Fetal Cardiac Intervention

This chapter addresses minimally invasive, ultrasound-guided percutaneous fetal cardiac interventions (FCI) for selected forms of congenital heart disease. The goal of FCI is to alter the natural history in utero and improve postnatal morbidity and/or mortality. The most commonly performed FCI include aortic valvuloplasty for severe mid-gestation aortic stenosis with evolving hypoplastic left heart syndrome (HLHS), pulmonary valvuloplasty for pulmonary atresia with intact ventricular septum or critical pulmonary stenosis and evolving hypoplastic right heart syndrome (HRHS), and fetal atrial septoplasty ± stent placement for established HLHS with a highly restrictive or intact atrial septum (IAS). Fetal aortic valvuloplasty and fetal pulmonary valvuloplasty are performed with the goal of achieving a biventricular circulation postnatally, thereby avoiding staged univentricular palliation. Among technically successful cases of fetal aortic valvuloplasty for evolving HLHS, approximately half achieve a biventricular outcome. For evolving HRHS, selection of appropriate candidates has been challenging, but patients have undergone successful fetal pulmonary valvuloplasty from a technical perspective. Fetal atrial septoplasty ± stent placement for established HLHS with a highly restrictive or intact atrial septum (IAS) is performed in order to improve neonatal stability and survival and perhaps mitigate pulmonary lymphangiectasia and lung disease. Although technical success and greater neonatal stability have been achieved, survival has not been significantly impacted thus far. As FCI continues to evolve with refined patient selection and technical innovation and expand to sites and patients across the world, better outcomes may be realized.