Off-pump atrial septostomy with thoracoscopic scissors under transesophageal echocardiography guidance
An 8-month-old female child with single ventricle physiology (double-inlet left ventricle) with hypoplastic mitral valve (9 mm, Z score = −2.44) and intact atrial septum and unobstructed pulmonary blood flow needed PA banding and creation of an inter-atrial communication.\nAfter detailed evaluation of the child and taking informed consent from her parents, the child was prepared under anesthesia as for open-heart surgery and the procedure was carried out through a median sternotomy. The patient was heparinized. A purse-string suture was made on the right atrial (RA) appendage. A stab was made within the purse string, and through this, thoracoscopy scissors [] was introduced in the RA. Under TEE guidance, the closed tip of the instrument was used to tent the fossa ovalis below the limbus [] and a small perforation was created. It was then dilated by stretching with the opening of the blades of the scissors []. The orifice was assessed and found to be restrictive with a peak gradient of 4 mmHg and a mean gradient of 2 mmHg.\nThe scissors was then rotated to face inferiorly with one blade on either side of the inter-atrial septum, and two cuts were made in the inferior and lateral directions, away from the AV valves and conduction tissue, creating an orifice of maximum size 9 mm with free laminar flow across the resulting defect []. PA banding was done as per Trussler's formula to 27mm.\nThe child recovered uneventfully and was discharged from the hospital on the 6th postoperative day. The PA band gradient on the pre-discharge echo was 60 mm Hg. At 1 month follow-up, the child was well and symptom free with an oxygen saturation of 92%. The child had gained 0.5 kg in the 1 month following discharge. The follow-up echo at 1 month showed a band gradient of 50 mm Hg. The atrial septal opening measured 9 mm with laminar flows across the defect. A bidirectional Glenn shunt is planned in the subsequent 3-6 months.