Natural history of 107 cases of fetal aortic stenosis from a European multicenter retrospective study

H. M. Gardiner, A. Kovacevic, G. Tulzer, T. Sarkola, U. Herberg, J. Dangel, A. Öhman, J. Bartrons, J. S. Carvalho, H. Jicinska, V. Fesslova, I. Averiss, M. Mellander, Frances Bulock, Suhair Shebani, Sally Ann Clur, Ingo Daehnert, Giovanni Di Salvo, Ruth Heying, Marc GewilligEls Grijseels, Laurens Koopmann, Kaarin Makikallio, Aydin Tekay, Markku Leskinen, Nicky Manning, Nick Archer, Renate Oberhoffer, Cristina Romeo, Keld Ejvind Sørensen, Trevor Richens, Klaus Schmidt, Anna Seale, Victoria Jowett, Cecile Tissot, Viktor Tomek, Frank Uhlemann, Niels Vejlstrup, Jochen Weil, Fetal Working Group of the AEPC

Research output: Contribution to journalArticle

Abstract

Objectives: Fetal aortic valvuloplasty (FV) aims to prevent fetal aortic valve stenosis progressing into hypoplastic left heart syndrome (HLHS), which results in postnatal univentricular (UV) circulation. Despite increasing numbers of FVs performed worldwide, the natural history of the disease in fetal life remains poorly defined. The primary aim of this study was to describe the natural history of fetal aortic stenosis, and a secondary aim was to test previously published criteria designed to identify cases of emerging HLHS with the potential for a biventricular (BV) outcome after FV. Methods: From a European multicenter retrospective study of 214 fetuses with aortic stenosis (2005–2012), 107 fetuses in ongoing pregnancies that did not undergo FV were included in this study and their natural history was reported. We examined longitudinal changes in Z-scores of aortic and mitral valve and left ventricular dimensions and documented direction of flow across the foramen ovale and aortic arch, and mitral valve inflow pattern and any gestational changes. Data were used to identify fetuses satisfying the Boston criteria for emerging HLHS and estimate the proportion of these that would have been ideal FV candidates. We applied the threshold score whereby a score of 1 was assigned to fetuses for each Z-score meeting the following criteria: left ventricular length and width > 0; mitral valve diameter > −2; aortic valve diameter > −3.5; and pressure gradient across either the mitral or aortic valve > 20 mmHg. We compared the predicted circulation with known survival and final postnatal circulation (BV, UV or conversion from BV to UV). Results: Among the 107 ongoing pregnancies there were eight spontaneous fetal deaths and 99 livebirths. Five were lost to follow-up, five had comfort care and four had mild aortic stenosis not requiring intervention. There was intention-to-treat in these 85 newborns but five died prior to surgery, before circulation could be determined, and thus 80 underwent postnatal procedures with 44 BV, 29 UV and seven BV-to-UV circulatory outcomes. Of newborns with intention-to-treat, 69/85 (81%) survived ≥ 30 days. Survival at median 6 years was superior in cases with BV circulation (P = 0.041). Those with a postnatal UV circulation showed a trend towards smaller aortic valve diameters at first scan than did the BV cohort (P = 0.076), but aortic valve growth velocities were similar in both cohorts to term. In contrast, the mitral valve diameter was significantly smaller at first scan in those with postnatal UV outcomes (P = 0.004) and its growth velocity (P = 0.008), in common with the left ventricular inlet length (P = 0.004) and width (P = 0.002), were reduced significantly by term in fetuses with UV compared with BV outcome. Fetal data, recorded before 30 completed gestational weeks, from 70 treated neonates were evaluated to identify emerging HLHS. Forty-four had moderate or severe left ventricular depression and 38 of these had retrograde flow in the aortic arch and two had left-to-right flow at atrial level and reversed a-waves in the pulmonary veins. Thus 40 neonates met the criteria for emerging HLHS and BV circulation was documented in 13 (33%). Of these 40 cases, 12 (30%) had a threshold score of 4 or 5, of which five (42%) had BV circulation without fetal intervention. Conclusions: The natural history in our cohort of fetuses with aortic stenosis and known outcomes shows that a substantial proportion of fetuses meeting the criteria for emerging HLHS, with or without favorable selection criteria for FV, had a sustained BV circulation without fetal intervention. This indicates that further work is needed to refine the selection criteria to offer appropriate therapy to fetuses with aortic stenosis.

Original languageEnglish
Pages (from-to)373-381
Number of pages9
JournalUltrasound in Obstetrics and Gynecology
Volume48
Issue number3
DOIs
Publication statusPublished - Sep 1 2016

Fingerprint

Aortic Valve Stenosis
Hypoplastic Left Heart Syndrome
Natural History
Multicenter Studies
Fetus
Retrospective Studies
Aortic Valve
Mitral Valve
Thoracic Aorta
Patient Selection
Foramen Ovale
Fetal Diseases
Pregnancy
Fetal Death
Pulmonary Veins
Lost to Follow-Up
Growth
Depression
Pressure

Keywords

  • aortic valve stenosis
  • fetal heart
  • natural history
  • valvuloplasty

ASJC Scopus subject areas

  • Radiological and Ultrasound Technology
  • Reproductive Medicine
  • Radiology Nuclear Medicine and imaging
  • Obstetrics and Gynaecology

Cite this

Gardiner, H. M., Kovacevic, A., Tulzer, G., Sarkola, T., Herberg, U., Dangel, J., ... Fetal Working Group of the AEPC (2016). Natural history of 107 cases of fetal aortic stenosis from a European multicenter retrospective study. Ultrasound in Obstetrics and Gynecology, 48(3), 373-381. https://doi.org/10.1002/uog.15876

Natural history of 107 cases of fetal aortic stenosis from a European multicenter retrospective study. / Gardiner, H. M.; Kovacevic, A.; Tulzer, G.; Sarkola, T.; Herberg, U.; Dangel, J.; Öhman, A.; Bartrons, J.; Carvalho, J. S.; Jicinska, H.; Fesslova, V.; Averiss, I.; Mellander, M.; Bulock, Frances; Shebani, Suhair; Clur, Sally Ann; Daehnert, Ingo; Salvo, Giovanni Di; Heying, Ruth; Gewillig, Marc; Grijseels, Els; Koopmann, Laurens; Makikallio, Kaarin; Tekay, Aydin; Leskinen, Markku; Manning, Nicky; Archer, Nick; Oberhoffer, Renate; Romeo, Cristina; Sørensen, Keld Ejvind; Richens, Trevor; Schmidt, Klaus; Seale, Anna; Jowett, Victoria; Tissot, Cecile; Tomek, Viktor; Uhlemann, Frank; Vejlstrup, Niels; Weil, Jochen; Fetal Working Group of the AEPC.

In: Ultrasound in Obstetrics and Gynecology, Vol. 48, No. 3, 01.09.2016, p. 373-381.

Research output: Contribution to journalArticle

Gardiner, HM, Kovacevic, A, Tulzer, G, Sarkola, T, Herberg, U, Dangel, J, Öhman, A, Bartrons, J, Carvalho, JS, Jicinska, H, Fesslova, V, Averiss, I, Mellander, M, Bulock, F, Shebani, S, Clur, SA, Daehnert, I, Salvo, GD, Heying, R, Gewillig, M, Grijseels, E, Koopmann, L, Makikallio, K, Tekay, A, Leskinen, M, Manning, N, Archer, N, Oberhoffer, R, Romeo, C, Sørensen, KE, Richens, T, Schmidt, K, Seale, A, Jowett, V, Tissot, C, Tomek, V, Uhlemann, F, Vejlstrup, N, Weil, J & Fetal Working Group of the AEPC 2016, 'Natural history of 107 cases of fetal aortic stenosis from a European multicenter retrospective study', Ultrasound in Obstetrics and Gynecology, vol. 48, no. 3, pp. 373-381. https://doi.org/10.1002/uog.15876
Gardiner, H. M. ; Kovacevic, A. ; Tulzer, G. ; Sarkola, T. ; Herberg, U. ; Dangel, J. ; Öhman, A. ; Bartrons, J. ; Carvalho, J. S. ; Jicinska, H. ; Fesslova, V. ; Averiss, I. ; Mellander, M. ; Bulock, Frances ; Shebani, Suhair ; Clur, Sally Ann ; Daehnert, Ingo ; Salvo, Giovanni Di ; Heying, Ruth ; Gewillig, Marc ; Grijseels, Els ; Koopmann, Laurens ; Makikallio, Kaarin ; Tekay, Aydin ; Leskinen, Markku ; Manning, Nicky ; Archer, Nick ; Oberhoffer, Renate ; Romeo, Cristina ; Sørensen, Keld Ejvind ; Richens, Trevor ; Schmidt, Klaus ; Seale, Anna ; Jowett, Victoria ; Tissot, Cecile ; Tomek, Viktor ; Uhlemann, Frank ; Vejlstrup, Niels ; Weil, Jochen ; Fetal Working Group of the AEPC. / Natural history of 107 cases of fetal aortic stenosis from a European multicenter retrospective study. In: Ultrasound in Obstetrics and Gynecology. 2016 ; Vol. 48, No. 3. pp. 373-381.
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abstract = "Objectives: Fetal aortic valvuloplasty (FV) aims to prevent fetal aortic valve stenosis progressing into hypoplastic left heart syndrome (HLHS), which results in postnatal univentricular (UV) circulation. Despite increasing numbers of FVs performed worldwide, the natural history of the disease in fetal life remains poorly defined. The primary aim of this study was to describe the natural history of fetal aortic stenosis, and a secondary aim was to test previously published criteria designed to identify cases of emerging HLHS with the potential for a biventricular (BV) outcome after FV. Methods: From a European multicenter retrospective study of 214 fetuses with aortic stenosis (2005–2012), 107 fetuses in ongoing pregnancies that did not undergo FV were included in this study and their natural history was reported. We examined longitudinal changes in Z-scores of aortic and mitral valve and left ventricular dimensions and documented direction of flow across the foramen ovale and aortic arch, and mitral valve inflow pattern and any gestational changes. Data were used to identify fetuses satisfying the Boston criteria for emerging HLHS and estimate the proportion of these that would have been ideal FV candidates. We applied the threshold score whereby a score of 1 was assigned to fetuses for each Z-score meeting the following criteria: left ventricular length and width > 0; mitral valve diameter > −2; aortic valve diameter > −3.5; and pressure gradient across either the mitral or aortic valve > 20 mmHg. We compared the predicted circulation with known survival and final postnatal circulation (BV, UV or conversion from BV to UV). Results: Among the 107 ongoing pregnancies there were eight spontaneous fetal deaths and 99 livebirths. Five were lost to follow-up, five had comfort care and four had mild aortic stenosis not requiring intervention. There was intention-to-treat in these 85 newborns but five died prior to surgery, before circulation could be determined, and thus 80 underwent postnatal procedures with 44 BV, 29 UV and seven BV-to-UV circulatory outcomes. Of newborns with intention-to-treat, 69/85 (81{\%}) survived ≥ 30 days. Survival at median 6 years was superior in cases with BV circulation (P = 0.041). Those with a postnatal UV circulation showed a trend towards smaller aortic valve diameters at first scan than did the BV cohort (P = 0.076), but aortic valve growth velocities were similar in both cohorts to term. In contrast, the mitral valve diameter was significantly smaller at first scan in those with postnatal UV outcomes (P = 0.004) and its growth velocity (P = 0.008), in common with the left ventricular inlet length (P = 0.004) and width (P = 0.002), were reduced significantly by term in fetuses with UV compared with BV outcome. Fetal data, recorded before 30 completed gestational weeks, from 70 treated neonates were evaluated to identify emerging HLHS. Forty-four had moderate or severe left ventricular depression and 38 of these had retrograde flow in the aortic arch and two had left-to-right flow at atrial level and reversed a-waves in the pulmonary veins. Thus 40 neonates met the criteria for emerging HLHS and BV circulation was documented in 13 (33{\%}). Of these 40 cases, 12 (30{\%}) had a threshold score of 4 or 5, of which five (42{\%}) had BV circulation without fetal intervention. Conclusions: The natural history in our cohort of fetuses with aortic stenosis and known outcomes shows that a substantial proportion of fetuses meeting the criteria for emerging HLHS, with or without favorable selection criteria for FV, had a sustained BV circulation without fetal intervention. This indicates that further work is needed to refine the selection criteria to offer appropriate therapy to fetuses with aortic stenosis.",
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author = "Gardiner, {H. M.} and A. Kovacevic and G. Tulzer and T. Sarkola and U. Herberg and J. Dangel and A. {\"O}hman and J. Bartrons and Carvalho, {J. S.} and H. Jicinska and V. Fesslova and I. Averiss and M. Mellander and Frances Bulock and Suhair Shebani and Clur, {Sally Ann} and Ingo Daehnert and Salvo, {Giovanni Di} and Ruth Heying and Marc Gewillig and Els Grijseels and Laurens Koopmann and Kaarin Makikallio and Aydin Tekay and Markku Leskinen and Nicky Manning and Nick Archer and Renate Oberhoffer and Cristina Romeo and S{\o}rensen, {Keld Ejvind} and Trevor Richens and Klaus Schmidt and Anna Seale and Victoria Jowett and Cecile Tissot and Viktor Tomek and Frank Uhlemann and Niels Vejlstrup and Jochen Weil and {Fetal Working Group of the AEPC}",
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TY - JOUR

T1 - Natural history of 107 cases of fetal aortic stenosis from a European multicenter retrospective study

AU - Gardiner, H. M.

AU - Kovacevic, A.

AU - Tulzer, G.

AU - Sarkola, T.

AU - Herberg, U.

AU - Dangel, J.

AU - Öhman, A.

AU - Bartrons, J.

AU - Carvalho, J. S.

AU - Jicinska, H.

AU - Fesslova, V.

AU - Averiss, I.

AU - Mellander, M.

AU - Bulock, Frances

AU - Shebani, Suhair

AU - Clur, Sally Ann

AU - Daehnert, Ingo

AU - Salvo, Giovanni Di

AU - Heying, Ruth

AU - Gewillig, Marc

AU - Grijseels, Els

AU - Koopmann, Laurens

AU - Makikallio, Kaarin

AU - Tekay, Aydin

AU - Leskinen, Markku

AU - Manning, Nicky

AU - Archer, Nick

AU - Oberhoffer, Renate

AU - Romeo, Cristina

AU - Sørensen, Keld Ejvind

AU - Richens, Trevor

AU - Schmidt, Klaus

AU - Seale, Anna

AU - Jowett, Victoria

AU - Tissot, Cecile

AU - Tomek, Viktor

AU - Uhlemann, Frank

AU - Vejlstrup, Niels

AU - Weil, Jochen

AU - Fetal Working Group of the AEPC

PY - 2016/9/1

Y1 - 2016/9/1

N2 - Objectives: Fetal aortic valvuloplasty (FV) aims to prevent fetal aortic valve stenosis progressing into hypoplastic left heart syndrome (HLHS), which results in postnatal univentricular (UV) circulation. Despite increasing numbers of FVs performed worldwide, the natural history of the disease in fetal life remains poorly defined. The primary aim of this study was to describe the natural history of fetal aortic stenosis, and a secondary aim was to test previously published criteria designed to identify cases of emerging HLHS with the potential for a biventricular (BV) outcome after FV. Methods: From a European multicenter retrospective study of 214 fetuses with aortic stenosis (2005–2012), 107 fetuses in ongoing pregnancies that did not undergo FV were included in this study and their natural history was reported. We examined longitudinal changes in Z-scores of aortic and mitral valve and left ventricular dimensions and documented direction of flow across the foramen ovale and aortic arch, and mitral valve inflow pattern and any gestational changes. Data were used to identify fetuses satisfying the Boston criteria for emerging HLHS and estimate the proportion of these that would have been ideal FV candidates. We applied the threshold score whereby a score of 1 was assigned to fetuses for each Z-score meeting the following criteria: left ventricular length and width > 0; mitral valve diameter > −2; aortic valve diameter > −3.5; and pressure gradient across either the mitral or aortic valve > 20 mmHg. We compared the predicted circulation with known survival and final postnatal circulation (BV, UV or conversion from BV to UV). Results: Among the 107 ongoing pregnancies there were eight spontaneous fetal deaths and 99 livebirths. Five were lost to follow-up, five had comfort care and four had mild aortic stenosis not requiring intervention. There was intention-to-treat in these 85 newborns but five died prior to surgery, before circulation could be determined, and thus 80 underwent postnatal procedures with 44 BV, 29 UV and seven BV-to-UV circulatory outcomes. Of newborns with intention-to-treat, 69/85 (81%) survived ≥ 30 days. Survival at median 6 years was superior in cases with BV circulation (P = 0.041). Those with a postnatal UV circulation showed a trend towards smaller aortic valve diameters at first scan than did the BV cohort (P = 0.076), but aortic valve growth velocities were similar in both cohorts to term. In contrast, the mitral valve diameter was significantly smaller at first scan in those with postnatal UV outcomes (P = 0.004) and its growth velocity (P = 0.008), in common with the left ventricular inlet length (P = 0.004) and width (P = 0.002), were reduced significantly by term in fetuses with UV compared with BV outcome. Fetal data, recorded before 30 completed gestational weeks, from 70 treated neonates were evaluated to identify emerging HLHS. Forty-four had moderate or severe left ventricular depression and 38 of these had retrograde flow in the aortic arch and two had left-to-right flow at atrial level and reversed a-waves in the pulmonary veins. Thus 40 neonates met the criteria for emerging HLHS and BV circulation was documented in 13 (33%). Of these 40 cases, 12 (30%) had a threshold score of 4 or 5, of which five (42%) had BV circulation without fetal intervention. Conclusions: The natural history in our cohort of fetuses with aortic stenosis and known outcomes shows that a substantial proportion of fetuses meeting the criteria for emerging HLHS, with or without favorable selection criteria for FV, had a sustained BV circulation without fetal intervention. This indicates that further work is needed to refine the selection criteria to offer appropriate therapy to fetuses with aortic stenosis.

AB - Objectives: Fetal aortic valvuloplasty (FV) aims to prevent fetal aortic valve stenosis progressing into hypoplastic left heart syndrome (HLHS), which results in postnatal univentricular (UV) circulation. Despite increasing numbers of FVs performed worldwide, the natural history of the disease in fetal life remains poorly defined. The primary aim of this study was to describe the natural history of fetal aortic stenosis, and a secondary aim was to test previously published criteria designed to identify cases of emerging HLHS with the potential for a biventricular (BV) outcome after FV. Methods: From a European multicenter retrospective study of 214 fetuses with aortic stenosis (2005–2012), 107 fetuses in ongoing pregnancies that did not undergo FV were included in this study and their natural history was reported. We examined longitudinal changes in Z-scores of aortic and mitral valve and left ventricular dimensions and documented direction of flow across the foramen ovale and aortic arch, and mitral valve inflow pattern and any gestational changes. Data were used to identify fetuses satisfying the Boston criteria for emerging HLHS and estimate the proportion of these that would have been ideal FV candidates. We applied the threshold score whereby a score of 1 was assigned to fetuses for each Z-score meeting the following criteria: left ventricular length and width > 0; mitral valve diameter > −2; aortic valve diameter > −3.5; and pressure gradient across either the mitral or aortic valve > 20 mmHg. We compared the predicted circulation with known survival and final postnatal circulation (BV, UV or conversion from BV to UV). Results: Among the 107 ongoing pregnancies there were eight spontaneous fetal deaths and 99 livebirths. Five were lost to follow-up, five had comfort care and four had mild aortic stenosis not requiring intervention. There was intention-to-treat in these 85 newborns but five died prior to surgery, before circulation could be determined, and thus 80 underwent postnatal procedures with 44 BV, 29 UV and seven BV-to-UV circulatory outcomes. Of newborns with intention-to-treat, 69/85 (81%) survived ≥ 30 days. Survival at median 6 years was superior in cases with BV circulation (P = 0.041). Those with a postnatal UV circulation showed a trend towards smaller aortic valve diameters at first scan than did the BV cohort (P = 0.076), but aortic valve growth velocities were similar in both cohorts to term. In contrast, the mitral valve diameter was significantly smaller at first scan in those with postnatal UV outcomes (P = 0.004) and its growth velocity (P = 0.008), in common with the left ventricular inlet length (P = 0.004) and width (P = 0.002), were reduced significantly by term in fetuses with UV compared with BV outcome. Fetal data, recorded before 30 completed gestational weeks, from 70 treated neonates were evaluated to identify emerging HLHS. Forty-four had moderate or severe left ventricular depression and 38 of these had retrograde flow in the aortic arch and two had left-to-right flow at atrial level and reversed a-waves in the pulmonary veins. Thus 40 neonates met the criteria for emerging HLHS and BV circulation was documented in 13 (33%). Of these 40 cases, 12 (30%) had a threshold score of 4 or 5, of which five (42%) had BV circulation without fetal intervention. Conclusions: The natural history in our cohort of fetuses with aortic stenosis and known outcomes shows that a substantial proportion of fetuses meeting the criteria for emerging HLHS, with or without favorable selection criteria for FV, had a sustained BV circulation without fetal intervention. This indicates that further work is needed to refine the selection criteria to offer appropriate therapy to fetuses with aortic stenosis.

KW - aortic valve stenosis

KW - fetal heart

KW - natural history

KW - valvuloplasty

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U2 - 10.1002/uog.15876

DO - 10.1002/uog.15876

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EP - 381

JO - Ultrasound in Obstetrics and Gynecology

JF - Ultrasound in Obstetrics and Gynecology

SN - 0960-7692

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