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Table of Contents
LETTER TO EDITOR
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 58-59

Anesthesia for fetal intervention for congenital aortic stenosis


Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Date of Submission01-Aug-2020
Date of Decision27-Aug-2020
Date of Acceptance07-Sep-2020
Date of Web Publication05-Oct-2020

Correspondence Address:
Dr. Lakshmi Kumar
Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Kochi, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/BJOA.BJOA_170_20

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How to cite this article:
Varghese R, Puthenveettil N, Rajan S, Kumar L. Anesthesia for fetal intervention for congenital aortic stenosis. Bali J Anaesthesiol 2021;5:58-9

How to cite this URL:
Varghese R, Puthenveettil N, Rajan S, Kumar L. Anesthesia for fetal intervention for congenital aortic stenosis. Bali J Anaesthesiol [serial online] 2021 [cited 2021 Mar 3];5:58-9. Available from: https://www.bjoaonline.com/text.asp?2021/5/1/58/308886



Sir,

A 38-year-old second gravida presented at 28th week of pregnancy for the management of critical fetal aortic stenosis. Fetal echocardiography revealed a dysfunctional left ventricle, moderate mitral regurgitation, reverse flow into aortic arch with good right ventricle function [Figure 1]a. She was scheduled to undergo fetal aortic balloon valvotomy under general anesthesia.
Figure 1: (a) Fetal echo showing critical aortic stenosis. (b) Balloon wire assembly across aortic valve

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After ensuring an optimal fetal lie, the patient was given general anesthesia. In order to ensure immobility during intervention, the fetus was anesthetized by intramuscular injection of vecuronium 200 μg/kg, fentanyl 10 μg/kg, atropine 20 μg/kg under ultrasonographic guidance. Then a needle was passed through the uterus and across the chest wall of the fetus into the left ventricular (LV) apex to reach the aortic valve. A balloon wire assembly was then passed across aortic valve and the balloon inflated repetitively until flow was established [Figure 1]b. Fetal bradycardia during procedure was treated with intracardiac administration of adrenaline (10 μg/kg) on two occasions. After confirmation of a desired effect on aortic blood flow, the patient was extubated. Her postoperative management included magnesium sulfate infusion at 2 g/h for 18 h and oral digoxin at 0.25 mg twice daily until delivery. She underwent an elective cesarean section at 37 weeks' gestation with advice for continued cardiac perinatal care for the baby.

Severe aortic stenosis in the newborn is a rare condition with an incidence of 1 in 10,000 that can evolve to hypoplastic left heart syndrome (HLHS).[1],[2] Fetal interventions for aortic stenosis evolving to HLHS have been recommended by the American Heart Association[3] to promote forward flow, allow biventricular function to develop, and allow candidacy for repair. Anesthetic challenges include care of a pregnant patient, modifying fetal stress responses during the procedure, provision of fetal anesthesia or analgesia, and maintenance of maternal and fetal homeostasis.[4]

The ideal timing for the intervention is during the second trimester for which maternal safety and good fetal outcomes have been documented.[5] However, fetal intervention alone may not be adequate in all cases and delivery must be planned at a center equipped for perinatal cardiac care and the need for palliative surgery, valve replacement, and long-term follow-up.

Although the general anesthesia to the mother could also provide fetal anesthesia, we needed to supplement analgesia and fetal immobility by intramuscular fetal injections. Fetal bradycardia during ballooning of the valve is a well-recognized complication with an incidence of 37.5%.[1] Other procedural risks included hemopericardium and LV thrombus for the baby and induction of preterm labor in the mother. The fetus had minimal hemopericardium following intervention that resolved in a few minutes. Magnesium sulfate was infused to prevent preterm labor and periodic fetal echocardiography and fetal monitoring were instituted.

We wish to highlight this case as an evolving procedure for fetal cardiac interventions. The provision of combined anesthesia for the mother and fetus is the challenge for the anesthesiologist. A multidisciplinary team involving pediatric cardiologist, perinatologist, and anesthesiologist is mandatory and postoperative follow-up for fetal LV function is required.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tworetzky W, Wilkins-Haug L, Jennings RW, van der Velde ME, Marshall CA, Marx GR et al. Balloon dilatation of severe aortic stenosis in the fetus: Potential for prevention of hypoplastic left heart syndrome: Candidate selection, technique, and results of successful intervention. Circulation 2004;110:2125-31.  Back to cited text no. 1
    
2.
Donofrio MT, Moon-Grady AJ, Hornberger LK, Copel JA, Sklansky MS, Abuhamad A, et al. Diagnosis and treatment of fetal cardiac disease: A scientific statement from the American Heart Association. Circulation 2014;129:2183-242.  Back to cited text no. 2
    
3.
Wilkins-Haug LE, Benson CB, Tworetzky W, Marshall AC, Jennings RW, Lock JE. In-utero intervention for hypoplastic left heart syndrome-a perinatologist's perspective. Ultrasound Obstet Gynecol 2005;26:481-6.  Back to cited text no. 3
    
4.
Gupta R, Kilby M, Cooper G. Fetal surgery and anesthetic implications. Continuing education in Anaesthesia. Crit Care Pain 2008;2:71-5.  Back to cited text no. 4
    
5.
Wohlmuth C, Tulzer G, Arzt W, Gitter R, Wertaschnigg D. Maternal aspects of fetal cardiac intervention. Ultrasound Obstet Gynecol 2014;44:532-7.  Back to cited text no. 5
    


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