Robotic atrial septal defect closure

Sahin Senay 2 Ahmet Umit Gullu 2 Muharrem Kocyigit 0 Aleks Degirmencioglu 1 0 Department of Anesthesiology and Reanimation, Acbadem University Vocational Schools , Istanbul, Turkey 1 Department of Cardiology, Acbadem University School of Medicine , Istanbul, Turkey 2 Department of Cardiovascular Surgery, Acbadem University School of Medicine , Istanbul, Turkey MMCTS Atrial septal defect (ASD) is one of the most common congenital cardiac diseases. This pathology can be treated with percutaneous devices. However, some of the ASDs are not suitable for device closure. Also, there may be device-related late complications of transcatheter ASD closure. Currently, robotic surgical techniques allow surgeons to close ASDs in a totally endoscopic fashion with a high success rate and a low complication rate. This study demonstrates the basic concepts and technique of robotic ASD closure. - INTRODUCTION Atrial septal defect (ASD) is one of the most common congenital cardiac diseases [1]. This pathology can be treated with percutaneous devices with a low rate of early post-procedural complications [2]. However, ASDs with unfavourable anatomy and the type of ASD other than the secundum are not suitable for transcatheter closure. Moreover, there are important device-related late complications of transcatheter ASD closure including device migration, device malposition, cardiac erosion or perforation leading to tamponade and death, atrioventricular block and bacterial endocarditis [14]. Currently, robotic surgical techniques allow surgeons to close ASDs in a totally endoscopic fashion with a high success rate and a low complication rate [1]. The robotic technique can be applied to ASDs with different anatomical sizes and also to both secundum and sinus venosus types. Moreover, since this technique does not require implantation of any prosthetic material, it may offer patients a safe long term that is free from any device-related complications. This study demonstrates the basic concepts and technique of totally endoscopic robotic ASD closure. SURGICAL TECHNIQUE Patients should undergo preoperative evaluation by transthoracic echocardiography, coronary angiography and vascular ultrasound or computed tomographic angiographic examination (if necessary) of the femoral vessels. The operation can be performed for secundum or sinus venosus type ASDs and can be combined with right-sided robotic operations including mitral or tricuspid valve pathologies. The exclusion criteria for this operation are recommended as primum-type ASD as well as extensive coronary artery disease, severe peripheral vascular disease and previous median sternotomy or right thoracotomy. Anaesthesia, patient positioning and cardiopulmonary bypass set-up A double-lumen endotracheal tube is placed along with a multiplane transoesophageal echocardiography (TOE) probe after induction of general anaesthesia. The size of the ASD should be determined with TOE before cross-clamping for preparation of a pericardial patch. A chest roll is placed under the right shoulder, the right arm is placed at the side of the operation table and the table is rotated 20 to be right side up. The incision sites are marked (Fig. 1). A 15- or 17-Fr venous cannula (Medtronic Bio-Medicus, Eden Prarie, MN, USA) is inserted percutaneously via the right internal jugular vein and placed into the superior vena cava with its tip being at least 23 cm superior to the cavoatrial junction under TOE guidance. The common femoral artery is cannulated with a 17- or 19-Fr aortic cannula (Medtronic Bio-Medicus). A 21- or 24-Fr venous cannula (Medtronic Bio-Medicus) is inserted into the right common femoral vein and placed into the inferior vena cava, with its tip being 23 cm inferior to the cavoatrial junction. Unlike the set-up for robotic mitral operations, the reason for leaving a space of 23 cm at both venae cavae is the need for clamping for bicaval occlusion. The space at the superior vena cava should be even longer in sinus venosus-type defects. Port implantation, cardioplegia and cross-clamping A 20-mm working port is placed in the right fourth intercostal space, 3 cm laterally to the nipple. The camera port is placed 12 cm The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. Video 2: Placement of a cross-clamp. Video 1: Pericardial stay sutures and external fixation. medially to the working port at the same intercostal space. In usual set-up, a 30 camera is used. However, since the atrial septum is horizontally visualized intraoperatively, a 0 camera may be a better choice, at least in some cases. Insufflation of carbon dioxide is used with 8 mmHg pressure and a flow rate of 6 l/min. The right-arm port Video 3: Administration of cardioplegia. is placed two intercostal spaces inferior to the thoracotomy, and the left-arm port is placed one or two intercostal spaces above. The atrial retractor port is placed approximately 3 cm medially to the camera port in the fourth or fifth intercostal space. After port implantation, the robotic arms are connected to the ports (Fig. 2). Cardiopulmonary bypass (CPB) is instituted. The pericardium is opened 23 cm anteriorly to the phrenic nerve and the pericardial edges are suspended on stay sutures, which are then snared and pulled through the lateral chest wall inferior to the thoracotomy. These sutures are fixed externally (Video 1). Given that the magnification of the endocamera system may mislead the precise sizing intraoperatively, a pericardial patch is prepared in sizes according to the TOE measurements of the ASD. The ascending aorta is cross-clamped with a transthoracic clamp, which is inserted through one intercostal space above the working port in the direction of the transverse sinus. The position of this clamp should be arranged to pass through the upper side of the junction of the atrium and superior vena cava, leaving a space of 12 cm for the caval bulldog clamp (Video 2). The heart is arrested using cold crystalloid cardioplegia delivered into the aortic root with a transthoracic cannula through the thoracotomy (Video 3). Crossclamping and cardioplegia delivery should be confirmed using TOE. The inferior and superior venae cavae are occluded with bulldog clamps delivered through the working port [5] (Video 4). Alternatively, both venae cavae can be snared. After bicaval occlusion, the right atrium is opened through a classical incision and the exposure of the ASD is established by proper placement of the atrial retractor (Video 5). In most of the cases, the ASD is closed with pericardial patch material pretreated with glutaraldehyde (Video 6). Knots are tied with a knot pusher through the working port. After patch closure, the inferior vena cava clamp is released partially to allow Video 7: Release of bulldog clamps. Video 4: Occlusion of both venae cavae with endoscopic bulldog clamps. Video 5: Right atri (...truncated)