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(Circulation. 2004;110:1549-1556.)
© 2004 American Heart Association, Inc.

Congenital Heart Disease

Acute Cardiovascular Effects of Fetal Surgery in the Human

Jack Rychik, MD; Zhiyun Tian, MD; Meryl S. Cohen, MD; Stanford G. Ewing, MD; David Cohen, MD; Lori J. Howell, MD; R. Douglas Wilson, MD; Mark P. Johnson, MD; Holly L. Hedrick, MD; Alan W. Flake, MD; Timothy M. Crombleholme, MD; N. Scott Adzick, MD

From the Center for Fetal Diagnosis and Treatment and the Fetal Heart Program at The Children’s Hospital of Philadelphia; Divisions of Cardiology, General and Thoracic Surgery, and Anesthesia, The Children’s Hospital of Philadelphia; and Departments of Pediatrics, Surgery, and Anesthesia, University of Pennsylvania School of Medicine, Philadelphia, Pa.

Correspondence to Jack Rychik, MD, Fetal Heart Program, The Children’s Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA 19104. E-mail rychik{at}email.chop.edu

Received December 30, 2003; accepted May 20, 2004.

Background— Prenatal surgery for congenital anomalies can prevent fetal demise or alter the course of organ development, resulting in a more favorable condition at birth. The indications for fetal surgery continue to expand, yet little is known about the acute sequelae of fetal surgery on the human cardiovascular system.

Methods and Results— Echocardiography was used to evaluate the heart before, during, and early after fetal surgery for congenital anomalies, including repair of myelomeningocele (MMC, n=51), resection of intrathoracic masses (ITM, n=15), tracheal occlusion for congenital diaphragmatic hernia (CDH, n=13), and resection of sacrococcygeal teratoma (SCT, n=4). Fetuses with MMC all had normal cardiovascular systems entering into fetal surgery, whereas those with ITM, CDH, and SCT all exhibited secondary cardiovascular sequelae of the anomaly present. At fetal surgery, heart rate increased acutely, and combined cardiac output diminished at the time of fetal incision for all groups including those with MMC, which suggests diminished stroke volume. Ventricular dysfunction and valvular dysfunction were identified in all groups, as was acute constriction of the ductus arteriosus. Fetuses with ITM and SCT had the most significant changes at surgery.

Conclusions— Acute cardiovascular changes take place during fetal surgery that are likely a consequence of the physiology of the anomaly and the general effects of surgical stress, tocolytic agents, and anesthesia. Echocardiographic monitoring during fetal surgery is an important adjunct in the management of these patients.

Key Words: fetus • pregnancy • cardiac output • surgery

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