Patel Neil D, Nageotte Stephen, Ing Frank F, Armstrong Aimee K, Chmait Ramen, Detterich Jon A, Galindo Alberto, Gardiner Helena, Grinenco Sofia, Herberg Ulrike, Jaeggi Edgar, Morris Shaine A, Oepkes Dick, Simpson John M, Moon-Grady Anita, Pruetz Jay D
Division of Pediatric Cardiology, Children's Hospital, University of Southern California Keck School of Medicine of USC, Los Angeles, California, USA.
Division of Pediatric Cardiology, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine, St Louis, Missouri, USA.
Catheter Cardiovasc Interv. 2020 Sep 1;96(3):626-632. doi: 10.1002/ccd.28846. Epub 2020 Mar 26.
We aimed to evaluate the effect of technical aspects of fetal aortic valvuloplasty (FAV) on procedural risks and pregnancy outcomes.
FAV is performed in cases of severe mid-gestation aortic stenosis with the goal of preventing hypoplastic left heart syndrome (HLHS).
The International Fetal Cardiac Intervention Registry was queried for fetuses who underwent FAV from 2002 to 2018, excluding one high-volume center.
The 108 fetuses had an attempted cardiac puncture (mean gestational age [GA] 26.1 ± 3.3 weeks). 83.3% of attempted interventions were technically successful (increased forward flow/new aortic insufficiency). The interventional cannula was larger than 19 g in 70.4%. More than one cardiac puncture was performed in 25.0%. Intraprocedural complications occurred in 48.1%, including bradycardia (34.1%), pericardial (22.2%) or pleural effusion (2.7%) requiring drainage, and balloon rupture (5.6%). Death within 48 hr occurred in 16.7% of fetuses. Of the 81 patients born alive, 59 were discharged home, 34 of whom had biventricular circulation. More than one cardiac puncture was associated with higher complication rates (p < .001). Larger cannula size was associated with higher pericardial effusion rates (p = .044). On multivariate analysis, technical success (odds ratio [OR] = 10.9, 95% confidence interval [CI] = 2.2-53.5, p = .003) and later GA at intervention (OR = 1.5, 95% CI = 1.2-1.9, p = .002) were associated with increased odds of live birth.
FAV is an often successful but high-risk procedure. Multiple cardiac punctures are associated with increased complication and fetal mortality rates. Later GA at intervention and technical success were independently associated with increased odds of live birth. However, performing the procedure later in gestation may miss the window to prevent progression to HLHS.
我们旨在评估胎儿主动脉瓣成形术（FAV）的技术因素对手术风险和妊娠结局的影响。
FAV用于治疗妊娠中期严重主动脉瓣狭窄，目的是预防左心发育不全综合征（HLHS）。
查询国际胎儿心脏介入注册中心2002年至2018年接受FAV的胎儿情况，排除一个高手术量中心。
108例胎儿尝试进行心脏穿刺（平均孕周[GA]26.1±3.3周）。83.3%的尝试性干预在技术上成功（前向血流增加/新的主动脉瓣关闭不全）。70.4%的介入套管大于19G。25.0%的病例进行了不止一次心脏穿刺。术中并发症发生率为48.1%，包括心动过缓（34.1%）、需要引流的心包积液（22.2%）或胸腔积液（2.7%）以及球囊破裂（5.6%）。16.7%的胎儿在48小时内死亡。81例存活出生的患者中，59例出院回家，其中34例有双心室循环。不止一次心脏穿刺与更高的并发症发生率相关（p<0.001）。较大的套管尺寸与更高的心包积液发生率相关（p=0.044）。多因素分析显示，技术成功（优势比[OR]=10.9，95%置信区间[CI]=2.2-53.5，p=0.003）和干预时较晚的孕周（OR=1.5，95%CI=1.2-1.9，p=0.002）与活产几率增加相关。
FAV是一种常能成功但风险较高的手术。多次心脏穿刺与并发症和胎儿死亡率增加相关。干预时较晚的孕周和技术成功与活产几率增加独立相关。然而，在妊娠后期进行该手术可能会错过预防进展为HLHS的时机。
