Closure of a Large Secundum ASD

Midline sternal incision is made and carried down to the anterior sternal table. The sternum is then divided with an oscillating saw. The right lobe of the thymus is resected and a pericardial well created. Heparin is administered and cannulation is performed aortic and bicavally. After initiating cardiopulmonary bypass caval snares are placed around the SVC and IVC. Antegrade cardioplegia is administered and caval snares tightened. Oblique right atriotomy is then performed to allow direct vision of the ASD. Non-autologous patch material is then brought to the field and sized accordingly. The patch is then sewn in place with 5-0 Prolene in a continuous running fashion. Several large breaths are provided prior to tying the patch down for de-airing. The patch is then evaluated and any fenestrations are reinforced with interrupted 5-0 Prolene. When final evaluation shows no intra-atrial communications, the caval snares are released and the right side of the heart allowed to fill for de-airing. The atriotomy is then closed with 5-0 Prolene in a continuous running fashion and patient removed from cardiopulmonary bypass. Decannulation is performed and a ventricular pacing wire is placed and secured with a grounding wire. After ensuring proper hemostasis the right pleural space is opened and a 20 French pleural chest tube is placed via a stab incision and secured. An additional anterior mediastinal chest tube is placed through a second stab incision and secured The sternum is then reapproximated with interrupted steel wire. The anterior sternal table fascia and deep subcutaneous layers are closed separately in a continuous running fashion. The skin is then closed with 4-0 Monocryl.

ASD too large for catheter-based closure
Insufficient rims
Blood vessels too narrow for catheter-based delivery system
Blood clots present in the heart
Presence of other heart defects
Bleeding disorders or inability to take aspirin
Active infection

Irreversible Pulmonary Hypertension

N/A

N/A

Transesophageal and/or Transthoracic Echocardiogram

N/A

Pericardial effusion

Pleural effusions

Arrhythmias

Bleeding

Pneumothorax

Wound infection

None

Bezold L and Wesley Vick G. (2020). Isolated atrial septal defects in children: Management and outcome. In T.W. Post, P. Rutgeerts, & S. Grover (Eds.), UptoDate. Available from https://www-uptodate-com.libproxy.uams.edu/contents/isolated-atrial-septal-defects-in-children-management-and-outcome?search=ASD%20repair&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#topicContent

Jonas, R. (2014). Comprehensive Surgical Management of Congenital Heart Disease. CRC Press.