Postnatal circulation in patients with aortic stenosis undergoing fetal aortic valvuloplasty: systematic review and meta-analysis.
Vorisek CN, Zurakowski D, Tamayo A, Axt-Fliedner R, Siepmann T, Friehs I.Ultrasound Obstet Gynecol. 2021 Nov 2. doi: 10.1002/uog.24807. Online ahead of print. PMID: 34726817
Take Home Message
- Fetal aortic balloon valvuloplasty (FAV) is feasible with very low rate of maternal complications.
- FAV can be successful in the vast majority of the cases (82%). Successful FAV results in biventricular circulation in about 50% of liveborn infants.
- Further controlled trials with standardized inclusion criteria and long term follow up are needed to evaluate the true effect of FAV in the type of postnatal circulation and quality of life achieved.
Commentary from Dr. Anna Tsirka (Hartford, CT, USA), section editor of Pediatric and Fetal Cardiology Journal Watch
The current standard treatment of HLHS remains palliative surgery resulting in univentricular circulation (UVC). Despite improved postnatal surgical and clinical management of HLHS, morbidity and mortality rates in patients with UVC remain high. Fetal aortic valvuloplasty aims to improve fetal hemodynamics, prevent myocardial damage, and promote biventricular circulation (BVC).
This study is a systematic review of the literature and meta-analysis of eligible studies investigating the type of postnatal circulation achieved in patients with AS undergoing FAV.
This analysis reviewed studies investigating the type of postnatal circulation achieved following FAV in patients diagnosed prenatally with AS. Only original papers published in peer-reviewed journals in the English language after 2000 were included. Studies with (median) follow-up less than 1 year after birth were excluded from review. Seven articles met the criteria and were included in the systematic review and meta-analysis. The flowchart below summarizes the selection review process.
A total of 266 subjects from seven studies were included. The sample size of the included studies ranged from 8 to 100.
There were no maternal deaths, and maternal complication was noted in two cases: in one case placental abruption occurred following FAV, resulting in delivery at 25 weeks’ gestation, and in another maternal preeclampsia occurred at 34 weeks, unrelated to FAV.
The table below summarizes the outcomes of all pregnancies after FAV, regardless of technical success (infant death is defined death after the neonatal period):
The following table displays the prevalence of BVC or UVC in 182 cases with prenatal diagnosis of aortic stenosis that had technically successful fetal aortic valvuloplasty and were liveborn:
The current meta-analysis shows that FAV is successful in 82% of pregnancies, and of those 97.7% deliver a liveborn infant. Of all cases of live birth after FAV, 46% achieved BVC, and 44% UVC. Of those with successful BAV, 52% achieved BVC, 40% UVC and 8% died.
None of these studies included a control group, and none of them were randomized. Well-designed international collaborative RCTs with evaluation of outcomes beyond the neonatal period to conclusively determine the postnatal circulation outcome following FAV are needed.