Specialists collaborate on an aortic valvuloplasty on 29-week-old fetus
Harrington Heart & Vascular Institute Innovations - Spring 2017
JAMES STRAINIC, MD
Director, Fetal Heart Program, University Hospitals Rainbow Babies & Children’s Hospital; Assistant Professor of Pediatrics, Case Western Reserve University School of Medicine
A team of physicians recently performed a successful fetal heart procedure at University Hospitals Rainbow Babies & Children’s Hospital. The procedure, a fetal aortic valvuloplasty performed on a 29-week-old fetus, is the first heart procedure done before birth in Ohio.
This rare approach helps prevent the progression of hypoplastic left heart syndrome (HLHS) in about half of all treated patients. Babies born with HLHS are sometimes referred to as having half a heart, because the left chambers of the heart are too small to pump blood to the body. The minimally invasive procedure may make the baby healthier and more stable at birth and may decrease the number of open-heart surgeries for the child later in life.
“This particular case was a fetus with aortic stenosis with markers for evolving HLHS,” says James Strainic, MD, Director, Fetal Heart Program at UH Rainbow. “The fetus also had severe mitral valve regurgitation and exhibited signs of hydrops fetalis. The purpose of the intervention was to alter the progression of the evolving HLHS and treat the hydrops fetalis that was present. Right now, mom and baby are doing well. The discharge fetal echocardiogram demonstrated improved antegrade flow across the aortic valve, the left ventricular function improved, and the pulmonary venous flow suggested improved left atrial pressures. The flow in the transverse arch prior to the procedure was retrograde; after the procedure, the flow was mostly antegrade. Subsequent follow-up fetal echocardiograms have demonstrated left ventricular growth and continued antegrade flow in the transverse aorta.”
The procedure took place at UH Rainbow through the Congenital Heart Collaborative’s Fetal Heart Program, which offers cardiac interventions for unborn babies with developing HLHS and other critical, congenital heart conditions. The Congenital Heart Collaborative, formalized two years ago, is a partnership between UH Rainbow Babies & Children’s in Cleveland and Nationwide Children’s in Columbus, which brings together expert physicians, surgeons and teams to provide world-class care for patients and families in Northeast Ohio.
For the fetal valvuloplasty, the team used ultrasound guidance and a catheter-based approach to gain access to the fetal heart and to open the aortic valve using a tiny inflated balloon. This increases blood flow through the left ventricle of the heart to help its development.
“On the morning of the procedure, the maternal-fetal pair was evaluated by the Fetal Cardiac Intervention Team,” says Dr. Strainic. “Fetal cardiac intervention procedures are at UH Rainbow are performed with maternal epidural anesthesia. The fetus was monitored for optimal position and then provided intramuscular analgesia and a paralytic. Using a percutaneous, trans-abdominal approach under ultrasound guidance, the fetal left ventricle was accessed by passing a trocar through the fetal chest wall. A pre-mounted balloon catheter was passed through the trocar and across the aortic valve. The balloon was maximally inflated across the aortic valve. The entire time spent in the fetal heart was less than five minutes. Increased blood flow across the aortic valve was noted immediately after the procedure. The maternal-fetal pair was then monitored for complications and eventually was discharged the following morning with long-term follow-up in place.”
Aimee K. Armstrong, MD, Director of Cardiac Catheterization and Interventional Therapies at Nationwide Children’s Hospital, has performed fetal heart procedures more than a dozen times in her career, but this is her first fetal intervention patient since joining the Congenital Heart Collaborative in 2015. Dr. Armstrong built a team of experts from Nationwide Children’s, UH Rainbow and UH MacDonald Women’s hospitals, as part of the Congenital Heart Collaborative.
“By performing interventions on the fetal heart, we are able to alter the trajectory of heart and lung disease development before a baby is born with the goal of making the baby’s heart healthier at birth,” said Dr. Armstrong. “We ultimately hope to be able to decrease morbidity and mortality for these babies.”
“The Fetal Heart Program at UH Rainbow Babies & Children’s Hospital is proud to be the first site in Ohio to offer this state-of-the-art care for babies who are diagnosed with a congenital heart condition before birth,” says David Hackney, MD, Division Chief of Maternal Fetal Medicine at UH MacDonald Women’s Hospital. “Our goal is to provide comprehensive care, from initial diagnosis through the entire pregnancy and beyond.”
With UH Rainbow Babies & Children’s and UH MacDonald Women’s hospitals both under one roof, maternal-fetal medicine specialists and the Congenital Heart Collaborative team can offer the full continuum of care in rare cases like this, for optimal outcomes.
For more information or to refer a patient, please call the Cardiac Fetal Intervention Hotline at 866-929-2099.