Creation of an Atrial Septal DefectWithout Thoracotomy

A Palliative Approach to Complete Transposition of the Great ArteriesWilliam J. Rashkind, MD, and William W. Miller, MD

Transposition of the great vessels (TGV) occursin approximately 20% of children who die withcongenital heart disease.1 With rare exceptions, pa-tients with this lesion die in the first 6 months oflife (50% within the first month). Approximately40% of patients with TGV have an otherwise nor-mal heart. In recent years, various types of com-plete corrections for this lesion have been at-tempted. Mustard et al2 has simplified these pro-cedures and has reduced mortality to reasonablelevels. Best results are obtained in children wellbeyond 6 months of age. Therefore, it is imperativeto provide early palliation that is effective until theoptimal age for complete correction and that doesnot interfere significantly with subsequent surgery.Creation of an interatrial communication seemsthe best available choice to suit these require-ments. The Blalock-Hanlon technique,3 or somemodified version, is commonly used to remove a por-tion of the atrial septum surgically. The purpose ofthis report is to present a technique for producingan atrial septal defect without thoracotomy andwithout anesthesia, using a cardiac catheter intro¬duced into a femoral vein.

Method and MaterialThe femoral vein is exposed as for routine car¬

diac catheterization in infancy. The device is adouble-lumen cardiac catheter. One lumen con¬tinues the entire length of the catheter, the otherends in the balloon. It is passed via the femoralvein into the right atrium and is then manipulatedthrough the foramen ovale into the left atrium.Location in the left atrium is verified by passingthe catheter tip into a pulmonary vein, by samplinghighly saturated blood, or by selective angiogra-phy. The balloon is inflated in the left atrium with2 to 6 ml of dilute radiopaque solution. It is thenwithdrawn rapidly (one to two seconds) into theright atrium tearing the atrial septum. The balloonis then deflated rapidly (two to four seconds) and

1. illustration of the special balloon-tipped catheter(6.5 F). Insert shows the tip magnified in both deflatedand inflated positions.

the procedure repeated until the filled balloon canbe withdrawn from the left to the right atriumwithout resistance. Figure 1 illustrates the specialcatheter. The insert is a magnificent view of the cath¬eter tip with the balloon deflated and inflated.Seven littermate puppies weighing between 6

and 8 lb (2.7 to 3.6 kg) were studied. Six had atrialseptal defects created by the technique described.The seventh served as a normal control. Five ofthe puppies have been sacrificed at intervals of onehour to two months after the procedure. The re¬

maining puppy is being kept for one year of follow-up study. Figure 2 compares the atrial septal de¬fect and the tricuspid valve in the animal sacrificedtwo months after septotomy.Three infants with TGV, age 15 hours, 5 weeks,

and 6 weeks, have been treated successfully withthis technique. None of them showed ventricularor ductal shunting on angiography. They are now

From the Cardiovascular Laboratories, The Children's Hospitalof Philadelphia.Reprint requests to Children's Hospital of Philadelphia, 18th

and Bainbridge Streets, Philadelphia 19146 (Dr. Rashkind).

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2. Comparison of atrial septal defect and tricuspid valveorifice in puppy sacrificed two months postseptotomy.

four months, seven months, and nine months post¬septotomy. All are clinically well and at home.The roentgenographic heart size is unchanged, ordecreased, in all. Figures 3 and 4 are from thebaby nine months postseptotomy. The roentgeno-grams shown in Fig 3 were taken just prior to, andnine months following, the procedure. Figure 4shows the inflated balloon in situ in various posi¬tions during the septotomy.

CommentWe have not encountered any clinical problems

related to the procedure per se using the techniquedescribed. Theoretical problems would include thefollowing: (1) inability to pass the catheterthrough the foramen ovale or nonpatency of theforamen ovale, (2) too small a left atrium to allowballoon inflation, (3) impairment of venous returndue to slow emptying of the balloon, (4) rupture ofthe balloon, and (5) misplacement of the ballooninto the right ventricle or other chamber. Thesepossibilities could be handled, respectively, thus:(1) use of the trans-septal puncture technique toreach the left atrium, (2) rapid inflation to what¬ever volume is tolerated with rapid withdrawalacross the septum, (3) rapid emptying of the bal¬loon while allowing it to float free in the right atrialcavity, (4) filling the balloon with fluid so thatbreakage would release fluid not air, and (5) thedouble-lumen catheter permits exact localizationby permitting pressure measurements, blood sam¬

pling, or contrast material injection via the innerlumen.

Summary and ConclusionsA technique for producing an atrial septal de¬

fect without thoracotomy or anesthesia is pre¬sented. It can be performed rapidly in any cardiaccatheterization laboratory. Preliminary experimen¬tal data suggest that this type of septotomy pro-

3. Roentgenograms of the chest of a child. Left, Beforeprocedure. Right, Seven months after procedure.

4. Single frame from cineangiogram obtained duringballoon septotomy. Balloon is at level of interatrial sep¬tum.

duces large defects. Early clinical trials on infantswith TGV indicate that the procedure is as effectivein prolonging life as surgical septotomy. Moreover,since pericardiotomy and chest wall scarring areavoided, subsequent surgery is not hampered. TGVwith inadequate intracardiac mixing is the idealclinical condition for this procedure. It may also bean effective temporizing measure in Ebstein'sanomaly or tricuspid atresia with inadequate rightatrial egress and in total anomalous pulmonaryvenous return with an inadequate atrial septaldefect.This investigation was supported in part by the Southeastern

Pennsylvania Chapter of the American Heart Association.References

1. Keith, J.D., et al: Transposition of the Great Vessels, Circu-lation 7:830-838 (June) 1953.2. Mustard, E.T., et al: Successful Two-Stage Correction of

Transposition of Great Vessels, Surgery 55:469-472 (March) 1964.3. Blalock, A., and Hanlon, C.R.: The Surgical Treatment of

Complete Transposition of the Aorta and the Pulmonary Artery,Surg Gynec Obstet 90:1-15 (Jan) 1950.

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