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Dec 15, 2011 - INTRODUCTION. Atrial septal defect (ASD) is one of the most common forms of congenital heart disease. It occurs in 1 child per 1500 live births.
ORIGINAL ARTICLE

European Journal of Cardio-Thoracic Surgery 41 (2012) 1316–1319 doi:10.1093/ejcts/ezr193 Advance Access publication 15 December 2011

Totally thoracoscopic closure for atrial septal defect on perfused beating hearts Zeng-Shan Maa,b, Ming-Feng Donga, Qiu-Yang Yina, Zhi-Yu Fenga and Le-Xin Wanga,b,* a b

Department of Cardiac Surgery, Liaocheng People’s Hospital and Liaocheng Clinical School of Taishan Medical University, Liaocheng, Shandong, China School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW, Australia

* Corresponding author. School of Biomedical Sciences, Charles Sturt University, Wagga Wagga NSW 2678, Australia. Tel: +61-2-69332905; fax: +61-2-69332587, e-mail: [email protected] (L. Wang). Received 20 July 2011; received in revised form 29 September 2011; accepted 11 October 2011

Abstract OBJECTIVES: To investigate the feasibility and safety of non-robotically assisted totally thoracoscopic closure for atrial septal defect (ASD) on perfused beating hearts. METHODS: Twenty-four patients (8–45 years, mean 14.4 ± 18.7) underwent ASD closure on beating hearts by a totally thoracoscopic approach without the aid of a robotic surgical system. Additional 72 patients undergoing totally thoracoscopic ASD closure on cardioplegic arrested hearts were selected as a control. Cardiopulmonary bypass (CPB) was achieved peripherally. The aorta was not crossclamped in the study group but it was cross-clamped in the control group. RESULTS: ASD closure was successful in all study and control group patients without in-hospital mortality or major complications. The total duration of operation (76 ± 9 vs. 98 ± 6 min, P = 0.012), CPB time (32 ± 5 vs. 48 ± 4 min, P = 0.001), duration of intensive care stay (10.0 ± 5.1 vs. 19.2 ± 4.2 h, P = 0.003) and post-operative hospital stay (4.5 ± 0.8 vs. 5.0 ± 1.1 days, P = 0.045) in the study group were shorter than in the control group. There was no statistically significant difference in the proportion of patients requiring in-operation blood transfusion between study group and control group (25.0 vs. 36.1%, P = 0.226). Follow-up transthoracic echocardiography on Day 5 and Day 30 showed no residual shunts in study or control group patients. CONCLUSIONS: Non-robotically assisted totally thoracoscopic closures of ASD on perfused beating hearts are feasible and safe. These procedures are associated with a shorter operation time and a shorter hospital stay than in surgeries on cardioplegic arrested hearts. Keywords: Minimally invasive cardiac surgery • Thoracoscopy • Atrial septal defect • Beating heart • Congenital heart disease

INTRODUCTION Atrial septal defect (ASD) is one of the most common forms of congenital heart disease. It occurs in 1 child per 1500 live births and makes up 30–40% of all congenital heart diseases in adults [1]. Conventional surgical closure of an ASD often involves sternotomy, right atriotomy and repair of the defect with a patch under direct visualization. In recent years, totally endoscopic techniques using robotically assisted surgical systems have been developed for ASD closure [2–7]. These techniques visualize and repair the ASD through three small incisions or ports on the chest, and are associated with high success and low complication rates [2–7]. Recently, totally thoracoscopic closure of an ASD or ventricular septal defects without robotic technologies has also been found to be feasible and safe [8, 9]. Compared with conventional surgery, totally thoracoscopic closures of the ASD of a ventricular septal defect had better cosmetic results, a shorter intensive care or hospital stay and lower use of morphine analgesics following the surgery [8, 9]. Most of the reported thoracoscopic ASD closures are performed during a brief period of cardiac arrest induced by

injecting cold cardioplegic solutions or cold blood to the heart [2–9]. In patients who underwent coronary bypass grafting where cardioplegic arrest was induced, some reperfusion injuries to the myocardium occur when the aorta was declamped [10]. Beating-heart or off-pump coronary surgery has been developed in an attempt to prevent reperfusion injuries and to decrease cardiopulmonary bypass (CPB)-related morbidity [11, 12]. There has been limited information about surgical ASD closures on beating hearts. The purpose of this study was to investigate the feasibility of a totally thoracoscopic closure of an ASD on a beating heart without the aid of a robotic surgical system.

PATIENTS AND METHODS Patient selection This study was approved by the institutional review board of Liaocheng People’s Hospital. Written informed consent was obtained from all participants before the study. The selection criteria for totally thoracoscopic ASD repair at our hospital are as

© The Author 2011. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Z.-S. Ma et al. / European Journal of Cardio-Thoracic Surgery

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Age Male Preoperative symptoms Chest pain Palpitations Dyspnoea Qp/Qs Size of defect (cm)

Control group (n = 72)

Study group (n = 24)

P-value

13.0 ± 16.1 28 (38.9%)

14.4 ± 18.7 9 (37.5%)

0.362 0.597

2 (3.6%) 3 (5.4%) 13 (23.2%) 2.53 ± 0.48 2.36 ± 0.72

4 (4.2%) 5 (5.2%) 21 (21.9%) 2.52 ± 0.41 2.25 ± 0.57

0.296 0.682 0.594 0.226 0.108

Figure 1: Location of the three ports on the right chest wall.

following: (1) ≥5 years old with a body weight of ≥20 kg; (2) pulmonary arterial systolic pressure measured by echocardiography ≤60 mm Hg; (3) no previous history of lung disease or surgeries on the right chest and (4) no other serious cardiovascular disease or chronic illnesses. Patients who were unable to meet all of the above selection criteria or unable to give informed consent were excluded from this study. Between January and April 2011, 24 patients were recruited to the study group to undergo totally thoracoscopic closure of a secundumtype ASD on beating hearts. Between January 2009 and April 2011, 72 patients received totally thoracoscopic closure of secundum-type ASD on cardioplegic arrested hearts in our department. These patients were recruited as control. The baseline characteristics of study and control group patients are listed in Table 1. None of the patients had known history of diabetes, coronary artery disease, lipid disorders or respiratory illnesses.

Surgical techniques We have previously reported the techniques for totally thoracoscopic ASD closures without robotic assistance on cardioplegic arrested hearts [8]. In brief, under general anaesthesia, a singleor double-lumen endotracheal tube was placed to allow for single-lung or double-lung ventilation. Patients were positioned in the supine position with the right side of the body elevated to 15–20°. After systemic heparinization, a Carpentier doublelumen catheter (16F/20F, 20F/24F, 24F/29F or 30F/33F, Medtronic or Kangxin) was inserted through the right femoral vein into the inferior and superior vena cava. The bypass circuit was completed by positioning a catheter (7F, 12F, 14F or 21F, Medtronic, or Kangxin) in the abdominal aorta through the right femoral artery. On the right side of the chest, three 1–1.5 cm incisions were made in the fourth intercostal space on the right side of the sternum, in the sixth intercostal space on a mid-clavicular line and in the fifth intercostal space on the right mid-axilliary line, respectively (Fig. 1). These incisions allow the entry of tissue forceps, or suture needles or scissors, and thoracoscopy. Pericardiotomy was performed and caval snares were placed in the superior and inferior vena cava to install total CPB. Core body temperature was reduced to 32°C. With study group patients, a thoracoscopy was inserted to the chest through port 1 (Fig. 1) to visualize the aorta. A large perfusion needle was inserted into the root of the aorta through port 3 on the chest,

and was connected to the left heart suction tube to exhaust in left ventricle. The aorta, which was not cross-clamped, was perfused with normothermic oxygenated blood throughout the procedure. The thoracoscopy was then repositioned through port 3 to visualize the right atrium. Ports 1 and 2 were used for the entries of scissors and tissue forceps, respectively. On the beating heart, right atriotomy was performed from a site parallel to the atrioventricular annulus, and a suction tube was positioned in the coronary sinus ostium through port 1 to keep the operation field bloodless. The internal structures of the right atrium were exposed and the ASD was closed by direct 4-0 prolene sutures. A bovine patch (Bairen Med Pharma Co., Beijing, China) was used to repair larger ASDs, using running prolene sutures (Ethicon, NJ, USA). The right atrium incision was subsequently closed with sutures, and the integrity of the ASD closure was assessed by transoesophageal echocardiography. Left atrial and ventricular de-airing was performed at the end of the ASD closure by aspiration of air from the left ventricle through the perfusion needle in the aortic root. After adequate haemostasis was achieved, all instruments were removed from the chest, and a 24F chest tube was inserted in the right pleural space through one of the chest ports for drainage. With the control group patients, totally thoracoscopic ASD repair was performed under cardioplegic arrest. An aortic crossclamp was positioned on the ascending aorta under the direct view of thoracoscopy. Cardiac arrest was achieved by injecting cold cardioplegic solution to the aortic root [8]. Thoracoscopy was then repositioned to visualize the right atrium, which was subsequently opened. The ASD was closed by direct 4-0 prolene sutures or a bovine patch in the same fashion as in study group patients. The aortic clamp was released and the heart beat resumed.

Post-operative management Following the operation, patients were monitored in the intensive care unit overnight. Bedside chest X-ray was routinely performed in the intensive care unit to exclude complications in the lungs. Mechanical ventilation was ceased once patient’s haemodynamics and spontaneous respiration stabilized. Patients were encouraged to perform respiratory exercises and have regular coughs.

CONGENITAL

Table 1: Clinical demographics of patients in study and control group

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Frusemide (1 mg/kg/day, i.v.) with methylprednisolone (0.5 mg/ kg/day, i.v., once daily) was used in all patients to prevent pulmonary oedema [6]. Non-steroidal anti-inflammatory drugs were prescribed to all patients for post-operative pain relief. For patients with severe pain not relieved by simple analgesics, opioid analgesics (intravenous fentanyl) were provided.

Follow-up The mean follow-up time of the study and control group was 93 ± 15 days and 185 ± 26 days, respectively (P = 0.001). There were no major post-operative complications in either group of patients. Transthoracic echocardiographic examination on postoperative Day 5 and Day 30 showed no residual shunts.

Statistical analysis SPSS v13.0 was used for the statistical analysis. Quantitative variables are expressed as mean ± SD. Differences between groups were compared by one-way ANOVA. Categorical data were analysed by χ 2 test. P-value < 0.05 was considered statistically significant.

RESULTS General findings There was no statistically significant difference between the two groups in age, sex, pre-operative symptoms or the size of the ASD (Table 1). Totally thoracoscopic ASD closures on beating or arrested hearts were successful in all patients. There was no in-hospital mortality nor was there a need for reverting from the thoracoscopic approach to a sternotomy in the study or control group. Post-operative pulmonary atelectasis and lung infection were noticed in three of the control and one of the study group patients (Table 1, P= 0.889). There were no other cardiovascular complications, such as major bleeding or femoral vessel injuries. As shown in Table 2, the total duration of operation, CPB time, mechanical ventilation time, duration of intensive care stay and post-operative hospital stay in the study group were shorter than in the control group. There was no statistically significant difference in the proportion of patients requiring in-operation blood transfusion between the study and control group (P = 0.226). Post-operative mechanical ventilation was used in all control group patients, but 19 patients (80%) in the study group were extubated on the operation table following the completion of the surgery.

Table 2: Comparison of operational data between study and control group

Total operation time (min) CPB (min) Aortic cross-clamp time (min) Mechanical ventilation time (h) Intensive care stay (h) Hospital stays (day) Volume of thoracic drainage (ml) Blood transfusion during operation Pulmonary atelectasis or lung infection CPB: cardiopulmonary bypass.

Control (n = 72)

Study (n = 24)

P-value

98 ± 6 48 ± 4 30 ± 5 3 ± 5.5 19.2 ± 4.2 5.0 ± 1.1 260 ± 79 26 (36.1%) 3 (4.1%)

76 ± 9 32 ± 5 0 0.7 ± 1.1 10.0 ± 5.1 4.5 ± 0.8 65 ± 29 6 (25.0%) 1 (4.2%)

0.012 0.001 0.000 0.001 0.003 0.045 0.001 0.227 0.899

DISCUSSION Cardiac surgeries involving CPB and cardioplegic arrest are associated with several pathophysiological processes that may contribute to myocardial ischaemia and tissue injuries. CPB is known to activate a systemic acute phase reaction of protease cascades and to stimulate platelets that result in tissue injuries [11]. Cardiac or other organ dysfunction may ensue in patients with an excessive inflammatory response or in those with limited functional reserve [11]. In addition, aortic cross-clamping and cardioplegic arrest is associated with myocardial ischaemia and reperfusion injuries. To avoid these potential disadvantages associated with CPB and cardioplegic arrest, cardiac surgeries on beating hearts have been developed for coronary bypass grafting or mitral valve repair [11–15]. Corrective surgeries for congenital heart diseases have rarely been performed on beating hearts, primarily due to the complexity of the defects, small working area and the fact that most defects require exposure to intracardiac structures. Pendse and associates [16] reported methodologies and results of ASD closures on beating hearts, where a median sternotomy, total CPB and cross-clamping of the aorta were used. They found that all patients survived the procedures and were extubated within 4 h after the operation, with no ventricular dysfunction before discharge [16]. Gao et al. [17] recently used a robotically assisted surgical system to perform totally endoscopic ASD repairs on beating hearts. They reported no operative deaths, strokes or other complications associated with the surgery on beating hearts [17]. Since early reports on endoscopic repair of congenital heart defects repair, the use of thoracoscopic techniques for ASD closure has been steadily increasing. Although robotically assisted endoscopic repairs are the most commonly used techniques to date, totally thoracoscopic closures without computerized surgery systems are emerging [8, 9]. Our initial clinical observations have shown that totally thoracoscopic repairs of cardiac defects on cardioplegic arrested hearts were associated with a reduced operation time and faster post-operative recovery in comparison with conventional surgery through a sternotomy [8, 9]. In the present study, we attempted totally thoracoscopic ASD closures on beating hearts without cross-clamping the aorta in adults or in children who were 5 years or older, with a body weight of 20 kg or above. For smaller children, this technique was impossible as Carpentier catheters were too large for the femoral vessels to establish CPB. Compared with the surgeries on cardioplegic arrested hearts, the beating heart surgeries were associated with a shorter operation time, and a shorter intensive care or hospital stay. Post-operative mechanical ventilation was not required in 80% of the patients who received the beating-heart surgery, as they were safely extubated on the operation table. There was no statistically significant difference in the blood transfusion rate or in peri-operative complications between beating-heart and arrested-heart groups, but post-operative chest

drainage volumes in the beating-heart group were lower than in the arrested-heart group. In conclusion, in this preliminary report, non-robotically assisted totally thoracoscopic closure of an ASD can be safely performed on beating hearts without cross-clamping the aorta. These procedures are associated with a shorter duration of operation, and a shorter intensive care or hospital stay following the surgeries. Further clinical studies are required to assess the long-term protective effect of beating-heart ASD closures on ventricular function.

Funding This study received no funding. Authors have complete access to the study data that support the publication. Conflict of interest: none declared.

REFERENCES [1] Kaplan S. Congenital heart disease in adolescents and adults. Natural and postoperative history across age groups. Cardiol Clin 1993;11: 543–56. [2] Burke RP, Michielon G, Wernovsky G. Video-assisted cardioscopy in congenital heart operations. Ann Thorac Surg 1994;58:864–8. [3] Torracca L, Ismeno G, Alfieri O. Totally endoscopic computer-enhanced atrial septal defect closure in six patients. Ann Thorac Surg 2001;72: 1354–7. [4] Wimmer-Greinecker G, Dogan S, Aybek T, Khan MF, Mierdl S, Byhahn C et al. Totally endoscopic atrial septal repair in adults with computerenhanced telemanipulation. J Thorac Cardiovasc Surg 2003;126:465–8. [5] Argenziano M, Oz MC, Kohmoto T, Morgan J, Dimitui J, Mongero L et al. Totally endoscopic atrial septal defect repair with robotic assistance. Circulation 2003;108(Suppl 2):191–4.

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[6] Bonaros N, Schachner T, Oehlinger A, Ruetzler E, Kolbitsch C, Dichtl W et al. Robotically assisted totally endoscopic atrial septal defect repair: insights from operative times, learning curves, and clinical outcome. Ann Thorac Surg 2006;82:687–93. [7] Morgan JA, Peacock JC, Kohmoto T, Garrido MJ, Schanzer BM, Kherani AR et al. Robotic techniques improve quality of life in patients undergoing atrial septal defect repair. Ann Thorac Surg 2004;77: 1328–33. [8] Ma ZS, Dong MF, Yin QY, Feng ZY, Wang LX. Totally thoracoscopic repair of atrial septal defect without robotic assistance: a single-center experience. J Thorac Cardiovasc Surg 2011;141:1380–3. [9] Ma ZS, Dong MF, Yin QY, Feng ZY, Wang LX. Totally thoracoscopic repair of ventricular septal defect: a short term clinical observation on safety and feasibility. J Thorac Cardiovasc Surg 2011;142:850–4. [10] Weman SM, Karhunen PJ, Penttila A, Jarvinen AA, Salminen US. Reperfusion injury associated with one-fourth of deaths after coronary artery bypass grafting. Ann Thorac Surg 2000;70:807–12. [11] Murphy GJ, Ascione R, Angelini GD. Coronary artery bypass grafting on the beating heart: surgical revascularization for the next decade? Eur Heart J 2004;25:2077–85. [12] Briffa N. Off pump coronary artery bypass: a passing fad or ready for prime time? Eur Heart J 2008;29:1346–9. [13] Misare BD, Krukenkamp IB, Lazer ZP, Levitsky S. Recovery of postischemic contractile function is depressed by antegrade warm continuous blood cardioplegia. J Thorac Cardiovasc Surg 1993;105: 37–44. [14] Prifti E, Bonacchi M, Giunti G, Frati G, Leacche M, Bartolozzi F. Beating heart ischemic mitral valve repair and coronary revascularization in patients with impaired left ventricular function. J Cardiac Surg 2003;18: 375–83. [15] Thompson MJ, Behranwala A, Campanella C, Walker WS, Cameron EW. Immediate and long-term results of mitral prosthetic replacement using a right thoracotomy beating heart technique. Eur J Cardiothorac Surg 2003;24:47–51. [16] Pendse N, Gupta S, Geelani MA, Minhas HS, Agarwal S, Tomar A et al. Repair of atrial septal defects on the perfused beating heart. Tex Heart Inst J 2009;36:425–7. [17] Gao C, Yang M, Wang G, Wang J, Xiao C, Wu Y et al. Totally endoscopic robotic atrial septal defect repair on the beating heart. Heart Surg Forum 2010;13:E155–8.

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