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Ann Thorac Surg 2001;72:1354-1357
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Totally endoscopic computer-enhanced atrial septal defect closure in six patients

^a Division of Cardiac Surgery, San Raffaele Hospital, Milan, Italy

Accepted for publication June 11, 2001.

Address reprint requests to Dr Torracca, Division of Cardiac Surgery, San Raffaele Hospital, Via Olgettina, 60, 20132 Milan, Italy
e-mail: lucia.torracca{at}hsr.it

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Totally endoscopic procedures have been introduced into cardiac surgery with the application of telemanipulating robotic systems. We report 6 cases of closed-chest atrial septal defect (ASD) closure using a robotic device.

Methods. After deflating the right lung, the endoscopic camera and two robotic arms were inserted into the right hemithorax through 8-mm ports. An accessory port was placed for blood suction and for introduction of ancillary endoscopic instruments. After femoral-femoral cannulation for cardiopulmonary bypass (CPB), aortic occlusion, and cardioplegia delivery, the intracardiac correction was carried out in 5 patients with an ostium secundum ASD and in 1 patient with a patent foramen ovale (PFO) and atrial septal aneurysm (ASA). The ASDs were closed with a continuous braided polyester suture. The PFO closure with septal aneurysm plication was carried out with interrupted stiches.

Results. Mean CPB and cross-clamp times were 106 ± 22 and 67 ± 13 minutes, respectively. Extubation was carried out within the seventh postoperative hour. All patients returned to normal function within the first postoperative week.

Conclusions. Totally endoscopic ASD closure can be carried out safely using robotic techniques with rapid postoperative recovery and an excellent cosmetic result.

	Introduction

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Atrial septal defect (ASD) is one of the most common congenital cardiac defects found in adults. Untreated ASD can progressively lead to cardiac failure and early death [1, 2]. ASD closure with the conventional midline sternotomy has been successfully performed but it is associated with the risk of sternal wound problems and poor cosmetic results.

To minimize surgical trauma and improve cosmetic results, different minimal invasive surgical approaches have recently been applied with good clinical results [3–6]. Interventional cardiologists have developed percutaneous techniques for ASD closure in selected patients using a variety of devices [7–10]. We report a technique of totally endoscopic closed chest ASD closure with the aid of a robotic device (Da Vinci System; Intuitive Surgical Inc, Mountain View, CA) and of the Heartport system for CPB (Heartport Inc, Redwood City, CA), aortic occlusion, and cardioplegia delivery.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Robotic system
The Da Vinci surgical system consists primarily of two components: the surgeon’s viewing and control console, and the surgical arms that hold and move the surgical instruments. The surgeon operates from the console while looking into a high-resolution 3-dimensional stereoscopic display of the operating field. The manipulating instru-ment controllers are positioned below the surgeon console display. The telemanipulated instruments are supported by two mechanical arms that are articulated at their distal extremities. The instrument tips reproduce the surgeon’s hand movements. The mechanical wrists of the instruments have 7 degrees of freedom and are able to mimic the flexibility of the human wrist. A detailed description of the system is provided elsewhere [11–13].

Patient selection
Between December 1999 and December 2000, 5 patients with an ostium secundum type ASD and 1 patient with a patent foramen ovale (PFO) and atrial septal aneurysm (ASA) were treated with the totally endoscopic robotic technique.

Only adult patients with ostium secundum ASD or PFO with or without ASA were selected to undergo surgical correction with the totally endoscopic robotic technique. The presence of sinus venous type ASD, anomalous pulmonary venous connection and persistent left superior vena cava were considered contraindications for the technique. In all patients, the aortic valve, the aorta, and the iliac-femoral arteries were examined with a transesophageal echocardiography and echo-color Doppler. Patients with aortic regurgitation, small femoral arteries, or arteriosclerotic disease of the aorta or the femoral arteries were excluded as a contraindication to the safe application of the Heartport system for CPB.

Patient characteristics
Four female and two male patients were operated on with a mean age of 42 ± 12 years (range 18 to 55). All the patients had a body surface area greater than 1.6 m². All patients with an ASD were asymptomatic with a mean ratio of pulmonary to systemic blood flow (QP/QS) of 2.8. The size of the defect ranged between 13 and 21 mm. The patient with PFO and ASA had recurrent episodes of cerebral embolism.

All patients had normal sinus rhythm before the operation. Four patients (aged between 39 and 55 years) were studied with coronary angiography to exclude coexisting coronary disease. Patient informed consent was obtained regarding the procedure, along with the possibility of conversion to a standard sternotomy technique.

Surgical technique
After induction of anesthesia, the patients were intubated with a double-lumen endotracheal tube to allow right lung deflation. Central lines were inserted and both radial arteries were cannulated for arterial pressure monitoring, as is necessary in patients who undergo CPB with the Heartport system. A 14F arterial cannula was inserted into the jugular vein for the drainage of the superior vena cava.

A multiple plane transesophageal echocardiographic probe was placed to evaluate the position of the venous cannulas and the endoaortic balloon in the ascending aorta. External defibrillation pads were placed on the chest wall. The patients were placed in a supine position with the right hemithorax elevated approximately 30 degrees and were draped for exposure of the entire chest and groin.

After right lung deflation, the first port was placed in the fourth intercostal space on the anterior axillary line. This first port was utilized for endoscopic camera introduction and CO₂ insufflation. Two additional ports were created (one in the third and one in the fifth intercostal space) on the midaxillary line for introduction of the robotic instruments (Fig 1). An accessory port was located in the fourth intercostal space on the posterior axillary line. The accessory port introduced a standard endoscopic instrument and was also used for scavenging of blood with a small diameter sucker. Moderately hypothermic CPB was established using the Heartport system after cannulation of the right femoral artery, the inferior vena cava (through the right femoral vein) and connection with the superior vena cava. The venous drainage of the pump was enhanced by a vacuum system.

View larger version (45K): [in this window] [in a new window]   Fig 1. Thoracoscopic view of sites of camera (red) and instruments (green) insertion into the thorax.

After cardiac arrest the right atrium was opened with an incision parallel to the interatrial groove. The superior edge of the atriotomy was fixed to the pericardium by a traction suture. Intracardiac anatomy was carefully inspected to identify the septal defect and its relation to the atrial structures. In the first case, the PFO was closed and the ASA was plicated with interrupted stitches. In the other patients, the ASD was closed with continuous suture of 2-0 Ticron (Ethicon Inc, Sommerville, NJ). Before the suture was secured, the left side of the heart was filled with blood by ventilating the left lung.

The right atriotomy was closed with two continuous sutures. With the patient in Trendelenburg position the endoaortic balloon was deflated and suction was started on the ascending aorta to complete the deairing. Cardiac activity resumed in sinus rhythm, and the patient was weaned from the CPB. A single chest tube was inserted in the right pleural space.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
All procedures were completed endoscopically. No major intraoperative or postoperative complications were observed. At the conclusion of the procedure all patients were assessed using transesophageal echocardiography, and the closure of the ASD was documented.

The mean duration of cardiopulmonary bypass and aortic occlusion were 106 ± 22 minutes and 67 ± 13 minutes, respectively. All patients were weaned from CPB without the use of inotropic agents and were extubated within the seventh postoperative hour. Table 1 reports the data for each patient.

The absence of the linear incision in the thoracic wall accounted for an excellent esthetic result (Fig 2). Successful correction of the defect was assessed in all the patients by echocardiography 1 month after the operation.

View larger version (79K): [in this window] [in a new window]   Fig 2. Cosmetic result of totally endoscopic atrial septal defect closure.

	Comment

Top Abstract Introduction Material and methods Results Comment References

Many patients are reluctant to undergo an operation that requires a long vertical incision in the midline of the chest. The vertical incision leaves an unsightly scar that may be a source of persistent psychologic problems and permanent dissatisfaction. A better cosmetic outcome can be obtained when the operation is performed through a right thoracotomy, particularly in association with minimally invasive techniques. Using these less traumatic approaches, excellent clinical results have recently been reported in a large series of adult patients [3–6].

In the last decade, with the development of new interventional technology, the transcatheter closure of ASD has become a standard technique in some centers [7–10]. With increasing interventional experience and the development of an easy-to-handle device, a larger diffusion of the percutaneous approach can be expected in the future. Certainly the correction of the intracardiac defect without surgical incisions and extracorporeal circulation is attractive, although rigorous patient selection is mandatory and the success rate of the procedure is presently around 80% [14]. Recurrence of the intracardiac shunt as well as dislodgment of the occluder has been reported [15–19].

With the advent of computer-assisted robotic surgery, another option is offered for ASD closure without opening the chest. In this preliminary experience we applied the endoscopic technique in patients with an ASD closure utilizing direct suturing, excluding the sinus venous type ASD repair that requires a patch closure. The possibility of closing every type of ASD regardless of the size and location is realistic and particularly appealing. Unfortunately, the operation cannot be carried out in small children because the percutaneous cannulation for cardiopulmonary bypass is required. The need to use percutaneous cannulation and an endoaortic balloon occlusion can be considered a limitation of the technique. Preoperative patient selection and monitoring can reduce the risk of complications.

Data from the literature indicates that port access operations can be performed safely with mortality and morbidity rates similar to that associated with open chest operations [20–22]. Since its introduction in May 1999, robotic cardiac surgery has mainly been applied to coronary surgery for single vessel disease (implantation of the left mammary artery onto the left anterior descending coronary artery) [23, 24]. Valve reconstructive surgery has been performed by some surgeons with the aid of a computer-assisted robot [25–28]. As far as ASD closure is concerned, Reichenspurner and colleagues [29] reported a gratifying experience in 7 patients. A small thoracotomy (3.5 cm to 5 cm) was always needed, however, to complete the intracardiac repair.

In this paper we report our experience with 6 patients in whom totally endoscopic ASD closure was successful using the robotic technique. Operating times, however, still exceed those needed for a conventional procedure and a substantial learning curve has to be overcome. As a result, a true benefit for the patients in terms of shorter hospitalization or fewer complications can not yet be claimed. Technical evolution in the field of robotic guided surgery can be expected in the near future and will facilitate the procedure and shorten times of surgery. Potentially, the lack of a thoracotomy or sternotomy should allow for a faster recovery and should quicken the return to a normal lifestyle. Although the results presented in this paper are encouraging, the numbers are for now too small to confirm this concept. More clinical data are certainly needed, and after a routine standardized procedure has been established, randomized trials will be necessary to support the use of computer-assisted robotic surgery.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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