Changes in left heart hemodynamics after technically successful in‐utero aortic valvuloplasty

Abstract

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). Conclusion Fetal aortic valvuloplasty, when technically successful, improves left ventricular systolic function and left heart Doppler characteristics. Copyright © 2007 ISUOG. Published by John Wiley & Sons, Ltd.