Case reports British Heart Journal, I974, 36, I040-IO4. Balloon atrial septostomy via the umbilical vein H. H. Kaye' and Michael Tynan From the Department ofCardiology, Newcastle General Hospital, Westgate Road, Newcastle upon Tyne A case of transposition of the great arteries is presented in which an adequate balloon septostomy was per- formed through the umbilical vein. Some diffxiculty was experienced in traversing the ductus venosus. The possible complications of umbilical vein catheterization are reviewed but it is suggested that some of them may be avoided since the procedure is carried out under x-ray control. The outlook for children with transposition of the left ventricle, but this reverted spontaneously to sinus great arteries has improved in recent years. Balloon rhythm. A diagnosis of transposition of the great atrial septostomy (Rashkind and Miller, I966) has arteries with only an interatrial communication was made. shown to be the Bidirectional shunting was demonstrated before septo- been palliative treatment of choice stomy which could only have been taking place at atrial (Tynan, I97I) and considerable success has been level. An unsuccessful attempt was then made to intro- achieved by surgical correction (Clarkson et al., duce a 5 5 French Rashkind catheter into the right 1972), particularly in infancy (Breckenridge et al., femoral vein, and owing to extensive damage to the 1972). vein it had to be tied off. Because the baby's condition Technical difficulties, however, can be a problem had deteriorated, it was decided to attempt a balloon in the catheter room and some authors have drawn septostomy via the umbilical vein thus saving time and attention to this when discussing balloon atrial limiting further surgical trauma. A 5.5 French Rashkind septostomy via the femoral vein (Singh, Astley, and catheter was introduced into the umbilical vein at the Burrows, I969; umbilicus but could not be manipulated through the Venables, I970). ductus venosus. However, a 4 French Rashkind catheter In this report a case is described in which sep- was similarly introduced and manipulated into the left tostomy was performed through the umbilical vein, atrium with little difficulty. The atrial septostomy was as an alternative to the femoral route. performed and the procedure terminated. Three weeks later, because of poor clinical progress Case report and persistent cyanosis, a further cardiac catheterization A male infant, who had been born normally weighing was carried out; the results are shown in the Table. 3-8 kg, was transferred to Newcastle General Hospital There had been no significant rise in the aortic oxygen when he was i day old because ofpersistent cyanosis and saturation, but it was at the mean value for late post- dyspnoea. His condition at birth was good (Apgar Io) operative results quoted by Tynan (1972a), the left and but he had deteriorated from the age of 2 hours. right atrial mean pressures were similar, and the relation On examination he showed pronounced central between the aortic oxygen saturation and the pul- cyanosis and dyspnoea. His heart rate was 15o/min, both monary to systemic flow ratio suggested that an adequate heart sounds were palpable, but there were no audible atrial septal defect was present (Tynan, 1972b). murmurs. Chest x-ray showed a normal sized heart and One month after theoriginal investigation several signs plethoric lung fields. The electrocardiogram showed suggesting thromboembolism appeared. He was noticed sinus rhythm, a mean frontal QRS axis of + IIO, and to have a number of small areas of skin infarction on the right ventricular hypertrophy. right wrist and the left small toe, and at the same time Cardiac catheterization and angiocardiography were developed a left hemiparesis which has persisted. performed on the day of admission; the haemodynamic Subsequently the baby's condition slowly improved. data are shown in the Table. The diagnostic procedure Though he required considerable assistance with feed- was performed using a right saphenous vein cut down in ing initially, at the age of 6 months he was at home and the groin. It was complicated by an episode of complete gaining weight at a satisfactory rate. At follow-up he was heart block which occurred while the catheter was in the found to be moderately cyanosed but with no signs of heart failure. Chest x-ray showed only minimal cardiac 1 Present address: The Royal Aberdeen Children's Hospital, enlargement with no increase in pulmonary plethora and Foresterhill, Aberdeen. an electrocardiogram showed an expected degree ofright Transumbilical balloon septostomy 1041 TABLE Cardiac catheterization data point out that there is no evidence that they were directly related to the umbilical vein catheteriza- Before Three weeks tion. Enterocolitis and perforation of the bowel are septostomy after sepiostomy now well-recognized complications of exchange transfusion via the umbilical vein. Their aetiology, Oxygen saturations however, remains obscure (Hey, Ellis, and Walker, Aorta 57% 59% Superior vena cava 47% 43% I972) but it is relevant to note one of the cases de- Right atrium 46% 59% scribed by Orme and Eades (I968) in which in- Pulmonary artery 86% 88% testinal perforation occurred following continuous Pulmonary vein 95% 96% infusion of dextrose via the umbilical vein. If retro- Left atrium 83% 96% grade injection of solutions into the portal vein play Pulmonary: systemic a part in the aetiology of this condition, the risk flow ratio I: I 2: I should be decreased if the procedure is carried out under x-ray control. However, even with the help Mean pressures Left atrium 3 mmHg 5 mmHg of x-rays, local damage to the vein may occur Right atrium I mmHg 5 mmHg during catheter insertion. This was probably the cause of the umbilical arteriovenous fistula de- scribed by Reagan, James, and Dutton (1970). Such damage may easily be caused using the relatively ventricular hypertrophy for transposition of the great large and stiff Rashkind catheter. arteries. Transumbilical balloon atrial septostomy has been performed at two centres in Israel (Abinader, Discussion Zeltzer, and Riss, I970; Romney, Katzuni, and Catheterization of the umbilical vein is commonly Aygen, 1972). To our knowledge the case de- employed in neonatal practice for therapeutic pur- scribed above is the first British report and taken poses but the use of this route in the diagnosis of together with the previous reports, demonstrates congenital heart disease has seldom been described. the possibility of performing an adequate balloon Linde et al. (i966) investigated 50 neonates and septostomy using the umbilical vein as an alterna- were unable to reach the heart in 36 per cent of tive to the femoral route. In view of the possibility cases under the age of 6 days. The difficulty was of serious complications following even short-term encountered, as in our case, when trying to traverse umbilical vein catheterization, it is not recom- the ductus venosus. mended that this route be used as a routine. Complications of therapeutic umbilical vein cath- eterization have been reported frequently: Syman- sky and Fox (I972) found an overall complication References rate of 35 per cent. The incidence of bacterial col- onization of the catheter, with its accompanying Abinader, E., Zeltzer, M., and Riss, E. (I970). Transumbilical atrial septostomy in the newborn. American Journal of risk of local or systemic infection, does not appear to Diseases of Children, 119, 354. be related to the duration of catheterization (Balag- Balagtas, R. C., Bell, C. E., Edwards, L. D., and Levin, S. tas et al., I97i), and it seems likely that organisms (I97i). Risk oflocal and systemic infections associated with are introduced when the catheter is inserted. When umbilical vein catheterization; a prospective study in 86 newborn patients. Pediatrics, 48, 359. considering the use of this route the special risks of Breckenridge, I. M., Oelert, H., Stark, J., Graham, G. R., bacteraemia in infants with congenital heart disease Bonham-Carter, R. E., and Waterston, D. J. (I972). should be taken into account. There appears to be Mustard's operation for transposition of the great arteries. conflicting evidence concerning the relation be- Review of 200 cases. Lancet, I, II40. Clarkson, P. M., Barratt-Boyes, B. G., Neutze, J. M., and tween thrombosis of the umbilical vein and its Lowe, J. B. (I972). Results over a ten-year period of immediate connexions and the length of time that palliation followed by corrective surgery for complete the catheter is in place (Laroche, I970; Symansky transposition of the great arteries. Circulation, 45, 125I. and Fox, I972), but there is no doubt that umbilical Hey, E. N., Ellis, M. I., and Walker, W. (1972). Ileocolitis after exchange transfusion. Lancer, I, 266. vein catheterization can lead to pulmonary em- Laroche, J. C. (1970). Umbilical catheterisation; its compli- bolism (Scott, I965) and portal phlebitis or portal cations. Biology of the Neonate, I6, IOI. vein thrombosis which may be followed by portal Linde, L. M., Higashino, S. M., Berman, G., Sapin, S. O., hypertension (Tizard, I962) or hepatic necrosis and Emmanouilides, G. C. (I966). Umbilical vessel cardiac catheterization and angiocardiography. Circulation, 34, 984. (Scott, i965). Orme, R. L. E., and Eades, S. M. (I968). Perforation of the We wish to draw attention to the occurrence of bowel in the newborn as a complication of exchange thromboembolic complications in our case, but transfusion. British MedicalJournal, 4, 349. zo42 Kaye and Tynan Rashkind, W. J., and Miller, W. W. (I966). Creation of an rizard, J. P. M. (I962). Portal hypertension following ex- atrial septal defect without thoracotomy. Yournal of the change transfusion through the umbilical vein. Proceedings American Medical Association, I96, 99I. of the Royal Society ofMedicine, 55, 772. Reagan, L. C., James, W., and Dutton, R. V. (I970). Tynan, M. (I971). Survival of infants with transposition of Umbilical artery-vein fistula. American Journal of Diseases the great arteries after balloon atrial septostomy.