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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.


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.


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.


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


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.


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
Thank you for all the constructive comments. This healthy dialogue is important as we advance our field. @JamesHammel: Thank you for the encouraging and insightful words. I wholeheartedly agree that glutaraldehyde-fixed pericardium would be less expensive. This particular patient was relatively young and I was hoping to preserve as much native pericardium in the event the patient required a reoperation in the future. I also agree that fibrillatory arrest is a reasonable alternative. I use Del Nido cardioplegia which ends up costing roughly $40 when compounded by our pharmacy. Sternotomy (either partial or full) vs. thoracotomy will always be a controversial topic but it's important to continue the dialogue. There are obviously pro's and con's of both. I prefer a mini thoracotomy for the following reasons: 1) preserves the sternum and essentially no physical restrictions postop, 2) near zero risks of mediastinitis, and 3) less blood loss. The argument about thoracotomy pain is an interesting one. Since this video release, I don't use cryoprobe anymore and have been very happy with direct Exparel injection as an intercostal block (not just into the wound, per se). I learned this technique from our colleagues at MD Anderson and it works great. Patients are extubated in the OR and rarely complain of pain, especially if we minimize rib spreading. @Zubritsky: Thank you for the question. I have not used transthoracic aortic or venous canulas but it's a reasonable option. I try to keep my thoracotomy incision small so try to avoid a venous cannula through the incision. Transthoracic Chitwood cannula is a fair option. @Burke: Thanks for the comments. For all patients, I tell them my priorities are the following in this order: 1) safety, 2) address the lesion without compromise, and 3) incision location. I feel confident in being able to address priority #1 and #2 with most patients via a minimally invasive approach. More importantly, the data also supports this. I could go on and on why in many ways a mini incision offers a more ergonomic and direct view of the aortic and mitral, but will save that for another venue. That said, as you can see from the video, there's a direct and unobstructed view of the ASD. Most surgeons could easily and "precisely" patch the ASD with the proper exposure techniques. There are subtle nuances, though, with the exposure that surgeons need to know and which I tried to highlight. Neck trauma: I don't make any incisions in the neck. Venous drainage is via a bi-caval peripheral cannula. Damage the leg: I don't damage the leg. Sternotomy: Please see my comments to Dr. Hammel above. Faster: This all depends on surgeon experience but minimally invasive surgery does not have to be longer than sternotomy, although I'll admit the data does show slightly longer ccx and cpb times (The tradeoff is the data also shows decreased time of the vent, ICU, length of stay, and recovery, not to mention lower incidence of afib and blood transfusions). In our case, we have two surgeons opening and closing, i.e. one exposes the groin while the other exposes the chest. We tend to easily finish cases in 3hrs skin-to-skin. I'm also a Stanford graduate and there have been a lot of advances in minimally invasive surgery since your first endoscopic pediatric repairs in 1993 and the Heartport days.
Dear Tom, Congratulations for making things easier. I do agree that "safety first, then cosmesis", and that a program in minimally-invasive pediatric cardiac surgery should be customized for every new adopter. We offer different approaches according body size and cardiac condition: lower sternotomy for VSD closure in small children, axillary closure for ASD in kids between 3-5 years, mini-thoracotomy (with peripheral cannulation) over 25 Kg and GUCH patients. Before reaching expertise in these above mentioned incisions, young surgeons become familiar with alternative techniques such as postero-lateral thoracotomy and sub-mammary (central cannulation) ones. The rationale is to provide a conversion escape (different to a regular sternotomy) in case that any problem arises. Again, it is a matter of safety and step-by-step learning curve. Experienced surgeons, as you smartly show, round up in making things easier. Juan-Miguel Gil-Jaurena. Chief Pediatric Cardiac Surgery. Hospital Gregorio Marañón. Madrid. Spain.

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