Surgical atrial septostomy without cardiopulmonary bypass

Utility of Fetal Cardiovascular Magnetic Resonance for Prenatal Diagnosis of Complex Congenital Heart Defects

Importance

Prenatal diagnosis of complex congenital heart defects reduces mortality and morbidity in affected infants. However, fetal echocardiography can be limited by poor acoustic windows, and there is a need for improved diagnostic methods.

Objective

To assess the clinical utility of fetal cardiovascular magnetic resonance imaging in cases in which fetal echocardiography could not visualize all relevant anatomy.

Design, Setting, and Participants

This cohort study was conducted between January 20, 2017, and June 29, 2020, at Skåne University Hospital (Lund, Sweden), a tertiary center for pediatric cardiology and thoracic surgery. Participants were fetuses referred for fetal cardiovascular magnetic resonance examination by a pediatric cardiologist after an inconclusive echocardiograph.

Exposures

Fetal cardiovascular magnetic resonance examination requested by the patient's pediatric cardiologist.

Main Outcomes and Measures

Any change in patient management because of diagnostic information gained from fetal cardiovascular magnetic resonance imaging.

Results

A total of 31 fetuses underwent cardiovascular magnetic resonance examination at a median gestational age of 36 weeks (range, 31-39 weeks). Overall, fetal cardiovascular magnetic resonance imaging had clinical utility, affecting patient management and/or parental counseling in 26 cases (84%). For aortic arch anatomy including signs of coarctation (20 fetuses), fetal cardiovascular magnetic resonance imaging added diagnostic information in 16 cases (80%). For assessment of univentricular vs biventricular outcome in borderline left ventricle, unbalanced atrioventricular septal defect, and pulmonary atresia with intact ventricular septum (15 fetuses), fetal cardiovascular magnetic resonance imaging visualized intracardiac anatomy and ventricular function, allowing assessment of outcome in 13 cases (87%). In 4 fetuses with hypoplastic left heart syndrome, fetal cardiovascular magnetic resonance imaging helped delivery planning in 3 cases (75%). Finally, fetal cardiovascular magnetic resonance imaging provided valuable information for parental counseling in 21 cases (68%).

Conclusions and Relevance

In this cohort study, fetal cardiovascular magnetic resonance imaging added clinically useful information to what was available from echocardiography. These findings suggest that fetal CMR has the potential to affect clinical decision-making in challenging cases of congenital heart defects with inconclusive data from echocardiography. Fetal cardiovascular magnetic resonance imaging showed an association with clinical decision-making, including mode of delivery and early postnatal care, as well as with parental counseling.

Off-pump atrial septostomy with thoracoscopic scissors under transesophageal echocardiography guidance

Selected children with congenital heart defects undergoing palliative closed heart procedures require a cardiopulmonary bypass (CPB) run only for the purpose of creating an inter-atrial communication. We report a simple technique of atrial septostomy using thoracoscopy scissors under transesophageal echocardiography guidance without the need for CPB.

New technique of off-pump atrial septostomy for complex congenital cardiac anomalies

OBJECTIVES

Atrial septostomy is essential for palliation of some complex congenital cardiac anomalies, such as transposition of the great arteries and left-/right-sided atrioventricular valve stenosis or atresia. Conventionally, balloon atrial septostomy is done in neonates. Beyond the neonatal period, surgical septostomy is done using cardiopulmonary bypass and can lead to increased morbidity and mortality. We report a new technique of atrial septostomy without cardiopulmonary bypass and its follow-up.

METHODS

Eleven cases underwent atrial septostomy without using cardiopulmonary bypass from January 2009 to June 2010. Median age of patients was 7 months (2-12 months) and median weight was 6.3 kg (range 4.5-10 kg). Surgical septostomy was performed through the right atrial appendage with a Tubb's dilator, aided by intra-operative transesophageal echocardiography. Atrial septal defect (ASD) less than 5mm was enlarged with a Kerrison bone punch and then dilated with a Tubb's dilator. Associate procedures performed were off-pump Glenn in seven cases, pulmonary artery (PA) banding in three cases, and shunt with PA band in one case.

RESULTS

All the restricted ASDs were successfully enlarged with adequate interatrial shunting without any gradient. Echocardiography revealed no evidence of introduction of air or particulate emboli, and no tricuspid valve injury or heart block. There was no postoperative mortality. Follow-up ranged from 1 to 18 months (median 11 months). Echocardiography showed good PA band gradient/well-functioning Glenn shunt and unobstructed ASD with good oxygen saturation.

CONCLUSIONS

This technique demonstrates the surgical feasibility of a beating-heart atrial septostomy. It avoids the adverse effects of cardiopulmonary bypass, reduces morbidity, and has no mortality. It is safe, economical, and easily reproducible. To our knowledge, this technique has not been reported in literature so far.

Three-dimensional echocardiography–guided atrial septectomy: An experimental study

OBJECTIVES

The surgical feasibility of beating-heart atrial septectomy under the guidance of two different types of real-time 3-dimensional echocardiography systems was examined.

METHODS

A modified real-time 3-dimensional echocardiography system with a x4 matrix transducer (Sonos 7500; Philips Medical Systems, Andover, Mass) or a mechanical 1-dimensional array transducer (SSD-5500; Aloka Co, Ltd, Tokyo, Japan) was used. Small porcine atrial septal defects (n = 8) were enlarged with a Kerrison bone punch in the tank model. In the animal studies, small atrial septal defects (n = 8) were enlarged with the same device through a transatrial port. In both experiments, the area of the atrial septal defect measured by real-time 3-dimensional echocardiography was compared with the area measured directly.

RESULTS

Real-time 3-dimensional echocardiography provided satisfactory images and sufficient anatomic detail for the atrial septectomy in both experimental settings. All the atrial septal defects were successfully enlarged; an increase of as much as 293% of the preoperative atrial septal defect area was achieved in the tank experiment, and an increase of as great as 449% of the preoperative area was achieved in the animal experiment. The size of the atrial shunt was increased significantly after the atrial septectomy relative to that before the surgery (P <.0001). The percentage enlargement of the atrial septal defect measured by real-time 3-dimensional echocardiography was strongly correlated with that measured directly (both r(2) = 0.997, P <.0001) Bland-Altman analysis showed close agreement between the results obtained by the two measurement methods in both models.

CONCLUSIONS

Real-time 3-dimensional echocardiography provides satisfactory images and sufficient anatomic detail for atrial septectomy. This experiment demonstrates the surgical feasibility of a beating-heart intracardiac procedure such as atrial septectomy under real-time 3-dimensional echocardiographic guidance.