Secundum ASD closure using a right lateral minithoracotomy: Five-Year experience in 122 patients

doi:10.1016/S0003-4975(02)04889-0

The Annals of Thoracic Surgery

Volume 75, Issue 5, May 2003, Pages 1527-1530

https://doi.org/10.1016/S0003-4975(02)04889-0 Get rights and content

Abstract

Background

Surgical closure of secundum atrial septal defect (ASD) is a standard procedure associated with very low mortality and morbidity. We evaluated outcomes in the era of catheter-based interventional closure and minimally invasive techniques.

Methods

From May 1996, February 2002, 177 patients with a body weight of more than 30 kg underwent surgical ASD closure. A right lateral minithoracotomy (LMT) was used in 122 patients and a conventional approach, in 55. Diagnoses included secundum ASD in 106 patients in the LMT group and 40 in the conventional group, sinus venosus ASD in 13 patients in each group, and status post interventional closure in 3 and 2 patients, respectively. Mean age was 37 ± 17 years in the LMT group and 43 ± 20 years, in the conventional group and mean body weight was 66 ± 17 kg and 70 ± 16 kg, respectively. In the LMT group, femoral cannulation was performed for cardiopulmonary bypass.

Results

Direct ASD closure was carried out in 67.2% of patients in the LMT group and 58.2% of those in the conventional group. The remaining patients had pericardial patch closure. There was one death: A patient in the conventional group who required explantation of an Amplatzer device because of infection died postoperatively. Average stay in the intensive care unit was 1.2 ± 0.5 days. Two patients required reoperation for residual ASD after direct closure; 1 sustained a temporary neurological deficit that resolved completely. On postoperative echocardiography, a minimal residual shunt was seen in only 3 patients. All patients were in good clinical condition with improved functional status at discharge from the hospital.

Conclusions

Secundum ASD closure by LMT has become as standard and safe an operation as the conventional technique and achieves good perioperative results and satisfactory long-term outcomes. Thus LMT is an attractive option for patients who are not suitable for closure using catheter-based devices.

Section snippets

Patient population

All patients with a body weight of more than 30 kg undergoing operation between May 1996 and February 2002 were prospectively evaluated. Indications for secundum ASD closure were based on standard criteria: the presence of clinical signs such as dyspnea, recurrent respiratory tract infections, arrhythmias, or both, and a major shunt on the atrial level leading to a pulmonary to systemic flow ratio greater than 1.5:1 [6].

A total of 177 patients were evaluated, 122 of whom underwent a right LMT

Intraoperative results

All operations were performed without incident. No conversions from the LMT to the conventional technique were required. Total duration of the operation was 126 ± 47 minutes in the LMT group and 117 ± 42 minutes in the conventional group (p = NS), and cardiopulmonary bypass averaged 67 ± 32 minutes versus 50 ± 29 minutes, respectively (p < 0.01). Closure of the defect was carried out using aortic cross-clamping in 35.2% of the LMT group versus 87.3% of the conventional group (p < 0.05) or

Comment

Beginning in the 1950s, surgical closure of an ASD was performed using either a lateral thoracotomy or a conventional median sternotomy. Since the 1990s, interventional approaches for simple pathological conditions and minimally invasive surgical techniques have been increasingly applied. The aim of this study was to evaluate current outcome with the LMT approach and to compare it with results using the conventional approach. Our experience with a right LMT indicate that surgical ASD closure

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Ultra-fast channel anesthesia (UFTA) can reduce the dosage of opioid narcotic drugs, allow for a rapid postoperative extubation and reduce the harmful stress response during perioperative period. However, there has been limited information about the application of UFTA during thoracoscopic closure of ventricular septal defect (VSD). The aim of this study was to assess the feasibility and safety of UFTA technique in patients undergoing totally thoracoscopic closure of VSD.
Seventy-eight patients were randomly divided into study (UFTA) and control (standard general anesthesia) group. Totally thoracoscopic closure of VSD was performed in all patients. Extubation in the study and control group was attempted in the operating room and the intensive care unit, respectively.
All patients in the study group were extubated in the operating room immediately after surgery, but 2 (6.1%) required reintubation. All the control group patients were extubated after a period of mechanical ventilation (3.0 ± 3.7 h vs 0 h in the study group, p = 0.001) in the intensive care unit. The intensive care and hospital stays in the study group were shorter than in the control group (4.3 ± 2.5 vs 13.4 ± 4.4 h, p = 0.003, and 5.8 ± 0.8 vs 6.5 ± 1.2 d, p = 0.047). The total costs for the treatment in the study group was lower than in the control group (5264 ± 514 vs 4662 ± 461 US dollars, p = 0.02).
UFTA and operating room extubation was feasible and safe in the majority of patients following totally thoracoscopic closure of VSD. This technique was associated with a shorter intensive care stay and lower overall costs for the surgical treatment.
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Thoracoscope-assisted Right Vertical Infra-axillary Mini-incision for Cardiac Surgery
2015, Heart Lung and Circulation
Citation Excerpt :
Therefore, transition from standard median sternotomy to a minimally invasive incision in cardiac surgery is very important. Recently, minimally invasive surgery has been used in cardiac surgery [4–6]. In 2013, our institution also reported one minimally invasive cardiac surgery technique “right vertical infra-axillary mini-incision” (RVAI) approach [7].
The thoracoscope and minimally invasive techniques have been effectively used in cardiac surgery.
The study included 27 consecutive patients (aged 24.8±17.6 years), who underwent cardiac surgery from January 2012 to July 2013. Six patients were diagnosed with mitral valve stenosis (MS), 17 patients with atrial septal defects (ADSs), and four with ventricular septal defects (VSDs). All the patients underwent thoracoscope-assisted right vertical infra-axillary mini-incision (TARVAI).
The procedure was successfully performed in all patients. For the patients with ASDs or VSDs, the times for cardiopulmonary bypass, aortic cross-clamping, operating (skin-to-skin), ventilation, ICU stay, postoperative hospital stay were 63±25 min, 28.1±15.5 min, 167.1±35.7 min, 5.2±2.7 h, 25.3±10.5 h, 8.7±3.6 days, and for the patients with MS, these were 143.3±25.2 min, 88.2±15.4 min, 236.5±48.5 min, 7.3±1.5 h, 36.7±9.1 h, and 13.5±4.4 days, respectively. The median postoperative drainage (total) for the ASD/VSD and MS patients was 136.3±54.5 ml and 203.8±94.4 ml, respectively.
In our institution, the TARVAI approach is feasible and safe in cardiac surgery. It may be particularly useful in young patients with simple congenital heart disease and mitral valve disease.
Totally thoracoscopic closure of ventricular septal defect without a robotically assisted surgical system: A summary of 119 cases
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To summarize the clinical outcomes of totally thoracoscopic closure of a ventricular septal defect (VSD).
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.
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.
Totally thoracoscopic closure of VSD through a 3-port entry was safe and effective.
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Catheter-based closure is preferable in patients with secundum ASD and suitable anatomy [24–26]. However, in the ASD patients who are not suitable for catheter based treatment, minimally invasive surgical techniques including endoscopic repair or closure have been developed as an alternative method [6,26–28]. With the development of the robotic technologies and peripheral CPB, totally endoscopic repair or closure for ASD has been successfully conducted in a number of centres [12,14,29–32].
To evaluate the safety and efficacy of totally endoscopic repair of atrial septal defect (ASD).
A review of the literature was conducted. Studies were obtained from the following sources: MEDLINE, EMBASE, Web of Science and CENTRAL Library. Inclusion criteria were: (1) randomised controlled trials, non-randomised trials, observational studies, case series, and full text conference proceedings; (2) use of totally endoscopy closure of ASD; and (3) outcomes reported as clinical efficacy. When available, we also quantified the complication rates from each included study. Meta-analysis was performed on outcomes with a random-effects model.
Six studies met all inclusion criteria. The pooled average success rate of totally endoscopic ASD repair was 94.8% from a total of 114 cases (95% CI, 88.0% to 97.8%), with a minimal heterogeneity in the group of studies (Q value x² = 1.807, I² = 0.000). In the studies with no robotic assistance, an average success rate of totally endoscopic ASD repair was 96.9% (95% CI, 85.9–99.4%), with a minimal heterogeneity in the two studies (Q value x² = 0.683, I² = 0.000). There were few complications for totally endoscopic ASD repair in the studies with and without robotic assistance. There were no statistically significant differences in success rates between robotically and non-robotically assisted totally endoscopic repairs (p > 0.05).
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Shinkawa and colleagues23 analyzed 73 patients undergoing pulmonary valve replacement and reported zero perioperative deaths.23 Mortality for ASD repair was zero in our study and has been reported to be 0% to 1.2%.24,25 This is an important observation that should be considered in evaluation of innovative nonsurgical means of accomplishing ASD closure.
Outcomes data for adults undergoing congenital heart surgery are limited. Previous analyses used administrative data or focused on single-center outcomes. We describe the most common operations, patient characteristics, and postoperative outcomes using a multicenter clinical database.
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A total of 5265 patients (68 centers) from the Society of Thoracic Surgeons Congenital Heart Surgery Database were included. Patients’ median age was 25 years (interquartile range, 20–35). Common preoperative risk factors included noncardiac abnormalities (17%) and arrhythmia (14%). Overall, in-hospital mortality was 2.1%, 27% had 1 or more complication, and median length of stay was 5 days. Common operations included right ventricular outflow tract procedures (21%) and pacemaker/arrhythmia procedures (20%). We further evaluated cardiopulmonary bypass procedures in more than 100 patients. Mortality ranged from 0% (atrial septal defect repair) to 11% (Fontan revision/conversion). Separate evaluation of the Society of Thoracic Surgeons Adult Cardiac Surgery Database revealed 39,872 adults undergoing congenital heart operations.
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Original article: cardiovascularSecundum ASD closure using a right lateral minithoracotomy: Five-Year experience in 122 patients

Abstract

Background

Methods

Results

Conclusions

Section snippets

Patient population

Intraoperative results

Comment

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Am J Cardiol

Ann Thorac Surg

Original article: cardiovascular
Secundum ASD closure using a right lateral minithoracotomy: Five-Year experience in 122 patients