Radiofrequency ablation through a right atrium incision in congenital atrial septal defect

BACKGROUND: The incidence of atrial fibrillation is similar in the clinical history of patients with atrial septal defect, either surgically corrected and uncorrected. We present an unpublished technique for treating atrial fibrillation by left endocardial radiofrequency ablation through the lone right atrium incision, coupled to atrial septal defect septum primum and secundum closure, thus reducing the surgical trauma related to paraseptal left atrium incision. PATIENTS AND METHODS: We treated 2 patients through a lone right atrium incision by radiofrequency ablation because of congenital atrial septal defect and chronic atrial fibrillation. RESULTS: The patients after defect closure were weaned off cardiopulmonary bypass in sinus rhythm. The postoperative hospital stay was uneventful and at more than 1 year of follow-up they are still in sinus rhythm. CONCLUSIONS: The radiofrequency ablation procedure is possible through the lone right atrium incision, avoiding any further incision and new source of possible bleeding when in presence of interatrial septal defects, and the technique is simple and useful.     

Combined ablation of atrial fibrillation and minimally invasive mitral valve surgery: a case report

A partial lower inverted J sternotomy and an extended transseptal incision provide excellent exposure for minimally invasive mitral valve surgery. However, the extended trasnsseptal incision causes dividing the sinus node artery, which may result in conduction system disturbance and need for permanent pacemaker implantation. Therefore, there is a challenge in the patient who requires concomitant ablation for atrial fibrillation because of possible conduction system disturbance caused by extended transseptal incision. We describe a new strategy for combined ablation of atrial fibrillation with minimally invasive cardiac surgery by a transseptal approach to the mitral valve through a partial lower sternotomy incision. Cryoablation was performed using a T-shaped cryoprobe with a lesion set of pulmonary vein isolation and ablation of the left and right isthmus in performing mitral annuloplasty, tricuspid annuloplasty, and atrial septal defect closure through a limited sternotomy incision. This technique might minimize possible conduction system disturbance and provide good surgical result for the patients who undergo mitral valve surgery and ablation of atrial fibrillation.     

Surgical repair of coronary sinus type partial anomalous pulmonary venous drainage with intact atrial septum

We experienced a rare form of PAPVD without atrial septal defect. The patient was a 33-year-old male and he was referred to our institute because of mild right pulmonary congestion detected by a routine chest X-P. Enlarged coronary sinus, right atrium and right ventricle were documented by UCG. The Qp/Qs was 1.9 and pulmonary artery pressure was 38/7 mmHg (mean: 17 mmHg) by cardiac catheterization. Selective pulmonary angiogram showed that all right pulmonary veins drained into the coronary sinus without evidence of an atrial septal defect. Enhanced chest CT clearly demonstrated the connection between the right pulmonary vein and the coronary sinus. Intracardiac repair without atrial baffle was carried out under hypothermic cardiopulmonary bypass. Under cardiac arrest with cardioplegia, the common wall between the right pulmonary vein and the left atrium was incised and the connection between the right pulmonary vein and the left atrium was established. The flap made by this incision was brough posterior to close the right pulmonary vein opening to the coronary sinus. The postoperative course was uneventful and the minimum diameter of the right pulmonary vein was found to be 15.5 mm by a postoperative pulmonary artery angiogram. This operative method without an atrial baffle could be an alternative procedure for coronary sinus type PAPVD.     

Surgical treatment for ectopic atrial tachycardia.

Atrial tachycardia is an infrequent but potentially dangerous arrhythmia which often determines cardiac enlargement. Surgical ablation of the arrhythmia is effective and safe, provided a careful atrial mapping is performed and the surgical technique is tailored to the individual focus location. Eight patients underwent surgical ablation of ectopic atrial tachycardia between 1977 and 1990. Different techniques were adopted for each patient according to the anatomical location of the focus and possibly associated arrhythmias. Whenever possible, a closed heart procedure was chosen. In 1 patient a double focal origin was found and treated by separate procedures. In 1 patient with ostium secundum atrial septal defect and atrial flutter, surgical isolation of the right appendage and the ectopic focus was performed. In all patients ectopic atrial tachycardia was ablated with maintenance of the sinoatrial and atrioventricular nodal function as well as internodal conduction. In follow-up up to December 1991, no recurrency was recorded.     

Raghib’s syndrome: A report of two cases

We treated two patients with a rare developmental complex. The persistent left superior vena cava draining into the left atrium (PLSVC into LA) was associated with an absent coronary sinus and an atrial septal defect. Ligation of PLSVC and patch-repair of the atrial septal defect were successfully performed in one stage. The atrial septal defect was located in the upper and posterior aspect of the interatrial septum and appeared to be an unique type of atrial septal defect. In the other patient, additional multiple cardiac defects were associated with this syndrome, including ventricular septal defect, pulmonary stenosis, tricuspid insufficiency, and complete transposition of the great arteries. Palliative Blalock procedure was used for this patient. The PLSVC into LA was discovered accidentally in both cases during heart catheterization and it was clearly demonstrated by venography. For a preoperative recognition of PLSVC, computed tomograms of the heart are of great assistance. Surgical correction of the persistent superior vena cava was emphasized for treatment of this syndrome.     

Raghib's syndrome: a report of two cases

We treated two patients with a rare developmental complex. The persistent left superior vena cava draining into the left atrium (PLSVC into LA) was associated with an absent coronary sinus and an atrial septal defect. Ligation of PLSVC and patch-repair of the atrial septal defect were successfully performed in one stage. The atrial septal defect was located in the upper and posterior aspect of the interatrial septum and appeared to be an unique type of atrial septal defect. In the other patient, additional multiple cardiac defects were associated with this syndrome, including ventricular septal defect, pulmonary stenosis, tricuspid insufficiency, and complete transposition of the great arteries. Palliative Blalock procedure was used for this patient. The PLSVC into LA was discovered accidentally in both cases during heart catheterization and it was clearly demonstrated by venography. For a preoperative recognition of PLSVC, computed tomograms of the heart are of great assistance. Surgical correction of the persistent superior vena cava was emphasized for treatment of this syndrome.     

Sinus Venosus Atrial Septal Defect Associated with Partial Anomalous Pulmonary Venous Drainage: Surgical Repair

This report describes a new technique for the repair of sinus venosus atrial septal defect associated with partial anomalous pulmonary venous drainage. A right atrial wall flap is used both to deflect the anomalous venous blood into the left atrium and to close the atrial septal defect. Then an atrioplasty is performed. This method does not employ any foreign materials, avoids injury to the sinoatrial node and internodal tracts, and minimizes the risk of obstruction of the ostia of the anomalous pulmonary veins and superior vena cava.     

Surgical cure of automatic atrial tachycardia by partial left atrial isolation

Partial left atrial isolation was performed in a 16-year-old girl with persistent atrial tachycardia refractory to antiarrhythmic agents for 3 years. Intraoperative atrial epicardial and endocardial mapping showed that the earliest atrial activation occurred in an area lateral to the junction of the right superior pulmonary vein and the left atrium. An incision isolating the right half of the left atrial body containing the area of the earliest atrial activation and both right pulmonary veins from the remainder of the left atrium was made. The incision was then reapproximated. An excision encircling the interatrial septum containing the upper anterior portion of the septum with early activation was also made, and the atrial septal defect was repaired with a pericardial patch. The patient has been in sinus rhythm and free of arrhythmia for a follow-up period of 12 months.     

Ebstein's anomaly associated with a definite atrial left to right shunt--case report

A case with Ebstein's anomaly associated with large left to right atrial shunt was operated upon. The patient did not demonstrate any tricuspid insufficiency in spite of the downward displacement of the septal and posterior leaflets of tricuspid valve. The surgical closure of the atrial septal defect relieved the impending heart failure. The pulmonary congestion disappeared but the cardiomegaly persisted after the operation.     

Ebstein's anomaly associated with a definite atrial left to right shunt—Case report

A case with Ebstein's anomaly associated with large left to right atrial shunt was operated upon. The patient did not demonstrate any tricuspid insufficiency in spite of the downward displacement of the septal and posterior leaflets of tricuspid valve. The surgical closure of the atrial septal defect relieved the impending heart failure. The pulmonary congestion disappeared but the cardiomegaly persisted after the operation.     

Map-guided surgery for atrial fibrillation

BACKGROUND: Although current surgical procedures result in a high success rate for atrial fibrillation, they are not guided by electrophysiologic findings in individual patients and thus might include unnecessary incisions in some patients or be inappropriate for other patients. We sought to determine whether intraoperative mapping is beneficial for the surgical treatment of atrial fibrillation. METHODS: A 256-channel 3-dimensional dynamic mapping system with custom-made epicardial patch electrodes was used to examine the atrial activation during atrial fibrillation and to determine the optimal procedure in 37 patients with continuous and 9 patients with intermittent atrial fibrillation intraoperatively. RESULTS: Surgical intervention for atrial fibrillation was not indicated in 3 patients in whom the atrial electrograms had a low voltage over a broad area. Concurrent, multiple, and repetitive activations arising from the pulmonary veins or left atrial appendage were observed in all patients. A simple left atrial procedure consisting of pulmonary vein isolation and left atrial incisions without any right atrial incisions was performed in 8 patients in whom the right atrial activation was passive, and all (100%) were cured of atrial fibrillation. The radial procedure was performed in the remaining 35 patients, and 31 (89%) of the patients were cured of atrial fibrillation. In this subset of patients, 10 exhibited reentrant or focal activation in the posterior left atrium between the right and left pulmonary veins and required an additional linear ablation on the posterior left atrium. The total amount of postoperative bleeding after the simple left atrial procedure was significantly less than after the radial procedure (378 +/- 135 vs 711 +/- 364 mL, P = .03). The right and left atrial transport functions were well preserved after both the radial and simple left atrial procedures. CONCLUSION: Intraoperative mapping facilitates determining the optimal procedure for atrial fibrillation in each patient.     

A case of successful surgical treatment of straddling tricuspid valve associated with dextrocardia and VSD

A case of straddling tricuspid valve associated with dextrocardia and VSD was presented. Closure of ventricular septal defect and tricuspid valve replacement were performed on this patient. Since the straddling septal leaflet of the tricuspid valve shared a posterior papillary muscle in the left ventricle with the posterior mitral leaflet, division of this papillary muscle was thought to induce papillary muscle dysfunction of both leaflet. Hence, the chordae of straddling tricuspid leaflet was detached from the shared papillary muscle and the ventricular septal defect was closed by a large pericardial patch. Because of peculiar anatomy of the conduction system in this situation, the junctional area of the inlet septum and tricuspid annulus was avoided from stitching in VSD closure. Suture through the tricuspid septal leaflet and pericardial patch for VSD were used for tricuspid valve replacement as well. The patient showed uneventful postoperative course without any conduction disturbance including the right bundle branch block.     

电视胸腔镜辅助下房间隔缺损修补术36例报告

目的　总结 36例电视胸腔镜下房间隔缺损修补的体外循环方法 ;　方法　 36例房间隔缺损患者 ,采用股动脉和股静脉 ,上腔静脉插管建立体外循环 ,经第七肋置入胸腔镜 ,另选第四肋打两个用作手术操作孔 ,在电视胸腔镜下行房间隔缺损修补 ;　结果　第 1例因体外循环停机后血氧饱和度在80 %～ 88% ,而延长第四肋间切口重新作心内探查 ,其他手术顺利 ,术后无并发症 ;　结论　电视胸腔镜体外循环下行房间隔缺损修补术安全可靠。     

The results of surgical treatment of total anomalous pulmonary venous return in neonates

By the time, the results of surgical treatment for total anomalous pulmonary venous return have been unsatisfactory. From 1981, we changed a surgical procedure fro Gersony-Malm procedure to the posterior approach method, and a surgical technique from the deep hypothermia and the circulatory arrest to the moderate hypothermia and the pump perfusion. Consequently, the results of surgical treatment was improved. From 1981 to 1987, 18 neonates with total anomalous pulmonary venous return underwent corrective operations in our institute. This diagnosis was decided by echocardiography without cardiac catheterization, because the preoperative status of these neonates were poor. Under the cardiopulmonary bypass, we performed the posterior approach method for type I and III, the cut-back method and Van Praagh procedure for II and IV without aortic clamping. According to the posterior approach method, the atrial septal defect was closed through the left atrial incision and the left atrium was anastomosed to the common pulmonary trunk during ventricular fibrillation. The incision was limited within the common pulmonary trunk or the vertical vein and was not extended into the pulmonary veins. According to cut-back method and Van Praagh procedure, the coronary sinus was closed internally so as to avoid the postoperative conduction disturbance. There were four hospital deaths (22.2%). The causes of deaths were pulmonary hypertension in two, low cardiac output in one, and intracranial bleeding in one. From the results of our institution, we concluded that the primary factors determining the outcome were the condition of the patients prior to repair and the severity of pulmonary hypertension.     

Transatrial Repair of Post-infarction Posterior Ventricular Septal Rupture

Ventricular septal rupture (VSR) is a rare but lethal complication of myocardial infarction. The event occurs 2~8 days after an infarction and often precipitates cardiogenic shock. Post myocardial infarction VSR is known for difficult to repair. Especially, Transmural myocardial infarction involved in the posterior VSD area, exposure of the affected site is difficult and postoperative mortality rate is high. We have experienced a case of a 75-year-old female patient who suffered posterior VSD due to acute myocardial infarction, and attained good result by approaching the lesion through right atrial incision and repaired the defect by using patch closure technique.     

The Operative Management of a Displaced Atrial Septal Occluder

Abstract We present a case of a displaced atrial septal defect (ASD) occluder in the left ventricle. We successfully adapted a strategy to remove the device through a single right atrial incision which permitted retrieval of the occluder and the closure of the ASD . (J Card Surg 2010;25:382‐384)     

Right axillary incision: a cosmetically superior approach to repair a wide range of congenital cardiac defects

OBJECTIVES: We sought to evaluate the safety of a right axillary incision, a cosmetically superior approach than anterolateral thoracotomy, to repair various congenital heart defects. METHODS: All the patients who were approached with this incision between March 2001 and October 2004 were included in the study. There were 80 patients (median age, 4 years) with atrial septal defect closure (38 patients), repair of partial abnormal pulmonary venous return (14 patients), partial atrioventricular canal (16 patients), and perimembranous ventricular septal defect (12 patients). The surgical technique involved peripheral and central cannulation for institution of cardiopulmonary bypass. Electrically induced ventricular fibrillation was used for defects located in front of the atrioventricular valves, and cardioplegic arrest was used for those located at the level or behind these valves. RESULTS: The repair was possible without need for conversion to another approach. One patient sustained a transient neurologic deficit. The patients were all in excellent condition after a mean follow-up of 14 months. The cardiac defect was repaired with no residual defect in 75 patients and with trivial residual defect in 5 patients (3 with mitral valve regurgitation, 1 with atrial septal defect, and 1 with ventricular septal defect). The incision healed properly in all, and the thorax showed no deformity. CONCLUSION: The right axillary incision provides a quality of repair for various congenital defects similar to that obtained by using standard surgical approaches. Because it lies more laterally and is hidden by the resting arm, it provides superior cosmetic results compared with conventional incisions, including the anterolateral thoracotomy. Finally, the incision is unlikely to interfere with subsequent development of the breast.     

Bilateral partial anomalous pulmonary venous connection; report of a case

We have experienced a case of bilateral partial anomalous pulmonary venous connection with a fossa ovalis type of atrial septal defect and pulmonary stenosis. The right upper pulmonary vein returned to the superior vena cava and the left upper pulmonary vein returned to the left innominate vein via the vertical vein. The atrial septal defect was enlarged and the right upper pulmonary vein was baffled into the left atrium with an equine pericardial patch. The left upper pulmonary vein was divided and anastomosed to the left atrial appendage. Pulmonary commissurotomy was also done for concomitant pulmonary stenosis. Postoperative course of the patient was excellent with constantly normal sinus rhythm. Angiography 2 weeks after operation showed no evidence of pulmonary venous obstructions on both sides.     

Cor triatriatum associated with large atrial septal defect and partial anomalous pulmonary venous return. Case report

A rare variant of cor triatriatum is presented with a large true atrial septal defect and partial anomalous pulmonary venous return into the right atrium. The correct diagnosis was made at the operation and abnormal left atrial septum was excised completely and a new interatrial septum was created with pericardial patch in such a position that the abnormally drained right upper pulmonary vein was left in the left atrium. It was thought to use the abnormal left atrial septum to close the atrial septal defect by excising only the right lateral border of this abnormal septum and resuturing it to the right atrial wall to close the true atrial septal defect. This thought could not be realized because of the small size of this abnormal septum and large size of the atrial septal defect. This technique can be realized in small or medium sized atrial septal defects associated with cor triatriatum.     

Polysplenia with anomalous pulmonary venous drainage to right atrium caused by atrial septal displacement; report of a case

A 3-year-old girl with polysplenia, atrial septal defect (ASD), and partial anomalous pulmonary venous connection (PAPVC) was admitted to our unit to have total correction. Preoperative three-dimensional computed tomography (3D-CT) and transesophageal echo (TEE) showed that the pulmonary veins were connected with what normally constitutes the posterior wall of the left atrium, but right pulmonary veins became incorporated into the right atrium because of the atrial septal displacement. In the procedure, intracardiac inspection revealed absence of septum secondum and leftward deviation of septum primum. Deviated septum primum was incised at the posterior edge and shifted rightward to incorporate right pulmonary veins into the left atrium. ASD was closed using autologous pericardial patch. This type of PAPVC was rare and preoperative 3D-CT and TEE was quite useful in evaluating unique anatomical characteristics.