Balloon Atrial Septostomy in Congenital Heart Disease

To the Editor:

The article by Sugiyama and coworkers was interesting and the novel double balloon static septostomy technique has the potential to improve results with balloon septostomy.¹ This could potentially reduce particle embolization-related complications in some of these babies, and the authors deserve credit for the method.

We had some reservations about the decision for a balloon septostomy in patient number 1. The report mentions an 8-month-old baby with dextrocardia, transposition of great arteries, ventricular septal defect (VSD) and pulmonary stenosis, who had undergone a prior balloon septostomy and a modified BT shunt with oxygen saturation of 72%. Indeed, the catheterization data suggest that the baby had restrictive circulatory mixing. Although balloon atrial septostomy (BAS) could relieve the baby’s symptoms, definitive surgical intervention without BAS could have been a better option. Whether delaying definitive repair with the additional time procured through a repeat BAS would benefit this condition at 8 months of age is conjectural. A Nikaidoh procedure with aortic root translocation and VSD closure would be the best option if the anatomy permits.² In other situations, intracardiac routing of the left ventricle to the aorta with VSD closure may be considered. A repeat balloon septostomy to improve oxygenation would definitely be of value in the remote consideration of univentricular repair in a patient with poor anatomy precluding biventricular repair or resource-limited settings.^3,4 Even in the presence of subpulmonary stenosis, the pulmonary artery pressures generally tend to be higher in this subset of infants compared with other children considered for univentricular repair.⁵ We would then have proceeded with complete right heart catheterization with estimation of pulmonary artery pressures. It would be enlightening to know further from experts in the field.

Funding

None of the authors has any financial relationship (within the past 12 months) with a biotechnology manufacturer, a pharmaceutical company, or other commercial entity that has been involved in the subject matter or materials discussed in the manuscript to disclose.

Conflict of Interests

None.

• Arun Gopalakrishnan, MD
• Bijulal Sasidharan, MD
• Kavassery Mahadevan Krishnamoorthy, MD
• Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India

(Released online March 8, 2016)

References

• 1.    Sugiyama  H,  Fujimoto  K,  Ishii  T,  Nakanishi  T,  Tomita  H. Impact of novel balloon catheter on static balloon atrial septostomy with double balloon technique in infants with congenital heart disease. Circ J 2015; 79: 2367–2371.
• 2.    Nikaidoh  H. Aortic translocation and biventricular outflow tract reconstruction: A new surgical repair for transposition of the great arteries associated with ventricular septal defect and pulmonary stenosis. J Thorac Cardiovasc Surg 1984; 88: 365–372.
• 3.    Nakano  T,  Kado  H,  Tatewaki  H,  Hinokiyama  K,  Oda  S,  Ushinohama  H, et al. Results of extracardiac conduit total cavopulmonary connection in 500 patients. Eur J Cardiothorac Surg 2015 48: 825–832.
• 4.    Rogers  LS,  Glatz  AC,  Ravishankar  C,  Spray  TL,  Nicolson  SC,  Rychik  J, et al. 18 Years of the Fontan operation at a single institution: Results from 771 consecutive patients. J Am Coll Cardiol 2012; 60: 1018–1025.
• 5.    Viles  PH,  Ongley  PA,  Titus  JL. The spectrum of pulmonary vascular disease in transposition of the great arteries. Circulation 1969; 40: 31–41.