- Email: [email protected]
Percutaneous balloon atrial septostomy in infants with transposition of the great arteries
Percutaneous balloon atrial septostomy in infants with transposition of the great arteries Roger A. Hurwitz, M.D. Donald A. Girod, M.D. Indianapolis, Ind.
Since the report of Rashkind and Miller in 1966,1 atrial septostomy has generally been the palliative treatment of choice for neonates with transposition of the great arteries (TGA). The procedure, as commonly performed by inguinal cutdown, requires meticulous dissection. It may necessitate ligation of the femoral vein or result in significant inguinal scarring, making succeeding catheterization more difficult. Though percutaneous catheterization of infants and children has been performed in increasing numbers, 2-~ septostomy catheters have not been introduced percutaneously. Since almost all our catheterizations are performed by the percutaneous technique, we endeavored to expand this approach to include balloon septostomy. It is the purpose of this paper to describe initial experience with percutaneous balloon atrial septostomy (PBAS) in palliation of infants with TGA. To test effectiveness, PBAS was then compared to septostomy as performed by the conventional cutdown method. Patients and Methods
Since January, 1971, PBAS has been attempted at initial catheterization of all infants with TGA admitted to the Riley Hospital for Children. The PBAS procedure (Fig. 1) is a modification of previously described techniques~-6: (1) after local From the Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Ind. Supported in part by a research grant from the James Whitcomb Riley Memorial Association. Presented in part at the annual meeting of the American Academy of Pediatrics, Chicago, Ill., October, 1973, Received for publication Jan. 22, 1975. Reprint requests: R. A. Hurwitz, M.D., Indiana University Hospitals, Section of Pediatric Cardiology, 1100 W. Michigan St., Indianapolis, Ind. 46202.
618
anesthesia, the femoral vein is punctured through a thin-walled 21 gauge needle (Becton-Dickinson, Rutherford, N. J.); (2) an 0.021 inch steel guide wire (Cook, Bloomington, Indiana) is advanced through the needle; (3) the site of entrance into the skin is enlarged by the tip of a No. 11 scalpel blade; (4) a tapered No. 4 Teflon dilator (Penntube Plastics, Clifton Heights, Pa.) is introduced, and then withdrawn; a woven Teflon tapered No. 4 catheter (Cook) is inserted for physiologic and angiographic studies. After diagnosis is confirmed, ballooning is performed by: (1) reintroduction of the 0.021 inch wire with withdrawal of the catheter; (2) progressive dilation with a tapered No. 5 Teflon dilator and 0.025 inch wire, and tapered No. 6 Teflon dilator and 0.035 inch wire; (3) insertion of a tapered No. 7 or No. 8 Teflon dilator covered by a snug-fitting Mylar sheath (Cook) approximately 3 inches in length; (4) insertion of a No. 5 dilation (septostomy) catheter (Edwards, Santa Ana, Calif.) through the Mylar sheath; and (5) removal of the sheath after catheter insertion. Septostomy is carried out in the usual manner, using fluoroscopic frontal and lateral projection to check catheter position in the left atrium. Following completion of the procedure, firm external pressure is applied approximately 1 inch cephalad to skin insertion. Hemostasis is accomplished in 10 to 30 minutes. PBAS was compared to the cutdown method of septostomy as performed in our laboratory. Group 1 includes those infants treated by PBAS between January, 1971, and June, 1973, thus affording at least a 1 year follow-up. Group 2 includes all infants with TGA initially catheterized between 1967 and 1971. These underwent septostomy by routine inguinal cutdown method. Group 3 includes all infants who required cutdown introduction of the septostomy catheter de-
May, 1976, Vol. 91, No. 5, pp. 618-622
Septostomy in transposition of great arteries
Fig. 1. Equipment used for PBAS: A, thin-walled needle; B, representative steel guide wires; C, woven Teflon catheter; D, Teflon dilator; E, larger Teflon dilator through mylar sheath (F); and G, partially inflated No. 5 dilation catheter.
spite initial attempt at percutaneous insertion. Patients excluded from the study were: those with single ventricle, tricuspid atresia, or "corrected transposition"; those initially catheterized beyond 3 months of age; and the few infants ballooned in 1966, when septostomy was a newly described technique. All procedures were performed by the authors or senior cardiology trainees under direct supervision of the authors. When the sample was significantly large, biostatistical analysis (Student's t test) was used to compare results. Results PBAS. PBAS was attempted in 30 infants and accomplished in 25. The balloon catheter could not be inserted in five; in four (weight 51/~ to 889 pounds), the vein could not be initially entered percutaneously, and in the other patient (weight 6 pounds), the balloon catheter could not be inserted into the vein despite successful percutaneous diagnostic catheterization, Thirteen of those treated by PBAS weighed less than 8 pounds. The mean aortic oxygen saturation rose from 55 per cent before ballooning to 72 per cent (p < 0.005) after ballooning. Twenty-four patients demonstrated an early improvement in clinical status and oxygen saturation. In one case
American Heart Journal
the procedure was performed twice, without discernible physiologic or clinical benefit. This infant then underwent surgical septostomy but died following surgery. Postmortem examination disclosed two atrial defects, one presumably produced by the ballooning. Other complications consisted of: (1) the above-mentioned patient was noted at surgery to have an atrial wall perforation t h a t had sealed itself-there were, however, approximately, 30 c.c. of blood in the pericardial cavity; (2) one infant had a mild infection at the percutaneous site t h a t responded well to antibiotics; (3) two patients required transfusion of 5 to 10 c.c./per kilogram packed cells following the procedure. However, one had a precatheterization hemoglobin of only 14.0 rag., per 100 ml.; which exaggerated the postballooning anemia (hemoglobin 12.0 mg.); and (4) one patient developed atrial flutter-fibrillation which spontaneously converted 6 hours after septostomy. Twenty-three PBAS patients had repeat catheterization. In 17, the vein used for PBAS was again used. Angiography disclosed a blocked inferior vena cava in one case and isolated femoral vein occlusion in one patient. In two of the others, percutaneous catheterization of the vein previously used for PBAS was unsuccessfully
619
Hurwitz and Girod
Table I. Infants with transposition of the great arteries catheterized from J a n u a r y , 1967, to,June, 1973" Group 1~
Values Age (days)
Weight (Kg.) Associated defects Aortic s a t u r a t i o n (%) Pr ocedure t i m e (min.) Complications Death
Bleeding or infection Inadequate septostomy Immediate Later Blocked inferior vena cava
11 3.6 10 55-+72 134
Group 2
No, of patients
(25) (25) (25) (25)
Values
17 3.5 14 56-+71
Group 3
No, of patients
Values
No. of patients
(28) (28) (28) (ll)
20 3.7 1 52--+70
(5) (5) (5) (3)
(16)
144
(16)
155
(4)
3
(25) (25)
0 7
(28} (28)
0 1
(5) (5)
1 5 1
(25) (24) (24)
1 6 1
(28) (26) (22)
0 1 0
(5) (5) (5)
0
*All weights, ages, aortic saturations, and times are group mean values. tGroup 1 ffi percutaneous balloon atrial septostomy; Group 2 = balloon atrial septostomy by cutdown catheter insertion Group 3 = balloon atrial septostomy by cutdown after unsuccessful attempt at percutaneous catheter insertion.
a t t e m p t e d . Angiographic s t u d y of vein p a t e n c y was not done in these two patients. All 24 patients initially palliated by P B A S were living at the end of 3 months. By our own criteria and those of others, `+ however, i n a d e q u a c y of intra-atrial mixing became evident before 1 y e a r of age in five patients. T h e s e patients b e c a m e progressively more cyanotic and irritable, failed to gain weight, and showed increasing cardiomegaly by roentgenogram. Arterial oxygen s a t u r a t i o n s were less t h a n 55 per cent in four. At surgery, an unusually thick atrial s e p t u m and small defect was seen in three and large atrial septal defects were n o t e d in two. Comparison of PBAS and cutdown technique (Table I). T w e n t y - e i g h t patients (Group 2) underwent s e p t o s t o m y with catheters inserted by cutdown. Twelve had s e p t o s t o m y with No. 6.5 Rashkind catheters, 10 with No. 5 E d w a r d s embolectomy catheters, and 6 with No. 5 E d w a r d s sept o s t o m y catheters. T h e m e a n weight and m e a n age of these patients were not statistically different from those in G r o u p 1. T h e r e was, however, a slightly greater incidence of additional cardiac defects in G r o u p 2. T h e p r o c e d u r e resulted in a statistically similar increase in aortic oxygen s a t u r a t i o n in b o t h groups. C a t h e t e r i z a tion and septostomy b y c u t d o w n required slightly more time and had a greater incidence of m i n o r complications of wound infection a n d / o r bleeding. E a r l y and late a d e q u a c y of s e p t o s t o m y was
620
the same for b o t h techniques. T h e type and size of catheter had no a p p a r e n t significance. R e p e a t catheterization disclosed a blocked inferior vena cava in one p a t i e n t from b o t h Groups 1 and 2. In nine of 17 attempts, patients were successfully recatheterized from the same leg as used for cutdown septostomy. Five patients required i n t r o d u c t i o n of septosto m y catheters following an unsuccessful a t t e m p t at percutaneous introduction {Group 3). T h e procedure time was 11 minutes longer t h a n in those initially t r e a t e d by c u t d o w n c a t h e t e r insertion. Otherwise, the patients and results were similar to those in Groups 1 and 2.
Discussion P e r c u t a n e o u s catheterization was developed to reduce technical problems and minimize time spent with c a t h e t e r insertion. All catheterizations at Riley Hospital for Children are a t t e m p t e d percutaneously, with an 80 to 90 per cent success rate in infants2 For technical reasons of table position and vena caval a n a t o m y , the right leg is more easily used. If a h e m a t o m a develops before c a t h e t e r insertion or if there is a decrease in arterial pulsation, we switch to the left leg. W h e n catheters are n o t inserted in 25 minutes, we perform an inguinal cutdown. Early reports of ballooning b y saphenous cutdown advise "careful, meticulous dissection, prophylactic blood type and cross-match, etc.,"
May, 1976, Vol. 91, No. 5
Septostomy in transposition of great arteries
b u t do not give exact number of minor complications or procedural time. v, s To reduce our problems with inguinal cutdown and later difficulty with insertion of catheters through scarred areas, PBAS was attempted as an extension of routine diagnostic catheterization. ThOugh of importance, size of patient has not been a limiting factor, since PBAS was performed in an infant weighing 5 pounds 5 ounces and in four others less than 7 pounds. Technically, the inability to measure pressure with a single lumen catheter is only a slight handicap. No known problems occurred due to catheter position during septostomy. In addition, atrial pressure gradients before ballooning and at repeat catheterization had only fair correlation with apparent size of the septal defect. Though PBAS afforded initial palliation to 24 infants, five who appeared well palliated required early surgery due to inadequate atrial mixing. Two of these had anatomically adequate septal defects, suggesting the severe desaturation to be caused by factors other than actual Size of atrial communication. In three there was a very thick atrial septum with an inadequate defect. Perhaps this thick septal tissue allowed the foramen ovale to stretch but not tear. It might also be that the initial septostomy caused an inflammatory process with hypertrophy, scarring, and later closure of the defect. The early clinical effectiveness of the percutaneous single lumen catheter septostomy is similar to that reported after femoral vein cutdown and insertion of single and double lumen catheters. 7-9 When we compared our own success in PBAS to the cutdown method of septostomy, early gains from percutaneous technique were: less bleeding, less local infection, and slightly less procedural time. The latter was true even with addition of those requiring cutdown after unsuccessful attempted PBAS. In addition, the total percutaneous technique afforded access to an arterial line for monitoring without further deep femoral dissection and arterial repair. It might be that if we waited for our ballooned patients to reach an older age for open repair, the septostomy created b y a No. 5 catheter would not be as effective as that created b y larger catheters. However, in an effort to minimize complications such as cerebral vascular accidents, we, and other, 7 have been performing the intra-atrial baffle operation ~~ when children approach 20 pounds. Approximately 70 per cent of our pa-
American Heart Journal
tients with PBAS reached t h a t size with no further septostomy or septectomy. This figure compares favorably with other reports 7-9. 11 and our own results using various-sized catheters inserted by cutdown. Repeat catheterization is usually necessary for patients with TGA. The percutaneous method often preserves vessels, and in 17 patients in this study repeat catheterization was performed through the vein used for PBAS. This was significantly higher than the figure achieved in those ballooned by previous cutdown. One patient from each group had a thrombosed inferior vena cava; however, this complication has been observed in other cardiac patients, especially those with cyanosis. 1-~Use of umbilical veins would totally spare femoral vessels. 13Unfortunately, more than half the paddnts with TGA enter the hospital beyond expected sinus venosus patency.
Summary Initial experience with P B A S in early management of neonates w i t h TGA is described. Standard percutaneous techniques were. used and modified b y a series of dilations designed to introduce a septostomy catheter into the femoral vein. Thirty infants with TGA were catheterized, and PBAS was accomplished in 25. The mean aortic oxygen saturation rose from 55 to 72 per cent. Twenty-four infants were clinically pa !hated for at least 3 months; h o w e v e r , five required pre-elective surgery thought due to inadequate atrial mixing. No severe complications followed PBAS. T w e n t y - t h r e e patients underwent fol!ow-up catheterization, in 17 through the vein used for PBAS. When compared to patients with TGA who had cutdown insertion of balloon septostomy catheters, the grouptreated by PBAS Was similar i n patient material, and successful septostomy. Those ballooned percutaneously had fewer Complications and required slightly less time for t h e procedure. We feel that PBAS is a relatively easy and safe palliative procedure when performed in an infant with TGA. I t should be considered by all those performing percutaneous diagnostic catheterization in infants and children. Addendum Since the manuscript was written, we have been able to insert No, 5 balloon catheters into a commercially available No. 7 s h e a t h ( s p e c i a l
621
Hurwitz and Girod
procedure set, Cook Inc., Bloomington, Ind.) after d i l a t i n g u p t o N o . 6 d i l a t o r a s d e s c r i b e d in t h e
7.
protocol. REFERENCES
1. Rashkind, W. J., and Miller, W. W.: Creation of an atrial septal defect without thoracotomy; A palliative approach to complete transposition of the great vessels, J. A. M. A. 198:991, 1966. 2. Desilets, D. T., and Hoffman, R.: A new method of percutaneous catheterization, Radiology 85:147, 1965. 3. Carter, G. A., Girod, D. A., and Hurwitz, R. A.: Percutaneous cardiac catheterization of the neonate, Pediatrics 55:662, 1975. 4. Neches, W. H., Mullins, C. E., Williams, R. L., Vargo, T. A.. and McNamara. D. G.: Percutaneous sheath cardiac catheterization, Am. J. Cardiol. 30:378, 1972. 5. Kirkpatrick, S. E., Takahashi, M., Petry, E. L., Stanton, R. E., and Lurie, P. R.: Percutaneous heart catheterization in infants and children, Circulation 42:1049, 1970. 6. Lurie, P. R., Armer, R. M:, and Klatte, E. C.: Percuta-
622
8. 9. 10. 11. 12. 13.
neous guide wire catheterization: Diagnosis and therapy, Am. J. Dis. Child. 106:189, 1963. Neches, W. H., Mullins, C. E., and McNamara, D. G.: The infant with transposition of the great arteries. II. Results of balloon atrial septostomy, AM. HEART J. 84:603, 1972. Singh, S. P., Astley, R., and Burrows, F. G. O.: Balloon septostomy for transposition of the great arteries, Br. Heart J. 31:722, 1969. Rashkind, W. J.. and Miller, W. W.: Transposition of the great arteries: Results of palliation by balloon atrioseptostomy in 31 infants, Circulation 38:453, 1968. Mustard, W. T.: Successful two-stage correction of transposition of the great vessels, Surgery 55:469, 1964. Rashkind, W. J.: Palliative procedures for transposition of the great arteries, Br. Heart. J. 33 (Suppl.):69, 1971. Kuehl, K. S., Perry, LI W., and Scott, L. P.: Thrombosis of the inferior vena cava in patients with cyanotic congenital heart disease, Pediatrics 79:430, 1971. Newfeld, E. A., Purcell, C., Paul, M. H., Cole, R. B., and Muster, A. J.: Transumbilical balloon atrial septostomy with transposition of the great arteries, Pediatrics 54:495, 1974.
May, 1976, Vol. 91, No. 5
Since the report of Rashkind and Miller in 1966,1 atrial septostomy has generally been the palliative treatment of choice for neonates with transposition of the great arteries (TGA). The procedure, as commonly performed by inguinal cutdown, requires meticulous dissection. It may necessitate ligation of the femoral vein or result in significant inguinal scarring, making succeeding catheterization more difficult. Though percutaneous catheterization of infants and children has been performed in increasing numbers, 2-~ septostomy catheters have not been introduced percutaneously. Since almost all our catheterizations are performed by the percutaneous technique, we endeavored to expand this approach to include balloon septostomy. It is the purpose of this paper to describe initial experience with percutaneous balloon atrial septostomy (PBAS) in palliation of infants with TGA. To test effectiveness, PBAS was then compared to septostomy as performed by the conventional cutdown method. Patients and Methods
Since January, 1971, PBAS has been attempted at initial catheterization of all infants with TGA admitted to the Riley Hospital for Children. The PBAS procedure (Fig. 1) is a modification of previously described techniques~-6: (1) after local From the Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Ind. Supported in part by a research grant from the James Whitcomb Riley Memorial Association. Presented in part at the annual meeting of the American Academy of Pediatrics, Chicago, Ill., October, 1973, Received for publication Jan. 22, 1975. Reprint requests: R. A. Hurwitz, M.D., Indiana University Hospitals, Section of Pediatric Cardiology, 1100 W. Michigan St., Indianapolis, Ind. 46202.
618
anesthesia, the femoral vein is punctured through a thin-walled 21 gauge needle (Becton-Dickinson, Rutherford, N. J.); (2) an 0.021 inch steel guide wire (Cook, Bloomington, Indiana) is advanced through the needle; (3) the site of entrance into the skin is enlarged by the tip of a No. 11 scalpel blade; (4) a tapered No. 4 Teflon dilator (Penntube Plastics, Clifton Heights, Pa.) is introduced, and then withdrawn; a woven Teflon tapered No. 4 catheter (Cook) is inserted for physiologic and angiographic studies. After diagnosis is confirmed, ballooning is performed by: (1) reintroduction of the 0.021 inch wire with withdrawal of the catheter; (2) progressive dilation with a tapered No. 5 Teflon dilator and 0.025 inch wire, and tapered No. 6 Teflon dilator and 0.035 inch wire; (3) insertion of a tapered No. 7 or No. 8 Teflon dilator covered by a snug-fitting Mylar sheath (Cook) approximately 3 inches in length; (4) insertion of a No. 5 dilation (septostomy) catheter (Edwards, Santa Ana, Calif.) through the Mylar sheath; and (5) removal of the sheath after catheter insertion. Septostomy is carried out in the usual manner, using fluoroscopic frontal and lateral projection to check catheter position in the left atrium. Following completion of the procedure, firm external pressure is applied approximately 1 inch cephalad to skin insertion. Hemostasis is accomplished in 10 to 30 minutes. PBAS was compared to the cutdown method of septostomy as performed in our laboratory. Group 1 includes those infants treated by PBAS between January, 1971, and June, 1973, thus affording at least a 1 year follow-up. Group 2 includes all infants with TGA initially catheterized between 1967 and 1971. These underwent septostomy by routine inguinal cutdown method. Group 3 includes all infants who required cutdown introduction of the septostomy catheter de-
May, 1976, Vol. 91, No. 5, pp. 618-622
Septostomy in transposition of great arteries
Fig. 1. Equipment used for PBAS: A, thin-walled needle; B, representative steel guide wires; C, woven Teflon catheter; D, Teflon dilator; E, larger Teflon dilator through mylar sheath (F); and G, partially inflated No. 5 dilation catheter.
spite initial attempt at percutaneous insertion. Patients excluded from the study were: those with single ventricle, tricuspid atresia, or "corrected transposition"; those initially catheterized beyond 3 months of age; and the few infants ballooned in 1966, when septostomy was a newly described technique. All procedures were performed by the authors or senior cardiology trainees under direct supervision of the authors. When the sample was significantly large, biostatistical analysis (Student's t test) was used to compare results. Results PBAS. PBAS was attempted in 30 infants and accomplished in 25. The balloon catheter could not be inserted in five; in four (weight 51/~ to 889 pounds), the vein could not be initially entered percutaneously, and in the other patient (weight 6 pounds), the balloon catheter could not be inserted into the vein despite successful percutaneous diagnostic catheterization, Thirteen of those treated by PBAS weighed less than 8 pounds. The mean aortic oxygen saturation rose from 55 per cent before ballooning to 72 per cent (p < 0.005) after ballooning. Twenty-four patients demonstrated an early improvement in clinical status and oxygen saturation. In one case
American Heart Journal
the procedure was performed twice, without discernible physiologic or clinical benefit. This infant then underwent surgical septostomy but died following surgery. Postmortem examination disclosed two atrial defects, one presumably produced by the ballooning. Other complications consisted of: (1) the above-mentioned patient was noted at surgery to have an atrial wall perforation t h a t had sealed itself-there were, however, approximately, 30 c.c. of blood in the pericardial cavity; (2) one infant had a mild infection at the percutaneous site t h a t responded well to antibiotics; (3) two patients required transfusion of 5 to 10 c.c./per kilogram packed cells following the procedure. However, one had a precatheterization hemoglobin of only 14.0 rag., per 100 ml.; which exaggerated the postballooning anemia (hemoglobin 12.0 mg.); and (4) one patient developed atrial flutter-fibrillation which spontaneously converted 6 hours after septostomy. Twenty-three PBAS patients had repeat catheterization. In 17, the vein used for PBAS was again used. Angiography disclosed a blocked inferior vena cava in one case and isolated femoral vein occlusion in one patient. In two of the others, percutaneous catheterization of the vein previously used for PBAS was unsuccessfully
619
Hurwitz and Girod
Table I. Infants with transposition of the great arteries catheterized from J a n u a r y , 1967, to,June, 1973" Group 1~
Values Age (days)
Weight (Kg.) Associated defects Aortic s a t u r a t i o n (%) Pr ocedure t i m e (min.) Complications Death
Bleeding or infection Inadequate septostomy Immediate Later Blocked inferior vena cava
11 3.6 10 55-+72 134
Group 2
No, of patients
(25) (25) (25) (25)
Values
17 3.5 14 56-+71
Group 3
No, of patients
Values
No. of patients
(28) (28) (28) (ll)
20 3.7 1 52--+70
(5) (5) (5) (3)
(16)
144
(16)
155
(4)
3
(25) (25)
0 7
(28} (28)
0 1
(5) (5)
1 5 1
(25) (24) (24)
1 6 1
(28) (26) (22)
0 1 0
(5) (5) (5)
0
*All weights, ages, aortic saturations, and times are group mean values. tGroup 1 ffi percutaneous balloon atrial septostomy; Group 2 = balloon atrial septostomy by cutdown catheter insertion Group 3 = balloon atrial septostomy by cutdown after unsuccessful attempt at percutaneous catheter insertion.
a t t e m p t e d . Angiographic s t u d y of vein p a t e n c y was not done in these two patients. All 24 patients initially palliated by P B A S were living at the end of 3 months. By our own criteria and those of others, `+ however, i n a d e q u a c y of intra-atrial mixing became evident before 1 y e a r of age in five patients. T h e s e patients b e c a m e progressively more cyanotic and irritable, failed to gain weight, and showed increasing cardiomegaly by roentgenogram. Arterial oxygen s a t u r a t i o n s were less t h a n 55 per cent in four. At surgery, an unusually thick atrial s e p t u m and small defect was seen in three and large atrial septal defects were n o t e d in two. Comparison of PBAS and cutdown technique (Table I). T w e n t y - e i g h t patients (Group 2) underwent s e p t o s t o m y with catheters inserted by cutdown. Twelve had s e p t o s t o m y with No. 6.5 Rashkind catheters, 10 with No. 5 E d w a r d s embolectomy catheters, and 6 with No. 5 E d w a r d s sept o s t o m y catheters. T h e m e a n weight and m e a n age of these patients were not statistically different from those in G r o u p 1. T h e r e was, however, a slightly greater incidence of additional cardiac defects in G r o u p 2. T h e p r o c e d u r e resulted in a statistically similar increase in aortic oxygen s a t u r a t i o n in b o t h groups. C a t h e t e r i z a tion and septostomy b y c u t d o w n required slightly more time and had a greater incidence of m i n o r complications of wound infection a n d / o r bleeding. E a r l y and late a d e q u a c y of s e p t o s t o m y was
620
the same for b o t h techniques. T h e type and size of catheter had no a p p a r e n t significance. R e p e a t catheterization disclosed a blocked inferior vena cava in one p a t i e n t from b o t h Groups 1 and 2. In nine of 17 attempts, patients were successfully recatheterized from the same leg as used for cutdown septostomy. Five patients required i n t r o d u c t i o n of septosto m y catheters following an unsuccessful a t t e m p t at percutaneous introduction {Group 3). T h e procedure time was 11 minutes longer t h a n in those initially t r e a t e d by c u t d o w n c a t h e t e r insertion. Otherwise, the patients and results were similar to those in Groups 1 and 2.
Discussion P e r c u t a n e o u s catheterization was developed to reduce technical problems and minimize time spent with c a t h e t e r insertion. All catheterizations at Riley Hospital for Children are a t t e m p t e d percutaneously, with an 80 to 90 per cent success rate in infants2 For technical reasons of table position and vena caval a n a t o m y , the right leg is more easily used. If a h e m a t o m a develops before c a t h e t e r insertion or if there is a decrease in arterial pulsation, we switch to the left leg. W h e n catheters are n o t inserted in 25 minutes, we perform an inguinal cutdown. Early reports of ballooning b y saphenous cutdown advise "careful, meticulous dissection, prophylactic blood type and cross-match, etc.,"
May, 1976, Vol. 91, No. 5
Septostomy in transposition of great arteries
b u t do not give exact number of minor complications or procedural time. v, s To reduce our problems with inguinal cutdown and later difficulty with insertion of catheters through scarred areas, PBAS was attempted as an extension of routine diagnostic catheterization. ThOugh of importance, size of patient has not been a limiting factor, since PBAS was performed in an infant weighing 5 pounds 5 ounces and in four others less than 7 pounds. Technically, the inability to measure pressure with a single lumen catheter is only a slight handicap. No known problems occurred due to catheter position during septostomy. In addition, atrial pressure gradients before ballooning and at repeat catheterization had only fair correlation with apparent size of the septal defect. Though PBAS afforded initial palliation to 24 infants, five who appeared well palliated required early surgery due to inadequate atrial mixing. Two of these had anatomically adequate septal defects, suggesting the severe desaturation to be caused by factors other than actual Size of atrial communication. In three there was a very thick atrial septum with an inadequate defect. Perhaps this thick septal tissue allowed the foramen ovale to stretch but not tear. It might also be that the initial septostomy caused an inflammatory process with hypertrophy, scarring, and later closure of the defect. The early clinical effectiveness of the percutaneous single lumen catheter septostomy is similar to that reported after femoral vein cutdown and insertion of single and double lumen catheters. 7-9 When we compared our own success in PBAS to the cutdown method of septostomy, early gains from percutaneous technique were: less bleeding, less local infection, and slightly less procedural time. The latter was true even with addition of those requiring cutdown after unsuccessful attempted PBAS. In addition, the total percutaneous technique afforded access to an arterial line for monitoring without further deep femoral dissection and arterial repair. It might be that if we waited for our ballooned patients to reach an older age for open repair, the septostomy created b y a No. 5 catheter would not be as effective as that created b y larger catheters. However, in an effort to minimize complications such as cerebral vascular accidents, we, and other, 7 have been performing the intra-atrial baffle operation ~~ when children approach 20 pounds. Approximately 70 per cent of our pa-
American Heart Journal
tients with PBAS reached t h a t size with no further septostomy or septectomy. This figure compares favorably with other reports 7-9. 11 and our own results using various-sized catheters inserted by cutdown. Repeat catheterization is usually necessary for patients with TGA. The percutaneous method often preserves vessels, and in 17 patients in this study repeat catheterization was performed through the vein used for PBAS. This was significantly higher than the figure achieved in those ballooned by previous cutdown. One patient from each group had a thrombosed inferior vena cava; however, this complication has been observed in other cardiac patients, especially those with cyanosis. 1-~Use of umbilical veins would totally spare femoral vessels. 13Unfortunately, more than half the paddnts with TGA enter the hospital beyond expected sinus venosus patency.
Summary Initial experience with P B A S in early management of neonates w i t h TGA is described. Standard percutaneous techniques were. used and modified b y a series of dilations designed to introduce a septostomy catheter into the femoral vein. Thirty infants with TGA were catheterized, and PBAS was accomplished in 25. The mean aortic oxygen saturation rose from 55 to 72 per cent. Twenty-four infants were clinically pa !hated for at least 3 months; h o w e v e r , five required pre-elective surgery thought due to inadequate atrial mixing. No severe complications followed PBAS. T w e n t y - t h r e e patients underwent fol!ow-up catheterization, in 17 through the vein used for PBAS. When compared to patients with TGA who had cutdown insertion of balloon septostomy catheters, the grouptreated by PBAS Was similar i n patient material, and successful septostomy. Those ballooned percutaneously had fewer Complications and required slightly less time for t h e procedure. We feel that PBAS is a relatively easy and safe palliative procedure when performed in an infant with TGA. I t should be considered by all those performing percutaneous diagnostic catheterization in infants and children. Addendum Since the manuscript was written, we have been able to insert No, 5 balloon catheters into a commercially available No. 7 s h e a t h ( s p e c i a l
621
Hurwitz and Girod
procedure set, Cook Inc., Bloomington, Ind.) after d i l a t i n g u p t o N o . 6 d i l a t o r a s d e s c r i b e d in t h e
7.
protocol. REFERENCES
1. Rashkind, W. J., and Miller, W. W.: Creation of an atrial septal defect without thoracotomy; A palliative approach to complete transposition of the great vessels, J. A. M. A. 198:991, 1966. 2. Desilets, D. T., and Hoffman, R.: A new method of percutaneous catheterization, Radiology 85:147, 1965. 3. Carter, G. A., Girod, D. A., and Hurwitz, R. A.: Percutaneous cardiac catheterization of the neonate, Pediatrics 55:662, 1975. 4. Neches, W. H., Mullins, C. E., Williams, R. L., Vargo, T. A.. and McNamara. D. G.: Percutaneous sheath cardiac catheterization, Am. J. Cardiol. 30:378, 1972. 5. Kirkpatrick, S. E., Takahashi, M., Petry, E. L., Stanton, R. E., and Lurie, P. R.: Percutaneous heart catheterization in infants and children, Circulation 42:1049, 1970. 6. Lurie, P. R., Armer, R. M:, and Klatte, E. C.: Percuta-
622
8. 9. 10. 11. 12. 13.
neous guide wire catheterization: Diagnosis and therapy, Am. J. Dis. Child. 106:189, 1963. Neches, W. H., Mullins, C. E., and McNamara, D. G.: The infant with transposition of the great arteries. II. Results of balloon atrial septostomy, AM. HEART J. 84:603, 1972. Singh, S. P., Astley, R., and Burrows, F. G. O.: Balloon septostomy for transposition of the great arteries, Br. Heart J. 31:722, 1969. Rashkind, W. J.. and Miller, W. W.: Transposition of the great arteries: Results of palliation by balloon atrioseptostomy in 31 infants, Circulation 38:453, 1968. Mustard, W. T.: Successful two-stage correction of transposition of the great vessels, Surgery 55:469, 1964. Rashkind, W. J.: Palliative procedures for transposition of the great arteries, Br. Heart. J. 33 (Suppl.):69, 1971. Kuehl, K. S., Perry, LI W., and Scott, L. P.: Thrombosis of the inferior vena cava in patients with cyanotic congenital heart disease, Pediatrics 79:430, 1971. Newfeld, E. A., Purcell, C., Paul, M. H., Cole, R. B., and Muster, A. J.: Transumbilical balloon atrial septostomy with transposition of the great arteries, Pediatrics 54:495, 1974.
May, 1976, Vol. 91, No. 5