ASD closure (Autologous Pericardium)

One of the most widespread congenital heart diseases is an atrial septal defect (ASD). This pathology can be managed with a percutaneous pericardial patch with a low likelihood of immediate post-procedural problems. Transcatheter closure is not recommended for ASDs with unfavorable anatomy or for ASDs other than the secundum. Additionally, there are significant late consequences of ASD closure due to patch, such as patch migration, malposition, cardiac erosion or perforation resulting in tamponade and mortality, atrioventricular block, and bacterial endocarditis. At the moment, robotic surgical methods enable doctors to completely endoscopically close ASDs with a high success rate and low complication rate. Both secundum and sinus venosus forms of ASDs and ASDs of various anatomical sizes can be treated with the robotic approach. Additionally, as this approach does not call for the installation of any prosthetic components, it may provide patients with a long-term safe experience free from issues caused by any devices.

 

ASD Closure Indications

Every infant has a typical little opening between the left and right atria at birth. Soon after birth, this hole frequently closes or shrinks considerably. However, in some kids, it remains open. Most of the time, doctors are unclear about why this occurs.

Many kids with ASD don't need the hole to be fixed. There may not be much blood flow between the atria through very tiny holes. The heart and lungs don't have to work much more than usual in these circumstances. There is no need to repair these smaller holes because they don't produce any symptoms. These tiny holes are occasionally close by themselves. Before intending to repair, a healthcare professional might wait to see if that occurs, especially in very young children.

The patient might require some sort of repair if they have a more severe ASD. Breathlessness is one of the symptoms that patients with more severe ASDs may experience. The arteries in the lung may eventually experience excessive pressure if a larger ASD is left untreated. The body may then have low oxygen levels as a result of this. Even if a patient with severe ASD does not yet manifest any symptoms, healthcare professionals frequently advise a repair. It can stop the lungs from suffering long-term, irreversible harm. Patients have this procedure most frequently. However, if an adult's ASD wasn't discovered during childhood, they might require this kind of treatment.

ASDs can be repaired transcatheter rather than surgically. Additionally, it needs less time to recover. Healthcare professionals frequently elect transcatheter repair over surgery when given the choice. Only some types of ASDs, such as those in the center of the septum (referred to as secundum), are amenable to transcatheter treatment. The septum's other atrial abnormalities require surgical correction. Large ASDs could also need to be surgically repaired. If a child needs concurrent treatment for additional heart problems, transcatheter repair may not be possible.

 

Closure of ASD

ASD closure can be achieved in one of two ways:

• Open-heart surgery. Patients with ostium primum and sinus venous ASD require open heart surgery, and early intervention (during childhood) is advised.
• Catheter-based closure. ASD closure using a catheter may be chosen by patients with secundum ASD.

 

How to Prepare for ASD Closure?

Fasting. You must go six to eight hours without eating or drinking before your surgery. You can continue taking your prescriptions by consuming a modest amount of clear liquids.

Medication. Let your cardiologist know about every drug you use. Your cardiologist might suggest that you temporarily cease taking some medications for a few days before your surgery, such as blood thinners.

Allergies or past reactions to contrast. Let Intra staff know if you have any known allergies, especially seafood and x-ray contrast allergies, at the time of scheduling your operation.

Diabetes. When scheduling your procedure, you should let the Angiography staff and your cardiologist know if you have diabetes. Your cardiologist may need to know how much insulin you are taking. 

Bring any medications you are taking as well as any recent x-rays, ultrasound, or blood test results. Visit the heart group the day before your procedure to speak with the cardiologist, get some last questions answered, and complete the consent form. Following that, you will be shown to the hospital reception, where someone will be waiting for you. After being checked into a hospital ward, you will be taken for your surgery.

 

Preparation for Children

Consult your doctor about ways to get your child ready for an ASD transcatheter repair. Before the procedure, your child shouldn't eat or drink anything after midnight. Additionally, he or she might need to cease taking any medications first. Before the treatment, the doctor may want to do a few additional tests on your child. These could consist of:

• Chest X-ray
• An electrocardiogram (ECG) is used to evaluate heart rhythm.
• Blood tests to determine general health
• Using echocardiography, you can examine the heart's structure and evaluate its blood flow.

 

ASD Closure Procedure

Patients should have transthoracic echocardiography, coronary angiography, vascular ultrasonography, and (if necessary) computed tomographic angiography examinations of the femoral vessels performed before surgery. The procedure can be paired with right-sided robotic surgeries for mitral or tricuspid valve diseases as well as secundum or sinus venosus type ASDs. Primum-type ASD, significant peripheral vascular disease, substantial coronary artery disease, and prior median sternotomy or right thoracotomy are considered the exclusion criteria for this procedure.

 

Anesthesia and Cardiopulmonary Bypass Setup

After inducing general anesthesia, a multiplane transesophageal echocardiography (TEE) probe and a double-lumen endotracheal tube are inserted. Before cross-clamping to prepare a pericardial patch, the size of the ASD should be assessed by TEE. The right shoulder is rolled under, the right arm is put at the side of the operating table, and the table is turned right side up by 20 degrees. The areas of the incision are marked. Under the guidance of a TEE, a venous cannula is percutaneously inserted into the right internal jugular vein and positioned into the superior vena cava with its tip at least 2-3 cm above the cavoatrial junction. The aortic cannula is inserted into the common femoral artery. The right common femoral vein is used to implant a venous cannula, which is then placed in the inferior vena cava with its tip 2-3 cm below the cavoatrial junction. Contrary to the setup for robotic mitral surgeries, the need for clamping for bicaval occlusion is the rationale for leaving a space of 2-3 cm at both vena cava. In faults of the sinus venosus type, the space at the superior vena cava ought to be even longer.

 

Cardioplegia and Cross-Clamping

In the fourth intercostal space on the right, 3 cm laterally from the nipple, a 20-mm working port is positioned. In the same intercostal space, the camera port is positioned 1-2 cm medially to the working port. Typically, a 30° camera is utilized for setup. However, a 0° camera may be a superior option, at least in some circumstances, because the atrial septum is horizontally seen intraoperatively. Carbon dioxide is inhaled at a pressure of 8 mmHg and a flow rate of 6 l/min. The left-arm port is positioned in one or two intercostal spaces above while the right-arm port is positioned in two intercostal spaces below the thoracotomy. The fourth or fifth intercostal space is where the atrial retractor port is located, around 3 cm medially from the camera port. The robotic arms are attached to the ports after port implantation.  Cardiopulmonary bypass (CPB) is established.

• Pericardial stay sutures and external fixation

The pericardium is separated from the chest wall by two to three centimeters anterior to the phrenic nerve, and the pericardial margins are suspended on stay sutures before being snared and pushed through the chest wall of the side opposite the thoracotomy. These stitches are secured on the outside. A pericardial patch is made in sizes according to the TEE measurements of the ASD because the endocamera system's magnification could cause the accurate sizing intraoperatively to be misled.

• Placement of a cross-clamp

A transthoracic clamp is used to cross-clamp the ascending aorta. It is introduced via one intercostal space above the working port and toward the transverse sinus. The caval bulldog clamp should have a space of 1-2 cm between it and this clamp so that it can pass through the top side of the confluence of the atrium and superior vena cava.

• Administration of cardioplegia

Through a transthoracic cannula inserted through a thoracotomy, cold crystalloid cardioplegia is used to stop the heart. Utilizing TEE, cross-clamping and cardioplegia administration should be confirmed.

• Occlusion of both vena cava

The working port is used to deliver bulldog clamps that occlude the inferior and superior vena cava.

• Right atriotomy and exposure of the right atrium

The alternative is to trap both vena cava. Following bicaval occlusion, the right atrium is opened via a traditional incision, and the ASD is exposed by carefully positioning the atrial retractor.

• Patch closure of the defect

The ASD is often closed using pericardial patch material that has already been glutaraldehyde-pretreated. A knot pusher is used to tie knots through the working port. The inferior vena cava clamp is partially loosened after patch closure to enable de-airing and regulation of the inferior caval orifice flow. A ready-made loop suture is used to stitch the atriotomy shut.

• Release of bulldog clamps

The two bulldog clamps are let go. At the site of the cardioplegia needle, a suture is applied, and a vent is threaded through it. It ventilates the left lung. To regulate intracardiac air, TEE is used.

• De-airing

The aortic cross-clamp is relaxed after de-airing. The hemostasis is adequate. The drainage tube is inserted via the right port incision once the robotic arms have been removed. Heparin is turned off after decannulation, and all wounds are then closed in layers.

 

What Happens After ASD Closure?

Find out what will happen following the ASD repair from your doctor. Generally, you can anticipate the following:

• The patient will stay in the recovery area for a while.
• Vital signs of the patient, like breathing and heart rate, will be monitored.
• After the treatment, you might need to lie flat for several hours without bending your legs. This will aid in reducing bleeding.
• A medication that prevents blood clotting (anticoagulants) may be prescribed by your doctor.
• If necessary, you will receive pain medication.
• An electrocardiogram or echocardiography may be recommended as a follow-up test by your medical professional.
• Most likely, you will require at least a day of hospitalization.

Following the procedure, at home:

• Find out what medications you should take. You might need to take antibiotics or clot-preventing medication for a while. As necessary, administer painkillers.
• Refrain from strenuous activity. Advice to rest is given.
• Stitches may be removed at a subsequent visit. Keep a record of every follow-up visit.
• If you have a fever, significant bleeding or drainage, increased swelling, or other serious symptoms, call the medical professional right away. It's typical for the site to drain a little bit.
• Respect any instructions for medication, physical activity, food, and wound care that your doctor gives you.

You will require routine cardiologists' monitoring for a brief period following the procedure. Following that, you will only require occasional visits to a cardiologist. You could also require antibiotics before specific medical and dental treatments to help avoid an infection of the heart valves for a while after the surgery.

 

ASD Closure Risks

The majority of patients respond favorably to ASD repair. But complications do occasionally arise. Complication risk is generally lower with the transcatheter method than with a surgical technique. Age, the size of the defect, and other health issues can all affect potential risks. Possible risks include:

• Irregular heartbeats
• Unattached patch dislodging through the heart or blood vessels (embolization)
• Fluid accumulation around the heart
• Infection
• Excess bleeding
• Puncturing the heart
• Tear in the blood vessel in the groin where the catheter is placed
• Decreased cardiac blood flow temporarily
• Hematoma, or a collection of blood, in the groin

The surgery could fail to successfully treat ASD. Talk with your doctor about the particular risk factors that apply to you.

 

Conclusion

One of the most frequent operations carried out in cardiac catheterization labs is the closure of the pericardial patch. Given how straightforward the operation is in theory, the morbidity and fatality rates related to it should be as low as possible. Attempts to reduce morbidity and mortality rates to the barest minimal nevertheless face difficulties. Doctors firmly think that by thoroughly evaluating the flaws and eliminating those that shouldn't be closed, the dangers of pericardial patch closure can be reduced to a minimum. This can be done by conducting a thorough evaluation, anticipating the hemodynamic effects of closing the defects, improving understanding of the procedures that are available and their limits, and using the interventionist's echocardiographic expertise.