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Ann Thorac Surg 2006;81:1417-1419
© 2006 The Society of Thoracic Surgeons

Original article: Cardiovascular

New Minimally Invasive Technique to Occlude Secundum Atrial Septal Defect in 53 Patients

Tao Liang, MDa, Zeng XiangJun, MDa,*, Ma XiaoJing, MDb, Lin Yun, MDb, Chua Yeow Leng, MDc

a Cardiac Surgical Department, Wuhan Asia Heart Hospital, WuHan, China
b Ultrasonic Department, Wuhan Asia Heart Hospital, WuHan, China
c Cardiac Surgical Department, Singapore National Heart Center, Singapore

Accepted for publication September 30, 2005.

* Address correspondence to Dr XiangJun, Tao Liang Cardiac Surgical Department, Wuhan Asia Heart Hospital, WuHan 430022, China (Email: zengxiangjun{at}sohu.com).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 
Background: Conventional surgical atrial septal defect (ASD) closure requires cardiopulmonary bypass, whereas percutaneous transcatheter closure is limited by maximal defect size of 34 mm and access to the neck. We describe a new minimally invasive approach using a right minithoracotomy to deploy an occluder without cardiopulmonary bypass.

Methods: Between October 2004 and April 2005, 53 secundum ASDs were closed by this method. Through a 3-cm incision in the right fourth intercostal space, a minithoracotomy exposes the right atrium to facilitate deployment of the septal closure device. The age of the patients was from 2 to 61 years. The ASD size was 12 to 39 mm.

Results: All ASDs were successfully closed with a mean device size of 33.1 ± 8 mm (range, 16 to 46 mm). The procedure duration was 30 to 60 minutes. All patients were extubated on table, with less than a 1-day stay in the intensive care unit. The hospital stay was 3 to 7 days. There was no postoperative mortality. At mean follow-up of 1 to 8 months, there were no major morbidities. One patient had minimal residual shunt that resolved 1 month later.

Conclusions: This new minimally invasive method of secundum ASD closure is safe and cosmetically superior to conventional surgery. Early results are encouraging.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 Acknowledgments
 References
 
Surgical closure of secundum atrial septal defects (ASD) has become so safe over the past 30 years that the emphasis now is on cosmesis. Since the first successful deployment of an Amplatzer device in an animal in 1997, percutaneous ASD closure has become the standard therapy in the pediatric population. Cai Zhenjjie first introduced a new minimally invasive technique of atrial septal defect closure. We report our experience with the new minimally invasive surgical technique of secundum ASD closure without cardiopulmonary bypass using the occluder.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Acknowledgments
 References
 
Study Population
Between October 2004 and April 2005, 53 secundum ASDs were closed by this method. Thirty-eight patients were female. Fifteen patients were male. The mean age of the patients was 25.6 ± 14.6 years (range, 2 to 61). Four patients (7.5 %) were New York Heart Association class III; 49 patients (92.5%) were NYHA I or II. Average ASD size was 24.4 ± 7.5 mm (12 to 39 mm). The statistical analysis is shown in Table 1.


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  		Table 1 Statistical Analysis
 
Technique
The supine patient is placed under general anesthesia with single-lumen tracheal intubation. Intraoperative transesophageal echocardiography is mandatory to reassess the ASD with particular note of the defect size, and circumferential margins adjacent to the superior vena cava, inferior vena cava, pulmonary vein, mitral valve, and aortic sinus.

A 3-cm incision is made in the right fourth intercostal space (Fig 1). The anterior minithoracotomy exposes the pericardium, which is opened and sutured with five 2-0 Ethibond (Ethicon, Somerville, New Jersey) stay sutures to suspend the heart. Right atriotomy follows the placement of two parallel 4-0 polypropylene pursestring sutures with approximately 10 mm in diameter. The patient is then given 1.0 mg/kg of heparin, and the activated clotting time is confirmed to be greater than 250 s.


Figure 1
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  		Fig 1. A 3-cm incision in the right fourth intercostal space.

 
Our occluder device includes a composite nickel and titanium occluder, a metal sheath, a pushing rod, and a hook (Fig 2). The double-umbrella occluder has a loop on the right atrium umbrella with a 100-cm thread through the loop, facilitating its withdrawal into the 40-cm long sheath. Our unique metallic sheath is larger (6 to 10 mm diameter), allowing deployment of larger occluder devices. The occluder is compatible with this delivery system.


Figure 2
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  		Fig 2. The occluder device.

 
In our experience, we chose the occluders (or Amplatzer device) based on the largest diameter of ASD, allowing for a margin of 6 to 12 mm in excess of the diameter in adults and 4 to 6 mm in children.

The occluder is drawn into the sheath. A right atriotomy within the pursestring suture is then made, and the sheath inserted (Fig 3). Under transesophageal echocardiography guidance, it is advanced through the ASD into the left atrium (Fig 4). The left atrial umbrella is deployed first using the pushing rod, and then with gradual withdrawal of the sheath, the right atrium umbrella opens on the other side to occlude the ASD (Fig 5).


Figure 3
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  		Fig 3. The sheath is inserted into the right atrium through a right atriotomy.

 

Figure 4
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  		Fig 4. The sheath is detected by transesophageal echocardiography.

 

Figure 5
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  		Fig 5. The occluder is deployed.

 
A completion transesophageal echocardiogram confirms device placement, by gently tugging on the thread attached to the right atrium umbrella. Evaluation for residual shunt, atrioventricular valve distortion, and obstruction of the superior vena cava, inferior vena cava, or coronary sinus completes the procedure. The thread is cut, and the sheath is withdrawn with the pursestring snugly tied. The chest is closed as per normal with no drainage tube placement.

These patients consented to have this operation, and they were informed that this was a new operation. There is no ethics committee in our hospital; the administration committee of our hospital that acts as an ethics committee approved this operation.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Acknowledgments
 References
 
All ASDs were successfully closed with a mean device size of 33.1 ± 8 mm (range, 16 to 46 mm). The procedure duration was 30 to 120 minutes. All patients were extubated on table, with less than a 1-day stay in the intensive care unit. The hospital stay was 3 to 7 days.

There was no postoperative death. At follow-up of 1 to 8 months, there were no major morbidities. Hydrothorax was noted on echocardiography in 7 patients (5 mild, 1 moderate, and 1 severe. One patient had minimal residual shunt that resolved 1 month later. To date, there is no cerebral embolic event, device embolization, or failure.

The NYHA status improved in 5 patients and remained the same in 48 patients. All patients were given aspirin, 50 to 100 mg daily for 3 months. There were no wound problems.


   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Acknowledgments
 References
 
Conventional surgical ASD closure requires cardiopulmonary bypass, whereas percutaneous transcatheter closure is limited by maximal defect size of 34 mm and access to the neck [1, 2]. We describe a new minimally invasive approach using a right minithoracotomy to deploy an occluder (or Amplatzer device) without cardiopulmonary bypass.

In conclusion, this new minimally invasive method of secundum ASD closure is safe and cosmetically superior to conventional surgery. Early results are encouraging.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
References
 
The authors thank Kang YunFan, MD, for his technical support and Dr Soon Jia Lin. This article was supported in part by Long Teng Xing Kong Medical, Inc, Beijing, China.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Rigby ML. The era of transcatheter closure of strial septal defects[Editorial] Heart 1999;81:227-228.[Free Full Text]
  2. Nakanishi T. Interventional catheterization Curr Opin Cardiol 2000;15:211-215.[Medline]



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