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Ann Thorac Surg 1996;62:638-639
© 1996 The Society of Thoracic Surgeons
Division of Cardiovascular-Thoracic Surgery, Department of Surgery, The Children's Memorial Hospital, Chicago, Illinois
Minimally invasive video-assisted thoracic surgery (VATS) has quickly assumed an important therapeutic role in the treatment of thoracic diseases such as empyema thoracis, pulmonary emphysema, and lung cancer [1, 2]. Recent reports have documented extended application of VATS for closed congenital operations [3, 4] (ligation of patent ductus arteriosus and interruption of vascular rings), as well as open procedures including coronary artery bypass [5], mitral valve repair (A. Carpentier, personal communication, 1996), and atrial septal defect (ASD) closure [6, 7]. Presented in this issue are two reports by Dr Devi P. Shetty and associates [6] from the Medical University at Madras and Dr Chan-Hsing Chang and associates [7] from Chang Gung Medical Center, Taipei. Both groups report the use of various techniques of minimally invasive VATS in combination with femoral artery-femoral vein-internal jugular vein cardiopulmonary bypass to accomplish direct suture closure of a secundum ASD under fibrillatory arrest. Shetty and associates' patient (age not given) had ASD closure through two ports and was discharged on the twentieth postoperative day. Chang and colleagues' patients (n = 8) underwent hypothermic femoral perfusion (22°C), fibrillatory arrest, clamping of the superior vena cava without drainage (n = 3), and direct closure of the ASD and atrial wall through a 4- to 7-cm intercostal incision.
See also 697 and 940.
Traditional secundum ASD closure can be accomplished via a median sternotomy or a right thoracotomy. Normothermic or mildly hypothermic (32°C) aorto-bicaval cardiopulmonary bypass is established and the ASD is closed directly or by patch technique under fibrillatory or cardioplegic arrest. The results are generally excellent. A 10-year review (1985 to 1995) at our institution (Children's Memorial Hospital, Chicago; unpublished data) for the purpose of establishing surgical guidelines revealed 212 patients (135 females, 77 males) who had closure of an isolated secundum ASD. One hundred patients (47%) had pericardial patch closure of a large ASD. One hundred twelve patients (53%) had primary suture closure of a small or moderate ASD. Postoperative length of stay ranged from 2 to 11 days (mean, 3.6 ± 1.1 days). Postoperative length of stay decreased from 5.0 ± 1.1 days in 1991 to 3.2 ± 0.5 days in 1994. There were no deaths, no reoperations for bleeding, no neurologic complications, and no residual ASDs. Minor postoperative complications occurred in 8 patients, which included postpericardiotomy syndrome, pleural effusion, and transient arrhythmias.
Obviously, the hallmark of ASD closure is that it is a high-benefit, low-risk operation with excellent results. Newly developed therapeutic modalities, whether by VATS or by transcutaneous-transcatheter techniques, must at least duplicate the efficacy and safety of the standard surgical procedure. Decreased length of stay, decreased costs, and decreased incisional pain, although laudable, do not make up for the complications that can be caused by inadequate exposure, femoral vessel injury, or device embolization (in the case of catheter device ASD closure).
Both Shetty's group and Chang's group used femoral cannulation and induced fibrillatory arrest to prevent air embolism during ASD closure. Chang and associates employed hypothermia to 22°C. When these techniques are applied to a large number of patients under VATS conditions, the incidence of accidental defibrillation and air embolism during ASD closure, resultant femoral vessel stenoses, and the development of hypothermia-induced choreoathetosis increases. Moreover, both reports did not address the problems of unexpected findings such as (1) the large ASD, which may require a patch; (2) partial anomalous pulmonary venous return, which may require two patches; (3) the presence of pulmonary stenosis, which may require valvular exploration; (4) persistent left superior vena cava, which will require some form of control to effectively perform the operation; and others.
To be sure, these obstacles are not insurmountable and can be solved given the appropriate use of technology, attention to detail, and surgical persistence. The question, of course is, "why bother?" Do the benefits of VATS ASD closure outweigh those of the standard approach? Are the inherent risks of decreased exposure and control worth the effort to spare a median sternotomy or right thoracotomy? Based on the experience of these authors, I conclude that the espoused approach is not worth the effort or risks. The bottom line is that 212 consecutive children had safe secundum ASD closure via median sternotomy with no deaths, minimal complications, a length of stay of 3.2 days, and a well-healed sternotomy scar. The proponents of VATS ASD closure must show an equal or better experience without any long-term effects of lower-extremity problems due to femoral cannulation.
More likely to change the therapeutic options for secundum ASD closure is transcutaneous-transcatheter device closure [8–10]. When the patients are chosen correctly (a circumferential rim of atrial septum is necessary for device deployment), there is a high likelihood of successful closure. Device embolization can and has occurred and is related to the experience of the operator [11]. Unlike VATS ASD closure and traditional ASD closure, device closure does not require cardiopulmonary bypass or any thoracic incisions. The femoral catheters tend to be large, leaving the femoral vessels at risk for immediate and future complications. Device closure is currently undergoing prospective collaborative clinical trials in the United States and will probably be available in the near future for those selected patients in whom a high success rate is expected.
Ultimately, the thoughtful surgeon will determine the most efficacious and safest mode of therapy for his or her patient. The introduction of avante garde therapy to replace a well-established, safe procedure will require careful short- and long-term analysis before general use can be recommended.
Footnotes
Address reprint requests to Dr Mavroudis, Division of Cardiovascular-Thoracic Surgery, Department of Surgery, The Children's Memorial Hospital, 2300 Children's Plaza, M/C 22, Chicago, IL 60614.
References
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