Minimally invasive atrial septal defects repair.

This study reviews the current method of atrial septal defect closure at our institute with a minimally invasive approach without median sternotomy. From September 1997 to August 1998, 37 patients (13 males, 24 females) with mean age 36.5 years (range 18-67 years) underwent atrial septal defect closure by right anterior thoracotomy. Femoral vessels were cannulated through a small groin incision and extracorporeal circulation was established. Venous drainage was assisted with a centrifugal pump. Aortic crossclamping was performed through the intact chest wall using a special transthoracic clamp with sliding rod design inserted through a separate tiny 3 mm incision in the right second intercostal space in the mid clavicular line. Mean duration of cardiopulmonary bypass and aortic crossclamp time was 35 +/- 14 and 23 +/- 7 minutes respectively; mean endotracheal intubation time after surgery 6.2 +/- 3 hours; mean ICU stay 10.6 +/- 2.8 hours; mean length of thoracotomy incision 7.2 +/- 1.8 cm; and, mean hospital stay 4.2 +/- 1.8 days. There was no post-operative neurological dysfunction or femoral cannulation related complication. There was no perioperative or late mortality. No residual atrial septal defect was observed by transoesophageal echocardiography in any patient. The procedure described here provides secure closure of the atrial septal defects in minimally invasive fashion with good results.     

经右腋下小切口外科封堵继发孔型房间隔缺损的手术体会

【摘要】目的 总结经右腋下小切口封堵治疗继发孔型房间隔缺损（ASD）的手术经验,探讨其疗效、适应证及技术要点。 方法 回顾性分析自2013年1月至2016年12月在中山大学附属江门市中心医院采用右腋下小切口行继发孔型房间隔缺损封堵的36例患者的临床资料,其中男21例、女15例,缺损大小5～36mm。所有手术均在全身麻醉、气管插管下进行。患者取左侧卧位,在腋中线与腋前线之间做直切口,长度约2～4cm,约经第4肋间进胸,切开并悬吊心包,于右心房壁缝双荷包线并切开,通过输送导管在食管超声监视下释放房间隔缺损封堵伞。结果 全组无手术死亡;术中无恶性心律失常和气栓发生,术后无脑部并发症,1例封堵伞脱落至右房,经原切口改行体外循环下手术、1例术后有2mm残余分流,术后3个月随访残余分流消失。结论 经右腋下小切口外科封堵是一种治疗继发孔型房间隔缺损的有效手术方式,具有安全可靠、简便、创伤小及术后恢复快等优点,值得临床推广。     

Peratrial closure of atrial septal defects without cardiopulmonary bypass

The objective of this study was to introduce a new technique for occlusion of an atrial septal defect without cardiopulmonary bypass, using a modified Amplatzer device. Between October 2004 and November 2005, 96 secundum atrial septal defects in 83 patients were occluded by this method. A 3-cm incision in the right 4(th) intercostal space and a minithoracotomy were performed. Via this incision, the right atrium was exposed and the septal closure device was deployed under transesophageal echocardiographic guidance. The sizes of the defects ranged from 10 to 39 mm. The mean device size was 34.1 +/- 9 mm (12-46 mm). There was no operative mortality and no major morbidity on follow-up of 3-15 months. This new minimally invasive method of secundum atrial septal defect closure is safe and cosmetically superior to conventional surgery. Avoidance of cardiopulmonary bypass can reduce recovery time and complications. The indications are more extensive than percutaneous transcatheter closure, and the results are encouraging.     

Video-assisted thoracoscopic surgery for congenital heart disease

We report our experience with video-assisted thoracoscopy in the surgical closure of heart septal defects. Nine patients, aged 10 to 26 years, underwent operation for closure of an atrial septal defect; and 3, aged 10 to 22 years, for closure of a ventricular septal defect. Three minithoracotomies with a diameter of 2 to 3 cm were made in the fourth intercostal space of the right parasternum and the fourth and seventh intercostal spaces of the right middle axillary line, respectively. Through the openings and guided by a thoracoscope, a catheter was inserted into the superior vena cava, femorofemoral extracorporeal circulation was built, the aorta was crossclamped, and the myocardium was protected by cold cardioplegia. The right atrium was opened, and the defect was exposed with a traction suture. Primary closure of defects was performed successfully in all patients. The duration of aortic crossclamping and extracorporeal circulation ranged from 11 to 56 minutes and from 50 to 168 minutes, respectively. Postoperatively, cardiac murmur disappeared and echocardiograms showed no residual shunt. Repair of heart septal defects can be completely done with the assistance of video-assisted thoracoscopy, offering a new option with minimal incision.     

Autologous right atrial patch for closure of atrial septal defect

BACKGROUND: Prosthetic or pericardial patches used for the closure of atrial septal defects are associated with infrequent but definite problems. As an alternative, we used a right atrial free-wall patch in 12 patients, 7-54 years of age. METHODS AND RESULTS: The presence of a large secundum atrial septal defect (n=2). associated mitral valve regurgitation (n=7), primum atrial septal defect (n=2) and sinus venosus defect (n=1) necessitated the use of a patch. The mitral valve was repaired in 9 patients (including 2 with a primum defect). One patient with a primum defect who was in congestive heart failure preoperatively died after 3 weeks due to refractory ventricular fibrillation. The remaining patients were discharged 5 to 7 days post procedure. No flow was detected across the septal patch on predischarge echocardiography. One patient underwent reoperation for failed mitral valve repair one month postprocedure. At reoperation, the patch was found to be intact with normal texture and without any suture dehiscence. Histopathological examination of the explanted patch revealed viable endothellum and subendothelial muscle on both surfaces of the patch. Follow-up ranged from 6 to 36 months. Echocardiography performed after 6 to 32 months post procedure showed an intact patch with no residual defect. All the patients are in sinus rhythm. Holter monitoring performed in 6 patients was normal in all of them. Electrophysiological study was performed in 2 patients using a mapping catheter 4 and 6 months post-procedure, respectively, and recorded normal atrial potentials from the site of the patch. CONCLUSIONS: The use of an autologous free right atrial wall as a patch for atrial septal defect closure is a viable option.     

Transcatheter closure of atrial septal defect using self-expandable septal occluder

Transcatheter closure of atrial septal defect is an accepted alternative to surgical closure. It was attempted in 63 patients (age range 1.5-55 years) using self-expandable Amplatzer septal occluder (AGA Med. Co., USA). The atrial septal anatomy was evaluated by transthoracic and multiplane transoesophageal echocardiography with special reference to septal margins and adjacent structures. The size of atrial septal defect on echocardiographic evaluation varied from 9-28 (17.5 +/- 4.7) mm. Fifty (79.4%) patients had adequate septal margins of 5 mm or larger, while remaining 13 (20.6%) had insufficient anterosuperior margin. Cardiac catheterisation revealed Qp/Qs ranging from 1.5 to 5.3 and balloon-stretched atrial septal defect diameter of 10-32 (20.3 +/- 5.3) mm. The procedure was overall successful in 62 (98.4%) patients and in all patients with insufficient anterosuperior margin. Embolisation of the device occurred in one (1.6%) patient within five minutes of the device release, which could not be retrieved non-surgically. Size of the device used was either same or preferably 1-3 mm more than the balloon-stretched atrial septal defect diameter. Total procedure time was 40-90 (59 +/- 12.4) minutes and the fluoroscopy time was 12-30 (17.3 +/- 4.2) minutes. Immediate post-procedure and pre-discharge echocardiography in patients with successful deployment of the device revealed complete abolition of shunt in 61 (98.4%) and trivial residual shunt in one (1.6%) patient. No patient developed atrioventricular valve regurgitation or cardiac arrhythmias. Thus, atrial septal defect closure using self-expandable septal occluder is a safe and efficacious procedure requiring a short procedural time. There is full control in the system for proper positioning or repositioning of the device with excellent technical success rate even in cases with insufficient anterosuperior septal margin.     

改良输送鞘通过法行房间隔缺损封堵术100例临床分析

目的：分析使用改良输送鞘通过法行房间隔缺损介入封堵术治疗继发孔型房间隔缺损的临床效果。方法回顾性分析2012年12月至2013年12月,在北京安贞医院以改良输送鞘通过法行房间隔介入封堵术完成的100例继发孔型房间隔缺损患者,其中女72例,平均年龄3～76（37±16）岁。全部患者经胸超声心动图完成诊断及对缺损大小进行测量,并使用改良输送鞘通过法行房间隔缺损封堵术,该术式输送鞘无需加硬导丝导引而直接经过缺损送入左心房。结果经胸超声心动图证实100例患者共存在101处缺损,其中有1例患者有2处缺损。测得缺损平均最大径为（20.3±6.7）mm,共植入4个品牌的100枚封堵器,封堵器平均尺寸为（28.1±7.5）mm。封堵器均通过改良输送鞘通过法植入成功,经胸超声心电图证实100例患者房水平分流消失。术中1例患者出现心房颤动（房颤）,术后房颤消失。随访时间为1～12个月,随访期间无严重并发症发生。结论使用改良输送鞘通过法实施房间隔缺损介入封堵术并发症发生率低,近中期疗效肯定。     

Effect of atrial septal mobility on transcatheter closure of interatrial communications

BACKGROUND: Transcatheter techniques have evolved as alternatives to surgical closure of interatrial communications due to its less invasive nature and low morbidity. The technique may be limited by the inability to deploy the device and, thus, may be complicated by significant residual shunting. Mobile or redundant septal tissue has been implicated as a possible cause of unsuccessful closure. METHODS: To determine if atrial septal hypermobility precludes successful transcatheter device closure of interatrial communications, 69 patients (mean age 46.4 +/- 17.5 years [male:female ratio 34:35]) with periprocedural transesophageal echocardiograms were reviewed. Septal excursion was defined as the maximal transit of the interatrial septum between either side of the plane connecting the superior and inferior attachment points. Unsuccessful closure was defined as subsequent cardiac surgery to close the defect, inability to deploy the device, recurrent attempts at closure, device malalignment, residual shunting greater than mild in degree on follow-up transthoracic study, and procedural complications. RESULTS: Reasons for closure were the following: embolic events (n = 48); platypnea/orthodeoxia (n = 15); atrial septal defect with right ventricular dilatation and paroxysmal atrial tachycardia (n = 2); atrial septal defect (n = 3); and prophylactic patent foramen ovale closure in a scuba diver (n = 1). Successful closure occurred in 76% of patients (n = 53). Compared with those patients with successful transcatheter closure, the mean septal excursion in patients with failed closure was 0.66 +/- 0.56 cm versus 0.76 +/- 0.47 cm (P = not significant [NS]). CONCLUSION: Our results do not support the concern that exaggerated septal mobility compromises successful device closure of interatrial communications.     

Percutaneous mitral commissurotomy and Lutembacher syndrome

INTRODUCTION: Lutembacher syndrome refers to the rare combination of congenital atrial septal defect and acquired mitral stenosis. This condition is usually treated surgically by mitral valve operation with concomitant closure of the atrial septal defect. MATERIALS AND METHODS: Between 1993 and 2003, 4 patients with congenital Lutembacher syndrome had percutaneous mitral commissurotomy without closure of the atrial septal defect at our institution. The 4 patients were very symptomatic with right-sided heart failure signs and NYHA functional class III-IV. RESULTS: The procedure was carried out successfully for the four patients. Mitral valve area increased from 0.87 to 1.97 cm2 at mean; left atrial pressure decreased from 28.2 to 12.7 mmHg and the mean valve mitral gradient was reduced from 15.5 to 3.9 mmHg. Functional and clinical improvement was observed in all the cases. During a mean follow up of 55 +/- 29 months, our 4 patients remain pauci symptomatic under medical treatment. CONCLUSION: The percutaneous treatment of the Lutembacher syndrome is currently a possible alternative to the surgery among patients having an anatomy favourable to the procedure.     

Diagnostic catheterization and balloon sizing of atrial septal defects by echocardiographic guidance without fluoroscopy

To avoid x-ray exposure prior to interventional closure of atrial septal defects (ASDs), we recently developed a technique for diagnostic catheterization and balloon sizing of the defect by echocardiographic guidance without fluoroscopy. We report on our first experiences with this technique. Fourteen patients with atrial septal perforations (mean age, 23 years; range, 1-66 years) underwent diagnostic catheterization and balloon sizing prior to possible interventional defect closure. Mean size of the defects was 16 mm (7-29 mm). Mean left-to-right shunt was Qp/Qs = 2.0 (range, 1.0-4.0). Without fluoroscopy, the procedures were performed in two children by transthoracic echocardiography (TTE) and in 12 patients by both TTE and transesophageal echocardiography (TEE). Mean procedure time was 59 minutes (range, 35-90 minutes). We conclude that oxymetry, pressure recordings, and the estimation of the balloon-stretched size of atrial septal perforations can be performed safely by echocardiographic guidance without fluoroscopy. The x-ray exposure for patient selection prior to a transcatheter closure of an ASD can be avoided with this technique.     

Limited right posterior thoracotomy approach to atrial septal defect

Experience of atrial septal defect closure via a limited posterior thoracotomy is described. From July 1999 to May 2001, 75 prepubertal girls with a median age of 7 years (range, 3 to 13 years) and a median weight of 18 kg (range, 10 to 46 kg) underwent atrial septal defect closure through a limited right posterior thoracotomy. All but 2 patients had an uneventful postoperative recovery. The median duration of ventilation was 13.3 hours (range, 4 to 24 hours). Median hospital stay was 6 days (range, 6 to 8 days). All patients were followed up for 7 to 32 months (mean, 15 months). The wounds healed well without any restriction of limb movement. The limited posterior thoracotomy gave excellent cosmetic results and can be used as a safe alternative approach for atrial septal defect closure in prepubertal females.     

单纯经食道超声心动图引导下经皮房间隔缺损封堵术的疗效分析

分析单纯经食管超声心动图引导下经皮行房间隔缺损封堵术的临床资料,评价方法的安全性和有效性。 方法：回顾性分析2017年6月至2018年6月采用经食道超声心动图引导经皮房间隔缺损封堵术患者共16例,操作均在普通手术室进行,单纯采用经食道超声心动图引导,在全身麻醉下,经股静脉穿刺封堵房间隔缺损。食道超声全程监测封堵全过程并评估手术效果。所有患者均在术后1个月、6个月接受经胸超声心动图复查。结果 共14例患者封堵成功,1例患者术中封堵器释放后超声心动图提示封堵器靠近下腔边缘存在大量分流,封堵器收入鞘管再次释放后仍存在残余分流,调整为经右胸小切口成功释放封堵伞,另一例术后7日出院前复查超声心动图提示封堵器脱落位于右心室内,再次行房间隔缺损修补术。随访过程中均未见明显并发症。结论 经食道超声心动图引导下可以完成大多数房间隔缺损经皮封堵术,避免放射线可能引起伤害,取得良好的临床应用效果。     

Combined Percutaneous Management of an Atrial Septal Defect and Coronary Artery Disease

A 52-year-old female was admitted to the hospital with a 1-month history of increasing breathlessness, exertional chest tightness, palpitation, and lethargy. Echocardiography revealed a secundum atrial septal defect. Cardiac catheterization confirmed the diagnosis, and the coronary angiogram revealed a critical 90% stenosis in the midright coronary artery (RCA). Under general anaesthesia, two 15-mm intracoronary stents were placed in the RCA with an excellent angiographic result. The atrial septal defect was then closed percutaneously using the Angel-Wings atrial septal defect occluder device. Perioperative transesophageal echocardiography confirmed satisfactory positioning of the Angel Wings device and color flow mapping showed no residual shunt across the atrial septum. The patient was discharged home the following day. Percutaneous closure of atrial septal defects offers the chance to replace an open heart surgical procedure with a minimally invasive treatment that allows discharge from the hospital on the day after the closure. To date, adult patients who have concomitant coronary artery disease and an atrial septal defect have undergone surgery even if their coronary lesion was amenable to percutaneous treatment with angioplasty. We describe a patient in whom stenting of the RCA and percutaneous closure of an atrial septal defect were performed concomitantly . (J Interven Cardiol 2000;13:35–38)     

Surgical options for complex transposition of the great arteries

Between September 1976 and November 1987, 53 patients underwent surgical treatment by the same surgeon for "complex transposition of the great arteries" with ventricular septal defect or severe left ventricular outflow tract obstruction, or both. Six patients with transposition and left ventricular outflow tract obstruction underwent atrial rerouting and direct relief of the left ventricular outflow tract obstruction. Twenty-two patients presented with transposition plus ventricular septal defect; 15 of these patients underwent atrial rerouting and ventricular septal defect closure and 7 underwent an arterial switch procedure. Twenty-five patients presented with transposition plus ventricular septal defect and left ventricular outflow tract obstruction, 23 of whom underwent a Rastelli procedure. There were one early death (mortality rate 1.9%; 90% confidence limits 0-7%) and three late deaths (mortality rate 5.8%) during a mean follow-up period of 42 months (range 2 to 124). These results show that 1) atrial rerouting is an appropriate surgical procedure for transposition of the great arteries with left ventricular outflow tract obstruction; 2) the arterial switch procedure provides excellent early correction of transposition with ventricular septal defect and is currently the preferred procedure for this lesion; and 3) the Rastelli procedure can be performed with a low early mortality rate and excellent long-term results for transposition with ventricular septal defect and left ventricular outflow tract obstruction.     

Transcatheter closure of atrial septal defects under echocardiographic guidance without X-ray: initial experiences.

BACKGROUND: Transcatheter closure of atrial septal defects is performed under fluoroscopy, but echocardiography has gained an important role in the procedure. With the new Amplatzer Septal Occluder a device has become available which is easy to implant with minimal fluoroscopy time. We developed an interventional procedure with this device under transesophageal echocardiography alone without fluoroscopy. METHODS AND RESULTS: Four patients (3 to 16 years of age, bodyweight 14 to 60 kg) with atrial septal defects centrally located in the oval fossa were elected for transcatheter closure. After sedation with midazolam and propofol a diagnostic and interventional catheterization was performed in all cases without fluoroscopy. Oxymetric shunt was Qp: Qs = 1.7 (1.5 to 2.1). Under transesophageal echocardiography, the defects were sized over the wire with a balloon catheter. Mean balloon stretched diameter was 10 mm (7 to 14 mm). Under transesophageal echocardiography an Amplatzer Septal Occluder was placed into the defect. In two patients this was achieved with a 5 MHz monoplane pediatric transducer, in two patients a 10mm 5 MHz multiplane probe was used. Complete closure was achieved in all patients and no complications were encountered. CONCLUSION: We conclude that in selected cases with an atrial septal defect located in the oval fossa and clear-cut echocardiographic findings, an Amplatzer Septal Occluder can be safely deployed under echocardiographic guidance alone.     

经胸彩色多普勒超声心动图在房间隔缺损经导管封堵术中的应用价值

目的探讨经胸彩色多普勒超声心动图(TTE)在房间隔缺损(ASD)经心导管封堵治疗中的应用价值。方法应用TTE选择适于行Amplatzer式封堵术的继发孔型ASD患者27例，在TTE监测引导下经右心导管应用房间隔封堵器关闭ASD。结果26例ASD获成功封堵，术后即刻、1天、1个月和3个月TTE检查显示封堵器位置稳定良好，无残余分流。结论在TTE引导下行ASD封堵术是一种简便、可靠和安全的方法。     

Immediate Change in Pulmonary Venous Flow Pattern after Deployment of Occluder Device for Atrial Septal Defect

Transcatheter closure of a secundum defect using a septal occluder is a safe and effective procedure based on long-term follow-up, but no clinical studies have examined immediate hemodynamic changes. We evaluated pulmonary venous flow velocity pattern before and immediately after deployment of the Amplatzer septal occluder for closure of atrial septal defect. From May 2003 to January 2005, 48 patients with secundum atrial septal defect received transcatheter closure with complete occlusion. Patients were divided into two groups according to age: pediatric group, under 16 years (n = 30, age 7.3 ± 3.2 years), and adult group, 16 years or older (n = 18, age 30.1 ± 11.4 years). Pulmonary venous flow pattern was recorded by transesophageal echocardiography before and immediately after occluder deployment. Immediately after deployment in both patient groups, pulmonary vein systolic (S) and diastolic (D) wave velocity decreased, but atrial reversal (AR) wave velocity increased. In the pediatric group, S-wave was 56.1 ± 17.1 versus 35.5 ± 11.3 cm/sec (P < 0.001); D-wave was 57.6 ± 12.5 versus 42.9 ± 11.8 cm/sec (P < 0.001); and AR wave velocity was 12.2 ± 3.8 versus 15.5 ± 4.1 cm/sec (P < 0.001). In the adult group, S-wave was 48.4 ± 13.7 versus 32.7 ± 10.3 cm/sec (P < 0.001); D-wave was 51.9 ± 11.7 versus 38.0 ± 8.5 m/sec (P < 0.001); and AR wave velocity was 12.1 ± 4.1 versus 16.2 ± 4.9 cm/sec (P < 0.001). Comparison of pulmonary venous flow before and immediately after deployment of the Amplatzer septal occluder provides an excellent model to evaluate the influence of an atrial communication on pulmonary venous flow. Pulmonary venous forward flow decreases following atrial septal defect (ASD) closure.     

超声心动图在成人房间隔缺损治疗决策中的作用

目的　探讨超声心动图在成人房间隔缺损(ASD)治疗决策中的作用 ,选择适合的病例进行经皮导管堵闭治疗。方法　本组资料来源于 2 0 0 2年 8月至 2 0 0 3年 8月广东省心血管病研究所 ,12 8例患者经胸超声心动图 (TTE)诊断为继发孔型ASD ,使用TTE筛选和患者同意的 5 2例进行导管堵闭治疗 ,78例患者进行了外科手术治疗。结果　经超声心动图筛选的病例 ,导管介入治疗能有效地关闭 96 %(5 0 /5 2 )的继发孔型ASD ,外科手术修补房间隔缺损的成功率为 10 0 % ,超声心动图显示的房间隔缺损分型与外科术中分型的差异无显著的统计学意义 (P >0 0 5 )。结论　经胸超声心动图能准确的显示成人ASD解剖变异和确定分型 ,经皮导管介入治疗能成功地堵闭绝大多数经超声心动图筛选的患者     

新型导丝在单纯经胸超声心动图引导下经皮房间隔缺损封堵术中的应用

目的:探索一种新型超声专用导丝在单纯经胸超声心动图(TTE)引导下封堵房间隔缺损的安全性和有效性。方法:于2017年11月至2017年12月在中国医学科学院阜外医院入选10例房间隔缺损患者,均采用一种新设计的导丝进行单纯TTE引导下房间隔缺损封堵术,这种新型导丝的特点是头端为梭形弹性结构,可以在超声心动图引导下精确定位。手术由3名在单纯超声心动图引导下行封堵手术不超过10例的医生完成。术后即刻通过TTE评价手术疗效。术后1个月、3个月和6个月门诊随访,复查TTE和心电图。结果:10例患者在TTE引导下应用新型导丝成功封堵房间隔缺损。10例患者中,男性4例,女性6例,平均年龄(45.2±13.5)岁,平均体重(65.5±8.8)kg,平均房间隔缺损直径(14.9±5.1)mm。平均手术时间为(20.2±8.9)min,导丝从进入股静脉至左心房所需的时间为(3.6±2.6)min。无导丝脱入右心房。患者在住院期间均无残余分流、外周血管损伤、三尖瓣损伤及心脏穿孔等并发症。随访至术后6个月,均无封堵器脱落、残余分流和心包积液等并发症。结论:新型超声专用导丝可以在超声心动图引导下精确定位,可安全、有效地引导经皮房间隔缺损封堵术。     

老年性房间隔缺损介入封堵治疗临床观察

目的探讨介入封堵治疗对老年性房间隔缺损的临床疗效。方法选取我院于2008年1月-2012年6月收治的老年性房间隔缺损患者27例,对其进行介入封堵治疗,观察其临床治疗效果。结果 27例患者均封堵成功,成功率为100%,术后并发症发生率为3.7%(1/27),介入封堵治疗后,在肺动脉压力、右心室内径以及三尖瓣的反流面积上,与介入治疗前相比差异明显,P0.05,差异有统计学意义。结论介入封堵治疗老年性房间隔缺损患者,成功率高,创伤小,疗效显著,且手术安全可靠,值得临床推广与应用。