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Balloon Atrial Septostomy in Complete Transposition of Great Arteries in Infancy

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Balloon Atrial Septostomy in Complete Transposition of Great Arteries in Infancy Br Heart J: first published as 10.1136/hrt.32.1.61 on 1 January 1970. Downloaded from British HeartJournal, I970, 32, X6i. Balloon atrial septostomy in complete transposition of great arteries in infancy A. W. Venables From Royal Children's Hospital, Melbourne, Australia The results of 26 completed balloon atrial septostomies in complete arterial transposition in infancy are described, and complications discussed. Of 7 deaths following this procedure, 3 were clearly or probably related to it or to its failure to produce an adequate septal defect, while 4 were unrelated. Atrial perforations occurred on 4 occasions. Necropsy information regarding the defects produced by the procedure is given. Anatomical features of the fossa ovalis appear to determine the size of the defect created. The effect of the procedure is illustrated by photographs of representative necropsy specimens. Apparently adequate initial defects do not guarantee satisfactory long-term palliation, and 4 of iI infants followed for more than 6 months after effective initial palliation have required surgical procedures to provide more adequate atrial mixing of blood. Despite this, the procedure appears to offer considerable advantage over initial surgical procedures to create atrial defects. The value of palliative procedures in com- Subjects and methods plete arterial transposition is indisputable. From to mid-May I23 cases of trans- ig60 i969, http://heart.bmj.com/ Most commonly, atrial septal defects arz cre- position of the great arteries in infancy were diag- ated in order to increase effective pulmonary nosed in the Cardiac Unit of the Royal Children's flow. Since I966 the balloon catheter tech- Hospital, Melbourne. These cases include 53 nique of atrial septostomy introduced by infants previously discussed (Venables, I966). Rashkind (Rashkind and Miller, I966) has Palliative procedures to create atrial septal defects come widely into use, displacing the surgical were performed in 88 infants, with 59 survivors to create who obtained effective immediate palliation. De- procedures previously employed fects were made surgically in 62, while balloon atrial septal defects (Plauth et al., I968; Ven- septostomy was completed in 26 infants. Balloon ables, I966). Though there is no doubt of the septostomy has been performed since late I966 on October 1, 2021 by guest. Protected copyright. value of this procedure in obtaining palliation in preference to initial surgical procedures, pro- in many cases (Watson and Rashkind, I967), vided balloon catheters were available. there are few detailed reports of series indicat- Balloon septostomy was performed after the ing limitations of technique and follow-up diagnosis of complete transposition of the great progress, and permitting asse3sment of its arteries had been made by selective angiocardio- true role in treatment of complete transposi- graphy from right ventricle and left atrium or left tion in infancy (Rashkind and Miller, I968; ventricle. Pressure and oxygen saturation mea- surements were not always possible when the Venables, I968). procedures were performed as emergency mea- This paper presents information regarding sures. Information about the response of these 26 infants in whom balloon atrial septostomy parameters to septostomy is therefore not available was completed as initial palliative treatment in all cases. Initially U.S. Catheter Corporation for complete transposition. The results are catheters were used, but from early in I968 the related to previous and current surgical ex- Edwards Company balloon catheter was em- perience in the same Unit (Venables, I966), ployed routinely (Venables, I968). and problems are discussed. Information is Age at the time of balloon septostomy ranged given about the necropsy findings in those from 6 hours to 7 weeks. Weight ranged from 2-I6 kg. to 4-8o kg., with a mean weight of 3-38 kg. infants who died early, either as a result of Eight infants weighed less than 3 kg. The degree technical failure or unrelated problems. of hypoxia and of consequent metabolic acidosis varied considerably. Six infants presented with Received 13 June I969. pH values in capillary (heel-prick) blood of 7TI5 Br Heart J: first published as 10.1136/hrt.32.1.61 on 1 January 1970. Downloaded from 62 A. W. Venables or less, the lowest pH recorded being 6-95. Acid- TABLE I Initial palliative procedures osis was treated with intravenous sodium bicar- bonate in while appropriate dosage preparations No. Unrelated were made for cardiac catheterization. of Early being Fur- cases deaths* late deaths ther bicarbonate was not ordinarily necessary after septostomy, the pH and base excess return- Surgical atrial septal defects, I960-68 62 22* I0 ing to normal levels and stabilizing there (Fig. i). Surgical defects, I967-68 I3t 2 I Ventricular septal defects of varying size were Balloon atrial septostomy (completed), 26 7 2 detected in I0 of the infants in whom balloon I966-69 septostomy was completed. Persistence ofthe duc- tus arteriosus was shown angiocardiographically * Includes some early failures of surgical procedures in I6 instances. One infant with ventricular septal to create adequate defects. defect required pulmonary artery banding be- t Includes 2 after abandonment of balloon cause of the development of cardiac failure after procedure because of atrial perforation. septostomy, and one infant died of heart failure due to persistence of a large ductus. In one in- fant included in the series, the attempt at septos- TABLE 2 Balloon septostomy tomy showed the presence of an atrial septal defect contemplated through which a completely filled balloon passed but abandoned readily without evidence of preliminary splitting of the fossa ovalis. No. of The outcome of the procedures is shown in cases Table i. Balloon septostomy was contemplated but abandoned in 5 of the infants operated on in Failure to introduce balloon into vein 2 i967-I968. The reasons for this are shown in Atrial perforation recognized, procedure 2 Table 2. On two occasions accidental perforation abandoned of the atrial wall occurred before septostomy was Manipulative difficulty I attempted. The procedure was abandoned and the baby treated by immediate thoracotomy, repair of the perforation, and a Blalock-Hanlon procedure. These infants have been transferred to the surgical TABLE 3 Balloon atrial septostomy group (Table I). One survived, but the other died of complications of the surgical procedure. No. of The factors responsible for early death in the cases first few days after completed balloon septostomy http://heart.bmj.com/ are set out in Table 3. Two deaths clearly repre- Procedures completed 26 sent technical failures. They were due to tricuspid Early deaths 7 Tricuspid valve laceration I Failure to split fossa ovalis I Circulatory failure I FIG. I pH and base excess levels before and Diffuse pulmonary haemorrhage, atrial i after balloon septostomy in an infant with perforation complete arterial transposition. Neonatal septicaemia Cardiac failure from persistent ductus I Anoxic organ damage I on October 1, 2021 by guest. Protected copyright. 7.5. A.M. W + 3-4 kg. 74. 73.3 TABLE 4 Initial balloon atrial septostomy (completed) 7.1 Survivor follow-up 70t No. of cases 0 Procedure performed before November 1968 -.._ Total survivors II -5. u Further procedure necessary 4 E Late deaths -10 Infection x.4 Sagittal sinus thrombosis 2 -15. 2OmEq sod-bicarb. iv. Current survivors 9 -20' Balloon septostomy Procedure performed since November 1963 I~~~~~~~~~~~~~~~~~~~~~~~~ Total survivors 8 2 3 4 5 Late deaths 0 Days of life Br Heart J: first published as 10.1136/hrt.32.1.61 on 1 January 1970. Downloaded from Balloon septostomy in complete transposition 63 valve laceration and to an inadequate defect. The of the detection of inadequate atrial defects. death from circulatory failure appeared to be re- In this series, 4 of II infants observed for lated at least partly to the presence of a greater more than 6 months since septostomy have degree of acidosis than appreciated. The remain- required further procedures to provide a ing 4 deaths were due to unrelated problems, though the baby who was moribund from diffuse more adequate atrial septal defect. The others, pulmonary haemorrhage when catheterization was including 2 infants observed for 32 and 2I begun was found at necropsy to have previously months, respectively, remain satisfactory. unrecognized atrial perforation and haemoperi- Rashkind (Rashkind and Miller, I968) re- cardium. Necropsies were performed after 6 of ported 3 repeat septostomies between i4 and the 7 early deaths. 5 months after the initial procedure, further Follow-up data are given in Table 4. Of II study being prompted by 'the development survivors with satisfactory initial palliation fol- of cardiomegaly plus some increase in cyano- lowed for more than 6 months, 4 have required sis'. further surgical palliation at ages of from 5 to 7 months. All had Blalock-Hanlon procedures, The degree of cyanosis after successful though in one a further balloon procedure was palliation has varied in the present series as first performed without satisfactory response. after successful Blalock-Hanlon procedures The 2 late deaths occurred after secondary sur- (Venables, I966). The patients who were con- gical procedures, but were unrelated to surgery. sidered to require enlargement of their atrial These deaths were due to presumed sagittal sinus defects were considerably cyanosed. Their thrombosis and to severe infection. Necropsy was condition
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