Radiofrequency Energy-Assisted Wire Atrial Septostomy to Easily Create a Large Atrial Septal Defect

Wire atrial septostomy, a new transcatheter technique, combines 2 atrial septal defects (ASDs) into a large one in a thickened atrial septum. Although the thin-wire-looped atrial septum between ASDs needs to be pulled deeply into a hard catheter to tear the septum, this action might harm the surrounding cardiac structures. We utilized radiofrequency wire energy to facilitate the tearing of the septum, making the procedure easier and safer. This technical article presents the modified procedure in detail; the procedure was performed in a 6-month-old boy with double outlet right ventricle and intact ventricular septum. Mini-abstract This technical article describes modified wire atrial septostomy for thickened atrial septum in detail. Radiofrequency energy facilitated a thin wire-loop in tearing the septum between 2 atrial septal defects to combine the defects into a large one. We believe that this transcatheter procedure is easier and safer than the original one not using a radiofrequency wire energy.

A Reductive Metabolic Switch Protects Infants with Transposition of Great Arteries Undergoing Atrial Septostomy against Oxidative Stress

Transposition of the great arteries (TGA) is one of the most common cyanotic congenital heart diseases requiring neonatal surgical intervention. Parallel circulations that result in impaired cerebral oxygen delivery already in utero may lead to brain damage and long-term neurodevelopmental delay. Balloon atrial septostomy (BAS) is often employed to mix deoxygenated and oxygenated blood at the atrial level. However, BAS causes a sudden increase in arterial blood oxygenation and oxidative stress. We studied changes in oxygen saturation as well as metabolic profiles of plasma samples from nine newborn infants suffering from TGA before and until 48 h after undergoing BAS. The plasma metabolome clearly changed over time and alterations of four metabolic pathways, including the pentose phosphate pathway, were linked to changes in the cerebral tissue oxygen extraction. In contrast, no changes in levels of lipid peroxidation biomarkers over time were observed. These observations suggest that metabolic adaptations buffer the free radical burst triggered by re-oxygenation, thereby avoiding structural damage at the macromolecular level. This study enhances our understanding of the complex response of infants with TGA to changes in oxygenation induced by BAS.

Interventional and Surgical Treatments for Pulmonary Arterial Hypertension

Despite significant advancements in pharmacological treatment, interventional and surgical options are still viable treatments for patients with pulmonary arterial hypertension (PAH), particularly idiopathic PAH. Herein, we review the interventional and surgical treatments for PAH. Atrial septostomy and the Potts shunt can be useful bridging tools for lung transplantation (Ltx), which remains the final surgical treatment among patients who are refractory to any other kind of therapy. Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) remains the ultimate bridging therapy for patients with severe PAH. More importantly, VA-ECMO plays a crucial role during Ltx and provides necessary left ventricular conditioning during the initial postoperative period. Pulmonary denervation may potentially be a new way to ensure better transplant-free survival among patients with the aforementioned disease. However, high-quality randomized controlled trials are needed. As established, obtaining the Eisenmenger physiology among patients with severe pulmonary hypertension by creating artificial defects is associated with improved survival. However, right-to-left shunting may be harmful after Ltx. Closure of the artificially created defects may carry some risk associated with cardiac surgery, especially among patients with Potts shunts. In conclusion, PAH requires an interdisciplinary approach using pharmacological, interventional, and surgical modalities.

Balloon atrial septostomy through azygos vein in two cases of D-TGA with left atrial isomerism

Balloon atrial septostomy is a palliative procedure that is performed in D-transposition of great arteries when surgery is not immediately available. Although D-TGA and left isomerism association are rare, it is an important condition as the BAS procedure approach is unique. In this case report, we present two cases of D-TGA with left isomerism where BAS was performed due to restrictive atrial septal defect and lack of immediate availability of the paediatric cardiac surgeon.

Emergency atrial septostomy with nasogastric tube through umbilical venous route in neonates with critical congenital heart defects

Neonates born with critical duct dependent congenital heart diseases acutely deteriorate in first few days after birth when physiological conduits which allow for mixing blood close. Balloon Atrial septostomy is performed on emergency basis in such neonates to create a right to left intracardiac shunt, until a definitive surgery is performed, but requires a cardiac intervention setup. In settings where advanced cardiac interventions are not available, we propose an alternative approach for atrial septostomy using nasogastric feeding tube through umbilical venous route, under echocardiographic guidance. Feeding tube gradually inserted into the umbilical vein, reaches the right atrium, following which it is thrust into the atrial septum at the location of foramen ovale, perforating it to create an emergency conduit between the atria. We performed the above procedure in a neonate with dTGA at our NICU setup, with partially successful outcome. We propose this method as an alternative, safe, simple and cost effective procedure, though not definitive, in resource limited settings for emergency stabilisation of neonates with critical duct dependent heart defects.

Successful Management of a COVID-19 Positive Infant With Transposition of the Great Arteries

A six-week-old infant presented in extremis and was diagnosed with dextro-transposition of the great arteries, intact ventricular septum, features of left ventricular deconditioning, and abnormal coronary arteries. Treatment with prostaglandin E1 and balloon atrial septostomy was insufficient, necessitating extracorporeal membrane oxygenation (ECMO). Severe acute respiratory syndrome coronavirus-2 was detected. The arterial switch operation was delayed by eight days because of COVID-19. Although stable on ECMO, the infant was treated with remdesivir. Extracorporeal membrane oxygenation was not required postoperatively with chest closure on day 2 and extubation on day 5.