Balloon Atrioseptostomy Research Articles

Balloon atrioseptostomy under echocardiographic and fluoroscopic guide in patients with congenital heart diseases under 3 months in a national reference pediatric center

Balloon atrioseptostomy is an emergency procedure in congenital heart diseases requiring an atrial septal defect to increase cardiac output in right-sided obstructive lesions or to improve mixing in patients with transposition of the great arteries. This procedure is currently performed with both fluoroscopy and echocardiography. The main objective is to describe our experience with the use of balloon atrioseptostomy under echocardiographic and fluoroscopic guidance in patients under 3 months. A descriptive, comparative and retrospective study in patients in whom balloon atrioseptostomy was performed under echocardiographic and fluoroscopic guidance between 2018 and 2023 in a referral hospital in Peru. 36 patients were analyzed, of which 21 were from the fluoroscopy group. and 15 patients from the echocardiography group. More than 2/3 of the cases were males, and more than 60% of patients in both groups had transposition of the great vessels. No significant differences were found in terms of ventilatory support and inotropic support. The success of the procedure was 100% in both groups, without complications. Both balloon atrioseptostomy performed by fluoroscopy and those performed by echocardiography were successful and without complications, emphasizing that the one performed by echocardiography is performed in the patient's crib, avoiding the transfer of the critical unit to the angiography room and without the use of radiation.

Improvised bespoke technique for atrial septostomy in the shortage of atrioseptostomy balloon catheters.

Atrioseptostomy balloon catheter is an essential item to have on our shelves. However, the recall and shortage in production of the commonly used balloon atrioseptostomy catheters posed an imminent threat to our patients. Herein, we present the case of a newborn with a post-natal diagnosis of simple transposition of great arteries and restrictive atrial communication where repeated static balloon atrial septostomy using a 9 mm x 20 mm Sterling balloon failed to improve his status. We had to improvise per-operatively a new bespoke technique to perform a vital pull-through balloon atrial septostomy. The distal third of a 10 mm x 20 mm semi-compliant Cristal balloon was exteriorised out the tip of a 6-Fr 55 cm Cook Flexor sheath in the left atrium, and both were simultaneously pulled back to the right atrium to create an 8 mm septal defect. The procedure was successful without any complications. The baby was weaned off prostaglandin on day 3 and surgically repaired on day 5 with excellent results.

Creation of atrial communication in patients with pulmonary hypertension: from balloon atrioseptostomy to atrial flow regulator

Creation of atrial communication in patients with pulmonary hypertension: from balloon atrioseptostomy to atrial flow regulator

Neurodevelopmental and functional outcome in hypoplastic left heart syndrome after Hybrid procedure as stage I.

Patients with hypoplastic left heart syndrome (HLHS) undergoing staged palliation until Fontan procedure are at risk for impaired neurodevelopmental (ND) outcome. The Hybrid procedure with bilateral pulmonary artery banding, ductal stenting, and balloon atrioseptostomy may offer a less invasive stage I procedure compared to the Norwood stage I procedure avoiding early neonatal cardiopulmonary bypass (CPB) surgery. Despite altered fetal cerebral hemodynamics, the type of stage I procedure may be a covariate influencing ND outcome and functional outcome may also be altered due to postponing neonatal CPB surgery. Within this review, we analyzed ND outcome as well as functional outcome after Hybrid procedure as stage I procedure. The review analyzed original publications (OPs) published before March 15, 2022, identified by Cochrane, EMBASE, OVID, Scopus, and Web of science. An OP was included if short-to-long-term neurodevelopment outcome, brain development, somatic, and cardiac outcome in patients for HLHS and variants treated by Hybrid procedure were analyzed. In addition to database searches, we reviewed all references of the analyzed OP to obtain a comprehensive list of available studies. The author, year of publication, demographic characteristics of study population, study design (prospective or retrospective), study assessment, and main findings were summarized. Twenty-one OPs were included with data of patients with ND outcome and functional cardiac outcome. Overall, there is an impaired mid-term ND outcome in patients with Hybrid procedure as stage I for HLHS. Only slight differences between stage I procedures (Hybrid vs. Norwood) in two comparing studies have been determined affecting right ventricular remodeling, short- and mid-term ND outcome, reduced brain growth until two years of age, sufficient quality of life, and altered hemodynamics influencing brain volumes and cerebral perfusion pattern. Despite some minor differences regarding the mid-term follow-up in patients with HLHS comparing Hybrid vs. Norwood procedure, its impact on ND outcome seems rather low. This may be explained by the large number of covariates as well as the small study populations and the different selection criteria for patients undergoing Hybrid or Norwood procedure as stage I.

Balloon Atrial Septostomy: Does the Balloon Size Matter?

Dextro-transposition of the great arteries is a congenital heart defect with eventually lethal life-threatening consequences of hypoxic low cardiac output. When a balloon atrial septostomy (BAS) is needed, it is performed shortly after birth to create an interatrial shunt and improve systemic blood oxygenation and haemodynamic conditions. In 2019 and 2020, the withdrawal of some balloon atrioseptostomy catheters from the market led to increased use of catheters with different materials, shapes, and sizes. The main objective of this study was to investigate whether the size of the Miller and Fogarty balloon (Edwards Lifesciences) in its 2 variations, the 4.0 cc and the 1.8 cc, had a different impact on the systemic oxygen saturation, on the atrial septal defect (ASD) size, or on the type and frequency of procedure-related complications. We conducted a retrospective study on 134 consecutive patients diagnosed with dextrotransposition of the great arteries between 2002 and 2018 who underwent BAS in a tertiary paediatric hospital in Canada. BAS resulted in a significant increase in oxygen saturation of 18.91% ± 12.95% points (P < 0.0001) and a significant increase in the resulting ASD by 3.92 ± 1.58 mm (P < 0.0001). There was no significant difference in resulting oxygen saturation (P= 0.8370) or the final ASD size (P= 0.2193) based on the balloon size. Severe or life-threatening complications were rare (1%) with no subsequent patient demise. This is the first study to show that the small balloon is as efficient as the large balloon catheter including in premature patients. This raises the question whether different balloon sizes are necessary.

Successful combination treatment with transcatheter balloon atrioseptostomy and bilateral pulmonary artery banding in a collapsed preterm neonate.

There has been an increase in the use of extracorporeal membrane oxygenation for severe neonatal cardiac failure. However, the frequency of complications is high, particularly in preterm and low-birth-weight neonates. Herein, we present combination treatment with transcatheter balloon atrioseptostomy and bilateral pulmonary artery banding in a collapsed preterm neonate. This strategy can be an alternative to circulatory support using extracorporeal membrane oxygenation.

A low incidence of preoperative neurosonographic abnormalities in neonates with heart defects

Background and aimTo investigate whether neonates with prenatally detected congenital heart defects (CHD) demonstrate cerebral abnormalities on early preoperative cranial ultrasound (CUS), compared to healthy neonates, and to measure brain structures to assess brain growth and development in both groups. Study design, subjects and outcome measuresProspective cohort study with controls. Between September 2013 and May 2016 consecutive cases of prenatally detected severe isolated CHD were included. Neonatal CUS was performed shortly after birth, before surgery and in a healthy control group. Blinded images were reviewed for brain abnormalities and various measurements of intracranial structures were compared. ResultsCUS was performed in 59 healthy controls and 50 CHD cases. Physiological CUS variants were present in 54% of controls and in 52% of CHD cases. Abnormalities requiring additional monitoring (both significant and minor) were identified in four controls (7%) and five CHD neonates (10%). Significant abnormalities were only identified in four CHD neonates (8%) and never in controls. A separate analysis of an additional 8 CHD neonates after endovascular intervention demonstrated arterial stroke in two cases that underwent balloon atrioseptostomy (BAS). Cerebral measurements were smaller in CHD neonates, except for the cerebrospinal fluid measurements, which were similar to the controls. ConclusionsThe prevalence of significant preoperative CUS abnormalities in CHD cases was lower than previously reported, which may be partially caused by a guarding effect of a prenatal diagnosis. Arterial stroke occurred only in cases after BAS. As expected, neonates with CHD display slightly smaller head size and cerebral growth.

P02.07: Prediction of emergency balloon atrioseptostomy at birth in transposition of the great arteries: a different approach

P02.07: Prediction of emergency balloon atrioseptostomy at birth in transposition of the great arteries: a different approach

Interventional Treatment of Cardiac Emergencies in Children with Congenital Heart Diseases

Abstract Cardiac emergencies in children represent an extremely important issue in medical practice. In general, interventional treatment could be optional in many situations, however it can be indicated in emergency conditions. There are many diseases at pediatric age that can benefit from interventional treatment, thus reducing the surgical risks and subsequent complications. Balloon atrioseptostomy, patent ductus arteriosus (PDA) closure, percutaneous or hybrid closure of a ventricular septal defect, pulmonary or aortic valvuloplasty, balloon angioplasty for aortic coarctation, implantation of a stent for coarctation of the aorta, for severe stenosis of the infundibulum of the right ventricle, or for PDA correction are among the procedures that can be performed in emergency situations. This review aims to present the current state of the art in the field of pediatric interventional cardiology.

OC32 HYBRID PALLIATION FOR HYPOPLASTIC LEFT HEART SYNDROME AND VARIANTS: A SINGLE CENTER 5-YEAR EXPERIENCE

Background: Hybrid palliation is an alternative to Norwood stage I for the initial management of hypoplastic left heart syndrome (HLHS). We aimed to report our experience with hybrid strategy in HLHS over 5 years in a tertiary care Institution. Methods and Results: Forty-four consecutive patients with HLHS or variants underwent hybrid palliation at a mean age of 2.7 days and mean weight of 3.08 Kg. Balloon atrioseptostomy was required in 5 patients and surgical septectomy in 2 cases. In-hospital death was 11% (5 patients, including 2 preterms and 1 congenital atrioventricular block). Three high-risk patients were diverted to rescue Norwood operation between 37 and 60 days, with 2 early deaths. Interstage mortality was 11% (5 patients, including 1 preterm and 2 intracranial hemorrhage). Fifteen patients required interventional procedures during interstage (mean age 3 months), such as atrial septal dilatation (3 cases) or stenting (7 cases), ductal stent dilatation (9 cases) or restenting (2 cases). Three patients underwent stage II operation in other Institutions. At a mean age of 6 months, 14 patients had comprehensive Norwood stage I-II, whereas 14 received biventricular repair. Survival after surgical stage II was 79% (11 patients) and 93% (13 patients), respectively. All 11 patients after comprehensive I-II and 4/13 after biventricular repair required interventional procedures for pulmonary branches stenosis, either balloon dilatation (16 procedures) or stenting (7 procedures). Four patients underwent Fontan operation and 7 are currently awaiting. Overall survival is 76%. Conclusions: In our experience hybrid palliation has been the treatment of choice for HLHS and variants, unless contraindicated by the presence of aortic reverse coarctation or excessive ductal diameter. Despite the tendency described by the Society of Thoracic Surgeons Congenital Heart Surgery 2015 Database, that institutions with higher hybrid use are expected to have low annual HLHS case volume (&lt;5/year), our average case volume is almost double (9/year). Besides, our in-hospital mortality lies below that reported by STS database. Moreover, hybrid approach resulted in a successful bridge to biventricular repair in as much as 7 patients with hypoplastic mitral and aortic valves, who would have not been eligible for biventricular repair at birth.

RESULTS OF APPLICATION OF THE MODIFIED “CLOSED” METHOD OF REIMPLANTATION OF CORONARY ARTERIES IN ARTERIAL SWITCH OPERATION

Introduction. Currently, the standard surgical treatment of patients with transposition of the great arteries (TGA) is an arterial switch operation in the neonatal period. Reimplantation of the coronary arteries during the operation is the key to success. Therefore, constant search for new and modification of known techniques are ongoing. The goal of our work was to present the results of arterial switch operation using a modified closed technique for reimplantation of the coronary arteries. Materials and Methods. During the period from 2011 to December, 2016, in Research Institute — Regional Clinical Hospital No. 1 n.a. Prof. S.V. Ochapovsky, 63 operations of arterial switch using modified closed technique reimplantation of the coronary arteries were performed. The average age at operation was 4.77±2.54 days; the average weight was 3.33±0.35 kg. On average, the operation was performed on the 5th day after birth. Diagnoses: Patients with simple TGA (n=49); patients with TMA and ventricular septal defect (VSD) (n=11); patients with TGS and VSD (including one patient with multiple defects) who had obstruction of the aortic arch (n=3). The study showed that the only limitation of the modified closed method for reimplantation of the coronary arteries was an intramural course of the coronary arteries. 58 patients (92%) received alprostadil infusion; 22 patients (34.9%) received balloon atrioseptostomy (Rashkind procedure). Results. The hospital mortality rate was 7.93% (5 patients). The mortality rates were 6.1% (3 patients in the 49 operations) in the group with simple TGA and 18.1% (2/11 patients) in patients with VSD. No fatal outcomes occurred among patients with an anomaly of the aortic arc. The causes of mortality were the multiple organ failure (2 patients) and sepsis in the presence of necrotizing enterocolitis (3 patients). Discussion. Arterial switch operation at the present stage of pediatric cardiac surgery development is the operation of choice for patients with the transposition of the great vessels with feasible biventricular correction. Mortality was primarily due to the initial severity of patient condition and concomitant infection. Closed technique for reimplantation can improve the control of bleeding by reducing the number of weak spots of the aortic anastomosis (weak spots in U-shaped or trap door anastomoses are the areas of tying the yarns to create neoaortic root) and by generating the neoaortic sinotubular junction which reduces the risk of aortic insufficiency. Analysis of literature data and our own observations suggest that the closed technique and its modifications reduce the likelihood of coronary ischemia. Reimplantation of the coronary arteries by the closed procedure is feasible in case of any coronary anatomy except intramural coronary artery. Moreover, our modification allows to reduce the time of myocardial ischemia (due to the absence of a stage for aortic clamp removal for the filling neoaorta with blood) and, consequently, the duration of cardiopulmonary bypass and the time of entire procedure.

Percutaneous balloon atrial septostomy on top of venoarterial extracorporeal membrane oxygenation results in safe and effective left heart decompression.

Transcatheter techniques are emerging for left atrial (LA) decompression under venoarterial extracorporeal membrane oxygenation (VA-ECMO). We aimed to assess whether balloon atrioseptostomy (BAS) is a safe and efficient strategy. All patients who underwent percutaneous static BAS under VA-ECMO at four tertiary institutions were retrospectively reviewed. From 2000 to 2014, BAS was performed in 64 patients (32 adults and 32 children). Indications for ECMO support included acute myocarditis (31.3%) and non-myocarditis cardiac disease, mostly end-stage dilated cardiomyopathy (32.8%). BAS was required because of pulmonary oedema/haemorrhage and left ventricular (LV) distension. The mean balloon diameter was 21.8 ± 8.4mm. Adequate LA decompression was achieved in all patients. Mean LA pressure fell from 24.2 ± 6.9 mmHg to 7.8 ± 2.6 mmHg ( p < 0.001). The left-to-right atrial pressure gradient fell from 17.2 ± 7.1 mmHg to 0.09 ± 0.5 mmHg ( p < 0.001). Echocardiography showed an unrestrictive left-to-right atrial shunting in all patients. Improvement of day 1 chest X-ray was observed in 76.6% of patients, clinical status in 98.4% of patients and pulmonary haemorrhage in 14 out of 14 patients. Complications occurred in 9.4% of patients, representing pericardial effusion, fast atrial fibrillation, ventricular fibrillation requiring defibrillation, transient complete heart block and femoral venous dissection requiring covered stent placement. In the 37 (57.8%) patients who were successfully decannulated, the median ECMO duration was 9 (range: 4-24) days. After a median follow-up of 12.3 (range: 0.1-142) months, 35.9% patients died, 17.2% received a LV assist device as a bridge to transplantation, 31.2% were transplanted and 56.2% were home discharged and alive. Percutaneous BAS may be a safe and efficient strategy for discharging the LA in both adults and children supported by VA-ECMO.

Pericardial tamponade as a fatal complication during atrial septostomy in the critically ill neonate with hypoplastic left heart syndrome and intact atrial septum: a case report as a viewpoint of a cardiac catheterization laboratory nurse.

2016;11(3-4):137. VII. nacionalni sastanak o kardiovaskularnim intervencijama s međunarodnim sudjelovanjem VI. sastanak intervencijskih kardioloskih medicinskih sestara i tehnicara A critically ill female newborn with profound hypoxemia and acidosis was transferred from the county hospital with presumptive diagnosis of complex congenital heart disease. A hypoplastic left heart syndrome with double outlet right ventricle, restrictive ventricular septal defect and aortic coarctation was diagnosed in our institution by echocardiography and cardiac catheterization.1 Repetitive ventricular tachycardias with hemodynamic deterioration complicated catheterization procedure. In a dismal situation, atrial septostomy was performed. Because paroxysmal supraventricural tachycardia during balloon atrioseptostomy, the perforation of right atrium was caused by catheter manipulations. Followed by an abrupt loss of atrial pressure. Cardiac tamponade was recognized immediately and confirmed by echocardiography. Pericardial drainage was instituted right away, together with blood transfusions. An urgent sternotomy with surgical closure of punctured site was performed on the catheterization table. Only a transient hemodynamic stabilization followed, but eventually the baby died because of irretrievable cardiac arrest in spite of resuscitation efforts.

Pulmonary Root Translocation with the Lecompte Maneuver: For Transposition of the Great Arteries with Ventricular Septal Defect and Pulmonary Stenosis

A five-month-old boy who had undergone previously transcatheter balloon atrioseptostomy at 3 days of age for complete transposition of the great arteries with ventricular septal defect and pulmonary stenosis underwent pulmonary root translocation with the Lecompte maneuver. This operation has the advantages of maintaining pulmonary valve function, preserving the capacity for growth, and avoiding problems inherent to the right ventricular to pulmonary artery conduit. This patient progressed well for 9 months postoperatively and we report this case of pulmonary root translocation with the Lecompte maneuver.

P20.07: Fetal balloon atrioseptostomy and interatrial stent: a single center experience

Hypoplastic left heart syndrome (HLHS) with restrictive or closed foramen ovale (Fo) is a fatal condition. In our experience the mortality among such neonates was 100%. In other series it was about 90% if the immediate surgery was performed after delivery, but the further treatment had also very high risk due to the severe damage of the pulmonary circulation. Knowing this, in an era of fetal interventions, fetal balloon atrioseptostomy or interatrial stent placement should be considered. Between June 2011 and April 2014 we performed 4 balloon atrioseptostomies and 6 stent placements in 9 fetuses. In one fetus the stent was placed after ineffective atrioseptostomy. All procedures were performed in anesthetized fetuses and mothers. There were 6 cases of HLHS and 3 cases of secondary closure of the Fo in fetuses with severe aortic stenosis and mitral insufficiency. All procedures were performed after 24 weeks. They were technically successful and improved pulmonary venous flow. There were 2 intrauterine deaths related to the procedure and 2 premature deliveries (not related to the procedure) with neonatal death. One fetus is still in utero. 4 neonates were born at term in good general condition but deteriorated quickly due to increased pulmonary flow after delivery. 3 died in spite of intensive treatment few weeks after delivery. All of them were immediately operated on. One was operated on in the 5th hour of life and his condition is stable during the first week. Atrioseptostomy and stent placement can be successfully performed in fetuses. They are potentially lifesaving procedures for otherwise lethal defects. They should always be considered in fetuses whose parents opt for active treatment. In spite of poor results, technical success and better organization for the whole team is promising for better outcome in the future.

P09.14: Sonographic characteristics of the atrial septum in fetuses with d‐transposition of the great arteries needing emergency neonatal balloon atrioseptostomy

<scp>P</scp>09.14: Sonographic characteristics of the atrial septum in fetuses with d‐transposition of the great arteries needing emergency neonatal balloon atrioseptostomy

Pulmonary arterial hypertension in adults: novel drugs and catheter ablation techniques show promise? Systematic review on pharmacotherapy and interventional strategies.

This systematic review aims to provide an update on pharmacological and interventional strategies for the treatment of pulmonary arterial hypertension in adults. Currently US Food and Drug Administration approved drugs including prostanoids, endothelin-receptor antagonists, phosphodiesterase type-5 inhibitors, and soluble guanylate-cyclase stimulators. These agents have transformed the prognosis for pulmonary arterial hypertension patients from symptomatic improvements in exercise tolerance ten years ago to delayed disease progression today. On the other hand, percutaneous balloon atrioseptostomy by using radiofrequency perforation, cutting balloon dilatation, or insertion of butterfly stents and pulmonary artery catheter-based denervation, both associated with very low rate of major complications and death, should be considered in combination with specific drugs at an earlier stage rather than late in the progression of pulmonary arterial hypertension and before the occurrence of overt right-sided heart failure.

Cerebral lesions on magnetic resonance imaging correlate with preoperative neurological status in neonates undergoing cardiopulmonary bypass surgery

To determine the prevalence, spectrum and course of cerebral lesions in neonates with congenital heart disease (CHD) undergoing full flow cardiopulmonary bypass (CPB) surgery using magnetic resonance imaging (MRI) and to examine the correlation between cerebral lesions and clinical neurological abnormalities. Prospective cohort study of neonates with d-transposition of the great arteries (n = 22), univentricular heart malformation with hypoplastic aortic arch (n = 6) and aortic arch obstructions (n = 2) undergoing CPB. Neonates underwent cerebral MRI and blinded standardized neurological examination before (median day 6) and after surgery (day 13). The MRI findings were compared with those of 20 healthy controls. Preoperative cerebral lesions were present in 7 of 30 patients (23%) with isolated mild or moderate white matter injury (WMI) (n = 4), isolated small cerebral stroke (n = 1) and combined WMI and stroke (n = 2). None of the healthy controls had cerebral lesions on MRI. CHD neonates with preoperative cerebral lesions had more neurological abnormalities (P = 0.01) than neonates without cerebral lesions. Low arterial oxygen saturation (P = 0.03) was a risk factor for preoperative cerebral lesions, while balloon atrioseptostomy (P = 0.19) was not. After surgery, preoperative cerebral lesions persisted in 5 of 7 neonates, and 2 neonates (7%) showed signs of additional WMI in their postoperative MRI. In neonates with severe CHD, WMI was the predominant preoperative finding, while cerebral strokes were less frequent. New postoperative lesions were rare. Preoperative neurological abnormalities correlated with the presence of cerebral lesions on MRI.

Extracorporeal Life Support and Left Ventricular Unloading in a Non-Intubated Patient as Bridge to Heart Transplantation

Veno-arterial extracorporeal life support (ECLS) is a well-established bridging therapy in patients with cardiac or pulmonary failure to maintain organ function and is frequently performed in patients who are not intubated. However, severly impaired cardiac function can occur pulmonary edemy in these patients, necessitating left ventricular unloading. In this study we report a 37-year old female patient with familiar dilated cardiomyopathy suffering from acute biventricular heart failure. After implantation of a peripheral ECLS, the decreased ventricular led to refractory pulmonary edema. To unload the left ventricle, an percutaneous balloon atrioseptostomy was performed without intubating the patient. The left ventricle was vented by the venous cannula resting inside the atrioseptostomy. After twelve days on ECLS, the patient underwent orthotopic heart transplantation. The postoperative course was uneventful and the patient discharged from intensive care unit four days after surgery. In this report we present a patient in which the hybrid technique of ECLS with secondary left ventricular unloading was successfully used as a bridge to transplant therapy. This procedure may offer an alternative bridge-to-decision options in selected patients, including those that were not intubated or anaesthetized.

Extra-corporeal life support, transradial thrombus aspiration and stenting, percutaneous blade and balloon atrioseptostomy, all as a bridge to heart transplantation to save one life

In patients with cardiogenic shock, the Extra-Corporeal Life Support (ECLS) has been shown to be lives saving. But, in some situations, it proves inadequate for the discharge of the left heart. Several device-based techniques have been proposed to decompress the left side either surgically or percutaneously, each of them with the proper potential risks and complications. One technique, the percutaneous blade and balloon atrioseptostomy that requires transseptal catheter based experience and consists of creating an atrial septal defect (ASD) could be an elegant technique as an "add on" to the classic assistance making together a bridge to partial recovery or to heart transplantation. Herein, we present a case of an adult patient who presented with inaugural resistant cardiac arrest with a thrombotic occlusion of the left anterior descending artery (LAD) who required Extra-Corporeal Life Support, thrombus aspiration, stenting of the culprit lesion, and percutaneous blade and balloon atrioseptostomy to bridge "safely" to the heart transplantation.