Atrial septal defect surgical closure
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Atrial Septal Defect Microchapters | |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Priyamvada Singh, MBBS [[2]]; Cafer Zorkun, M.D., Ph.D. [3]; Assistant Editor-In-Chief: Kristin Feeney, B.S. [[4]]
Overview
Surgical closure is the most common treatment method for atrial septal defect patients and has been the gold standard for many years. Many surgeons prefer more minimally invasive techniques to avoid potential for additional complications. Special consideration must be taken into account for the age of the patient and the size of the defect involved.
Mechanisms of benefit
Indication
Contra-indications
Primary operation includes pericardial patch closure or direct suture closure. Tricuspid valve repair should be performed for significant tricuspid regurgitation (TR). Anomalous pulmonary venous drainage should be repaired. The Warden procedure (translocation of the superior vena cava to the right atrial appendage) may be applied to the sinus venosus ASD when the anomalous pulmonary venous drainage enters the mid or upper superior vena cava. A concomitant Maze procedure may be performed for intermittent/chronic atrial fibrillation/flutter. The surgical approach can be by right thoracotomy or sternotomy, and more limited incisions are feasible with either approach.
Early mortality is approximately 1% in the absence of PAH or other major comorbidities. Long-term follow-up is excellent, and preoperative symptoms decrease or abate. The incidence of atrial fibrillation/flutter is reduced when concomitant antiarrhythmic procedures (eg, Maze) are performed; however, atrial arrhythmias may occur de novo after repair.
The need for reoperation of residual/recurrent ASD is uncommon. Superior vena cava stenosis or pulmonary vein stenosis may occur after closure of sinus venosus ASD.
Surgical approaches for small atrial septal defects
In the case of a small atrial septal defect, a surgeon can perform a direct arterial and double venuous cannulation via a median sternotomy incision. Most small atrial septal defects can be repaired while the heart is under an a cardioplegia solution induced arrest utilizing a prolene suture.
Surgical approaches for larger atrial septal defects
In larger atrial septal defects, the atrium of the aorta can become distorted during closure. A superior defect, when closed directly, may result in an distortion of the aortic anulus. Instead, a synthetic patch made of Dacron or PTFE can be used to close the aorta. It is not recommended that synthetic patches be used for primary closure.[1]
Some atrial septal defects may have additional complications such as cleft mitral valves. This is commonly found in ostium primum defects. In this situation, a surgical approach must address correcting both, the atrial septal defect and the cleft mitral valve. Procedures such as mitral valve repair, involving the closure of the cleft mitral leaflet, may be merited to address and prevent mitral insufficiency. Some patients, depending on the severity of mitral insufficiency, may require a full mitral valve replacement.
In larger defects, it is essential to ensure the usage of a synthetic patch be placed strategically to allow anomalous pulmonary venous drainage, whereby blood is diverted from the left atrium. In this case, pulmonary venous return must be carefully monitored and assessed. Complications can arise resulting in localized pulmonary venous hypertension.
Surgical therapy
Surgical closure of an atrial septal defect involves opening up at least one atrium and closing the defect.
General techniques for engaging in surgical closure include:
- Median sternotomy
- Right anterolateral submammary sub pectoral (most preferred in females)
Other minimally invasive approaches include:
- Upper hemisteronomy
- Right parasternal
- Right submammary bikini line (for females)
- Limited median sternotomy (for males)
- Transxiphoid sternotomy (for children or young adults)
It is advised that an anterolateral approach only be used in adults as it may damage prepubescent girls during development of breast tissue.
ACC/AHA recommendations for interventional and surgical therapy
Supportive trial data
References
- ↑ Hopkins RA, Bert AA, Buchholz B, Guarino K, Meyers M (2004). "Surgical patch closure of atrial septal defects". Ann Thorac Surg. 77 (6): 2144–9, author reply 2149-50. doi:10.1016/j.athoracsur.2003.10.105. PMID 15172284.