What are the anesthesia implications for balloon arterial septostomy?

Anesthesia Implications for Balloon Arterial Septostomy

Balloon arterial septostomy requires careful anesthetic management with close hemodynamic monitoring, echocardiographic guidance, and preparation for potential complications including cardiac perforation, arrhythmias, and embolic events. 1

Procedure Overview and Indications

Balloon arterial septostomy (BAS), also known as Rashkind procedure, is performed to:

• Enhance atrial mixing in transposition of great vessels with restrictive/intact atrial communication 1
• Decompress the left atrium in conditions with left atrial hypertension 1
• Provide palliative treatment in select patients with pulmonary arterial hypertension unresponsive to medical management 1

The procedure involves creating or enlarging an opening in the atrial septum using a balloon catheter, sometimes preceded by blade septostomy in cases of thickened septa 1.

Pre-Anesthetic Considerations

Patient Assessment

• Evaluate cardiac anatomy and function via recent echocardiography 1
• Assess right heart catheterization data and pulmonary vascular resistance 1
• Review baseline oxygen saturations and hemodynamic parameters 1
• Evaluate for coexisting congenital cardiac anomalies 1

Procedural Planning

• Determine procedure location (catheterization laboratory vs. bedside) - both have similar safety profiles 2, 3
• Assemble multidisciplinary team including cardiac anesthesiologists 1
• Plan for echocardiographic guidance (transesophageal or transthoracic) 4

Anesthetic Management

Monitoring

• Standard ASA monitors plus:
  • Arterial line for continuous blood pressure monitoring 1
  • Central venous catheter for central venous pressure monitoring and medication administration 1
  • Transesophageal echocardiography (TEE) for procedural guidance and complication detection 1, 4

Anesthetic Technique

• For neonates/infants: Consider local anesthesia with sedation when possible 2
• For major procedures: General anesthesia with careful induction and maintenance 1
• Maintain hemodynamic stability throughout the procedure 1
• Avoid significant changes in pulmonary vascular resistance 1

Medication Considerations

• Continue pulmonary vasodilator therapy perioperatively 1
• Plan for inhaled nitric oxide (iNO) if patient is on inhaled prostacyclins 1
• Avoid medications that increase pulmonary vascular resistance 1

Potential Complications and Management

Immediate Procedural Complications

• Balloon rupture and embolization of fragments - be prepared for retrieval 1
• Failure of balloon deflation - have stylet wire available 1
• Cardiac perforation or damage - monitor for sudden hemodynamic changes 1
• Arrhythmias - have antiarrhythmic medications readily available 1, 3
• Vascular injuries including pulmonary vein avulsion or IVC tear 1

Post-Procedure Complications

• Embolic events including stroke - monitor neurological status 1, 3
• Bleeding - maintain access to blood products 1
• Cardiac tamponade - monitor for signs of cardiac compression 1
• Refractory hypoxemia - be prepared for respiratory support 1

Post-Procedure Care

• Admit to cardiac critical care unit for at least 24 hours of monitoring 1
• Continue close hemodynamic monitoring 1
• Watch for delayed complications which may manifest 1-2 days following the procedure 1
• Maintain pulmonary vasodilator therapy as indicated 1

Special Considerations

Pulmonary Hypertension Patients

• Higher risk of complications including refractory hypoxemia 1
• Consider early elective procedure rather than "rescue" therapy 1
• Be prepared for possible need for ECMO support 1

Thickened Atrial Septum

• May require blade septostomy before balloon septostomy 1
• Higher risk of temporary rather than permanent defect creation 1
• May need static balloon dilation or stenting 1

Neonates

• Consider bedside procedure to avoid risks associated with patient transport 2, 3
• Echocardiographic guidance may reduce radiation exposure 4
• Umbilical venous access may reduce vascular complications 1