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Ann Thorac Surg 1996;62:940
© 1996 The Society of Thoracic Surgeons

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Correspondence

Video-Assisted Closure of Atrial Septal Defect

Bm Birla Heart Research Centre, 1/1 National Library Ave, Calcutta 700 027 India

For editorial comment, see page 638

To the Editor:

Thoracoscopic surgery, of purely historical interest for many decades, is now again part of the standard armamentarium of the cardiothoracic surgeon. Although the technique was initially used by Jacobaeus for adhesiolysis, its therapeutic and diagnostic uses have been expanding since the advent of modern video-assisted thoracoscopy [1].

Laborde and associates [2] brought the techniques of video-assisted thoracic surgery into the realm of cardiac surgery in 1991 when he used it to close patent ductus arteriosus. Subsequently, it has been used to interrupt major aortopulmonary collateral arteries, divide vascular rings, and perform other "closed procedures" [3].

There has been much excitement over the recent reports of minimally invasive coronary artery bypass grafting on a "beating heart." However, it seemed that most of cardiac surgery remained outside the scope of this technology due to the complexity of cardiopulmonary bypass.

For editorial comment, see page 638

Many groups have been toying with the idea of performing video-assisted intracardiac repairs using cardiopulmonary bypass. Our center had been working on the use of percutaneous cardiopulmonary bypass in tandem with video-assisted thoracic surgery to carry out such intracardiac repairs. Recently, we successfully performed a video-assisted repair of an atrial septal defect using the procedure described here.

Our technique was as follows: Under general anesthesia and with monitoring lines and two self-adhesive defibrillator paddles in place the patient was positioned in the 15-degree left oblique position. The right femoral artery was cannulated by the open technique after heparinization, and subsequently the right femoral vein was cannulated (Medtronic Biomedicus Inc, Eden Prairie, MN) through the same incision. The right internal jugular vein was cannulated through a 2-cm skin crease incision directly over the vein between the heads of the sternomastoid muscle.

With the patient thus ready to go on bypass two thoracoscopic ports were made as follows: (1) A 5-cm submammary incision in the right fourth intercostal space in the region of the costal cartilages for instrumentation. (2) A 2-cm incision in the midclavicular line in the right fifth intercostal space for use of the thoracoscopic camera (Baxter Healthcare Corp, Deerfield, IL).

The pericardium was opened vertically, anterior to the phrenic nerve, and the flaps held apart with specially prepared Ethibond (Ethicon Ltd, Edinburgh, United Kingdom) stay sutures. These were brought out through the skin for traction. Two fibrillator cables were positioned within the pericardium against the heart (as an additional security against failure of one).

After these preparations, cardiopulmonary bypass was initiated and large vascular bulldog clamps were used to occlude ("snug") the venous return. (These were dropped into the thorax and applied using long forceps.)

The right atrium was opened vertically and stay sutures applied using pledgeted 4-0 Prolene sutures as above, after fibrillatory arrest was achieved. The 1.5-cm atrial septal defect was then sutured with the laparoscopic needle holder (Ethicon Ltd) directly using 4-0 Prolene, ensuring all through that the left atrium was not emptied. No formal deairing was performed, other than "bagging" the lungs during the last stitch.

The right atrium was similarly closed using 5-0 Prolene, and the venous occlusion was relieved. The patient was then defibrillated using the externally fixed paddles. The thoracoscopic instrumentation port was sutured and a chest tube was brought out through the camera port. The cannulation sites were then repaired after decannulation.

Our patient finally had a small submammary scar and one chest tube site. Besides that she had one scar along the neck crease, the size of a lymph node biopsy scar, and another in the inguinal region. She was discharged from hospital on the 20th postoperative day after adequate observation.

In conclusion, cardiac surgery had remained the last bastion of "open" conventional surgery, largely due to the technical difficulties of putting the patient on cardiopulmonary bypass. With the advent of percutaneous cardiopulmonary support and video-assisted thoracic surgery this bastion appears to be crumbling, and the procedure we have described can be regarded as one of the early breaches in the wall.

References

1. Landreneau RJ. VATS: basic technical concepts and intercostal approach strategies. Ann Thorac Surg 1992;54:800–7.
2. Laborde F, Noiromme P, Karam J, Batisse A, Bourel P, Saint Maurice O. A new video-assisted thoracoscopic surgical technique for interruption of patent ductus arteriosus in infants and children. J Thorac Cardiovasc Surg 1993;105:278–80.
3. Burke RP, Wernovsky G, van der Velde M, Hansen D, Castañeda AR. Video-assisted thoracoscopic surgery for congenital heart disease. J Thorac Cardiovasc Surg 1995;109:499–507.

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This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mohan D. Gan Mrinal B. Das Lalit Kapoor Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Shetty, D. P. Articles by Surendranath, K. V. Search for Related Content PubMed PubMed Citation Articles by Shetty, D. P. Articles by Surendranath, K. V. Related Collections Related Articles