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Surgical patch closure of atrial septal defects
Richard A Hopkins1, Arthur A Bert, Bryan Buchholz
1Division of Cardiothoracic Surgery, Providence, Rhode Island, USA. rahopkins@lifespan.org
Background:
Development of nonsurgical techniques for closure of atrial septal defects (ASD) has prompted reevaluation of current surgical outcomes with an emphasis on less invasive methods.
Methods:
This retrospective review is based on a single surgeon's experience between July 1, 1988 and December 21, 2002 with 176 consecutive adult (n = 47) and pediatric (n = 129) surgeries, in which ASD was the primary anatomical diagnosis to ascertain current optimal methods and outcomes expected for surgical closure. Patch closure with pericardium was used in all cases. Surgical methods encompassed three phases. The first phase was defined by traditional sternotomy; the second phase involved a series of technical modifications to shorten incisions and reduce surgical trauma; the third phase consisted of standardized less invasive techniques based upon age and gender with "bikini line" incisions for adult females, limited median sternotomy for adult males, and mini-median sternotomy for children. All patients underwent echocardiography to assess ASD closure.
Results:
There were no deaths. The most frequent perioperative complications were atrial fibrillation (adult 10%, pediatric 1.2%) and post pericardiotomy syndrome (adult 2%, pediatric 4.7%). All patients had secure and complete closure of ASDs with no residual shunts (trivial or otherwise) documented by echocardiography. No less invasive procedures required conversion.
Conclusions:
Surgical technique evolved from standard sternotomy to limited access incisions using modified cannulation techniques and incision locations determined by age and gender of the patient without deterioration in outcome quality. Both standard and less invasive surgical methods can achieve secure closure of the septum with biological patches, which are incorporated into the tissue structure of the heart and which are free from materials-related failure modes. Patient satisfaction is enhanced by utilizing the least invasive, least traumatic, and most cosmetically appealing techniques for access and cardiopulmonary bypass.