Minimally Invasive ASD Repair With Limited Resources
In the past, atrial septal defects (ASD) have been repaired via open heart surgery through a median sternotomy. Recent advances have allowed ASD closure via catheter inserted devices and also via minimally invasive surgical techniques utilizing endoscopy and robot-assisted surgery. Described below is a minimally invasive approach to ASD closure that is performed without specialized equipment while utilizing basic equipment that is readily available to most surgeons.
This video describes the steps of a minimally invasive, resource limited ASD closure, and the relevant technical pearls and pitfalls are emphasized. Cannulation of the femoral artery and vein was performed for cardiopulmonary bypass. Upper extremity venous drainage was achieved with a peripheral bicaval venous cannula. A 4 cm anterior chest incision was required for ASD visualization. The pericardium was opened 2 cm above the phrenic nerve, and pericardial stay sutures provided retraction of the diaphragm. The superior and inferior vena cava were snared with vessel loops to provide a hemostatic seal. A vertical atriotomy was performed and extended toward the atrial appendage. Atrial retraction sutures allowed for excellent exposure without additional retractors. A bovine pericardial patch was used to close the ASD, using a running 5-0 Prolene™ suture. The atrium is closed in two layers with a 4-0 Prolene™ suture. Cryoablation of the intercostal nerves two interspaces above and two interspaces below the incision and liposomal bupivacaine injections were performed for postoperative analgesia.
The final result was a tension-free ASD closure with no interatrial communication seen on the postoperative echocardiogram.
ASD closure can be accomplished through a variety of means. As outlined here, this procedure is possible with a minimally invasive approach, without the need for specialized equipment, and with limited resources.