Atrial septal defect ostium primum surgical closure
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Priyamvada Singh, M.B.B.S. [2]; Cafer Zorkun, M.D., Ph.D. [3]; Assistant Editor-In-Chief: Kristin Feeney, B.S. [4]
Overview
Surgical closure is the commonest treatment method for atrial septal defect and has been the gold standard for many years. Many surgeons prefer more minimally invasive techniques over the conventional sternotomy to avoid potentials for additional complications. Special consideration must be taken into account for the age of the patient and the size of the defect involved. Surgical closure is indicated for patients with primum, sinus venosus and coronary sinus type of atrial septal defects. However, ostium secundum atrial septal defects are commonly treated by percutaneous closure. With uncomplicated atrial septal defect, (without pulmonary hypertension and other comorbidities) the post-surgical mortality is as low as 1%.
Surgical Closure
Mechanisms of Benefit
Surgical closure involves closing the defect either by putting a pericardial patch or via direct suture closure. The decision for suture closure or patch closure depends on the morphology and size of defect. The closure of the defect prevents the left-to-right shunting of blood across the atrium and thus improving the circulation in heart. It is not recommended that synthetic patches be used for primary closure.[1].
Indications
Surgical closure is indicated for patients with primum, sinus venosus and coronary sinus type of atrial septal defects. Whereas, ostium secundum atrial septal defects are commonly treated by percutaneous closure.
Contraindications
Surgery is contraindicated in patients with severe irreversible pulmonary artery hypertension, Eisenmenger's syndrome and no evidence of a left-to-right shunt. Also, for uncomplicated cases with ostium secundum defects percutaneous closure is preferred.
General Considerations During Surgery
- Small to moderate defects with oval shape, can be closed with the help of sutures.
- Direct suture closure of large round defects may cause distortion of the atrium and aortic annulus. Thus, a patch closure is preferred in these cases.
- The patch can be made up of either natural (made out of the patient's pericardium) or artificial polytetrafluoroethylene, (dacron).
- Other operations that are done for anomalies associated with atrial septal defects are tricuspid valve repair for significant tricuspid regurgitation, repair for anomalous pulmonary venous drainage, Warden procedure (translocation of the superior vena cava to the right atrial appendage) for sinus venosus ASD when the anomalous pulmonary venous drainage enters the mid or upper superior vena cava and maze procedure for intermittent/chronic atrial fibrillation/flutter.
- Considerations in an ostium primum repair:
- Surgical closure is more complicated compared to other atrial septal defect repairs.
- The patch should be attached to the septum at the juncture of the mitral and tricuspid valves.
- Mitral valve repair, closure of the cleft mitral leaflet, annuloplasty and mitral valve replacement may be required to repair mitral insufficiency.
- Devices used are:
- Amplatzer septal occluder
- STARFlex septal occluder
- PFO Star
- HELEX
Steps During Surgery
- Median sternotomy or right anterolateral submammary sub pectoral incision (preferred in females).
- Sternum is split in the midline.
- Direct arterial and double venous (superior vena cava and inferior vena cava) cannulation are performed.
- Cardiopulmonary bypass applied.
- Aorta clamped.
- Heart is arrested with a cardioplegia solution.
- Right atrium is opened.
- Defect repaired either by continuous prolene suture or with the use of patch.
- Patch can be natural (autologus pericardium), bovine pericardium or artificial polytetrafluoroethylene (PTFE) or dacron.
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Post Surgical Follow Up
Due to the development of new minimally invasive techniques, percutaneous closure and improvement in surgical closure, most patients with atrial septal defect can start eating and ambulating within the first or second postoperative days. Also, most patients with surgical closure are discharged by the third or fourth postoperative days and patients with percutaneous closure, are generally discharged the next day. Surgical follow-up care is mostly for 1-2 months. Ideally, at least 1 follow-up echocardiogram to confirm complete closure of the atrial septal defect should be obtained. A cardiologist with good experience with heart defects should continue patient care. An yearly follow up to monitor development of complications like arrhythmias should be arranged. Six months of aspirin with or without clopidogrel is recommended for prevention of thrombus formation.
Complications
In some patients, surgical intervention may result in developing complications such as:
- Atrial fibrillation
- Infective endocarditis (primarily within the first 6 months post-surgery)
- Congestive heart failure
- Arrhythmia
- Pulmonary hypertension
- Cyanosis
- Paradoxical emboli
- Stroke
Post Surgical Prognosis
Post-surgical prognosis depends on type of defect, amount of shunting, age at surgery and pulmonary pressure. Early mortality is approximately 1% in the absence of pulmonary hypertension 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.
Age at Surgery and Pulmonary Pressure
- Age ≤ 25 years - Survival rates comparable to age and sex-matched control subjects.
- Age 25-40 years - Surgical survival reduced compared to surgical repair ≤ 25 years.
- Pulmonary artery pressures are normal- Survival comparable with surgery done at ≤ 25 years.
- Pulmonary artery pressure ≥40 mm Hg- Late survival 50% less than control rates.
- Age ≤ 45 years + no comorbidities like heart failure, pulmonary artery pressures ≤60 mm Hg. Mortality rate post surgery ≤1%.
- Age ≥ 60 years + no serious comorbidities - Atrial septal defect should be closed as early as possible as surgery can cause an improvement in symptoms.
- Life expectancy in surgically treated older patients is better than that of medically treated patients.
- Patient's age at time of surgical closure is a good predictor of development of atrial arrhythmias as complications.
- Atrial fibrillation, stroke, and heart failure common after surgical repair in adult.
Post Surgical Arrhythmias
- Surgical closure during childhood - Late onset supraventricular arrhythmias. The reason for these could be:
- Patchy fibrosis of the right atrium secondary to dilatation.
- SA node dysfunction.
- Surgical closure in adults:
- Atrial fibrillation may continue post surgery and require cardioversion and antiarrhythmics treatment.
- Age at surgery ≥40 years - 1/2 patients with preoperative normal sinus rhythm will develop postoperative atrial fibrillation.
- Common in the sinus venosus type than in the ostium secundum type.
2008 ACC/AHA Guidelines for the Management of Adults With Congenital Heart Disease (DO NOT EDIT)[2]
Recommendations for Postintervention Follow-Up (DO NOT EDIT)[2]
| Class I |
| "1. Early postoperative symptoms of undue fever, fatigue, vomiting, chest pain, or abdominal pain may represent postpericardiotomy syndrome with tamponade and should prompt immediate evaluation with echocardiography. (Level of Evidence: C) " |
| "2. Annual clinical follow-up is recommended for patients postoperatively if their ASD was repaired as an adult and the following conditions persist or develop: " |
| "a. PAH. (Level of Evidence: C) " |
| "b. Atrial arrhythmias. (Level of Evidence: C)" |
| "c. RV or LV dysfunction. (Level of Evidence: C)" |
| "d. Coexisting valvular or other cardiac lesions. (Level of Evidence: C)" |
| "3. Evaluation for possible device migration, erosion, or other complications is recommended for patients 3 months to 1 year after device closure and periodically thereafter. (Level of Evidence: C)" |
| "4. Device erosion, which may present with chest pain or syncope, should warrant urgent evaluation.(Level of Evidence: C)" |
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.
- ↑ 2.0 2.1 Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA; et al. (2008). "ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 52 (23): e1–121. doi:10.1016/j.jacc.2008.10.001. PMID 19038677.