle Attempt # Proced time Complications Technic success Delivery None 38 wks 3125 grs Severe bradycardia, resolved with norepinephrine TOP 23 wks None 37 wks 1980 grs None 38 wks 2740 grs Pericardial effusion (autolimited) Pleural effusion Rupture of balloon Subcutaneous edema (thorax & head) 39 wks 2970
16 # G A Needle Attempt # Proced time Complications Technic success Delivery None 38 wks 3125 grs Severe bradycardia, resolved with norepinephrine TOP 23 wks None 37 wks 1980 grs None 38 wks 2740 grs Pericardial effusion (autolimited) Pleural effusion Rupture of balloon Subcutaneous edema (thorax & head) 39 wks 2970
17 # G A Needle Attempt # Proced time Complications Technic success Delivery None 38 wks 3125 grs Severe bradycardia, resolved with norepinephrine TOP 23 wks None 37 wks 1980 grs None 38 wks 2740 grs Pericardial effusion (autolimited) Pleural effusion Rupture of balloon Subcutaneous edema (thorax & head) 39 wks 2970
18 # G A Needle Attempt # Proced time Complications Technic success Delivery None 38 wks 3125 grs Severe bradycardia, resolved with norepinephrine TOP 23 wks None 37 wks 1980 grs None 38 wks 2740 grs Pericardial effusion (autolimited) Pleural effusion Rupture of balloon Subcutaneous edema (thorax & head) 39 wks 2970
19 Case 2: 20 weeks: Severe bradycardia resolved with intracardiac norepinephrine
20 # G A Needle Attempt # Proced time Complications Technic success Delivery None 38 wks 3125 grs Severe bradycardia, resolved with norepinephrine TOP 23 wks None 37 wks 1980 grs None 38 wks 2740 grs Pericardial effusion (autolimited) Pleural effusion Rupture of balloon Subcutaneous edema (thorax & head) 39 wks 2970
21 Case 5: 30 weeks: 1 st attempt
22 Case 5: 30 weeks: 2 nd attempt
23 Case 5: 30 weeks: 3 rd attempt. Valvuloplasty and rupture of the balloon
24 Pleural effusion Pericardial effusion Pre op Post PUG-FAV: 1 day Post PUG-FAV: 13 day Pericardial effusion Post PUG-FAV: 23 day
25 Case 5: Transient scalp and thoracic subcutaneous edema Scalp edema Post PUG-FAV: 3 day Post PUG-FAV: 13 day
26 # G A Needle Attempt # Proced time Complications Technic success Delivery None 38 wks 3125 grs Severe bradycardia, resolved with norepinephrine TOP 23 wks None 37 wks 1980 grs None 38 wks 2740 grs Pericardial effusion (autolimited) Pleural effusion Rupture of balloon Subcutaneous edema (thorax & head) 39 wks 2970
27 Case 3: 22 weeks
28 Comments PUG-FAV procedures were feasible in all cases. There were no fetal losses, nor PPROM & premature delivery. It seems to carry a very low maternal risk.
29 Comments Urgent need for custom-made, dedicated equipment for this type of fetal surgery* More animal research* International Multicenter Collaboration* IFMSS: Monday 16, 7:00 to 9:00 pm Research Updates with Beer and Wine Fetal Cardiac Interventions Anita Moon-Grady * Oepkes el al. Prenat Diagn 2011
30 Unidad de Medicina Fetal Horacio Aiello César Meller María Cohen Laura Giménez Gustavo Izbizky Pablo Marantz Lucas Otaño Marcelo Pietrani Raquel Sod Adriana Wojakowsky Thank you
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