Transcatheter right ventricle decompression in neonates with pulmonary atresia and intact ventricular septum is technically challenging, with risk of cardiac perforation and death. Further, despite successful right ventricle decompression, re-intervention on the pulmonary valve is common. The association between technical factors during right ventricle decompression and the risks of complications and re-intervention are not well described.

This is a multicentre retrospective study among the participating centres of the Congenital Catheterization Research Collaborative. Between 2005 and 2015, all neonates with pulmonary atresia and intact ventricular septum and attempted transcatheter right ventricle decompression were included. Technical factors evaluated included the use and characteristics of radiofrequency energy, maximal balloon-to-pulmonary valve annulus ratio, infundibular diameter, and right ventricle systolic pressure pre- and post-valvuloplasty (BPV). The primary end point was cardiac perforation or death; the secondary end point was re-intervention.

A total of 99 neonates underwent transcatheter right ventricle decompression at a median of 3 days (IQR 2–5) of age, including 63 patients by radiofrequency and 32 by wire perforation of the pulmonary valve. There were 32 complications including 10 (10.5%) cardiac perforations, of which two resulted in death. Cardiac perforation was associated with the use of radiofrequency (p=0.047), longer radiofrequency duration (3.5 versus 2.0 seconds, p=0.02), and higher maximal radiofrequency energy (7.5 versus 5.0 J, p<0.01) but not with patient weight (p=0.09), pulmonary valve diameter (p=0.23), or infundibular diameter (p=0.57). Re-intervention was performed in 36 patients and was associated with higher post-intervention right ventricle pressure (median 60 versus 50 mmHg, p=0.041) and residual valve gradient (median 15 versus 10 mmHg, p=0.046), but not with balloon-to-pulmonary valve annulus ratio, atmospheric pressure used during BPV, or the presence of a residual balloon waist during BPV. Re-intervention was not associated with any right ventricle anatomic characteristics, including pulmonary valve diameter.

Technical factors surrounding transcatheter right ventricle decompression in pulmonary atresia and intact ventricular septum influence the risk of procedural complications but not the risk of future re-intervention. Cardiac perforation is associated with the use of radiofrequency energy, as well as radiofrequency application characteristics. Re-intervention after right ventricle decompression for pulmonary atresia and intact ventricular septum is common and relates to haemodynamic measures surrounding initial BPV.

Nasal septal perforation can cause troublesome symptoms. Surgical repair is indicated in symptomatic patients. Many approaches and techniques have been described, each with its advantages and indications.

The study included six patients with symptomatic nasal septal perforations sized 1–2.5 cm horizontally by 0.5–1.5 vertically. Patient symptoms included nasal crusts (all patients), nasal obstruction (five), cacosmia (three) and recurrent epistaxis (three). Patients underwent endonasal endoscopic repair using an inferior turbinate free graft applied between the mucoperichondrium of both septum sides. Follow up ranged from six months to two years.

Five patients (83 per cent) had complete perforation closure and one had partial closure. All patients were symptom-free post-operatively.

This endoscopic endonasal approach, using an inferior turbinate free graft, is effective in closing small and medium-sized nasal septal perforations.

Nasal septal perforation is a structural or anatomical defect in the septum. The present study focused on the effects of septal perforation on nasal airflow and nasal patency, investigated using a computer simulation model.

The effect of nasal septal perforation size on nasal airflow pattern was analysed using computer-generated, three-dimensional nasal models reconstructed using data from magnetic resonance imaging scans of a healthy human subject. Computer-based simulations using computational fluid dynamics were then conducted to determine nasal airflow patterns.

The maximum velocity and wall shear stress were found always to occur in the downstream region of the septal perforation, and could potentially cause bleeding in that region, as previously reported. During the breathing process, there was flow exchange and flow reversal through the septal perforation, from the higher flow rate to the lower flow rate nostril side, especially for moderate and larger sized perforations.

In the breathing process of patients with septal perforations, there is airflow exchange from the higher flow rate to the lower flow rate nostril side, especially for moderate and large sized perforations. For relatively small septal perforations, the amount of cross-flow is negligible. This cross-flow may cause the whistling sound typically experienced by patients.

A 29-year-old man presented with sudden onset of severe pain in his throat, difficulty breathing and a hoarse voice, following an episode of vomiting.

Initial laboratory tests were normal. The patient underwent fibre-optic nasendoscopy, which demonstrated a haematoma in the piriform fossa. Lateral neck radiography and subsequent computed tomography scanning confirmed a 2 cm, loculated, gas-containing collection at the level of the vallecula in the right posterolateral wall, extending to the false vocal folds and communicating between the right parapharyngeal space and the right carotid sheath. Water-soluble contrast swallow confirmed the diagnosis.

Contained oesophageal perforation.

Conservative treatment was adopted involving nil orally, intravenous antibiotics and nasogastric feeding. The patient made an uneventful recovery.