Off-Pump ASD Closure With a Two-Layer Patch Attached to the Right Atrium

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Objective 

The goal was to perform a beating-heart closure of an atrial septal defect (ASD) with a two-layer patch attached to the right atrium. 

Methods 

This technique is indicated for the repair of any type of secundum atrial septal defect, such as large ASDs or defects with deficient rims, which are not often considered amenable to transcatheter closure and are referred for surgery. This technique is less invasive and can be an accepted alternative to the traditional surgical repair for ASD. Compared to open-heart surgery, the advantages of this new technique include fewer complications. 

The Procedure 

A right anterolateral thoracotomy through the fourth intercostal space or midline sternotomy was used.  A patch of pericardium, Dacron, or preserved calf or bovine pericardium can be used and fashioned to close the ASD.  

The patch consisted of two layers: an inferior layer and a superior layer, which were connected to each other to form a three-dimensional structure similar to an open-mouthed pocket. The shape of each layer represents either a half-circle or half-oval. The opening of this structure was sutured to the wall of the right atrium.  

The patch size was determined based on the measurement of the distance between (2) and (1) and on the measurement of the ASD diameters. The closure of the ASD was performed with echocardiographic guidance to confirm the ASD closure and detect any residual shunt. 

Transesophageal echocardiography can be used during the procedure, and the procedure can be conducted using a real-time 3D echocardiography guidance system, where the probe can be applied to the wall of the right atrium. The ASD closure was performed without cardiopulmonary bypass, following intravenous heparin administration. 

The orifice of the patch was sutured to the right atrium at the mid portion of the inter-atrial grove between (2) and (1). The superior border of the inferior layer of the patch was sutured to the mid portion of the interatrial grove between (2) and (1). The first suture was placed a few millimeters cephalad from the junction of the inferior vena cava (IVC) and the right atrium, and the line of the suture was completed several millimeters from the junction of the superior vena cava (SVC) and the right atrium.  

The superior border of the superior layer of the patch was sutured to the right atrium wall, approximately 1 cm superior to the first line of suture. A scimitar blade was inserted through a purse string in the cavity of the patch through the upper pole of the patch to evacuate air. Additional measures include inserting a needle via the upper pole of the patch to inject the serum into the cavity of the patch, expelling any remaining air.  

The right atrium was then opened superiorly 3-4 mm to the inferior line of the suture, and the incision was extended from the placed marking suture (2) to (1). Air was expelled via the upper part of the patch, and the purse string was used to secure the knife. The stitch was then tied. The patch was inverted and advanced by finger toward the right atrial cavity through the atriotomy, positioning the inferior layer of the patch over the ASD. Pressure was continuously applied to the inferior layer against the septum to eliminate the space between the inferior layer of the patch and the atrial septum to detect the anatomy of the ASD, ensuring that this layer remained in direct contact with the atrial septum. The suture was then performed so that it penetrated both the patch material and the tissue at the rim of the ASD. The lower part of the patch was sutured to the lower corner of the ASD, and the patch was then sutured around the ASD with 6-0 Prolene. A transparent inferior layer of the patch was used, and pressure was applied to remove the space and blood existing between it and the atrial septum making the atrial septum and the anatomy of the ASD visible. The suture was then performed under direct vision, and the atriotomy was closed. 

Results 

Complete occlusion of the ASD was achieved. 

Conclusion 

This technique is feasible and less invasive, and it can be an accepted alternative to the traditional surgical repair for ASD. 

References

1. Guiraudon GM, Jones DL, Bainbridge D, et al. Off-Pump Atrial Septal Defect Closure Using the Universal Cardiac Introducer®. Innovations. 2009;4(1):20-26. doi:10.1097/imi.0b013e31819878f2

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