Ann Thorac Surg 2008;85:672-674. doi:10.1016/j.athoracsur.2007.03.100
© 2008 The Society of Thoracic Surgeons
How To Do It
Surgical Removal of an Atrial Septal Defect Closure Device Embolized Into the Pulmonary Trunk by Port Access Technique
Christophe De Decker, MD*,
Ruben Hamerlijnck, MD, PhD,
Dominique Goosens, MD,
Pieter Pletinckx, MD
Department of Cardiac Surgery, Algemeen Ziekenhuis Maria Middelares, Ghent, Belgium
Accepted for publication March 26, 2007.
* Address correspondence to Dr De Decker, Kortrijksesteenweg 1026, Gent, B-9000, Belgium (Email: christophededecker{at}hotmail.com).
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Abstract
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It is not obvious to visualize and expose the main trunk of the pulmonary artery through a port access approach. We describe surgical and anesthesiology measures necessary to perform the removal of an atrial septal defect closure device safely and adequately.
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Introduction
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The most frequent indication for surgical intervention after percutaneous closure of an atrial septal defect (ASD) is device malpositioning or embolization [1–5].
Since 1999, the port access technique has been used at our institution for surgical procedures through the left and right atriums with ASD closures, removals of myxoma, and mitral and tricuspid valve surgeries.
We describe a case of the port access technique for the surgical removal of an ASD closure device, which was embolized into the pulmonary trunk.
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Technique
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A 55-year-old woman had a percutaneous closure of her ASD (ostium secundum type) with a Cardio Seal (38 mm; NMT Medical, Boston, MA). On cardiological examination, a transthoracic echocardiography showed an ASD remaining and the chest x-ray film showed migration of the device into the main trunk of the pulmonary artery [3].
Through a right submammary skin incision of 6 cm, the third intercostal space was entered, creating a working port (Fig 1). Arterial cannulation was established through the femoral artery, the venous cannulation of the superior vena cava through the jugular vein and of the inferior vena cava through the femoral vein. Cardiopulmonary bypass was instituted. The ascending aorta was occluded with a Cardiovations endo-aortic balloon (Johnson & Johnson, Somerville, NJ) and cold crystalloid cardioplegia was given. A right atriotomy was performed. A large ASD was found (diameter, 1.5 cm), but no device or traces of the device were visible. Inspection was made of the right ventricle through the tricuspid valve and left atrium and the left ventricle through the ASD, which all showed no device. On fluoroscopy the device was located high up in the main pulmonary trunk (Fig 2). The ASD was closed by a running suture (Prolene 4-0 [Ethicon, Somerville, NJ]), and the right atriotomy was closed.
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Fig 2. Fluoroscopic visualization of the embolized closure device. (Left arrow is the transesophageal echocardiography [TEE] probe; right arrow is the closure device.)
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To be able to reach the pulmonary trunk (Fig 3), the following steps were performed: (1) the endoaortic clamp was removed, allowing manipulation of the ascending aorta, which resulted in reperfusion of the coronary arteries, so the operation was continued on the beating heart; (2) the ascending aorta was encircled with a loop and was retracted to the right; and (3) the left lung was insufflated, gradually moving the mediastinum to the right.
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Fig 3. Positioning to reach the pulmonary trunk. (Left: color photograph of the operation field; right: digitally enhanced black and white image with legend.)
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By these three actions the pulmonary trunk was reached and became surgically accessible. A transverse arteriotomy was performed and the device was gradually delivered (Fig 4). The closure device (Fig 5) had to be peeled off of the intima from the posterior vessel wall.
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Fig 4. Removal of the device. (Left: color photograph of the operation field; right: digitally enhanced black and white image with legend.)
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The patient had an uneventful recovery and was discharged on postoperative day 7.
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Comment
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Surgery of the pulmonary trunk does not necessarily imply a full sternotomy or conversion during an operation initiated by using a port access technique. This case demonstrates the possibility of exposing and accessing the pulmonary trunk through a port access technique.
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References
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- Berdat PA, Chatterjee T, Pfammatter JP, Windecker S, Meier B, Carrel T. Surgical management of complications after transcatheter closure of an atrial septal defect or patent foramen ovale J. Thorac Cardiovasc Surg 2000;120:1034-1039.[Abstract/Free Full Text]
- Critterio E, Manasse E, Pilato E, Eusebio A, Bandera A, Gallotti R. Port-access cardiac surgery: clinical experience with first 50 cases Ital Heart J 2001;12:904-909.
- Fann JI, Pompili MF, Stevens JH, et al. Port-access cardiac operations with cardioplegic arrest Ann Thorac Surg 1997;63:S35-S39.[Medline]
- Chessa M, Carminati M, Butera G, et al. Early and late complications associated with transcatheter occlusion of secundum atrial septal defect J Am Coll Cardiol 2002;39:1061-1065.[Abstract/Free Full Text]
- Mellert F, Preusse CJ, Haushofer M, et al. Surgical management of complications caused by transcatheter ASD closure Thorac Cardiov Surg 2001;49:338-342.
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Abstract
Introduction
