Valvuloplasty in 103 fetuses with critical aortic stenosis: outcome and new predictors for postnatal circulation

Objectives Patients with prenatally diagnosed critical aortic stenosis (CAS) and evolving hypoplastic left heart syndrome (eHLHS) still carry significant morbidity and mortality. The aims of this study were to review our 20-year experience with fetal aortic valvuloplasty (FAV) in fetuses with CAS and eHLHS including early and mid-term postnatal outcome and to refine selection criteria for FAV. Methods This was a retrospective review of all fetuses with CAS and eHLHS undergoing FAV at our center since 2001. Echocardiograms and patient charts were analyzed for ventricular and valvular dimensions, as well as for hemodynamics and outcome. CART analysis was performed to investigate the predictive capacities of analyzed parameters. Results Since 2001 103 fetuses underwent 125 FAV at our center. 87.4% of fetuses had a technical successful procedure. Technical success per fetus was higher in the recent period since 2014 (96.2% (51/53) vs. 78%, p= 0.0068). 78 fetuses were liveborn after successful intervention and received further treatment. Biventricular outcome at one year of age could be achieved in 55% of liveborn patients and was significantly better when compared to those patients of the natural history cohort (23.7%) with similar inclusion criteria (p= 0.0015). Decision tree analysis based on the ratios of right and left ventricular length combined with LV pressure estimates (mitral regurgitation Vmax) showed a high sensitivity and specificity of 96.97% and 94.44% with regards to biventricular outcome without signs of PAH at one year of age. Conclusion FAV could be performed with high success rates and an acceptable risk with improving results after a learning curve. Ratios of right and left ventricular length combined with LV pressure estimates were able to predict a successful BV outcome with high sensitivity and specificity