K. Tchatcheva

Encouraging Early Clinical Experience with Deliberately Delayed Temporary Fetoscopic Tracheal Occlusion for the Prenatal Treatment of Life-Threatening Right and Left Congenital Diaphragmatic Hernias

Objective: In order to assess the effect of deliberately delayed percutaneous fetoscopic tracheal occlusion on survival of fetuses with life-threatening congenital diaphragmatic hernia. Methods: Eight fetuses with life-threatening congenital diaphragmatic hernia underwent fetoscopic tracheal balloon occlusion between 29 + 0 and 32 + 4 weeks of gestation. Delayed occlusion was chosen in order to minimize potentially negative pulmonary effects from premature delivery as a result of fetal surgery. In addition, we wanted to become able to provide all available postnatal intensive care treatment means in these patients. Results: Six of the 8 fetuses survived to discharge from hospital. Conclusion: Delayed fetoscopic tracheal balloon occlusion may be rewarded with lung growth sufficient to allow survival of fetuses with life-threatening congenital diaphragmatic hernia.

Analysis of the stepwise clinical introduction of experimental percutaneous fetoscopic surgical techniques for upcoming minimally invasive fetal cardiac interventions

BackgroundThis study assessed the feasibility and safety of surgical techniques developed in sheep for fetoscopic fetal cardiac interventions during three selected less complex procedures for noncardiac fetal conditions in humans. On the basis of this assessment, the implications for the clinical introduction of minimally invasive fetoscopic fetal cardiac interventions in the near future are discussed.MethodsThe authors performed 16 percutaneous fetoscopic procedures in 13 human fetuses at between 19 + 2 and 34 + 6 weeks of gestation, then analyzed various parameters of surgical relevance for minimally invasive fetoscopic fetal cardiac interventions. Each of the three noncardiac malformations posed typical surgical challenges that will be critical for the technical success of minimally invasive fetoscopic cardiac interventions.ResultsOverall technical success was achieved in 14 of the 16 procedures. Percutaneous fetoscopic surgery did not result in any untoward effects and was well tolerated by all but two pregnant women: one with bleeding complication and one with mild postoperative pulmonary edema. No fetal complications or injuries from the various percutaneous fetoscopic surgical approaches were observed.ConclusionsThe author’s experience with surgical techniques introduced for percutaneous fetoscopic fetal cardiac intervention in selected noncardiac fetal lesions has led them to believe the time has come for the clinical introduction of fetoscopic fetal cardiac interventions. After an adequate learning curve supervised by committees of human research, the overall outcome and quality of postnatal life for the unborn patients ultimately will determine whether fetoscopic or other fetal cardiac interventions will be better therapeutic alternatives to currently available postnatal procedures.

Fetal transesophageal echocardiography: clinical introduction as a monitoring tool during cardiac intervention in a human fetus.

Because of insufficient imaging by maternal transabdominal fetal echocardiography (TAE) in a human fetus with aortic atresia, imperforate atrial septum and progressive cardiac failure, we assessed the feasibility of fetal transesophageal echocardiography (TEE) as a monitoring tool during fetal cardiac intervention at 24 + 6 weeks of gestation. Percutaneous fetoscopic intraesophageal deployment of the ultrasound catheter was achieved and did not result in any maternal or fetal complications. Fetal TEE permitted substantially clearer definition of fetal cardiac anatomy and intracardiac device manipulations than conventional maternal TAE. Despite the employment of various devices, no sufficiently large opening could be achieved within the atrial septum. Although the fetus tolerated the procedure remarkably well and satisfactory fetoplacental flow could be documented at the end of the procedure, the fetus died from progressive cardiac failure 3 days after the intervention. Fetoscopic TEE is feasible in the human fetus and permits substantially clearer definition of fetal cardiac anatomy and intracardiac manipulations than conventional maternal TAE. Based on the observation of spontaneous closure of multiple iatrogenic perforations of the atrial septum, specialized devices are required in order to improve the technical success rate of septoplasty methods and hence the survival odds of these high‐risk patients. Copyright

Maternal haemodynamics and lung water content during percutaneous fetoscopic interventions under general anaesthesia

BACKGROUND The purpose of our study was to evaluate the maternal cardiopulmonary function and lung water content during percutaneous fetoscopic interventions under general maternal-fetal anaesthesia and continuous tocolytic medication. METHODS We prospectively studied 13 women between 19 and 30 weeks of gestation undergoing percutaneous fetoscopic procedures that were performed under general maternal-fetal anaesthesia and tocolysis using indomethacin. Invasive haemodynamic monitoring using pulmonary artery catheters and the transpulmonary indicator dilution technique was applied to determine intrathoracic blood volume (ITBV), cardiac output, and extravascular lung water (EVLW). Pulmonary vascular permeability was estimated as the ratio of EVLW/ITBV. Measurements were performed during and for 24 h after the interventions. RESULTS Respective mean (SD) maternal ITBV and cardiac output were 894 (191) ml min(-1) m(-2) and 3.29 (0.51) litre(-1) min(-1) m(-2) intraoperatively, and 843 (169) ml min(-1) m(-2) and 4.47 (0.55) litre min(-1) m(-2) during the first postoperative day. EVLW was 7.9 (2.7) ml kg(-1) during the interventions and 7.7 (1.8) ml kg(-1) during the first postoperative day. The pulmonary vascular permeability index was calculated as 0.35 (0.06) during the interventions and 0.38 (0.14) for the first postoperative day. Clinically overt pulmonary oedema was not detected in any woman while pulmonary gas exchange remained normal. CONCLUSIONS In mid-gestational women undergoing percutaneous fetoscopic interventions under general maternal-fetal anaesthesia, cardiopulmonary function remained stable. However, a moderate increase in EVLW and pulmonary vascular permeability indicates an increased risk for maternal pulmonary oedema.

Partial Amniotic Carbon Dioxide Insufflation During Minimally Invasive Fetoscopic Interventions Seems Safe for the Fetal Brain in Sheep

BACKGROUND Partial amniotic carbon dioxide insufflation (PACI) during fetoscopic interventions greatly improves visualization of intraamniotic contents. The purpose of this study was to assess any histologically discernable effects from this approach on the fetal brain after long-term survival in sheep. METHODS Six pregnant ewes between 63 and 92 days of gestation underwent PACI after fetoscopic intraamniotic access. Insufflation pressures ranged between 7 and 15 mm Hg (mean 11.7; median 12.5). Insufflation times ranged between 45 and 80 minutes (mean 55.8 minutes; median 52.5) and depended on the duration of various percutaneous fetoscopic maneuvers (e.g., posturing, fetal transesophageal electrocardiography, and chronic fetal vascular access) that were tested during these studies. After fetal spontaneous delivery between 147 and 150 days of gestation, 5 of the lambs were observed for abnormal neurological symptoms. The last ewe and her sheep were terminated at 133 days of gestation for humane reasons. All six brains were examined for hemorrhage, embolism, infarctions, inflammatory changes, and abnormal cortical maturation. An unoperated sibling was available as a control. RESULTS The 5 sheep that were spontaneously delivered exhibited no abnormal neurological findings. In all 6 sheep, PACI did not result in any histologically discernable damage to their brain in these long-term studies. Maternal and fetal complications were not observed during or after the approach. CONCLUSION The application of PACI during minimally invasive fetoscopic interventions seems safe for the fetal brain. Due to the still limited clinical experience with PACI, continued assessment of its maternal and fetal risks as well as management are required.

Life-saving effects of fetal tracheal occlusion on pulmonary hypoplasia from preterm premature rupture of membranes.

BACKGROUND: Preterm premature rupture of membranes before 22 weeks of gestation may result in severe fetal pulmonary hypoplasia. Fetoscopic tracheal balloon occlusion might result in catch-up pulmonary growth. CASE: After preterm premature rupture of membranes at 16 weeks of gestation, magnetic resonance imaging at 26 0/7 weeks showed a fetal lung volume of 13 mL and pulmonary blood flow hardly could be detected. Fetoscopic tracheal balloon occlusion was performed at 27 6/7 weeks; within 6 days, fetal lung volume increased to 70 mL and lung blood flow normalized. The fetus was delivered electively at 28 6/7 weeks. Six hours after delivery, the neonate required only 21% oxygen and was extubated after 55 hours. CONCLUSION: Short-term fetoscopic tracheal balloon occlusion may result in rapid normalization of fetal lung volume and blood flow in fetuses with life-threatening pulmonary hypoplasia from preterm premature rupture of membranes before 22 weeks of gestation.

Intraamniotic Fetal Echocardiography A New Fetal Cardiovascular Monitoring Approach During Human Fetoscopic Surgery

A 33-year-old pregnant women had been referred to our center at 28+1 weeks’ gestation. Maternal transabdominal fetal ultrasound imaging at that time revealed a fetal congenital diaphragmatic hernia with very hypoplastic lungs. Because of the poor prognosis of the fetal congenital diaphragmatic hernia, temporary fetoscopic balloon occlusion was performed as a potentially live-saving experimental treatment approach. Fetoscopic tracheal balloon removal was scheduled at 32+5 weeks’ gestation. At that time, fetal ultrasound imaging was more difficult because of the more advanced gestational age in combination with severe adipositas (body mass index = 43 kg/m2) and polyhydramnios (Figure 1). Therefore, the feasibility of intraamniotic fetal echocardiography (IFE) was assessed as a more suitable monitoring tool. The fetoscopic and ultrasound-guided procedure was performed with parental informed consent and approval from the local committee of human research, in accordance with the ethical standards for human experimentation established by the Declaration of Helsinki. Figure 1. Preoperative magnetic resonance image (top) at 32+4 weeks’ gestation demonstrating the obstacles adipositas and polyhydramnios for conventional maternal transabdominal fetal echocardiography in this patient (arrow points at latex balloon inside the fetal trachea). At that time, maternal transabdominal imaging was even more difficult than at initial presentation because of the more advanced gestational age in combination with severe adipositas (body mass index = 43 kg/m2) and polyhydramnios. Two-dimensional cross-section images (middle …A 33-year-old pregnant women had been referred to our center at 28+1 weeks’ gestation. Maternal transabdominal fetal ultrasound imaging at that time revealed a fetal congenital diaphragmatic hernia with very hypoplastic lungs. Because of the poor prognosis of the fetal congenital diaphragmatic hernia, temporary fetoscopic balloon occlusion was performed as a potentially live-saving experimental treatment approach. Fetoscopic tracheal balloon removal was scheduled at 32+5 weeks’ gestation. At that time, fetal ultrasound imaging was more difficult because of the more advanced gestational age in combination with severe adipositas (body mass index = 43 kg/m2) and polyhydramnios (Figure 1). Therefore, the feasibility of intraamniotic fetal echocardiography (IFE) was assessed as a more suitable monitoring tool. The fetoscopic and ultrasound-guided procedure was performed with parental informed consent and approval from the local committee of human research, in accordance with the ethical standards for human experimentation established by the Declaration of Helsinki. Figure 1. Preoperative magnetic resonance image (top) at 32+4 weeks’ gestation demonstrating the obstacles adipositas and polyhydramnios for conventional maternal transabdominal fetal echocardiography in this patient (arrow points at latex balloon inside the fetal trachea). At that time, maternal transabdominal imaging was even more difficult than at initial presentation because of the more advanced gestational age in combination with severe adipositas (body mass index = 43 kg/m2) and polyhydramnios. Two-dimensional cross-section images (middle …

OP06.05: Partial amniotic carbon dioxide insufflation (PACI) during fetoscopic surgery on 60 fetuses with spina bifida aperta

congenital diaphragmatic hernia (CDH) in the prediction of neonatal survival. Methods: Between January 2006 and December 2009, the lung-tohead ratio was evaluated before and every two weeks after FETO in cases of severe isolated CDH (LHR <1.0 with liver up). Results: A total of 35 fetuses undergoing FETO were evaluated. The overall survival rate survival was 19/35 (54.3%) cases after FETO. The LHR increased progressively up to 4 weeks after fetal intervention (P < 0.01). Six weeks after FETO, a small decrease in the LHR was observed. The increase of LHR was significantly higher in cases that survived in comparison to those that died 2, 4 and 6 weeks after FETO (P < 0.01). Using ROC analysis, it was possible to determine that LHR ≤0.71 before FETO was associated with neonatal mortality (RR: 4.08; 95% CI: 1.3–12.0). Conclusions: The LHR before and after FETO can be used to predict neonatal survival.

Images in cardiovascular medicine. Intraamniotic fetal echocardiography: a new fetal cardiovascular monitoring approach during human fetoscopic surgery.

A 33-year-old pregnant women had been referred to our center at 28+1 weeks’ gestation. Maternal transabdominal fetal ultrasound imaging at that time revealed a fetal congenital diaphragmatic hernia with very hypoplastic lungs. Because of the poor prognosis of the fetal congenital diaphragmatic hernia, temporary fetoscopic balloon occlusion was performed as a potentially live-saving experimental treatment approach. Fetoscopic tracheal balloon removal was scheduled at 32+5 weeks’ gestation. At that time, fetal ultrasound imaging was more difficult because of the more advanced gestational age in combination with severe adipositas (body mass index = 43 kg/m2) and polyhydramnios (Figure 1). Therefore, the feasibility of intraamniotic fetal echocardiography (IFE) was assessed as a more suitable monitoring tool. The fetoscopic and ultrasound-guided procedure was performed with parental informed consent and approval from the local committee of human research, in accordance with the ethical standards for human experimentation established by the Declaration of Helsinki. Figure 1. Preoperative magnetic resonance image (top) at 32+4 weeks’ gestation demonstrating the obstacles adipositas and polyhydramnios for conventional maternal transabdominal fetal echocardiography in this patient (arrow points at latex balloon inside the fetal trachea). At that time, maternal transabdominal imaging was even more difficult than at initial presentation because of the more advanced gestational age in combination with severe adipositas (body mass index = 43 kg/m2) and polyhydramnios. Two-dimensional cross-section images (middle …A 33-year-old pregnant women had been referred to our center at 28+1 weeks’ gestation. Maternal transabdominal fetal ultrasound imaging at that time revealed a fetal congenital diaphragmatic hernia with very hypoplastic lungs. Because of the poor prognosis of the fetal congenital diaphragmatic hernia, temporary fetoscopic balloon occlusion was performed as a potentially live-saving experimental treatment approach. Fetoscopic tracheal balloon removal was scheduled at 32+5 weeks’ gestation. At that time, fetal ultrasound imaging was more difficult because of the more advanced gestational age in combination with severe adipositas (body mass index = 43 kg/m2) and polyhydramnios (Figure 1). Therefore, the feasibility of intraamniotic fetal echocardiography (IFE) was assessed as a more suitable monitoring tool. The fetoscopic and ultrasound-guided procedure was performed with parental informed consent and approval from the local committee of human research, in accordance with the ethical standards for human experimentation established by the Declaration of Helsinki. Figure 1. Preoperative magnetic resonance image (top) at 32+4 weeks’ gestation demonstrating the obstacles adipositas and polyhydramnios for conventional maternal transabdominal fetal echocardiography in this patient (arrow points at latex balloon inside the fetal trachea). At that time, maternal transabdominal imaging was even more difficult than at initial presentation because of the more advanced gestational age in combination with severe adipositas (body mass index = 43 kg/m2) and polyhydramnios. Two-dimensional cross-section images (middle …

OP06.03: High survival rate after late fetoscopic tracheal occlusion followed by postnatal ECMO therapy in infants with severe right diaphragmatic hernia

congenital diaphragmatic hernia (CDH) in the prediction of neonatal survival. Methods: Between January 2006 and December 2009, the lung-tohead ratio was evaluated before and every two weeks after FETO in cases of severe isolated CDH (LHR < 1.0 with liver up). Results: A total of 35 fetuses undergoing FETO were evaluated. The overall survival rate survival was 19/35 (54.3%) cases after FETO. The LHR increased progressively up to 4 weeks after fetal intervention (P < 0.01). Six weeks after FETO, a small decrease in the LHR was observed. The increase of LHR was significantly higher in cases that survived in comparison to those that died 2, 4 and 6 weeks after FETO (P < 0.01). Using ROC analysis, it was possible to determine that LHR ≤ 0.71 before FETO was associated with neonatal mortality (RR: 4.08; 95% CI: 1.3–12.0). Conclusions: The LHR before and after FETO can be used to predict neonatal survival.