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• W2002807710 abstract "In the October issue of the Journal, Wilkins-Haug et al. provided the readers with an exhaustive overview on a challenging topic represented by in-utero cardiac interventions for hypoplastic left heart syndrome (HLHS)1. Fetal echocardiography has contributed to a better understanding of the pathophysiology of HLHS. It is now clear that HLHS at birth may be associated with a wide spectrum of sequences of abnormal left heart development in utero. In addition to the complete anatomical type of HLHS with both aortic and mitral atresia diagnosed from mid-gestation, severe aortic valve obstructions have been found to potentially impede the development of a normal left ventricle at mid-gestation leading to a small dysfunctional left ventricle at birth. It has been tempting for the pioneers of fetal echocardiography to speculate that the prenatal relief of the aortic valve obstruction would promote a functional recovery of the affected ventricle thereby allowing postnatal biventricular repair. We do not share the enthusiasm of the authors regarding the ability of fetal echocardiography to precisely assess the anatomical and hemodynamic characteristics of small left ventricule at mid-gestation. Furthermore, predicting that a small ventricle, with or without aortic obstruction, will grow enough in late gestation is an unsolved challenge. Consequently, the adequate selection of patients eligible for fetal catheterization remains a crucial issue. In addition, some small left ventricles may grow during late gestation or during the postnatal period following the postnatal relief of aortic obstruction. In the latter case, this renders the benefit of a prenatal invasive procedure even more questionable. Several attempts at in-utero aortic valve dilatation using an ultrasound-guided direct fetal transthoracic approach have been reported in the past two decades2. The major contribution from these procedures was to demonstrate that the prenatal dilatation of a stenotic aortic valve was feasible. However, looking at the results, in term of clinical success (postnatal biventricular repair) one has to admit that the initial goal has not yet been achieved. Wilkins-Haug et al.1 have precisely listed the major technical limitations associated with the direct trans-thoracic approach: (1) insertion of the needle directly into the fetal heart, making it impossible to achieve correct alignment of the device with the outflow tract in ∼50% of cases and (2) diffraction of the ultrasound beam due to the presence of the needle, making echocardiographic guidance of the device difficult. The substantial mortality rate, together with the relatively high failure rate associated with this procedure, should encourage perinatologists to reconsider the direct trans-thoracic approach. Other approaches mimicking the Seldinger-derived technique might be used to overcome these technical pitfalls3, 4. Finally, owing to previous experience with open fetal surgery for other congenital malformations5, 6, we do not believe that the option for maternal laparotomy to enhance imaging resolution or to facilitate fetal positioning would represent any substantial improvement for fetal cardiac interventions. J. M. Jouannic*, Y. Boudjemline†, J. L. Benifla*, D. Bonnet†, * Service de Gynécologie-Obstétrique, Hôpital Rothschild, Assistance Publique Hôpitaux de Paris, Université Paris VI, 33 Boulevard de Picpus, 75012 Paris, France, † Service de Cardiopédiatrie, Hôpital Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris, Université Paris V, Paris, France" @default.
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• W2002807710 date "2005-12-22" @default.
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• W2002807710 title "Re: <i>In‐utero</i> intervention for hypoplastic left heart syndrome: for which fetus and for what?" @default.
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• W2002807710 doi "https://doi.org/10.1002/uog.2679" @default.
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