Direct Cannulation for Right Axillary ASD Closure in Pediatric Patients

Introduction  

Minimally invasive closure of atrial septal defects (ASD) can be safely achieved using a range of techniques. In pediatric patients, femoral cannulation can be difficult due to the small caliber of their vessels. Peripheral cannulation is convenient but carries risks of retrograde dissection, embolization, stroke, and ipsilateral limb ischemia. Central aortic cannulation has the advantage of providing antegrade flow. 

Surgical Technique and Video  

Patient Presentation 

A four-year-old girl, weighing 10 kg, presented with failure to thrive. A two-dimensional echocardiogram showed a large ostium secundum ASD with a deficient rim and mild pulmonary hypertension. 

Patient Preparation and Surgical Exposure

ASD closure was performed through a right axillary approach using a direct cannulation technique. A single-lumen endotracheal tube was used for intubation. The patient was placed in a supine position with a sandbag below the right shoulder to maintain a 30-degree tilt. A vertical incision in the axilla was made, the muscles were separated, and the fifth intercostal space was entered. A standard chest spreader was used to open the intercostal space. Sometimes, an additional chest spreader is used perpendicular to the first one. The pericardium was pulled up with stay sutures, and a pericardial patch was harvested. 

Cannulation and Cardiopulmonary Bypass (CPB)  

The aortic, superior vena caval, and inferior vena cava cannulas, along with antegrade cardioplegia, were placed centrally through the primary incision. Positioning the patient, the site of the incision, and the placement of retraction sutures were crucial for successful cannulation.  

Aortic Cannulation 

Double purse-string sutures were placed, and relative hypotension was maintained with a systolic blood pressure (SBP) of approximately 90 mmHg. The aorta was retracted down with long artery forceps, or the cardioplegia purse-string was pulled down. The adventitia was cut over the incision site, and the aorta was stabilized with two pickups at the incision site. The lungs were deflated during cannulation.  

Venous Cannulation 

The superior vena cava (SVC) cannula was inserted first, as it was easily accessible, followed by inferior vena cava (IVC) cannula once the heart was decompressed and the lungs were deflated.

Sometimes, the IVC or SVC cannula is placed through a separate incision in the midaxillary line, one space above or below the incision in the intercostal space. A small straight aortic clamp is used directly through the incision. St.Thomas cardioplegia was administered.  

ASD Closure and Coming Off CPB  

The right atrium (RA) was opened and retracted with stay sutures. The ASD was closed with a pericardial patch. Deairing was performed, and the RA was closed. Pacing wires were placed before releasing the cross-clamp. An extensive deairing protocol was followed, which included positioning the patient in deep Trendelenburg during aortic unclamping, volume loading of the heart, positive pressure ventilation to clear pulmonary venous air, and alternation of left-right table positioning to remove air trapped. The aortic cross-clamp was then removed. 

Decannulation and Chest Closure 

Upon coming off CPB when rewarmed, protamine was administered, decannulation was performed, and hemostasis was achieved. Drains were placed, and the chest was closed with ethibond sutures. A local nerve block was applied before the chest was fully closed. 
 
Outcome 

From January 2018 to December 2024, the authors performed130 cases with a range of patients aged 10 months to 12 years. In the pediatric age group, the most common surgery was ASD at 61 percent, followed by ventricular septal defect (VSD) at 26 percent, ASD with pulmonary valve repair at four percent, ASD with tricuspid valve repair at five percent, partial anomalous pulmonary venous connection (PAPVC) at two percent and partial atrioventricular canal at two percent. There was no conversion and no re-exploration for bleeding. No patient experienced a stroke or renal failure, and there were no aortic dissections. 

Conclusion 

This approach is a reliable minimally invasive cardiac surgery (MICS) procedure for ASD closure. It has low complication rates, and the scar is not visible, which ensures that the incision does not hamper breast development especially in girls. Additionally, it is very cost-effective, as regular instruments and cannulas are used. 

References

1. Iribarne A, Russo MJ, Easterwood R, Hong KN, Yang J, Cheema FH, Smith CR, Argenziano M. Minimally invasive versus sternotomy approach for mitral valve surgery: a propensity analysis. Ann Thorac Surg. 2010 Nov;90(5):1471-7.
2. Kandakure PR, Batra M, Garre S, Banovath SN, Shaikh F, Pani K. Direct Cannulation in Minimally Invasive Cardiac Surgery with Limited Resources. Ann Thorac Surg. 2020 Feb;109(2):512-516.
3. Iribarne A, Easterwood R, Chan EY, Yang J, Soni L, Russo MJ, Smith CR, Argenziano M. The golden age of minimally invasive cardiothoracic surgery: current and future perspectives. Future Cardiol. 2011 May;7(3):333-46.

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