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Ann Thorac Surg 2003;75:1532-1534
© 2003 The Society of Thoracic Surgeons

Original article: cardiovascular

Safety and efficacy of minimally invasive atrial septal defect closure

William H. Ryan, MDa*, Jorge Cheirif, MDa, Todd M. Dewey, MDa, Syma L. Prince, RNa, Michael J. Mack, MDa

a Cardiopulmonary Research Science and Technology Institute, Dallas, Texas, USA

Accepted for publication November 1, 2002.

* Address reprint requests to Dr Ryan, 8230 Walnut Hill Lane, Professional Building 3, Suite 208, Dallas, TX 75231, USA.
e-mail: whryanmd{at}yahoo.com


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
BACKGROUND: Atrial septal defects (ASDs) have been surgically closed with low mortality utilizing the conventional sternotomy approach (CSA). The technical ease of ASD closure has triggered interest in minimally invasive closure (MIC) to obviate the morbidity associated with sternotomy. Our study assesses the safety and efficacy of minimally invasive ASD closure.

METHODS: Preoperative, intraoperative, and postoperative data were collected on 68 patients (39 CSA, 29 MIC) who underwent ASD closure from January 1997 to August 2002. Using univariate analysis of 17 preoperative risk factors there was no statistically significant difference between the two groups.

RESULTS: MIC resulted in equivalent success rates in ASD closures, with similar morbidity, no mortality, and a significant difference in postoperative length of stay (3.93 ± 1.6 days versus 5.36 ± 2.51 days, p = 0.006).

CONCLUSIONS: In experienced hands, MIC is an excellent alternative to CSA in ASD closure.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
Surgical closure of atrial septal defects (ASDs) in the adult population utilizing conventional sternotomy carries low morbidity, 0% to 1% mortality, and is efficacious with less than 1% recurrence after surgery. Many patients express concern over the sternotomy incision and want an incision that is more cosmetically and psychologically acceptable. During the period from January 1997 to August 2002 we developed a technique employing either a 4-cm right submammary or a right third intercostal incision with a 3-cm transverse groin cannulation incision to close adult ASDs. This modification from the conventional approach, however, must be shown to be equivalent in morbidity, mortality, and efficacy. To that end we retrospectively compared the results of consecutive patients undergoing minimal incision closures (MIC) by two surgeons with those of consecutive patients undergoing conventional sternotomy (CSA) by four other surgeons during the same period.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
From January 1997 to August 2002, 68 patients with secundum or sinus venosus defects underwent ASD closure (39 by CSA and 29 by MIC). We used univariate analysis of 17 preoperative risk factors to compare the patient groups.

Operative technique
The MIC patient is prepared and draped in the usual manner. A 2 to 3 cm transverse incision is made in the femoral crease to isolate the femoral artery and vein. The vein is cannulated through an anterior purse string suture with a Medtronic Biomedicus (Medtronic, Minneapolis, MN) or CardioVations venous cannula (CardioVations, a division of Ethicon, Somerville, NJ). The right internal jugular (IJ) vein is cannulated anteromedially to the sternocleidomastoid. A guide wire is used to position a 15F DLP cannula in the superior vena cava (SVC). The IJ cannula is connected to the femoral cannula with a Y connector. Femoral and IJ venous cannulas are positioned in the SVC and inferior vena cava (IVC) under transesophageal echocardiography (TEE) guidance. The femoral artery is sized and cannulated through a transverse arteriotomy with a 21F or 23F CardioVations arterial cannula with a side port. An endoaortic balloon clamp (CardioVations) is passed under TEE guidance into the proximal ascending aorta (Fig 1).



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  		Fig 1. Schematic of instrumentation for atrial septal defect repair. (IJ = interval jugular; RA/SVC = right atrial/superior vena cava.)

 
A 4 to 5 cm right submammary incision is made and the chest is entered in the fourth intercostal space (Fig 2). In two cases the right third intercostal space was utilized to close sinus venosus defects. A Touffier retractor (Codman and Shurtleff, a Raynham, MA) is utilized for exposure. The pericardium is opened 2 cm anterior to the phrenic nerve and retraction sutures are placed and passed through the chest wall. Cardiopulmonary bypass is instituted and the cavae are encircled with umbilical tapes. The heart is arrested with antegrade cardioplegia, the atrium opened longitudinally, and stay sutures are placed in the atrium. The ASD is then closed, either with previously harvested pericardium or a Hemashield Dacron patch (Meadox; Boston Scientific, Natick, MA). To diminish intracardiac air, CO2 is infused into the right chest at 2.5 L/min and the left ventricle is allowed to fill before tying down the patch. After completion of the operation a small 20F chest tube is inserted into the pleura and a Jackson-Pratt drain with bulb section (Baxter Healthcare, Deerfield, IL) is placed over the right hilum and looped inferiorly. Decannulation is carried out in the standard fashion and the chest and groin wounds are closed cosmetically with subcuticular sutures. The neck stab wound is closed with a simple nylon suture. Bupivacaine hydrochloride (Abbott Laboratories, Chicago, IL) anesthesia is used to infiltrate the incisions and inner spaces above and below the chest incision.



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  		Fig 2. Submammary incision.

 
The CSA group underwent conventional sternotomy with direct aortic and bicaval cannulation. Cardioplegia was delivered antegrade through a DLP cannula and inserted directly into the ascending aorta. The sternal closure employed encircling wires.

Postoperatively no "fast track" methods or techniques were employed in either group. The time of discharge was determined by conventional surgical judgement and patient threshold for discharge.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
All patients underwent repair in accordance with an intent-to-treat strategy. The two groups were comparable except that the MIC group had a significantly lower incidence of preoperative arrhythmia (Table 1).


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  		Table 1. Risk Comparison Variables

 
Postoperatively there were no significant differences in blood usage, arrhythmias, neurologic events, prolonged ventilation, or mortality. The MIC group had a statistically significant shorter length of hospital stay (Table 2).


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  		Table 2. Results

 
In the MIC group the average chest incision length was 4.1 cm and the average groin incision was 2.3 cm. No patient in the MIC group required rib or cartilage division, conversion to sternotomy, or extension of the original incision. Patient satisfaction with the MIC closure has been high and cosmetic results excellent. Groin cannulation was free from complications; there were no lymphoceles, venous thromboses, arterial flaps or embolization, or groin infections.


   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
In this report we describe our first 29 patients undergoing minimally invasive ASD closure and compare this group with a contemporaneous cohort of patients undergoing conventional sternotomy. These data demonstrate a shorter length of stay for the minimally invasive group.

Various minimal access incisions have been employed for ASD closure, allowing the surgeon to use familiar exposure, cannulas, and instruments [1–8]. Whether these incisions are parasternal, upper partial sternotomy, lower partial sternotomy, or midsternotomy, all leave obvious scars in the midline of the female patient. Further, none of these approaches demonstrates any advantage over conventional sternotomy in regard to pain management, pulmonary physiology, or hospital stay [9].

The method we describe of minimally invasive ASD closure violates no intrathoracic cardiac structures other than the easily visible, low-pressure right atrium thus decreasing concerns with postoperative hemorrhage. Additionally the suture lines are entirely hidden under the "bikini" lines.

This method is technically more difficult because it does employ specialized cannulas and cannulation techniques with TEE guidance. Once the chest is open, however, the cava can be looped easily and the position of the superior and inferior cannula and the endoaortic balloon readily palpated. This assures the surgeon that the cannula are correctly positioned. Fluoroscopy can also be employed during the first few cases to help position the cannula and endoaortic balloon.

This technique is not suitable for patients with peripheral vascular disease involving the iliac or femoral vessels. Mobile atheroma in the descending or ascending aorta or TEE are contradictions to the endoaortic balloon. In such patients a lower ministernotomy or right anterior thoracotomy with chest cannulation should be employed.

A cost analysis was not performed to determine whether the decreased length of stay compensates for the costs associated with the arterial cannula and endoaortic balloon. We believe that a fast tracking program in these patients may lead to accelerated discharge and an even more favorable reimbursement balance sheet. Efforts are under way to implement this program.

An important limitation of this retrospective study is that the relationships between individual pain thresholds and length of convalescence are difficult to measure. Nevertheless it may be that in the absence of other demonstrable factors the relief of postoperative pain may account for earlier discharge in the MIC group.

Given its equivalent result, low mortality and morbidity, shortened hospital stay, and improved cosmesis, the minimal incision technique has become our approach of choice for closing ASDs in the adult population.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. Akins C.W. Full sternotomy through a minimally invasive incision. Ann Thorac Surg 1998;66:1429-1430.[Abstract/Free Full Text]
  2. Laks H., Hammond G.L. A cosmetically acceptable incision for the median sternotomy. J Thorac Cardiovasc Surg 1980;79:146-149.[Abstract]
  3. Bedard P., Keon W.J., Brais M.P., Goldstein W. Submammary skin incision as a cosmetic approach to median sterntomy. Ann Thorac Surg 1986;41:339-341.[Abstract]
  4. Wilson W.R., Ilbawi M.N., DeLeon S.Y., Piccione W., Tubeszewski K., Cutilletta A.F. Partial median sternotomy for repair of heart defects. Ann Thorac Surg 1992;54:892-893.[Abstract]
  5. We Y.C., Chang C.H., Lin P.J., et al. Minimally invasive cardiac surgery for intracardiac congenital lesions. Eur J Cardiothorac Surg 1998;14(Suppl 1):154-159.
  6. Black M.D., Freedom R.M. Minimally invasive repair of atrial septal defects. Ann Thorac Surg 1998;65:765-767.[Abstract/Free Full Text]
  7. Gundry S.R., Shattuck O.H., Razzouk A.J., del Rio M.J., Sardari F.F., Bailey L.L. Facile minimally invasive cardiac surgery via ministernotomy. Ann Thorac Surg 1998;65:1100-1104.[Abstract/Free Full Text]
  8. Khan J.H., McElhinney D.B., Reddy V.M., Hanley F.L. Repair of secundum atrial septal defect. Ann Thorac Surg 1998;66:1433-1435.[Abstract/Free Full Text]
  9. Bichell D.P., Geva T., Bacha E.A., Mayer J.E., Jonas R.A., del Nido P.J. Minimally access approach for the repair of atrial septal defect: the initial 135 patients. Ann Thorac Surg 2000;70:115-118.[Abstract/Free Full Text]



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This Article
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Syma L. Prince
Michael J. Mack
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Right arrow Articles by Mack, M. J.
Related Collections
Right arrow Congenital - acyanotic

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