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.

Total Thoracoscopic versus Robotic Surgery for Repair of Atrial Septum Defect: A Propensity Matching Score Analysis

Robotic surgery can provide less surgical trauma than conventional surgery, but differences between robotic and thoracoscopic surgery for atrial septal defect (ASD) repair are not well documented. To explore whether ASD can be repaired by thoracoscopic surgery or robotic surgery, which procedure is less invasive, and the difference in outcomes between these two procedures, this article studies 160 patients undergoing ASD repair at our institution. Sixty-five patients underwent total thoracoscopic surgery and 95 patients underwent total endoscopic robotic surgery. Propensity score matching yielded 64 well-matched patient pairs. Surgical data and early postoperative outcomes between the two matched groups were analyzed and compared. The results show that thoracoscopic and robotic surgery to repair ASD are both safe and reliable, and the early curative effect is good. However, regardless of similar complication rates, robotic surgery has a shorter time, less postoperative drainage, and faster recovery than thoracoscopic surgery.

Intermediate-Term Outcomes of Totally Endoscopic Atrial Septal Defect Repair on Beating Heart in Small Children

Objective: Manipulation in a narrow surgical field and risks of femoral arterial (FA) complications are difficulties when applying totally endoscopic surgery (TES) for congenital heart disease in small children. This study was conducted to investigate the feasibility of TES for atrial septal defect (ASD) repair in children weighing 13 to 20 kg. Methods: From July 2016 to July 2021, 14 patients with a mean age of 5.4 ± 2.2 years and mean weight of 15.57 ± 2.39 kg (range, 13 to 20 kg), underwent TES for ASD repair on the beating heart. FA cannulation was established through a Dacron graft. An additional FA cannula (2 to 4 Fr smaller than the expected size) was placed into the left FA in case of increasing arterial pressure. Three 5 or 5.5 mm trocars and one 12 mm port were used. The surgical field was filled with CO₂. No aortic clamp, no aortic root needle, and no snaring of the inferior vena cava were used. The mean follow-up time was 37.9 ± 12.5 months. Results: Cardiopulmonary bypass (CPB) installation time, CPB time, and operation time were 42.6 ± 16.5 min, 113.1 ± 33.1 min, and 209.6 ± 50.6 min, respectively. Total drainage volume was 125.4 ± 89.2 mL. Patients did not need analgesics on day 4 or 5 after surgery. No severe complications, including arterial complications, were recorded during follow-up. Conclusions: By optimizing the surgical field and setting the FA cannula correctly, TES for ASD closure is feasible in small children weighing between 13 and 20 kg.

Case report: Total thoracoscopic repair of sinus of Valsalva aneurysm combined with ventricular septal defect

The sinus of Valsalva aneurysm (SVA) is a rare cardiac anomaly. It can develop into the heart failure if it ruptures, which requires early intervention. However, such congenital anomalies are usually treated using a median sternotomy approach. Here, we report a rare case of SVA combined with a ventricular septal defect in which the patient underwent patch repair of the defects under a total thoracoscopy approach. She was discharged uneventfully and showed no residual shunt or aortic regurgitation postoperatively or at the 12-month follow-up. The total thoracoscopic approach for SVA repair is technically feasible.

Total endoscopic repair of atrial septal defect under on-pump beating heart

Background

We previously reported the techniques for total endoscopic atrial septal defect (ASD) repair on hearts arrested with cardioplegia through three small incisions in the chest wall without aid of a surgical robotic system. The optimal results motivated us to use total thoracoscopic technology for ASD on perfused beating hearts.

Methods

From 2010 to 2017, 161 patients with a mean age of 28.31±12.34 years who underwent non-robotically assisted total thoracoscopic closure for ASD were included in this study, and those patients were also divided into two groups, including group A and group B. In group A, 115 patients underwent the procedure on beating hearts without aorta cross-clamped; in group B, 46 patients underwent the procedure on hearts arrested with cardioplegia with aorta cross-clamped. Cardiopulmonary bypass (CPB) was peripherally achieved as well.

Results

Total thoracoscopic ASD closures were successfully performed without in-hospital mortality or other serious complications in all patients of both groups. Dacron or bovine patches were used in 81 and 32 patients in the two groups, respectively. Duration of operation, duration of CPB, aorta cross-clamped time, duration of mechanical ventilation, the length of intensive care unit (ICU) and post-operative hospital stay in group A, were all shorter than those in group B (P<0.05). There was no statistically significant difference in blood transfusion during operation or post-operation thoracic drainage. During follow-up, echocardiograms at 3, 30, 90 and 365, showed no residual shunt or tricuspid regurgitation.

Conclusions

Total thoracoscopic closure of ASD without assistance of a surgical robotic system on beating heart is safe and feasible and can be used as a therapeutic option for ASD, and by using the mentioned technique, less injuries are applied to patients.

Totally endoscopic atrial septal defect repair using transthoracic aortic cannulation in a 10.5-kg-boy

INTRODUCTION

Although totally endoscopic surgery (TES) has been widely applied for the treatment of atrial septal defect (ASD), small children receive few benefits from this technique due to risks of the femoral cannulation.

CASE PRESENTATION

A 23-month-old boy, weighing 10.5 kg, with the diagnosis of sinus venosus ASD underwent successful repair by TES. We performed this surgery through 4 small trocars (one 12 mm trocar and three 5 mm trocars), without robotic assistance. In this case, we inserted the arterial cannula directly into the ascending aorta instead of the femoral artery (FA). The defects were repaired on the beating heart with CO₂ insufflation.

DISCUSSION

Femoral cannulation in small children pose some risks, such as increased arterial line pressure, critical lower limb ischaemia, and post-operative iliac or femoral arterial stenosis. Putting the arterial cannula directly into the ascending aorta is a good solution but is difficult to be performed through TES, especially in small children. The major concern of operating on the beating heart is the air embolism, which requires special preventative methods.

CONCLUSION

Transthoracic aortic cannulation may facilitate TES in small children. However, the safety and efficacy of this approach needs to be validated by larger studies preferably randomised controlled trials.

Totally Endoscopic Cardiac Surgery for Atrial Septal Defect Repair on Beating Heart Without Robotic Assistance in 25 Patients

Supplemental digital content is available in the text.

Objective

The aim of the study was to investigate the effectivity and safety of totally endoscopic cardiac surgery without robotic assistance for atrial septal defect (ASD) closure on beating hearts.

Methods

Twenty-five patients (adults/children: 15/10) underwent ASD closure using nonrobotically assisted totally endoscopic approach on beating heart. Three 5-mm trocars and one 12-mm trocar were used, only the superior vena cava is snared, filling the pleural and pericardial cavities with CO₂, and the heart was beating during the surgery. Twenty-three patients had isolated secundum ASD (2 of which had severe tricuspid regurgitation) and two patients had ASD combined with partial anomalous pulmonary venous connection. All ASDs were closed using artificial patch, continuous suture; tricuspid regurgitations were repaired and the anomalous pulmonary veins were drained to the left atrium.

Results

No postoperative complications or deaths occurred. Mean ± SD operation time and mean cardiopulmonary bypass time were 267.2 ± 44.6 and 156.1 ± 33.6 min, respectively. These patients were extubated within the first 5 hours, and the volume of blood drainage on the first day was less than 80 mL. Four days after surgery, patients did not need analgesics and were able to return to normal activities 1 week postoperatively.

Conclusions

Totally endoscopic operation for ASD closure on beating heart is safe, with short recovery period, and surgical scars are of high cosmetic value, especially in a woman and girl.

Minimally invasive video-assisted surgical closure of atrial septal defects: a safe approach

OBJECTIVE

To compare the safety and effectiveness of video-assisted thoracic surgery (VATS) versus conventional median sternotomy (open) in the repair of secundum atrial septal defect (ASD) or patent foramen ovale (PFO).

DESIGN

Among 415 consecutive patients undergoing open or VATS ASD/PFO closure between 1993 and October 2012, 153 patients were compared using 2:1 frequency matching (n=102 open vs 51 VATS). Matching variables include age, gender, body surface area, past medical history of neurologic events, and need of patch closure. Median age was 43 years (3-71 years), and 67% were female.

RESULTS

There were no early deaths in either group. There were no conversions to open sternotomy. Although mean cross-clamp time (14.5±7.6 vs 26.3±13.2 minutes, P<.001) and bypass time (31.7±13.8 vs 60.9±20.9 minutes, P<.001) were longer in the VATS group, patients who underwent VATS had shorter postoperative ventilation time (7.5±6.4 vs 4.4±2.8 hours, P=.03) with 62.7% extubated in the operating room, along with shorter intensive care unit stay (26.7±10.8 vs 19.1±9.9 hours, P<.001) and hospital stay (5.2±1.9 vs 3.5±0.9 days, P<.001). At early follow-up (mean 1.5 years, maximum 4.2 years), there was no difference in need for reintervention. Of the 27 patients who underwent VATS ASD/PFO closure for a neurologic event, none had a recurrence.

CONCLUSION

The use of VATS provides a safe, equally effective alternative to conventional sternotomy for ASD/PFO closure, using a less invasive approach.

Totally thoracoscopic repair of atrial septal defect reduces systemic inflammatory reaction and myocardial damage in initial patients

Background

To compare the effect of totally thoracoscopic with conventional, open repair of atrial septal defect.

Methods

Forty atrial septal defect cases were divided into two groups by surgical approach: totally thoracoscopic approach (group A, n = 20) and conventional open approach (group B, n = 20). In group A, surgical procedures were performed through three portal incisions in the right lateral chest wall under thoracoscopic vision without the aid of a computerized robotic surgical system. Notably, all operations were completed by one surgeon who had just begun using this technique. In group B, the atrial septal defects were repaired in conventional open fashion. Clinical outcomes and serum levels of tumor necrosis factor α (TNF-α), interleukin-6 (IL-6), interleukin-10 (IL-10), intercellular adhesion molecule 1 (ICAM-1), and creatine kinase isoenzyme-myocardial band (CK-MB) for the two groups were evaluated and compared.

Results

All operations were performed successfully without serious complications. Durations of cardiopulmonary bypass (CPB), CPB setup, aortic cross-clamping, and operative procedure were significantly longer in group A than in group B (P < 0.05). The recovery times for body temperature and laboratory values of leukocytes were significantly shorter for group A than for group B (P < 0.05). There were no differences in durations of postoperative assisted ventilation or intensive care unit and hospital stays, volumes of blood transfused intraoperatively or thoracic drainage, or medical costs between the two groups. Serum levels of inflammatory factors (TNF-α, IL-6, IL-10, and ICAM-1) and CK-MB increased significantly in both groups after surgery. However, 6 h and 12 h after surgery, levels of these inflammatory factors and CK-MB were significantly lower in group A than in group B (P < 0.05).

Conclusions

Thoracoscopic cardiac surgery is technically feasible and safe, with less trauma and quicker recovery even when done by a surgeon newly introduced to the technique.

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.

Evaluation of different minimally invasive techniques in the surgical treatment of atrial septal defect

OBJECTIVE

Minimally invasive cardiac surgery is becoming a safe and cosmetic alternative to standard median sternotomy (SMS). In the present retrospective study, we reviewed our results and experience with the totally thoracoscopic (TTS) and right vertical infra-axillary thoracotomy (RVIAT) techniques for atrial septal defect closure compared with SMS.

METHODS

From December 2010 to February 2012, 198 patients underwent repair of atrial septal defect using the TTS technique (n = 66), RVIAT (n = 59), or SMS (n = 73). Cardiopulmonary bypass was achieved peripherally in the TTS group and directly in the RVIAT and SMS groups.

RESULTS

The procedures were performed successfully in all 3 groups, and no in-hospital mortality occurred. No patient required conversion to SMS in the TTS group, although 2 patients did so in the RVIAT group. The cardiopulmonary bypass time was 87.26 ± 21 minutes in the TTS group, 41.81 ± 13.97 minutes in the RVIAT group, and 36.99 ± 10.84 minutes in the SMS group (P < .01). The crossclamp time was 32.86 ± 13.36, 22.54 ± 9.08, and 19.23 ± 6.92 minutes in the TTS, RVIAT, and SMS groups, respectively (P < .01). The total incision length in the SMS group (7.45 ± 1.54 cm) was longer than that in the other groups (TTS group, 5.21 ± 0.63 cm; RVIAT group, 6.48 ± 1.37 cm); the difference was statistically significant (P < .01).

CONCLUSIONS

The TTS technique and RVIAT can both be performed with favorable cosmetic and acceptable clinical results for closing atrial septal defects. They are promising alternatives to SMS and merit additional study.