ABC | Volume 112, Nº5, May 2019

Guideline Brazilian Fetal Cardiology Guidelines – 2019 Arq Bras Cardiol. 2019; 112(5):600-648 is recommendable to deliver the baby and begin postnatal treatment immediately. 8. Fetal Cardiac Interventions The potential benefits of fetal cardiac interventions have been emphasized for many years. In the year 2000, Kohl et al. 188 published the worldwide experience of fetal aortic valvuloplasty, which, at that time, consisted of 12 cases, with 7 technically well-succeeded but only 1 survival. Since that time, the Boston Children’s Hospital group has initiated an invasive intrauterine cardiac therapy program, stimulating vast progress in the field and disseminating technical application throughout various other centers around the world. 189,190 The main reason for invasive procedures during fetal life is to improve outcome and postnatal prognosis, either because the fetus is at a risk of not surviving or because postnatal outcome is strongly unfavorable. Early therapy for CHD may improve the chances of myocardial and vascular remodeling and offer better chances of adapting the blood supply to the developing myocardium. Thus, provided that the technique is well Table 8.1 – Main indications for fetal cardiac interventions Aortic valvuloplasty Gestational age between 22 and 30 weeks Critical aortic stenosis with impending HLHS Thick aortic valve with little mobility Minimal or no aortic anterograde flow Reverse flow in the transverse arch Reverse shunt at the atrial level (L → R) Monophasic LV inflow (single E wave of short duration) Moderate or severe LV systolic dysfunction (subjective analysis) Critical aortic stenosis with giant LA Same criteria as previously described LV function may not be very abnormal due to the presence of massive mitral regurgitation Giant LA Pulmonary valvuloplasty Gestational age between 22 and 30 weeks Pulmonary atresia with intact interventricular septum/ critical pulmonary stenosis Thick pulmonary valve with little or no mobility Minimal or no pulmonary anterograde flow Inverted flow in the ductus arteriosus, i.e., aorta → pulmonary Monophasic RV inflow (single E wave of short duration) Some degree of RV hypoplasia or no growth during 2–4 weeks of observation Balloon atrial septostomy Gestational age between 28 and 33 weeks HLHS or variants with intact interatrial septum or minimal foramen ovale Minimal or no flow at the atrial level Dilated LA and pulmonic veins Biphasic and bidirectional pulmonary vein Doppler tracing HLHS: hypoplastic left heart syndrome; L: left; LA: left atrium; LV: left ventricle; R: right; RV: right ventricle. established, the equipment is appropriate, and, above all, the medical team is trained in fetal surgery, pediatric interventions, and Fetal Cardiology, fetal percutaneous interventions represent another form of therapy in the field of Pediatric Cardiology. 189 The main heart diseases that benefit from intervention in utero are HLHS with severe flow restriction through the interatrial septum, critical aortic valve stenosis with impending left ventricular hypoplasia, and pulmonary atresia with intact interventricular septum (PAIVS), or critical pulmonary stenosis with right ventricular hypoplasia. 191 8.1. Indications The main indications for fetal cardiac interventions are summarized in Table 8.1 and subsequently described. 8.1.1. Critical Aortic Stenosis with ImpendingHypoplastic Left Heart Syndrome Aortic stenosis is defined as the following morphological and functional characteristics: thick valve, little mobility, and turbulent or no antegrade 636