Reducing the Trauma of Atrial

Septal Defect Repair:

Justine Chinn
Undergraduate Fellow
University of California, Los Angeles
Redmond P. Burke
Chief, Division of Cardiovascular Surgery
The Congenital Heart Institute
Miami Childrens Hospital and Arnold Palmer
Hospital
www.pediatricheartsurgery.com
Overview of Atrial Septal Defect
(ASD)
An opening in the septum between the
atria results in the flow of oxygenated
blood from the left atrium back into the
right atrium.
This blood mixes with the
deoxygenated blood of the right atrium.
High flow through an ASD will result in
a failure to thrive (poor growth/appetite
and shortness of breath) and over time
may result in arrhythmia, stroke, and/or
pulmonary hypertension.
Atrial septal defects are relatively
common, occurring in 1 out of every
1500 live births.
Common Types of ASD
The is the most
common type of ASD (6-10% of all CHD).
The secundum ASD typically arises from an
enlarged formen ovale or the inadequate growth
of the septum secundum, or septum primum.
The is a
defect in the atrial septum creating deformities in
the tricuspid and mitral valves.
A occurs
when the defect in the septum involves the
venous inflow of the superior or inferior vena
cava.

The technical evolution of the operation has resulted in a
very safe procedure with low mortality rates. Patient
survival is no longer an adequate measure of success.
Jenkins KJ et al, JTCVS, January 2002
This suggests that we should refocus on improving long
term patient health and decreasing the number of negative
consequences.

Achieve complete
anatomic repair.
Inflict the least
cumulative
lifetime patient
trauma.


How is this achieved?
Through a united approach with
interventional cardiologists.
By finding the best incision for the job:
Should ensure short/long term pain
management and good aesthetic result.
By implementing conditions that support
stronger surgical abilities:
Speed, Precision, and Adaptability are key.
Unified Multi-Disciplinary Approach
At Miami Childrens Hospital, all patients are presented
in a combined conference with surgeons, cardiologists,
anesthesiologist and nurses present.
For selected patients with Secundum Atrial Septal Defect, we
consider device closure the least traumatic form of therapy.
For Sinus Venosus Defects, patients undergo surgical closure
via median sternotomy and baffling of PAPVR
For Primum ASD, patients undergo surgical closure via median
sternotomy with cleft repair as needed.
Patients who are found not to be suitable for device
closure in the cath lab can undergo immediate surgery
under one anesthetic.
Collaboration ensures that each patient receives
specialized treatment based on his/her individual needs.
ASD Closures in 1996 Versus 2008
0
10
20
30
Number of
Procedures
Secundum
ASD
Sinus
Venosus
ASD
Primum
ASD
Secundum
ASD
Sinus
Venosus
ASD
Primum
ASD
1996
(249 total CPB cases)
2008
(245 total CPB cases)
ASD Closures: 1996 2008
Mean Weight (kg) 19.8 22.3
Mean LOS (days) 4.75 4.29
Our volumes reflect the evolution of therapy for ASD:
Depending on the patients individualized needs, surgery
may not always be the answer.
Predicates for a Unified Approach
A positive, innovative
interaction between surgeons
and cardiologists.
On site availability of surgery,
perfusion, anesthesia, and
cardiology teams.
Best surgical and device
options available in one
institution for fast and easy
transitions.

Suggested criterion for selecting an
operative approach for ASD closure:
Maintain short and long term
patient safety
Cardiopulmonary Bypass
Autologous Materials
Enable excellent surgical
technique
Optimal cardiac repair
Achieve a perfect functional
outcome
Pain free short and long term
Normal strength and flexibility
Create an optimal aesthetic
result
The only part of our work the
patient can see.



Complications of transcatheter
closure of ASD
M S Spence. et. al.
Heart. Dec 2005;
91(12): 1512
1514.

Long term safety is enhanced by using autologous
material for repairs pericardium. This is a
powerful factor in increasing long term stability.

Benefits of Pericardium:
Its free
We have 5 decades of experience
with the material, and there is no
uncertainty about long term effects
in the circulation.
There is no erosion into adjacent
structures.
When anchored by continuous
suture, the likelihood of patch
dehiscence is very rare, and
embolization never occurs.
A residual leak is rare.
Each patch is customized to the
patients defect, very low profile
There is no need for long term
anticoagulation or antibiotic
prophylaxis.


Standard Incision Options:
Sternotomy variants
Full sternotomy with
limited skin incision
Partial lower
sternotomy
Transxyphoid incision
(Non-sternotomy)
Right anterior
thoracotomy

Patient Safety:
Cardiopulmonary Bypass
Myocardial Protection
Sternotomy: Cardioplegia is
easy to administer,
obstructed cannula easily
adjusted
Partial Sternotomy
Aorta is under the
manubrium: obstructs
access.
Thoracotomy: because the
aorta is far from the surgeon,
severe myocardial
dysfunction may result from
a failed cardioplegia
infusion.

Aortic Cannulation/Clamp
Sternotomy: Offers direct
control for cannula insertion.
Strong visibility makes it
easy to manipulate to
ensure good flows.
Partial Sternotomy
Aorta is under the
manubrium: offers low
visibility.
Thoracotomy: Aorta is far
from surgeon, and is difficult
to cannulate, position, and
suture. The creates the risk
of catastrophic bleeding.



Favors Sternotomy
approach
Patient Safety:
Cardiopulmonary Bypass
Neuroprotection
Sternotomy:
Deairing is simple due to
the direct control of anterior
ascending aorta
Lower Sternotomy
Aortic vent is under the
manubrium, risk of
bleeding/embolism
Thoracotomy:
Deairing is difficult, due to
complete lack of direct
aortic control. The
increases the risk of an air
embolism and stroke.

Favors Full Sternotomy
Excellent surgical technique has three
characteristics, which may be enhanced or
hindered by the incision.
1) Precision
2)Adaptability
3) Speed

Precision
For sinous venosus ASD
repair, precise suturing is
critical to avoid pulmonary
vein stenosis, baffle
obstruction, and superior
vena cava obstruction.

This level of suture precision
from superior vena cava to
inferior vena cava is difficult to
achieve through a remote
incision.
Enhanced by
Sternotomy approach
Precision protects the
conduction system
Reported incidence:
Great Ormond Street review of
over 2000 patients (.6% complete
heart block)
Ann Thorac Surg. 2006
Sep;82(3):948-56; discussion 956-
7.
Primum ASD and Sinus Venosus
defects are closely related to the
His Bundle and Sinus Node
respectively.
We have a zero incidence of
temporary pacing or heart block
after ASD repair.
Fishberger et.al. Congenital
cardiac surgery without routine
placement of wires for temporary
pacing. Cardiology in the Young
18(1):96-9 2008 Feb
Enhanced by
sternotomy
approach
Adaptability
Unexpected problems are regularly
encountered during open heart
operations. These include:
Loss of vascular control
Difficult access to or exposure of
lesions
Prolonged ischemic times
Bleeding
Unanticipated anatomic variations
The surgical response in these
situations is to improve exposure, by
enlarging a limited incision, or by
converting to median sternotomy
This leaves the patient whose primary
concern was cosmetic, with the worst
possible result a prolonged
operation with a large incision or two
separate incisions.
facilitated by median sternotomy
Consistent Results
The medial sternotomy is used in more difficult
surgeries because it is consistently effective. It
provides surgeons with great visibility and the
ability to adapt quickly.
Anatomic repair via sternotomy is conceptually
appealing. The surgery results in a safe and
reliable repair in patients with a wide age
spectrum
Jensen H. et. Al. Eur J Cardiothorac Surg. 2014
Jun;45(6):1066-9.
Speed
Clearly enhanced by
sternotomy approach
The above is performed on a
euthanized pig, with no
pressure. Edited between each
throw. This is a simple straight
suture line, with a large needle.
The above is performed on a living
child, with performance pressure.
No editing. Pericardial patch is
placed with a small needle.
Speed is essential during Sinus
Venosus ASD repair
Baffle suture lines are
long, and the superior
vena cava to right atrium
patch suture lines are
long.
Remote suturing
techniques result in
extremely long ischemic
times. Long ischemic
times can result in
serious injury to the heart.
Functional Outcome
Sternotomy
No pectoral muscle
is cut.
No intercostal
muscle is cut.
No intercostal
nerves are injured.
No breast
ennervation is
injured.
No breast tissue is
cut.
Sternum heals
stronger.


Thoracotomy
Pectoral muscle
may be cut.
Intercostal muscle
will be cut.
Intercostal nerves
will be injured.
Breast ennervation
may be injured.
Breast tissue may
be cut.
The anatomy of
the intercostal
nerve makes it
susceptible to
injury. Retractor
placementinduce
s mechanical
deformation and
damage
Timmermanns et.
al. Hernia. 2013
Feb;17(1):89-94
Favors Sternotomy
approach
Short Term Pain
Management
Local Anesthetic Infusion
Catheters provide
immediate pain relief.
Miami Childrens Hospital
performed the first
prospective randomized
trial of this technology in
pediatric open heart
surgery.
Results show a significant
reduction in narcotic
requirement.
Tirotta. et. al. Paediatr
Anaesth. 2009
Jun;19(6):571-6
Can be used for all
incisions
Long Term Pain: Post
Thoracotomy Pain
Syndrome
Pain after thoracotomy is very severe,
probably the most severe pain
experienced after
surgeryPostthoracotomy Pain
Management Problems
Anesthesiology Clinics - Volume 26,
Issue 2 (June 2008) - Copyright
2008 Saunders. Peter Gerner, MD
Persistent postsurgical pain (PPP) after
thoracotomy effect 50% to 80%. Nerve
damage may play an important role.
Adding epidural or IV racemic
ketaminedid not lead to any reduction in
pain
Tena B. et.al. Clin J Pain. 2014 Jun;30(6):490-
500.



Favors Sternotomy Approach

Reliability of Sternotomy
Studies support the variety of
conditions in which median sternotomy
provides unrivalled access to the
mediastinum.

Gopal M. Et.al. S Afr Med J. 2013 Jun 5;103(10):732-5
Attending surgeon performs incision and closure, with three
levels of running sutures: placed in the fascia,
subcutaneous layer, and subcuticular layer. This technique
provides ideal cosmetic results with no visible staples or
stitches.
Post-Op Results
Sternotomy provides a safe, precise, and rapid repair
with a strong functional and cosmetic result.
Defect N LOS Morbidity/Mortality
PFO 0 NA 0
Secundum 24 4.4 0
Sinus Venosus 10 3.9 0
Common Atrium 1 4.0
Coronary Sinus 0 NA 0
NOS 1 3.0 0
Our Current surgical Results for ASD closure: STS 2006
Need data for recent year
Conclusions
A unified approach to atrial septal defect repair, synthesizing
a combination of interventional techniques and surgery, may
optimize patient care.

If your goals in order of importance are:
Maintain short and long term patient safety
Enable excellent surgical technique
Achieve a perfect functional outcome
Create an optimal aesthetic result

then a median sternotomy with a limited skin incision may be
the best approach for atrial septal defects.