Robotic-Assisted Atrial Septal Defect Closure Via the Left Atrium: Dual Case Reports

In this new CTSNet President’s Series, Dr. Husam Balkhy, president of ISMICS, showcases cutting-edge, totally endoscopic cardiac procedures from the University of Chicago. Watch for more videos in this series coming soon.   

Both patients were taken to the operating room (OR) and positioned supine with a roll under the right side. General endotracheal anesthesia was initiated using a single-lumen tube. Five 8 mm ports were placed, and the femoral artery and vein were accessed through a 2 cm right groin incision. 

After administering heparin and under transesophageal echocardiogram (TEE) guidance, a long right femoral venous cannula was positioned with its tip in the superior vena cava (SVC), and a standard right femoral arterial cannula was placed. With adequate activated clotting time (ACT), cardiopulmonary bypass (CPB) was initiated, and the ventilator circuit was disconnected. 
 
After docking the robot, the pericardium was opened longitudinally anterior to the phrenic nerve, and two pericardial retraction sutures were placed and exteriorized posterior-laterally to the working port. A temporary pacing wire was placed on the right ventricle, and the patient was cooled to 31°C. Rapid ventricular pacing was then performed to achieve stable fibrillary arrest. Snares were placed around the superior and inferior venae cavae (IVC). 
 
A generous left atriotomy was made along Sondergaard’s groove, and the robotic dynamic atrial retractor was positioned to expose the septal defect. 
 
Patient 1 had a large secundum defect with multiple fenestrations. The thin secundum tissue was sharply resected, and a PhotoFix ultrathin bovine pericardial patch was brought into the field and sutured to the edges of the fossa ovalis, encompassing all the small fenestrations with a running 4-0 Prolene suture. 

Patient 2 had a defect extending fairly low toward the inferior vena cava (IVC). A PhotoFix bovine pericardial patch was brought into the field and sutured onto the edges of the fossa ovalis with a running 4-0 Prolene suture. 

Once the patch was secured, the right atrium was filled, and there was no residual septal defect. The left atriotomy was then closed with a running 4-0 Prolene suture while the patient was slowly rewarmed, and de-airing was completed. 
 
As the patient rewarmed, spontaneous conversion to sinus rhythm was observed. Further de-airing was completed, and the transmitral drain was removed. The left atrial suture line was completed, and hemostasis was confirmed. CPB was discontinued. 
 
The pericardium was loosely closed with a running V-Loc suture. Postoperative TEE showed no atrial-level shunt on either an agitated bubble study or a Doppler study. Left and right ventricular function remained preserved. Protamine was administered to reverse heparin, and two 24 mm Blake drains were placed in the pericardial and right pleural spaces. The groin was decannulated and closed in multiple layers. 
 
Both patients were discharged on postoperative day 1, with complete resolution of symptoms at their 1–2-month follow-up visit. 

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