Mustard baffle obstruction and leak - How successful are percutaneous interventions in adults?

Abstract

Atrial switch operations for D-Transposition of the great arteries (D-TGA) were performed until the late 20th century. These patients have substantial rates of re-operation, particularly for baffle related complications. This study sought to analyze the efficacy of percutaneous transcatheter intervention (PTI) for baffle leak and/or stenosis in adult atrial switch patients. Adult patients with a prior atrial switch operation who underwent heart catheterization (2002-2014) at a tertiary adult congenital heart disease referral center were retrospectively analyzed. In 58 adults (30 ± 8 years, 75% men, 14% New York Heart Association (NYHA) functional class ≥2) who underwent 79 catheterizations, PTI was attempted in 50 (baffle leak (n = 10, 20%), stenosis (n = 27, 54%), or both (n = 13, 26%)). PTI was successful in 45 and 5 were referred for surgery due to complex anatomy. A total of 40 bare metal stents, 18 covered stents, 16 occlusion devices, 2 angioplasties, and 1 endovascular graft were deployed. In isolated stenosis, there was improvement in NYHA functional class after PTI (8 vs. 0 patients were NYHA FC > 2, p = 0.004), which was matched by improvement in maximal oxygen consumption on exercise testing (VO₂) (25.1 ± 5.4 mL/kg/min vs. 27.9 ± 9 mL/kg/min, p = 0.03). There were no procedure-related deaths or emergent surgeries in this cohort. This single-center cohort is the largest reported series of adult atrial switch operation patients who have undergone PTI for baffle stenosis and/or leak. We demonstrate that PTI with an expert multi-disciplinary team is a safe and effective alternative to surgery in adult patients with an atrial switch operation.

Keywords: Baffle leak; Baffle stenosis; D-transposition of the great arteries; Mustard repair; Percutaneous intervention.

Fig. 1

Search methods.

Fig. 2

Characteristics pre/post percutaneous intervention A. Isolated baffle stenosis cases: Mean pre and post-PTI gradient, diameters. Mean VO2 test results and NYHA functional class pre and post-PTI B. Isolated baffle leak cases: Pre and post-PTI baseline oxygen saturation, VO2, and nadir oxygen saturation on VO2 testing. * p < 0.0001. † p < 0.05. PTI: Percutaneous transcatheter intervention.

Fig. 3

Multiple baffle stenoses Significant superior and inferior baffle stenoses that have been treated with bare metal stents. Lead extraction and re-implantation was required in this case.

Fig. 4

Combined baffle stenosis/leak Baffle stenosis and leak treated during a single procedure using a combined EP-interventional catheterization team. Superior baffle stenosis along with a large right to left shunt at the old right atrial appendage (arrow) with contrast seen entering the pulmonary venous atrium (double arrows) (A), intracardiac pacing leads removed and subsequent placement of a covered stent was implanted to treat both the superior baffle stenosis and leak (B). Small baffle leak (arrow) in the inferior baffle (C), interval placement of an Amplatzer PFO Occluder to close the inferior baffle leak and replacement of permanent pacing leads (D). EP: Electrophysiology PFO: Patent foramen ovale.