We describe our approach to patients with atrial septal defects, emphasizing a focus on reducing the cumulative trauma of care over the patient's lifetime. The presentation reviews surgical history, the evolution of our current technique, pitfalls, and controversies regarding the surgical and interventional repair of one of the most common congenital heart defects.
Original Title
Reducing the Trauma of Atrial Septal Defect Repair
We describe our approach to patients with atrial septal defects, emphasizing a focus on reducing the cumulative trauma of care over the patient's lifetime. The presentation reviews surgical history, the evolution of our current technique, pitfalls, and controversies regarding the surgical and interventional repair of one of the most common congenital heart defects.
We describe our approach to patients with atrial septal defects, emphasizing a focus on reducing the cumulative trauma of care over the patient's lifetime. The presentation reviews surgical history, the evolution of our current technique, pitfalls, and controversies regarding the surgical and interventional repair of one of the most common congenital heart defects.
Justine Chinn Undergraduate Fellow University of California, Los Angeles Redmond P. Burke Chief, Division of Cardiovascular Surgery The Congenital Heart Institute Miami Childrens Hospital and Arnold Palmer Hospital www.pediatricheartsurgery.com Overview of Atrial Septal Defect (ASD) An opening in the septum between the atria results in the flow of oxygenated blood from the left atrium back into the right atrium. This blood mixes with the deoxygenated blood of the right atrium. High flow through an ASD will result in a failure to thrive (poor growth/appetite and shortness of breath) and over time may result in arrhythmia, stroke, and/or pulmonary hypertension. Atrial septal defects are relatively common, occurring in 1 out of every 1500 live births. Common Types of ASD The is the most common type of ASD (6-10% of all CHD). The secundum ASD typically arises from an enlarged formen ovale or the inadequate growth of the septum secundum, or septum primum. The is a defect in the atrial septum creating deformities in the tricuspid and mitral valves. A occurs when the defect in the septum involves the venous inflow of the superior or inferior vena cava.
The technical evolution of the operation has resulted in a very safe procedure with low mortality rates. Patient survival is no longer an adequate measure of success. Jenkins KJ et al, JTCVS, January 2002 This suggests that we should refocus on improving long term patient health and decreasing the number of negative consequences.
Achieve complete anatomic repair. Inflict the least cumulative lifetime patient trauma.
How is this achieved? Through a united approach with interventional cardiologists. By finding the best incision for the job: Should ensure short/long term pain management and good aesthetic result. By implementing conditions that support stronger surgical abilities: Speed, Precision, and Adaptability are key. Unified Multi-Disciplinary Approach At Miami Childrens Hospital, all patients are presented in a combined conference with surgeons, cardiologists, anesthesiologist and nurses present. For selected patients with Secundum Atrial Septal Defect, we consider device closure the least traumatic form of therapy. For Sinus Venosus Defects, patients undergo surgical closure via median sternotomy and baffling of PAPVR For Primum ASD, patients undergo surgical closure via median sternotomy with cleft repair as needed. Patients who are found not to be suitable for device closure in the cath lab can undergo immediate surgery under one anesthetic. Collaboration ensures that each patient receives specialized treatment based on his/her individual needs. ASD Closures in 1996 Versus 2008 0 10 20 30 Number of Procedures Secundum ASD Sinus Venosus ASD Primum ASD Secundum ASD Sinus Venosus ASD Primum ASD 1996 (249 total CPB cases) 2008 (245 total CPB cases) ASD Closures: 1996 2008 Mean Weight (kg) 19.8 22.3 Mean LOS (days) 4.75 4.29 Our volumes reflect the evolution of therapy for ASD: Depending on the patients individualized needs, surgery may not always be the answer. Predicates for a Unified Approach A positive, innovative interaction between surgeons and cardiologists. On site availability of surgery, perfusion, anesthesia, and cardiology teams. Best surgical and device options available in one institution for fast and easy transitions.
Suggested criterion for selecting an operative approach for ASD closure: Maintain short and long term patient safety Cardiopulmonary Bypass Autologous Materials Enable excellent surgical technique Optimal cardiac repair Achieve a perfect functional outcome Pain free short and long term Normal strength and flexibility Create an optimal aesthetic result The only part of our work the patient can see.
Complications of transcatheter closure of ASD M S Spence. et. al. Heart. Dec 2005; 91(12): 1512 1514.
Long term safety is enhanced by using autologous material for repairs pericardium. This is a powerful factor in increasing long term stability.
Benefits of Pericardium: Its free We have 5 decades of experience with the material, and there is no uncertainty about long term effects in the circulation. There is no erosion into adjacent structures. When anchored by continuous suture, the likelihood of patch dehiscence is very rare, and embolization never occurs. A residual leak is rare. Each patch is customized to the patients defect, very low profile There is no need for long term anticoagulation or antibiotic prophylaxis.
Standard Incision Options: Sternotomy variants Full sternotomy with limited skin incision Partial lower sternotomy Transxyphoid incision (Non-sternotomy) Right anterior thoracotomy
Patient Safety: Cardiopulmonary Bypass Myocardial Protection Sternotomy: Cardioplegia is easy to administer, obstructed cannula easily adjusted Partial Sternotomy Aorta is under the manubrium: obstructs access. Thoracotomy: because the aorta is far from the surgeon, severe myocardial dysfunction may result from a failed cardioplegia infusion.
Aortic Cannulation/Clamp Sternotomy: Offers direct control for cannula insertion. Strong visibility makes it easy to manipulate to ensure good flows. Partial Sternotomy Aorta is under the manubrium: offers low visibility. Thoracotomy: Aorta is far from surgeon, and is difficult to cannulate, position, and suture. The creates the risk of catastrophic bleeding.
Favors Sternotomy approach Patient Safety: Cardiopulmonary Bypass Neuroprotection Sternotomy: Deairing is simple due to the direct control of anterior ascending aorta Lower Sternotomy Aortic vent is under the manubrium, risk of bleeding/embolism Thoracotomy: Deairing is difficult, due to complete lack of direct aortic control. The increases the risk of an air embolism and stroke.
Favors Full Sternotomy Excellent surgical technique has three characteristics, which may be enhanced or hindered by the incision. 1) Precision 2)Adaptability 3) Speed
Precision For sinous venosus ASD repair, precise suturing is critical to avoid pulmonary vein stenosis, baffle obstruction, and superior vena cava obstruction.
This level of suture precision from superior vena cava to inferior vena cava is difficult to achieve through a remote incision. Enhanced by Sternotomy approach Precision protects the conduction system Reported incidence: Great Ormond Street review of over 2000 patients (.6% complete heart block) Ann Thorac Surg. 2006 Sep;82(3):948-56; discussion 956- 7. Primum ASD and Sinus Venosus defects are closely related to the His Bundle and Sinus Node respectively. We have a zero incidence of temporary pacing or heart block after ASD repair. Fishberger et.al. Congenital cardiac surgery without routine placement of wires for temporary pacing. Cardiology in the Young 18(1):96-9 2008 Feb Enhanced by sternotomy approach Adaptability Unexpected problems are regularly encountered during open heart operations. These include: Loss of vascular control Difficult access to or exposure of lesions Prolonged ischemic times Bleeding Unanticipated anatomic variations The surgical response in these situations is to improve exposure, by enlarging a limited incision, or by converting to median sternotomy This leaves the patient whose primary concern was cosmetic, with the worst possible result a prolonged operation with a large incision or two separate incisions. facilitated by median sternotomy Consistent Results The medial sternotomy is used in more difficult surgeries because it is consistently effective. It provides surgeons with great visibility and the ability to adapt quickly. Anatomic repair via sternotomy is conceptually appealing. The surgery results in a safe and reliable repair in patients with a wide age spectrum Jensen H. et. Al. Eur J Cardiothorac Surg. 2014 Jun;45(6):1066-9. Speed Clearly enhanced by sternotomy approach The above is performed on a euthanized pig, with no pressure. Edited between each throw. This is a simple straight suture line, with a large needle. The above is performed on a living child, with performance pressure. No editing. Pericardial patch is placed with a small needle. Speed is essential during Sinus Venosus ASD repair Baffle suture lines are long, and the superior vena cava to right atrium patch suture lines are long. Remote suturing techniques result in extremely long ischemic times. Long ischemic times can result in serious injury to the heart. Functional Outcome Sternotomy No pectoral muscle is cut. No intercostal muscle is cut. No intercostal nerves are injured. No breast ennervation is injured. No breast tissue is cut. Sternum heals stronger.
Thoracotomy Pectoral muscle may be cut. Intercostal muscle will be cut. Intercostal nerves will be injured. Breast ennervation may be injured. Breast tissue may be cut. The anatomy of the intercostal nerve makes it susceptible to injury. Retractor placementinduce s mechanical deformation and damage Timmermanns et. al. Hernia. 2013 Feb;17(1):89-94 Favors Sternotomy approach Short Term Pain Management Local Anesthetic Infusion Catheters provide immediate pain relief. Miami Childrens Hospital performed the first prospective randomized trial of this technology in pediatric open heart surgery. Results show a significant reduction in narcotic requirement. Tirotta. et. al. Paediatr Anaesth. 2009 Jun;19(6):571-6 Can be used for all incisions Long Term Pain: Post Thoracotomy Pain Syndrome Pain after thoracotomy is very severe, probably the most severe pain experienced after surgeryPostthoracotomy Pain Management Problems Anesthesiology Clinics - Volume 26, Issue 2 (June 2008) - Copyright 2008 Saunders. Peter Gerner, MD Persistent postsurgical pain (PPP) after thoracotomy effect 50% to 80%. Nerve damage may play an important role. Adding epidural or IV racemic ketaminedid not lead to any reduction in pain Tena B. et.al. Clin J Pain. 2014 Jun;30(6):490- 500.
Favors Sternotomy Approach
Reliability of Sternotomy Studies support the variety of conditions in which median sternotomy provides unrivalled access to the mediastinum.
Gopal M. Et.al. S Afr Med J. 2013 Jun 5;103(10):732-5 Attending surgeon performs incision and closure, with three levels of running sutures: placed in the fascia, subcutaneous layer, and subcuticular layer. This technique provides ideal cosmetic results with no visible staples or stitches. Post-Op Results Sternotomy provides a safe, precise, and rapid repair with a strong functional and cosmetic result. Defect N LOS Morbidity/Mortality PFO 0 NA 0 Secundum 24 4.4 0 Sinus Venosus 10 3.9 0 Common Atrium 1 4.0 Coronary Sinus 0 NA 0 NOS 1 3.0 0 Our Current surgical Results for ASD closure: STS 2006 Need data for recent year Conclusions A unified approach to atrial septal defect repair, synthesizing a combination of interventional techniques and surgery, may optimize patient care.
If your goals in order of importance are: Maintain short and long term patient safety Enable excellent surgical technique Achieve a perfect functional outcome Create an optimal aesthetic result
then a median sternotomy with a limited skin incision may be the best approach for atrial septal defects.