Kardiale Interventionen bei Feten

Zusammenfassung

Fetale kardiale Interventionen werden minimal-invasiv als perkutane transthorakale Eingriffe unter Ultraschallkontrolle zunehmend häufiger technisch erfolgreich durchgeführt. Überwiegend erfolgen sie mit dem Ziel, die postnatale Mortalität und Morbidität zu mindern, selten auch sind sie erforderlich, um das Überleben des Feten zu gewährleisten. Die aortale Ballonvalvuloplastie erfolgt bei Feten mit schwerer Aortenstenose, um eine weiteres Wachstum der Linksherzstrukturen zu sichern und so postnatal einen biventrikulären Repair zu ermöglichen, selten als lebensrettender Notfalleingriff bei Feten mit Hydrops fetalis infolge einer Kompression und Dysfunktion des rechten Herzens durch eine ausgeprägte linksatriale und linksventrikulären Dilatation bei schwerer Aortenstenose mit konsekutiver Mitralinsuffizienz. Bei einem intakten atriale Septum können eine Atrioseptoplastie oder eine Stenteinlage zur Dekompression des linken Vorhofs und damit zur Druckentlastung der Lungenvenen führen, um die durch eine chronische pulmonalvenöse Hypertonie bedingten Gefäß- und Parenchymveränderungen der Lungen zu verhindern oder zu bessern. Eröffnung und Valvuloplastie der Pulmonalklappe bei Pulmonalatresie und schwerer Pulmonalstenose mit intakten Septum erscheinen nur in Einzelfällen indiziert zu sein, ebenfalls zur Erhaltung der ventrikulären Funktion und Größe für einen biventrikulärer Repair des Neugeborenen. Derzeit sind all diese Eingriffe nur einer sehr kleinen Gruppe von Feten mit Herzfehlern vorbehalten; es ist aber zu erwarten, dass der Stellenwert fetaler kardialer Interventionen bei Feten mit Herzfehlern durch weitere Verbesserungen der Technik und Bildgebung einerseits und durch zunehmende Erfahrungen beim klinischen Einsatz andererseits in den nächsten Jahren steigen wird.

Abstract

Fetal cardiac interventions are being performed with growing success by a minimally invasive percutaneous and transthoracic approach. The primary aim of these interventions is to minimise postnatal morbidity and mortality, rarely also to achieve intrauterine survival. Valvuloplasty in utero for severe aortic stenosis is performed in order to achieve sufficient growth of the left ventricle and to make a later biventricular repair possible. In rare cases with hydrops secondary to massive left ventricular dilatation and mitral insufficiency it is used as a salvage therapy. Premature obstruction of the foramen ovale can be treated by balloon atrioseptoplasty or stenting of the atrial septum with the aim to attain a decompression of the left atrium and consequently of the pulmonary veins. This might reduce the extent of pulmonary hypertension and the resulting vascular and parenchymal changes in affected infants. Intrauterine valvuloplasty of a highly stenotic pulmonary valve or a pulmonary atresia with intact ventricular septum in order to prevent hypoplasia of the right ventricle and to enable postnatal biventricular repair is only rarely justified. Currently these intrauterine cardiac interventions are limited to a small group of fetuses with cardiac defects. However, with enhanced imaging modalities and equipment and with growing experience, fetal cardiac interventions are likely to increase in the next years.

Schlüsselwörter

fetale kardiale Interventionen - fetale Aortovalvuloplastie - fetale Atrioseptostomie - vorzeitiger Verschluss des Foramen ovale - hypoplastisches Linksherz - Hydrops fetalis - fetales Stenting des interatrialen Septums - fetale Chirurgie - Aortenstenose - Atrioseptoplastie

Key words

fetal cardiac intervention - fetal aortovalvuloplasty - fetal atrioseptostomy - premature obstruction of foramen ovale - hypoplastic left heart - hydrops fetalis - fetal stenting of interatrial septum - fetal surgery - aortic stenosis

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