The switch to balloon atrial septostomy with echocardiographic guidance--a severe complication.

To warn about a severe complication of balloon atrial septostomy (BAS) guided by echocardiography, a retrospective review was undertaken of all BASs performed at Red Cross War Memorial Children's Hospital in Cape Town from 1984 to the end of 1992. BAS with fluoroscopy was carried out in 41 infants (group I). Since April 1991, 17 infants had BAS with two-dimensional echocardiography guidance in the intensive care unit (group II). The majority of patients (72%) had simple transposition of the great arteries. Only 3 patients in group I were catheterised via the umbilical vein (the remaining 38 via the femoral vein). In group II, 12 patients (71%) were catheterised via the umbilicus. The only fatality as a result of the procedure occurred in group II. This was the result of rupture of the splenic vein. The patient was catheterised via the umbilical vein, and echocardiography was not adequately used to guide the catheter below the diaphragm. There were no other severe complications in either group. Although echocardiographically guided BAS is easier, quicker, potentially safer and keeps the baby in a better homeostatic environment, we describe a severe complication of this procedure in the learning phase that has not been noted previously.