Atrial Septal Defect Closure Through a Right Lateral Thoracotomy

This video submission is from the 2025 CTSNet Instructional Video Competition. Watch all entries from the competition, including the winning videos.  

This video illustrates the approach for closing an atrial septal defect (ASD) via a right lateral thoracotomy. 

A transesophageal echocardiogram (TEE) revealed a large atrial septal defect approximately 3 cm in diameter lacking an aortic rim, which precluded transcatheter closure. The patient was positioned with the left arm elevated and fixed to facilitate access to the lateral thoracic wall. A natural skin crease beneath the mammary gland was marked for the incision site. Cardiopulmonary bypass was established peripherally via the right internal jugular vein above the clavicle, and the right femoral artery and vein.  

A thoracotomy was performed through the fourth intercostal space. A soft tissue retractor was placed to prevent subcutaneous fat from entering the operative field. The pericardium was opened in the region of the venous sinus and the inferior aspect of the right atrium. A 4×4 cm autologous pericardial patch was harvested during the pericardial access and treated with a glutaraldehyde solution. The pericardial edges were suspended with sutures for optimal exposure.  

The right atrium and the openings of the venae cavae were well visualized. The orifices of the superior and inferior venae cavae were encircled with vessel loops to ensure a bloodless field within the right atrium.  

A purse-string suture was placed on the ascending aorta for the insertion of the cardioplegia cannula. The cardioplegia cannula was then inserted. The aorta was clamped using a Chitwood clamp introduced through the third intercostal space. The right atrium was incised from the superior to the inferior vena cava, fully exposing the septal defect. The autologous pericardial patch was trimmed to match the size of the defect and was placed using a running suture with 4-0 Prolene.  

With sufficient care taken with the septum tissues and surrounding structures, especially the aortic root, it was additionally reinforced with five interrupted stitches using 6-0 Prolene for added safety. The septal defect was securely closed, with the patch size perfectly matching the defect’s size without excessive patch prolapse. The atriotomy was closed with running sutures using 4-0 Prolene. Before completing the closure, the vessel loops on the caval veins were released to allow blood to fill the right atrium and evacuate any trapped air.  

The aortic clamp was then removed, and a chest drain was placed into the right pleural cavity through the Chitwood clamp insertion site in the third intercostal space. The postoperative TEE showed perfect closure of the septal defect. Finally, the wound was closed, with the main access scar located in the natural skin crease, which will be almost invisible after two or three months. 

References

1. Dodge-Khatami A. Right Axillary Thoracotomy for Transatrial Repair of a Wide Range of Congenital Heart Defects. Ctsnet.org. Published April 12, 2016. Accessed September 3, 2025. https://www.ctsnet.org/article/right-axillary-thoracotomy-transatrial-repair-wide-range-congenital-heart-defects
2. Mashadi A. Repair of Partial Atrioventricular Septal Defect via Vertical Right Axillary Thoracotomy (VRAT) in Eleven-Year-Old. Ctsnetorg. Published online 2023. doi:https://doi.org/10.25373/ctsnet.21821604.v1
3. Dodge-Khatami A. Minimal Invasive Repairs of Congenital Heart Defects: An Interview With Ali Dodge-Khatami. Ctsnet.org. Published 2025. Accessed September 3, 2025. https://www.ctsnet.org/article/minimal-invasive-repairs-congenital-heart-defects-interview-ali-dodge-khatami
4. Dayoub W. Off-Pump ASD Closure With a Two-Layer Patch Attached to the Right Atrium. Ctsnetorg. Published online November 27, 2024. doi:https://doi.org/10.25373/ctsnet.27905121

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.