Atrial Septal Defect Repair Research Articles

The ASD that Wouldn’t Go Away: An Unusual Case of ASD Device Failure in a Patient with Marfan Syndrome

Marfan syndrome patients have connective tissue abnormalities that predispose them to intracardiac defects and postoperative complications. We present a case of late onset ASD device failure secondary to device movement within the atrial septum in a girl with Marfan syndrome. This case study suggests that further studies are necessary to determine the optimal device and approach for ASD repair in this patient cohort.

Surgery for Residual Inferior Left-to-Right Atrial Shunt

We report the case of three female patients who were scheduled for surgical correction of residual left-to-right shunt after initial repair of sinus venosus atrial septal defect (SV-ASD) during childhood. After excluding the possibility of an hemodynamic intervention, all three patients underwent a successful surgical closure through a right mini sub-axillary approach by using total peripheral cannulation for cardiopulmonary bypass and leaving the inferior vena cava completely un-snared allowing for an optimal visualization of the residual atrial septal communication and avoiding extensive dissection of mediastinal structures.

Status of cardiovascular surgery in Japan: A report based on the Japan Cardiovascular Surgery Database 2017-2018. 1. Congenital heart surgery.

We aimed to analyze the mortality and morbidity associated with congenital heart surgery in Japan. Data on congenital heart surgeries performed between January 2017 and December 2018 were obtained from Japan Cardiovascular Surgery Database. The 20 most frequent procedures were selected, and mortalities and major morbidities associated with the procedures were analyzed. All procedures were classified into Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery mortality categories, and mortalities in each category were also analyzed. The mortality rates in atrial septal defect repair and ventricular septal repair were 0% and 0.2%, respectively. The mortality rates in more complex cases (tetralogy of Fallot repair, complete atrioventricular repair, bidirectional Glenn, and total cavopulmonary connection) were 2%-3%. The mortality rates in systemic-to-pulmonary shunt, total anomalous pulmonary venous connection repair, and the Norwood procedure were 4.9%, 11.1%, and 15.7%, respectively, which were not different from those reported in 2015-2016. The mortalities according to the Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery categories 1-5 were 0.3%, 2.7%, 2.9%, 5.9%, and 15.5%, respectively, and comparable to those of the Society of Thoracic Surgeons database (2013-2016). The mortality rates and frequency of complications in major surgical procedures for congenital heart disease in Japan in 2017-2018 will play an important role as a basis for trends in Japan and for comparison with results from other countries.

Iatrogenic cyanosis in children, a pitfall of atrial septal defect repair

AbstractToday surgical repair of the atrial septal defect (ASD) is considered as relatively a simple and safe procedure with minor to no morbidity and mortality. When a complication occurs after ASD repair, is associated with considerable morbidity and mortality, which is much higher than primary surgical procedure. We report two patients that underwent ASD repair with caval inflow occlusion without CPB with late presentations of iatrogenic diversion of IVC to LA and subsequent complications of right to left shunting.

Limited Utility of Surveillance Echocardiograms in Pediatric Patients with Isolated Secundum Atrial Septal Defects

Atrial septal defects (ASDs) are the third most common form of congenital heart defects worldwide.1 Most otherwise healthy pediatric patients with hemodynamically significant ASDs remain asymptomatic throughout childhood. Pulmonary vascular disease or atrial arrhythmias associated with long-standing ASDs rarely occur before late adolescence or early adulthood.2 In the absence of failure to thrive or frequent respiratory infections, most patients undergo elective ASD repair in early childhood (2-5 years of age).

Role of Transesophageal Echocardiography in Retrieval of Dislodged Atrial Septal Defect Device Occluder

AbstractTranscatheter atrial septal defect (ASD) device closure has emerged as a safe and effective alternative procedure for surgical ASD repair. However, ASD device malposition and embolization has been reported with an incidence of 0.5 to 1.1%. We report here a case of a 32-year-old male, who presented to the hospital 5 months after ASD device closure for routine follow-up. This case reports highlights the significance of transesophageal echocardiography (TEE) evaluation in successful surgical retrieval of a dislodged ASD Amplatzer device.

Adult congenital cardiac life-long needs evaluation in a low-middle income country, Pakistan.

Adult congenital heart diseases (ACHD) have distinct health care needs that require life-long care. Limited data is available from low-middle income countries (LMIC). This descriptive study conducted in Pakistan, aimed to assess patients and health care professionals understanding of the needs for ACHD care and the perceived barriers to care. A telephone survey was conducted of ACHD patients. An e mail survey was sent to the paediatric and adult cardiologists of five institutions (3 public and 2 private) that provide ACHD services in Pakistan. Descriptive statistics (frequencies, mean ± SD, median) were used for data analysis. A total of 128 ACHD patients were surveyed, 65 (51%) were females with a mean age of 29.4±10.4 years. Atrial septal defect repair was the most common surgical procedure. Mean age at surgery was 25.6±10.49 years, and a surgical follow-up period of 3.8±2.3 years. Majority (n=3, 60%) of the health care professionals (HCPs) responded that 75-100% of the ACHD surgical patients would need lifelong care, yet 10-25% return to their cardiology clinics. Most of the surveyed ACHD patients (89%, n=114) demonstrated a lack of understanding of life-long care after surgery due to not being communicated by their HCPs. Cost and travelling issues were the barriers highlighted by HCPs. Both ACHD patients (96%, n=122) and HCP (100%, n=5) underscored their interest in life long care. Majority of ACHD patients in Pakistan did not know that life-long follow-up is needed. Education regarding lifelong care for ACHD patients was identified as a means to alleviate the knowledge gap.

MitraClip Implantation in a Patient With Post-Surgical Repair of Primum Atrial Septal Defect and Residual Mitral Cleft

This paper presents the case of a 67-year-old female with primum atrial septal defect and congenital mitral cleft status-post surgical repair 40 years previously who was recently found to have severe mitral regurgitation. Percutaneous mitral valve repair was successfully performed using implantation of 2 MitraClips with mild residual mitral regurgitation. (Level of Difficulty: Advanced.)

Open heart surgery or echocardiographic transthoracic or percutaneous closure in secundum atrial septal defect: a developing approach in one Chinese hospital

BackgroundTo study the clinical manifestations and advantages of open-heart surgery and echocardiographic transthoracic or percutaneous closure with secundum atrial septal defect (ASD). The surgeon’s learning curve was also analyzed.MethodsIn all, 115 consecutive patients with ASD from May 2013 to May 2019 were enrolled. According to the operative procedure, patients were divided into three groups: group one (open repair group) (n = 24), where patients underwent ASD repair (ASDR) under cardiopulmonary bypass (CPB); group two (closed surgical device closure group) (n = 69), where patients (six patients ≤1 y and sixteen ≤10 kg) underwent transthoracic ASD occlusion under transesophageal echocardiographic (TEE) guidance; and group three (transcatheter occlusion group) (n = 22), where patients underwent percutaneous ASD occlusion under echocardiography. The clinical features and results of each group were analyzed. All patients were telephonically followed-up after 3 months.ResultsAll the three methods treating ASD were successfully performed in our hospital. It was also a typical developing history of congenital heart disease (CHD) surgery in China. One patient in the group two was transferred to emergency surgery for occluder retrieval and CPB-ASDR. Eight patients experienced failed transthoracic or percutaneous occlusion, two of whom underwent unsuccessful percutaneous closure at another hospital. Two patients each in the groups two and three were intraoperatively converted to CPB-ASDR. Two patient in the group three was converted to transthoracic occlusion surgery. All patients were discharged without any residual shunt. The three-month follow-up also did not show any residual shunt and occluder displacement.ConclusionIn low-weight, infants, or huge ASDs with suitable rim for device occlusion, transthoracic ASD closure was successfully performed. Based on knowledge of ASD anatomy and skilled transthoracic occlusion of ASD, surgeons can perform percutaneous occlusion of ASD under echocardiographic guidance.

Prolonged length of stay after surgery for adult congenital heart disease: a single-centre study in a developing country.

With the growing number of adults requiring operations for CHD, prolonged length of stay adds an additional burden on healthcare systems, especially in developing countries. This study aimed to identify factors associated with prolonged length of stay in adult patients undergoing operations for CHD. This retrospective study included all adult patients (≥18 years) who underwent cardiac surgery with cardiopulmonary bypass for their CHD from 2011 to 2016 at a tertiary-care private hospital in Pakistan. Prolonged length of stay was defined as hospital stay >75th percentile of the overall cohort (>8 days). This study included 166 patients (53.6% males) with a mean age of 32.05 ± 12.11 years. Comorbid disease was present in 59.0% of patients. Most patients underwent atrial septal defect repair (42.2%). A total of 38 (22.9%) patients had a prolonged length of stay. Post-operative complications occurred in 38.6% of patients. Multivariable analysis showed that pre-operative body mass index (odds ratio: 0.779; 95% confidence interval: 0.620-0.980), intraoperative aortic cross-clamp time (odds ratio: 1.035; 95% confidence interval: 1.009-1.062), and post-operative acute kidney injury (odds ratio: 7.392; 95% confidence interval: 1.036-52.755) were associated with prolonged length of stay. Predictors of prolonged length of stay include lower body mass index, longer aortic cross-clamp time, and development of post-operative acute kidney injury. Shorter operations, improved pre-operative nutritional optimisation, and timely management of post-operative complications could help prevent prolonged length of stay in patients undergoing operations for adult CHD.

Comparison of Short-Term Quality of Life between Percutaneous Device Closure and Surgical Repair via Median Sternotomy for Atrial Septal Defect in Adult Patients

Objective To compare the quality of life and psychological state of patients after receiving different closure treatments for atrial septal defect (ASD) and to explore some factors affecting the quality of life of patients after ASD closure. Methods Fifty-five patients who underwent percutaneous device closure of ASD (group A) and fifty-five patients who underwent surgical repair via median sternotomy of ASD (group B) were followed up from before to one year after surgery to assess their quality of life. We used the Medical Outcomes Study 36-Item Short-Form (SF-36) and the Hospital Anxiety and Depression Scale (HADS) to evaluate the quality of life of patients. Results Both groups had improved HADS scores after operation. In the comparison of the postoperative quality of life between the two groups, group A was superior to group B on some dimensions of the SF-36, and there was a significant difference in HADS scores. Age was negatively correlated with quality of life. Conclusions In adults over 18 years of age, the quality of life after surgical repair or percutaneous device closure of ASD improved significantly. Compared with surgical repair via median sternotomy, percutaneous device closure has a more significant effect on the improvement in some aspects of people’s quality of life.

Evolution and Current Results of a Unified Strategy for Sinus Venosus Surgery

Given recent reports of percutaneous closure of sinus venosus atrial septal defects, we reviewed our experience with surgical repair. Owing to the high incidence of arrhythmias with the two-patch technique, since 2001 we have used either one-patch repairs or the Warden procedure. A retrospective review was performed of pediatric patients undergoing sinus venosus atrial septal defect repair at our institution from January 1, 1990, to July 1, 2018. Standard demographic data such as echocardiographic and cross-sectional imaging along with operative details and clinical echocardiographic outcomes were collected. The cohort included 144 patients with a median age of 4.3 years (interquartile range, 8.5). Inferior SVASD was present in 24 patients (17%). A single autologous untreated pericardial patch was used for 114 patients (79%), a two-patch technique for 20 patients (14%, last performed in 2000), and a Warden procedure in 10 patients (7%). Median length of stay was 4 days (interquartile range, 2). On echocardiogram follow-up, no patient had pulmonary vein stenosis. One patient who had the Warden procedure required a balloon dilation of the superior caval vein 2 years postoperatively and a stent 3 years later. Two-patch patients were substantially less likely to be in normal sinus rhythm (41%) on postoperative electrocardiograms compared with the other two techniques (81% one-patch and 89% Warden, P= .02). The great majority of patients with sinus venosus atrial septal defects can be successfully repaired with a single patch of autologous pericardium. We transitioned to using either a single pericardial patch or the Warden procedure, resulting in a higher frequency of normal sinus rhythm on postoperative electrocardiograms.

Atrial septal defect closure via mini-thoracotomy in pediatric patients: Postoperative analgesic effect of intercostal nerve block.

In this study, we evaluated the efficacy of intercostal nerve block for postoperative pain management in pediatric patients undergoing atrial septal defect closure through a right lateral mini-thoracotomy. Between January 2016 and January 2019, a total of 63 pediatric patients (37 males, 26 females; mean age 34.8±26.8 months; range, 2 to 96 months) who underwent corrective congenital heart surgery for atrial septal defect closure through a right lateral mini-thoracotomy were retrospectively reviewed. The patients were divided into two groups as those (Group 1, n=33) receiving intercostal nerve block and general anesthesia and those (Group 2, n=30) receiving general anesthesia alone. Intravenous morphine at a dose of 0.03 mg/kg was applied as rescue analgesia to the patients with a Ramsay Sedation Scale score of >4 and Children"s Hospital of Eastern Ontario Pain Scale score of >7. The total analgesic requirement, adverse effects, duration of mechanical ventilation and length of stay in the intensive care unit were recorded. The mean duration of mechanical ventilation and intensive care unit stay was shorter in Group 1 compared to Group 2 (3.6±1.3 vs. 9.4±2.1 h; 23±2.6 vs. 30±7.2 h, respectively) (p<0.0001). The need for postoperative rescue analgesia was statistically significantly lower in Group 1 compared to Group 2 (0.3±0.5 mg vs. 1.1±0.9 mg, respectively) (p=0.003). The mean total morphine consumption was also lower in Group 1 compared to Group 2 (4.0±2.2 mg vs. 9.0±3.4 mg, respectively) (p<0.0001). Intercostal nerve block before thoracotomy closure in pediatric patients undergoing atrial septal defect repair under mini-thoracotomy provides early extubation, shorter mechanical ventilation duration and intensive care unit stay, and reduced analgesic requirements.

Open Heart Surgery with Cardiopulmonary Bypass using Dexmedetomidine‐based Monitored Anesthesia Care without Endotracheal intubation Improves Postoperative Recovery

BackgroundStudies have demonstrated the feasibility of performing awake cardiac surgery (ACS) in non‐intubated patients with consciousness and spontaneous breathing using epidural anesthesia. However, major concerns about severe complications of epidural anesthesia, such as epidural hematoma, have seriously hampered the development of ACS. Monitored anesthesia care (MAC) is a planned procedure during which the patients undergo local anesthesia together with sedation and analgesia. Dexmedetomidine (Dex), a highly selective α‐2 agonist, can facilitate fast recovery in patient undergoing cardiac surgery. We aimed to evaluate the feasibility and safety of Dex‐based MAC without intubation and the potential of achieving enhanced recovery after surgery (ERAS).MethodsWith patients’ consent, 11 patients scheduled to undergo cardiac surgeries under cardiopulmonary bypass (CPB) were arranged for MAC. Surgery was performed with a conventional median sternotomy. MAC composed of continuous Dex infusion (0.2 – 0.5 g/kg/hour) supplemented with low‐dose remifentanil/sufentanil, regional anesthesia and electroacupuncture was applied to satisfy the need for analgesia and sedation during cardiac surgery while avoid significant respiratory depression. 11 patients who routinely underwent general anesthesia (GA) that matched for age, gender and types of operation were used as controls. Intraoperative respiration and hemodynamics, postoperative vasoactive‐inotropic score (VIS), serum troponin I, complications and recovery after surgery were evaluated.Results11 cardiac surgeries including mitral valve replacements, valvoplasty, valve replacement plus valvoplasty, resection of atrial myxoma, and repair of atrial septal defect, were uneventfully accomplished under MAC. None of them required conversion to GA. The whole process of surgery was accompanied by adequate spontaneous breathing, stable hemodynamics, satisfactory surgical conditions, good patient satisfaction and no anesthesia awareness. Compared with GA group, intraoperative dosage of opioids and general anesthetics, VIS at 6 hours after entry into intensive care unit (ICU), serum cardiac troponin I concentrations, the time to drink and duration of ICU stay were significantly reduced in the MAC group (all p&lt;0.05).ConclusionThe minimally invasive Dex‐based MAC for heart surgery with CPB is safe and feasible. Moreover, it shows the potential of cardioprotection and enhanced recovery after surgery.Support or Funding InformationStudy supported in part by a NSFC grant(81774108)

Repair of isolated atrial septal defect in infants less than 12 months improves symptoms of chronic lung disease or shunt-related pulmonary hypertension.

Infants with isolated atrial septal defects are usually minimally symptomatic, and repair is typically performed after infancy. Early repair may be considered if there is high pulmonary blood flow and reduced respiratory reserve or early signs of pulmonary hypertension. Our aim was to review the characteristics and outcomes of a cohort of patients who underwent infant repair at our institute. The study included 56 infants (28 female, 19 trisomy 21) with isolated atrial septal defect (age: 8 months (1.5-12), weight: 6 kg (2.8-7.5), echo Qp/Qs: 1.9 ± 0.1) who underwent surgical closure (20 fenestrated). Three groups were identified: 1) chronic lung disease and pulmonary hypertension (group A: n = 28%); 2) acutely unwell infants with pulmonary hypertension but no chronic lung disease (group B: n = 20, 36%); and 3) infants with refractory congestive heart failure without either pulmonary hypertension or chronic lung disease (group C: n = 9, 16%). Post-operatively, pulmonary hypertension infants (47/56) showed improvement in tricuspid annular plane systolic excursion z-score (p < 0.001) and right ventricular systolic/diastolic duration ratio (p < 0.05). All ventilator (14.3%) or oxygen-dependent (31.6%) infants could be weaned within 2 weeks after repair. One year later, weight z-score increased in all patients and by +1 in group A, +1.3 in group B and +2 in group C. Over a median follow-up of 1.4 years, three patients died, four patients continued to have pulmonary hypertension evidence and two remained on targeted pulmonary hypertension therapy. Atrial septal defect repair within the first year may improve the clinical status and growth in infants with early signs of pulmonary hypertension or those requiring respiratory support and facilitate respiratory management.

Intraoperative localization of cardiac conduction tissue regions using real-time fibre-optic confocal microscopy: first in human trial.

The aim of this study was to evaluate the feasibility and safety of fibre-optic confocal microscopy (FCM) using fluorescein sodium dye for the intraoperative location of conduction tissue regions during paediatric heart surgery. The pilot study included 6 patients undergoing elective surgery for the closure of isolated secundum atrial septal defect aged 30 days to 21 years. FCM imaging was integrated within the normal intraoperative protocol for atrial septal defect repair. Fluorescein sodium dye was applied on the arrested heart. FCM images were acquired at the atrioventricular node region, sinus node region and right ventricle (RV). Total imaging time was limited to 3 min. Any adverse events related to the study were recorded and analysed. Subjects received standard postoperative care. Trained reviewers (n = 9) classified, de-identified and randomized FCM images (n = 60) recorded from the patients as presenting striated, reticulated or indistinguishable microstructures. The reliability of reviewer agreement was assessed using Fleiss' kappa. The FCM imaging instruments were integrated effectively into the cardiac surgery operating room. All adverse events found in the study were deemed expected and not related to FCM imaging. Reticulated myocardial microstructures were found during FCM imaging at atrioventricular node and sinus node regions, while striated microstructures were observed in RV. Reliability of agreement of reviewers classifying the FCM images was high (Fleiss' kappa: 0.822). FCM using fluorescein sodium dye was found to be safe for use during paediatric heart surgery. The study demonstrates the potential for FCM to be effective in identifying conduction tissue regions during congenital heart surgery. NCT03189134.

Long-term outcome of atrial septal defect (ASD) repair by the figulla flex II ASD occluder: A retrospective cohort study at a referral heart center in Iran

Long-term outcome of atrial septal defect (ASD) repair by the figulla flex II ASD occluder: A retrospective cohort study at a referral heart center in Iran

Right Minithoraсotomy as a Standard Approach for Mitral Valve Surgery

&#x0D; Background. Minimally invasive mitral valve surgery provides many advantages for patients.&#x0D; The aim. To investigate and represent our own experience in minimally invasive mitral valve surgery, and to describe the operative technique.&#x0D; Materials and methods. The study was included 100 consecutive patients who underwent a minimally invasive mitral valve repair or replacement through the right lateral minithoracotomy from June 2017 to December 2019.&#x0D; Results. Mitral valve repair was performed in 87 patients (87%), and 13 patients (13%) were required mitral valve replacement. In 24 patients (24%), concomitant procedures were performed: tricuspid valve repair, atrial septal defect repair and left atrial myxomectomy. Ring anuloplasty was performed in all patients who underwent mitral valve repair. Additional methods of correction were used in accordance to the lesion anatomy: neochords implantation, cleft and leaflet perforation closure, leaflet resection, Alfieri (edge-to-edge) stitch, posterior leaflet plication. There was no in-hospital and 30-day mortality. Post-operative strokes were not reported. No wound complications were observed in the femoral cannulation area. The total length of stay in a hospital was 6 ± 1.46 (3–9) days. There were no cases of mitral valve insufficiency greater more than mild degree after mitral valve repair at the time of discharge.&#x0D; Conclusions. Minimally invasive mitral valve surgery can be performed as a routine standard approach, provides safe and effective correction of the mitral valve defects, allows excellent results of mitral valve repair and replacement in various abnormalities. Minimally invasive approach enables to perform a large number of reconstructive valve techniques and perform simultaneous correction of atrial septal defects, tricuspid valve repair and atrial neoplasm removal.

Nursing Intervention of Nonstop Minimally Invasive Tricuspid Valve Forming with Simultaneous Atrial Flutter After Secondary Cardiac Surgery: A Case Report

We discuss the nursing intervention of nonstop minimally invasive tricuspid valve forming with simultaneous atrial flutter after secondary cardiac surgery. Patient is a 50-years-old male who undergoing repair of atrial septal defect by central thoracotomy with extracorporeal circulation as atrial septal defect in the 30 years ago require repair of atrial septal defect by central thoracotomy with extracorporeal circulation again as residual shunt after repair. In patient checking report of January 2019, it indicated that in the case of no obvious inducement patients appear palpitation, palpitation, is persistent. Base on admission dynamic electrocardiogram, it indicated: (1) Persistent atrial flutter (2) second degree atrioventricular block with junctional escape (3) severe tricuspid regurgitation. In result of operation, we successfully completed the operation, and the patient had no complications after the operation. The surgical procedure was to perform electrophysiological mapping of the right atrium, establish extracorporeal circulation, surgical bipolar radiofrequency ablation, and tricuspid valve formation. Base on result of this operation, effective implementation of prospective nursing interventions can reduce the risk of surgery. In addition, in operation process, as the operation involves a large number of instruments and equipment and surgical personnel, the position of equipment and the rationality of personnel station will influence the result of operation.

1108 Inferior vena cava diversion into the left atrium after surgical repair of atrial septal defect: a rare case of chronic hypoxemia

Abstract Abnormal inferior vena cava (IVC) drainage into the left atrium (LA) is an infrequent complication after surgical closure of an atrial septal defect (ASD). We present the case of a 45-year-old woman, with surgical closure of an ASD 8 years before, who consulted for exertional dyspnea and cyanosis. Transthoracic and transesophageal echocardiography showed no residual shunt after contrast administration in both arms, and thoracic CT scan and pulmonary ventilation / perfusion gammagraphy were normal. In the presence of signs strongly suggesting a right-to-left shunt, we decided to complete the study with a CMR,which revealed an anomalous systemic drainage with IVC draining into the LA with right-to-left shunt. Surgical repair of the abnormal IVC drainage was successfully performed. During the intervention cardiac surgeons found a repaired ASD located in the lower portion of the interatrial septum, a large Eustachian valve, which are anatomical features which can sometimes lead to an erroneous suture causing the drainage of the IVC towards the LA. In conclusion, it is essential to carry out an extensive search for possible residual anatomical shunts in patients who undergo surgery and develop hypoxia. The reported case underlines the importance of being aware of this possible complication of the closure of an ASD and highlights that the absence of passage of agitated saline contrast to left chambers with conventional injection by the arms does not rule out any residual shunt, recommending its administration by the lower limbs, as well as the CMR for the definitive diagnosis. Abstract 1108 Figure. CMR imaging 3D reconstruction