Ivy Finn is a special little girl. She was born on Sept. 14, 2018 at Texas Children’s Pavilion for Women in Houston, Texas with a congenital heart defect and underwent successful cardiac surgery in her first few days of life. That was in and of itself an amazing occurrence, but not an unusual one at Texas Children’s Heart Center, ranked no. 1 in the United States for pediatric cardiology and heart surgery (U.S. News & World Report 2017, 2018, 2019).
What was unusual was that Ivy was the world’s first patient to have undergone an innovative in-utero cardiac surgery long before she was ever born. Ivy’s mother, Rachel, was referred to Texas Children’s Fetal Center by her doctors in Florida after it was discovered that Ivy had a rare congenital heart abnormality called hypoplastic left heart syndrome with intact interatrial septum. This had caused significant damage to her lungs and it was thought that nothing could be done to help Ivy. Rachel (25) had been seen at some other major U.S. children’s hospitals and turned down for in-utero treatment because of the severity of the lesion and the technical difficulty and risk of fetal treatment. That was when her doctor in Florida turned to Texas Children’s Hospital and asked for help.
Prof. Michael Belfort (Pembroke 1975), the chairman of the Department of Obstetrics and Gynecology at Baylor College of Medicine and obstetrician and gynecologist-in-chief at Texas Children’s had been waiting for a patient like Ivy for years. He had seen the devastation of this condition and was involved in a number of similar cases where technical issues made it almost impossible to do what was needed. Sadly, the inability to perform those procedures often resulted in the death of those children.
What was needed was to place a needle through the mother’s abdominal wall into her uterus, and then guide that needle (using only ultrasound) across the baby’s chest wall, through the lung, into the beating fetal heart and onto the intact septum inside the baby’s heart. Then, once the needle was touching the septum, to push it all the way through the septum dividing the two atria and deliver a catheter into the left atrium. Once the catheter was inside the atrium, a metal stent (usually used to open the coronary artery of an adult with atherosclerosis), had to be deployed to create an opening through which blood could flow from the left atrium into the right atrium at birth. In Ivy’s case, her septum was so thick and her left atrium so small, that other centers who saw Ivy declined to attempt the procedure.
Prof. Belfort had recently heard about a new laser technology used in adults to destroy prostate tissue and he wondered if it could be used to make the procedure possible. His idea was to place the thulium laser fiber inside the needle and then use it to vaporize the tissue ahead of the needle to allow it to easily pass through the thick septum. It had never been done before. After discussions with the Heart Center team and getting permission from his Fetal Therapy Board, Prof. Belfort and his team offered the experimental procedure to Rachel and her husband, Geoff, as a last resort. They didn’t take long to make their decision…it was the only hope for Ivy.
In July 2018, when Ivy was 29-5/7 weeks, a 550-μm laser fiber inside an 18G needle was used to deliver thulium laser energy (10W) (LISA Laser, San Francisco, CA, USA) inside the grape sized heart of Ivy Finn to vaporize a hole through the thick septum. The needle used to deliver the stent was then easily advanced over the fiber into the right atrium (Figure) under continuous ultrasound guidance with minimal pressure. The laser had made what was thought to be an impossible procedure, possible – and successful! Ivy tolerated the in-utero procedure and Rachel continued her pregnancy to term.
Following an uncomplicated spontaneous vaginal delivery, Ivy was delivered at 40+1 weeks with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. She then had a Norwood procedure and three months later a Glenn procedure, both of which were successful. Ivy is currently 6 months old and thriving. Her case was recently published in the medical literature and presented at a the Fetal Medicine Foundation World Congress in Spain and other teams around the world are now planning to use this new procedure to help in their most difficult patients.
In other news, Prof. Belfort visited South Africa earlier this year where he and his team worked with a team in Johannesburg to perform the first fetoscopic spina bifida repair on the African continent. The surgery went well and the baby was born at 36-5/7 weeks via cesarean section and is doing well with good neurological function moving his legs and feet. He was thrilled to be able to train the team in Johannesburg to do this innovative procedure and glad to have brought this highly specialized procedure to South Africa. Later this year, a South African doctor from the University of the Witwatersrand will travel to Houston to spend time with Prof. Belfort at Texas Children’s Hospital in the Maternal Intensive Care Unit to learn about managing the highest risk pregnant patients in one the world’s most advanced ICUs for pregnant women.
Here are some links to stories in the press:
https://people.com/human-interest/baby-surgery-in-womb-goes-home/
https://www.youtube.com/watch?v=HJfra-hg5eg
These images show the procedure used to place a stent inside a fetal heart. The stent, on its balloon tipped delivery catheter is shown in the lower right panel.
The images below are ultrasound pictures taken after the procedure while Ivy was still in-utero and show the metal stent inside Ivy’s heart (bright white structure inside the heart) on the left, while the image on the right shows color flow demonstrating the flow of blood through the stent.
Dr Michael Belfort
