Reducing the Trauma of Atrial Reducing the Trauma of Atrial Septal Defect Repair:Septal Defect Repair:

Justine ChinnJustine Chinn

Undergraduate FellowUndergraduate Fellow

University of California, Los AngelesUniversity of California, Los Angeles

Redmond P. BurkeRedmond P. Burke

Chief, Division of Cardiovascular SurgeryChief, Division of Cardiovascular SurgeryThe Congenital Heart InstituteThe Congenital Heart Institute

Miami Children·s Hospital and Arnold Palmer Miami Children·s Hospital and Arnold Palmer HospitalHospital

www.pediatricheartsurgery.comwww.pediatricheartsurgery.com

Overview of Atrial Septal Defect Overview of Atrial Septal Defect (ASD)(ASD)

An opening in the septum between the An opening in the septum between the atria results in the flow of oxygenated atria results in the flow of oxygenated blood from the left atrium back into the blood from the left atrium back into the right atrium.right atrium.

This blood mixes with the deoxygenated This blood mixes with the deoxygenated blood of the right atrium.blood of the right atrium.

High flow through an ASD will result in a High flow through an ASD will result in a failure to thrive (poor growth/appetite and failure to thrive (poor growth/appetite and shortness of breath) and over time may shortness of breath) and over time may result in arrhythmia, stroke, and/or result in arrhythmia, stroke, and/or pulmonary hypertension. pulmonary hypertension.

Atrial septal defects are relatively common, occurring in 1 out of every 1500 live births.

Common Types of ASDCommon Types of ASD

The technical evolution of the operation has resulted in a The technical evolution of the operation has resulted in a very safe procedure with low mortality rates. Patient very safe procedure with low mortality rates. Patient

survival is no longer an adequate measure of success. survival is no longer an adequate measure of success.

Jenkins KJ et al, JTCVS, January 2002

This suggests that we should refocus on improving long This suggests that we should refocus on improving long term patient health and decreasing the number of negative term patient health and decreasing the number of negative

consequences.consequences.

Achieve complete Achieve complete anatomic repair. anatomic repair.

Inflict the least Inflict the least cumulative cumulative lifetime patient lifetime patient trauma.trauma.

How is this achieved?How is this achieved?

Through a Through a united approach with united approach with interventional cardiologists.interventional cardiologists.

By finding the By finding the best incision best incision for the job:for the job: Should ensure short/long term pain Should ensure short/long term pain

management and good aesthetic result.management and good aesthetic result. By implementing conditions that support By implementing conditions that support

stronger surgical abilitiesstronger surgical abilities:: Speed, Precision, and Adaptability are key.Speed, Precision, and Adaptability are key.

Unified Multi-Disciplinary Approach Unified Multi-Disciplinary Approach At Miami Children’s Hospital, all patients are presented in a At Miami Children’s Hospital, all patients are presented in a

combined conference with surgeons, cardiologists, combined conference with surgeons, cardiologists, anesthesiologist and nurse’s present. anesthesiologist and nurse’s present. For selected patients with Secundum Atrial Septal Defect, we consider For selected patients with Secundum Atrial Septal Defect, we consider

device closure the least traumatic form of therapy.device closure the least traumatic form of therapy. For Sinus Venosus Defects, patients undergo surgical closure via For Sinus Venosus Defects, patients undergo surgical closure via

median sternotomy and baffling of PAPVRmedian sternotomy and baffling of PAPVR For Primum ASD, patients undergo surgical closure via median For Primum ASD, patients undergo surgical closure via median

sternotomy with cleft repair as needed.sternotomy with cleft repair as needed. Patients who are found not to be suitable for device closure in Patients who are found not to be suitable for device closure in

the cath lab can undergo immediate surgery under one the cath lab can undergo immediate surgery under one anesthetic.anesthetic.

CollaborationCollaboration ensures that each patient receives specialized ensures that each patient receives specialized treatment based on his/her individual needs.treatment based on his/her individual needs.

ASD Closures in 1996 Versus 2008

0

10

20

30

Number of Procedures

SecundumASD

Sinus Venosus

ASD

PrimumASD

SecundumASD

Sinus Venosus

ASD

PrimumASD

1996(249 total CPB cases)

2008(245 total CPB cases)

ASD Closures: 1996 2008Mean Weight (kg) 19.8 22.3Mean LOS (days) 4.75 4.29

Our volumes reflect the evolution of therapy for ASD: Depending on the patient’s individualized needs, surgery

may not always be the answer.

Predicates for a Unified ApproachPredicates for a Unified Approach

A positive, innovative A positive, innovative interaction between surgeons interaction between surgeons and cardiologists.and cardiologists.

On site availability of surgery, On site availability of surgery, perfusion, anesthesia, and perfusion, anesthesia, and cardiology teams.cardiology teams.

Best surgical and device Best surgical and device options available in one options available in one institution for fast and easy institution for fast and easy transitions. transitions.

Suggested criterion for selecting an Suggested criterion for selecting an operative approach for ASD closure:operative approach for ASD closure:

Maintain short and long term Maintain short and long term patient safetypatient safety Cardiopulmonary BypassCardiopulmonary Bypass Autologous MaterialsAutologous Materials

Enable excellent surgical Enable excellent surgical techniquetechnique Optimal cardiac repairOptimal cardiac repair

Achieve a perfect Achieve a perfect functional functional outcomeoutcome Pain free short and long termPain free short and long term Normal strength and flexibilityNormal strength and flexibility

Create an optimal Create an optimal aesthetic aesthetic resultresult The only part of our work the The only part of our work the

patient can see.patient can see.

Complications of Complications of transcatheter closure of transcatheter closure of

ASDASD M S Spence. et. M S Spence. et.

al. Heart. Dec al. Heart. Dec 2005; 91(12): 2005; 91(12): 1512–1514.1512–1514.

Long term safetyLong term safety is enhanced by using autologous is enhanced by using autologous material for repairs – pericardium. This is a material for repairs – pericardium. This is a

powerful factor in increasing long term stability.powerful factor in increasing long term stability.

Benefits of PericardiumBenefits of Pericardium:: ItIt’’s frees free We have 5 decades of experience with We have 5 decades of experience with

the material, and there is no the material, and there is no uncertainty about long term effects in uncertainty about long term effects in the circulation.the circulation.

There is no erosion into adjacent There is no erosion into adjacent structures.structures.

When anchored by continuous suture, When anchored by continuous suture, the likelihood of patch dehiscence is the likelihood of patch dehiscence is very rare, and embolization never very rare, and embolization never occurs.occurs.

A residual leak is rare.A residual leak is rare. Each patch is customized to the Each patch is customized to the

patientpatient’’s defect, very low profiles defect, very low profile There is no need for long term There is no need for long term

anticoagulation or antibiotic anticoagulation or antibiotic prophylaxis.prophylaxis.

Standard Incision Options: Standard Incision Options:

Sternotomy variantsSternotomy variants Full sternotomy with Full sternotomy with

limited skin incisionlimited skin incision Partial lower Partial lower

sternotomysternotomy Transxyphoid incision Transxyphoid incision

(Non-sternotomy)(Non-sternotomy) Right anterior Right anterior

thoracotomythoracotomy

Patient SafetyPatient Safety: : Cardiopulmonary BypassCardiopulmonary Bypass

Myocardial ProtectionMyocardial Protection Sternotomy: Sternotomy: Cardioplegia is Cardioplegia is

easy to administer, obstructed easy to administer, obstructed cannula easily adjustedcannula easily adjusted

Partial SternotomyPartial Sternotomy Aorta is under the Aorta is under the

manubrium: obstructs access.manubrium: obstructs access. Thoracotomy: Thoracotomy: because the because the

aorta is far from the surgeon, aorta is far from the surgeon, severe myocardial dysfunction severe myocardial dysfunction may result from a failed may result from a failed cardioplegia infusion.cardioplegia infusion.

Aortic Cannulation/ClampAortic Cannulation/Clamp Sternotomy: Offers direct Sternotomy: Offers direct

control for cannula insertion. control for cannula insertion. Strong visibility makes it easy Strong visibility makes it easy to manipulate to ensure good to manipulate to ensure good flows.flows.

Partial SternotomyPartial Sternotomy Aorta is under the Aorta is under the

manubrium: offers low manubrium: offers low visibility.visibility.

Thoracotomy: Aorta is far from Thoracotomy: Aorta is far from surgeon, and is difficult to surgeon, and is difficult to cannulate, position, and cannulate, position, and suture. The creates the risk of suture. The creates the risk of catastrophic bleeding.catastrophic bleeding.

Favors Sternotomy approach

Patient SafetyPatient Safety: : Cardiopulmonary BypassCardiopulmonary Bypass

NeuroprotectionNeuroprotection Sternotomy: Sternotomy:

Deairing is simple due to Deairing is simple due to the direct control of anterior the direct control of anterior ascending aortaascending aorta

Lower SternotomyLower Sternotomy Aortic vent is under the Aortic vent is under the

manubrium, risk of manubrium, risk of bleeding/embolismbleeding/embolism

Thoracotomy:Thoracotomy: Deairing is difficult, due to Deairing is difficult, due to

complete lack of direct complete lack of direct aortic control. The aortic control. The increases the risk of an air increases the risk of an air embolism and stroke.embolism and stroke.

Favors Full Sternotomy

Excellent surgical technique has three Excellent surgical technique has three characteristics, which may be enhanced or characteristics, which may be enhanced or

hindered by the incision.hindered by the incision.

1) Precision1) Precision

2)Adaptability2)Adaptability3) Speed3) Speed

PrecisionPrecision

For sinous venosus ASD repair, precise suturing is critical to avoid pulmonary vein stenosis, baffle obstruction, and superior vena cava obstruction.

This level of suture precision from superior vena cava to inferior vena cava is difficult to achieve through a remote incision.

Enhanced by Sternotomy approach

Precision protects the Precision protects the conduction systemconduction system

Reported incidence: Great Ormond Street review of over

2000 patients (.6% complete heart block)

Ann Thorac Surg. 2006 Sep;82(3):948-56; discussion 956-7.

Primum ASD and Sinus Venosus defects are closely related to the His Bundle and Sinus Node respectively.

We have a zero incidence of temporary pacing or heart block after ASD repair.

Fishberger et.al. Congenital cardiac surgery without routine placement of wires for temporary pacing. Cardiology in the Young 18(1):96-9 2008 Feb

Enhanced by sternotomy approach

AdaptabilityAdaptability Unexpected problems are regularly Unexpected problems are regularly

encountered during open heart encountered during open heart operations. These include: operations. These include:

Loss of vascular control Loss of vascular control Difficult access to or exposure of Difficult access to or exposure of

lesions lesions Prolonged ischemic times Prolonged ischemic times Bleeding Bleeding Unanticipated anatomic variationsUnanticipated anatomic variations

The surgical response in these The surgical response in these situations is to improve exposure, by situations is to improve exposure, by enlarging a limited incision, or by enlarging a limited incision, or by converting to median sternotomyconverting to median sternotomy

This leaves the patient whose primary This leaves the patient whose primary concern was cosmetic, with the worst concern was cosmetic, with the worst possible result – a prolonged possible result – a prolonged operation with a large incision or two operation with a large incision or two separate incisions.separate incisions.

facilitated by median sternotomy

Consistent ResultsConsistent Results The medial sternotomy is used in more difficult The medial sternotomy is used in more difficult

surgeries because it is consistently effective. It surgeries because it is consistently effective. It provides surgeons with great visibility and the provides surgeons with great visibility and the ability to adapt quickly. ability to adapt quickly.

““Anatomic repair… via sternotomy is conceptually Anatomic repair… via sternotomy is conceptually appealing. The surgery results in a safe and appealing. The surgery results in a safe and reliable repair in patients with a wide age reliable repair in patients with a wide age spectrum”spectrum” Jensen H. et. Al. Eur J Cardiothorac Surg. 2014 Jensen H. et. Al. Eur J Cardiothorac Surg. 2014

Jun;45(6):1066-9.Jun;45(6):1066-9.

SpeedSpeedClearly enhanced by sternotomy approach

The above is performed on a euthanized pig, with no pressure. Edited between each throw. This is a simple straight suture line, with a large needle.

The above is performed on a living child, with performance pressure. No editing. Pericardial patch is placed with a small needle.

Speed is essential during Sinus Speed is essential during Sinus Venosus ASD repairVenosus ASD repair

Baffle suture lines are long, and the Baffle suture lines are long, and the superior vena cava to right atrium patch superior vena cava to right atrium patch suture lines are long.suture lines are long.

Remote suturing techniques result in Remote suturing techniques result in extremely long ischemic times. Long extremely long ischemic times. Long ischemic times can result in serious injury ischemic times can result in serious injury to the heart.to the heart.

Functional OutcomeFunctional Outcome SternotomySternotomy

No pectoral muscle No pectoral muscle is cut.is cut.

No intercostal No intercostal muscle is cut.muscle is cut.

No intercostal No intercostal nerves are injured.nerves are injured.

No breast No breast ennervation is ennervation is injured.injured.

No breast tissue is No breast tissue is cut.cut.

Sternum heals Sternum heals stronger.stronger.

ThoracotomyThoracotomy Pectoral muscle may Pectoral muscle may

be cut.be cut. Intercostal muscle Intercostal muscle

will be cut.will be cut. Intercostal nerves will Intercostal nerves will

be injured.be injured. Breast ennervation Breast ennervation

may be injured.may be injured. Breast tissue may be Breast tissue may be

cut.cut. ““The anatomy of the The anatomy of the

intercostal nerve intercostal nerve makes it susceptible makes it susceptible to injury. Retractor to injury. Retractor placement…induces placement…induces mechanical mechanical deformation and deformation and damage”damage”

Timmermanns et. Timmermanns et. al. al. Hernia. 2013 Hernia. 2013 Feb;17(1):89-94Feb;17(1):89-94

Favors Sternotomy approach

Short Term Pain Short Term Pain ManagementManagement

Local Anesthetic Infusion Local Anesthetic Infusion Catheters provide immediate Catheters provide immediate pain relief.pain relief.

Miami Children’s Hospital Miami Children’s Hospital performed the first performed the first prospective randomized trial prospective randomized trial of this technology in of this technology in pediatric open heart surgery.pediatric open heart surgery.

Results show a significant Results show a significant reduction in narcotic reduction in narcotic requirement.requirement.

Tirotta. et. al. Paediatr Tirotta. et. al. Paediatr Anaesth. 2009 Anaesth. 2009 Jun;19(6):571-6Jun;19(6):571-6

Can be used for all incisions

Long Term Pain: Post Long Term Pain: Post Thoracotomy Pain Thoracotomy Pain

SyndromeSyndrome ““Pain after thoracotomy is very severe, Pain after thoracotomy is very severe,

probably the most severe pain probably the most severe pain experienced after surgeryexperienced after surgery……Postthoracotomy Pain Management Postthoracotomy Pain Management ProblemsProblems Anesthesiology Clinics - Volume 26, Anesthesiology Clinics - Volume 26,

Issue 2 (June 2008)  -  Copyright © Issue 2 (June 2008)  -  Copyright © 2008 Saunders. Peter Gerner, MD2008 Saunders. Peter Gerner, MD

““Persistent postsurgical pain (PPP) after Persistent postsurgical pain (PPP) after thoracotomy effect 50% to 80%. Nerve thoracotomy effect 50% to 80%. Nerve damage… may play an important role.”damage… may play an important role.”

““Adding epidural or IV racemic ketamine…Adding epidural or IV racemic ketamine…did not lead to any reduction” in paindid not lead to any reduction” in pain

Tena B. et.al. Clin J Pain. 2014 Jun;30(6):490-Tena B. et.al. Clin J Pain. 2014 Jun;30(6):490-500.500.

Favors Sternotomy Approach Favors Sternotomy Approach

Reliability of SternotomyReliability of Sternotomy

Studies support “the variety of Studies support “the variety of conditions in which median sternotomy conditions in which median sternotomy provides provides unrivalled access unrivalled access to the to the mediastinum.”mediastinum.”

Gopal M. Et.al. S Afr Med J. 2013 Jun 5;103(10):732-5Gopal M. Et.al. S Afr Med J. 2013 Jun 5;103(10):732-5

Attending surgeon performs incision and closure, with three levels of running sutures: placed in the fascia, subcutaneous layer, and subcuticular layer. This technique provides ideal cosmetic results with no visible staples or stitches.

Post-Op ResultsPost-Op Results

Sternotomy provides a safe, precise, and rapid repair

with a strong functional and cosmetic result.

DefectDefect NN LOSLOSMorbidity/Morbidity/MortalityMortality

PFOPFO 00 NANA 00

SecundumSecundum 2424 4.44.4 00

Sinus VenosusSinus Venosus 1010 3.93.9 00

Common AtriumCommon Atrium 11 4.04.0

Coronary SinusCoronary Sinus 00 NANA 00

NOSNOS 11 3.03.0 00

Our Current surgical Results for ASD closure: STS 2006

Need data for recent year

ConclusionsConclusions A unified approach to atrial septal defect repair, synthesizing A unified approach to atrial septal defect repair, synthesizing

a combination of interventional techniques and surgery, may a combination of interventional techniques and surgery, may optimize patient care.optimize patient care.

If your goals in order of importance are:If your goals in order of importance are: Maintain Maintain short and long term patient safetyshort and long term patient safety Enable excellent Enable excellent surgical techniquesurgical technique Achieve a perfect Achieve a perfect functional outcomefunctional outcome Create an optimal Create an optimal aesthetic resultaesthetic result

then a then a median sternotomy with a limited skin incision median sternotomy with a limited skin incision may be may be the best approach for atrial septal defects.the best approach for atrial septal defects.