Ultrasound-guided laser treatment of hydropic fetal lung lesions with a systemic arterial supply

Abstract

To report innovative minimally invasive fetal therapy for massive lung lesions associated with hydrops. 2 cases, followed prospectively. 2 hydropic fetuses, at 19 and 23 wks, respectively, had massive bronchopulmonary sequestrations occupying most of the chest and everting the diaphragm well into the abdomen. A large aortic feeding vessel was identified in each case. Using IV sedation and continuous ultrasound guidance, an 18g needle was placed intra-amniotically, through which a longer 22g needle was advanced into the fetal IHV to sample, paralyze, and anesthetize the fetus. This was then redirected into one of the larger cysts, and microbubble contrast agent (Levovist) was injected to document cyst communication. A 600-micron ND: YAG laser fiber was passed through the 18g needle, and the tip was placed adjacent to the feeding vessel, which was successfully ablated in each case. In the first case at 19 wks, finally a fetal Rocket pleuroamniotic shunt was placed, traversing several cysts. The left-sided mass resolved dramatically in size over the next 3 wks, and hydrops resolved completely. A healthy 3.7-kg male, requiring no assisted ventilation, was born at 39 wks. The involved lobe was resected the next day; pediatric follow-up is entirely normal. At 23 wks, GA was used for the 2nd right-sided mass and no shunt was placed: 2 wks later, there has been some mass shrinkage; so far, hydrops persists. The pregnancy is ongoing. The prognosis for large fetal cystic chest masses associated with hydrops is dismal—all die. This has prompted attempts at treatment by open fetal surgery, with mixed results and a high risk of premature labor. We have demonstrated an excellent outcome by US-guided laser ablation of the systemic arterial supply. This is a preferable, much less invasive approach to such lesions—with far less risk of premature labor. A fetal pleuroamniotic shunt may have a beneficial adjunctive effect.