1.DR AWADHESH KUMAR SHARMA DEPTT OF CARDIOLOGY PGIMER & DR RML HOSPITAL,NEW DELHI ATRIAL SEPTOSTOMY

2. Introduction A technique for producing an atrial septal defect without thoracotomy or anesthesia. It can be performed rapidly in any cardiac catheterization laboratory. (William J. Rashkind, 1966) ...The initial response to this report varied between admiration and horror but, in either case, the procedure stirred the imagination of the invasive cardiologists throughout the entire cardiology world and set the stage for all future intracardiac interventional procedures the true beginning of pediatric and adult interventional cardiology. (Charles E. Mullins, 1998) 3. Indian perspective IHJ 1987 Balloon septostomy is an effective palliative method in newborn infants with TGA. The technique may however be ineffective in older infants.We describe, for the first time,an alternative technique of palliation by dilating the atrial septum using percutaneous balloon dilatation technique.The technique was usefull in an older infant of TGA with intact ventricular septum where balloon septostomy was unlikely to succeed.It is possible that even in the newborn period this technique may result in a better interatrial communication. 4. Commonest intervention was Balloon atrial septostomy (32.9%) , followed by Balloon aortic valvotomy (21.6%), Balloon pulmonary valvotomy (19.6%), Balloon angioplasty of coarctation of aorta (10.3%) , PDA device /coil closure (14.42%) and post operative MAPCA coiling (1.03%). 20 cases had significant ventricular dysfunction preprocedure requiring inotropes. Preprocedure Prostaglandin E1 infusion required by 15.4% PERCUTANEOUS CARDIAC INTERVENTIONS IN INFANTS AND NEONATES IN A TERTIARY CARE CARDIAC INSTITUTE WITH SHORT AND MIDTERM FOLLOW UP Maitri Chaudhuri ,Manisha Chakrabarti,S. Radhakrishnan,Savitri Shrivastava. Escorts Heart Institute,Okhla , New Delhi IHJ 2004 5. An Indian perspective 6. Indications of Interventions on the Intact Atrial Septum 1. Transposition to improve mixing. 2. Tricuspid atresia 3. Double inlet ventricle with hypoplastic left or right atrioventricular valves 4. Hypoplastic left heart syndrome 5. With the Fontan circulation, atrial septostomy is performed to relieve left or right atrial hypertension. 6. Patients with left ventricular failure who are supported by extracorporeal membrane oxygenation may also need trans- septal puncture and atrial septostomy. 7. Intact or Highly Restrictive Atrial Septum Associated with Obstructive Anomalies of the Left Heart In the fetus with severe left ventricular inflow obstruction, unrestricted flow across the oval foramen is essential to ensure unobstructed pulmonary venous drainage from the left to the right atrium. If the left-to-right atrial shunt is restrictive, left atrial hypertension and pulmonary venous congestion develop, often with major consequences on the pulmonary vascular morphology and function. J. Rychik, J.J. Rome, M.H. Collins, et al.: The hypoplastic left heart syndrome with intact atrial septum: Atrial morphology, pulmonary vascular histopathology and outcome. J Am Coll Cardiol. 34:554-560;1999 8. Types of complex congenital cyanotic heart diseases subjected for balloon septostomy 9. One of the main causes of early mortality in case of D-TGA is hypoxia secondary to restrictive ASD. (Chantepie A, Schleich JM, Gournay V, Blaysat G, Maragnes P. Preoperative mortality in transposition of the great vessels.Arch Pediatr 2000;7:34-9. Pedra CA, Braga SL, Esteves CA, Fontes VF. Current role of therapeutic heart catheterization in pediatric cardiology. J Pediatr 1999;75:407-17.) BAS is one of the life-saving palliative procedures that can be performed in catheterization laboratory or even intensive care unit under transthoracic echocardiography. (Guarnera S, Contarini M, Sciacca P, Patane L, Parisi MG, Pulvirenti A, et al. Indications for percutaneous atrioseptostomy: Comparison of echocardiographic and fluoroscopic monitoring. Pediatr Med Chir 1997;19:253-6.) Indications of Interventions on the Intact Atrial Septum Contd.. 10. When to intervene The decision to perform the BAS was made based on the clinical findings of 1. Hypoxia 2. Echocardiographic confirmation of restrictive atrial septal defect, characterized by - a) The absence of visible communication or b) Small-size1/3 of the total septal diameter measured at the subcostal view or 3. Around 5 mm with ample border motility and clinical improvement. 38. Cardiac perforation of left atrial appendage (LAA) occurred in one patient and managed surgically. (Out of 192 patients) Balloon rupture occurred in 7% of cases and all ruptured balloons were of Miller type, no embolization of balloon fragments was reported. There were no procedural deaths and five patients developed a sepsis-like picture after the procedure and died. Complications 39. Recently ,the routine use of septostomy has come under scruitiny following the observation in one institutional series,of an association between septostomy and abnormal finding on postoperative cranial magnetic rasonance studies. These observations have provoked caution in the application of septostomy although their significance will be a matter for debate and further investigation in future. Complications Circulation 2006;113;280-285 40. Complications Circulation 2006;113;280-285 41. Multiple factors are likely to contribute to brain injury in children with CHD. In the past, attention has largely been focused on operative factors, such as surgical and perfusion strategies and early post-operative problems including reduced systemic oxygen delivery and organ dysfunction, as well as genetic, familial, and social influences . More recently the focus has expanded to include pre- operative events and pre-natal brain development. Pre-operative cerebral magnetic resonance imaging (MRI) abnormalities have been demonstrated in 25% to 40% of neonates with CHD. The predominant abnormality is white matter injury (WMI), with infarction, hemorrhage, and abnormalities of maturation also seen. Complications 42. Types of septostomy Blade septostomy Balloon atrial septostomy has limitations in older infants, due to the increased thickness of the atrial septum. In these cases blade septostomy and static balloon dilation of the atrial septum are prefered to enlarge the interatrial communication. Static balloon dilation is unlikely to create a reliable atrial septal defect. In older children with thick septum, blade atrial septostomy is possible but seldom performed because of its inherent risks. 43. Blade Atrial Septostomy Catheter The catheter is 65 cm long and is made of 6F radiopaque polyethylene tubing (Cook Incorporated). The catheter tip consists of a 3.5-cm section of stainless steel tubing with a 2.5-cm slit on its long axis. The metal tubing contains a small blade that is linked to a lever whose distal portion pivots at the catheter tip. The proximal portion of the blade is linked to a solid guide wire that passes through the entire catheter and exits at the hub. Advancing the wire extends the blade and the lever through the slit to form a triangle. 44. There is a Y connector at the proximal portion of the catheter; one side branch is for fluid infusion and pressure measurement and the other for the wire that controls the blade. 6F &7F introducer should be used because most balloon septostomy catheters cannot be introduced through a smaller sheath. The maximal height of the extended blade is 12-13 mm. Thus, when the diameter of the IAO is greater than 10 mm, it is unlikely that the blade could effectively engage the interatrial septum and the procedure is not recommended. Blade Atrial Septostomy Catheter 45. Complications in blade septostomy 46. Types of atrial septostomy Radiofrequency puncture of Fossa Ovalis 47. Surgeons perspective of creation of atrial septal defect Closed-heart methods of creation of atrial septal defect have been previously described. The first technique described was the Blalock Hanlon septectomy. Azzolina G, Eufrate SA, Pensacola PM. Closed Interatrial septostomy. Ann Thorac Surg 1972;13:338-41. Simpson JM, Anderson DR, Qureshi SA. Closed atrial septostomy with Brock punch aided by transesophageal echocardiography, Ann Thorac Surg 1995;60:1794-5. This involves snaring of right pulmonary veins and right pulmonary artery and has been associated with complications such as arrhythmias, pulmonary hemorrhage, and neurological insult. More recent techniques include the use of a Brock punch under TEE guidance and a specially designed atriotomy knife through a thoracotomy. (Kawahira Y, Kishimoto H, Kawata H, Ikawa S, Ueda H, Ueno T, et al. Surgical atrial septostomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1016-8.) 48. Minisurgical technique Benedict RR, Kumar A, Francis E, Kumar RK. Off-pump atrial septostomy with thoracoscopic scissors under transesophageal echocardiography guidance. Ann Pediatr Card 2013;6:170-2. 49. Benedict RR, Kumar A, Francis E, Kumar RK. Off-pump atrial septostomy with thoracoscopic scissors under transesophageal echocardiography guidance. Ann Pediatr Card 2013;6:170-2. An off-pump technique to perform atrial septostomy under transesophageal echocardiography (TEE) guidance using thoracoscopic scissors. The procedure was carried out through a median sternotomy. The patient was heparinized. A purse-string suture was made on the right atrial (RA) appendage. A stab was made within the purse string, and through this, thoracoscopy scissors was introduced in the RA. Under TEE guidance, the closed tip of the instrument was used to tent the fossa ovalis below the limbus and a small perforation was created. 50. It was then dilated by stretching with the opening of the blades of the scissors. The scissors was then rotated to face inferiorly with one blade on either side of the inter-atrial septum, and two cuts were made in the inferior and lateral directions, away from the AV valves and conduction tissue. Benedict RR, Kumar A, Francis E, Kumar RK. Off-pump atrial septostomy with thoracoscopic scissors under transesophageal echocardiography guidance. Ann Pediatr Card 2013;6:170-2. 51. Benedict RR, Kumar A, Francis E, Kumar RK. Off-pump atrial septostomy with thoracoscopic scissors under transesophageal echocardiography guidance. Ann Pediatr Card 2013;6:170-2. Technique of atrial septostomy using thoracoscopic scissors under transesophageal echocardiography guidance is relatively simple and has the following advantages: 1. The narrow body of the instrument requires only a small stab incision on the RA. The manipulation of this slender instrument was well tolerated and there was no arrhythmia or bleeding with minimal risk. 2. It is well controlled and visible on TEE. 3. Avoidance of CPB is possible, with a low chance of injury to the neighboring structures. 52. Photograph of the thoracoscopic scissors in the open position (left) and in the closed position 53. Intraoperative transesophageal echocardiography of the procedure: The tips of the scissors are shown tenting the inter-atrial septum (a) and subsequently passing into the left atrium (LA) through the atrial septum (b) Pre-discharge transthoracic echocardiogram shows the atrial septal opening. Color Doppler (right frame) shows a laminar flow across the atrial septum 54. Stenting of the atrial septum Catheter-based techniques tend to be relatively unreliable unless a stent is used. (Leonard GT Jr, Justino H, Carlson KM, Rossano JW, Neish SR, Mullins CE, et al. Atrial septal stent implant: Atrial septal defect creation in the management of complex congenital heart defects in infants. Congenit Heart Dis 2006;1:129-35) Stenting of the atrial septum is risky and technically challenging, especially in very young patients. (Holzer RJ, Wood A, Chisolm JL, Hill SL, Phillips A, Galantowicz M, et al. Atrial septal interventions in patients with hypoplastic left heart syndrome. Catheter Cardiovasc Interv 2008;72:696-704.) 55. Stenting of the atrial septum 56. Atrial septostomy in Primary PAH 57. Current recommendations suggest four exclusion criteria for AS: 1. RAP >20 mm Hg 2. SaO2 4400 dyne*s/cm5 ). Barst RJ. Role of atrial septostomy in the treatment of pulmonary vascular disease. Thorax 2000;55:956. Sandoval J, Rothman A, Pulido T. Atrial septostomy for pulmonary hypertension. Clin Chest Med 2001;22:54760. Rich S, ed. Primary pulmonary hypertension: Executive Summary from the World Symposium Primary Pulmonary Hypertension 1998. Available at www.who.int/ncd/cvd/pph.html. Atrial septostomy in Primary PAH 58. Candidates for atrial septostomy should have a systemic arterial oxygen saturation on room air of more than 90%. The end point for the procedure should be considered a reduction in systemic arterial oxygen saturation of 510%. Atrial septostomy in Primary PAH 59. Indian Heart J. 2002 Mar-Apr;54(2):164-9. Graded balloon atrial septostomy in severe pulmonary hypertension. Kothari SS1, Yusuf A, Juneja R, Yadav R, Naik N. BACKGROUND: The prognosis of patients with severe primary pulmonary hypertension is poor. The role of balloon atrial septostomy as a palliative procedure in these patients is not well defined. We retrospectively analyzed our data regarding the safety, clinical outcome and survival benefit of graded balloon atrial septostomy in patients with severe pulmonary hypertension. 60. METHODS AND RESULTS: Eleven patients (7 males), aged 6 to 30 years (mean age 16.2+/- 8.9 years), with severe pulmonary artery hypertension (mean pulmonary artery pressure of 76+/-16.9 mmHg) and refractory congestive heart failure and/or recurrent syncope underwent balloon atrial septostomy. Graded balloon dilatation under echocardiographic guidance and arterial oxygen saturation monitoring was done in all the patients. Procedure-related mortality was 18.2%. Significant acute hemodynamic improvement was seen in the survivors (pre-balloon atrial septostomy cardiac index 1.88+/-0.48 L/min/m2; post-balloon atrial septostomy cardiac index 2.18+/-0.37 L/min/m2, p