I. Background
China is one of the countries with a high incidence of congenital heart disease (congenital heart disease) in the world, with about 150,000-170,000 congenital heart disease patients born each year and about 100,000 patients requiring surgical treatment. Since the successful ligation of patent ductus arteriosus by Gross et al. in 1938, surgical treatment of congenital heart disease has made great progress, enabling the majority of patients to be treated in a timely manner.
However, surgery requires open-heart, or (and) extracorporeal cardiopulmonary diversion, surgical complications, and cosmetic problems associated with surgical scarring. These prompted attempts to replace surgery by inserting various catheters and devices from the peripheral vasculature to the cardiovascular cavity to be treated through a non-open route, which developed into interventional catheterization.
Due to the wide variety of precardiac diseases, varying pathological types, age and severity of disease, and hemodynamics, postoperative follow-up and comparative studies with surgical procedures have been performed. Although transcatheter interventions have the advantages of better aesthetics, less trauma, avoidance of extracorporeal circulation and shorter hospitalization days, they may still be accompanied by serious complications such as thromboembolism, vascular injury, and even cardiac perforation, and there is a deep understanding of the problems as well as the limitations. In recent years, minimally invasive cardiac surgery (MICS) has developed rapidly, and now minimally invasive parachute occlusion with small incisions in the chest has been widely used in the treatment of pediatric congenital heart disease (CHD).
In this paper, we briefly introduce the common surgical interventions for atrial septal defect in congenital heart disease as follows.
II. Historical review of interventional treatment for pediatric congenital heart disease
Transcatheter interventions for precardiac disease began in the mid-20th century. 1966 Rashkind and Miller first proposed the use of balloon catheters to perform atrial septal stoma for palliative treatment of transposition of the great arteries; 1971 Porstmann first carried out interventions for patent ductus arteriosus (PDA); 1974 King and Mills et al. first tried transcatheter delivery of double umbrella In 1976, Rashkind invented the umbrella closure device and successfully treated atrial septal defects (ASDs) with sealing; in 1982, Kan first reported balloon dilation for pulmonary artery braid stenosis, followed by Lababidi’s successful balloon dilation of the aortic braid in 1984; In 1988, Lock et al. first applied the Rashkind double-sided umbrella to close VSD, and in 1989, Lock et al. designed a double-umbrella closure called the Clamshell occluder to close ASD, but a high residual shunt rate was found in clinical trials.
In 1990, Sideris applied a button-type double-disc occluder system device to close ASD, but it was not popularized due to the complicated operation and high residual shunt rate. 1992, Combier et al. first reported the success of using spring ring to occlude PDA, and then it was popularized at home and abroad; Amplatzer developed a new generation of occluder with nickel-titanium alloy braid in 1997 and used it in clinical use. The “waist” of the device matches the diameter of the ASD, which makes the plugger less likely to be displaced.
The use of this type of blocker is easy to operate and the delivery sheath is thin, which makes it suitable for ASD blocking in pediatric patients, thus significantly improving the safety and success rate of the interventional treatment for precardiac disease. In addition, the localization of interventional devices for precardiac disease has played a positive role in promoting the interventional treatment of precardiac disease in China.
In 1997, Amin et al. first introduced the technique of transventricular closure of ventricular septal defects based on animal studies of myocardial and membranous ventricular septal defects, and successfully operated on an infant with myocardial ventricular septal defect under non-extracorporeal circulation. In 2002, Yu Shiqiang et al. were the first to report a large number of cases of atrial septal defect occlusion by umbilical slices with a small transthoracic incision and non-extracorporeal circulation.
In 2007, Diab et al. reported the use of the Amplatzer parachute to seal the atrial septal defect via the right atrium. In the same year, Li Hongxin also reported the experience of 100 cases of intraoperative closure of atrial septal defects with an umbrella piece device via a small right anterior thoracic incision.
Small thoracic incision for non-extracorporeal circulation atrial septal defect (ASD) occlusion
Atrial septal defect is one of the common congenital heart diseases, and its incidence accounts for about 6-10% of congenital heart diseases. There are primary orifice type and secondary orifice type, 84% of which are secondary orifice type ASD, and those who can be cured by interventional means are secondary orifice type ASD.
1. Indications for surgical occlusion of ASD.
(1) Age > 1 year, weight > 8 Kg;
(2) ASD diameter 5mm-34mm;
(3) Distance from the edge of the defect to the coronary sinus, upper and lower vena cava and pulmonary vein opening >5mm, and distance to the atrioventricular braid >7mm;
(4) The diameter of the interatrial septum is larger than the diameter of the left atrial lateral disc of the selected blocker;
(5) No other cardiac malformations that require surgical intervention. With the maturation of surgical occlusion techniques, the age of surgery can be relaxed to infants less than 1 year old.
The following conditions are contraindicated for ASD intervention:
(1) Primary foramen ovale ASD and venous sinus ASD;
(2) Patients with combined endocarditis and hemorrhagic disease;
(3) thrombosis at the placement of the blocking device or thrombosis at the catheter insertion route;
(4) Severe pulmonary hypertension resulting in right-to-left shunt;
(5) Patients with other serious myocardial disorders or heart braid disease.
2.Surgical methods.
(1) TEE guidance: The patient is placed in a supine position with the right chest elevated by 30 degrees under intravenous complex anesthesia, and the esophageal echocardiographic probe is placed.
(2) Umbrella piece type selection: The double-disc umbrella piece blocker is the same as the blocker used in the medical transcatheter route. If the shape of ASD is round or circular; choose the maximum ASD diameter plus 4 mm, if the ASD is oval, choose the longest ASD diameter plus ≥4 mm; if it is a double-hole ASD, choose the model of the umbrella piece as the sum of the maximum ASD diameter and the distance between the two holes plus 4 or 6 mm.
(3) Placement of the blocker: routine disinfection and towel laying, small incision of 2-2.5 cm in the fourth intercostal space of the right anterior chest next to the sternum, layer by layer through the intercostal space into the chest, “H” shaped incision of the pericardium, both sides of the suspension. The right atrium was double loaded with heparinized 1mg/kg and the blocker was soaked with heparinized saline for 1min. The right atrium was incised and the sheath was inserted. Under the guidance of ultrasonic esophageal probe, the sheath was inserted into the left atrium through the atrial defect, and the blocker was pushed forward to open the blocking umbrella on the left atrial side, and the pull-back umbrella covered the left atrial side of the atrial septal defect. The position of the blocker was normal without dislodgement in the pull-back boost test. The left-to-right shunt disappeared, and the mitral and tricuspid orifices and the right pulmonary vein opening in the upper and lower vena cava were not affected by the ultrasound color test.
The blocker was released by rotating the detachment transfer wire, and the lead was cut and withdrawn after confirming the normal position of the blocker by cardiac ultrasound. The right atrial ruffle was tied without bleeding. No neutralization of heparin, sutured intercostal, intraoperative chest venting, routine chest closure, no need to place closed chest drainage tube.
3.The advantages of surgical non-extracorporeal circulation atrial septal defect sealing.
(1) Wide range of surgical indications, especially for young infants and children, it is not necessary to transmit the blocker through the femoral artery tube.
(2) High safety, the procedure is performed by a surgeon who is familiar with the anatomy of the heart, and the procedure is performed in the operating room, and can be repaired directly by extracorporeal circulation in case of accidents, whereas medical interventions are usually performed in the DSA catheterization room and operated by an internist.
(3) Avoidance of extracorporeal circulation, eliminating the need for splitting the sternum and postoperative placement of drainage tubes.
(4) Small chest incision and inconspicuous scars.
(5) Using esophageal ultrasound or four-chamber subxiphoid view to seal the atrial septal defect, the whole sealing process can be clearly displayed during the operation without X-ray guidance, avoiding long time X-ray radiation and the intake of contrast agent.
(6) The blocking process is intuitive and safe pushing the sheath to put the blocker in a short path and the sheath is perpendicular to the atrial septal defect with accurate and rapid position, while catheter interventions with the delivery device inserted from the inferior vena cava into the right atrium need to turn to reach the atrial septal defect, which can easily stimulate the right atrium and cause arrhythmia.
(7) The incidence of blocker dislodgement is low. The blocker is stiffer and generates greater retraction force, which can snap more closely to the edge of the atrial septal defect, and the blocker is tested for dislodgement by pushing and pulling vertically back and forth.
(8) The operation time is shorter, the postoperative recovery is faster than conventional open chest, the postoperative time off the ventilator is shorter, the ICU time is significantly reduced than conventional extracorporeal circulation repair, and the hospital stay is correspondingly reduced.
(9) The overall cost of the operation is comparable to that of extracorporeal repair, and cheaper than that of medical interventional blockage.
Complications are mainly intraoperative detachment of the umbrella piece, small amount of pleural effusion, intraoperative transient arrhythmia, etc. Intraoperative detachment of the umbrella piece can be removed and the atrial septal defect repaired under extracorporeal circulation. A small amount of pleural effusion can be thoracentesis or self-absorption.