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Subramanian S, Jani S, Well A, Mikulski MF, Agrawal H, Byron Holt D, Venardos N, Mery CM, Fraser CD. Revisiting the Role of Balloon Atrial Septostomy Prior to the Arterial Switch Operation. World J Pediatr Congenit Heart Surg 2024:21501351241252428. [PMID: 39119670 DOI: 10.1177/21501351241252428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
OBJECTIVES Patients with dextro-transposition of the great arteries (d-TGA) frequently undergo balloon atrial septostomy (BAS) prior to the arterial switch operation (ASO) to promote atrial-level mixing. Balloon atrial septostomy has inherent risks as an invasive procedure and may not always be necessary. This study revisits the routine utilization of BAS prior to ASO. METHODS Single-center, retrospective review of d-TGA patients undergoing the ASO from July 2018 to March 2023. Preoperative patient characteristics, pulse oximetry oxygen saturations (SpO2), cerebral/renal near-infrared spectroscopy (NIRS) readings along with prostaglandin status at the time of the ASO were analyzed with descriptive and univariate statistics. RESULTS Thirty patients underwent the ASO. Of these, 7 (23%) were female, 25 (83%) were white, and median weight at ASO was 3.2 kg (range 0.8-4.2). Twenty-two (73%) patients underwent BAS. There were no demographic differences between BAS and no-BAS patients. Of those who underwent BAS, there was a significant increase in SpO2 (median 83% [range 54-92] to median 87% [range 72-95], P = .007); however, there was no change in NIRS from pre-to-post BAS. Six (27%) patients in the BAS group were prostaglandin-free at ASO. Balloon atrial septostomy patients underwent the ASO later compared with no-BAS patients (median 8 [range 3-32] vs 4 [range 2-10] days old, P = .016) and had a longer hospital length of stay (median 13 [range 7-43] vs 10 [range 8-131] days, P = .108). CONCLUSIONS While BAS is an accepted preoperative procedure in d-TGA patients to improve oxygen saturations, it is also an additional invasive procedure, does not guarantee prostaglandin-free status at the time of ASO, and may increase the interval to ASO. Birth to direct early ASO, with prostaglandin support, should be revisited as an alternative, potentially more expeditious strategy.
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Affiliation(s)
- Sujata Subramanian
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin & Dell Children's Medical Center, Austin, TX, USA
- Department of Surgery and Peri-operative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Sagar Jani
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin & Dell Children's Medical Center, Austin, TX, USA
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Andrew Well
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin & Dell Children's Medical Center, Austin, TX, USA
- Department of Surgery and Peri-operative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Matthew F Mikulski
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin & Dell Children's Medical Center, Austin, TX, USA
- Department of Surgery and Peri-operative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Hitesh Agrawal
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin & Dell Children's Medical Center, Austin, TX, USA
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - D Byron Holt
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin & Dell Children's Medical Center, Austin, TX, USA
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Neil Venardos
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin & Dell Children's Medical Center, Austin, TX, USA
- Department of Surgery and Peri-operative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin & Dell Children's Medical Center, Austin, TX, USA
- Department of Surgery and Peri-operative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Charles D Fraser
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin & Dell Children's Medical Center, Austin, TX, USA
- Department of Surgery and Peri-operative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
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Gezer M, Demirci O, Yücel İK. How reliably does prenatal echocardiography predict urgent balloon atrial septostomy in fetuses with d-TGA? J Gynecol Obstet Hum Reprod 2024; 53:102813. [PMID: 38857825 DOI: 10.1016/j.jogoh.2024.102813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 04/12/2024] [Accepted: 06/07/2024] [Indexed: 06/12/2024]
Abstract
OBJECTIVE To analyze the prenatal and postnatal outcomes of fetuses with d-TGA and to determine whether prenatal echocardiography may predict postnatal urgent BAS. STUDY DESIGN A retrospective study of fetuses with d-TGA, for which fetal echocardiography was performed at our tertiary hospital from January 2018 to May 2023. We assessed the appearance of the septum primum and the FO flap in the four-chamber view as to whether the FO had a restrictive appearance during measurement of the diameter of the FO at its maximal angle to the attachment point. Color Doppler was used to detect VSDs and measure its diameter both in the four-chamber view and when visualizing the outlets of the great arteries in the sagittal section of the heart. RESULTS During the study period, 64 fetuses were diagnosed with d-TGA, which was also confirmed postnatally. Of these, 16 fetuses were excluded due to additional cardiac anomalies or the inability to reach the mother. In total, 48 cases were included in this series. In our study, the FO diameter was significantly decreased in the urgent BAS group, compared with the fetuses without urgent BAS (5.1 mm vs 6.3 mm). A cut off of 6 mm for the FO diameter (sensitivity, 73.3 %; specificity, 72.2 %; area under the curve [AUC], 0.764) and 3.2 mm for the VSD diameter (sensitivity, 75 %; specificity, 75 %; AUC, 0.728) suggested urgent BAS. CONCLUSION Prenatal echocardiography performed after 37 weeks of gestation in fetuses with d-TGA provides valuable information to estimate the need for postnatal urgent BAS that would prevent immediate life-threatening complications.
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Affiliation(s)
- Murad Gezer
- Department of Perinatology, University of Health Sciences Zeynep Kamil Women's and Children's Disease Training and Research Hospital, Istanbul, Turkey.
| | - Oya Demirci
- Department of Perinatology, University of Health Sciences Zeynep Kamil Women's and Children's Disease Training and Research Hospital, Istanbul, Turkey
| | - İlker Kemal Yücel
- Department of Pediatric Cardiology, Cerrahpasa Medical Faculty, Istanbul, Turkey
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Dorobantu DM, Espuny Pujol F, Kostolny M, Brown KL, Franklin RC, Crowe S, Pagel C, Stoica SC. Arterial Switch for Transposition of the Great Arteries: Treatment Timing, Late Outcomes, and Risk Factors. JACC. ADVANCES 2023; 2:100407. [PMID: 38939004 PMCID: PMC11198700 DOI: 10.1016/j.jacadv.2023.100407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/23/2023] [Accepted: 04/06/2023] [Indexed: 06/29/2024]
Abstract
Background Reports of long-term mortality and reintervention after transposition of the great arteries with intact ventricular septum treatment, although favorable, are mostly limited to single-center studies. Even less is known about hospital resource utilization (days at hospital) and the impact of treatment choices and timing on outcomes. Objectives The purpose of this study was to describe survival, reintervention and hospital resource utilization after arterial switch operation (ASO) in a national dataset. Methods Follow-up and life status data for all patients undergoing ASO between 2000 and 2017 in England and Wales were collected and explored using multivariable regressions and matching. Results A total of 1,772 patients were identified, with median ASO age of 9.5 days (IQR: 6.5-14.5 days). Mortality and cardiac reintervention at 10 years after ASO were 3.2% (95% CI: 2.5%-4.2%) and 10.7% (95% CI: 9.1%-12.2%), respectively. The median time spent in hospital during the ASO spell was 19 days (IQR: 14, 24). Over the first year after the ASO patients spent 7 days (IQR: 4-10 days) in hospital in total, decreasing to 1 outpatient day/year beyond the fifth year. In a subgroup with complete risk factor data (n = 652), ASO age, and balloon atrial septostomy (BAS) use were not associated with late mortality and reintervention, but cardiac or congenital comorbidities, low weight, and circulatory/renal support at ASO were. After matching for patient characteristics, BAS followed by ASO and ASO as first procedure, performed within the first 3 weeks of life, had comparable early and late outcomes, including hospital resource utilization. Conclusions Mortality and hospital resource utilization are low, while reintervention remains relatively frequent. Early ASO and individualized use of BAS allows for flexibility in treatment choices and a focus on at-risk patients.
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Affiliation(s)
- Dan-Mihai Dorobantu
- Children's Health and Exercise Research Centre (CHERC), University of Exeter, Exeter, United Kingdom
- Population Health Sciences, University of Bristol, Bristol, United Kingdom
- Cardiology Department, University Hospitals Bristol and Weston National Health Service Foundation Trust, Bristol, United Kingdom
| | - Ferran Espuny Pujol
- Clinical Operational Research Unit, Department of Mathematics, University College London, London, United Kingdom
| | - Martin Kostolny
- Heart and Lung Division, Great Ormond Street Hospital NIHR Biomedical Research Centre, London, United Kingdom
| | - Katherine L. Brown
- Heart and Lung Division, Great Ormond Street Hospital NIHR Biomedical Research Centre, London, United Kingdom
| | - Rodney C. Franklin
- Department of Paediatric Cardiology, Royal Brompton and Harefield National Health Service Foundation Trust, London, United Kingdom
| | - Sonya Crowe
- Clinical Operational Research Unit, Department of Mathematics, University College London, London, United Kingdom
| | - Christina Pagel
- Clinical Operational Research Unit, Department of Mathematics, University College London, London, United Kingdom
| | - Serban C. Stoica
- Cardiology Department, University Hospitals Bristol and Weston National Health Service Foundation Trust, Bristol, United Kingdom
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