Asian Cardiovasc Thorac Ann 2007;15:191-193
© 2007 Asia Publishing EXchange Ltd
Peratrial Closure of Atrial Septal Defects without Cardiopulmonary Bypass
Xiang-Jun Zeng, PhD,
Xu-Fa Chen, MD,
Duan Cheng, PhD,
Xiao-Jing Ma, MD,
Xue-Song Hu, MD,
Liang Tao, MD
Wuhan Asia Heart Hospital, Wuhan, China
For reprint information contact: Xiang-Jun Zeng, PhD Tel: 86 27 6579 6782 Fax: 86 27 8585 4036 Email: zengxiangjun{at}sohu.com, #753 Jinghan Avenue, Wuhan 430022, China.
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ABSTRACT
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The objective of this study was to introduce a new technique for occlusion of an atrial septal defect without cardiopulmonary bypass, using a modified Amplatzer device. Between October 2004 and November 2005, 96 secundum atrial septal defects in 83 patients were occluded by this method. A 3-cm incision in the right 4th intercostal space and a minithoracotomy were performed. Via this incision, the right atrium was exposed and the septal closure device was deployed under transesophageal echocardiographic guidance. The sizes of the defects ranged from 10 to 39 mm. The mean device size was 34.1 ± 9 mm (12–46 mm). There was no operative mortality and no major morbidity on follow-up of 3–15 months. This new minimally invasive method of secundum atrial septal defect closure is safe and cosmetically superior to conventional surgery. Avoidance of cardiopulmonary bypass can reduce recovery time and complications. The indications are more extensive than percutaneous transcatheter closure, and the results are encouraging.
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INTRODUCTION
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Isolated atrial septal defect (ASD) is one of the most common congenital cardiac defects. Surgical closure is recommended for hemodynamically significant defects. With the recent surge of minimally invasive techniques in adults, a few institutions have attempted to repair ASD under endoscopic guidance by placing the patient on cardiopulmonary bypass (CPB) through the femoral vessels.1,2 This technique may injure the femoral vessels, and the risks associated with CPB persist. In addition, this technique cannot be applied in young patients because of their small vessel size. Since the first successful deployment of an Amplatzer device, percutaneous ASD closure has become the standard therapy in the pediatric population. We utilized a new technique for ASD closure without CPB. This technique is simple, and the procedure can be accomplished with a small incision.
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PATIENTS AND METHODS
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The ASD device was modified from the Amplatzer atrial septal occluder (AGA Medical, Golden Valley, MN, USA). The device comprised a composite nickel and titanium occluder, a metal sheath, a pushing rod, and a hook (Figure 1
). The double umbrella occluder has a loop on the right atrial umbrella with a 100-cm thread through the loop, facilitating its withdrawal into the 40-cm long sheath. Our unique metallic sheath is large (6–10 mm in diameter), allowing deployment of large occluder devices. The occluder is compatible with this delivery system.
Between October 2004 and November 2005, 96 secundum ASDs in 83 patients were closed by this method; 13 patients had 2 defects. The patients were informed that this was a new operation, and they or their parents gave written consent. The ethics committee of our hospital approved this procedure. Fifty-six patients were female and 27 were male. The mean age of the patients was 25.6±14.6 years (range, 2–61 years). Body weights ranged from 10 to 80 kg. There were 7 (8%) patients in New York Heart Association functional class III, and 76 (92%) in class I or II. Mean ASD size was 25.5±8.4 mm (range, 10–39 mm).
General anesthesia was induced with the patient in the supine position, with single lumen tracheal intubation. Intraoperative transesophageal echocardiography (TEE) was used to assess the ASD; in particular, the defect size and circumferential margins adjacent to the superior and inferior venae cavae, pulmonary vein, mitral valve, and aortic sinus. A 3-cm incision was made in the right 4th intercostal space. The pericardium was exposed through a minithoracotomy and opened by cautery. The opened pericardium was sutured with five 2/0 Ethibond stay sutures to expose the right atrium. Two parallel 4/0 Prolene pursestring sutures of approximately 10 mm in diameter were sewn into the right atrium. The patient was given 1.0 mg·kg–1 of heparin, and the activated clotting time was confirmed to be greater than 250 sec.
Based on our experience, we chose occluders according to the largest diameter of the ASD, allowing for a margin of 6–12 mm in excess of the diameter in adults, and 4–6 mm in children. The margin of the ASD was also taken into consideration. The occluder was drawn into the sheath. A right atriotomy was made within the pursestring suture, and the sheath was inserted (Figure 2). Under continuous TEE guidance, the sheath was advanced through the ASD into the left atrium (Figure 3). The left atrial umbrella was deployed first using the pushing rod, and then with gradual withdrawal of the sheath, the right atrial umbrella opened on the other side to occlude the ASD (Figure 4). Transesophageal echocardiography on completion confirmed device placement by gently tugging on the thread attached to the right atrial umbrella. Evaluation of any residual shunt, atrioventricular valve distortion, and obstruction of the venae cavae or coronary sinus completed the procedure. The thread was cut and pulled out. The sheath was withdrawn with the pursestring suture snugly tied. The chest was closed routinely with no drainage tube placement.
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RESULTS
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All ASDs were successfully closed with a mean device size of 34.1 ± 9 mm (range, 12–46 mm). The duration of the procedure was 30–120 min. All patients were extubated on the table. The intensive care unit stay was less than 1 day, and hospital stay was 3–7 days. There was no postoperative mortality. On follow-up of 3–15 months, there was no major morbidity. Hemothorax was noted on echocardiography in 10 patients (mild in 8, moderate in 1, and severe in 1). One patient had a minimal residual shunt that resolved 1 month later. At a mean follow-up of 8 months, there was no cerebral embolic event, device embolization or failure. Functional status improved in 7 patients and remained the same in 76. All patients were given aspirin 50–100 mg 4-times daily for 3 months. There were no wound problems.
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DISCUSSION
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Surgical ASD closure requires CPB, whilst percutaneous transcatheter closure is limited to a maximal defect size of 34 mm.3,4 The largest defect in this group was 39 mm, the largest size of occluder was 46 mm, and the lowest body weight was 10 kg. Patients who have 2 defects are easy to treat with this technique; in the 13 patients with 2 defects, all ASDs were occluded successfully. Hemothorax is a common complication. Of the 10 patients with hemothorax, one was re-opened through the same incision. The bleeding point was the intercostal muscle. One patient underwent closed thoracic drainage, and the others needed no treatment.
The sheath diameter was 6–10 mm, which was selected according to the size of the occluder. A slender sheath can be selected provided that the occluder can be easily drawn into the sheath. The sheath is not commercially available, but it is easy to make oneself. The pursestring suture in the right atrial wall should be close to the atrioventricular groove.
This new minimally invasive method of secundum ASD closure is safe and cosmetically superior to conventional surgery. Avoidance of CPB can reduce recovery time and complications. The indications are more extensive than percutaneous transcatheter closure, and the results are encouraging.
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REFERENCES
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- Akins CW. Full sternotomy through a minimally invasive incision: a cardiac surgeon’s true comfort zone. Ann Thorac Surg 1998;66:1429–30.[Abstract/Free Full Text]
- Laks H, Hammond GL. A cosmetically acceptable incision for the median sternotomy. J Thorac Cardiovasc Surg 1980;79:146–9.[Abstract]
- Rigby ML. The era of transcatheter closure of atrial septal defects. Heart 1999;81:227–8.[Free Full Text]
- Nakanishi T. Interventional catheterization. Curr Opin Cardiol 2000;15:211–5.[Medline]
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ABSTRACT
INTRODUCTION
