Closure of Coronary Sinus Atrial Septal Defect Using a Minimally Invasive Surgical Technique

A 53-year-old man presented with exertional dyspnea. Transthoracic echocardiography demonstrated a coronary sinus atrial septal defect measuring 16 × 21 mm with a left-to-right shunt. Significant secondary tricuspid regurgitation was noted, along with a dilated right ventricle. The pulmonary artery systolic pressure was estimated at 46 mmHg. Further imaging, including transesophageal echocardiography and multislice computed tomography, confirmed the presence of a coronary sinus atrial septal defect without a persistent left superior vena cava. 

The patient underwent general anesthesia with a double-lumen endotracheal tube and was positioned supine with a pillow placed behind his back to elevate the right chest. Both arms were lowered alongside the body. Peripheral cannulation was performed to establish cardiopulmonary bypass. 

A 4 cm incision was made in the right fourth intercostal space to serve as the main working port. A camera port was placed in the third intercostal space. An additional 5 mm incision was made at the fourth intercostal space for the placement of the Chitwood clamp and the left ventricular venting catheter. The pericardium was opened transversely approximately 3 cm above the phrenic nerve and was suspended with sutures. 

The superior vena cava was encircled with a tape and gently snared. The inferior vena cava was also encircled using a plastic sonde to facilitate passing and tightening the tape. Myocardial protection was achieved with histidine–tryptophan–ketoglutarate (HTK) solution delivered via a long cardioplegia cannula. The aorta was cross-clamped with a Chitwood clamp introduced through the fourth intercostal space port. 

The right atrium was opened with a transverse incision and exposed with stay sutures. Following the insertion of the left ventricular vent, the coronary sinus atrial septal defect was visualized, with no associated pulmonary venous anomalies. The coronary sinus was partially unroofed at its terminal portion. 

The defect was closed with a fresh autologous pericardial patch using a continuous 4-0 Prolene suture, starting at the 12 o’clock position and proceeding downward to the edge of the coronary sinus roof to create a baffle directing the coronary sinus drainage into the right atrium. The suture line was continued circumferentially and tied at the 11 o’clock position. The coronary sinus was seen draining into the right atrium, confirming the completion of the defect repair. 

After completion of the atrial septal and coronary sinus repair, the tricuspid valve was carefully assessed. Intraoperative inspection revealed severe tricuspid regurgitation secondary to annular dilatation, with otherwise normal leaflet morphology and mobility. Tricuspid annuloplasty was performed using a 3D annuloplasty ring secured to the annulus with multiple interrupted 2-0 Ethibond sutures. A saline test demonstrated no residual tricuspid regurgitation. 

The patient was successfully weaned from cardiopulmonary bypass after 68 minutes, with an aortic cross-clamp time of 46 minutes. Postoperatively, he was extubated uneventfully within four hours. Predischarge transthoracic echocardiography confirmed complete closure of the atrial septal defect, with pulmonary artery systolic pressure reduced to 27 mmHg. The patient was discharged on postoperative day five and remained free of complications at the three-month, six month, and one year follow-up evaluations. 

References

1. Handa K, Fukui S, Kitahara M, Kakizawa Y, Nishi H. Minimally invasive surgical repair for unroofed coronary sinus syndrome directed by three-dimensional transesophageal echocardiography. Surg Case Rep. 2020;6(1):244.

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