Noninvasive Creation of an Atrial Septal Defect by Histotripsy in a Canine Model

Xu, Zhen; Owens, Gabe E.; Gordon, David; Cain, Charles A.; Ludomirsky, Achi

doi:10.1161/circulationaha.109.889071

Cited by 114 publications

(85 citation statements)

References 33 publications

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“…Questions concerning the most effective technique for opening the atrial septum in utero, including balloon atrial septoplasty versus stent placement, in addition to the optimal timing to perform the procedure to mitigate against the development of pulmonary vasculopathy, remain unanswered. [483][484][485][486] However, given the significant mortality and morbidity of HLHS with a restrictive or intact atrial septum, fetal intervention may be reasonable to perform in this disease, not only to stabilize the patient in the immediate postnatal period but also to potentially prevent or reverse the damage to the lungs and vasculature.…”

Section: Hlhs With Restrictive or Intact Atrial Septummentioning

confidence: 99%

Diagnosis and Treatment of Fetal Cardiac Disease

Donofrio¹,

Moon-Grady²,

Hornberger³

et al. 2014

Circulation

1,016

543

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Background— The goal of this statement is to review available literature and to put forth a scientific statement on the current practice of fetal cardiac medicine, including the diagnosis and management of fetal cardiovascular disease. Methods and Results— A writing group appointed by the American Heart Association reviewed the available literature pertaining to topics relevant to fetal cardiac medicine, including the diagnosis of congenital heart disease and arrhythmias, assessment of cardiac function and the cardiovascular system, and available treatment options. The American College of Cardiology/American Heart Association classification of recommendations and level of evidence for practice guidelines were applied to the current practice of fetal cardiac medicine. Recommendations relating to the specifics of fetal diagnosis, including the timing of referral for study, indications for referral, and experience suggested for performance and interpretation of studies, are presented. The components of a fetal echocardiogram are described in detail, including descriptions of the assessment of cardiac anatomy, cardiac function, and rhythm. Complementary modalities for fetal cardiac assessment are reviewed, including the use of advanced ultrasound techniques, fetal magnetic resonance imaging, and fetal magnetocardiography and electrocardiography for rhythm assessment. Models for parental counseling and a discussion of parental stress and depression assessments are reviewed. Available fetal therapies, including medical management for arrhythmias or heart failure and closed or open intervention for diseases affecting the cardiovascular system such as twin–twin transfusion syndrome, lung masses, and vascular tumors, are highlighted. Catheter-based intervention strategies to prevent the progression of disease in utero are also discussed. Recommendations for delivery planning strategies for fetuses with congenital heart disease including models based on classification of disease severity and delivery room treatment will be highlighted. Outcome assessment is reviewed to show the benefit of prenatal diagnosis and management as they affect outcome for babies with congenital heart disease. Conclusions— Fetal cardiac medicine has evolved considerably over the past 2 decades, predominantly in response to advances in imaging technology and innovations in therapies. The diagnosis of cardiac disease in the fetus is mostly made with ultrasound; however, new technologies, including 3- and 4-dimensional echocardiography, magnetic resonance imaging, and fetal electrocardiography and magnetocardiography, are available. Medical and interventional treatments for select diseases and strategies for delivery room care enable stabilization of high-risk fetuses and contribute to improved outcomes. This statement highlights what is currently known and recommended on the basis of evidence and experience in the rapidly advancing and highly specialized field of fetal cardiac care.

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Section: Hlhs With Restrictive or Intact Atrial Septummentioning

confidence: 99%

Diagnosis and Treatment of Fetal Cardiac Disease

Donofrio¹,

Moon-Grady²,

Hornberger³

et al. 2014

Circulation

1,016

543

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“…Promising animal studies have shown the potential of histotrispy, a novel ultrasonic technique that produces non-thermal, mechanical tissue fractionation through the use of high-intensity ultrasound pulses, in the non-invasive creation of atrial and ventricular septal defects [21,22]. Perhaps a measured delivery of such a therapy can result in the treatment of local or even global myocardial hypertrophy.…”

Section: Alternative Techniquesmentioning

confidence: 99%

How Can we Improve Non-Surgical Septal Reduction for Hypertrophic Obstructive Cardiomyopathy?

Cleator¹,

Kasasbeh²

2016

J Cardiovasc Dis Diagn

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The goal for treatment of medical refractory Hypertrophic Obstructive Cardiomyopathy (HCM) is reduction of the hypertrophied left ventricular septum which obstructs blood flow. A surgical approach consists of an open-heart myomectomy, while the less invasive percutaneous approach involves creating a myocardial infarction by injecting 95 to 100% ethanol through a septal artery, a procedure termed alcohol septal ablation (ASA). Although less invasive than myomectomy, there are several limitations of alcohol septal ablation. The most important appears to be full thickness infarction that is often complicated by heart block and ventricular tachycardia/fibrillation. The ideal therapy for septal hypertrophy would be to find an agent that induces a less severe injury and/or atrophy of the hypertrophied septum. We review several alternative techniques for selective injury of the septum and describe the ideal characteristics of such an ideal agent. Our central hypothesis is that the anthracycline antibiotic such as doxorubicin may be the perfect agent. Anthracycline-based chemotherapies have been used in the treatment of solid and hematological tumors for many years. These agents have known cardiotoxic side effects that are related to cumulative dose which can lead to heart failure. Although the mechanism of action of doxorubicin cardiotoxicity is controversial, it is very clear that these agents cause atrophy of the myocardium, induce apoptosis and necrosis, as well as anti-angiogenic effects. We propose that selectively treating the hypertrophied septum of HCM patients with injection of the anthracycline doxorubicin will lead to superior outcomes compared to ASA.

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“…As such, creating an atrial septal communication after birth is probably too late to mitigate the pulmonary pathological process, and an alternative such as noninvasive creation of atrial septal defect by histotripsy is still not clinically available yet. 23 Paucity of an animal model of HLHS-IAS currently prevents us from conducting an experiment that includes perforation of an intact septum with the subsequent placement of a stent. In the sheep model at the gestational age we used, the large size of the fetal FO with the little area of septum available for stent placement outside the FO renders intraseptal positioning of an 8-mm stent impossible.…”

Section: Downloaded From Stenting the Foramen Ovale In Fetal Sheepmentioning

confidence: 99%

Percutaneous Fetal Cardiac Catheterization Technique for Stenting the Foramen Ovale in a Midgestation Lamb Model

Edwards

Veldman

Nitsos

et al. 2015

Circ: Cardiovascular Interventions

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Background-Intact or highly restricted intra-atrial septum can be reliably diagnosed in the human fetus as early as 22 to 24 weeks of gestation. Fetal interventions targeting the atrial septum have used a direct approach through the atrial wall.Here, we report stenting of the foramen ovale with a large, open-cell stent via percutaneous access through the fetal hepatic vein in a sheep model. Methods and Results-In 5 fetal sheep of 109 to 111 days of gestation (term, 147 days), the fetal hepatic vein was punctured percutaneously under ultrasound guidance and a 13.3-cm 14-gauge intravenous catheter was inserted. After catheterization of the inferior vena cava, right atrium, foramen ovale, and left atrium with a guidewire and 1.8F to 2.6F tapered catheter, a self-expandable, 8×12-mm flexible open-cell stent was positioned in an unrestricted foramen ovale. Flow and fetal well-being were documented for 45 minutes after the procedure. Access to the left atrium was achieved in all 5 animals and all survived. In 4 animals, the stent was successfully positioned in the foramen ovale. One fetus was born at term and euthanized on day 3: postmortem examination confirmed the patency of the stent. The other 3 fetuses were well after being monitored by ultrasound for 45 minutes. In 1 animal, the stent dislodged immediately after release obstructing the mitral valve. This fetus developed ascites and was euthanized after 4 days. Key Words: atrial septum ◼ cardiac catheterization ◼ fetal heart ◼ foramen ovale ◼ hypoplastic left heart syndrome ◼ stent

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Noninvasive Creation of an Atrial Septal Defect by Histotripsy in a Canine Model

Cited by 114 publications

References 33 publications

Diagnosis and Treatment of Fetal Cardiac Disease

Diagnosis and Treatment of Fetal Cardiac Disease

How Can we Improve Non-Surgical Septal Reduction for Hypertrophic Obstructive Cardiomyopathy?

Percutaneous Fetal Cardiac Catheterization Technique for Stenting the Foramen Ovale in a Midgestation Lamb Model

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