An 18-day-old cyanotic neonate presented to the emergency department in a state of circulatory collapse, with severe hypoxemia, and metabolic acidosis. He was resuscitated with fluids, inotropes, and PGE1 infusion. Echocardiogram revealed transposition of great arteries, with an intact ventricular septum, very small patent foramen ovale (PFO), and small patent ductus arteriosus (PDA). After adequate preprocedure heparinization (100 U/kg), emergency balloon atrial septostomy (BAS) was performed with 4F and 5F Embolectomy catheter (Biosensors International, Hillegom, the Netherlands) sequentially, through 5F and 6F femoral sheath, respectively.
After the procedure, the patient had improvement in SpO2 to 70% and was shifted to the neonatal cardiac intensive care unit. Five hours post procedure, the patient developed deep-vein thrombosis (DVT) at the vascular access site, right common femoral vein, and external iliac vein complete occlusion, for which heparin infusion was started. Within 12 h of the procedure, there was a worsening of SpO2 (45%) and metabolic acidosis (pH 7.02) with an increase in inotrope requirement. Echocardiography done at this time revealed an echogenic mass across the PFO, occluding the blood flow across it [Figure 1] and Video 1]. There was no evidence of any other intracardiac thrombus. Heparin bolus of 100 unit/kg was administered and infusion rate was increased. At this time, PDA had closed and did not respond to the highest dose of PGE1. The patient succumbed despite prostaglandin and inotropes even as emergency surgery was being planned.
Figure 1: Subcostal short axis view showing echogenic mass across atrial septal defect in a neonate with transposition of great arteries, after successful balloon atrial septostomy
BAS is a life-saving procedure. Despite the good anatomical result, thrombus at this critical location (atrial septal defect [ASD]) might destabilize the patient, especially in the absence of other sites of inter-circulatory mixing. To the best of our knowledge, thrombus across ASD has not been reported after BAS. Probably, this was “thrombus in-transit” due to DVT being present in our patient.In situ thrombus, due to trauma to endothelium of the inter-atrial septum couldn't be ruled out. Such occurrence has been reported at septal puncture site during percutaneous mitral intervention. Septal dissection causing atrial septal hematoma could conceivably complicate BAS but such has not been described. However, it has been reported as a complication during minimally invasive aortic valve replacement. Whatever may be the origin, the end result of restriction of the critical site of inter-circulatory mixing led to fatal consequences.
Post BAS, nonimprovement or deterioration of clinical status can occur due to hypovolemia, hypothermia, anemia, severe pulmonary hypertension, and a stretched PFO which retracts back. In addition to these, another rare cause of a decrease in inter-circulatory mixing due to thrombus or hematoma across ASD should be kept in mind.
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