Alberto Mendoza

Prediction of coarctation of the aorta in the second half of pregnancy

To determine which combination of cardiac parameters provides the best prediction of postnatal coarctation of the aorta (CoAo) in fetuses with cardiac asymmetry.

Gestational age-specific scoring systems for the prediction of coarctation of the aorta

To determine which combination of cardiac parameters provides the best prenatal prediction of coarctation of aorta (CoAo).

Fetal Intervention in Right Outflow Tract Obstructive Disease: Selection of Candidates and Results

Objectives. To describe the process of selection of candidates for fetal cardiac intervention (FCI) in fetuses diagnosed with pulmonary atresia-critical stenosis with intact ventricular septum (PA/CS-IVS) and report our own experience with FCI for such disease. Methods. We searched our database for cases of PA/CS-IVS prenatally diagnosed in 2003–2012. Data of 38 fetuses were retrieved and analyzed. FCI were offered to 6 patients (2 refused). In the remaining it was not offered due to the presence of either favourable prognostic echocardiographic markers (n = 20) or poor prognostic indicators (n = 12). Results. The outcome of fetuses with PA/CS-IVS was accurately predicted with multiparametric scoring systems. Pulmonary valvuloplasty was technically successful in all 4 fetuses. The growth of the fetal right heart and hemodynamic parameters showed a Gaussian-like behaviour with an improvement in the first weeks and slow worsening as pregnancy advanced, probably indicating a restenosis. Conclusions. The most likely type of circulation after birth may be predicted in the second trimester of pregnancy by means of combining cardiac dimensions and functional parameters. Fetal pulmonary valvuloplasty in midgestation is technically feasible and in well-selected cases may improve right heart growth, fetal hemodynamics, and postnatal outcome.

Pulmonary atresia/critical stenosis with intact ventricular septum: prediction of outcome in the second trimester of pregnancy

To determine which cardiac parameters provide the best prediction of postnatal outcome—biventricular (BV) versus non‐BV—in fetuses with pulmonary atresia/critical stenosis with intact ventricular septum (PA/CS‐IVS).

Transposition of the Great Arteries in Fetal Life: Accuracy of Diagnosis and Short-Term Outcome

Objective: To review our series of prenatally diagnosed transposition of the great arteries (TGA) to analyze the accuracy of fetal echocardiography for achieving a precise diagnosis of the TGA type (simple vs. complex) and to examine the short-term outcome. Methods: A total of 94 cases of simple and complex TGA types (ventriculoarterial discordance with atrioventricular concordance) prenatally evaluated in our referral center between 1998 and 2014 were included. Fetuses with additional congenital anomalies and those with incomplete follow-up were excluded. Prenatal diagnostic accuracy and short-term survival were analyzed for the different types of TGA. Results: The TGA type was correctly ascertained prenatally in 93.3%. Most fetuses were diagnosed with simple TGA (62.7%). There were 6 discrepancies: 5 fetuses with simple TGA had postnatally TGA + ventricular septal defect (VSD; n = 3) or TGA + VSD + coarctation of the aorta (n = 2), and 1 fetus with TGA + VSD postnatally showed severe left ventricular outflow tract obstruction. The mortality rate was 6.6%; it was higher in complex versus simple forms (12.8 vs. 1.9%, p = 0.038), and in cases with intramural coronary artery versus those without (60 vs. 3.5%, p < 0.001). We found no relationship between the arrangement of the great arteries and coronary arterial abnormalities. Conclusions: Simple TGA has a better outcome than the complex forms. A discrepancy rate of 7% with potential influence on the prognosis of survival between the prenatal diagnosis of the TGA type and the definitive diagnosis was found.

Fetal Aortic Valvuloplasty: Experience and Results of Two Tertiary Centers in Spain

Objective: Fetal aortic valvuloplasty (FAV) may avoid progression of critical aortic stenosis (CAS) to hypoplastic left ventricle, improving the options for biventricular circulation (BVC). We describe the results of FAV in 2 referral centers in Spain. Methods: We analyzed all FAVs performed in the period 2007-2015. The selection of candidates, the technique, and postnatal management were made following an agreed protocol. A descriptive analysis of survival, type of circulation after birth, and complications was made, considering all deaths in the first 48 h after FAV as FAV-related. Results: FAV was performed in 28 fetuses at a median gestational age (GA) of 23 weeks (range, 20-32). FAV was technically successful in 22 (78.6%), of whom 11 were born alive and with intention to treat. Eight (72.7%) resulted in BVC and 3 (27.3%) in univentricular circulation. The rate of FAV-related deaths was 32%. These patients underwent FAV earlier than live-born fetuses (median GA at FAV 22 weeks [range, 20.0-25.0] vs. 24.5 weeks [range, 21.0-32.0], respectively, p = 0.031). Conclusions: A significant proportion of fetuses with CAS who undergo technically successful FAV have BVC postnatally. However, FAV implies a high risk of fetal death, which highly depends on the GA at which this intervention is required.

Prenatal Prediction of Surgical Approach for Coarctation of the Aorta Repair

Objective: To evaluate the capacity of fetal echocardiography for predicting the more likely surgical approach in newborns with coarctation of the aorta (CoAo) (left thoracotomy vs. median sternotomy). Material and Methods: We selected all cases of suspected CoAo prenatally diagnosed in 2003-2012 (n = 95). 49/95 were considered at high-risk and 46/95 at low-risk of CoAo, and 38/49 and 7/46 were postnatally confirmed, respectively. We firstly evaluated in 40 cases of CoAo surgically repaired (24 thoracotomy, 16 sternotomy) whether there were differences in fetal echocardiographic parameters between both groups. Secondly, we assessed the performance of these parameters for predicting the surgical approach in fetuses at high risk of CoAo. Results: Sternotomy approach was associated with higher rate of postoperative complications and longer hospital stay compared with thoracotomy (81.3 vs. 41.7%, p = 0.014; 30.5 vs. 15.4 days, p = 0.0004, respectively). The Z-score of the aortic isthmus, measured in the sagittal plane, was significantly smaller in the sternotomy group. In fetuses at high-risk of having CoAo a cut-off value of the isthmus Z-score ≤ -2.5 had sensitivity of 78% and specificity of 82% for predicting sternotomy approach, with 9% false positive cases in which CoAo was not confirmed. Discussion: The surgical approach for CoAo repair may be prenatally predicted by means of the Z-score of aortic isthmus, measured in the sagittal plane.

Contents Vol. 40, 2016

R. Achiron, Tel Hashomer N.S. Adzick, Philadelphia, Pa. L. Allan, London A.A. Baschat, Baltimore, Md. K.J. Blakemore, Baltimore, Md. T.-H. Bui, Stockholm F.A. Chervenak, New York, N.Y. T. Chiba, Tokyo R. Chmait, Los Angeles, Calif. F. Crispi, Barcelona J.E. De Lia, Milwaukee, Wisc. J.A. Deprest, Leuven G.C. Di Renzo, Perugia J.W. Dudenhausen, Berlin N.M. Fisk, Brisbane, Qld. A.W. Flake, Philadelphia, Pa. U. Gembruch, Bonn M.R. Harrison, San Francisco, Calif. J.C. Hobbins, Denver, Colo. L.K. Hornberger, Edmonton, Alta. E.R.M. Jauniaux, London M.P. Johnson, Philadelphia, Pa. J.-M. Jouannic, Paris P.M. Kyle, London O. Lapaire, Basel S. Lipitz, Tel Hashomer E. Llurba, Barcelona G. Malinger, Tel Aviv G. Mari, Detroit, Mich. M. Martinez-Ferro, Buenos Aires A. McLennan, Sydney, N.S.W. K.J. Moise, Houston, Tex. F. Molina, Granada K.H. Nicolaides, London L. Otaño, Buenos Aires Z. Papp, Budapest R.A. Quintero, Miami, Fla. G. Ryan, Toronto, Ont. J. Rychik, Philadelphia, Pa. H. Sago, Tokyo W. Sepulveda, Santiago P. Stone, Auckland D.V. Surbek, Bern B.J. Trudinger, Westmead, N.S.W. Y. Ville, Paris J.M.G. van Vugt, Nijmegen Clinical Advances and Basic Research

OC02.05: Fetal cardiac intervention: 8-year experience

Objectives: To assess blood flow measurements of the fetal aorta performing cardiac MRI using a newly developed MR compatible Doppler-ultrasound device for triggering of the fetal heart in utero and to compare them with ultrasound studies in a sheep model. Methods: Four pregnant sheep carrying singleton fetuses (123 days gestational age) underwent ultrasound examination for determination of blood flow velocity in the fetal aorta descendens. The ewes were then anesthetized to undergo fetal MRI examination on a 1.5 T imager. A newly developed MR-compatible Doppler-ultrasound sensor was placed on the abdomen of the ewe, above the fetal heart and fixed with a belt. The recorded signal of the fetal heart was transferred to the ECG trigger unit of the MR scanner and used for cardiac triggering. Blood flow velocity measurements of the fetal aorta descendens were performed and compared to ultrasound measurements. Mean values and peak velocities were calculated. Results: Triggering of the fetal heart rate was possible in all examinations. Using the trigger signal excellent MR images of the fetal heart and high quality flow measurements of the fetal aorta were obtained. Comparison of both methods revealed no significant differences with mean peak flow velocities of 60 cm/s (± 3.4) and 62 cm/s (± 9.2). Conclusions: Blood flow measurements of the fetal aorta were successfully performed using the newly developed MR-compatible Doppler-ultrasound device for fetal cardiac triggering in a sheep model, revealing no significant differences compared to fetal ultrasound examination. The newly developed Doppler-ultrasound device for triggering fetal cardiovascular MRI enables precise intrauterine fetal blood flow measurements and might be an alternative to fetal ultrasound.

OP04.03: Prediction of coarctation of the aorta in the second half of pregnancy

6–10 10 1 1 4 2 7 2 3 2 1 1 1 8 2 6 51 10–12 8 2 5 11 8 16 1 12 7 9 6 1 2 1 3 4 4 6 106 12–14 7 1 10 18 1 10 24 1 11 4 1 5 6 5 10 3 1 1 1 1 3 124 14–16 3 1 13 8 3 10 18 13 7 5 5 2 8 4 7 2 1 3 113 16–20 11 9 14 10 4 3 6 57 20–24 10 4 12 7 2 3 3 41 24–28 3 2 7 3 1 16 28–32 2 2 6 2 1 3 16 32–40 3 3 1 2 3 12 Total/Class 28 5 28 29 38 8 30 15 65 2 38 28 21 3 19 33 18 9 20 12 8 4 13 9 15 4 18 16 Total System 90 91 133 76 59 34 53 536