Revisiting the Role of Balloon Atrial Septostomy Prior to the Arterial Switch Operation
Subramanian S, Jani S, Well A, Mikulski MF, Agrawal H, Byron Holt D, Venardos N, Mery CM, Fraser CD Jr.World J Pediatr Congenit Heart Surg. 2024 Nov;15(6):746-752. doi: 10.1177/21501351241252428. Epub 2024 Aug 9.PMID: 39119670
Commentary by:

Dr. Milan Prsa (Switzerland, Europe), section editor of Congenital Heart Disease Interventions Journal Watch :
Take-home Points:
- Balloon atrial septostomy does not ensure successful weaning off prostaglandin and may delay the arterial switch operation in neonates with dextro-transposition of the great arteries.
- Early arterial switch operation with prostaglandin support should be reconsidered as a more efficient strategy.
This retrospective, single-center study investigated the common practice of performing balloon atrial septostomy (BAS) in neonates with dextro-transposition of the great arteries (d-TGA) prior to the arterial switch operation (ASO). The analysis included 30 patients who underwent ASO between July 2018 and March 2023, comparing outcomes between those who received BAS (n=22) and those who did not (n=8). Key variables such as pre-operative oxygen saturation (SpO2), near-infrared spectroscopy (NIRS) readings, prostaglandin (PGE) status, and post-operative outcomes were evaluated.
BAS significantly improved SpO2 levels (median increase from 83% to 87%, p=0.007). However, there was no corresponding improvement in cerebral or renal NIRS readings, suggesting the increased SpO2 did not enhance oxygen delivery to vital organs. A notable proportion of patients in the BAS group (27%, 6 out of 22) could not be weaned off PGE, and 62% (10 out of 16) required PGE re-initiation, often within 24 hours of BAS. The median age at ASO was significantly higher in the BAS group (8 days) compared to the no-BAS group (4 days, p=0.016). Additionally, the BAS group showed a trend toward longer hospital stay (median 13 days vs. 10 days in the no-BAS group). Two patients (9%) in the BAS group developed low cardiac output syndrome post-ASO, while no such complication was observed in the no-BAS group.
The study’s retrospective, single-center design, small sample size, and potential selection bias may limit the generalizability of the findings. However, the results provide important insights that challenge the routine use of BAS in the preoperative management of d-TGA. This study suggests that early ASO with prostaglandin support may be a safer and more efficient alternative to BAS. While a prospective, multi-center study would be needed to establish a definitive best practice, these findings encourage a re-evaluation of BAS as a standard preoperative intervention for newborns with d-TGA.