A novel approach to preparation of neonates with transposition of great arteries with intact ventricular septum for successful arterial switch operation: Combined balloon atrial septostomy and patent ductus arteriosus stenting.

Background: The corrective surgery of transposition of great arteries with intact interventricular septum (TGA-IVS) is an arterial switch operation (ASO), and this requires a neonate with hemodynamic stability, absence of infection, and left ventricle (LV) prepared to take the afterload. ASO is carried out at 2-3 weeks of life at our center thus making stabilization procedures like balloon atrial septostomy (BAS) essential. We hypothesized that in neonates with TGA-IVS with restrictive interatrial communication requiring BAS, simultaneous stenting of the patent ductus arteriosus (PDA) will maintain an adequate left ventricular load so that the LV is prepared to undergo ASO. We present our experience of combined BAS with PDA stenting as a first-stage procedure prior to ASO and compare the data with those who did not undergo PDA stenting. Methods: A single-center, retrospective study of neonates with TGA-IVS with restrictive interatrial communication who underwent BAS with PDA stenting as stage 1 procedure was done. These neonates underwent ASO in stage 2. Echocardiographic assessment of the LV volumes, mass, geometry, and free wall thickness was performed prior to stage 1 and stage 2 and compared. After surgery and the postoperative clinical, hemodynamic and morbidity parameters were analyzed. Results: Five neonates were included in the BAS with PDA stenting group and six patients were included in the non-PDA stenting group controls. Study neonates after stage I procedure had favorable LV geometry with significant improvement in LV mass from 36.7 ± 2.6 to 56.3 ± 3.1 g/m2 (p < 0.0001), posterior wall thickness in systole from 0.49 ± 0.08 mm to 0.54 + 0.08 mm (p = 0.002), LV end-diastolic volume from 14.7 + 7.4 ml to 24.2 + 8.6 ml (p = 0.001), good ejection fraction, and favorable LV geometry. A "limited" BAS was associated with consistent saturations above 84%. All patients underwent ASO subsequently with favorable outcomes to discharge. The control patients without a PDA stent had no significant changes in LV mass after BAS alone and had longer requirement of postoperative ventilation; one patient required extracorporeal membrane oxygenation. Conclusion: Combined BAS with PDA stenting is a safe and effective stage 1 procedure to pretrain the LV in TGA-IVS while simultaneously maintaining adequate saturations till ASO.