Atrial septostomy


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Atrial septostomy

  2. 2. Introduction  “A technique for producing an atrial septal defect without thoracotomy or anesthesia. It can be performed rapidly in any cardiac catheterization laboratory.” (William J. Rashkind, 1966)  “...The initial response to this report varied between admiration and horror but, in either case, the procedure stirred the imagination of the “invasive” cardiologists throughout the entire cardiology world and set the stage for all future intracardiac interventional procedures – the true beginning of pediatric and adult interventional cardiology.” (Charles E. Mullins, 1998)
  3. 3. Indian perspective IHJ 1987 “Balloon septostomy is an effective palliative method in newborn infants with TGA. The technique may however be ineffective in older infants.We describe, for the first time,an alternative technique of palliation by dilating the atrial septum using percutaneous balloon dilatation technique.The technique was usefull in an older infant of TGA with intact ventricular septum where balloon septostomy was unlikely to succeed.It is possible that even in the newborn period this technique may result in a better interatrial communication.”
  4. 4. Commonest intervention was Balloon atrial septostomy (32.9%) , followed by Balloon aortic valvotomy (21.6%), Balloon pulmonary valvotomy (19.6%), Balloon angioplasty of coarctation of aorta (10.3%) , PDA device /coil closure (14.42%) and post operative MAPCA coiling (1.03%). 20 cases had significant ventricular dysfunction preprocedure requiring inotropes. Preprocedure Prostaglandin E1 infusion required by 15.4% PERCUTANEOUS CARDIAC INTERVENTIONS IN INFANTS AND NEONATES IN A TERTIARY CARE CARDIAC INSTITUTE WITH SHORT AND MIDTERM FOLLOW UP Maitri Chaudhuri ,Manisha Chakrabarti,S. Radhakrishnan,Savitri Shrivastava. Escorts Heart Institute,Okhla , New Delhi IHJ 2004
  5. 5. An Indian perspective
  6. 6. Indications of Interventions on the Intact Atrial Septum 1. Transposition to improve mixing. 2. Tricuspid atresia 3. Double inlet ventricle with hypoplastic left or right atrioventricular valves 4. Hypoplastic left heart syndrome 5. With the Fontan circulation, atrial septostomy is performed to relieve left or right atrial hypertension. 6. Patients with left ventricular failure who are supported by extracorporeal membrane oxygenation may also need trans- septal puncture and atrial septostomy.
  7. 7. Intact or Highly Restrictive Atrial Septum Associated with Obstructive Anomalies of the Left Heart  In the fetus with severe left ventricular inflow obstruction, unrestricted flow across the oval foramen is essential to ensure unobstructed pulmonary venous drainage from the left to the right atrium.  If the left-to-right atrial shunt is restrictive, left atrial hypertension and pulmonary venous congestion develop, often with major consequences on the pulmonary vascular morphology and function. J. Rychik, J.J. Rome, M.H. Collins, et al.: The hypoplastic left heart syndrome with intact atrial septum: Atrial morphology, pulmonary vascular histopathology and outcome. J Am Coll Cardiol. 34:554-560;1999
  8. 8. Types of complex congenital cyanotic heart diseases subjected for balloon septostomy
  9. 9.  One of the main causes of early mortality in case of D-TGA is hypoxia secondary to restrictive ASD. (Chantepie A, Schleich JM, Gournay V, Blaysat G, Maragnes P. Preoperative mortality in transposition of the great vessels.Arch Pediatr 2000;7:34-9. Pedra CA, Braga SL, Esteves CA, Fontes VF. Current role of therapeutic heart catheterization in pediatric cardiology. J Pediatr 1999;75:407-17.)  BAS is one of the life-saving palliative procedures that can be performed in catheterization laboratory or even intensive care unit under transthoracic echocardiography. (Guarnera S, Contarini M, Sciacca P, Patane L, Parisi MG, Pulvirenti A, et al. Indications for percutaneous atrioseptostomy: Comparison of echocardiographic and fluoroscopic monitoring. Pediatr Med Chir 1997;19:253-6.) Indications of Interventions on the Intact Atrial Septum Contd………..
  10. 10. When to intervene  The decision to perform the BAS was made based on the clinical findings of 1. Hypoxia 2. Echocardiographic confirmation of restrictive atrial septal defect, characterized by - a) The absence of visible communication or b) Small-size<2.0 mm or c) Less than one fourth of the total measurement of the interatrial septum measured in the subcostal position.
  11. 11. Technical consideration  Types of atrial septostomy 1. Balloon Atrial septostomy 2. Blade septostomy 3. Static/Graded balloon dilation 4. Radiofrequency wave based atrial septostomy 5. Atrial septal stenting
  12. 12. Types of vascular access for atrial septostomy  Femoral vein or umbilical vein, whenever available, is the access of choice for the procedure.  In cases where either of the access is not available like thrombosed vein due to previous use, or interrupted inferior vena cava (IVC), trans-hepatic approach is used. (Neves JR, Ferreiro CR, Fontes VF, Pedra CAC. Transhepatic access for atrioseptostomy in a neonate. Arq Bras Cardiol 2007;88:e57-9.)  The transhepatic route usually not accessed due to the reported rate of intra-peritoneal bleed as high as 4.5% even in experienced hands. (Erenberg FG, Shim D, Beekman RH 3rd. Intraperitoneal hemorrhage associated with transhepatic cardiac catheterization: A report of two cases. Cathet Cardiovasc Intervent 1998;43:177-8.)
  13. 13. vascular access for atrial septostomy contd………..  Infants older than 1 to 2 months (due to thick septum primum) and those with interrupted IVC pose technical challenges for performing BAS.  Inspite of few Indian case reports, IJV is not used as it is difficult to enter LA through this route and the perceived risk of injuring the sinoatrial node (SA node).
  14. 14. Ann of paediatric cardiology 2010 Vol 3 issue 1
  15. 15. Left femoral venogram showing blocked external iliac vein. The vein that reforms distally passes along the right border of vertebra suggesting blocked lower end of inferior vena cava also
  16. 16. Technical consideration contd……  The IJV access was taken and a 7F sheath was introduced.  Care was taken to keep the tip of the sheath beyond the superior vena cava – right atrial junction, so that injury to the SA node could be avoided during the „pull‟ of the catheter .  The position of the tip was checked prior to performing the procedure.  Since the Rashkind balloon could not be negotiated to LA by standard maneuver through the FO ASD, the balloon was pre- shaped to 90º angulation by inserting a pacemaker lead stylet .  Once the balloon entered the LA, the stylet was removed from the balloon and septostomy could be done similar to that is done through IVC route.
  17. 17. Short sheath through IJV, the tip of which is restraining the Rashkind balloon at SVC-RA junction
  18. 18. Technical consideration contd……  However, even after three attempts, a sufficiently large ASD with good flap could not be made, even though there was increase in the saturations from about 30% to 50–55%.  Subsequently, the ASD was crossed with a 0.014” coronary wire with support of 4F right coronary artery catheter.  The distal end of the wire was parked in the LV.
  19. 19. Technical consideration contd……  Over the wire a NuMED Z-5TM SPT 002–9.5 mm atrio septostomy catheter (NuMED, Inc.) was introduced and BAS was performed .  A 5.1 mm ASD, with good bidirectional laminar flow could be created after the procedure. The saturation improved up to 75 to 78%.  The procedure could be completed without any complications.
  20. 20. Rashkind balloon in LA, which was passed through the PFO after pre-shaping it with pacemaker lead stylet NuMED atrioseptostomy catheter in the left atrium passed over a 0.014” coronary wire, which is parked in left ventricle Technical consideration contd……
  21. 21. Atrial septostomy catheters  A variety of catheters are in use for balloon atrial septostomy.  The most commonly used catheter at the present time- 1. The 5F Miller balloon atrial septostomy catheter (Edwards Lifesciences, Irvine, CA, USA), needs an 7F to 8F introducer. 2. The low profile, dual lumen Z-5 atrioseptostomy catheter (Numed, Cornwall, ON, Canada), comes in 4F or 5F sizes, depending on the balloon diameter, and requires a 5 or 6F introducer, respectively.
  22. 22.  Miller-Edwards Balloon Septostomy Catheter (Edwards Life sciences, Irvine, CA) is an extruded catheter with a single lumen connected to a Latex balloon at the tip.  The Latex balloon is very compliant and, in order to be truly effective, it must be inflated with 5–6 cc of fluid to make the balloon even somewhat non- compliant.  With a 4 or 6 cc volume the balloon reaches approximately 2 cm in diameter, and at that diameter the balloon does lose most of its compliance.  Although not advertised, the burst volume of these balloons is 10–12 cc. Awad S, Hijazi ZM. Balloon atrial septostomy and stenting of the atrial septum. 1st ed. Complications during percutaneous interventions for congenital and structural heart disease. United Kingdom: Informa UK Ltd; 2009, pp 47–48. Miller-Edwards septostomy catheters
  23. 23.  These balloons do not have a separate true lumen and must be manipulated and positioned visually using fluoroscopy or echo.  They do come with a very fine stainless steel stylet which is useful, not only for deflecting the tip of the catheter, but also for clearing the very tiny lumen should it become clogged and prevent deflation of the balloon. Miller-Edwards septostomy catheters
  24. 24. Atrial septostomy catheters
  25. 25.  Z-5 septostomy catheter [NuMED, Inc., Hopkinton, NY]) has been designed for the neonate with CHD requiring septostomy & suitable for patients with a small left atrium.  Low-profile balloon catheter for atrioseptostomy  Non-compliant balloon, low profile in relaxed state  Inner lumen with an opening at the catheter end for inserting a guide wire.  Catheter with 35° angulation to facilitate access to the left atrium  Easy to use on newborns with a small left atrium  Platinum markers for clear positioning under fluorescent illumination Z-5 septostomy catheters Patel HT, QI-Ling CAO, Hijazi ZM. Balloon atrial septostomy: the oldest pediatric interventional procedure. J Interv
  26. 26. REF Balloon diameter Balloon length Guide wire Introduce r size PU SPT002 9.5 mm 95 mm 0.014" 5 F 1 SPT003 13.5 mm 135 mm 0.021" 6 F 1 Z-5 septostomy catheters
  27. 27. Atrial septostomy catheters contd…  Of the balloons available commercially, Numed and Fogarty are available in India.  Edwards Miller septostomy balloon is a preferred balloon but not available in the sub-continent.  Of these balloons, Numed is the only one which is an over-the-wire balloon.
  28. 28. Technique  The procedure was done in the catheterization laboratory under fluoroscopic guidance .  In life-saving conditions and risky neonatal transport, the procedure was performed in the neonatal intensive care unit as a bedside procedure under trans thoracic echo cardiographic guidance; the standard sub costal view was mainly used to delineate the interatrial septum and to guide the balloon catheter from the right atrium to the left atrium via the patent foramen ovale (PFO) or tiny atrial septal defect (ASD)
  29. 29. CONCLUSION: Echocardiographic monitoring of BAS avoids the transportation of severely sick neonates to the cath lab,helps determining position of the balloon catheter, immediate assessment of the result of every traction of the balloon without using radiation thus making the procedure effective and safe.
  30. 30. Subcostal view to guide the balloon through PFO and creat wide ASD.
  31. 31. Limitations of transthoracic echo guidance  The limitations of transthoracic echo guidance of BAS include the possibility of poor echo window in an ill neonate on assisted ventilation and possible interference with maneuverability for either echocardiographer or catheter operator particularly when umbilical vein cannulation is performed.
  32. 32. TEE guided JACC vol62,No18,29oct,2013
  33. 33.  Venous (umbilical/femoral) access is obtained with the appropriate size sheath.  A balloon septostomy catheter (the Miller catheter [Edwards-Baxter Healthcare Corporation, Santa Ana, CA] or the Z-5 septostomy catheter [NuMED, Inc., Hopkinton, NY]) is then advanced through the sheath up to the right atrium and through the atrial communication to the left atrium. Technique
  34. 34.  Appropriate positioning of the balloon at the atrial septum to avoid any potential complication is of crucial importance.  Abnormal positions of the balloon such as: left atrial appendage or the right atrial appendage in patients with juxtaposed right atrial appendage, the left pulmonary veins, through the left atrioventricular (AV) valve to the left ventricle must be avoided.  The balloon is then inflated in the left atrium then pulled into the right atrium using a rapid and forceful jerk.  The forceful jerk/pull motion should be stopped at the right atrium inferior vena cava junction. The catheter should be pushed back to the mid right atrium then deflated as rapidly as possible. Technique – contd……….
  35. 35.  The deflated catheter is advanced to the left atrium and the procedure is repeated until adequate atrial communication is achieved and no resistance is felt during passage of the inflated balloon across the defect.  At the end of the procedure the balloon is deflated and pulled outside the body.  The procedure was done under either general anesthesia or conscious sedation. Technique – contd………
  36. 36. Contrast filled balloon in the left atrium and pulled against the atrial septum under fluroscopy.
  37. 37. The success criterion  The success criterion of the procedure was- 1. The increase in the peripheral oxygen saturation 2. The increase in the atrial septal defect diameter >1/3 of the total septal diameter measured at the subcostal view or 3. Around 5 mm with ample border motility and clinical improvement.
  38. 38.  Cardiac perforation of left atrial appendage (LAA) occurred in one patient and managed surgically. (Out of 192 patients)  Balloon rupture occurred in 7% of cases and all ruptured balloons were of Miller type, no embolization of balloon fragments was reported.  There were no procedural deaths and five patients developed a sepsis-like picture after the procedure and died. Complications
  39. 39.  Recently ,the routine use of septostomy has come under scruitiny following the observation in one institutional series,of an association between septostomy and abnormal finding on postoperative cranial magnetic rasonance studies.  These observations have provoked caution in the application of septostomy although their significance will be a matter for debate and further investigation in future. Complications Circulation 2006;113;280-285
  40. 40. Complications Circulation 2006;113;280-285
  41. 41.  Multiple factors are likely to contribute to brain injury in children with CHD.  In the past, attention has largely been focused on operative factors, such as surgical and perfusion strategies and early post-operative problems including reduced systemic oxygen delivery and organ dysfunction, as well as genetic, familial, and social influences .  More recently the focus has expanded to include pre- operative events and pre-natal brain development.  Pre-operative cerebral magnetic resonance imaging (MRI) abnormalities have been demonstrated in 25% to 40% of neonates with CHD. The predominant abnormality is white matter injury (WMI), with infarction, hemorrhage, and abnormalities of maturation also seen. Complications
  42. 42. Types of septostomy Blade septostomy  Balloon atrial septostomy has limitations in older infants, due to the increased thickness of the atrial septum.  In these cases blade septostomy and static balloon dilation of the atrial septum are prefered to enlarge the interatrial communication.  Static balloon dilation is unlikely to create a reliable atrial septal defect.  In older children with thick septum, blade atrial septostomy is possible but seldom performed because of its inherent risks.
  43. 43. Blade Atrial Septostomy Catheter  The catheter is 65 cm long and is made of 6F radiopaque polyethylene tubing (Cook Incorporated).  The catheter tip consists of a 3.5-cm section of stainless steel tubing with a 2.5-cm slit on its long axis. The metal tubing contains a small blade that is linked to a lever whose distal portion pivots at the catheter tip.  The proximal portion of the blade is linked to a solid guide wire that passes through the entire catheter and exits at the hub.  Advancing the wire extends the blade and the lever through the slit to form a triangle.
  44. 44.  There is a Y connector at the proximal portion of the catheter; one side branch is for fluid infusion and pressure measurement and the other for the wire that controls the blade.  6F &7F introducer should be used because most balloon septostomy catheters cannot be introduced through a smaller sheath.  The maximal height of the extended blade is 12-13 mm. Thus, when the diameter of the IAO is greater than 10 mm, it is unlikely that the blade could effectively engage the interatrial septum and the procedure is not recommended. Blade Atrial Septostomy Catheter
  45. 45. Complications in blade septostomy
  46. 46. Types of atrial septostomy Radiofrequency puncture of Fossa Ovalis
  47. 47. Surgeons perspective of creation of atrial septal defect  Closed-heart methods of creation of atrial septal defect have been previously described.  The first technique described was the Blalock Hanlon septectomy. Azzolina G, Eufrate SA, Pensacola PM. Closed Interatrial septostomy. Ann Thorac Surg 1972;13:338-41. Simpson JM, Anderson DR, Qureshi SA. Closed atrial septostomy with Brock punch aided by transesophageal echocardiography, Ann Thorac Surg 1995;60:1794-5.  This involves snaring of right pulmonary veins and right pulmonary artery and has been associated with complications such as arrhythmias, pulmonary hemorrhage, and neurological insult.  More recent techniques include the use of a Brock punch under TEE guidance and a specially designed atriotomy knife through a thoracotomy. (Kawahira Y, Kishimoto H, Kawata H, Ikawa S, Ueda H, Ueno T, et al. Surgical atrial septostomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1016-8.)
  48. 48. Minisurgical technique Benedict RR, Kumar A, Francis E, Kumar RK. Off-pump atrial septostomy with thoracoscopic scissors under transesophageal echocardiography guidance. Ann Pediatr Card 2013;6:170-2.
  49. 49. Benedict RR, Kumar A, Francis E, Kumar RK. Off-pump atrial septostomy with thoracoscopic scissors under transesophageal echocardiography guidance. Ann Pediatr Card 2013;6:170-2.  An off-pump technique to perform atrial septostomy under transesophageal echocardiography (TEE) guidance using thoracoscopic scissors.  The procedure was carried out through a median sternotomy. The patient was heparinized. A purse-string suture was made on the right atrial (RA) appendage.  A stab was made within the purse string, and through this, thoracoscopy scissors was introduced in the RA. Under TEE guidance, the closed tip of the instrument was used to tent the fossa ovalis below the limbus and a small perforation was created.
  50. 50.  It was then dilated by stretching with the opening of the blades of the scissors.  The scissors was then rotated to face inferiorly with one blade on either side of the inter-atrial septum, and two cuts were made in the inferior and lateral directions, away from the AV valves and conduction tissue. Benedict RR, Kumar A, Francis E, Kumar RK. Off-pump atrial septostomy with thoracoscopic scissors under transesophageal echocardiography guidance. Ann Pediatr Card 2013;6:170-2.
  51. 51. Benedict RR, Kumar A, Francis E, Kumar RK. Off-pump atrial septostomy with thoracoscopic scissors under transesophageal echocardiography guidance. Ann Pediatr Card 2013;6:170-2.  Technique of atrial septostomy using thoracoscopic scissors under transesophageal echocardiography guidance is relatively simple and has the following advantages: 1. The narrow body of the instrument requires only a small stab incision on the RA. The manipulation of this slender instrument was well tolerated and there was no arrhythmia or bleeding with minimal risk. 2. It is well controlled and visible on TEE. 3. Avoidance of CPB is possible, with a low chance of injury to the neighboring structures.
  52. 52. Photograph of the thoracoscopic scissors in the open position (left) and in the closed position
  53. 53. Intraoperative transesophageal echocardiography of the procedure: The tips of the scissors are shown tenting the inter-atrial septum (a) and subsequently passing into the left atrium (LA) through the atrial septum (b) Pre-discharge transthoracic echocardiogram shows the atrial septal opening. Color Doppler (right frame) shows a laminar flow across the atrial septum
  54. 54. Stenting of the atrial septum  Catheter-based techniques tend to be relatively unreliable unless a stent is used. (Leonard GT Jr, Justino H, Carlson KM, Rossano JW, Neish SR, Mullins CE, et al. Atrial septal stent implant: Atrial septal defect creation in the management of complex congenital heart defects in infants. Congenit Heart Dis 2006;1:129-35)  Stenting of the atrial septum is risky and technically challenging, especially in very young patients. (Holzer RJ, Wood A, Chisolm JL, Hill SL, Phillips A, Galantowicz M, et al. Atrial septal interventions in patients with hypoplastic left heart syndrome. Catheter Cardiovasc Interv 2008;72:696-704.)
  55. 55. Stenting of the atrial septum
  56. 56. Atrial septostomy in Primary PAH
  57. 57.  Current recommendations suggest four exclusion criteria for AS: 1. RAP >20 mm Hg 2. SaO2 <90% 3. Predicted 1 year survival <40% 4. PVR >55 wood units/m2 (>4400 dyne*s/cm5 ). Barst RJ. Role of atrial septostomy in the treatment of pulmonary vascular disease. Thorax 2000;55:95–6. Sandoval J, Rothman A, Pulido T. Atrial septostomy for pulmonary hypertension. Clin Chest Med 2001;22:547–60. Rich S, ed. Primary pulmonary hypertension: Executive Summary from the World Symposium Primary Pulmonary Hypertension 1998. Available at Atrial septostomy in Primary PAH
  58. 58.  Candidates for atrial septostomy should have a systemic arterial oxygen saturation on room air of more than 90%.  The end point for the procedure should be considered a reduction in systemic arterial oxygen saturation of 5–10%. Atrial septostomy in Primary PAH
  59. 59. Indian Heart J. 2002 Mar-Apr;54(2):164-9. Graded balloon atrial septostomy in severe pulmonary hypertension. Kothari SS1, Yusuf A, Juneja R, Yadav R, Naik N.  BACKGROUND:  The prognosis of patients with severe primary pulmonary hypertension is poor. The role of balloon atrial septostomy as a palliative procedure in these patients is not well defined. We retrospectively analyzed our data regarding the safety, clinical outcome and survival benefit of graded balloon atrial septostomy in patients with severe pulmonary hypertension.
  60. 60.  METHODS AND RESULTS:  Eleven patients (7 males), aged 6 to 30 years (mean age 16.2+/- 8.9 years), with severe pulmonary artery hypertension (mean pulmonary artery pressure of 76+/-16.9 mmHg) and refractory congestive heart failure and/or recurrent syncope underwent balloon atrial septostomy. Graded balloon dilatation under echocardiographic guidance and arterial oxygen saturation monitoring was done in all the patients. Procedure-related mortality was 18.2%. Significant acute hemodynamic improvement was seen in the survivors (pre-balloon atrial septostomy cardiac index 1.88+/-0.48 L/min/m2; post-balloon atrial septostomy cardiac index 2.18+/-0.37 L/min/m2, p<0.009). Patients were followed up for a mean period of 20.3 months after the procedure (range: 3 months-5 years). There was functional improvement and increased exercise tolerance in all the patients for a mean follow-up period of 14.6 months (NYHA functional class 3.62+/-0.69 to 2+/-0.50). The estimated probability of survival in this cohort at 1 year was only 48%; but 7 of 8 patients (87%) who survived the procedure were alive at 1 year. Indian Heart J. 2002 Mar-Apr;54(2):164-9. Graded balloon atrial septostomy in severe pulmonary hypertension. Kothari SS1, Yusuf A, Juneja R, Yadav R, Naik N.  CONCLUSION:  We conclude that balloon atrial septostomy improves clinical status, hemodynamic variables and possibly also improves survival in selected patients with severe pulmonary artery hypertension. It remains a definite palliative option for refractory primary pulmonary hypertension. However, the procedure- related risks are high in very sick patients and, therefore, balloon atrial septostomy may be advocated early in the course of the disease.
  61. 61. Atrial septostomy in PAH following surgical closure of the ASD.  Balloon atrial septostomy (BAS), which involves artificially creating a communication across the interatrial septum following trans-septal puncture and repetitive balloon dilatation, is known to be associated with therapeutic benefit in patients with severe pulmonary artery hypertension (PAH).  Adult patients with large shunts and consequent severe PAH are not uncommon in the developing world, since they often seek medical attention late in the course of the disease.  Often PAH in such cases is reversible with amelioration of symptoms after closure of the defect. We report a case of large atrial septal defect (ASD) with severe PAH who developed gross right heart failure following surgical closure of the ASD.  A successful bail out BAS was performed using an Inoue balloon, avoiding the need for a redo surgery. The case highlights for the first time the use of Inoue balloon for performing a successful BAS. Kapoor A, Khanna R, Betra A, Kumar S. Inoue balloon atrial septostomy in severe persistent pulmonary hypertension following surgical ASD closure. J Cardiol Cases;
  62. 62. Atrial septostomy for pt on ECMO
  63. 63. INTRANATAL ATRIAL SEPTOSTOMY  Children born with hypoplastic left heart syndrome and a restrictive or intact atrial septum have a substantial increase in morbidity and mortality, even when the obstruction is successfully relieved immediately after birth by an emergency atrial septostomy. A.P. Vlahos, J.E. Lock, D.B. McElhinney, M.E. van der Velde:Hypoplastic left heart syndrome with intact or highly restrictive atrial septum: Outcome after neonatal transcatheter atrial septostomy.Circulation.
  64. 64.  Whenever a fetus with an intact or severely restrictive atrial septum in the setting of severe mitral valve stenosis or atresia is identified, the option of prenatal atrial septostomy should be considered.  If the pulmonary venous flow has minimal or no early diastolic forward movement, but shows significant reversal during atrial contraction, this will indicate severe restriction of intra-atrial flow.  Moreover, assessment of the severely restrictive atrial shunting by Doppler interrogation will show continuous left-to-right shunting at high velocity, suggesting a significant pressure gradient between the two atriums. INTRANATAL ATRIAL SEPTOSTOMY
  65. 65. The pulmonary venous Doppler pattern of flow is seen during several cardiac cycles in a normal fetus and in a fetus(A) with hypoplastic left heart syndrome and un- restrictive atrial communication (B). Note the small amount of backward flow during atrial systole. C, Comparable findings in a fetus with hypoplastic left heart syndrome and an intact atrial septum: There is complete absence of early diastolic flow and increased flow reversal during atrial systole. A, late diastolic flow at the time of atrial contraction; D, early diastolic flow; S, systolic flow;.
  66. 66. Technique of Fetal Atrial Septostomy  The interventional technique is comparable to intra- uterine aortic or pulmonary valvoplasty.  Using an ultrasonic guided percutaneous approach, either the right or the left atrial free wall is entered from the lateral chest wall, with the cannula pointing perpendicularly to the atrial septum.  A sharp needle is advanced via the cannula to perforate the thickened septum.  A guide-wire is then advanced across the cannula into a pulmonary vein, followed by placement of a coronary arterial balloon catheter across the atrial septum.  The balloon is then inflated to its maximal diameter.
  67. 67. A balloon placed across the atrial septum during fetal atrial septostomy. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right INTRANATAL ATRIAL SEPTOSTOMY
  68. 68. Results and Outcome  The current experience with fetal atrial septostomy is very limited, effectively representing the experience obtained in Boston.  Interventions were attempted on seven fetuses between 26 and 34 weeks of gestation, of which six were technically successful. There were no maternal complications.  Of the fetuses, one died prior to birth, and the remaining cases were live born, albeit that all died in the neonatal period.  The latest unpublished experience from Boston has extended to 18 fetal procedures, with technical success in more than nine-tenths, 17 of the fetuses being live born children, one dying prior to surgical intervention, and more than half successfully surviving postnatal surgical intervention. A.C. Marshall, M.E. van der Velde, W. Tworetzky, et al.: Creation of an atrial septal defect in utero for fetuses with hypoplastic left heart syndrome and intact or highly restrictive atrial septum. Circulation.110:253-258 2004
  69. 69.  Ultrasonically guided fetal atrial septostomy, therefore, is technically feasible, and can be achieved with a low risk of fetal death.  Whether the procedure ensures permanent left atrial decompression, with reversal of pulmonary vascular abnormalities, and with improved postnatal outcome, remains to be established. Results and Outcome
  70. 70. Am J Obstet Gynecol. 2005 Oct;193(4):1424-8. In utero cardiac fetal surgery: laser atrial septotomy in the treatment of hypoplastic left heart syndrome with intact atrial septum. Quintero RA1, Huhta J, Suh E, Chmait R, Romero R, Angel J.  OBJECTIVE: The purpose of this study was to report a novel technique, laser atrial septotomy, for the in utero treatment of hypoplastic left heart syndrome with intact atrial septum.  STUDY DESIGN: In utero atrial septotomy by Neodymium-YAG laser photofulguration in a fetus with hypoplastic left heart syndrome (HLHS) and intact atrial septum was performed at 30 4/7 weeks of gestation. Percutaneous fetal cardiocentesis was performed to guide a contact (Neodymium-YAG) laser fiber into the right atrium with the objective of creating an interatrial communication by photofulguration of the septal tissue.  RESULTS: New onset of blood flow from the left to the right atrium was confirmed by color Doppler imaging during the procedure. The neoatrial septal defect remained patent until delivery. A 3400-g neonate was born by spontaneous vaginal delivery at 37 weeks of gestation. A first stage Norwood procedure was performed on the first day of life and surgical correction of an obstructed right pulmonary vein at 3 months. Although pulmonary vascular resistance was normal at cardiac catheterization at 2 months of age, the infant died at 5 months of age from multiple organ failure. An autopsy was declined.  CONCLUSION: In utero laser atrial septotomy is feasible. Further experience is necessary to determine the risks and benefits of this technique for the treatment of fetuses hypoplastic left heart syndrome with intact atrial septum.
  71. 71. Summery of seminar  Balloon atria] septostomy remains useful for increasing the systemic oxygenation of most severely hypoxic babies with transposition of the great arteries and restrictive foramen ovale who do not show improved systemic oxygen tension during prostaglandin administration.  The procedure is still commonly performed in developing countries like India where complete repair during the neonatal period is not widely available.  For a successful BAS, a thin septum primum is essential. Hence the procedure yields best result if performed before 2 to 3 weeks.  Atrial septostomy can also be performed successfully in selected patients with advanced pulmonary vascular disease.
  72. 72. THANKS