International Fetal Medicine and Surgery Society Fetal ... · #G A Needle Attempt # Proced time Complications Technic success Delivery 1 25 18 2 48’ None Yes 38 wks 3125 grs A&W

Lucas OtañoUnidad de Medicina Fetal

Unidad de Diagnóstico y Tratamiento Fetal

Lucas OtañoUnidad de Medicina Fetal

Unidad de Diagnóstico y Tratamiento Fetal

Fetal aortic valvuloplasty procedures: experience from Hospital Italiano de Buenos Aires

Otaño L 1, Aiello H 1, Peña G2,, Trentacoste L 2, Granja M 2, Izbizky G 1, Marantz P 1,2

(1)Fetal Medicine Unit, (2) División of Pediatric C ardiolgy,

Fetal aortic valvuloplasty procedures: experience from Hospital Italiano de Buenos Aires

Otaño L 1, Aiello H 1, Peña G2,, Trentacoste L 2, Granja M 2, Izbizky G 1, Marantz P 1,2

(1)Fetal Medicine Unit, (2) División of Pediatric C ardiolgy,

International Fetal Medicine and Surgery Society

Sedona, ArizonaMay 13 - 18, 2011

IntroductionIntroduction

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.

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.

IFMSS 2011

22 weeks 33 weeks

Natural hystory of severe aortic estenosis Natural hystory of severe aortic estenosis

Editorial: In-utero intervention for hypoplastic left heart syndrome – a perinatologist’s perspective. LE Wilkins-Haug Ultrasound Obstet Gynecol 2005;26:481-6Editorial: In-utero intervention for hypoplastic left heart syndrome – a perinatologist’s perspective. LE Wilkins-Haug Ultrasound Obstet Gynecol 2005;26:481-6

LVLV LVLV

RVRVRVRV


• US guided

• Percutaneous

• Maternal epidural

• Fetal position

• Fetal paralysis & analgesisa

• 19-18G needle

• 0.014-in guidewire

• Valvuloplastic baloon smaller than the aortic annulus

• US guided

• Percutaneous

• Maternal epidural

• Fetal position

• Fetal paralysis & analgesisa

• 19-18G needle

• 0.014-in guidewire

• Valvuloplastic baloon smaller than the aortic annulus

Fetal aortic valvuloplasty Fetal aortic valvuloplasty

Tworetzky W et al. Circulation 2004;110:2125-2131Tworetzky W et al. Circulation 2004;110:2125-2131


IFMSS 2011

Tworetzky W et al. Circulation 2004;110:2125-2131Tworetzky W et al. Circulation 2004;110:2125-2131IFMSS 2011

Procedure complicationsProcedure 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

• 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


IFMSS 2011

ObjectiveObjective

• To describe the experience in fetal aortic valvuloplasty procedures from a single center.

• To describe the experience in fetal aortic valvuloplasty procedures from a single center.

IFMSS 2011

MethodsMethods

• Fetuses with severe aortic stenosis considered to be at risk of progression to hypoplastic left ventricule that underwent percutaneous ultrasound-guided fetal aortic valvuloplasty (PUG-FAV) in our Unit were included.

• Fetuses with severe aortic stenosis considered to be at risk of progression to hypoplastic left ventricule that underwent percutaneous ultrasound-guided fetal aortic valvuloplasty (PUG-FAV) in our Unit were included.

IFMSS 2011

Selection criteriaSelection criteria

• Single pregnancy

• Aortic stenosis at 20 – 30 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

• Single pregnancy

• Aortic stenosis at 20 – 30 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 contraindicationIFMSS 2011

ResultsResults

• 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.

• 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.

IFMSS 2011

# GA

Needle Attempt #

Procedtime

Complications Technicsuccess

Delivery

125

18 2 48’ None Yes 38 wks3125 grs

A&W

2 20 18 1 28’ Severe bradycardia, resolved with norepinephrine

Yes TOP 23 wks

3 22 18 1 7’ None Yes 37 wks1980 grs

A&W

4 30 19 1 14’ None Yes 38 wks2740 grs

A&W

5 30 19 3 45’ Pericardial effusion (autolimited)Pleural effusionRupture of balloonSubcutaneous edema (thorax & head)

Yes 39 wks2970A&W

ProceduresPercutaneous ultrasound guided - fetal aortic valvuloplasty

IFMSS 2011

# GA

Needle Attempt #

Procedtime


Delivery

125


A&W


Yes TOP 23 wks

3 22 18 1 7’ None Yes 37 wks1980 grs

A&W

4 30 19 1 14’ None Yes 38 wks2740 grs

A&W


Yes 39 wks2970A&W


IFMSS 2011

# GA

Needle Attempt #

Procedtime


Delivery

125


A&W


Yes TOP 23 wks

3 22 18 1 7’ None Yes 37 wks1980 grs

A&W

4 30 19 1 14’ None Yes 38 wks2740 grs

A&W


Yes 39 wks2970A&W


IFMSS 2011

# GA

Needle Attempt #

Procedtime


Delivery

125


A&W


Yes TOP 23 wks

3 22 18 1 7’ None Yes 37 wks1980 grs

A&W

4 30 19 1 14’ None Yes 38 wks2740 grs

A&W


Yes 39 wks2970A&W


IFMSS 2011

# GA

Needle Attempt #

Procedtime


Delivery

125


A&W


Yes TOP 23 wks

3 22 18 1 7’ None Yes 37 wks1980 grs

A&W

4 30 19 1 14’ None Yes 38 wks2740 grs

A&W


Yes 39 wks2970A&W


IFMSS 2011

# GA

Needle Attempt #

Procedtime


Delivery

125


A&W


Yes TOP 23 wks

3 22 18 1 7’ None Yes 37 wks1980 grs

A&W

4 30 19 1 14’ None Yes 38 wks2740 grs

A&W


Yes 39 wks2970A&W


IFMSS 2011

# GA

Needle Attempt #

Procedtime


Delivery

125


A&W


Yes TOP 23 wks

3 22 18 1 7’ None Yes 37 wks1980 grs

A&W

4 30 19 1 14’ None Yes 38 wks2740 grs

A&W


Yes 39 wks2970A&W


IFMSS 2011

# GA

Needle Attempt #

Procedtime


Delivery

125


A&W


Yes TOP 23 wks

3 22 18 1 7’ None Yes 37 wks1980 grs

A&W

4 30 19 1 14’ None Yes 38 wks2740 grs

A&W


Yes 39 wks2970A&W


IFMSS 2011


Case 2: 20 weeks: Severe bradycardia resolved with intracardiac norepinephrine

IFMSS 2011

# GA

Needle Attempt #

Procedtime


Delivery

125


A&W


Yes TOP 23 wks

3 22 18 1 7’ None Yes 37 wks1980 grs

A&W

4 30 19 1 14’ None Yes 38 wks2740 grs

A&W


Yes 39 wks2970A&W


IFMSS 2011


Case 5: 30 weeks: 1st attempt

IFMSS 2011


Case 5: 30 weeks: 2nd attempt

IFMSS 2011


Case 5: 30 weeks: 3rd attempt. Valvuloplasty and rupture of the balloon

IFMSS 2011

Post PUG-FAV: 1°dayPre op

Post PUG-FAV: 13°day Post PUG-FAV: 23°day

Pleural effusion

Pericardial effusion

Pericardial effusion

Post PUG-FAV: 3°day Post PUG-FAV: 13°day

Scalp edema


Case 5: Transient scalp and thoracic subcutaneous edema

# GA

Needle Attempt #

Procedtime


Delivery

125


A&W


Yes TOP 23 wks

3 22 18 1 7’ None Yes 37 wks1980 grs

A&W

4 30 19 1 14’ None Yes 38 wks2740 grs

A&W


Yes 39 wks2970A&W


IFMSS 2011


Case 3: 22 weeks

IFMSS 2011

CommentsComments

• 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.

• 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.

IFMSS 2011

CommentsComments

• 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

• 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 2011IFMSS 2011

Unidad de Medicina FetalHoracio Aiello César MellerMaría Cohen Laura Giménez Gustavo Izbizky Pablo MarantzLucas Otaño Marcelo PietraniRaquel Sod Adriana Wojakowsky

Unidad de Medicina FetalHoracio Aiello César MellerMaría Cohen Laura Giménez Gustavo Izbizky Pablo MarantzLucas Otaño Marcelo PietraniRaquel Sod Adriana Wojakowsky

Thank youThank [email protected]

www.hospitalitaliano.org.ar/medicinafetalwww.hospitalitaliano.org.ar/medicinafetalIFMSS 2011

Documents

International Fetal Medicine and Surgery Society Fetal ... · #G A Needle Attempt # Proced time Complications Technic success Delivery 1 25 18 2 48’ None Yes 38 wks 3125 grs A&W