Totally Endoscopic Atrial Septal Repair with or without Robotic Assistance: A Systematic Review and Meta-analysis of Case Series

Totally Endoscopic Atrial Septal Defect Repair on Beating Heart: Clinical Outcome and Single-Surgeon Learning Curve Experience

OBJECTIVE

To evaluate the safety and efficacy of the Hanoi ASD procedure, which is totally endoscopic surgery for atrial septal defect (ASD) repair on beating heart. In addition, the present study also aimed to analyze the learning curve for this procedure.

METHODS

From May 2016 to February 2023, 198 consecutive ASD patients weighing ≥20 kg were enrolled in the retrospective study. The Hanoi ASD procedure includes (1) unilateral or bilateral femoral arterial cannulation; (2) two or three 5 mm trocars and a 15 mm port; (3) ASD repair on beating heart, preventing air embolism with CO2 insufflation and keeping the left atrium full of blood; and (4) not snaring the inferior vena cava. Cumulative sum (CUSUM) analysis was used to evaluate the cardiopulmonary bypass (CPB) and operation time learning curves. Variables among the learning curve phases were compared.

RESULTS

The CPB and operation times were 90 (72 to 115) min and 180 (150 to 220) min, respectively. Total drainage volume was 190 (120 to 290) mL. No endoscopic failure or major complications were complications were excluding factors causing bias, the CUSUMCPBtime analysis for the remaining 131 patients included 3 phases. Phase 1 was the initial learning period (cases 1 to 34), phase 2 represented the technical competence period (cases 35 to 54), and phase 3 was the challenging period (cases 55 to 131).

CONCLUSIONS

The Hanoi ASD procedure is safe and feasible for repairing ASD in patients weighing ≥20 kg. According to the learning curve analysis, 34 cases were required to achieve technical efficiency, and 54 cases were required to address highly challenging cases.

Atrial septal defect in adulthood: a new paradigm for congenital heart disease

Atrial septal defects (ASDs) represent the most common congenital heart defect diagnosed in adulthood. Although considered a simple defect, challenges in optimal diagnostic and treatment options still exist due to great heterogeneity in terms of anatomy and time-related complications primarily arrhythmias, thromboembolism, right heart failure and, in a subset of patients, pulmonary arterial hypertension (PAH). Atrial septal defects call for tertiary expertise where all options may be considered, namely catheter vs. surgical closure, consideration of pre-closure ablation for patients with atrial tachycardia and suitability for closure or/and targeted therapy for patients with PAH. This review serves to update the clinician on the latest evidence, the nuances of optimal diagnostics, treatment options, and long-term follow-up care for patients with an ASD.

Feasibility of robotic-assisted atrial septal defect repair in a 6-year-old patient

BACKGROUND

The feasibility, safety and advantages of minimally invasive or robotic repair of atrial septal defect (ASD) in adults were reported previously. However, there is limited data for the application of these systems in paediatric patients. Although current robotic systems still have large instruments for surgical repair in children, some appropriate patients may benefit from this technology.

METHOD

A 6-year-old child with ASD underwent robotic assistant repair via Da-Vinci Robotic Systems. Venous cannulation was achieved by internal jugular and femoral veins (10F-14F) and arterial cannulation was performed via femoral artery under transesophageal echocardiography (TEE) guidance (10F). A 3 cm incision was made in the right fourth intercostal space, used for working and the camera port in the same time. The ports were placed considering not to damage the potential developing breast tissue. After the port implantation (8F) and cardiac arrest, the ASD repair was completed with primary closure technique.

RESULT

The perioperative period was uneventful and the patient was discharged from hospital 5 days after surgery.

CONCLUSION

ASD closure with robotic assistant was achieved in a large enough sized paediatric patient. With the development of thinner and shorter robotic arms, it will be possible to use robotic assistance more common during the repair of congenital heart diseases.

Transcatheter closure vs totally endoscopic robotic surgery for atrial septal defect closure: A single-center experience

BACKGROUND

Transcatheter closure is the preferred method for atrial septal defect (ASD) closure. Robotic surgery has become the least invasive technique for ASD closure. Therefore, we sought to evaluate the outcomes in patients who underwent ASD closure with transcatheter or robotic surgery techniques.

METHODS

A total of 462 patients underwent totally endoscopic robotic (n = 217) or transcatheter ASD closure (n = 245). Demographic data, perioperative data, and outcomes were compared.

RESULTS

The mean age was lower in the robotic surgery group than the transcatheter group (31.4 ± 11.8 vs 39.4 ± 13.2 years; P = .001). Ventilation time, intensive care unit (ICU) stay, and hospital stay was significantly lower in the transcatheter group. The postoperative new-onset neurological event was seen in one (0.5%) patient in robotic surgery, and four (1.6%) patients in the transcatheter closure group. New-onset atrial fibrillation was found to be higher in transcatheter closure (two vs seven patients; P = .133) group. Surgical conversion to a larger incision occurred in two patients (1%) in robotic surgery, while two patients (0.5%) underwent emergency median sternotomy due to device embolization to the main pulmonary artery. There was no mortality in both groups. During follow-up, one patient (0.5%) who underwent robotic surgery was reoperated, and two patients (0.8%) who underwent transcatheter procedure required surgical intervention due to device migration and severe residual shunting (P = .635).

CONCLUSION

Both transcatheter and robotic surgery approaches had excellent outcomes but transcatheter closure had shorter hospital and ICU stays. Robotic surgery provides a similar complication risk that can be comparable to the transcatheter approach as well as patient comfort and cosmetic advantage over the other surgical techniques.

Right anterolateral mini-thoracotomy without inferior vena cava cannulation for atrial septal defect repair in small children: A feasible technique

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Minimally invasive cardiac surgery is limited in small children.

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Femoral cannulation has high risks in children with body weight <15 kg.

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7–12 cm skin incision called “mini-thoracotomy” was used with less cosmetic results.

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Reducing the length of incision without femoral cannulation needs new approach.

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This technique is safe and feasible for atrial septal defect repair.

Objective

To evaluate the effectiveness and safety of right anterolateral mini-thoracotomy without inferior vena cava (IVC) cannulation for closing atrial septal defect (ASD) in small children.

Methods

From February 2016 to August 2017, 10 patients (the mean age was 18.5 ± 10.1 months and the mean weight was 8.3 ± 2.1 kg) underwent ASD closure via right anterolateral mini-thoracotomy. The superior vena cava cannula was placed through the right internal jugular vein. A 3–4 cm incision was made on the right chest. The pleural and pericardial cavities were filled with CO₂ and the heart was beating during the surgery. Blood returned from IVC was drained by a right heart sucker. All ASDs were closed using artificial patch, continuous suture. Mean follow-up was 18 months (range, 15–22 months).

Results

No post-operative complications or deaths occurred. Mean operation time and mean cardiopulmonary bypass time were 140.5 ± 27.8 min and 50.3 ± 16.5 min, respectively. These patients were extubated within the first 6 h. The intensive care unit stay time and the post-operative hospital stay time were 19.6 ± 2.6 h and 7.1 ± 1.2 days, respectively. Follow-up transthoracic echocardiography showed no residual shunts or lung atelectasis.

Conclusions

The right anterolateral mini-thoracotomy without IVC cannulation is feasible for repairing ASD in small children. This technique is effective and safe and can be used as a therapeutic option for ASD.

The Mid-term Results of Thoracoscopic Closure of Atrial Septal Defects

Background and Objectives

Recently, minimally invasive surgical (MIS) techniques including robot-assisted operations have been widely applied in cardiac surgery. The thoracoscopic technique is a favorable MIS option for patients with atrial septal defects (ASDs). Accordingly, we report the mid-term results of thoracoscopic ASD closure without robotic assistance.

Subjects and Methods

We included 66 patients who underwent thoracoscopic ASD closure between June 2006 and July 2014. Mean age was 27±9 years. The mean size of the ASD was 25.9±6.3 mm. Eleven patients (16.7%) had greater than mild tricuspid regurgitation (TR). The TR pressure gradient was 32.4±8.6 mmHg.

Results

Fifty-two (78.8%) patients underwent closure with a pericardial patch and 14 (21.2%) underwent direct suture closure. Concomitant procedures included tricuspid valve repair in 8 patients (12.1%), mitral valve repair in 4 patients (6.1%), and right isthmus block in 1 patient (1.5%). The mean length of the right thoracotomy incision was 4.5±0.9 cm. The mean cardiopulmonary bypass time was 159±43 minutes, and the mean aortic cross clamp time was 79±29 minutes. The mean hospital stay lasted 6.1±2.6 days. There were no early deaths. There were 2 reoperations. One was due to ASD patch detachment and the other was due to residual mitral regurgitation after concomitant mitral valve repair. However, there have been no reoperations since July 2010. There were 2 pneumothoraxes requiring chest tube re-insertion. There was one wound dehiscence in an endoscopic port. The mean follow-up duration was 33±31 months. There were no deaths, residual shunts, or reoperations during follow-up.

Conclusion

Thoracoscopic ASD closure without robotic assistance is feasible, suggesting that this method is a reliable MIS option for patients with ASDs.

Robotics in percutaneous cardiovascular interventions

INTRODUCTION

The fundamental technique of performing percutaneous cardiovascular (CV) interventions has remained unchanged and requires operators to wear heavy lead aprons to minimize exposure to ionizing radiation. Robotic technology is now being utilized in interventional cardiology partially as a direct result of the increasing appreciation of the long-term occupational hazards of the field. This review was undertaken to report the clinical outcomes of percutaneous robotic coronary and peripheral vascular interventions. Areas covered: A systematic literature review of percutaneous robotic CV interventions was undertaken. The safety and feasibility of percutaneous robotically-assisted CV interventions has been validated in simple to complex coronary disease, and iliofemoral disease. Studies have shown that robotically-assisted PCI significantly reduces operator exposure to harmful ionizing radiation without compromising procedural success or clinical efficacy. In addition to the operator benefits, robotically-assisted intervention has the potential for patient advantages by allowing more accurate lesion length measurement, precise stent placement and lower patient radiation exposure. However, further investigation is required to fully elucidate these potential benefits. Expert commentary: Incremental improvement in robotic technology and telecommunications would enable treatment of an even broader patient population, and potentially provide remote robotic PCI.

The Development of Robotic Technology in Cardiac and Vascular Interventions

Robotic technology has been used in cardiovascular medicine for over a decade, and over that period its use has been expanded to interventional cardiology and percutaneous coronary and peripheral vascular interventions. The safety and feasibility of robotically assisted interventions has been demonstrated in multiple studies ranging from simple to complex coronary lesions, and in the treatment of iliofemoral and infrapopliteal disease. These studies have shown a reduction in operator exposure to harmful ionizing radiation, and the use of robotics has the intuitive benefit of alleviating the occupational hazard of operator orthopedic injuries. In addition to the interventional operator benefits, robotically assisted intervention has the potential to also be beneficial for patients by allowing more accurate lesion length measurement, stent placement, and patient radiation exposure; however, more investigation is required to elucidate these benefits fully.

Robotic atrial septal defect closure

Atrial septal defect (ASD) is one of the most common congenital cardiac diseases. This pathology can be treated with percutaneous devices. However, some of the ASDs are not suitable for device closure. Also, there may be device-related late complications of transcatheter ASD closure. Currently, robotic surgical techniques allow surgeons to close ASDs in a totally endoscopic fashion with a high success rate and a low complication rate. This study demonstrates the basic concepts and technique of robotic ASD closure.

Atrial Fibrillation After Robotic Cardiac Surgery

Atrial fibrillation is one of the commonest complications after cardiac surgery and it is associated with considerable morbidity and increase in mortality. Recently, robotic approach to many heart operations has become feasible and reproducible. We here investigate and review the incidence of atrial fibrillation after robotic cardiac surgery. We found that its incidence is overall low and less than in conventional heart surgery.

Totally thoracoscopic closure of ventricular septal defect without a robotically assisted surgical system: a summary of 119 cases

OBJECTIVES

To summarize the clinical outcomes of totally thoracoscopic closure of a ventricular septal defect (VSD).

METHODS

Totally thoracoscopic VSD closure was performed in 119 patients (66 boys; mean age, 7.1 ± 3.6 years). An additional 35 patients undergoing open-chest VSD closure were selected as a control group. Using 3 port incisions in the right chest, pericardiotomy, bicaval occlusion, atriotomy, and VSD closure were performed by thoracoscopy without the aid of a robotically assisted surgical system.

RESULTS

Cardiopulmonary bypass and aortic crossclamp times were 42.2 ± 9.8 and 32.5 ± 7.3 minutes, respectively. There were no deaths but 1 patient required insertion of a permanent pacemaker as a result of postoperative atrioventricular conduction block. The length of stay in the intensive care unit (11.0 ± 2.6 vs 22.9 ± 4.9 hours, P < .01) or postoperative hospital stay (4.2 ± 1.1 vs 6.6 ± 2.1 days, P < .03) in the thoracoscopic group were shorter than in the control group. The percentage of patients who required postoperative opioid analgesics in the thoracoscopic group was lower than in the control group (31.9% vs 74.2%, P < .001). Rate of blood transfusion during the operation (17.6% vs 65.7%, P = .001) and the postoperative use of opioid analgesics (31.9% vs 74.3%, P = .003) in the thoracoscopic group was lower than in the control group. Transesophageal echocardiographic analysis 4.6 ± 2.3 months after the operation showed complete closure of the defect.

CONCLUSIONS

Totally thoracoscopic closure of VSD through a 3-port entry was safe and effective.