Minimally invasive atrial septal defect closure: what is that?

Abstract

In this issue, Nezafati et al. [1] present their centre’s experience on off-pump atrial septal defect closure. Interestingly, they opted for caval inflow occlusion. Technological advances enable treatment for a wide range of congenital defects with often excellent results. As a result, both children and adults with congenital heart defects can now expect better outcomes. In recent years, however, surgical techniques have also centred around reduction of trauma and postoperative recovery time and also improvement of cosmetic results. However, these techniques have had selective application in congenital cardiac surgery when compared with adults. Open heart procedures for congenital lesions have been largely confined to operations where an intracardiac repair is carried out through the right atrium. A conventional full sternotomy approach for treatment of ‘simple’ lesions can now largely be avoided; instead, approaches vary from an anterior thoracotomy, inframammary thoracotomy and posterior thoracotomy to a limited inferior sternotomy. Nowadays, Atrial septal communications can usually be closed by an interventional cardiologist, unless morphological features are unfavourable. I would call this a true minimally invasive method. Any other attempt is rather ‘minimal access’ surgery. For the latter, a range of approaches are currently used: cardiopulmonary bypass (CPB)-assisted operations with minimal thoracotomies or ‘hybrid procedures’. The term ‘hybrid procedures’ refers to the combined use of direct surgical access to cardiac structures and catheterbased techniques to treat cardiac defects [2]. Nezafati et al. [1] describe a technique that lies somewhat in between. Even though any percutaneous programme is costly and requires a specific setup, Butera et al. [3] showed in a summary of data from studies comparing surgical versus percutaneous closure of atrial septal defects that treatment by a percutaneous approach has a significantly lower rate of either total or major early post-procedural complications compared with surgery. Economical issues are, however, a concern in many countries. In part, this seemed to have led the colleagues to aim for avoidance of CPB. Even though they report on a low overall complication rate, I would personally not advocate the use of this approach unless patients are carefully informed and selected, and all team members are acquainted in detail with all procedural steps. It is of note, however, that, for instance, mitral valve surgery is occasionally done on the beating heart too [4]. Personally, potential neurological sequelae and assurance of 100% closure of any interatrial connection would be my major concern. The described technique must be carried out within a limited time, both for visualizing the atrial septal defect margins and subsequent closure. It is of note that none of the defects could be closed with a patch. With regard to the surgical approach, I am in favour of staying well away from future breast tissue in prepubescent patients, especially in female patients. We have highlighted this issue and have since only opted for a midaxillary incision in young patients [5]. Beyond puberty, we cannulate the jugular vein and the femoral vessels, and perform only a very limited anterolateral thoracotomy. It will be interesting to see whether the described contribution triggers further applications. If cardiologists fail to close an atrial septal defect, a surgeon ought to offer the patient a safe and reliable treatment, keeping cosmetic aspects in mind.