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Minimally Invasive ASD Repair With Limited Resources

Thursday, April 12, 2018

Hoffmann C, Nguyen TC. Minimally Invasive ASD Repair With Limited Resources. April 2018. doi:10.25373/ctsnet.6075950.

Objectives

In the past, atrial septal defects (ASD) have been repaired via open heart surgery through a median sternotomy. Recent advances have allowed ASD closure via catheter inserted devices and also via minimally invasive surgical techniques utilizing endoscopy and robot-assisted surgery. Described below is a minimally invasive approach to ASD closure that is performed without specialized equipment while utilizing basic equipment that is readily available to most surgeons.

Methods

This video describes the steps of a minimally invasive, resource limited ASD closure, and the relevant technical pearls and pitfalls are emphasized. Cannulation of the femoral artery and vein was performed for cardiopulmonary bypass. Upper extremity venous drainage was achieved with a peripheral bicaval venous cannula. A 4 cm anterior chest incision was required for ASD visualization. The pericardium was opened 2 cm above the phrenic nerve, and pericardial stay sutures provided retraction of the diaphragm. The superior and inferior vena cava were snared with vessel loops to provide a hemostatic seal. A vertical atriotomy was performed and extended toward the atrial appendage. Atrial retraction sutures allowed for excellent exposure without additional retractors. A bovine pericardial patch was used to close the ASD, using a running 5-0 Prolene™ suture. The atrium is closed in two layers with a 4-0 Prolene™ suture. Cryoablation of the intercostal nerves two interspaces above and two interspaces below the incision and liposomal bupivacaine injections were performed for postoperative analgesia.

Results

The final result was a tension-free ASD closure with no interatrial communication seen on the postoperative echocardiogram.

Conclusion

ASD closure can be accomplished through a variety of means. As outlined here, this procedure is possible with a minimally invasive approach, without the need for specialized equipment, and with limited resources.


This educational content was originally presented during the STSA 64th Annual Meeting. This content is published with the permission of the STSA. For more information on the STSA and its next Annual Meeting, please click here.

Comments

I enjoyed the presentation. It is worthwhile to consider the value of resources committed to the treatment of common and simple lesions. In this operation, for example, autologous pericardium is more commonly used for patch, and glutaraldehyde, if used, is much less expensive than bovine pericardium. Fibrillatory arrest is safe and would obviate the purchase of all the components of cardioplegia, a specialized aortic clamp with disposable inserts, as well as the cardioplegia heat exchanger and associated tubing. A single low partial sternotomy incision of equal length to the authors' anterior thoracotomy allows surgery with conventional instrumentation, provides greater versatility and less postoperative pain (without a disposable cryoprobe), and eliminates risk of femoral cannulation complications such as incisional infection, lymphocele, or vascular occlusion. In this case "resource-limited" seems to mean "non-robotic" but perhaps "less profligate" would be a better title.
What is your opinion about using induced ventricular fibrillation instead of aortic cross-clamping and cardioplegia? Have you ever used right midaxillary thoracotomy with transthoracic aortic and venous cannulas placement in your practice? Thank you!
I'm a proponent of reducing surgical trauma, and did the first endoscopic pediatric heart repairs in the US in 1993, so I'm no Luddite. Please tell me how you think your approach reduces trauma to your patient. You damage the leg, the neck and the chest. A small median sternotomy incision creates much less cumulative trauma than your approach, and is a much faster and more precise operation. How do you justify what you are doing? I tried to justify this many years ago, and I couldn't. So I went back to the safest and least traumatic approach, a limited sternotomy, and I'll never look back. Sincerely, Redmond Burke MD

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