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(Circulation. 2004;110:2125-2131.)
© 2004 American Heart Association, Inc.

Congenital Heart Disease

Balloon Dilation of Severe Aortic Stenosis in the Fetus

Potential for Prevention of Hypoplastic Left Heart Syndrome: Candidate Selection, Technique, and Results of Successful Intervention

Wayne Tworetzky, MD; Louise Wilkins-Haug, MD, PhD; Russell W. Jennings, MD; Mary E. van der Velde, MD; Audrey C. Marshall, MD; Gerald R. Marx, MD; Steven D. Colan, MD; Carol B. Benson, MD; James E. Lock, MD; Stanton B. Perry, MD

From the Departments of Cardiology (Children’s Hospital) and Pediatrics (Harvard Medical School) (W.T., M.E.v.d.V., A.C.M., G.R.M., S.D.C., J.E.L., S.B.P.); Department of Surgery, Children’s Hospital and Harvard Medical School (R.W.J.); Department of Obstetrics and Gynecology, Brigham and Women’s Hospital and Harvard Medical School (L.W.-H.); and Department of Radiology, Brigham and Women’s Hospital and Harvard Medical School (C.B.B.), Boston, Mass. Dr Perry currently is at Packard Children’s Hospital, Stanford, Calif.

Correspondence to Wayne Tworetzky, MD, Department of Cardiology Children’s Hospital Boston, 300 Longwood Ave, Boston MA 02115. E-mail wayne.tworetzky{at}cardio.chboston.org

Received December 30, 2003; revision received May 28, 2004; accepted June 4, 2004.

Background— Preventing the progression of fetal aortic stenosis (AS) to hypoplastic left heart syndrome (HLHS) requires identification of fetuses with salvageable left hearts who would progress to HLHS if left untreated, a successful in utero valvotomy, and demonstration that a successful valvotomy promotes left heart growth in utero. Fetuses meeting the first criterion are undefined, and previous reports of fetal AS dilation have not evaluated the impact of intervention on in utero growth of left heart structures.

Methods and Results— We offered fetal AS dilation to 24 mothers whose fetuses had AS. At least 3 echocardiographers assigned a high probability that all 24 fetuses would progress to HLHS if left untreated. Twenty (21 to 29 weeks’ gestation) underwent attempted AS dilation, with technical success in 14. Ideal fetal positioning for cannula puncture site and course of the needle (with or without laparotomy) proved to be necessary for procedural success. Serial fetal echocardiograms after intervention demonstrated growth arrest of the left heart structures in unsuccessful cases and in those who declined the procedure, while ongoing left heart growth was seen in successful cases. Resumed left heart growth led to a 2-ventricle circulation at birth in 3 babies.

Conclusions— Fetal echocardiography can identify midgestation fetuses with AS who are at high risk for developing HLHS. Timely and successful aortic valve dilation requires ideal fetal and cannula positioning, prevents left heart growth arrest, and may result in normal ventricular anatomy and function at birth.

Key Words: aortic valve stenosis • balloon dilatation • fetus • hypoplastic left heart syndrome

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