Surgical steps.
1.Direct suture of atrial septal defect: direct suture of atrial septal defect is suitable for central and inferior cavity type defects with small defects and well developed left atrium.
(1) Incision: A median chest incision, right subaxillary incision, right anterior external incision or partial longitudinal splitting incision of the lower sternum can be used according to the design of the surgical approach.
(2) Extracardiac exploration: Observe the size and morphology of the heart, the size and proportion of each atrium, the diameter and proportion of the main/pulmonary artery, the presence of abnormal coronary arteries, the ectopic connection of the pulmonary veins and the permanent left superior vena cava and its return site.
If the pulmonary trunk is palpable with rough systolic tremor, it may indicate a combined pulmonary stenosis. Diastolic fibrillation at the apex of the heart may indicate the presence of mitral stenosis; systolic fibrillation at the left atrial wall is a sign of coexisting mitral insufficiency. The presence of systolic fibrillation in the right atrial wall suggests tricuspid regurgitation. After a comprehensive cardiac exploration, the right atrial wall is finally pressed lightly with the index finger, and the site and size of the atrial septal defect can be initially detected.
(3) Intracardiac exploration: When the problem is still not clear enough in the extracardiac exploration, further intracardiac exploration is performed. The endocardial exploration through the right auricular incision can clarify the type and size of the atrial septal defect, whether it is combined with ectopic connection of pulmonary veins, the location and size of coronary sinus, tricuspid valve insufficiency, whether it is combined with right ventricular outflow tract stenosis, ventricular septal defect and pulmonary valve stenosis, and whether it is combined with mitral valve insufficiency, stenosis and triatrial heart malformation.
(4) Establishment of extracorporeal circulation and myocardial protection. For pure atrial septal defect, the circulation can be blocked when the nasopharyngeal temperature drops to 32℃. If extracorporeal circulation is chosen for nonstop cardiac surgery, the right atrium can be incised by simply blocking the superior and inferior vena cava, stopping respiration when the nasopharyngeal temperature is 32 to 33°C.
(5) Incision of the right atrium, usually using an oblique right atrial incision.
(6) To reveal the atrial septum, the anterior edge of the right atrial incision is pulled to the left with a right atrial hook to reveal the tricuspid valve orifice and the entire atrial septum.
(7) Repair the atrial septal defect: First, sew an “8” suture at the lower edge of the defect, and then make a similar “8” suture at the upper edge, and lift the septal defect to make it into a cleft shape.
For inferior cavernous defects, the suture at the inferior edge of the defect should be sutured through the interatrial septum to the posterior wall of the left atrium to prevent residual defects. A round-trip continuous or interrupted “8” suture can be used between the two sutures at the upper and lower edges of the defect. Before the last stitch is tied, the lung is expanded to allow blood to escape from the defect gap to drain the left heart gas.
(8) At the end of the intracardiac operation, completely remove the gas in the heart chamber, open the circulation, resuscitate the heart, and gradually stop the perfusion and withdraw the tube after the circulation is stabilized.
2.Atrial septal defect patch repair: This method is used for large defects, superior septal defects and combined with partial pulmonary vein ectopic connection, especially for cases with small left atrial development.
(1) For simple atrial septal defect, the selected patch should be slightly smaller than the area of the defect orifice, and the two ends should be fixed with interrupted mattress sutures with small spacers without injury, and the rest of the suture should be continuous.
(2) In the case of combined right pulmonary vein ectopic connection, the atrial septum near the opening of pulmonary vein should be partially removed to enlarge the atrial septal defect, and then a patch slightly larger than the defect area should be cut for repair. During the repair, an interrupted mattress suture with a non-invasive suture with a spacer is made to the right of the pulmonary vein opening and sutured to the right atrial wall, usually requiring about 4 or 5 stitches. The suture should be kept at a certain distance from the pulmonary vein opening to prevent poor pulmonary venous return. The rest of the defect edges can be closed with continuous sutures.
3.Repair of supraventricular septal defect.
(1) Superior ventricular septal defect is often combined with ectopic connection of the right pulmonary vein. In the process of establishing extracorporeal circulation, the position of the superior vena cava blocking band should be high to prevent damage to the right upper pulmonary vein. The right atrial incision extends inward and upward, which mostly involves part of the superior vena cava.
(2) The repair of superior vena cava type atrial septal defect is generally similar to the above-mentioned combined pulmonary vein ectopic connection, and more attention should be paid to prevent obstruction of pulmonary venous return.
(3) The superior vena cava and right atrial incision should be repaired with additional pericardial piece.
4.Minimally invasive atrial septal defect repair.
(1) Chest wall opening non-external circulation atrial septal defect closure
(2) TV-assisted thoracoscopic atrial septal defect repair.