Elective Surgical Closure Research Articles

Abstract 13987: Efficacy and Safety of Surgical Repair of Atrial Septal Defect in Asymptomatic Children Less Than 3 Years of Age

Background: Elective surgical closure of atrial septal defect (ASD) in asymptomatic children is commonly performed at 3 to 6 years of age when catheter-guided closure is not feasible. However, a recommended timing of surgical closure is not based on recent evidence. Hypothesis: Surgical ASD closure can be done safely in any age group. Methods: Asymptomatic patients with surgically closed isolated ASDs who were not indicated for catheter-guided closure in our cardiac center from 2002 to 2019 were studied. The patients were divided into 4 groups based on the age at surgery (<3 years, ≥3 to <6 years, ≥ 6 to >10 years, and ≥ 10 years). Demographic data, type of ASD, cardiopulmonary bypass time (CPBT), intensive care unit (ICU) stay, total hospitalization days, post-operative adverse events, and readmission rate were studied. Effects of creation of pericardial window (PW) was also examined. Data are shown as mean ± standard deviation. Results: Total 163 patients were studied (Table). There was no statistically significant difference in CPBT, ICU stay, or total hospitalization days among the 4 groups. There were no mortalities. Incidence of adverse events during hospitalization was low in < 6 years (1.9 to 4.2%) but higher in older ages (10.8 to 13.5%). Readmission rate was higher in younger groups: 18.6% in < 3 years old, 13.2% in ≥ 3 and < 6 years old, 8.0% in ≥ 6 and < 10 years, and 10.8% in ≥ 10 years, which was mainly due to pericardial effusion (PE). Total 18 patients developed PE postoperatively, 14 of whom were readmitted for treatment. With the creation of PW at the time of initial surgery, the incidence of PE and readmission rate were significantly reduced compared with without PW, especially in younger children. There was no complication due to PW. Conclusion: Surgical ASD closure can be performed safely even in younger children with ages <3 years, especially with creation of PW. Routine application of PW markedly reduced postoperative adverse events in surgical ASD closure.

Intraoperative Three-dimensional Imaging of Ventricular Septal Defects in Children Using Epicardial Echocardiography: A Novel Approach

To assess the feasibility and accuracy of intraoperative three-dimensional (3D) epicardial en face images of ventricular septal defects (VSD) in children using the 3D transesophageal echocardiography (TEE) probe as an epicardial probe. This was a prospective nonrandomized blinded observational study. The study was conducted at a single tertiary cardiac care center. Fifty pediatric patients, weighing between 5.0 kg and 20 kg, who were scheduled for elective surgical closure of their VSDs, prospectively were recruited for this study. Epicardial 3D images were acquired using the full-volume mode. VSD location and size were determined from the 3D data sets using multiplanar reconstruction mode (QLAB 9) by a blinded investigator. The accuracy in terms of location and size was compared with surgical findings. In 50 study subjects, 54 VSDs were located by epicardial 3D echocardiography (3DE): 12 perimembranous, 17 inlet, eight muscular, 15 malaligned, and two outlet. Average image acquisition time was 4.96 (±1.47) minutes. Average image reconstruction time was 6.18 (±1.93) minutes. Good en face views of the VSD could be rendered in all patients (100% feasibility). The highest image quality was for perimembranous and malaligned VSDs. The location of VSD by 3DE corresponded precisely with surgical findings (100% accuracy). With linear regression analysis, excellent correlation was observed between the diameters measured by surgery and that measured by 3DE from the right ventricle side (r2 = 0.97, p < 0.001). The authors' study demonstrated that diagnostic quality 3D en face images of VSD can be obtained intraoperatively using 3D epicardial echocardiography. The short acquisition and reconstruction times make this technique clinically applicable.

Diagnostic pitfalls: unexpectedly severe pulmonary hypertension with pulmonary hemorrhage after atrial septal defect closure - a case report

Introduction Certain elderly patients may suffer from an uncorrected congenital heart disease (CHD) and severe pulmonary hypertension (PHT). Methods A 69-year-old male patient presented for elective surgical closure of an atrial septal defect (ASD) and for a radiofrequency (RF) ablation of the pulmonary veins due to frequent episodes of atrial fibrillation. A transthoracic echocardiography revealed a small defect in the middle part of the atrial septum with a pulmonary to systemic blood flow ratio of 3:1 and a right ventricle (RV) systolic pressure of 45 mmHg. Results Following the cardiopulmonary bypass institution, surgical inspection detected a sinus venosus defect with anomalous drainage of the right upper pulmonary vein into the left atrium, apart from the ASD type secundum. A pericardial patch reconstruction and Cox-Maze IV procedure was performed. Several hours after the intervention, blood was noted, refluxing from the endotracheal tube. Simultaneously, a severe hemodynamic instability appeared with nodal cardiac rhythm, due to a malposition of the atrial pace-maker wire. Pulmonary artery pressure measured 45/35 mmHg, pulmonary capillary wedge pressure (PCWP): 16 mmHg, right heart chambers were enlarged and RV contractility was severely reduced. A chest X-ray and a CT scan revealed massive hemorrhage in the right upper pulmonary lobe. A bronchial blocker was placed immediately and a resection of the affected lobe was performed. Discussion This case illustrates underestimated severity of pulmonary hypertension under conditions of the reduced RV function. An assessment of PCWP indicates precapillary PHT. The permanent left to right shunt with increased pulmonary blood flow resulted in progressive endothelial and medial disturbances of the pulmonary vessels, and in creation of the complex vascular lesions with consequential intrapulmonary hemorrhage. Adult patients with CHD remain a high-risk perioperative population, requiring all available resources and a multidisciplinary approach.

Negative pressure wound treatment improves Acute Physiology and Chronic Health Evaluation II score in mediastinitis allowing a successful elective pectoralis muscle flap closure: Six-year experience of a single protocol

Optimal management of poststernotomy mediastinitis is controversial. Negative pressure wound treatment improves wound environment and sternal stability with low surgical invasiveness. Our protocol was based on negative pressure followed by delayed surgical closure. The aim of this study was to provide the results at early follow-up and to identify the risk factors for adverse outcome. In 5400 cardiac procedures, 44 consecutive patients with mediastinitis were enrolled in the study. Mediastinitis treatment was based on urgent debridement and negative pressure as the first-line approach. After wound sterilization, chest closure was achieved by elective pectoralis muscle advancement flap. Each patient's hospital data were collected prospectively. Variables included patient demographics and clinical and biological data. Acute Physiology and Chronic Health Evaluation (APACHE) II score was calculated at the time of diagnosis and 48 hours after debridement. Focus outcome measures were mediastinitis-related death and need for reintervention after pectoralis muscle closure. El Oakley type I and type IIIA mediastinitis were the most frequent types (63.6%). Methicillin-resistant Staphylococcus aureus was present in 25 patients (56.8%). Mean APACHE II score was 19.4±4 at the time of diagnosis, and 30 patients (68.2%) required intensive care unit transfer before surgical debridement. APACHE II score improved 48 hours after wound debridement and negative pressure application (mean value, 19.4±4 vs 7.2±2; P=.005) independently of any other variables included in the study. One patient in septic shock at the time of diagnosis died (2.2%). Negative pressure promotes a significant improvement in clinical status according to APACHE II score and allows a successful elective surgical closure.

Ventricular septal rupture complicating acute myocardial infarction following percutaneous coronary intervention

Abstract Ventricular septal rupture (VSR) is a rather rare, but at the same time very dreadful complication of acute myocardial infarction in the percutaneous coronary intervention (PCI) era and only limited evidence exist on the optimal treatment of this critical medical condition. VSR is less common following successful early thrombolysis and PCI occurring in myocardium supplied by infarct-related artery (IRA). We report two well-documented cases of successful VSR treatment which will provide valuable information for clinical practice especially due to the long-tem follow-up. Both cases underwent delayed elective surgical closure of VSR. This report clearly describes the incidence, potential risks and timing of occurrence, clinical features, and outcomes of ventricular septal rupture complicating acute myocardial infarction (AMI) after PCI. Hence the topic of this report is of great importance. Although the prognosis of patients who develop VSR is generally grave without immediate surgical repair, both our patients remained hemodynamically stable at discharge and during follow-up of more than 4 years.

Long‐term follow‐up of the STARFlex® device for closure of secundum atrial septal defect

There is limited published outcome data on the STARFlex device for transcatheter closure of atrial septal defects (ASD). To contribute to the long term outcomes of ASD device closure with the STARFlex device. Results of a prospective FDA approved clinical trial (1999-2001) from a single institution of the STARFlex device for simple ASD was reviewed. The inclusion criteria included age >or=2 years, isolated secundum ASD, evidence of right ventricular volume overload, and maximum stretched diameter <22 mm. A retrospective review of the original study data with most recent follow-up was performed. Clinical success in the trial was defined as complete closure or residual leak <or=2 mm, absence of a severe complication and no need for an additional device or surgery to treat the ASD. Twenty seven (27) patients were prospectively enrolled in the study period with a procedural success in 23 (85%). There were two severe complications, both 40 mm device embolizations that underwent semiurgent surgical intervention for device removal and ASD closure (40 mm device subsequently withdrawn from trial). Device placement was unsuccessful in two patients due to malposition related to an insufficient retro-aortic rim, with elective surgical closure. Unsuccessful procedural outcomes were statistically associated with deficient rims (P < 0.01). Of the 23 long term follow-up device patients, 23 (100%) achieved clinical success: 22 (96%) had complete closure at 1 year and latest echocardiographic follow-up and one case had a small <2 mm residual defect that has persisted. There have been no late complications with normalization of RV volumes in 92% and no deleterious ECG changes. Device fractures occurred in 8/23 (35%) devices and were more common in the larger devices (P < 0.05) but had no sequelae. None required any further intervention to treat the ASD and there were no infectious or thrombotic issues. In this cohort the STARFlex device for secundum ASD closure provided procedural success in 85% with failures due to surgical referral. All 23 patients with a STARFlex device with available long term follow-up had clinical success. Further long term data is required.

Clinical relevance of coronary angiography at the time of percutaneous closure of a patent foramen ovale

The value of incidental coronary angiography during percutaneous shunt closure to screen for asymptomatic coronary artery disease (CAD) is unknown. On the occasion of percutaneous closure of patent foramen ovale (PFO), incidental coronary angiography routinely offered to men >40 and women >50 years, or younger patients with particular risk patterns, was performed in 575 patients (64% men, mean age 55 +/- 10 years, mean 1.5 +/- 1.1 cardiovascular risk factors) without overt history, signs, or symptoms of CAD. CAD was found in 164 patients (29%); 53 (9%) had >or=50% diameter stenoses. Thirty patients (5%) had one-vessel, 13 (2%) two-vessel, and 10 (2%) three-vessel disease. Patients with CAD (n = 164) were older (60 +/- 9 vs. 53 +/- 10 years; P < 0.0001), more frequently male (76% vs. 59%; P = 0.0002), and had a higher body mass index (26.5 +/- 4.0 vs. 25.4 +/- 4.6; P = 0.006) and more cardiovascular risk factors (2.0 +/- 1.1 vs. 1.2 +/- 1.0; P < 0.0001). There were six procedural complications (1%). Two were unequivocally related to coronary angiography: one minor stroke (diplopia), and one iatrogenic dissection of the right coronary ostium requiring stenting. Furthermore, four arteriovenous fistulae at the puncture site requiring elective surgical closure were possibly related to coronary angiography. Forty-five patients (8% of total) underwent percutaneous (n = 43) or surgical (n = 2) revascularization. In selected asymptomatic patients referred for percutaneous PFO closure, incidental coronary angiography discloses a rather high prevalence of clinically unsuspected CAD. These findings are relevant not only for timely revascularization but also for maintenance of long-term antiplatelet therapy beyond the few months recommended after PFO closure.

Combined Atrial Septal Defect Surgical Closure and Irrigated Radiofrequency Ablation in Adult Patients

Atrial arrhythmias are relatively common among patients over 40 years old with atrial septal defect (ASD) and are a precipitating cause of heart failure. Surgical closure of the ASD in these patients is feasible and is associated with a low mortality rate and a beneficial effect on the clinical status; however the occurrence of atrial arrhythmia does not decrease after surgery. We present the results of our preliminary experience with surgical ASD closure combined with intraoperative irrigated radiofrequency (IRF) ablation in adult patients. During a 26-month period between September 2002 and December 2004, 15 patients more than 40 years old with ASD and atrial arrhythmia underwent elective surgical closure of the defect and intraoperative IRF ablation. All patients had supraventricular arrhythmias: 8 had permanent atrial fibrillation, whereas 7 had previous episodes of atrial flutter or intra-atrial reentry tachycardia. The biatrial approach (Cox-Maze III procedure) was used in 7 patients and a right-sided Maze procedure (ablation lines on the right atrium only) was carried out in the remaining 8 patients. All patients survived the procedure. Fourteen patients left the operating room in sinus rhythm and 1 had a pacemaker implanted. There were no complications resulting from the IRF ablation. All 15 patients survived over the average follow-up period of 24 months. Thirteen patients were still in sinus rhythm, 1 had pacemaker rhythm, and only 1 (1 of 15; 6.5%) suffered a recurrence of atrial fibrillation 3 months after the procedure. We suggest adding intraoperative IRF ablation during surgical closure of an ASD in all adult ASD patients with arrhythmias. The IRF ablation is easy to perform, safe, and effective.

Transcatheter closure of atrial septal defects within the oval fossa: medium-term results in children using the 'ASDOS'-technique.

The purpose of this study was to evaluate the safety and efficacy of the ASDOS-technique (Sulzer-Osypka GmbH, Germany) for transcatheter closure of atrial septal defects within the oval fossa. Although several attempts have been made to occlude defects within the oval fossa by transcatheter techniques, none of these has gained general acceptance. Patients with a defect in the oval fossa measuring equal to or less than 20 mm diameter, with a residual septal rim of 5 mm or greater, body weight greater than 10 kg, with clinical indications for surgical closure were considered for transcatheter closure. Follow-up investigations were performed at discharge, after 1, 3, 6 and 9 months, as well as after 1 and 2 years. Of 78 patients considered for closure, a device was inserted in 41 patients (53%), with success being achieved in 40 patients (98%). The ages ranged from 1.1 to 15 years (7.8 +/- 1.92 years), the 'stretched' diameter of the defect from 10 to 20 mm (14.7 +/- 2.60 mm), and the diameters of the inserted devices from 25 to 45 mm (33.2 +/- 5.43 mm). Transient impairment of atrioventricular conduction occured in 4 patients. During the follow-up of 23.0 +/- 5.6 months elective surgical closure of a residual shunt was performed 26 months after insertion of the device in one patient. None of the other patients required surgery, hospitalisation or medical treatment, and none is requiring further treatment of the defect within the oval fossa. Fracture of one arm of the device occurred in 4 patients, but the fractured arms are in an unchanged and stable position after a period of at least 19 months. Our medium-term data show that transcatheter closure in children of defects within the oval fossa can be performed with a high efficacy and safety using the ASDOS-device.

783-4 Follow-up Results of Transvenous Occlusion of Patent Ductus Arteriosus with the Adjustable Buttoned Device

During a 4-year period ending July 1994, 81 patients underwenttranscatheter occlusion of patent ductus arteriosus (PDA) with the adjustable buttoned device at 22 institutions around the world under an IRB-approved custom-made device protocol. The device is a modified version of the Sideris’ buttoned device for atrial septal defect closure. The patients were 11 mo to 65 years (median. 7.0 years) with weight range of 7.2 to 90 kg (median. 19 kg) The PDAs measured 1 to 15 mm (median, 4 mm) at the narrowest diameter; fifteen were larger than 8 mm and three larger than 10 mm with a Qp:Qs range of 1.3 to 3.2. They were occluded with devices measuring 15 to 35 mm; all but 10 were delivered via #7-French sheaths. Ten devices ≥ 25 mm were delivered to the implantation site via #8-French sheaths. 78 of 81 (96%) were implanted at first attempt. In all three with device dislodgment, the device was retrieved via the sheath and two of these underwent PDA occlusion with larger devices and third patient had elective surgical closure of PDA. Small residual shunts detected by color Doppler were present in 31 (39%) patients. Forty-one patients were followed for 1 to 24 months (8 ± 7 mo) with clinical, chest x-ray and echo-Doppler evaluation. None required repeat intervention. The device was found intact on chest x-ray and echo. No evidence for thromboembolism, endocarditis or hemolysis was found nor was there evidence for descending aortic or left pulmonary artery obstruction. Percent incidence of residual shunt by color Doppler gradually decreased and was 39,21.15.13 and 0% respectively at 1 day. 1.6,12 and 24 months following device implantation. Based on these data it is concluded that 1) transvenous occlusion of PDA is feasible, effective and safe, 2) small-sized sheaths (7-French in most, 8French in some) are adequate for all ductus sizes, 3) all types of PDAs (conical, tubular and short) and both long and short PDAs can be occluded because of the adjustable button loop design of the device. 4) further improvementlminiaturization may eventually result in extending the procedure to neonates and premature infants.

Role of “buttoned” double-disc device in the management of atrial septal defects

Sixteen patients seen over a 9-month period ending in August 1990 were offered transcatheter closure of their ASD with a custom-made “buttoned” double-disc device. The study was approved by the Institutional Review Board and informed consent was obtained in each case. The device consists of an occluder, a counteroccluder, and a loading wire and is delivered to the ASD site via an 8F sheath. Parents of two children elected surgical closure. In five children the stretched diameter of the ASD was too large (>20 mm) and transcatheter closure was not attempted. These seven children underwent elective surgical closure without incident. In one child the defect measured 5 mm and the Qp:Qs was 1.4:1 and therefore ASD closure was not recommended. In the remaining eight children transcatheter closure was attempted. In two of the children the occluder pulled through the ASD and was successfully retrieved and the children later underwent uneventful elective surgical closure. The device was implanted across the ASD in six children. In one child the device dislodged from the ASD site within minutes after implantation and the child was sent to emergency surgery, where the device was removed and the ASD was closed. In the remaining five patients, aged 7 months to 45 years (weight 3.6 to 50 kg), with a Qp:Qs range of 1.3 to 2.3 and a stretched diameter of 10 to 19 mm, the ASD closure was successful with 25 to 40 mm size devices. Repeat echo-Doppler studies 2 weeks and 3 months after the procedure in all patients and 6 months later in two children did not reveal any residual shunt.It is concluded that (1) the custom-made “buttoned” double-disc device can be implanted across the ASD safely and effectively via an 8F sheath, thus making transcatheter ASD closure feasible even in very young infants; (2) measurement of stretched diameter of the ASD in the catheterization laboratory is a useful guide for selection of an appropriate-sized device; and (3) additional clinical trials are warranted to confirm the efficacy and safety of the device.

Symptomatic atrial septal defect in infancy.

Atrial septal defect of the ostium secundum variety (ASD) is uncommonly diagnosed in infancy and rarely results in congestive heart failure (CHF). Eleven patients with uncomplicated ASD who developed CHF between 6 days and 13 months of age are presented. The diagnosis of ASD was documented by cardiac catheterization in all 11 patients. Left-to-right shunt ranged from 52 to 80%. Right ventricular pressure was near systemic levels in two patients and at least somewhat elevated in the other nine. Total pulmonary resistance (TPR) was within normal limits in all 11. No left ventricular obstructive lesions were found. Although one patient had unusual thickening of the left ventricular myocardium, and the left ventricular cavity was enlarged in two other cases, no specific abnormality in left or right ventricular function could be defined. Spontaneous closure of the ASD did not occur in any of our patients. Since spontaneous closure even of a large ASD can occur, however, it seems advisable to defer elective surgical closure until after 2 years of age if successful medical management can be achieved. In those patients in whom early surgery is not necessary, the clinical course usually becomes that of a typical ASD by age 2 years.

Surgical management of patent ductus arteriosus in infancy.

Congenital cardiovascular abnormalities remain a major cause of infant mortality. The incidence of congenital cardiovascular defects approximate 0.3% to 0.8% of all births. MacMahon et al 1 estimate that 25% of infants with major cardiovascular defects will die within the first month of life, and that 60% will die within the first year. Isolated patent ductus arteriosus, a readily corrected defect, accounts for about 15% of all congenital cardiovascular anomalies. During the first year of life, approximately 15% of patients with patent ductus arteriosus will develop either overt signs of cardiac failure, cardiomegaly, electrocardiographic abnormalities, repeated respiratory tract infection, dyspnea, or evidence of retarded growth. 2 The mortality of elective surgical closure of a patent ductus arteriosus has been shown to be extremely low, 3 and the value of operation in infancy has been increasingly recognized. Indeed, procrastination because of age or size in infants with congestive heart failure secondary to