Key result
Fetal aortic valvuloplasty achieved a biventricular outcome at 1 year of age in 55% of liveborn patients, significantly higher than the 23.7% rate in a natural history cohort (P=0.0015).
Why the study?
The authors sought to review experience with fetal aortic valvuloplasty in critical aortic stenosis and evolving hypoplastic left heart syndrome, assess postnatal outcomes, and refine selection criteria by identifying preprocedural predictors of biventricular outcome.
Does fetal aortic valvuloplasty improve the rate of biventricular circulation at 1 year of age in fetuses with critical aortic stenosis and evolving hypoplastic left heart syndrome compared to natural history?
Cohort (n=103)
No
Does fetal aortic valvuloplasty improve the rate of biventricular circulation at 1 year of age in fetuses with critical aortic stenosis and evolving hypoplastic left heart syndrome compared to natural history?
Absolute Event Rate: 55% vs 23.7%
p-value: p=0.0015
Fetal aortic valvuloplasty in fetuses with critical aortic stenosis and evolving hypoplastic left heart syndrome achieves a 55% biventricular outcome rate at 1 year, which can be accurately predicted by pre-procedural RV/LV length ratio and LV pressure estimates.
Supports FAV consideration in select critical AS cases; leaves open causal benefit without randomized confirmation.
OBJECTIVES: To review our experience with fetal aortic valvuloplasty (FAV) in fetuses with critical aortic stenosis (CAS) and evolving hypoplastic left heart syndrome (eHLHS), including short- and medium-term postnatal outcome, and to refine selection criteria for FAV by identifying preprocedural predictors of biventricular (BV) outcome. METHODS: This was a retrospective review of all fetuses with CAS and eHLHS undergoing FAV at our center between December 2001 and September 2020. Echocardiograms and patient charts were analyzed for pre-FAV ventricular and valvular dimensions and hemodynamics and for postnatal procedures and outcomes. The primary endpoints were type of circulation 28 days after birth and at 1 year of age. Classification and regression-tree analysis was performed to investigate the predictive capacity of pre-FAV parameters for BV circulation at 1 year of age. RESULTS: During the study period, 103 fetuses underwent 125 FAVs at our center, of which 87.4% had a technically successful procedure. Technical success per fetus was higher in the more recent period (from 2014) than in the earlier period (96.2% (51/53) vs 78.0% (39/50); P = 0.0068). Eighty fetuses were liveborn after successful intervention and received further treatment. BV outcome at 1 year of age was achieved in 55% of liveborn patients in our cohort after successful FAV, which is significantly higher than the BV-outcome rate (23.7%) in a previously published natural history cohort fulfilling the same criteria for eHLHS (P = 0.0015). Decision-tree analysis based on the ratio of right to left ventricular (RV/LV) length combined with LV pressure (mitral valve regurgitation maximum velocity (MR-Vmax)) had a sensitivity of 96.97% and a specificity of 94.44% for predicting BV outcome without signs of pulmonary arterial hypertension at 1 year of age. The highest probability for a BV outcome was reached for fetuses with a pre-FAV RV/LV length ratio of < 1.094 (96.4%) and for those fetuses with a RV/LV length ratio ≥ 1.094 to < 1.135 combined with a MR-Vmax of ≥ 3.14 m/s (100%). CONCLUSIONS: FAV could be performed with high success rates and an acceptable risk with improving results after a learning curve. Pre-FAV RV/LV length ratio combined with LV pressure estimates were able to predict a successful BV outcome at 1 year of age with high sensitivity and specificity.
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Tulzer et al. (2021) conducted a cohort in Critical aortic stenosis and evolving hypoplastic left heart syndrome (n=103). Fetal aortic valvuloplasty vs. Natural history cohort was evaluated on Biventricular circulation at 1 year of age (p=0.0015). Fetal aortic valvuloplasty achieved a biventricular outcome at 1 year of age in 55% of liveborn patients, significantly higher than the 23.7% rate in a natural history cohort (P=0.0015).
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