Mustard baffle obstruction and leak – How successful are percutaneous interventions in adults?

Abstract

Atrial switch operations for D-Transposition of the great arteries (D-TGA) were performed until the late 20th century. These patients have substantial rates of re-operation, particularly for baffle related complications. This study sought to analyze the efficacy of percutaneous transcatheter intervention (PTI) for baffle leak and/or stenosis in adult atrial switch patients. Adult patients with a prior atrial switch operation who underwent heart catheterization (2002–2014) at a tertiary adult congenital heart disease referral center were retrospectively analyzed. In 58 adults (30 ± 8 years, 75% men, 14% New York Heart Association (NYHA) functional class ≥2) who underwent 79 catheterizations, PTI was attempted in 50 (baffle leak (n = 10, 20%), stenosis (n = 27, 54%), or both (n = 13, 26%)). PTI was successful in 45 and 5 were referred for surgery due to complex anatomy. A total of 40 bare metal stents, 18 covered stents, 16 occlusion devices, 2 angioplasties, and 1 endovascular graft were deployed. In isolated stenosis, there was improvement in NYHA functional class after PTI (8 vs. 0 patients were NYHA FC > 2, p = 0.004), which was matched by improvement in maximal oxygen consumption on exercise testing (VO2) (25.1 ± 5.4 mL/kg/min vs. 27.9 ± 9 mL/kg/min, p = 0.03). There were no procedure-related deaths or emergent surgeries in this cohort. This single-center cohort is the largest reported series of adult atrial switch operation patients who have undergone PTI for baffle stenosis and/or leak. We demonstrate that PTI with an expert multi-disciplinary team is a safe and effective alternative to surgery in adult patients with an atrial switch operation.

Canadian Cardiovascular Society 2022 Guidelines for Cardiovascular Interventions in Adults With Congenital Heart Disease

“…Percutaneous intervention is often feasible for systemic venous baffle obstruction and successful in improving symptoms and/or facilitating nonobstructing access for transvenous pacemaker or defibrillator leads. 177,178 Leaks in the interatrial baffles are more common than clinically suspected, detectable in up to 65% of patients using echocardiography with saline contrast. 179 Transesophageal echocardiography is helpful to identify the size and location of the interatrial communication.…”

Systematic review and meta-analysis of outcomes of anatomic repair in congenitally corrected transposition of great arteries

“…Baffle complications of residual leaks or stenosis are well described after the Mustard/Senning operations and thus account for the other common reoperations after anatomic repair for cc-TGA[ 43 ]. However, in the current era, most of the baffle related complications can be adequately managed with transcatheter techniques minimizing the need for re-operations[ 44 , 45 ]. Furthermore, residual LVOT obstruction is known after both types of anatomic repair[ 46 ].…”

Efficient approach to superior vena cava baffle stenosis following the Mustard procedure: Expanding the role of a mechanical rotating dilator sheath for lead extraction

“…During the procedure, obtaining access from the bilateral femoral arteries and veins allows for accurate localization of the baffle from above and below, as well as continuous imaging during stent placement 2 . Further, obtaining access for emergent bypass and placing a sheath and balloon in the RIJ vein for emergent tamponade are necessary in procedural planning, as the periprocedural mortality rate for baffle‐related re‐intervention can be as high as 29% 2,5,11 . Additionally, the extent and timing of anticoagulation are pre‐planned to avoid excessive bleeding throughout the course of the combined procedure.…”

“…2 Further, obtaining access for emergent bypass and placing a sheath and balloon in the RIJ vein for emergent tamponade are necessary in procedural planning, as the periprocedural mortality rate for baffle-related re-intervention can be as high as 29%. 2,5,11 Additionally, the extent and timing of anticoagulation are pre-planned to avoid excessive bleeding throughout the course of the combined procedure.…”