Fetal cardiac interventions versus expectant management in congenital heart disease: a systematic review and meta-analysis

To evaluate biventricular circulation (BVC), live birth, and postnatal mortality after fetal cardiac intervention (FCI) compared with expectant management, and to examine outcomes according to technical success of FAV. This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Embase, Web of Science, and Cochrane Library were searched from database inception through 31 December 2025 for observational FCI studiehis systematic review and meta-analysis followed PRISs. The primary analysis was limited to studies with an internal expectant-management comparator; eligible non-comparative FAV studies were considered only for the secondary technical-success analysis. Random-effects meta-analyses were performed in Stata, and heterogeneity was assessed using I². Eleven comparative reports representing 11 independent study populations were included in the primary FCI-versus-expectant-management synthesis, comprising 775 fetuses (418 interventions and 357 controls). Overall FCI estimates included both technically successful and unsuccessful procedures. Among cohorts with available live-birth data, live birth occurred in 271/315 (86.0%) FCI cases and 287/319 (90.0%) controls, with no significant difference between groups (OR 0.680, 95% CI 0.350–1.320; p = 0.256). Postnatal death among live-born infants with available postnatal outcome data occurred in 53/271 (19.6%) in the FCI group and 94/287 (32.8%) in the expectant-management group and was lower after FCI (OR 0.457, 95% CI 0.280–0.746; p = 0.002). For FAV, postnatal death among live-born infants was lower (OR 0.419, 95% CI 0.216–0.813; p = 0.010), whereas BVC showed a non-significant trend (OR 2.260, 95% CI 0.970–5.290; p = 0.060). Fetal pulmonary valvuloplasty (FPV) showed no significant association with BVC (OR 2.430, 95% CI 0.880–6.760; p = 0.088) or postnatal death among live-born infants (OR 0.432, 95% CI 0.098–1.909; p = 0.268). Technically successful FAV was associated with higher odds of BVC and live birth compared with unsuccessful FAV. Fetal atrial septal intervention (FASI) analyses included live birth and postnatal death among live-born infants only. No statistically significant difference was found for live birth (OR 0.480, 95% CI 0.110–2.060; p = 0.325) or postnatal death among live-born infants (OR 0.433, 95% CI 0.127–1.482; p = 0.183). FAV was associated with lower odds of postnatal death among live-born infants and showed a non-significant trend toward improved BVC, while technically successful FAV was associated with higher odds of BVC and live birth than unsuccessful FAV. In contrast, comparative evidence for FPV and FASI remains sparse, and these findings should be interpreted as exploratory.