10 - Percutaneous Intervention in the Fetus, Including Postnatal Management

Abstract

The goal of percutaneous fetal cardiac intervention is to alter the natural history of select forms of congenital heart disease in utero and improve postnatal morbidity and/or mortality. Percutaneous fetal cardiac intervention may be performed for severe mid-gestation aortic stenosis with evolving hypoplastic left heart syndrome (HLHS); pulmonary atresia with intact ventricular septum and evolving hypoplastic right heart syndrome (HRHS); and established HLHS with a highly restrictive or intact atrial septum (IAS). Fetal aortic valvuloplasty and fetal pulmonary valvuloplasty are performed for evolving HLHS and HRHS, respectively, to achieve a biventricular circulation postnatally. Among technically successful cases of fetal aortic valvuloplasty, approximately half achieve a biventricular outcome, often with postnatal left ventricular rehabilitation. For evolving HRHS, selection of appropriate candidates has been challenging, but patients have undergone successful fetal pulmonary valvuloplasty from a technical perspective. Fetal atrial septoplasty, with or without stent placement, is performed for established HLHS with a highly restrictive or intact atrial septum (IAS) in order to improve survival. Although technical success and greater stability in the immediate postnatal period have been achieved, there has been no demonstrable improvement in survival to date. The advent of new fetal therapies is on the horizon, with maternal safety and autonomy at its core.