Association of Prior Balloon Atrial Septostomy with Mortality and Perioperative Outcomes in Neonates with D-Transposition of the Great Arteries Undergoing Arterial Switch Operation: A Systematic Review and Meta-analysis.

The role of balloon atrial septostomy (BAS) in the contemporary management of neonates with dextra-transposition of the great arteries (d-TGA) undergoing arterial switch operation (ASO) remains controversial, with marked inter-institutional practice variation and conflicting outcome data. We evaluated the association between prior BAS and mortality, length of stay, pre-operative intubation rate, and neurological outcomes in neonates with d-TGA undergoing ASO, with pre-specified subgroup analyses stratified by TGA anatomical subtype. We conducted a systematic review and meta-analysis of studies reporting outcomes in neonates with d-TGA undergoing ASO with and without prior BAS. Databases were searched from inception to 2024. Risk of bias was assessed using ROBIN-I. Random-effects meta-analyses were performed for mortality, length of stay, and pre-operative intubation rate. Studies reporting only adjusted effect estimates without counts data were described narratively. The protocol was registered in PROSPERO (CRD420251041501). Twenty-eight studies (1983-2024) were included. Six contributed to mortality analysis (n=1151; 43 deaths). The pooled odds ratio (OR) for mortality was 0.73 (95% CI 0.40-1.34, I2 = 0%). In TGA-IVS (4 studies, n = 443), OR was 0.89 (95% CI 0.30-2.65; I2 = 0%). in mixed TGA (2 studies, n=708), OR was 0.66 (95% CI 0.27-1.62, I2 = 34%), with no significant subgroup difference. Sensitivity analysis showed similar results. Overall length of stay did not differ significantly, though TGA-IVS neonates showed moderately longer pre-operative stay. Pre-operative intubation was more frequent with BAS (OR 8.96, 95% CI 3.69-21.71). Prospective MRI studies showed no clear association with pre-operative brain injury. Prior BAS was not associated with reduced mortality in neonates with d-TGA undergoing ASO. Higher intubation rates likely reflect illness severity rather than harm. This evidence does not exclude benefit in selected high-risk neonates but remains insufficient to confirm it.