Ann Thorac Surg 1995;60:1794-1795
© 1995 The Society of Thoracic Surgeons
Case Report
Closed Atrial Septectomy With Brock Punch Aided by Operative Transesophageal Echocardiography
John M. Simpson, MRCP,
David R. Anderson, FRCS,
Shakeel A. Qureshi, FRCP
Departments of Paediatric Cardiology and Cardiothoracic Surgery, Guy's Hospital, London, England
Accepted for publication May 23, 1995.
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Abstract
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A 5-week-old infant with mitral atresia and doubleoutlet right ventricle underwent blade atrial septostomy complicated by cardiac tamponade. Surgical septectomy was performed using a Brock punch aided by intraoperative transesophageal echocardiography. This was well tolerated, and the adequacy of the septectomy could be assessed immediately.
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Introduction
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The introduction of balloon atrial septostomy and blade atrial septostomy [1] has led to a decline in the need for surgical atrial septectomy [2]. One of the indications for septectomy is decompression of the left atrium when the left atrioventricular valve is atretic or stenotic and interatrial communication is restrictive [3]. The surgical technique most widely used is either the original or modified Blalock-Hanlon procedure [4], which involves direct visualization and excision of part of the atrial septum. In relation to this, a number of closed techniques have been described [5]. A disadvantage of the closed technique is that the atrial septum is not as well visualized as in the Blalock-Hanlon method.
We report the use of a Brock punch to perform closed atrial septectomy aided by the use of intraoperative transesophageal echocardiography in a patient in whom attempted blade atrial septostomy resulted in cardiac perforation and tamponade. Our technique simplifies the atrial septectomy procedure and reduces the risks.
A 5-week-old male infant presented with cyanosis, tachypnea, and a harsh ejection systolic murmur. An echocardiogram demonstrated mitral atresia. There was a rudimentary morphologic left ventricle, a large ventricular septal defect, double-outlet right ventricle, and subpulmonary stenosis with a Doppler gradient of 40 mm Hg. All pulmonary veins drained to the left atrium, which drained to the right atrium through a patent foramen ovale. Subsequent echocardiograms demonstrated that the patent foramen ovale was restrictive (Doppler velocity, 2.1 m/s), and in view of the increasing oxygen requirements, blade septostomy was attempted (9.4-mm blade). Two incisions in the atrial septum were successfully made. Balloon dilation of the atrial septum with a 10-mm balloon was complicated by cardiac tamponade when the balloon was being advanced to an optimum site across the atrial septum. This necessitated urgent surgical closure of a 2-mm perforation in the roof of the left atrium. Two weeks later, the infant's condition deteriorated. The atrial septal defect had become restrictive (Doppler velocity, 2 m/s). A surgical septectomy was then performed.
The procedure was carried out through a median sternotomy. A pursestring suture was placed on the right atrial appendage. Through this a pediatric Brock dilator was placed across the atrial septum under transesophageal echocardiographic guidance. The dilator was expanded and produced a good opening in the atrial septum. A Brock punch was then placed through the septostomy, and its position was optimized using transesophageal echocardiography (Fig 1A
). The cutting edge was aimed away from the atrioventricular valve and conduction tissue, bringing it into contact with the septum secundum tissue. Three pieces of atrial tissue were resected, thus enlarging the interatrial communication. Echocardiography (Fig 1B) showed that the Doppler velocity across the defect decreased from 2.3 m/s (gradient, 21 mm Hg) to 0.6 m/s (gradient, 1 mm Hg), indicating the effectiveness of the septectomy. The mean left and right atrial pressures (measured directly) were 18 and 6 mm Hg, respectively, before septectomy and 7 mm Hg in both atria after septectomy. The infant made an uncomplicated postoperative recovery and currently, 12 weeks after the procedure, has saturations of 85% in air.
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Fig 1. . (A) Transesophageal echocardiogram showing the Brock punch passing across the atrial septum (arrows) from the right atrium (RA) into the left atrium (LA). (B) Transesophageal echocardiogram demonstrating a large defect (arrows) in the atrial septum after closed atrial septectomy.
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Comment
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Balloon atrial septostomy is the most frequently used method for creation of an atrial septal defect in babies with congenital heart disease. Because of limited success in older children or when the atrial septum is intact [1], blade atrial septostomy or surgical septectomy may be required. Blade septostomy has been used successfully to create an atrial septal defect when the atrial septum is thickened or intact with a reported success rate of almost 80% [6]. However, complications such as perforation of the heart and neurologic sequelae were also reported.
The Blalock-Hanlon atrial septectomy involves incisions into the atria and excision of the right lateral portion of the atrial septum while the right pulmonary veins and right pulmonary artery are snared [4]. This method is associated with complications including arrhythmias, pulmonary hemorrhage, and neurologic sequelae [2]. A recent series (1985 to 1991) described a 9% mortality [4]. Inflow occlusion has also been employed for surgical septectomy [4] but involves snaring of the caval veins and cross-clamping of the aorta and pulmonary artery. Therefore, other methods for creation of an atrial septal defect have been developed. Closed atrial septectomy using a septectome does not involve circulatory arrest or cross-clamping of any vessels, and arrhythmias and pulmonary complications are less frequent [5].
Use of the Brock punch in pulmonary outflow tract obstruction has been well described for palliation in tetralogy of Fallot [7, 8]; here we report its use to perform an atrial septectomy. It has several potential advantages. The procedure was rapid, well tolerated, and controlled without blood loss or arrhythmias. A disadvantage of conventional closed atrial septectomy techniques is that the atrial septum is not well visualized. In our patient, this problem was overcome by the use of intraoperative transesophageal echocardiography, which was used to guide the Brock punch across the atrial septum, helping to minimize the risk of the procedure. Furthermore, inflow occlusion was avoided and bleeding controlled by the pursestring suture on the right atrial appendage. In addition, the adequacy of the septectomy could be assessed immediately by Doppler echocardiography, and any need for enlargement of the interatrial communication could be identified.
On the few occasions when a surgical atrial septectomy is required, Brock punch guided by intraoperative transesophageal echocardiography should be used as an alternative to the conventional techniques.
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Footnotes
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Address reprint requests to Dr Simpson, Department of Paediatric Cardiology, 11th Floor, Guy's Hospital, London SE1 9RT, UK.
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References
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- Park SC, Neches WM, Zuberbuhler JR, et al. Clinical use of blade atrial septostomy. Circulation 1978;58:600–6.[Abstract/Free Full Text]
- Cohen DJ, Chopra PS. The Blalock-Hanlon operation: an anachronism? Ann Thorac Surg 1987;44:407–10.[Abstract]
- Perry SB, Lang P, Keane JF, Jonas RA, Sanders SP, Lock JE. Creation and maintenance of an adequate interatrial communication in left atrioventricular valve atresia or stenosis. Am J Cardiol 1986;58:622–6.[Medline]
- Stark J. Surgical septectomy. In: Stark J, de Leval M, eds. Surgery for congenital heart defects. Philadelphia: Saunders, 1994:269--74.
- Rastan H. Palliative treatment of complete transposition of the great vessels. First clinical results of closed atrial septectomy with the new septectome. J Thorac Cardiovasc Surg 1974;69:407–14.
- Park SC, Neches WH, Mullins CE, et al. Blade atrial septostomy: collaborative study. Circulation 1982;66:258–66.[Abstract/Free Full Text]
- Brock RC. Pulmonary valvotomy for the relief of congenital pulmonary stenosis. Report of three cases. Br Med J 1948;1:1121–6.[Free Full Text]
- Brock RC, Campbell M. Infundibular resection or dilatation for infundibular stenosis. Br Heart J 1950;12:403–24.
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A. Mahajan, A. Shabanie, and H. Laks
Interatrial septostomy under transesophageal echocardiography guidance: A novel approach
J. Thorac. Cardiovasc. Surg.,
April 1, 2002;
123(4):
824 - 826.
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Abstract
Introduction
