in this video we will describe a
minimally-invasive ASD repair within
limited resources our goals provide the
critical steps to perform a minimally
invasive ASD with the limited resources
and equipment when pertinent will
emphasize important pearls and pitfalls
there are several notable key steps of
the procedure which include the
following peripheral cannulation with
bi-caval venous drainage a slightly
anterior 4 centimeter skin incision
diaphragm retraction using the
pericardium
bi-caval snares a vertical right atrial
incision attention free ASD patch
closure in cryoablation for analgesia
our patient is a 30 year old woman with
a large symptomatic ASD that was not
amenable to Amplatz occlusion
transesophageal echo reveals an ostium
secundum ASD the anterior surface of the
femoral artery and vein are exposed a
purse string suture is placed around the
femoral artery in vein using a 4-oh
prolene suture a circumferential
dissection around the vessel is not
necessary it is important to limit
lymphatic disruption during the
dissection
for right-sided minimally invasive surgery
venous drainage of the upper extremity
can be obtained via three ways one
option is to use a bi-caval peripheral
venous cannula another option is upper
extremity drainage via the internal
jugular vein and lastly another
alternative is insertion of a pump
sucker into the SVC after opening the
right atrium we prefer the use of a
bi-caval peripheral venous cannula the
location of the incision is particularly
important for a successful ASD repair
unlike mitral surgery where the incision
is more lateral the incision for an ASD
closure needs to be slightly anterior to
obtain a direct view of the ASD has seen
by the red dotted line the pleural cavity is
carefully entered and the pericardium is
open two centimeters from the phrenic
nerve pericardial stays sutures with in
place is important to be strategic about
the suture location in retraction
instead of a diaphragm retraction suture
we place pericardial sutures at the
lower right border of the pericardium as
demonstrated by the yellow arrows these
sutures are then exteriorize out the
chest wall and effectively retract the
diaphragm from the field of view
additional sutures are then placed at the
lower border of the pericardium the SVC
is then snared using vessel loops we
believe elastic vessel loops provide a
more hemostatic seal than umbilical tape
the IVC is snared in a similar fashion
the location of a right atrial incision is
important we believe a vertical incision
offers the best exposure since it
provides visualization around the venous
cannula the incision it is extended
upwards and then towards the right
atrial appendage we have found that
using a right angle scissors or pots
works best
you
once the atrium is open the ASD is
easily visualized
the location of the atrial
retraction suture is also important we place one
to two sutures to the top of the atrium
and then tie to the chest wall as seen
by the yellow arrows we then place a
suture from the bottom right atrium
through the pericardium and then tie as
seen by the yellow circles we believe
this offers the best exposure without
the need for additional retractors
excellent exposure can be obtained with
only retraction sutures we then close
our septal defect using either bovine or
autologus pericardium this is done
using a 5-O prolene suture in a running
fashion when using either bovine or
autologus pericardium it's important that
the smooth surface faces the left atrial
side during closure it's often helpful
to have a pump sucker inside the left
atrium to aid visibility our approach is
to start at the top of the septal defect
and suture forehand on the left side
when the bottom is reached we start
again at the top and suture forehand on
the right side while closing any
right-sided lesion it's important to
identify the SVC IVC tricuspid valve and
coronary sinus to avoid inadvertent
injury
the final septal closure can be seen
here
this figure summarizes the location of
our pericardial retraction sutures right
atrial retraction sutures as well as final
closure of the septal defect the right
atrium is then closed in the standard
fashion using a 4-O prolene suture we
prefer a two-layer closure
lastly we believe cryoablation of the
intercostal nerves and injection of X
al provides excellent post-operative
pain control we prefer to freeze tWo
inner spaces below and two inner spaces
above the incision
this final four-chamber TEE shows no
communication between the atrial chambers
in summary we believe the minimally
invasive repair of an ASD should not be
considered an obstacle and can be easily
performed with limited resources and no
additional equipment thank you for your
time