Clinical Investigation
Congenital Heart Disease
Fetal Predictors of Urgent Balloon Atrial Septostomy in Neonates with Complete Transposition

https://doi.org/10.1016/j.echo.2010.12.020Get rights and content

Background

In complete transposition of the great vessels, a restrictive patent foramen ovale leads to inadequate circulatory mixing and severe cyanosis. Urgent balloon atrial septostomy (BAS) improves mixing and bridges neonates to surgery. Several studies have determined risk factors in utero for poor postnatal outcomes in complete transposition of the great vessels, particularly a restrictive patent foramen ovale and ductus arteriosus. In addition to these risk factors, we studied two new features, a hypermobile septum and reverse diastolic patent ductus arteriosus shunt, to determine which patients will require an urgent BAS.

Methods

We reviewed all 26 fetuses from 2001 to 2010 with complete transposition of the great vessels and closely examined the patent foramen ovale and septum primum for hypermobility, restriction, flat appearance, or redundancy. We defined hypermobility as a septum primum flap that oscillates between both atria. We also examined the ductus size and shunting pattern to evaluate whether these features contributed to urgent BAS.

Results

In total, 14 of 26 fetuses required urgent BAS with improved cyanosis. Nine fetuses had an urgent BAS and a hypermobile septum, and 12 fetuses had no urgent BAS or hypermobile septum. Eight fetuses had an urgent BAS and a reverse diastolic patent ductus arteriosus, and 11 fetuses had no urgent BAS or reverse diastolic patent ductus arteriosus. A hypermobile septum and reverse diastolic patent ductus arteriosus had a significant association with urgent BAS (P < .01, sensitivity = 0.64 and 0.57, specificity = 1.0 and 0.92, positive predictive value = 1.0 and 0.89, negative predictive value = 0.71 and 0.65). No fetus had a restrictive patent foramen ovale/ductus arteriosus.

Conclusion

A hypermobile septum and reverse diastolic patent ductus arteriosus are new prenatal findings to help predict the need for an urgent BAS postnatally in patients with complete transposition of the great vessels.

Section snippets

Demographic Data Collection

We collected all fetal and neonatal patients with complete transposition from our reference database using the syngo Dynamics workstation (Siemens Medical Solutions USA, Inc., Ann Arbor, MI). We reviewed all data from January 1, 2001, to June 30, 2010. All newborns with a prenatal diagnosis of complete transposition of the great vessels and postnatal confirmatory echocardiograms were included in the study. Patients with a ventricular septal defect, double outlet right ventricle, or coarctation

Results

Among the 153 patients with complete transposition of the great vessels at our institution from January 1, 2001, to June 30, 2010, 26 (17%) were included in our study with both prenatal and postnatal studies for evaluation (Table 1). Given that our institution is a referral center, not all patients with complete transposition had available fetal studies for evaluation; none of the study patients delivered at the referring hospital. One patient had a persistent left superior vena cava noted

Discussion

In complete transposition of the great vessels, prenatal predictors for an urgent BAS are necessary because tardy management of atrial restriction may result in cerebral hypoxic damage. The results of our study indicate that the hypermobile septum and reverse diastolic ductal shunt represent important risk factors for an urgent BAS. Although there is a brief description of the hypermobile septum, no previous reported study in the literature makes this association.10 Other studies have discussed

Conclusions

Selection of fetuses in need of urgent BAS is necessary to provide optimal care for neonates with complete transposition. The hypermobile interatrial septum and reverse ductal shunt in fetuses with complete transposition are risk factors for urgent BAS postnatally. Taken together with other reported findings, these factors may improve postnatal therapy for neonates with transposition and inadequate circulatory mixing.

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    Conflicts of Interest: None.

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