Foetal bypass: concepts and controversies

One of the most controversial and challenging surgical undertakings of the next century promises to be foetal cardiac surgery. Animal studies have been underway for several years to gain an understanding of the physiological mechanisms required to achieve this undertaking. Not since the days of crosscirculation has there been a maternal risk associated with open-heart surgery. The diagnosis of congenital heart defects with foetal ultrasound can now be made as early as 12 weeks gestation. Simple cardiac abnormalities, such as valvular stenosis or atresia, alter intracardiac flow patterns and affect normal cardiac chamber development. Without early intervention, these complex lesions often require major surgical reconstruction, beginning in the neonatal period. Foetal cardiac bypass techniques have evolved from the use of roller pumps and bubble oxygenators primed with maternal blood to the use of an axial flow pump incorporated in a right atrial to pulmonary artery or aortic shunt. Because the blood entering the right atrium is oxygenated by the placenta, an oxygenator in the bypass circuit is probably not needed. The low prime axial flow pump system avoids the dilution of the foetus with the maternal adult haemoglobin and improves the outcome. A major focus of research has concentrated on maintenance of placental blood flow with the use of vasodilators and cyclooxygenase inhibitors. Investigation with primates will be necessary to confirm the placental physiology before human operations can be performed. As the foetal bypass challenges are overcome, there is the potential for a reduction in the number of complex cardiac lesions requiring early surgical intervention in the twenty-first century.