Analysis of 8681 neonates with transposition of the great arteries: Outcomes with and without Rashkind balloon atrial septostomy

ArticleinCardiology in the Young 20(4):373-80 · August 2010with30 Reads
DOI: 10.1017/S1047951110000296 · Source: PubMed
Rashkind balloon atrial septostomy is a common cardiac procedure aimed at improving systemic oxygenation in newborns with cyanotic congenital cardiac defects, such as transposition of the great arteries. Recent reports on the safety of this procedure were from limited series at single institutions. We analysed two complementary national databases to evaluate clinically relevant outcomes of this procedure. We performed an analysis of transposition of the great artery patients nationwide using 15 years of the Nationwide In-patient Sample and three complementary years of the Kids' Inpatient Database. Variables included gender, race, age, and co-existing diagnoses. Outcomes included mortality, length of stay, and hospital charges. Comparison between patients undergoing Rashkind procedure or not was performed using Pearson's chi-square and Kruskal-Wallis tests. We identified 8681 patients with transposition of the great arteries, of whom 1742 (20%) underwent Rashkind procedure. Patients undergoing Rashkind procedure had lower mortality (10% versus 12%, p = 0.021), despite higher median co-morbidities and longer median length of stay. Rashkind procedure was not associated with increased risk of necrotising enterocolitis (1% versus 1%, p = 0.630), but was associated with nearly twice the risk of clinically recognised stroke (1% versus 0%, p = 0.046). This study represents the largest national analysis of transposition of the great artery patients to date, with a subset treated with Rashkind procedure. Patients not undergoing Rashkind procedure had higher mortality. Rashkind procedure was not associated with increased risk of necrotising enterocolitis, but was associated with twice the risk of stroke.
    • "We agree with Beca et al. and Petit et al., that there is no clear correlation of brain injury with BAS. The causes of neurological complications in newborns with TGA may be as follows: preoperative hypoxic-ischemic encephalopathy and cerebral haemorrhage, unstable haemodynamics and changes in homeostasis in patients with restrictive atrial septal defects [2, 3]. Infusion therapy before the surgery correction of the defect may also be the cause of microemboli in the brain of newborns with TGA. "
    [Show abstract] [Hide abstract] ABSTRACT: This best evidence topic in congenital cardiac surgery was written according to a structured protocol. The question addressed was whether the use of balloon atrial septostomy (BAS) before the arterial switch surgery for transposition of the great arteries (TGA) improved the final outcome. Altogether more than 251 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The search was further limited to recent articles since the results have improved compared with previous years, due to newer equipment and techniques. This narrowed the search to five papers that have focused on this issue since 2006 when a study of 29 term neonates identified BAS as major risk factor for focal brain injury and reinvigorated the debate of adverse neurological outcome especially in the context of the fact that total correction by the arterial switch procedure is routine in neonates now. Subsequently, a prospective study of 64 newborn infants followed by another study of 26 neonates with TGA, have shown no association between BAS and brain injury. Similarly, in a study of more than 2000 cases of dTGA, no association has been found between BAS and increased risk of clinical stroke either in the neonatal period or in follow-up hospitalizations. On the other hand, another nationwide data analysis of 8681 patients with TGA, has shown increased risk of stroke in patients undergoing BAS but it could only show association and not establish causation of the complication. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated.
    Article · Apr 2012
  • [Show abstract] [Hide abstract] ABSTRACT: Balloon atrial septostomy (BAS) is a palliative procedure performed in the preoperative management of patients with transposition of great arteries (TGA), to improve the mixing of blood between the 2 systems. This report describes experience at the Clínica Cardiovascular Santa Maria in Medellin, Colombia. Between 2002 and 2010, 22 patients with TGA underwent BAS. Patient age at the time of the procedure was 21 days on average; 68% of patients were male. Average weight was 2.96 kg and interatrial gradient was between 4 and 12 mm Hg. The average systemic oxygen saturation at the beginning of the procedure was 60%, with a final saturation of 90%. Z5 atrioseptostomy balloons were used in 18 patients (81%), using Rashkind technique; Tyshak balloon catheters were used in 3 patients (13%) with the Shrivastava technique; and static high-pressure peripheral angioplasty balloons were used in 3 patients (13%). Two patients underwent BAS with 2 types of balloons. Although there were no complications clearly attributable to the procedure, 14% of patients had evidence of focal brain injury on the postoperative magnetic resonance image. Six patients died (27%), 5 of them because of postoperative complications and 1 because of infectious complications at another institution. All postoperative deaths occurred before 2006. The BAS is a safe technique for preoperative stabilization of patients with TGA.
    Full-text · Article · Apr 2011
  • [Show abstract] [Hide abstract] ABSTRACT: Opinion statement: Because a minority of patients with D-transposition of the great arteries are diagnosed in utero by ultrasound, most present after delivery with cyanosis. In the absence of apparent lung disease, cyanotic neonates suspected of having a cardiac lesion should be immediately transferred to an intensive care unit at a pediatric tertiary care center for monitoring, resuscitation, and to define the cardiac anatomy and physiology. A prostaglandin E-1 infusion is usually initiated to maintain ductal patency and promote intra-cardiac mixing. In the past, balloon atrial septostomy (BAS) was routinely performed to enlarge the atrial septal defect and improve intra-cardiac mixing while the infants awaited surgery. Recent literature has reported an increase risk of stroke in neonates who undergo BAS, although more recent studies refute this. Our current practice is to perform BAS in neonates who have both echocardiographic evidence of a restrictive atrial septum and hypoxia or instability that is unresponsive to other interventions. The occasional patient who does not respond to initial management may have elevated pulmonary vascular resistance and may stabilize with pulmonary vasodilators, such as inhaled nitric oxide. Rarely, a child does not respond to interventional and pharmacologic resuscitation and requires mechanical support pre-operatively with extracorporeal membrane oxygenation (ECMO). In our experience, ECMO has been a successful bridge to corrective surgery with excellent outcomes. After pre-operative stabilization, arterial switch procedure is typically performed in the first week of life with very favorable early results.
    Article · Jun 2011
Show more