Totally endoscopic robotic repair of coronary sinus atrial septal defect

CASE REPORT – ADULT CARDIAC Interactive CardioVascular and Thoracic Surgery 23 (2016) 662–664 doi:10.1093/icvts/ivw200 Advance Access publication 26 June 2016 Cite this article as: Onan B, Aydin U, Basgoze S, Bakir I. Totally endoscopic robotic repair of coronary sinus atrial septal defect. Interact CardioVasc Thorac Surg 2016;23:662–4. Totally endoscopic robotic repair of coronary sinus atrial septal defect Burak Onan*, Unal Aydin, Serdar Basgoze and Ihsan Bakir Department of Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Hospital, Istanbul, Turkey * Corresponding author. Istanbul Mehmet Akif Ersoy GKDC Hastanesi, Kalp ve Damar Cerrahi Kliniği, Turgut Ozal Bulvari No: 11, Kucukcekmece, 34303 Istanbul, Turkey. Tel: +90-553-6223878; e-mail: (B. Onan). Received 30 January 2016; received in revised form 9 May 2016; accepted 15 May 2016 Abstract Coronary sinus atrial septal defect is a rare congenital cardiac anomaly in adults. Patients with this anomaly are generally treated using conventional sternotomy or thoracotomy incisions. However, robotic surgery can be a feasible alternative in this anomaly. We report an adult patient, who presented with coronary sinus atrial septal defect. A totally endoscopic robotic repair was successfully done through a right atriotomy approach in this patient. Keywords: Robotic surgery • Atrial septal defect • Coronary sinus atrial septal defect • Unroofed coronary sinus INTRODUCTION Coronary sinus atrial septal defect (CS-ASD) is a rare congenital cardiac anomaly in adults. This anomaly is a part of unroofed CS syndrome, which is caused by incomplete formation of the atrioventricular fold. This may lead to a partial or complete defect in the roof of CS with or without left persistent superior vena cava [1]. CASE REPORT A 35-year old female was evaluated for multiple ASD. The complaints of the patient were fatigue and dyspnoea on exercise. Transthoracic echocardiography examination revealed a secundum-type ASD of 4 mm and a CS-ASD of 14 mm in diameter, which was localized at the terminal portion of the CS. There was a left-to-right shunt through the CS-ASD. It showed mild tricuspid regurgitation, ejection fraction of 65%, pulmonary artery pressure of 35 mmHg and Qp/Qs ratio of 1.9. Transoesophageal echocardiography confirmed CS-ASD (Fig. 1). Chest computed tomography excluded anomalous pulmonary or systemic venous return. The da Vinci SI robotic surgery system (Intuitive Surgical, Inc., Sunnyvale, CA, USA) was used. The patient was intubated for single-lung ventilation. After systemic heparinization, the right internal jugular vein and the right femoral vessels were cannulated for cardiopulmonary bypass. A service port was opened through the fourth intercostal space in the anterior axillary line. A 30° endoscope was inserted into the pleural space through the fourth intercostal space anteriorly. Two additional instrument ports in the third and fifth intercostal spaces were used. Atrial retractor was introduced through the fifth intercostal space anteriorly. The operative field was flooded with carbon dioxide. After pericardiotomy incision, a long-shafted cardioplegia cannula was placed on the ascending aorta. A Chitwood aortic cross-clamp was introduced through the fourth intercostal space in the midaxillary line. At moderate hypothermia, cardiac arrest was established using antegrade blood cardioplegia. Both vena cavae were occluded using atraumatic vascular bulldog clamps. The right atriotomy incision was done obliquely. CS-ASD was located at the terminal portion of the CS, which opened to the left atrium. Septal tissue between secundum ASD and CS-ASD was resected to create a large communication between two atriums (Fig. 2A and B). A ‘cut back’ incision of the atrial septal bridge between the CS-ASD and secundum ASD finally created an open atrial septum, unrestricted view on the mitral orifice and a ‘normally formed’ CS orifice (Fig. 2C and D). These manoeuvres clearly exposed the ostium of the CS and the rims of the large interatrial communication. The defect was closed using glutaraldehyde-treated autologous pericardial patch leaving the CS on the right. After the closure of the atrium, the patient was weaned from bypass. Cardiopulmonary bypass and aortic clamping times were 97 and 61 min, respectively. Postoperative transoesophageal echocardiography demonstrated no residual shunt. The patient was discharged home on postoperative day 3 and was clinically well after 6 months. DISCUSSION Robotic surgery is mostly preferred in secundum-type ASDs with inadequate septal rims and in ASDs presenting adjacent to the atrioventricular valves, or vena cavae. Previously, it has been © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. B. Onan et al. / Interactive CardioVascular and Thoracic Surgery used successfully in adults with sinus venous ASD, ventricular septal defect, partial atrioventricular canal defect or right ventricular outflow tract reconstruction [2]. According to the literature review, robotically-assisted repair of a CS-ASD has not been reported. Technically, the surgical management of CS-ASDs, which includes a terminal defect of the CS, involves closure of the defect causing a left-to-right shunting and increased pulmonary flow [1]. In cases with an additional small secundum ASD, each defect can be closed individually. If the CS defect is large, septal tissue between the defects can be removed and enlarged atrial defect is closed using a patch by leaving the CS in the right atrium. Alternatively, instead of the removal of the atrial septal bridge, CS can be closed directly by leaving CS orifice on the left side. The disadvantages of this approach include technical difficulty in patients with small coronary ostium and increased left atrial pressure due to the myocardial dysfunction or aortic/ mitral valve diseases. Increased coronary venous pressure may also cause myocardial dysfunction [1]. Moreover, percutaneous methods can be used for the closure of CS-ASDs with occluder devices [3], but additional studies to establish the safety and efficacy are needed. In robotic surgery, skin incisions are very limited, bleeding is minimal and postoperative rehabilitation is much better [2]. Nevertheless, the preoperative evaluation of the patient is of utmost importance to avoid any surprise during robotic surgery because congenital cardiac or vascular anomalies may present synchronously. In cases with CS-ASDs, the left-sided superior vena cava, anomalies of pulmonary venous return, totally unroofed CS, CASE REPORT Figure 1: Images show coronary sinus atrial septal defect and a small secundum atrial septal defect (A) and a dilated coronary sinus (B). CS: coronary sinus; csASD: coronary sinus atrial septal defect; LA: left atrium; LV: left ventricle; RA: right atrium; RV: right ventricle; sASD: sec (...truncated)