Fetal Cardiac Intervention

While a fetus is in utero, cardiologists can carefully and precisely help treat a variety of congenital heart defects (CHD) that could otherwise cause serious health problems or may be fatal. A fetal cardiac intervention (FCI) is a needle- and catheter-based procedure guided by an ultrasound image that can help improve some life-threatening heart problems in a fetus.

The first successful fetal cardiac intervention was performed in 2001 by cardiologists and maternal-fetal medicine (MFM) specialists at Boston Children’s and Brigham and Women’s Hospital. Since then, we have advanced the procedure, and our team now offers fetal cardiac interventions for the following conditions:

• Aortic stenosis with evolving hypoplastic left heart syndrome (HLHS)
• Pulmonary valve atresia with evolving hypoplastic right heart syndrome
• Hypoplastic left heart syndrome with an intact atrial septum

The procedure starts by the pregnant patient having an epidural for anesthesia and then positioning the fetus in the uterus in a way that the intervention team can access the tiny target in the fetus’ heart. Once optimal positioning is obtained, anesthesia medication is administered to the fetus. The pregnant patient will be awake but able to receive medication to feel more relaxed. They can listen to music on headphones.

Under the guidance of an ultrasound, our MFM team will insert a long needle, similar to an amniocentesis needle, through the uterus and into the fetal chest and heart. Our interventional cardiologists then thread a balloon catheter through the needle to dilate the narrowed aortic valve, pulmonary valve, or closed atrial septum. The goal of the fetal aortic valve dilation is to open the narrowed aortic valve and increase blood flow — to prevent HLHS and achieve a two-ventricle (pumping chamber) heart, instead of a single-ventricle heart.

The Fetal Cardiology Program at Boston Children’s has performed more fetal cardiac interventions than any hospital in the world. Our team has vast experience and a deep understanding of how to approach cardiac treatments before and after birth.

Our team is comprised of interventional and imaging cardiologists, maternal-fetal medicine specialists, obstetrical radiologists, maternal and fetal anesthesiologists, nurse practitioners, nurses, and social workers. With compassion and an understanding of what your family is experiencing, we work to provide our pregnant patients with the best possible care. Our team has the expertise and experience in treating CHDs before delivery to give children a proper start toward a higher quality of life.

To determine if you and your fetus are candidates for a fetal cardiac intervention, an in-person evaluation at Boston Children’s Hospital and Brigham and Women’s Hospital is required. The first step of the evaluation, however, is handled remotely; our team will review your fetal echo images while you’re at home. We will consult your primary obstetrical and cardiology team.

If this review determines your fetus is eligible for the procedure, you will then come to Boston for a full day, in-person evaluation to further confirm eligibility for you and your fetus. If eligible, you would then have the procedure.

Initial remote evaluation steps

• Our team reviews your fetal echocardiogram remotely
• Telephone consultation with Wayne Tworetzky, MD, the director of the Fetal Cardiology Program, and his colleagues, including Fetal Cardiology Coordinator Terra Lafranchi, NP-C

In-person full-day evaluation

The morning begins at Boston Children’s:

• Fetal echocardiogram
• Consultation with Dr. Tworetzky, Terra Lafranchi, and the rest of the team, which includes a social worker
• Consultation and procedural consent with a Boston Children’s interventional cardiologist

The next sequence of evaluation steps, mostly at Brigham and Women’s:

• An obstetric ultrasound 
• A maternal-fetal medicine (MFM) consultation and procedure consent with Louise Wilkins-Haug, MD (director of Brigham and Women’s MFM department), or Stephanie Guseh, MD, and colleagues
• Consultations with Brigham and Women’s maternal anesthesia specialists
• Neonatal ICU consult (depending on gestational age of fetus)
• Hospital finance team

If you and your fetus are candidates for a cardiac intervention, the risks and benefits of the procedure will be explained in detail during these consultations. You will need to sign consent forms before proceeding.

Sample schedule

The timing of the schedule will depend on the steps of your personalized treatment plan, but the entire process can last between four to six days. Each step below typically transpires over one day, and each step should happen in this order:

1. Fly or drive to Boston and stay overnight. If you are flying to Boston, do not purchase airline tickets until we have told you that we have a plan for your fetal cardiac intervention.
2. The in-person evaluation will begin with a full-day evaluation at Boston Children’s and Brigham and Women’s with the specialists named above. You will need lodging this night.
3. A fetal cardiac intervention procedure in a Brigham and Women’s obstetrician operating room will be performed, and you will be admitted to and stay in the hospital that night. 
4. A follow-up echocardiogram at Boston Children’s and then discharge from Brigham and Women’s Hospital. (It’s recommended you then stay locally one night before traveling home.)
5. Return home and follow-up with your local obstetric and cardiology providers.

Obstetricians and cardiologists, please make early referrals of patients with fetuses showing any signs of aortic stenosis to Boston Children’s Fetal Cardiology Program. Not all fetuses with aortic stenosis will progress to HLHS, but even mild aortic stenosis in mid-gestation can progress rapidly within a couple weeks. The earlier a patient is referred, the more likely a fetal cardiac intervention can be performed in a timely fashion if needed. Please follow the steps below.

Patients, you can also refer yourself. You, too, can follow these steps:

1. Please send a request with your or your patient’s name and medical records for current pregnancy. Records should include fetal echo reports, ultrasound and MRI reports, genetic testing results, demographics, and insurance information.
   • Phone: 617-355-1499
   • Fax: 617-730-0124
   • Fetal Cardiology Second Opinion Request Form
   • Email: FCSCReferrals@childrens.harvard.edu
2. Send DICOM echo imaging to https://bch.ambrahealth.com/share/bostonchildrenshospital.
   • Physicians, if this is your first time accessing Ambra, you will need to create an account. You will have access to the studies you upload going forward. Patients, you can have access to your own images in Ambra through its self-service patient portal. Speak to your healthcare provider to learn how.
   • If you already have Ambra, our share code is BostonChildrensHospital (all one word).
   • Please email FCSCReferrals@childrens.harvard.edu and CC our Cardiology Image Service Center at CISC@childrens.harvard.edu once the studies have been uploaded so that images can be processed and reviewed as quickly as possible. This same link can be used to send images to Boston Children’s Department of Cardiology going forward. Please email CISC@childrens.harvard.edu each time you send images.
   • If you have imaging and documentation that are in a non-DICOM format (AVI, MP4, MOV, PDF, etc.), please use https://access.ambrahealth.com/share/nondicomupload. 
3. When sending images electronically:
   • Please request a link to Life Image from a member of our team by emailing fetalcardio@cardio.chboston.org. Please only open the link when you are ready to upload. Links last for 30 days; if you attempt to use it and do not make an upload, a new link will have to be sent. Please upload ultrasound/MRI images to Life Image in DICOM format.
   • Please email our team when you have uploaded or sent the images so we can review them as quickly as possible.
4. To mail images, please send a disc to:
   • ATTN: Fetal Care and Surgery Center
     Boston Children’s Hospital
     300 Longwood Ave./Pavilion 2
     Boston, MA 02115