Abstract：
OBJECTIVE: To report our experience of fetal aortic valvuloplasty (FAV) for critical aortic stenosis (AS), with a focus on the postnatal evolution of the patients.
METHODS: This was a retrospective study including all fetuses with critical AS which underwent FAV in a single center between January 2011 and June 2022. FAV was performed under ultrasound guidance. Technical success was based upon balloon inflation across the aortic valve and improvement of the antegrade aortic flow across the aortic valve. At birth, a biventricular circulation (BVC) strategy was decided assuming the left ventricular (LV) systolic and diastolic function would ensure the systemic circulation.
RESULTS: Sixty-three FAV procedures were performed in 58 fetuses, at a median (range) gestational age of 26.2 (20.3-32.2) weeks. The procedure was technically successful in 50/58 (86.2%) fetuses. There were 11/58 (19.0%) cases of in-utero demise and 9/58 (15.5%) terminations of pregnancy. No patient was liveborn after an unsuccessful procedure. Thirty-eight (65.5%) infants were liveborn, at a median (range) gestational age of 38.1 (29.0-40.6) weeks, of whom 21 (55.3%) required prostaglandin treatment. Twenty-eight of the 38 (73.7%) liveborn children (48.3% of the study population) entered the BVC pathway at birth. Among them, 20 (71.4%) required an aortic valvuloplasty procedure at birth (11 (55.0%) percutaneous balloon, nine (45.0%) surgical) and eight (28.6%) did not require any treatment at birth, but, of these, five (62.5%) underwent surgical valvuloplasty between day 26 and day 1200 of age. Eleven (39.3%) of the infants with BVC at birth required a second intervention and four (14.3%) of them required a third intervention. Two (7.1%) infants who entered the BVC pathway at birth underwent conversion to univentricular circulation (UVC). None of the surviving children with BVC developed pulmonary hypertension. The overall survival rate in those with BVC at birth was 22/28 (78.6%) at a median (range) follow-up of 23.3 (2.0-112.6) months. Ten of the 58 (17.2%) patients had UVC at birth. Among these, six (60.0%) received compassionate care from birth and four (40.0%) underwent surgery. Three of the 10 patients who were UVC at birth were still alive at the latest follow-up assessment, at a median (range) gestational age of 24.3 (8.3-48.7) months.
CONCLUSIONS: FAV for critical AS led to increase of antegrade aortic flow in 86.2% of fetuses, with BVC being achieved in 48.3% (73.7% of the liveborn cases). Among patients with BVC at birth, the rate of reintervention was high, but 78.6% of these children were alive at the latest evaluation. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
METHODS: This was a retrospective study including all fetuses with critical AS which underwent FAV in a single center between January 2011 and June 2022. FAV was performed under ultrasound guidance. Technical success was based upon balloon inflation across the aortic valve and improvement of the antegrade aortic flow across the aortic valve. At birth, a biventricular circulation (BVC) strategy was decided assuming the left ventricular (LV) systolic and diastolic function would ensure the systemic circulation.
RESULTS: Sixty-three FAV procedures were performed in 58 fetuses, at a median (range) gestational age of 26.2 (20.3-32.2) weeks. The procedure was technically successful in 50/58 (86.2%) fetuses. There were 11/58 (19.0%) cases of in-utero demise and 9/58 (15.5%) terminations of pregnancy. No patient was liveborn after an unsuccessful procedure. Thirty-eight (65.5%) infants were liveborn, at a median (range) gestational age of 38.1 (29.0-40.6) weeks, of whom 21 (55.3%) required prostaglandin treatment. Twenty-eight of the 38 (73.7%) liveborn children (48.3% of the study population) entered the BVC pathway at birth. Among them, 20 (71.4%) required an aortic valvuloplasty procedure at birth (11 (55.0%) percutaneous balloon, nine (45.0%) surgical) and eight (28.6%) did not require any treatment at birth, but, of these, five (62.5%) underwent surgical valvuloplasty between day 26 and day 1200 of age. Eleven (39.3%) of the infants with BVC at birth required a second intervention and four (14.3%) of them required a third intervention. Two (7.1%) infants who entered the BVC pathway at birth underwent conversion to univentricular circulation (UVC). None of the surviving children with BVC developed pulmonary hypertension. The overall survival rate in those with BVC at birth was 22/28 (78.6%) at a median (range) follow-up of 23.3 (2.0-112.6) months. Ten of the 58 (17.2%) patients had UVC at birth. Among these, six (60.0%) received compassionate care from birth and four (40.0%) underwent surgery. Three of the 10 patients who were UVC at birth were still alive at the latest follow-up assessment, at a median (range) gestational age of 24.3 (8.3-48.7) months.
CONCLUSIONS: FAV for critical AS led to increase of antegrade aortic flow in 86.2% of fetuses, with BVC being achieved in 48.3% (73.7% of the liveborn cases). Among patients with BVC at birth, the rate of reintervention was high, but 78.6% of these children were alive at the latest evaluation. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
摘要：
目的：我们旨在报告我们在胎儿主动脉瓣成形术（FAV）治疗严重主动脉瓣狭窄（AS）的经验，重点是患者的出生后演变。
方法：这项回顾性研究得到了当地机构审查委员会的批准（n°2002-0128143827）。包括2011年1月1日至2022年6月在单个中心接受FAV的所有患有严重AS的胎儿。FAV在超声引导下进行。技术上的成功是基于跨主动脉瓣的球囊充气和跨主动脉瓣的顺行主动脉流量的改善。出生时,双心室循环（BVC）策略是在假设左心室（LV）的收缩和舒张功能将确保体循环的前提下决定的。
结果：在妊娠24.6[21.4-32.4]周时对58例胎儿进行了63例FAV。该程序在52/58（89.6％）胎儿中成功。子宫内死亡11/58（19％），妊娠终止9/58（15.5％）。手术失败后没有活出生患者。38/58（65.5％）婴儿的中位胎龄为38.1[29-40.6]周，其中21/38（55.3％）的婴儿需要前列腺素。28/38（73.7％）[28/58（48.3％）]儿童在出生时进入BVC路径。其中,20在出生时需要主动脉瓣成形术（11经皮，9手术）和8在出生时不需要任何治疗，但其中，5/8在生命的第26天和第1200天之间接受了手术瓣膜成形术。11/28（39.3％）出生时患有BVC的婴儿需要第二次干预，其中四人需要第三次干预。两名出生时进入BVC的婴儿转变为UVC。幸存的BVC患儿均未出现肺动脉高压。BVC在23.3[8-112]个月时的总体生存率为22/28（78.6％）。10例患者在出生时有UVC。其中,6人从出生起就接受了舒适护理，只有4人接受了手术。3/10的患者在最近的评估（48[22-102]个月）时仍然存活。
结论：临界主动脉瓣狭窄的FAV导致89.6％的胎儿顺行主动脉血流，48.3%的人实现了BVC(73.7%的活产)。在出生时患有BVC的患者中，再干预率高,但长期生存率令人满意.本文受版权保护。保留所有权利。
方法：这项回顾性研究得到了当地机构审查委员会的批准（n°2002-0128143827）。包括2011年1月1日至2022年6月在单个中心接受FAV的所有患有严重AS的胎儿。FAV在超声引导下进行。技术上的成功是基于跨主动脉瓣的球囊充气和跨主动脉瓣的顺行主动脉流量的改善。出生时,双心室循环（BVC）策略是在假设左心室（LV）的收缩和舒张功能将确保体循环的前提下决定的。
结果：在妊娠24.6[21.4-32.4]周时对58例胎儿进行了63例FAV。该程序在52/58（89.6％）胎儿中成功。子宫内死亡11/58（19％），妊娠终止9/58（15.5％）。手术失败后没有活出生患者。38/58（65.5％）婴儿的中位胎龄为38.1[29-40.6]周，其中21/38（55.3％）的婴儿需要前列腺素。28/38（73.7％）[28/58（48.3％）]儿童在出生时进入BVC路径。其中,20在出生时需要主动脉瓣成形术（11经皮，9手术）和8在出生时不需要任何治疗，但其中，5/8在生命的第26天和第1200天之间接受了手术瓣膜成形术。11/28（39.3％）出生时患有BVC的婴儿需要第二次干预，其中四人需要第三次干预。两名出生时进入BVC的婴儿转变为UVC。幸存的BVC患儿均未出现肺动脉高压。BVC在23.3[8-112]个月时的总体生存率为22/28（78.6％）。10例患者在出生时有UVC。其中,6人从出生起就接受了舒适护理，只有4人接受了手术。3/10的患者在最近的评估（48[22-102]个月）时仍然存活。
结论：临界主动脉瓣狭窄的FAV导致89.6％的胎儿顺行主动脉血流，48.3%的人实现了BVC(73.7%的活产)。在出生时患有BVC的患者中，再干预率高,但长期生存率令人满意.本文受版权保护。保留所有权利。
