Within the specified date range, 21 patients were included in the study. Among them, eight were female (F/M: 0,6). The median age of the patients was 2.6 years (ranging from 0 days to 8.4 years). The median body weight was 12 kg (2.7 kg to 20 kg). There were nine patients with a body weight of less than 10 kg. The median procedure and fluoroscopy times were 125 and 36.6 minutes, respectively. The patients' characteristics are shown in Table 1. Catheter ablation of left-sided supraventricular tachycardia (SVT) substrates was the primary rationale for TSP and access to the left atrium in 7/21 (33%) treatments.
Table 1
; The patients' characteristics
|
|
All
(n = 21, %100)
|
CHD interventions (n = 14, %66)
|
Catheter Ablation (n = 7, %33)
|
Median age
|
Years (min-max)
|
2,6 (0 day-8,4 years)
|
0,5 (0 day-6,7years)
|
6,6 (5, 5–8, 4)
|
Median body weight
|
kg (min-max)
|
12 (2,7–20)
|
5,7(2,7–19)
|
18 (16–20)
|
Primary diagnosis
|
|
|
|
Anatomically normal heart
|
n (%)
|
7 (%33)
|
0
|
7 (%100)
|
d-TGA
|
n (%)
|
1 (%5)
|
1 (%7)
|
0
|
HLHS
|
n (%)
|
7(%33)
|
7(%50)
|
0
|
BLV
|
n (%)
|
1 (%5)
|
1 (%7)
|
0
|
TAPVR
|
n (%)
|
3 (%14)
|
3 (%21)
|
0
|
Fontan
|
n (%)
|
2 (%9)
|
2(%14)
|
0
|
SVT
|
n (%)
|
1 (%5)
|
0
|
1(%14)
|
WPW
|
n (%)
|
6 (%28)
|
0
|
6 (%86)
|
Complications
|
n (%)
|
2 (%9)
|
2 (%14)
|
0
|
Success of the TSP
|
n (%)
|
16 (%76)
|
9 (%64)
|
7 (%100)
|
Procedure time
|
Minutes (min-max)
|
125 (60–285)
|
110 (60–210)
|
185 (95–285)
|
Floroscopy time
|
Second (min-max)
|
2198 (122–5109)
|
2866 (1157–5109)
|
125 (122–261)
|
Abbreviations: BLV: Borderline left ventricle, HLHS: Hypoplastic left heart syndrome, TAPVR: Total anomalous pulmonary venous return, TGA: Transposition of the great arteries, SVT: supraventricular tachycardia, WPW:Wolf-Parkinson-White.
Out of the total 21 patients, 14 (66%) required TSP due to CHD. Among these, seven individuals with HLHS underwent TSP to facilitate the formation of an interatrial shunt, accounting for 33% (7/21) of the cases. Additionally, another seven patients underwent TSP to establish a right-to-left shunt as a response to pulmonary hypertension, elevated Fontan pressure, or for desaturation in d-TGA patients, representing 33% of the cases. In the group of patients with CHD, the data revealed the following statistical values: the median age was 6,6 months (0 days-6,7 years), the median body weight was 5,7kg(2,7-19kg), the median procedure time was 110 minutes (60-210 minutes) and the median fluoroscopy time was 47,7 minutes (19,2-85,1 minutes). In the catheter ablation group, the median age was 6,6 years (5,5-8,4 years), the median body weight was 18kg(16-20kg), the median procedure time was 185 minutes (95-285 minutes) and the median fluoroscopy time was 2 minutes (2- 4,3 minutes). Only one patient with congenital heart disease in this group had a mild aortic stenosis secondary to the bicuspid aortic valve.
Among the 21 patients, a 7 French Mullins-style sheath (Fast-Cath Transseptal Guiding Introducer, St Jude Medical, Inc) with its dilator was employed in 18 cases, whereas 8 French sheaths were utilized in 3 cases.
Regrettably, TSP procedures did not yield the intended results in five patients within this cohort. IAS could not be passed in four patients, and tamponade developed in one of these four patients during the procedure. In another patient whose IAS was successfully passed, tamponade was observed; however, it was managed successfully. All unsuccessful and complicated procedures occurred among patients with CHD, as outlined in Table 2. For those patients for whom the procedure was unsuccessful, the median body weight was 2.9 kg, and the median age was two days.
Table 2; Patients with unsuccessful and complicated procedures during Transseptal punction
Primary diagnosis
|
Age at TSP
|
Body weight (kg)
|
TSP indication
|
IAS perforation
|
Complication
|
HLHS
|
1 days
|
2,8
|
Interatrial communication expansion
|
-
|
Tamponade
|
HLHS
|
2 days
|
3,9
|
Interatrial communication expansion
|
-
|
-
|
HLHS
|
2 days
|
2,7
|
Interatrial communication expansion
|
-
|
|
TAPVR
|
10 months
|
8,9
|
Pulmonary venous hypertension
|
-
|
|
HLHS
|
24 days
|
2,9
|
Interatrial communication expansion
|
+
|
Tamponade
|
Median
|
2 days
|
2,9
|
|
|
|
Abbreviations: HLHS: hypoplastic left heart syndrome, PE: pericardial effusion, TAPVR: Total anomalous pulmonary venous return, TSP: transseptal puncture
Pericardial tamponade, as a procedure-related complication, developed in two of our patients. The first patient was a newborn diagnosed with HLHS, who had previously undergone bilateral pulmonary banding and was monitored in the intensive care unit with a significant PDA. Due to the signs of pulmonary edema, the patient was taken to the angiography room with a TSP plan. After TSP with a transseptal needle, the left atrium was first passed with a 0.014'' guide wire. Balloon atrial septoplasty was performed twice on the IAS. Meanwhile, the patient had hypotension and bradycardia. The evaluation with TTE pericardial tamponade was observed, and the effusion was aspirated by puncturing the xiphoid region. The fluid was hemorrhagic. The surgical team was informed, and the patient was taken into operation by the surgical team in the catheter room because the invasive aortic pressure was around 40 mmHg and was unstable. The bleeding area located behind the left atrium was sutured. The second patient was an infant with HLHS, also. Despite multiple attempts, access to the left atrium could not be achieved. Subsequent echocardiography after the last puncture revealed the presence of pericardial effusion in the patient. Approximately 10 cc of hemorrhagic fluid was aspirated. Echocardiographically, it was observed that the pericardial effusion had drained, and subsequently, the patient was transported to the operating room, and the TSP procedure was abandoned.
The interatrial septum could not be crossed using the TSP method in four patients. The first of these patients was the second case mentioned above. The second patient was also a newborn, diagnosed with HLHS at the age of 3 days. The patient, weighing 2.7 kg, underwent the placement of a 5F ANL-1 catheter. An initial puncture attempt was made by advancing the needle through the femoral vein, but it was unsuccessful. This was followed by applying cautery, initially at 5 Watts and then at 10 Watts. While one of these attempts was successful, the catheter could not be advanced further due to the small size of the left atrium. Echocardiographically, a mild enlargement of the ASD was noted. Subsequent attempts were unsuccessful, and the intervention was terminated due to the prolonged procedure duration. The third case involved a 2-day-old patient diagnosed with HLHS. Despite attempts to penetrate the septum using a wire and cautery, the septum was excessively thick, rendering the procedure unsuccessful. The fourth was a patient diagnosed with Total Anomalous Pulmonary Venous Drainage (TAPVD) and a history of sutureless surgery but underwent a TSP procedure due to pulmonary venous hypertension.
Three patients required direct current monopolar electrocautery energy because the septum could not be bridged using the standard Brockenbrough needle technique. One of them was a borderline left ventricle patient with pulmonary hypertension (first 5 watts, then gradual escalation to 20 watts), and one of them was the cyanotic HLHS patient mentioned below (first 5 watts, then 10 watts, but could not be successful). The last one was an extracardiac Fontan patient with elevated Fontan pressure (first 10 watts, then escalated till 30 watts). There were no complications with these patients.