Thomas C, Yu S, Lowery R, Zampi JD. Pediatr Cardiol. 2023 Aug;44(6):1333-1341. doi: 10.1007/s00246-022-03079-5. Epub 2022 Dec 24.PMID: 36565310
Take Home Points:
- Patients with d-TGA transported from an outside institution had a longer median time time from birth to the BAS as compared to those born the authors’ tertiary care center (4.0 hours vs. 14.1 hours).
- Patients delivered at outside institutions had lower minimum PaO2 and greater frequency of inotropic support, as compared to those born at the authors’ tertiary care center.
- Neither time to BAS nor location of birth was associated with age at time of arterial switch operation, however a longer time from birth to BAS was associated with longer ICU LOS and total hospital LOS.
Commentary from Dr. Arash Salavitabar (Columbus, OH, USA), section editor of Congenital Heart Disease Interventions Journal Watch:
Commentary:
The authors report on a retrospective study aimed at evaluating their single-center experience with outcomes in infants with d-transposition of the great arteries (d-TGA) as they relate to timing of balloon atrial septostomy (BAS) and institution of birth. The primary outcome was time from birth to BAS and secondary outcomes included mortality, hospital and ICU length of stay, duration of mechanical ventilation, evidence of pulmonary hypertension, and neurologic abnormalities.
Of 217 patients with d-TGA physiology, 96 (44%) patients required emergent or urgent BAS, 69 (72%) of which were prenatally diagnosed. Patients born at outside institutions had a median travel distance of 99 miles (IQR 56, 115) and transport time of 10.3 hours (6.8, 12.0), with a shorter transport time for prenatally diagnosed patients vs. postnatally diagnosed patients born at outside institutions (6.4h vs. 10.7h). The median time from birth to BAS was 4.0 hours in those born at the authors’ center and 14.1 hours when transported from an outside institution. Importantly, patients delivered at outside institutions had lower minimum PaO2 (28.2 mmHg vs. 31.9 mmHg, p=0.02) and greater frequency of inotropic support (48.3% vs. 7.5%, p <0.0001) as compared to those born at the authors’ center.
Neither time to BAS nor location of birth was associated with age at time of arterial switch operation, however a longer time from birth to BAS was associated with longer ICU LOS and total hospital LOS. There were no differences in frequency of seizures or abnormal neuroimaging based on time to BAS or birth location.
The authors stressed the importance of patients with prenatally diagnosed d-TGA being delivered at a tertiary care center with access to interventional cardiology services to decrease the time to urgent or emergent BAS. Based on this data, this is certainly an important conclusion that has implications on both patient stability and oxygenation, as well as healthcare resource utilization. As the authors admit, more data is needed on neurological sequelae of late BAS in these patients, however the above data has been previously correlated with adverse neurologic outcomes, stressing its significance.
