Ann Thorac Surg 1999;67:573-574
© 1999 The Society of Thoracic Surgeons
How To Do It
Pericardial patch for atrial septal defect closure
Sanjeeth Peter, MCha
a Dharmsinh Desai Memorial Methodist Institute of Cardiology and Cardiovascular Surgery, Gujarat, India
Accepted for publication July 20, 1998.
Address reprint requests to Dr Peter, DDMM Institute of Cardiology and Cardiovascular Surgery, Mission Rd, Nadiad 387002 Gujarat, India
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Abstract
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Pericardium is an eminently suitable material for the closure of atrial septal defects. However, when it is not treated with glutaraldehyde, it is difficult to handle because of curling in of the edges. A technique is described by which pericardium can be used to close atrial septal defects with minimal handling and assistance, and without chemical pretreatment.
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Introduction
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Pericardium has been advocated as the material of choice for the closure of atrial septal defects. To overcome its main disadvantage of being difficult to handle [1], surgeons have treated it with 0.6% glutaraldehyde [2]. The technique described here is easy to follow and requires very little handling of the pericardium. Because the patch is cut free just before it is seated, the edges do not roll in, and treatment with glutaraldehyde is not required.
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Technique
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After a sternotomy or an anterolateral thoracotomy, the pericardium is dissected free of the fat and opened toward the left. Stay sutures are taken. After the standard protocol of cannulation and institution of cardiopulmonary bypass, the right atrium is opened and retracted to facilitate better exposure. A slit is made in the right flap of the pericardium, parallel to its free margin, at a distance equal to the width of the atrial septal defect. Using a 4-0 polypropylene double-arm suture, the margin of the slit is approximated to the posterior margin of the atrial septal defect, without seating it. The first stitch enters through the slit, pierces the adventitial surface, and emerges on the shiny surface of the pericardium. Suturing is thereafter continued with the same limb of the suture as shown in Figures 1A and B. When the inferior angle of the atrial septal defect is reached, the slit in the pericardium is extended toward its free margin and suturing is continued. After the anterior margin is reached, the superior edge of the pericardium is held by an assistant and the pericardium is cut free. It is then seated on the defect by applying gentle traction to both ends of the suture (Fig 1C), and the suturing is completed.
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Fig 1. The pericardium is opened to the left of the midline. A cut is made on the right flap, parallel to its free margin and the suturing begun with 4-0 polypropylene (a). Suturing is continued and the cut in the pericardium is extended as required (b). The pericardial patch is finally detached and seated on the defect by gentle traction on both ends of the suture (c). Suturing is completed. The figure illustrates closure of the defect when a midline sternotomy is used, but the technique is possible with a parasternal or a small right submammary incision.
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Comment
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Atrial septal defects (ostium secundum, ostium primum, sinus venosus, and those associated with intracardiac total anomalous pulmonary venous connection and other complex defects) often require closure by a patch. Even though pericardium is a good material to use, many surgeons use a synthetic material [3] because untreated pericardium is cumbersome to handle. The method described eliminates the steps of pretreatment of pericardium, while using it in a way that is simple and effective even when the surgery is done through a small incision.
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References
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McKeown P.P., Dillard D.H., Ivey T.D. Simplified technique for pericardial patch of the right ventricular outflow tract. Ann Thorac Surg 1986;41:451-452.[Abstract]
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Kirklin J.W., Barratt-Boyes B.G. Cardiac surgery, 2nd ed. New York: Churchill Livingstone, 1993:627-628.
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Stark J. Secundum atrial septal defect and partial anomalous pulmonary venous return. In: Stark J., de Leval M., eds. Surgery for congenital heart defects, 2nd ed. Philadelphia: WB Saunders Co, 1994:345-346.
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Abstract
Introduction
