Experiences in surgical closure of atrial septal defect with anterior mini-thoracotomy approach

Lateral atrial septal defect closure with induced ventricular fibrillation versus cardioplegic arrest

Minimally invasive surgical closure of atrial septal defects is gaining widespread acceptance and can be performed via a right midaxillary thoracotomy. In addition, the procedure can be performed in ischaemic cardiac arrest or fibrillation with a core body temperature between 34°C and 36°C.

OBJECTIVES

We present our single-centre results of paediatric patients who underwent surgical atrial septal defect II closure via lateral thoracotomy.

METHODS

Retrospective analysis. Patients were divided into a cardiac arrest group and a cardiac fibrillation group. All procedures were performed via right midaxillary thoracotomy through a single incision without side ports.

RESULTS

All 37 consecutive patients between March 2019 and August 2022 (median age 3 years; percentile 25th: 2; 75th: 5 years) in both groups were free of mortality and postoperative morbidity such as haemodynamically relevant residual shunt or malignant arrhythmias. Cardiopulmonary bypass time was significantly shorter in the fibrillation group (mean: 34.7 min vs 52.6 min, P = 0.01), and all patients were weaned off the ventilator immediately postoperatively. Length of the intensive care unit stay was not different between the 2 groups. Postoperative hospital stay was significantly longer in patients with cardiac arrest (mean: 5.6 days vs 4.9 days, P = 0.04). Postoperative laboratory parameters did not differ between the 2 groups. All patients were discharged with normal left ventricular function and normalized cardiac enzymes.

CONCLUSIONS

Minimally invasive closure of an atrial septal defect during atrial fibrillation is a safe procedure with results comparable to those of an induced cardiac arrest procedure.

Outcomes Following Surgical Repair of Sinus Venosus Atrial Septal Defects: A Systematic Review and Meta-Analysis

BACKGROUND

Sinus venosus atrial septal defect (SVASD) is a rare congenital cardiac anomaly comprising 5% to 10% of all atrial septal defects. Although surgical closure is the standard treatment for SVASD, data on outcomes have been confined to small cohorts. Thus, we conducted a systematic review of the outcomes of SVASD repair.

METHODS AND RESULTS

The primary outcome was death. Secondary outcomes encompassed atrial fibrillation, sinus node dysfunction, pacemaker insertion, cerebrovascular accident, reoperation, residual septal defect, superior vena cava obstruction, and reimplanted pulmonary vein obstruction. Pooled incidences of outcomes were calculated using a random-effects model. Forty studies involving 1320 patients who underwent SVASD repair were included. The majority were male patients (55.4%), with 88.0% presenting with associated anomalous pulmonary venous connection. The weighted mean age was 18.6±12.5 years, and the overall weighted mean follow-up period was 8.6±10.4 years. The in-hospital mortality rate was 0.24%, with a 30-day mortality rate of 0.5% reported in 780 patients. Incidences of atrial fibrillation, sinus node dysfunction, pacemaker insertion, and cerebrovascular accident over the long-term follow-up were 3.3% (2.18%-4.93%), 6.5% (5.09%-8.2%), 2.23% (1.34%-3.57%), and 2.03% (0.89%-2.46%) respectively. Reoperation occurred in 1.36% (0.68%-2.42%) of surgeries, residual septal defect in 1.34% (0.69%-2.42%), superior vena cava obstruction in 1.76% (1.02%-2.9%), and reimplanted pulmonary vein obstruction in 1.4% (0.7%-2.49%).

CONCLUSIONS

This is the first comprehensive analysis of outcomes following surgical repair of SVASD. The findings affirm the safety and effectiveness of surgery, establishing a reference point for evaluating emerging transcatheter therapies. Safety and efficacy profiles comparable to surgical repair are essential for widespread adoption of transcatheter treatments.

Effect of right anterolateral thoracotomy versus median sternotomy on postoperative wound tissue repair in patients with congenital heart disease: A meta-analysis

Right anterolateral thoracotomy (RAT) and median sternotomy (MS) are two major methods for treatment of congenital cardiac disease. But there are various types of surgery that provide a better operative outcome for the patient. Therefore, we carried out a meta-analysis to investigate the effects of these two methods in the treatment of wound tissue, hospitalization and so on, to find out which surgery method could provide the best short-term effect. In this research, we chose an English controlled trial from 2003 to 2022 to evaluate the influence of right anterolateral thoracotomy and median sternotomy on the short-term outcome of Cardiopulmonary bypass (CPB), time of operation, time spent in the hospital, and the time of scar formation. Our findings suggest that the RAT method was associated with a shorter surgical scars for congenital heart disease operations compared to MS with respect to post-operation scars (WMD, 3.55; 95% CI, 0.04, 7.05; p = 0.05). The RAT method is better suited to the needs of patients who care about their injuries. Nevertheless, in addition to other surgery related factors which might affect post-operative wound healing, we discovered that MS took a shorter time to perform CPB compared with RAT surgery (WMD, - 1.94; 95% CI, -3.39, -0.48; p = 0.009). Likewise, when it comes to the time taken to perform surgery, MS needs less operational time compared to RAT methods (WMD, -12.84; 95% CI, -25.27, -0.42; p = 0.04). On the other hand, the time needed for MS to recover was much longer compared to the RAT (WMD, 0. 60; 95% CI, 0.02, 1.18; p = 0.04). This indicates that while RAT is advantageous in terms of shortening the duration of post-operative scar, it also increases the time needed for surgical operations and CPB.

Minimal invasive approaches for pediatric & congenital heart surgery: safe, reproducible, more cosmetic than through sternotomy, and here to stay

Minimal invasive approaches through small thoracic incisions for the isolated repair of the most common congenital heart defects have been around for decades. However, the lack of belonging in established surgical training curriculums compared to the traditional median sternotomy, the requirement for more technical expertise and a certain learning curve, has limited their use, being routinely performed only by certain surgeons in specialized centers. More recently, through cumulated and increasingly mediatized shared experience, remote teaching potential through universally accessible surgical videos and simulation, the approach has gained traction and acceptance, and even established itself as the new norm in many centers. In this review, we present technically focused aspects of our own experience and protocols which have evolved over time, along with a brief overview of the literature pertaining to other right thoracic approaches, and some comparison to established results using the traditional median sternotomy. An increasing body of literature, produced more frequently and across all continents, seems to suggest that repairs of congenital heart defects through a minimal invasive right thoracic approach are becoming the new norm, as they are reported to be safe and reproducible, with excellent surgical results, and an obvious superior and more desirable cosmetic result. This comes at a cost of additional training and learning curve by surgeons, who are not offered the technique as part of their standard professional training curriculum.

Minimal-Access Atrial Septal Defect (ASD) Closure

Progress towards the development and adoption of minimally invasive techniques in cardiac surgery has been slower than that seen in other surgical specialties. Congenital heart disease (CHD) patients represent an important population within cardiac disease, of which atrial septal defect (ASD) is one of the most common diagnoses. Management of ASD encompasses a range of minimal-access and minimally invasive approaches, including transcatheter device closure, mini-sternotomy, thoracotomy, video-assisted, endoscopic, and robotic approaches. In this article, we will discuss the pathophysiology of ASD, along with diagnosis, management, and indications for intervention. We will review the current evidence supporting minimally invasive and minimal-access surgical ASD closure in the adult and paediatric patient, highlighting peri-operative considerations and areas for further research.

Mini right axillary thoracotomy for congenital heart defect repair can become a safe surgical routine

OBJECTIVE

Owing to its obvious cosmetic appeal, minimal invasive repair of congenital heart defects (CHDs) through the mini right axillary thoracotomy is becoming routine in many centres. Besides cosmesis, and before becoming a new norm, it is important to establish its outcomes as safe compared to repairs through traditional median sternotomy.

METHODS

Between 2013 and 2021, 116 consecutive patients underwent defect repairs through mini right axillary thoracotomy. Patient, operative data, and hospital outcomes were compared to contemporary mini right axillary thoracotomy and sternotomy series.

RESULTS

There was no mortality or need for approach conversion (mean age 4.3 years, range 0.17-17, mean weight 18.6 kg, range 4.8-74.4) in 118 repairs for atrial septal defect, ventricular septal defect, partial anomalous pulmonary venous return, partial atrioventricular canal with mitral cleft, scimitar syndrome, double-chambered right ventricle, cor triatriatum, and tricuspid valve repair. Protocol included on-table extubation, achieved in 97 children, with 23 outliers leading to 0.7 average hours of mechanical ventilation (range 0-66 hours), indwelling chest drain time of 2.6 days (range 1-9 days), intensive care stay of 1.8 days (range 1-10 days), and hospital stay of 3.9 days (range 2-18 days). Late revisions were required in one patient after scimitar repair for scimitar vein stenosis at 2 weeks, and in another for repair of superior caval vein stenosis after a Warden operation at 2 months; reoperations (5/116 = 4.3%) were successfully performed through the same mini right axillary incision.

CONCLUSIONS

While providing obvious cosmetic advantages, the minimally invasive right axillary thoracotomy approach for the surgical repair of common CHDs yields excellent results and is safe compared to the benchmark median sternotomy approach.

Anterolateral minithoracotomy versus median sternotomy for the surgical treatment of atrial septal defects: a meta-analysis and systematic review

Background

To compare the short-term safety and efficacy of right anterolateral minithoracotomy (ALMT) and median sternotomy (MS) for the surgical treatment of atrial septal defects (ASDs).

Methods

The PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched for comparative studies focusing on surgical repair of ASDs via ALMT or MS published up to the end of April 27, 2020. We used random-effect or fixed-effect models to obtain pooled estimates.

Results

A total of 7 publications, including 665 patients (ALMT 296 and MS 369), were included. Age (WMD: 1.80 years, 95% CI 0.31–3.29), weight (WMD: − 0.91 kg, 95% CI − 5.57 to 3.75), sex distribution (OR: 1.00, 95% CI 0.74–1.35) and surgical type (patch or direct closure) (OR: 1.00, 95% CI 0.67–1.49) were comparable in the ALMT group and MS group. No significant differences in the success rate (OR 0.23; 95% CI 0.05–1.07) or severe complication rate (OR 1.46; 95% CI 0.41–5.22) were found between the ALMT group and the MS group. In addition, the differences in the cardiopulmonary bypass (CPB) time (WMD 6.33; 95% CI − 1.92 to 14.58 min, p = 0.13) and the operation time (WMD 5.23; 95% CI − 12.49 to 22.96 min, p = 0.56) between the ALMT group and the MS group were not statistically significant. However, the ALMT group had a significantly longer aortic cross-clamp time (2.37 min more, 95% CI 1.07–3.67 min, p = 0.0003). The intubation time was 1.82 h shorter (95% CI − 3.10 to − 0.55 h; p = 0.005), the intensive care unit (ICU) stay was 0.24 days shorter (95% CI − 0.44 to − 0.04 days; p = 0.02), and the postoperative hospital stay was 2.45 days shorter (95% CI − 3.01 to − 1.88 days; p < 0.00001) in the ALMT group than in the MS group. Furthermore, the incision length was significantly shortened by 8.97 cm in the ALMT group compared with the MS group (95% CI − 9.36 to − 8.58 cm; p < 0.00001).

Conclusions

In the surgical treatment of ASD, ALMT and MS are equally safe and effective in terms of success rates and severe complication rates. The surgical procedures are equally difficult, but ALMT is associated with a faster functional recovery and better cosmetic results. Compared to MS, ALMT is the better choice for select ASD patients.

Surgical Closure of Atrial Septal Defects in Young Children-A Review of Anesthesia Care in Sternotomy and Thoracotomy Approaches

OBJECTIVES

To review and compare the anesthetic management of atrial septal defect (ASD) closures via mini lateral thoracotomy and sternotomy approaches.

DESIGN

Retrospective analysis.

SETTING

Single- center pediatric quaternary care hospital.

PARTICIPANTS

Patients aged <8 years of age undergoing ASD closure.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Outcome measures included anesthetic technique, total amount and type of analgesics, pain scores, procedure duration, complications, blood transfusion requirements, and duration of stay. Each group had 15 patients. All patients in the sternotomy group received 0.25% bupivacaine subcutaneous infiltration. Eleven of the 15 thoracotomy patients received a fascial plane block, including serratus anterior and erector spinae blocks, and 3 received subcutaneous infiltration. There was no difference in opioid consumption intraoperatively or in the first 24 hours after surgery (0.28 ± 0.24 mg/kg morphine equivalents in thoracotomy group and 0.21 ± 0.12 mg/kg in sternotomy group). Duration of procedure and cardiopulmonary bypass duration were longer in the thoracotomy group. There was no difference in cross-clamp duration between groups. There was no difference in intensive care unit or hospital stay.

CONCLUSIONS

The authors reviewed perioperative pain management strategies used in surgical ASD closures. Different fascial plane blocks were used. This study has paved way to design a randomized control trial to compare various regional techniques for cardiac surgeries and identified opportunities for improved pain assessment scoring in children after cardiac surgery.

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.

Mini-thoracotomy versus median sternotomy for atrial septal defect closure: Should mini-thoracotomy be applied as a standard technique?

BACKGROUND

This study aims to compare outcomes of minithoracotomy versus median sternotomy for atrial septal defect closure.

METHODS

Between January 2012 and May 2017, a total of 44 patients (8 males, 36 females; mean age 33.86 years; range, 14 to 63 years) who underwent atrial septal defect repair through mini-thoracotomy or median sternotomy in our clinic were retrospectively analyzed. Pre-, intra-, and postoperative data of the patients were recorded.

RESULTS

There was no significant difference in the cardiopulmonary bypass and cross-clamp times between the groups, although the duration of operation was shorter in the mini-thoracotomy group (p=0.001). No significant difference was observed between the groups in terms of early mortality, neurological complications, and residual atrial septal defect. The mean mechanical ventilation time and length of intensive care unit and hospital stay were statistically significantly shorter, and the amount of bleeding was statistically significantly lower in the mini-thoracotomy group (p=0.001 for all).

CONCLUSION

Mini-thoracotomy should be kept in mind as a favorable alternative to sternotomy following a satisfactory learning curve period with less cost and higher patient benefit.

Minimally invasive endoscopic surgery versus catheter-based device occlusion for atrial septal defects in adults: reconsideration of the standard of care

Objectives

Percutaneous ostium secundum atrial septal defect (ASD II) closure has become the standard of care for treatment of congenital ASD II in adults. Nevertheless, patients are frequently ineligible for this technique due to challenging morphology. In such cases, closure via minimally invasive cardiac surgery (MICS) is an appropriate treatment option. The aim of this study is to compare outcomes of MICS and use of a percutaneous Amplatzer septal occluder (ASO) device for treatment of ASD II in adults.

Methods

From July 2002 to June 2014, 95 patients underwent MICS for congenital ASD II closure. During the same period, 169 patients underwent ASO procedure. Outcomes in terms of remaining ASD II, new onset atrial fibrillation (AF), post-interventional stroke, myocardial infarction and the post procedural implementation of anticoagulation were compared.

Results

Apart from age (38.3 ± 12.7 vs 49.6 ± 15.7 years, P  < 0.0001) the groups did not differ in baseline characteristics. A significantly higher rate of residual ASD II was found in the ASO group at 3 months (0% vs 30.8%, P  < 0.0001), 6 months (0% vs 15.9%, P  < 0.0001) and 12 months follow-up (0% vs 7.1%, P  = 0.005). A significantly higher rate of new-onset AF was seen in the ASO group (0% vs 9.5%, P  = 0.0008).

Conclusions

MICS for ASD II is a safe and reproducible procedure with 0% mortality in our cohort. More complete closure of ASD, decreased rates of new onset AF and decreased need for oral anticoagulation are the advantages of the MICS procedure. Compared with the current standard of care, the MICS approach is feasible regardless of ASD morphology.

Atrial septal defects - clinical manifestations, echo assessment, and intervention

Atrial septal defect (ASD) is a common congenital abnormality that occurs in the form of ostium secundum, ostium primum, sinus venosus, and rarely, coronary sinus defects. Pathophysiologic consequences of ASDs typically begin in adulthood, and include arrhythmia, paradoxical embolism, cerebral abscess, pulmonary hypertension, and right ventricular failure. Two-dimensional (2D) transthoracic echocardiography with Doppler is a central aspect of the evaluation. This noninvasive imaging modality often establishes the diagnosis and provides critical information guiding intervention. A comprehensive echocardiogram includes evaluation of anatomical ASD characteristics, flow direction, associated abnormalities (eg, anomalous pulmonary veins), right ventricular anatomy and function, pulmonary pressures, and the pulmonary/systemic flow ratio. The primary indication for ASD closure is right heart volume overload, whether symptoms are present or not. ASD closure may also be reasonable in other contexts, such as paradoxical embolism. ASD type and local clinical expertise guide choice of a percutaneous versus surgical approach to ASD closure.