Minimal incision Partial Sternotomy ASD Repair

Atrial septal defects (ASD) are one of the most common congenital heart defects. The CDC estimates that more than 2,000 babies born in the United States a year will have an ASD (1). Due to it's high prevalence, pediatric cardiac surgeons have a plethora of experience and protocols to correct the defect. One new and innovative approach to surgical correction of an ASD is patch closure through a minimal incision. This approach allows for stability of the upper body by the avoidance of full sternotomy, quicker time to recover from surgery, and cosmesis. This operative video highlights a successful ASD closure through the minimally invasive approach. The patient's intra-operative echo demonstrated patch closure with no residual ASD or patch leak, and had a short and uneventful post-operative course. This highlights the safety and efficacy of this new and innovative approach.

The minimally invasive incision begins at the angle of Louis and extends inferiorly, just proximal to the xyphoid process. Bicaval cardiopulmonary bypass which is initiated with only one cannula in, and requires IVC cannulation in order to decompress the heart. Patent was given 15ml/kg of Del Nido cardioplegia solution and kept normothermic

A skin incision was made at the angle of Louis and extended inferiorly, just proximal to the xiphoid process. This was then extended with electrocautery. Limited bilateral mobilization of the muscle flaps were performed, and an oscillating saw was then used to create a partial sternal split, with J’ing at the angle of louis. The assistance use of the army/navy retractor aids in the avoidance of damaging the right internal mammary artery. Patient was then placed on cardiopulmonary bypass and arrested in the standard fashion. Right atriotomy was performed and allowed for direct vision of a secundum ASD. All 4 pulmonary veins were noted to be draining normally. CorMatrix patch material was brought to the field and sized accordingly and sewn in with 5-0 prolene in a running fashion. Several large breaths were provided prior to tying the patch down for de-airing the left atrium.

Intra-operative transesophageal echocardiogram demonstrated patch closure with no residual ASD or patch leak. The patient's post-operative course was uneventful and they were discharged on post-op day 3.

This operation was a resounding success with full patient and surgeon satisfaction. It should be noted however, that this procedure is not the best approach for every case. Not every patient is a good candidate for this approach and it should not be used in the case of severe/refractory pulmonary hypertension, bony abnormalities, or unfavorable anatomy which includes partial anomalous veins and more complex intra cardiac repair requirements. It should be carefully noted as well, that the surgeon must ensure the bone saw remains on the field for the duration of the procedure, in the event that conversion to full sternotomy is needed. When used correctly, this procedure allows for complete ASD resolution with a number of benefits both intra-op and post-op. This is a difficult window to operate in due to the minimal exposure, and this video will serve as a guide on proper technique, potential pitfalls, and tips to utilize this novel approach.

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1. Centers for Disease Control and Prevention. Congenital Heart Defects (CHDs). Atrial Septal Defect. https://www.cdc.gov/ncbddd/heartdefects/atrialseptaldefect.html. Accessed March 15, 2022. 2. Comprehensive Surgical management of Congenital Heart Disease – Richard Jonas ISBN: 978-1-4441-1215-3 3. Mylonas, K. S., Ziogas, I. A., Evangeliou, A., Hemmati, P., Schizas, D., Sfyridis, P. G., Economopoulos, K. P., Bakoyiannis, C., Kapelouzou, A., Tzifa, A., & Avgerinos, D. V. (2020). Minimally Invasive Surgery vs Device Closure for Atrial Septal Defects: A Systematic Review and Meta-analysis. Pediatric cardiology, 41(5), 853–861. https://doi.org/10.1007/s00246-020-02341-y 4. Liava'a, M., & Kalfa, D. (2018). Surgical closure of atrial septal defects. Journal of thoracic disease, 10(Suppl 24), S2931–S2939. https://doi.org/10.21037/jtd.2018.07.116