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Ann Thorac Surg 2007;84:913-916
© 2007 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Autologous Right Atrial Wall Patch for Closure of Atrial Septal Defects

Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India

Accepted for publication April 13, 2007.

^_* Address correspondence to Dr Kumar, Department of Cardiothoracic & Vascular Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India (Email: asampath_kumar{at}hotmail.com).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Background: We used the right atrial free wall as a patch to close atrial septal defects (ASD) and report its results.

Methods: Between July 1998 and April 2006, 87 patients (mean age, 21.9 ± 13.9 years; range, 7 months to 54 years), underwent closure of ASD with an autologous right atrial free wall patch. The underlying diagnosis were very large secundum ASD in 51 patients, sinus venosus defect in 15, primum ASD in 5, large defect resulting from excision of a left atrial myxoma in 12, complete atrioventricular canal defect in 1, total anomalous pulmonary venous return with ASD in 2, and Ebstein anomaly with a large ASD in 1. Associated surgical procedures were mitral valve repair in 18 patients, repair of total or partial anomalous pulmonary venous drainage in 17, mitral valve replacement in 1, and tricuspid valve repair for Ebstein anomaly in 1.

Results: There were two early deaths. One patient with primum defect and preoperative congestive heart failure died 3 weeks postoperatively from refractory ventricular fibrillation. Another patient died from persistent congestive heart failure after undergoing reoperation for residual mitral regurgitation. The remaining patients were discharged after 4 to 9 days. No flow was detected across the septal patch on predischarge echocardiography. At a mean follow up of 53.4 ± 26.7 months (range, 1 to 103 months), all patients except 1 are in sinus rhythm. One patient underwent reoperation for failed mitral valve repair after 1 month. At reoperation, the patch was intact with normal texture and without any suture dehiscence. Histopathologic examination of the explanted patch revealed viable endothelium and subendothelial muscle on both the surfaces of the patch. Results of Holter monitoring in 9 patients were normal. Electrophysiologic studies in 2 patients recorded normal atrial potentials from the site of the patch. No patch shrinkage, calcification, or thromboembolic complications were noted.

Conclusions: The autologous, free, right atrial wall can be safely used as a patch for ASD closure and offers several advantages.

	Introduction

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Atrial septal defect (ASD) closure is one of the most commonly performed cardiac surgical procedures. A patch is often required for ASD closure, but an ideal patch material has not yet been found. Autologous pericardium has been commonly used but is difficult to handle and its surfaces are not smooth. Thromboembolism, endocarditis, and hemolysis have been reported with the use of prosthetic patches [1–7]. Because the atrial wall patch is autologous, has the same texture as that of the normal atrial wall, and may be living tissue, we proposed its use as an ideal patch material to close the ASD [8]. We have continued to use this procedure and report its results.

	Patients and Methods

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Between July 1998 and April 2006, 87 patients (53 male) with a mean age of 21.9 ±13.9 years (range, 7 months to 54 years) underwent ASD closure with the atrial wall patch at the All India Institute of Medical Sciences, New Delhi, India. Informed consent was obtained from all patients, and the study was approved by the hospital Ethics Committee.

The underlying diagnoses are listed in Table 1. Associated lesions included severe mitral regurgitation (MR) in 18 patients. The MR in 9 patients was due to partial or complete atrioventricular septal defect, and in the rest, it was associated with large secundum ASD. One patient had severe rheumatic calcific mitral stenosis. Partial anomalous pulmonary venous drainage was present in 15 patients with sinus venosus ASD, and total anomalous pulmonary venous drainage with secundum ASD was present in 2 patients. One patient had Ebstein anomaly of the tricuspid valve with severe tricuspid regurgitation. Dyspnea on exertion was present in all patients; 5 patients were in congestive heart failure. In 15 patients, palpitation was the predominant complaint. Seven patients were in atrial fibrillation preoperatively; the remaining patients were in normal sinus rhythm.

Associated procedures were performed first. These included mitral valve repair in 18 patients, repair of total anomalous pulmonary venous drainage in 2, and mitral valve replacement in 1. Twelve patients had left atrial myxoma arising from the atrial septum in the region of the fossa ovalis. Wide excision of these myxomas was done, which left a large ASD that was subsequently closed with the atrial wall patch.

An appropriately sized patch of the right atrial free wall was now obtained from the inferolateral flap of the atriotomy incision, and the patch was cut out anterior to the crista terminalis so that it was not incised (Fig 1). The patch was sutured to close the ASD using 4-0 or 5-0 polypropylene suture, depending on the age of the patient. While suturing the patch, the endocardial trabeculated surface was placed towards the left atrium. The right atrium was closed in two layers: the first layer was closed with a running horizontal mattress suture of 4-0 or 5-0 polypropylene, followed by a second layer suture using the other arm of the same suture in an over and over fashion. The patient was then weaned from cardiopulmonary bypass. Intraoperative transesophageal echocardiography was used to assess the defect closure and associated procedures.

View larger version (12K): [in this window] [in a new window]   Fig 1. Line drawing of the harvesting of the right atrial wall patch. Shown in the figure are the aorta (Ao), superior vena cava (SVC), inferior vena cava (IVC), right ventricle (RV), crista terminalis (dotted arrows), atriotomy (solid arrow), and the area from where the patch is harvested (thatched area).

Follow-Up
After discharge from the hospital, all survivors were seen in the outpatient clinic after 1 month, 6 months, and then at yearly intervals. Follow-up consisted of clinical examinations, electrocardiograms, and serial echocardiograms. Nine patients underwent 24-hour ambulatory Holter monitoring after an interval of 4 to 18 months. Two patients underwent an electrophysiologic study using a mapping catheter at an interval of 4 and 6 months respectively.

The clinical, echocardiographic, and electrocardiographic data of all the patients were accumulated between June and October 2006 (closing interval) and were used to report the study results. In all, 23 patients (27.1%) were followed up for 5 years or more, 29 (34%) were followed up for 3 years or more, and 44 (51.8%) were followed up for 2 years or more. Follow-up was 100% complete. Mean follow-up was 53.4 ± 26.7 months (range, 1 to 103 months) and totaled 378.3 patient-years.

	Results

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All patients had an uneventful intraoperative course. For isolated ASD closure, the mean times were 32 ± 8.7 minutes (range, 19 to 41 minutes) for CPB and 22 ± 6.7 minutes (range, 11 to 28 min) for aortic cross-clamp. When associated procedures were performed, these times were 40 ± 6.2 minutes (range 32 to 89 minutes) for CPB and 32 ± 8.3 min (range, 26 to 73 minutes) for aortic across-clamp. One patient required reexploration for hemorrhage, which was found to be from the sternal edges.

Two early deaths occurred. One 30-year-old patient with primum defect and preoperative congestive heart failure, who had undergone ASD closure with mitral valve repair, died 3 weeks postoperatively from refractory ventricular fibrillation. Another 40-year-old patient underwent mitral valve replacement for residual MR but died from persistent low cardiac output syndrome.

The remaining patients were discharged after 4 to 9 days of hospital stay. Their echocardiograms before discharge showed no residual shunt, peripatch thrombosis, or other residual surgical defects. Three patients were in atrial fibrillation, and the rest were in normal sinus rhythm. The mean follow-up was 53.4 ± 26.7 months (range, 1 to 103 months) and was 100% complete.

One month after discharge, a 45-year-old woman required hospitalization for congestive heart failure. Echocardiography showed she had severe MR with no residual atrial level shunt. At reoperation, the atrial wall patch was intact and was of normal texture. Histopathologic examination of the explanted patch revealed intact endothelial lining. The original endocardial lining and the epicardium could not be differentiated. The subendocardial myocardium was histologically viable, as seen beneath both of the aspects of the patch. The central core of myocytes underwent coagulative necrosis with loss of nuclear details (Fig 2). The necrotic zone appeared bland, with no infiltration by inflammatory cells. Immunohistochemical stain for desmin showed preservation of viability within subendocardial myocytes signifying viability. The central necrotic muscle appeared unstained (Fig 3). This patient’s mitral valve was replaced, and she made an uneventful postoperative recovery.

View larger version (145K): [in this window] [in a new window]   Fig 2. Photomicrograph from the explanted right atrial patch. The myocytes (M) beneath the endocardial aspect (E) appear viable. Deeper down, the myocytes show coagulative necrosis (C) and lack stainable nuclei (hematoxylin and eosin stain, original magnification x80). (Reproduced with permission from Kumar AS, Choudhary SK, Ray R, Talwar S, Juneja R. Autologous right atrial patch for closure of atrial septal defect. Indian Heart J 2002;54:289–91.)

View larger version (148K): [in this window] [in a new window]   Fig 3. Photomicrograph shows immunohistochemical reactivity for desmin within the viable myocytes on both sides (arrows) beneath the endocardial and epicardial aspects. The central necrotic core (C) shows lack of desmin immunoreactivity (Peroxidase anti-peroxidase, DAB Chromogen, original magnification x35). (Reproduced with permission from Kumar AS, Choudhary SK, Ray R, Talwar S, Juneja R. Autologous right atrial patch for closure of atrial septal defect. Indian Heart J 2002;54:289–91.)

Eighty-two patients are in sinus rhythm and all are in New York Heart Association functional class I. There were no thromboembolic complications. Holter monitoring in 9 patients after an interval of 4 to 18 months revealed normal sinus rhythm in all patients, with occasional atrial ectopics in a 54-year-old woman who had undergone ASD closure and mitral valve repair. Electrophysiologic studies in 2 patients after 4 and 6 months of operation, respectively, recorded normal atrial potentials similar to those of the normal atrial septum from the site of the patch. That these potentials originated from the site of the patch and not the surrounding atrial wall or the septum was confirmed by positioning the catheter at the site of the patch under transthoracic echocardiographic guidance.

	Comment

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A wide variety of patch materials have been used to close large ASDs. The choice of these patches is usually determined by the personal preference of the surgeon. Available patches include autologous pericardium (fresh or treated with glutaraldehyde), knitted polyester, and polytetrafluoroethylene [3, 4]. Bovine pericardium has also been used with satisfactory results [9] but is not autologous tissue and may show evidence of calcification in some patients [10]. Synthetic patches have been associated with thromboembolic complications and hemolysis [1–7], especially in the setting of residual MR after repair of primum defects. Although autologous pericardium is commonly used, uncommon problems with its use include residual shunt due to lack of coaptation, shrinkage, aneurysm formation, and calcification [1–7].

Keeping these problems in mind, we advocate the free right atrial wall as a suitable patch material to close large ASDs. The right atrium is usually large in these patients, and obtaining a patch of atrial wall is easy without compromising on the right atrial volume. The advantages of using this patch have been the avoidance of prosthetic material, viability, absence of tissue reaction, and ease of handling and elasticity [8, 11]. The endothelialized surface of the right atrial patch, which is positioned toward the left atrium, may provide freedom from thromboembolic complications. Theoretically, there is a potential for growth and contractile activity that may be indicated by the normal atrial potentials that were elicited from the site of the patch in 2 patients. This is further corroborated by the histologic evidence of viability obtained from the patient in whom the patch was examined at reoperation. We are in the process of conducting more refined electrophysiologic studies to further investigate the role of this patch in the propagation of the normal atrial impulse.

The autologous free right atrial wall can be used safely as a patch for ASD closure and offers several advantages. Long-term studies with more electrophysiologic studies will further confirm the time of viability of the patch and long-term stability of cardiac rhythm.

	Acknowledgments

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We thank the editor of the Indian Heart Journal for permission to reproduce Figures 1 and 2 of our prior publication as Figures 2 and 3 of this article, with description of histologic findings. From: Kumar AS, Choudhary SK, Ray R, Talwar S, Juneja R. Autologous right atrial patch for closure of atrial septal defect. Indian Heart J 2002;54:289–91.

	References

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

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This Article Abstract Full Text (PDF) 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): Sachin Talwar Shiv Kumar Choudhary Arkalgud Sampath Kumar Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Talwar, S. Articles by Kumar, A. S. Search for Related Content PubMed PubMed Citation Articles by Talwar, S. Articles by Kumar, A. S. Related Collections Congenital - acyanotic