Thoracoscopic ASD closure is a reliable supplement for percutaneous treatment

Abstract

Objective: To determine the feasibility and effectiveness of endoscopic atrial septal defect (ASD) closure when percutaneous ASD closure is impossible or has failed. Patients: Between March 1997 and February 2003, 74 patients (63% female, mean (SD) age 44 (16) years) underwent an endoscopic ASD closure. Median preoperative New York Heart Association functional class was I. Clinical and echocardiographic follow up was obtained for all patients (mean (SD) 38 (19) months). Patients were assessed for scar aesthetics, procedure related pain, functional recovery, and overall patient satisfaction. Results: ASD closure was successful in all patients (two primum ASD, 68 secundum ASD, four sinus venosus type). Patch repair was performed in 42%. Mean aortic cross clamp and cardiopulmonary bypass times were 54 (24) minutes and 98 (35) minutes, respectively. There were no in-hospital deaths and no conversions to sternotomy. Complications included one iliac vein stenting, one femoral arterioplasty, two revisions for suspected bleeding, and seven cases of atrial fibrillation. Two patients required late reoperation: one for atrial thrombus and another for tricuspid regurgitation. Echocardiographic control confirmed complete ASD closure in 71 patients and a small residual shunt in three patients. Ninety three per cent of the patients were highly satisfied with very low procedure related pain and 97% felt they had an aesthetically pleasing scar. Conclusion: Endoscopic ASD closure can be safely done with a high degree of patient satisfaction. It is now the authors' exclusive surgical approach whenever percutaneous treatment is not indicated or has failed.T ranscatheter closure of secundum atrial septal defects (ASDs) is standard practice and excellent results have been reported with low early and late complication rates, both in low and higher risk patient groups.1 2 However, ostium primum and sinus venosus ASDs as well as large secundum defects with limited septal margins and fenestrated or aneurysmal interatrial septa are less suitable for percutaneous closure.3 In addition, surgery may be indicated for unsuccessful or complicated percutaneous closure of ASD or persistent foramen ovale. [3][4][5][6] To avoid a median sternotomy and its related discomfort, we have been operating on these patients with a minimally invasive endoscopic technique. We report our experience with this technique. METHODS PatientsBetween March 1997 and February 2003, 74 patients underwent endoscopic ASD closure. Mean (SD) age was 44 (16) years (range 10-74 years) and 63% were female. All patients were referred by a cardiological team who judged the patient unsuitable for percutaneous closure. In three patients, surgical closure followed an unsuccessful percutaneous procedure. All patients who presented were accepted for the technique. All procedures were primary surgical procedures. Median preoperative New York Heart Association (NYHA) functional class was I (range I-IV) and the preoperative rhythm was sinus rhythm in 68 patients (92%), atrial fibrillatio...

Clinical outcomes of minimally invasive endoscopic and conventional sternotomy approaches for atrial septal defect repair

“…Percutaneous ASD closure may also be associated with serious cardiac complications, such as device migration, neurologic events, obstruction to systemic and pulmonary venous drainage, endocarditis, postprocedural thromboemobolic risk, and less efficacious long-term results. 13,15 Although minimally invasive endoscopic approaches have been previously applied with excellent outcomes, 6,7,9 traditionalists remain concerned that the less invasive approach provides cosmesis at the expense of the excellent patient outcomes typical of conventional surgery. Our results suggest that minimally invasive endoscopic ASD closure and conventional ASD closure result in similar patient outcomes as closure via conventional sternotomy.…”

Clinical Outcomes of Minimally Invasive Endoscopic and Conventional Sternotomy Approaches for Atrial Septal Defect Repair

“…Percutaneous ASD closure may also be associated with serious cardiac complications, such as device migration, neurologic events, obstruction to systemic and pulmonary venous drainage, endocarditis, postprocedural thromboemobolic risk, and less efficacious long-term results. 13,15 Although minimally invasive endoscopic approaches have been previously applied with excellent outcomes, 6,7,9 traditionalists remain concerned that the less invasive approach provides cosmesis at the expense of the excellent patient outcomes typical of conventional surgery. Our results suggest that minimally invasive endoscopic ASD closure and conventional ASD closure result in similar patient outcomes as closure via conventional sternotomy.…”

“…Minimally invasive surgical approaches include partial sternotomy, right mini-thoracotomy (MT), and totally endoscopic repair for closure of adult ASD. [4][5][6] These techniques have been shown to have high rates of successful closure, low morbidity and decreased length of stay in hospital (LOS); [6][7][8][9] however, concerns exist regarding improved cosmesis at the expense of increased cardiopulmonary bypass (CPB) duration and possible compromised patient outcomes. 10 In Canada, there is a widespread belief among patients and the medical community that minimally invasive techniques are not available, forcing patients to seek specialized care in the United States.…”

Surgical device closure a new technique of ASD closure

“…Attention has shifted from the ability to perform the procedure safely to cosmesis 1 . Attempts have been made to close the defect through smaller incisions [2][3][4] and to avoid median sternotomy 2 . The advent of transcatheter closure shifted the treatment of straightforward secundum atrial septal defect from the surgeon to the interventional cardiologist.…”