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(Circulation. 2006;113:280-285.)
© 2006 American Heart Association, Inc.

Pediatric Cardiology

Balloon Atrial Septostomy Is Associated With Preoperative Stroke in Neonates With Transposition of the Great Arteries

Patrick S. McQuillen, MD; Shannon E.G. Hamrick, MD; Marta J. Perez, BA; A. James Barkovich, MD; David V. Glidden, PhD; Tom R. Karl, MD; David Teitel, MD; Steven P. Miller, MD

From the Pediatric Heart Center (P.S.M., S.E.G.H., T.R.K., D.T., S.P.M.) and Departments of Neurology (M.J.P., A.J.B., S.P.M.), Radiology (A.J.B.), Epidemiology (D.V.G.), and Biostatistics (D.V.G.), University of California, San Francisco, and the Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada (S.P.M.).

Correspondence to Patrick McQuillen, 505 Parnassus Ave, UCSF Medical Center, San Francisco, CA 94143-0106. E-mail patrick.mcquillen{at}ucsf.edu

Received June 19, 2005; revision received September 16, 2005; accepted October 7, 2005.

Background— Preoperative brain injury is common in neonates with transposition of the great arteries (TGA). The objective of this study is to determine risk factors for preoperative brain injury in neonates with TGA.

Methods and Results— Twenty-nine term neonates with TGA were studied with MRI before cardiac surgery in a prospective cohort study. Twelve patients (41%) had brain injury on preoperative MRI, and all injuries were focal or multifocal. None of the patients had birth asphyxia. Nineteen patients (66%) required preoperative balloon atrial septostomy (BAS). All patients with brain injury had BAS (12 of 19; risk difference, 63%; 95% confidence interval, 41 to 85; P=0.001). As expected on the basis of the need for BAS, these neonates had lower systemic arterial hemoglobin saturation (SaO₂) (P=0.05). The risk of injury was not modified by the cannulation site for septostomy (umbilical versus femoral, P=0.8) or by the presence of a central venous catheter (P=0.4).

Conclusions— BAS is a major identifiable risk factor for preoperative focal brain injury in neonates with TGA. Imaging characteristics of identified brain injuries were consistent with embolism; however, the mechanism is more complex than site of vascular access for BAS or exposure to central venous catheters. These findings have implications for the indications for BAS, timing of surgical repair, and use of anticoagulation in TGA.

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