Asian Cardiovasc Thorac Ann 2001;9:192-195
© 2001 Asia Publishing EXchange Pte Ltd
Surgical Closure of Secundum Atrial Septal Defects: the Cutting Edge?
Jacques G LeBlanc, MD,
Jennifer L Russell, MD,
James E Potts, PhD,
Margaret L Deagle, BSc,
Suvro S Sett, MD
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Division of Cardiovascular and Thoracic Surgery British Columbia's Children's Hospital Vancouver, British Columbia, Canada
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For reprint information contact: Jacques G LeBlanc, MD Tel: 1 604 875 3165 Fax: 1 604 875 3159 email: jleblanc{at}dowco.com Division of Cardiovascular and Thoracic Surgery, British Columbia's Children's Hospital, Suite 3G63, 4480 Oak Street, Vancouver, British Columbia V6H 3V4, Canada.
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Abstract
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Between January 1985 and November 1998, 270 patients (aged 2 to 220 months) underwent surgical closure of a secundum atrial septal defect. Cardiopulmonary bypass times ranged from 12 to 103 minutes, with aortic crossclamp times of 5 to 49 minutes. Use of blood products decreased from 2.7 units per patient in the first 5 years to 0.2 units in the last 4 years. Median intensive care unit and hospital stays were 2 days and 6 days, respectively. Complications included: bleeding in 6 patients (2%), which required reexploration in 3; air embolism in 1; and arrhythmias in 4. Postpericardiotomy syndrome occurred in 43 patients (16%), requiring drainage in 5. Follow-up (12 to 179 months) was available in 245 patients (91%). There were no early or late deaths. Most patients (94%) were in sinus rhythm, 8 had low atrial rhythm, 3 had first-degree atrioventricular block, and 1 had atrial flutter. Echocardiography in 207 patients (77%) demonstrated a residual shunt in 1 (0.5%), which was hemodynamically insignificant. Late reoperation was required in 4 patients for sternal nonunion. Surgical closure of secundum atrial septal defect remains the gold standard with which transcatheter closure should be compared, particularly with reference to morbidity and residual shunts.
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INTRODUCTION
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Atrial septal defect (ASD) accounts for 7% to 10% of all congenital cardiac malformations, with a frequency of 3.2 per 10,000 live births.1,2 It is being diagnosed with increasing frequency because of wider awareness and earlier cardiology referral. Echocardiography has greatly improved the accuracy of diagnosis of smaller defects. Following publication of early natural history studies suggesting significant morbidity and mortality associated with unrepaired defects, most patients with evidence of a significant left-to-right shunt are referred for closure.3 Surgical repair of ASD began before the development of cardiopulmonary bypass (CPB), and in 1953 it became the first intracardiac defect successfully corrected under CPB.4 Transcatheter closure was first reported by King and colleagues5 in 1976, and it has evolved substantially since then. Surgical closure of ASD remains the gold standard with mortality rates approaching zero. However, it requires a sternotomy or thoracotomy, CPB, and hospital stay, and it has a low but definite incidence of compli-cations. In addition, postoperative residual shunts have been reported in up to 16.7% of cases.6,7 These factors have led to the ongoing development and application of transcatheter closure techniques as an alternative to surgery. This study retrospectively reviewed a series of children undergoing surgical closure of secundum ASD in an institution where transcatheter closure is not performed. Our unselected population allows comparison with recent transcatheter experience reported in the literature.
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PATIENTS AND METHODS
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Between January 1985 and November 1998, 270 children underwent surgical closure of secundum ASD. There were 166 females (61%). The median age at operation was 55 months (range, 2 to 220 months). Diagnosis was exclusively by echocardiography. Associated cardiac defects included: abnormal mitral valve in 36 patients (13%), comprising prolapse in 24, regurgitation in 10, and stenosis in 1; pulmonic stenosis in 17 (6%); and an abnormal aortic valve in 1 (0.4%). Congenital complete heart block was present in 3 patients. Associated syndromes included Down's syndrome in 12 (4%), fetal alcohol syndrome in 5 (2%), Noonan syndrome in 2 (0.7%), and others in 4 (1%). Patients requiring concomitant pulmonary valvotomy were included in the study while those needing other procedures such as ventricular septal defect closure or mitral valve repair were excluded. At presentation, 155 patients (57%) were asymptomatic, 77 (29%) had shortness of breath on exertion, 17 (6%) had failed to thrive, and there was a history of frequent respiratory infections in 17 and supraventricular tachycardia in 4. All patients had a pre-operative echocardiogram demonstrating a defect larger than 5 mm with evidence of a significant left-to-right shunt as indicated by enlargement of the right-sided cardiac chambers. Data regarding surgical techniques, post-operative complications, lengths of stay, and follow-up were obtained retrospectively from the hospital records.
Surgery was carried out through a standard sternotomy incision. All patients were placed on conventional normothermic CPB with aortic and bicaval cannulation. Early in the study period, 77 patients underwent ASD closure with the heart beating; closure in the other 193 patients was carried out with aortic crossclamping and antegrade crystalloid cardioplegia. The need for a pericardial patch for closure of the defect was determined by its size and location. An inferior location necessitated patch closure because of the proximity to the inferior vena cava and the risk of diverting inferior vena caval flow to the left atrium with primary closure. Patch closure was also used for an ASD larger than 2 cm if primary closure created tension on the septal tissue with a risk of the stitches tearing through.
A univariate method was used to calculate the median and range for all descriptive variables. The Wilcoxon rank-sum test was used to test for the equality of the median values. All statistical analyses were completed using SAS statistical software (SAS Institute, Cary, NC, USA).
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RESULTS
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The surgical data are shown in Table 1
. When lengths of stay were examined in 3 periods (1985–9, 1990–4, and 1995–8), there was a statistically significant decrease in the durations of intensive care unit stay and hospital stay (p < 0.0001). The median length of stay in the intensive care unit decreased from 2 days (range, 1 to 6 days) in 1985–9 to 1 day (range, 1 to 3 days) in 1995–8. Similarly, hospital stay decreased from 7 days (range, 4 to 13 days) in 1985–9 to 4 days (range, 3 to 11 days) in 1995–8.
The use of blood products including red cells, fresh frozen plasma, and platelets was reviewed. Autologous donation products were not included as they were used in only 2 patients. The volume of blood products decreased from a median of 2.7 units per patient (range, 0 to 12 units) in the first study period (1985–90) to 0.2 units per patient (range, 0 to 2 units) in the last period (1995–8). In the first study period, 37/75 patients (49%) received no blood products whereas from 1991 onwards, 186/190 patients (98%) underwent operation without the use of blood products.
Postoperative complications are shown in Table 2. There was no early mortality. One patient had an air embolism and was treated in a hyperbaric chamber after substantial air was observed in the aortic cannula during dis-continuation of bypass. No patient required pacemaker insertion. Postoperative infections comprised sternal osteomyelitis requiring debridement in 1 patient, super-ficial wound infection in 1, and pneumonia in 2.
Follow-up was available in 245 patients (91%) at a median of 81 months (range, 12 to 179 months). There were no late deaths. Follow-up electrocardiograms were obtained in 236 patients (87%), of whom 222 (94%) were in sinus rhythm, 8 (3.4%) had a low atrial rhythm, and 3 (1.3%) required atrioventricular pacing for congenital complete heart block. Three patients (1.3%) had first-degree atrioventricular block, and 1 had episodic atrial flutter requiring medication. Two patients (0.8%) had complete right bundle branch block. Follow-up echocardiograms were completed in 207 patients (77%) and 1 of these (0.5%) had evidence of a residual shunt after 10 years of follow-up, which was hemodynamically insignificant. Noncardiac late reoperation was required in 4 patients (1.5%) for sternal nonunion unrelated to infection.
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DISCUSSION
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The gold standard for closure of ASD has been open heart surgery, with a mortality close to 0% in most but not all studies.8,9 The reported incidence of significant com-plications such as postoperative bleeding, pericardial effusion or tamponade, infection, and atrial arrhythmias varies from 2.5% to 13%.8–12 Residual shunts at follow-up are usually uncommon but an incidence as high as 16.7% has been noted.6,7,10 Postpericardiotomy syndrome is one of the most common complications (20% to 30%); it may be accompanied by significant morbidity and rarely mortality.13,14 Postpericardiotomy syndrome was diag-nosed clinically and by echocardiogram in 16% of our patients; this incidence is similar to previous reports, suggesting that broad clinical agreement exists regard-ing the diagnosis, despite the absence of an agreed definition.13,14
Median sternotomy has long been accepted as providing superior access to cardiac structures.11 Alternatively, an anterior right submammary incision for ASD closure is used by many, especially in females, for cosmetic appearance. Although not a minimally invasive technique, it provides adequate exposure. In an attempt to decrease postoperative pain, shorten hospital stay, and decrease costs, various minimally invasive approaches have been developed for coronary artery disease and also for aortic and mitral valve replacement. Minimally invasive procedures in pediatric cardiac surgery present some difficulties because of the complexity of the anomalies encountered and the variability in patient size.9,15 Minimally invasive approaches include a small sub-mammary incision, transxiphoid process window, and right submammary mini-incision with or without jugular vein and femoral artery cannulation.9,11,15 These new approaches and techniques are not devoid of compli-cations, and it is valid to point out that restrictive exposure of the heart through a small incision turns a simple operation into a technically demanding procedure, particularly when requiring femoral and jugular cannulation. A sophisticated adaptation of cannulae is required to gain optimal access. Incomplete air removal may become a greater risk. Longer than usual periods of ventricular fibrillation or arrest are required. Even small incisions can lead to substantial pain due to broken cartilage or crushed intercostal nerves, and subsequent chest developmental abnormalities may occur. Although shorter hospital stay has been cited as a positive factor in minimally invasive procedures, it has not materialized in all studies. Our current length of stay is 4 days, despite a small incision but with a full sternotomy.
Videoendoscopy has been used for biopsy, pericardial drainage, closure of patent ductus arteriosus, and division of vascular rings. Chang and colleagues16 recently used a video-assisted right anterolateral mini-thoracotomy with deep hypothermia and a long period of extracorporeal circulation (47 to 126 minutes) for ASD closure. Although all patients had a favorable outcome, this technique entails greater difficulty, longer CPB time, circulatory arrest, and the potential risk of air embolism. We certainly disagree with their statement that video-assisted cardiac surgery has major advantages in the avoidance of sternotomy, being more expedient and safer than con-ventional procedures, causing less postoperative pain, providing excellent cosmetic healing, and shortened length of stay. Their study, and the literature, have not supported these comments.
Various systems for interventional closure of ASD have been tested clinically in recent years.12,17,18 It is not within the scope of this paper to review each device. The published data make effective comparison of the various devices extremely difficult because of differences in design, levels of operator expertise, defect location, and patient selection. The disadvantages of many existing devices are the difficulty of implantation and the risk of complications including air embolism (1.3%), embo-lization of thrombus formed on the device (1% to 2%), systemic or pulmonary venous obstruction (1.1%), perforation of the atrial wall or aorta leading to hemo-pericardium (1% to 2%), atrial arrhythmias (1% to 3%), and malposition or embolization of the device (2% to 15%).19 In fact, the complication inventory of the Association of European Pediatric Cardiology reveals an embolization rate of 10% for the buttoned, angel wings, and ASDOS devices, 6% for the Cardioseal, and 1% for the Amplatzer device.18 Current indications for ASD closure are the presence of a left-to-right shunt larger than 1.5:1 with an enlarged right-sided cardiac chamber and the risk of paradoxical embolism. Residual atrial shunt can occur in up to one-third of patients. The latest results with the Amplatzer device quote a 1.5% incidence of insignificant residual shunt, a figure not yet achieved by any other system.12,17,18 Fracture of part of the metal frame supporting the fabric of a device is recognized as a late complication, although its clinical implication is unknown.20 Several questions remain to be answered: patient selection for device closure, risk of endocarditis in the setting of prosthetic material and a residual shunt, risk of long-term problems even with initially well-placed devices (arrhythmia, migration, perforation), potential risks from the prosthetic material or device design (arm fractures, incomplete endothelialization and thrombosis, nickel toxicity), and the optimal device design. Certainly, ASD device closure brings many advantages over surgery, and should be the preferred therapy in experienced hands. Standard surgical closure should remain the gold standard for comparison with new devices or minimally invasive techniques.
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REFERENCES
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Abstract
INTRODUCTION
