Atrial septostomy is a

surgical procedure Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...

in which a small hole is created between the upper two chambers of the heart, the atria. This procedure is primarily used to palliate dextro-Transposition of the great arteries or d-TGA (often imprecisely called transposition of the great arteries), a life-threatening

cyanotic Cyanosis is the change of body tissue color to a bluish-purple hue as a result of having decreased amounts of oxygen bound to the hemoglobin in the red blood cells of the capillary bed. Body tissues that show cyanosis are usually in locations ...

congenital heart defect seen in infants. It is performed prior to an arterial switch operation. Atrial septostomy has also seen limited use as a surgical treatment for pulmonary hypertension. The first atrial septostomy (then less precisely called a septectomy) was developed by Vivien Thomas in a canine model and performed in humans by Alfred Blalock. The Rashkind balloon procedure, a common atrial septostomy technique, was developed in 1966 by American cardiologist William Rashkind at the Children's Hospital of Philadelphia. There are two types of this procedure: balloon atrial septostomy (also called endovascular atrial septostomy, Rashkind atrial balloon septostomy, or simply Rashkind's procedure) and blade atrial septostomy (also called static balloon atrial septostomy).

Indications

In a normal heart, oxygen-depleted blood ("blue") is pumped from the

right side of the heart The heart is a muscular organ in most animals. This organ pumps blood through the blood vessels of the circulatory system. The pumped blood carries oxygen and nutrients to the body, while carrying metabolic waste such as carbon dioxide to ...

, through the pulmonary artery, to the

lung The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of t ...

s where it is oxygenated. This is the pulmonary circulation part of blood flow. The oxygen-rich ("red") blood then returns to the left heart, via the pulmonary veins, and is pumped through the aorta to the rest of the body, including the heart

muscle Skeletal muscles (commonly referred to as muscles) are organs of the vertebrate muscular system and typically are attached by tendons to bones of a skeleton. The muscle cells of skeletal muscles are much longer than in the other types of muscl ...

itself. This is the

systemic circulation The blood circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the entire body of a human or other vertebrate. It includes the cardiovascular system, or vascular system, tha ...

part of blood flow, the other loop of an interconnected normal cardio- pulmonary system. With d-TGA, certain major blood vessels are connected improperly, so oxygen-poor blood from the right heart is pumped immediately through the aorta and circulated to the body and the heart itself, bypassing the lungs altogether, while the left heart pumps oxygen-rich blood continuously back into the lungs through the pulmonary artery. This is a life-threatening situation due to the resultant low oxygen levels throughout the body. Atrial septostomy allows more of the oxygen-rich blood to circulate throughout the body. The procedure is a temporary measure meant to help the patient survive until further corrective surgery can be done. In the separate case of pulmonary hypertension, abnormally high blood pressure in the blood vessels within and connected to the lungs puts stress on the right side of the heart, potentially leading to

right heart failure Heart failure (HF), also known as congestive heart failure (CHF), is a syndrome, a group of signs and symptoms caused by an impairment of the heart's blood pumping function. Symptoms typically include shortness of breath, excessive fatigue, a ...

. Atrial septostomy relieves some of this pressure, but at the cost of lower oxygen levels in the blood (

hypoxia Hypoxia means a lower than normal level of oxygen, and may refer to: Reduced or insufficient oxygen * Hypoxia (environmental), abnormally low oxygen content of the specific environment * Hypoxia (medical), abnormally low level of oxygen in the tis ...

). As with d-TGA, this surgery is not a definitive solution to the underlying medical problem.

Procedure

The majority of atrial septostomies are performed on infants with d-TGA or other

cyanotic heart defect A cyanotic heart defect is any congenital heart defect (CHD) that occurs due to deoxygenated blood bypassing the lungs and entering the systemic circulation, or a mixture of oxygenated and unoxygenated blood entering the systemic circulation. It is ...

s. In these cases, a balloon catheter is guided through a large vein into the right atrium, during

cardiac catheterization Cardiac catheterization (heart cath) is the insertion of a catheter into a chamber or vessel of the heart. This is done both for diagnostic and interventional purposes. A common example of cardiac catheterization is coronary catheterization that ...

. The catheter is threaded into the

foramen ovale There are multiple structures in the human body with the name foramen ovale (plural: ''foramina ovalia''; Latin for "oval hole"): * Foramen ovale (heart), in the fetal heart, a shunt from the right atrium to left atrium * Foramen ovale (skull), at ...

, a naturally existing hole between the atria that normally closes shortly after birth. The balloon at the end of the catheter is inflated so as to enlarge the foramen ovale enough that it will no longer become sealed. This allows more oxygenated blood to enter the right heart (especially in the case of d-TGA) where it can be pumped to the rest of the body. The balloon is deflated and the catheter is removed. Sometimes the initial surgery is not entirely successful, or there are other factors that make a simple balloon atrial septostomy impossible, such as an older patient whose foramen ovale has already closed. This is when a blade atrial septostomy is performed. The details of the procedure are largely the same, except that a small blade on the end of the catheter is first used to create an opening between the right and left atria, before the insertion of the balloon. The Rashkind balloon atrial septostomy is performed during

(heart cath), in which a balloon catheter is used to enlarge a

, patent foramen ovale (PFO), or atrial septal defect (ASD) in order to increase oxygen saturation in patients with

congenital A birth defect, also known as a congenital disorder, is an abnormal condition that is present at birth regardless of its cause. Birth defects may result in disabilities that may be physical, intellectual, or developmental. The disabilities can ...

heart defects (CHDs). It was developed in 1966 by

American American(s) may refer to: * American, something of, from, or related to the United States of America, commonly known as the "United States" or "America" ** Americans, citizens and nationals of the United States of America ** American ancestry, pe ...

surgeon In modern medicine, a surgeon is a medical professional who performs surgery. Although there are different traditions in different times and places, a modern surgeon usually is also a licensed physician or received the same medical training as ...

s William Rashkind and William Miller at the Children's Hospital of Philadelphia. William Rashkind was not a surgeon, but a pediatric cardiologist at the Children's Hospital of Philadelphia. He was one of the fathers of the field of interventional catheterization, and he developed not only this life-saving technique and device for neonates with transposition of the great arteries, but also devices to close atrial septal defects (ASDs) and persistent patent ductus arteriosus (PDA). He was the chief of the Division of Pediatric Cardiology at the Children's Hospital of Philadelphia until his death in 1986 from malignant melanoma.

Risks

As with any surgery, there are certain risks to atrial septostomy, including tearing of the cardiac tissue,

arrythmia Arrhythmias, also known as cardiac arrhythmias, heart arrhythmias, or dysrhythmias, are irregularities in the heartbeat, including when it is too fast or too slow. A resting heart rate that is too fast – above 100 beats per minute in adults ...

s, and rarely, death.

References

External links

Endovascular atrial septostomy information for the public
from the National Institute for Health and Clinical Excellence
Interventional procedure overview of balloon or blade atrial septostomy
from the National Institute for Health and Clinical Excellence * ''The Merck Manual of Diagnosis and Therapy'', 18th edition, pp. 2416, 2417. Merck & Co., Inc., 2006. {{Cardiac surgery procedures Cardiac surgery Surgical procedures and techniques fr:Manœuvre de Rashkind