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Purpose:After patent foramen ovale interventional closure, puncture of the interatrial septum through the occluder is difficult but sometimes needed for further interventional treatment. This paper presents findings from an in vivo experimental study of a reserved atrial septal puncture area patent foramen ovale occluder.Materials and methods:A patent foramen ovale model was established in canines using trans-septal puncture of the fossa ovale and high-pressure balloon dilation. Then, patent foramen ovale closure was performed with a reserved atrial septal puncture area and all canines were raised for 3 months. Then, the occluder was crossed and left atrial angiography was performed on the septal area with the occluder. Finally, DSA angiography, echocardiography, and histology were used to evaluate the performance and feasibility of the reserved atrial septal puncture area.Results:A patent foramen ovale model was successfully established in 10 canines using the atrial septal puncture method. The average diameter of the patent foramen ovale was 3.77 ±0.19 mm, and the patent foramen ovale was successfully closed in all canines using a reserved atrial septal puncture area. As assessed using transoesophageal echocardiography, the new occluder exhibited an ideal position and was occluded entirely without a residual shunt intraoperatively and postoperatively. A 100% success rate of atrial septum puncture was achieved across the new occluder. The occluders were completely endothelialised 3 months post-implantation.Conclusions:The reserved atrial septal puncture area was effective in patent foramen ovale closure and exhibited positive sealing performance and biological compatibility. Trans-septal puncture was feasible and effective after reserved atrial septal puncture area patent foramen ovale closure.

BackgroundLeft atrial decompression is considered in patients with symptomatic heart failure with preserved ejection fraction (HFpEF). We aimed to evaluate the feasibility and efficacy of transcatheter generation of a restrictive atrial septum communication to manage HFpEF from infancy to adulthood with cardiomyopathy and congenital heart defect.Methods and resultsFrom June 2009 to December 2016, 24 patients (50% with an age less than 16 years) with HFpEF were palliated; NYHA-/Ross class IV (n = 10); median systemic ventricular ejection fraction 64 (range 35–78) %. Cardiomyopathy was classified as a restrictive (n = 4) or hypertrophic (n = 2). (75% related to congenital heart defects) Three patients had a systemic right ventricle; in the majority of patients, HFpEF was associated to complex congenital heart defects (n = 18). Mean pulmonary arterial pressures (PAP systolic/diastolic) were 56/28 (± 24/13), left atrial pressures (LAP, v-, a-wave, mean) 26/25/20 (± 7/10/6). Trans-septal puncture was used in 22 patients; foramen ovale dilatation in 2 patients. Median balloon size was 12 (range 6–18) mm; procedure time including diagnostic measures 125 (83–221) min. No procedural death or complications were observed. Mean LA-pressures decreased significantly to 19/19/15 ± 6/8/5 mmHg (p = 0.05); median brain natriuretic peptide (BNP) decreased from 392 (range 93–4401) pg/ml median BNP to 314 (range 61–1544) pg/ml (p = 0.05). Three patients died; one patient received orthotopic heart and one patient a heart–lung transplantation. No patient required so far an assist device. Clinical improvement occurred in all patients, in some after additional surgical or interventional approach.ConclusionsTranscatheter LA decompression is an age-independent, effective palliation treating patients with HFpEF.

Objective Restrictive foramen ovale (FO) in dextro-transposition of the great arteries (d-TGA) with intact ventricular septum may lead to severe life-threatening hypoxia within the first hours of life, making urgent balloon atrial septostomy (BAS) inevitable. Reliable prenatal prediction of restrictive FO is crucial in these cases. However, current prenatal echocardiographic markers show low predictive value, and prenatal prediction often fails with fatal consequences for a subset of newborns. In this study, we described our experience and aimed to identify reliable predictive markers for BAS. Methods We included 45 fetuses with isolated d-TGA that were diagnosed and delivered between 2010 and 2022 in two large German tertiary referral centers. Inclusion criteria were the availability of former prenatal ultrasound reports, of stored echocardiographic videos and still images, which had to be obtained within the last 14 days prior to delivery and that were of sufficient quality for retrospective re-analysis. Cardiac parameters were retrospectively assessed and their predictive value was evaluated. Results Among the 45 included fetuses with d-TGA, 22 neonates had restrictive FO postnatally and required urgent BAS within the first 24 h of life. In contrast, 23 neonates had normal FO anatomy, but 4 of them unexpectedly showed inadequate interatrial mixing despite their normal FO anatomy, rapidly developed hypoxia and also required urgent BAS (‘bad mixer’). Overall, 26 (58%) neonates required urgent BAS, whereas 19 (42%) achieved good O 2 saturation and did not undergo urgent BAS. In the former prenatal ultrasound reports, restrictive FO with subsequent urgent BAS was correctly predicted in 11 of 22 cases (50% sensitivity), whereas a normal FO anatomy was correctly predicted in 19 of 23 cases (83% specificity). After current re-analysis of the stored videos and images, we identified three highly significant markers for restrictive FO: a FO diameter < 7 mm ( p  < 0.01), a fixed ( p  = 0.035) and a hypermobile ( p  = 0.014) FO flap. The maximum systolic flow velocities in the pulmonary veins were also significantly increased in restrictive FO ( p  = 0.021), but no cut-off value to reliably predict restrictive FO could be identified. If the above markers are applied, all 22 cases with restrictive FO and all 23 cases with normal FO anatomy could correctly be predicted (100% positive predictive value). Correct prediction of urgent BAS also succeeded in all 22 cases with restrictive FO (100% PPV), but naturally failed in 4 of the 23 cases with correctly predicted normal FO (‘bad mixer’) (82.6% negative predictive value). Conclusion Precise assessment of FO size and FO flap motility allows a reliable prenatal prediction of both restrictive and normal FO anatomy postnatally. Prediction of likelihood of urgent BAS also succeeds reliably in all fetuses with restrictive FO, but identification of the small subset of fetuses that also requires urgent BAS despite their normal FO anatomy fails, because the ability of sufficient postnatal interatrial mixing cannot be predicted prenatally. Therefore, all fetuses with prenatally diagnosed d-TGA should always be delivered in a tertiary center with cardiac catheter stand-by, allowing BAS within the first 24 h after birth, regardless of their predicted FO anatomy.

Pulmonary arterial hypertension (PAH) is a well-known complication of congenital heart disease (CHD). The lack of a satisfactory animal model for PAH associated with CHD (PAH-CHD) has limited progress in understanding the pathogenesis of PAH and the development of therapeutic agents. The development of a rat model for PAH associated with atrial septal defect (ASD) was achieved through atrial septal puncture and thermal ablation. Two and 4 weeks after modeling, hematoxylin and eosin staining showed that the vascular thickness, vascular thickness index, vascular area, and vascular area index in pulmonary arteries with an outer diameter of 50–300 μm in the PAH-ASD 2 and 4 weeks group were higher than those in the sham group (all P  < 0.05). Alpha-smooth muscle actin (ɑ-SMA) staining showed that the medial thickness, medial thickness index, medial area, and medial area index in pulmonary arteries with an outer diameter of 50–300 µm at 2 and 4 weeks after modeling were significantly higher than those in the sham group (all P  < 0.05). Additionally, mean pulmonary arterial pressure (mPAP) and pulmonary vascular resistance (PVR) in the PAH-ASD 2 and 4 weeks groups were significantly higher than those in the sham group (both P  < 0.05). Elastin van Gieson staining showed that the vascular obstruction score in the PAH-ASD 2 and 4 weeks group was significantly higher than that in the sham group (both P  < 0.05). The PAH-ASD rats were successfully generated. These findings suggest that our model would be useful for further research into the pathogenesis, prevention, and treatment of PAH-ASD.

We present this case of cardiac rhabdomyoma in a term baby presenting with peripheral and central cyanosis. On echocardiography multiple masses were noted occupying the right ventricle and the adjacent myocardium. There was evidence of right ventricle outflow tract obstruction causing functional pulmonary atresia. A small patent ductus arteriosus was seen supplying the lungs. After instituting supportive treatment and consulting the cardiac surgical team palliation was decided. Balloon atrial septostomy and ductal stenting was done on 7th day of life.

Patients with d-looped transposition of the great arteries (d-TGA), especially those without an adequate atrial septal defect, can experience severe hypoxemia and hemodynamic compromise in the neonatal period. This can be mitigated by urgent balloon atrial septostomy (BAS). However, some patients with d-TGA are born at centers without this capability. The aim of this retrospective study of d-TGA patients who had urgent or emergent BAS at our institution between 2010 and 2021 was to evaluate time from birth to BAS for infants born at a tertiary care center as compared to those requiring transport from other institutions and to examine correlation between time to BAS and patient outcomes. Our primary outcome was time from birth to BAS. Secondary outcomes included hospital and ICU length of stay, mortality, and evidence of pulmonary or neurologic abnormalities including pulmonary hypertension, abnormal neuroimaging, or seizures. Of 96 patients, 67 (70%) were born at our institution. The median time to BAS was 4 h for patients born at our institution vs. 14.1 h for those born elsewhere ( p  < .0001). A longer time from birth to BAS was associated with longer ICU ( r  = 0.21, p  = 0.046) and hospital length of stay ( r  = 0.24, p  = 0.02) and increased likelihood of elevated right ventricular pressure on post-operative discharge echocardiogram ( p  = 0.01). There were no differences in mortality between the groups. Therefore, prenatal planning for patients with known d-TGA should include a delivery plan with access to urgent BAS.

Introduction Speckle tracking analysis of the endocardium of the right (RV) and left (LV) ventricles was used to evaluate the size, shape, and contractility of these chambers in fetuses with D-Transposition of the great arteries (D-TGA) to identify fetuses that would require emergent balloon atrial septostomy (BAS) after birth. Methods This was a retrospective analysis of fetuses with D-TGA and intact ventricular septum that were divided into 2 groups. Group 1 underwent urgent BAS after birth because of a restrictive atrial septum and group 2 did not. Using speckle tracking analysis, the end-diastolic and end-systolic RV and LV areas, lengths, widths, sphericity indices, and contractility were computed. Logistic regression analysis was performed to identify fetuses who would require urgent neonatal BAS. Results Of the 39 fetuses with D-TGA, 55% ( n  = 22) required urgent neonatal BAS (group 1) and 45% ( n  = 17) (group 2) did not. When comparing D-TGA groups 1 and 2, differences were seen in RV and LV area, sphericity index for segment 1 of the LV, LV fractional area of change and free wall annular plane systolic excursion, fractional shortening for LV segment 12, and RV free wall strain. Regression analysis of these measurements identified 91% of neonates who underwent BAS, with a false-positive rate of 12%. Conclusion Using speckle tracking analysis to evaluate the RV and LV, measurable differences were identified for the RV and LV size, shape, and contractility between fetuses who underwent neonatal urgent BAS vs. those who did not require this procedure.

Abstract Left atrial decompression (LAD) using transseptal puncture followed by balloon atrial septostomy recently has been described as a palliative minimally invasive procedure in dogs with advanced degenerative mitral valve disease (DMVD). We report herein the first use of intracardiac echocardiography (ICE) guidance combined with 3-dimensional transesophageal echocardiography (3D-TEE) to ensure the safety of the LAD procedure from a caudal approach, as performed in humans, in 2 American College of Veterinary Internal Medicine (ACVIM) stage C and D DMVD dogs (Jack Russell Terrier and Cavalier King Charles Spaniel) with recurrent episodes of acute pulmonary edema. Both LAD procedures were successful, as confirmed by markedly decreased systolic left atrial pressures (17 and 25 mmHg vs. 42 and 80 mmHg before LAD, respectively). Both dogs remained free of left-sided congestive heart failure signs for 8 and 10 months, respectively. The addition of ICE guidance to 3D-TEE is feasible and valuable in medium-sized dogs for safe LAD procedures.

Pulmonary arterial hypertension (PAH) is currently an irreversible disease, with many patients eventually progressing to right heart failure, severely affecting their quality of life and posing a life-threatening risk. Percutaneous atrial septostomy was first performed in infants with transposition of the great arteries in 1966. Since then, it has been used as a palliative treatment for patients with end-stage PAH, significantly improving their quality of life and providing a buffer period while waiting for lung transplantation. However, this method does not fundamentally alter the malignant outcomes of patients with PAH. This study reviews the development and evolution of atrial septostomy, summarises various emerging technologies, and systematically explains the mechanisms, efficacy, and prognosis of palliative treatment in patients with PAH. Furthermore, new ideas for this treatment approach are proposed with the hope that it will bring more benefits to patients with PAH in the future and be more fully utilised.