This document discusses the history and technique of atrial septostomy. It describes how William Rashkind first developed the procedure in 1966 as a way to create an atrial septal defect without surgery. The document outlines the common indications for atrial septostomy in various congenital heart conditions. It provides details on the technical aspects of the procedure, including types of catheters, approaches, positioning, and success criteria. Complications are also mentioned, such as cardiac perforation which occurred in one case and was managed with surgery.

1. DR AWADHESH KUMAR SHARMA
DEPTT OF CARDIOLOGY
PGIMER & DR RML HOSPITAL,NEW
DELHI
ATRIAL SEPTOSTOMY

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)

4. 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.”

5. 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

6. An Indian perspective

7. 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.

8. 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

9. Types of complex congenital cyanotic heart
diseases subjected for balloon septostomy

10.  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………..

11. 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.

12. 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

14. 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.)

15. 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).

16. Ann of paediatric cardiology 2010 Vol 3
issue 1

17. 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

18. 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.

19. Short sheath through IJV, the tip of which is restraining the
Rashkind balloon at SVC-RA junction

20. 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.

21. 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.

22. 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……

23. 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.

24.  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

25.  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

26. Atrial septostomy catheters

27.  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

28. 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

29. 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.

30. 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)

32. 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.

33. Subcostal view to guide the balloon
through PFO and creat wide ASD.

34. 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.

35. TEE guided
JACC vol62,No18,29oct,2013

36.  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

37.  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……….

38.  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………

39. Contrast filled balloon in the left atrium and pulled
against the atrial septum under fluroscopy.

40. 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.

41.  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

42.  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

43. Complications
Circulation 2006;113;280-285

45.  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

46. 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.

47. 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.

48.  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

49. Complications in blade
septostomy

52. Types of atrial septostomy
Radiofrequency puncture of Fossa
Ovalis

53. 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.)

54. 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.

55. 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.

56.  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.

57. 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.

58. Photograph of the thoracoscopic scissors in the open position (left)
and in the closed position

59. 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

60. 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.)

61. Stenting of the atrial septum

62. Atrial septostomy in Primary PAH

64.  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 www.who.int/ncd/cvd/pph.html.
Atrial septostomy in Primary
PAH

65.  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

66. 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.

67.  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.

68. 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; http://dx.doi.org/10.1016/j.jccase.2012.02.002.

69. Atrial septostomy for pt on
ECMO

70. 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.

71.  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

72. 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;.

73. 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.

74. 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

75. 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

76.  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

77. 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.

78. 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.

79. THANKS