Published Online
on January 9, 2006

A more recent version of this article appeared on January 17, 2006

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Submitted on June 19, 2005
Revised on September 16, 2005
Accepted on October 7, 2005

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, and 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.).

^* To whom correspondence should be addressed. E-mail: patrick.mcquillen{at}ucsf.edu.

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.

Key words: balloon • heart defects, congenital • magnetic resonance imaging • stroke • transposition of great vessels

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