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Bedside Septostomy Echo, Procedure & Complications

Dr Mohammad Daud Khan Director of Paed & ACHD Catheter Intervention Sheikh Khalifa Medical City, Cleveland Clinic, Abu Dhabi, U.A.E


Experience

‘ You cannot acquire experience by making experiments. You cannot create experience. You must undergo it Albert Camus


Balloon Atrial Septostomy This talk..

Introduction & history & of BAS  Types of Atrial Septum / PFO  Organisation / Planning for BBAS  Instruments / Balloons needed  The Technique / Procedure  Example of DBAS  Complications of BAS & Tips  Conclusion 


Balloon Atrial Septostomy • Introduction •

• • •

“A technique for producing an ASD without thoracotomy or anaesthesia is presented. 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, Procedure stirred the imagination of the “invasive” cardiologists throughout the entire cardiology world Set stage for all future ICC procedures – the true beginning of pediatric and adult interventional cardiology.” (Charles E. Mullins, 1998) Since then it has remained an integral part of cardiac catheterisation in neonates, even after the introduction of the arterial switch procedure by Jatene and associates in 1976.


History Balloon A Septostomy • • • •

Nonsurgical procedure to create ASD, using a balloon catheter First interventional cardiac catheter by Rashkind in 1966 Now done under echo guidance Life saving procedure in CHD


Balloon Atrial Septostomy This talk..

History of BAS  Types of Atrial Septum / PFO  Organisation / Planning for BBAS  Instruments / Balloons needed  The Technique / Procedure  Example of DBAS  Complications of BAS  Conclusion 


Types of atrial septum •Thick septa •Muscular septa •Aneurysmal septa •Probe patent PFO


Balloon Atrial Septostomy Indications         

TGA with IVS, Restrictive PFO HLHS With Small PFO TAPVD with restrictive PFO PA –TA /IVS/ Small PFO Pulmonary hypertension / excessive cyanosis Mitral Stenosis for LA decompression Cardiomyopathy ON ECMO if PFO present! Other types of Pulmonary Hypertension Others Misc


Balloon Atrial Septostomy This talk..

History of BAS  Types of Atrial Septum / PFO  Organisation / Planning for BBAS  Instruments / Balloons needed  The Technique / Procedure  Example of DBAS  Complications of BAS  Conclusion 


Balloon Atrial Septostomy •Contraindications? •Coagulation abnormalities •Good size ASD and mixing!!

•Thrombus / DIC / sepsis •Distorted anatomy ( Relative ) •Hypotension / HR- need correction •Thick hypertrophic AS with tiny PFO may need to take –Cath Lab •Older infant ( more than 6 weeks) with thick AS ( Blade / static B in CL)


Organisation & Planning BAS Preparation Pre / Post Balloon Septostomy • • • • • • • • •

Diagnostic confirmation by TTE Assess the whole situation Timing for septostomy / condition of baby Communication with PICU team Inform the Intensivist about Femoral Veins Communication with Neonatologist for transfer Consent and family meeting (Telephonic consent ) Complication &Risks Documentation and witness


Organisation & Planning BAS Preparation Pre / Post Balloon Septostomy • • • • • • • • •

Baby Preparation (Chase all investigation) Lease with Intensivist, Assistant echo) A dose of 1/V Antibiotic at induction? Femoral access very important step / UV/ IJ Ultrasound guided-easy Instruments, Catheters, wires, Balloon, Sheath Inform Senior colleagues, surgeon, Think about Cut down? / Int Jugular approach? Complication-cerebral, infection, Femoral A/V

Post septostomy Plan • (Repeat echo, Feeding, Prostin, Surgery)


Balloon Atrial Septostomy This talk..

History of BAS  Types of Atrial Septum / PFO  Organisation / Planning for BBAS  Instruments / Balloons needed  The Technique / Procedure  Example of DBAS  Complications of BAS  Conclusion 


Balloon Atrial Septostomy • The use of two-dimensional transthoracic echocardiography to monitor the procedure • Allan LD, Leanage R, Wainwright R, Joseph MC, Tynan M. Balloon atrial septostomy under 2-d echo control. Br Heart J. 1982;47:41–3. • Perry LW, Ruckman RN, Galioto FM, Jr, Shapiro SR, Potter BM, Scott LP. Echo assisted BAS . Pediatrics. 1982;70:403–8 •


Balloon Atrial Septostomy • The possibility of using the umbilical vein as an access site- 1 • This have simplified this procedure dramatically, so that it can be performed at the Bedside in the neonatal intensive care unit 2,3 • 1. Abinader E, Zeltzer M, Riss E. Trans umbilical BAS in the new born. Am J Dis Child. 1970;119:354. • 2. Baker EJ, Allan LD, Tynan MJ, Jones OD, Joseph MC, Deverall PB. BAS in the neonatal intensive care unit. Br Heart J. 1984;51:377–8. [ • 3. Zellers TM, Dixon K, Moake L, Wright J, Ramaciotti C. Bedside BAS is safe, efficious, and cost-effective compared with septostomy performed in the cardiac catheterization laboratory. A J Cardiol. 2002;89:613–5.


Balloon Atrial Septostomy •

Instruments needed for BAS

A variety of catheters are in use for BAS. The most commonly used catheter at the present time, the 5F Miller balloon atrial septostomy catheter (Edwards Lifesciences, Irvine, CA, USA), needs an 7F introducer.

The low profile, dual lumen Z-5 atrioseptostomy catheter-1 (Numed, Cornwall, ON, Canada), comes in 4F or 5F sizes, depending on the balloon diameter, and requires a 5 or 6F introducer, respectively. The Z-5 catheter is advanced over a guidewire, as opposed to the Miller catheter.

• 1- Hijazi Z, Geggel R, Aronovitz M, Marx G, Rhodes J, Fulton D. A new low profile balloon atrial septostomy catheter. Initial animal and clinical experience. J Invas Cardiol. 1994;6:209–12. • Get terumo wires, syringes, saline,


Balloon Atrial Septostomy • Atrio Septostomy Balloon & Blade Septostomy


Balloon Atrial Septostomy •

Septostomy Catheter – Z-5

• The AS catheter is suitable for baby with a small LA & Newborn • need atrioseptostomy due to a congenital ell as heart disease.

Septostomy Catheter – Z-5 REF

Balloon diameter

Balloon length

Guide wire

Introducer size

PU

SPT002

9.5 mm

95 mm

0.014"

5F

1

SPT003

13.5 mm

135 mm

0.021"

6F

1


Balloon Atrial Septostomy This talk..

History of BAS  Types of Atrial Septum / PFO  Organisation / Planning for BBAS  Instruments / Balloons needed  The Technique / Procedure  Example of DBAS  Complications of BAS  Conclusion 


Balloon Atrial Septostomy • • •

UMBILICAL VEIN IS BEST ACCESS UMBILICAL CORD = 2 ARTERIES AND 1 VEIN


Audit on Cardiac Catheter at SKMC • ECHO TO GUIDE CATHETER THROUGH UMBILICAL VEIN AND DUCTUS VENOSUS


Balloon Atrial Septostomy • Femoral Vein Access • Direct Access Or Ultrasound guided – Operator choice! • Check & Double check!


Balloon Atrial Septostomy • Check & Double check!


Balloon Atrial Septostomy • • • • • • • • • • • •

Technique of Passing from FV-IVC-RA-AS-LA The procedure can be performed under sedation or GA . Access can be achieved via femoral vein. The femoral vein is punctured , an 4 or 5F introducer placed & exchanged for a 7F when the Miller catheter is used. The balloon catheter is advanced into the RA. Then the PFO is crossed and the catheter is positioned LA. Correct position is documented 2-D Echo It is useful to position / direct cath to the orifice of the LUPV The balloon is quickly inflated with 3-4 ml saline, locked, and then sharply withdrawn into the RA down to the junction – IVC Advanced in middle of RA & deflate quickly This manoeuvre may be repeated 2-3 times, size on echo The results obvious, rise in systemic arterial saturation


Balloon Atrial Septostomy • Technique of Umbilical vein approach • • • • • •

• • •

The procedure can be performed under sedation or GA . Umbilical cord is cut transversely, flush & the vein is identified, Catheter directly inserted into UV with the aid of a forceps The U V is punctured , an 4 ,5, 7F if Miller catheter is used. The progress of the catheter through the ductus venosus can be monitored 2-D echo, If resistance think DV stenosis- 0.018 wire Borne in mind that the tip of the sheath is often inside the RA and may impede withdrawal of the inflated B important remember to withdraw the sheth well into DV prior to performing the septostomy. The balloon is quickly inflated, locked, and pull into the RA down .Advanced in middle of RA & deflate quickly This manoeuvre may be repeated 2-3 times, measure on echo The efficacy from the rise in systemic arterial saturation


Balloon Atrial Septostomy This talk..

History of BAS  Types of Atrial Septum / PFO  Organisation / Planning for BBAS  Instruments / Balloons needed  The Technique / Procedure  Example of DBAS  Complications of BAS  Conclusion 


Balloon Atrial Septostomy • • •

A- Easy Bed Septostomy Adequate least 5 mm in dia & by flapping of inferior rim of the AS


Balloon Atrial Septostomy • Tough AS need calculated force!


Balloon Atrial Septostomy SEQUENCE OF SEP ON FLUORO IN AP AND LAO


Balloon Atrial Septostomy •

BEWARE BALLOON HITTING SHEATH AND DAMAGED


Balloon Atrial Septostomy •

A Difficult one!


Bed side Sep -> Cath L Sep • A- From Bed Septostomy to Cath Lab Septostomy


Balloon Atrial Septostomy • DIFFICULT-?? ANY THOUGHTS!


Balloon Atrial Septostomy • B- From Bed Septostomy to Cath Lab Septostomy


Balloon Atrial Septostomy This talk..

History of BAS  Types of Atrial Septum / PFO  Organisation / Planning for BBAS  Instruments / Balloons needed  The Technique / Procedure  Example of DBAS  Complications of BAS  Conclusion 


Potential Complications CCC •Potential Complications of Cardiac Catheterisation Most emergencies can be dealt with by interventionists in the catheter Lab Need to have rescue equipment available Support from the team Without Complication, learning curve? Even the well known-start with embolisation / failure! 


Complications / Emergencies

Emergencies in the during intervention are,  Vascular include injury, haematoma, bleeding  

( Femoral V/ Artery / IVC / Hepatic / Ductus V Malposition of the BS, Perf / avulsion of AV Val

Injury to PV/tear in the sup aspect of the LA PV

Arrhythmias / usually respond to CPM / Drugs

Cardiac Perf – emergency Pericardiocenteses

Clots / NEC / Hypotension/ Infection / death


Balloon Atrial Septostomy This talk..

History of BAS  Types of Atrial Septum / PFO  Organisation / Planning for BBAS  Instruments / Balloons needed  The Technique / Procedure  Example of DBAS  Complications of BAS  Conclusion 


CONCLUSION • Although the arterial switch operation for TGA is typically performed within days after birth, and a L-R shunt through an open PDA can be maintained with PG E. • Creation of an additional shunt at the atrial level is easy to achieve, provides stable Saturation and can be recommended. • The learning curve of the operator and the team contribution is the most important for excellent results. • 2-D Echo assisted BAS minimizes risk of complications • No exposure to ionizing radiation for baby and operators • Complications continue to be associated in CHD Catheterization • Little disturbance for the baby & stay in the incubator


CONCLUSION Complication of Interventional Cardiac catheter • Complications continue to be associated in CHD Catheterisation • Efforts should be directed to improving equipment flexibility and size, and finding alternative methods for vascular access. • Patient age and weight are risk factors – M & M • The complication burden change as we push on to deal with smaller and smaller babies? • Many are avoidable with care and a meticulous approach, availability of all new technology and equipment's • Stocks of all life saving equipment's in cath Lab


Know your limits!


Balloon Atrial Septostomy • Access is the most important part of the procedure! •

UMUMBILICAL CORD = 2 ARTERIES AND 1 VEIN


Balloon Atrial Septostomy • Atrio Septostomy Balloon & Blade Septostomy


Balloon Atrial Septostomy • Write as u

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