Asian Cardiovasc Thorac Ann 1998;6:88-90
© 1998 Asia Publishing EXchange Pte Ltd
Minimally Invasive Technique for Closure of Atrial Septal Defect
Jacques AM van Son, MD, PhD,
Anno Diegeler, MD,
Eugene KW Sim, MD,
Rüdiger Autschbach, MD, PhD,
Friedrich W Mohr, MD, PhD
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Department of Cardiac Surgery Herzzentrum, University of Leipzig Leipzig, Germany
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For reprint information contact:Jacques AM van Son, MD, PhDDepartment of Cardiac SurgeryHerzzentrum, University of LeipzigRussenstrasse 19 Leipzig D-04289, Germany Tel: 49 341 865 1421 Fax: 49 341 865 1452
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ABSTRACT
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Minimally invasive techniques for repair of extracardiac anomalies in congenital heart disease have evolved over the last 5 years and laid the foundation for the next phase: the repair of intracardiac defects. Fifteen patients (9 females and 6 males) with a median age of 9.8 years (range, 5.2 to 54 years) underwent closure of a secundum atrial septal defect through a small right anterior thoracotomy. The right external iliac artery was cannulated through a small groin incision and the atrial septal defect was repaired during hypothermic fibrillatory arrest for a mean period of 14 ± 5 minutes. The mean length of the thoracotomy was 4.9 ± 0.8 cm (range, 4.5 to 8.8 cm) while the mean length of the groin incision was 3.9 ± 0.5 cm (range, 2.9 to 5.3 cm). In the 3 youngest patients, the external iliac artery was cannulated with an 8F arterial cannula. Direct closure of the atrial septal defect was possible in all patients. The mean operative time was 109 ± 39 minutes. There was no perioperative or late mortality and no morbidity except for a tear in the right femoral artery of a 19-year-old girl. No residual atrial septal defect was observed in any of the patients. Although minimally invasive techniques for repair of intracardiac defects are not fully developed with regard to indications, the procedure described here provided secure closure of the defects with excellent cosmetic results.
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INTRODUCTION
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The technique of surgical closure of a secundum atrial septal defect (ASD) has come a long way since the use of ingenious methods such as inflow occlusion, the atrial well, and the first ASD repairs using cardiopulmonary bypass.1–3 Major technologic advances during the next decades have improved the outcome of surgical ASD closure to such an extent that it is currently associated with essentially no operative mortality and very little morbidity.4 This development and the fact that the incidence of ASD is approximately twice as great in female as in male patients has led to an emphasis on the cosmetic aspect of the operation. Thus, the goal is a small incision away from the sternum if possible. We recently used a small right anterior thoracotomy for ASD closure and the technique is described in this report.
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MATERIALS AND METHODS
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From October 1996 to June 1997, 15 patients (median age 9.8 years; range, 5.2 to 54 years) underwent closure of a secundum ASD through a small right anterior thoracotomy. Nine patients were less than 15 years of age. There were 9 females and 6 males. The patients were positioned supine with the right side of the chest slightly elevated. External defibrillator pads were applied. The intended skin incisions in the right (or left) groin and the anterior thoracotomy were drawn with a sterile marker. The right (or left) external iliac artery was exposed through a small incision, heparin was administered, and the artery was cannulated (Figure 1
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Figure 1. Incisions for minimally invasive closure of atrial septal defect. (A) The right (or left) external iliac artery is cannulated. (B) A small skin incision is made approximately 4 cm distal to the right nipple. (C) Through a small incision in the 3rd intercostal space, a tape is placed around the superior vena cava. (D) Cannulation of the superior and inferior venae cavae and repair of the atrial septal defect is performed through a longer incision in the 4th intercostal space.
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A right anterior thoracotomy was made approximately 4 cm underneath the nipple. In our experience, the length of the incision varied with the age and anatomic features (such as obesity) of the patient. The medial edge of the incision was 4 cm lateral to the right sternal edge. Extreme care was taken in female patients to avoid incision of the (future) breast tissue. The right pleural space was entered through a 10-cm to 12-cm incision in the 4th intercostal space. In some patients, we found that an additional 6-cm to 7-cm incision in the 3rd intercostal space helped in placing a tape around the superior vena cava. The pericardium was opened approximately 3 cm anterior to the phrenic nerve and incised superiorly well beyond the superior vena cava-right atrial junction and inferiorly to the inferior vena cava. The medial edge of the pericardium was suspended to the anterior chest wall and the lateral edge of the pericardium was retracted with stay sutures that were led through the skin, lateral to the thoracotomy retractor. The lateral stay sutures helped to keep the right lung out of the operative field and if necessary, one or more gauzes were used for this purpose. With the rib retractor in the 4th intercostal space, the superior vena cava and inferior vena cava were cannulated with polyvinylchloride-tipped right-angled cannulae (DLP, Grand Rapids, MI, USA) that were inserted through pursestring sutures close to the right atrial-superior vena cava junction and right atrial-inferior vena cava junction, respectively.
Cardiopulmonary bypass under mild hypothermia (32°C) was started. The patient was positioned in a slightly head-down position. The heart was fibrillated, the tapes around the superior vena cava and inferior vena cava were snagged, and the right atrium was opened obliquely. Using two pump suckers, one in the coronary sinus and the other for exposure of the rim of the ASD (thereby avoiding suctioning deep into the left atrium), the ASD was closed with a continuous 4/0 polypropylene suture (Prolene; Ethicon, Inc., Somerville, NJ, USA). An autologous pericardial patch may be used if necessary. Just before closing the superior aspect of the ASD, the left atrium was de-aired by inflation of the lungs. The right atrium was then closed. When sinus rhythm did not develop spontaneously the heart was defibrillated. Once a stable hemodynamic state was reached, the venous and arterial cannulae were removed. The external iliac artery was repaired with a 7/0 polyglyconate suture (Maxon; Davis and Geck, Danbury, CT, USA). Only one chest tube was inserted and this was directed from a small right parasternal incision towards the right atrium.
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RESULTS
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The cosmetic result was excellent in all patients (Figure 2) and direct closure of the defect was possible in all cases. The mean length of the anterior thoracotomy incision was 4.9 ± 0.8 cm (range, 4.5 to 8.8 cm). In the three youngest patients (aged 5.2, 6.3, and 6.7 years), the external iliac artery was cannulated with an 8F arterial cannula. The mean operative time was 109 ± 39 minutes and the mean fibrillatory arrest time was 14 ± 5 minutes. There was no operative or late mortality and no morbidity except for the necessity of patch reconstruction of the right femoral artery in one patient. This was a 19-year-old girl in whom cannulation of the right femoral artery resulted in an intimal tear up to 2 cm proximal to the site of insertion of the cannula. The artery was successfully reconstructed with a saphenous vein patch.
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Figure 2. Postoperative result of minimally invasive closure of an atrial septal defect in a 12-year-old boy.
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Residual atrial septal defects were not observed in any patient and the mean postoperative blood loss was 179 ± 89 mL. The degree of postoperative pain in the patients in this series was comparable to that after a median sternotomy. However, in contrast to a sternotomy incision this technique resulted in no back pain because spreading of the vertebral-costal junctions was avoided.
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DISCUSSION
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Minimally invasive techniques in congenital heart surgery have evolved steadily over the past 5 years. The safety and efficacy of video-assisted endoscopic techniques for repair of simple extracardiac anomalies in congenital cardiac surgery such as ligation of a patent ductus arteriosus or division of a vascular ring, have been established.5,6 The development of new techniques and instruments has laid the foundation for the next phase of minimally invasive cardiac surgery: the repair of intracardiac congenital defects.
We believe that closure of an ASD through a small right anterior thoracotomy as described here, in analogy to coronary artery bypass grafting through a small left anterior thoracotomy, combines a secure closure of the defect with an optimal cosmetic result.7 For the following reasons, we believe that it may be advantageous in some (especially older athletic) patients to perform the operation through two intercostal spaces. (1) Placement of a tape around the superior vena cava can easily be done through the 3rd intercostal space; this maneuver may be awkward if performed through the 4th intercostal space. (2) Cannulation of the superior vena cava and inferior vena cava, placement of a tape around the inferior vena cava, and closure of the ASD is optimally performed through the 4th intercostal space. The earliest age at which we have performed ASD closure with the minimally invasive approach is 5 years. Currently, the only factor limiting the use of this technique is the size of the external iliac artery in relation to the size of the arterial cannula.
Compared with a conventional posterolateral thoracotomy, the potential long-term morbidity of the small anterior thoracotomy such as scoliosis, breast deformity, winged scapula, reduced shoulder mobility, and chest wall pain syndromes, may be reduced. Recently, there have been reports of ASD closure through a lower midline skin incision and partial sternotomy or a limited right anterior thoracotomy in association with a videoscopic technique.8,9 Disadvantages of these techniques compared to the small anterior thoracotomy are the less appealing cosmetic result and the cumbersome and time-consuming cardiac procedure itself, respectively.
Although the results of ASD closure through a limited right anterior thoracotomy as reported in this small series were favorable, it should be stated that minimally invasive techniques for the repair of intracardiac congenital defects are not yet fully developed with regard to indications and technique. Although the subject is a major one that may have great potential, more experience is necessary before it can be adopted by pediatric cardiac surgeons. The final judgement on minimally invasive techniques for the repair of intracardiac defects will depend on the long-term results. Therefore, careful follow-up of the patients operated by these techniques is mandatory.
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REFERENCES
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ABSTRACT
INTRODUCTION
