Clinical outcomes of a combined transcatheter and minimally invasive atrial septal defect repair program using a 'Heart Team' approach

Minimally Invasive Surgical Repair of a Partial Atrioventricular Canal Defect in a 20-Year-Old Patient-A Case Report and Review of Literature

The association of an ostium primum-type defect with a cleft anterior mitral valve is known in the medical literature as the partial form of an atrioventricular canal. We present a case report about a 20-year-old woman with minimal symptomatology that discovered her pathology on routine echocardiography. Today, surgical operation remains the gold standard in such pathologies, especially mandatory when there is important valvular regurgitation and left-to-right shunt. Currently living in the era of fast and good cosmetic outcomes, minimally invasive and endovascular approaches should be developed and more often practiced. This scientific presentation is the first step in showing our department steps in performing minimally invasive surgeries as a routine.

Minimally invasive versus transcatheter closure of secundum atrial septal defects: a systematic review and meta-analysis

BACKGROUND

Limited data exists demonstrating the efficacy of minimally invasive surgery (MIS) compared to transcatheter (TC) closure of atrial septal defects (ASD). This systematic review and meta-analysis aims to compare post-operative outcomes of MIS versus TC repair in ASD closure.

METHODS

PubMed, Medline and EMBASE were searched from inception until June 2018 for randomised and observational studies comparing post-operative outcomes for MIS and TC repair. The studies were reviewed for bias using the ROBINS-I Score and pooled in a meta-analysis using STATA (version 15).

RESULTS

Six observational studies, involving 1524 patients assessing three primary and five secondary outcomes were included. Evidence suggests TC repair yielded shorter hospital stay (MD = 3.32, 95% CI 1.04-5.60) and lower rates of transient atrial fibrillation (AF) (RR = 0.48, 95% CI 0.20-1.15). TC repair patients also had fewer pericardial effusions (RR = 0.27, 95% CI 0.05-1.54, I² = 0.0%) and pneumothoraxes (RR = 0.18, 95% CI 0.04-0.80, I² = 0.0%). However, TC repair results in more minor residual shunts (RR = 6.04, 95% CI 1.69-21.63 in favour of MIS, I² = 39.0%). No differences were found for incidences of strokes (RR = 1.58, 95% CI 0.23-10.91, I² = 19.3%), unexpected bleeding (RR = 0.44, 95% CI 0.19-1.04, I² = 0.0%) and blood transfusion (RR = 0.39, 95% CI 0.09-1.59, I² = 0.0%).

CONCLUSIONS

MIS closure for ASD has similar outcomes compared to TC repair. However, the lack of randomised literature related to MIS versus TC repair for ASD closure warrants further evidence in the form of RCTs to further support these findings.

Transcatheter versus surgical closure of atrial septal defects: a systematic review and meta-analysis of clinical outcomes

BACKGROUND

Atrial septal defects are a common form of CHD and dependent on the size and nature of atrial septal defects, closure may be warranted. The paper aims to compare outcomes of transcatheter versus surgical repair of atrial septal defects.

METHODS

A comprehensive electronic literature search was conducted. Primary studies were included if they compared both closure techniques. Primary outcomes included procedural success, mortality, and reintervention rate. Secondary outcomes included residual defect and mean hospital stay.

RESULTS

A total of 33 studies were included in meta-analysis. Mean total hospital stay was significantly shorter in the transcatheter cohort across both the adult (95% confidence interval, mean difference -4.05 (-4.78, -3.32) p < 0.00001) and paediatric populations (95% confidence interval, mean difference -4.78 (-5.97, -3.60) p < 0.00001). There were significantly fewer complications in the transcatheter group across both the adult (odds ratio 0.45, 95% confidence interval, [0.28, 0.72], p < 0.00001) and paediatric cohorts (odds ratio 0.26, 95% confidence interval, [0.14, 0.49], p < 0.00001). No significant difference in overall mortality was found between transcatheter versus surgical closure across the two groups, adult (odds ratio 0.76, 95% confidence interval, [0.40, 1.45], p = 0.41), paediatrics (odds ratio 0.62, 95% confidence interval, [0.21, 1.83], p = 0.39).

CONCLUSION

Both transcatheter and surgical approaches are safe and effective techniques for atrial septal defect closure. Our study has demonstrated the benefits of transcatheter closure in terms of lower complication rates and mean hospital stay. However, surgery still has a place for more complex closure and, as we have demonstrated, shows no difference in mortality.

Minimally Invasive Surgery vs Device Closure for Atrial Septal Defects: A Systematic Review and Meta-analysis

Device closure is the first-line treatment for most atrial septal defects (ASDs). Minimally invasive cardiac surgery (MICS) has been found safe and effective for ASD closure with comparable mortality/morbidity and superior cosmetic results compared to conventional median sternotomy. Our goal was to compare percutaneous versus MICS of ASDs. A systematic review was performed using PubMed and the Cochrane Library (end-of-search date on May 22, 2019). Meta-analyses were conducted using fixed and random effects models. In the present systematic review, we analyzed six studies including 1577 patients with ASDs who underwent either MICS (n = 642) or device closure (n = 935). Treatment efficacy was significantly higher in the MICS (99.8%; 95% CI 98.9-99.9) compared to the device closure group (97.3%; 95% CI 95.6-98.2), (OR 0.1; 95% CI 0.02-0.6). Surgical patients experienced significantly more complications (16.2%; 95% CI 13.0-19.9) compared to those that were treated with a percutaneous approach (7.1%; 95% CI 5.0-9.8), (OR 2.0; 95% CI 1.2-3.2). Surgery was associated with significantly longer length of hospital stay (5.6 ± 1.7 days) compared to device closure (1.3 ± 1.4 days), (OR 4.8; 95% CI 1.1-20.5). Residual shunts were more common with the transcatheter (3.9%; 95% CI 2.7-5.5) compared to the surgical approach (0.95%; 95% CI 0.3-2.4), (OR 0.1; 95% CI 0.06-0.5). There was no difference between the two techniques in terms of major bleeding, hematoma formation, transfusion requirements, cardiac tamponade, new-onset atrial fibrillation, permanent pacemaker placement, and reoperation rates. MICS for ASD is a safe procedure and compares favorably to transcatheter closure. Despite longer hospitalization requirements, the MICS approach is feasible irrespective of ASD anatomy and may lead to a more effective and durable repair.

Spectrum of morphological abnormalities and treatment outcomes in ostium secundum type of atrial septal defects: Single center experience in >500 cases

BACKGROUND

Transcatheter closure (TCC) has emerged as the first line treatment option for secundum type of atrial septal defects (ASD). Outcomes of TCC depend upon proper delineation of defect anatomy by transesophageal echocardiography (TEE). Stability and proper placement of the device mandates adequate rims and proper alignment to the septum. Failed or unfavorable morphology for TCC requires referral for surgical repair.

METHODS

We prospectively analyzed the ASD patients who were referred for treatment. The morphological features of the defect were evaluated and the outcomes of TCC studied. Patients who undergo TCC and surgical repair were followed for immediate and long-term outcome comparison.

RESULTS

Of the 512 patients who underwent treatment, TCC was attempted in 430/512 (83.2%) patients. It was successful in 393/430 (91.3%) patients. The remaining 119 patients underwent surgical patch closure. Twenty patients had failure of device alignment and device embolization occurred in 17 patients. Very large defect size ≥35 mm, absent or deficient posterior rim, absent/deficient inferior naval rim showed high chances for failure and formed major reasons for surgical referral. The surgical group had higher success (100%) across all anatomic variables. However, they had longer intensive care unit (ICU) and hospital stay (p < 0.001).

CONCLUSION

TCC offered a success rate of 91% in complex defects after TEE selection. Very large size and deficient inferior, posterior rims predicted failure of TCC. Surgery offered 100% success and it involved a longer hospital and ICU stay. The long-term clinical results were identical with both treatment modalities.