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(Circulation. 2005;111:736-741.)
© 2005 American Heart Association, Inc.

Congenital Heart Disease

Transhepatic Ultrasound-Guided Cardiac Catheterization in the Fetal Lamb

A New Approach for Cardiac Interventions in Fetuses

From the Service de Gynécologie-Obstétrique, Hôpital Rothschild, Assistance Publique Hôpitaux de Paris (J.-M.J., J.-L.B.) and Service de Cardiologie Pédiatrie, Hôpital Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris and EMIU 0016, Faculté de Médecine Necker Enfants Malades, Université Paris V (Y.B., D.B.), Paris, France.

Correspondence to Damien Bonnet, MD, Service de Cardiologie Pédiatrique, Hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris Cedex, France. E-mail damien.bonnet{at}nck.ap-hop-paris.fr

Received July 14, 2004; revision received October 27, 2004; accepted November 19, 2004.

Background— Percutaneous transventricular and fetoscopic umbilical catheterization have been applied to animal and human fetuses. These methods have a high rate of failure and complications. Here, we propose an alternative route for anterograde echocardiography-guided cardiac catheterization through a transhepatic approach of the intra-abdominal vessels in the fetal lamb.

Methods and Results— After exteriorization of the uterus in 12 pregnant ewes between 118 to 122 days’ gestation, a 4F sheath mounted over a 1.2-mm needle was placed into the intra-abdominal portion of the umbilical vein (n=2) and into the subdiaphragmatic portion of the inferior vena cava via a transhepatic approach (n=10) under ultrasound guidance. In the first 2 animals using a transumbilical approach, it was impossible to reach the heart through the ductus venosus. In the next 10 animals, using a conventional technique, echocardiography-guided catheterization of the 4 chambers was performed in the all fetuses, atrial or ventricular pacing in 6 fetuses, and ballooning of the pulmonary valve in 9 of 10 fetuses. Among the 10 fetuses catheterized through the transhepatic approach, 2 were euthanized immediately after the procedure to evaluate intraperitoneal bleeding (23 and 29 mL, respectively), and 3 died after the procedure (1 of major bleeding and 2 deaths related to balloon catheter manipulation). Finally, 5 were delivered vaginally after an uneventful pregnancy, and autopsy at day 5 did not show significant liver, vascular, or cardiac injury.

Conclusions— Echocardiography-guided fetal cardiac catheterization through a transhepatic approach is feasible and provides an interesting alternative approach for human fetal cardiac interventions.

Key Words: catheterization • ultrasonics • heart defects, congenital