Balloon Atrial Septostomy Is Associated With Preoperative Stroke in Neonates With Transposition of the Great Arteries

Abstract

Background-Preoperative brain injury is common in neonates with transposition of the great arteries (TGA). The objective of this study is to determine risk factors for preoperative brain injury in neonates with TGA. Methods and Results-Twenty-nine term neonates with TGA were studied with MRI before cardiac surgery in a prospective cohort study. Twelve patients (41%) had brain injury on preoperative MRI, and all injuries were focal or multifocal. None of the patients had birth asphyxia. Nineteen patients (66%) required preoperative balloon atrial septostomy (BAS). All patients with brain injury had BAS (12 of 19; risk difference, 63%; 95% confidence interval, 41 to 85; Pϭ0.001). As expected on the basis of the need for BAS, these neonates had lower systemic arterial hemoglobin saturation (SaO 2 ) (Pϭ0.05). The risk of injury was not modified by the cannulation site for septostomy (umbilical versus femoral, Pϭ0.8) or by the presence of a central venous catheter (Pϭ0.4). Conclusions-BAS is a major identifiable risk factor for preoperative focal brain injury in neonates with TGA. Imaging characteristics of identified brain injuries were consistent with embolism; however, the mechanism is more complex than site of vascular access for BAS or exposure to central venous catheters.

Prevalence and Spectrum of In Utero Structural Brain Abnormalities in Fetuses with Complex Congenital Heart Disease

“…In postnatal preoperative studies of infants with CHD, the most prevalent brain lesions included ischemic lesions 21 and diffuse and focal white matter injury, 6,25,26 including periventricular leukomalacia. 5,27 The brain MR imaging findings in our fetal cohort with CHD differed in both type and severity from these postnatal studies of infants with CHD.…”

Effect of balloon atrial septostomy on cerebral oxygenation in neonates with transposition of the great arteries

“…It has been suggested that BAS is a major risk factor for the development of preoperative brain injury, particularly stroke, in neonates with TGA (10,11). Recently, Mukherjee et al demonstrated that BAS was associated with nearly twice the risk of clinically recognized stroke in 8,681 neonates with TGA (11).…”

“…BAS aims at increasing systemic oxygenation by improving the mixing of deoxygenated and oxygenated blood at the atrial level. Adverse effects of BAS have also been reported (10,11). As yet, little is known about the direct effect of BAS on the neonatal brain and on cerebral oxygenation in particular.…”

Impact of balloon atrial septostomy in neonates with transposition of great arteries

“…The relationship between stroke, TGA and BAS in neonates has emerged as an intense focus of investigation. McQuillen et al 13,14 found that about 40% of infants with congenital heart defects had preoperative brain injury and implicated BAS as contributory to preoperative stroke in neonates with TGA. These findings were confounded by lower Apgar scores, lower arterial oxygen saturations and hemodynamic instability.…”

“…Lately, however, concerns about the 'routine' use of BAS have emerged, with some studies demonstrating an association with stroke and the recognition that the closure of the atrial septal defect may prolong the surgical repair and contribute to perioperative risk. [13][14][15] In addition, despite successful creation of an adequate-sized anatomic atrial septal defect in most cases, a high rate of 'failed BAS' with suboptimal increase in systemic oxygenation has been reported. 16 Apart from clinical improvement in oxygenation, another goal of the BAS procedure is discontinuation of PGE 1 .…”