Atrial septal defect ostium primum surgical closure

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Priyamvada Singh, M.B.B.S. [2]; Cafer Zorkun, M.D., Ph.D. [3]; Assistant Editor-In-Chief: Kristin Feeney, B.S. [4]

Overview

Surgical closure is the commonest treatment method for atrial septal defect and has been the gold standard for many years. Many surgeons prefer more minimally invasive techniques over the conventional sternotomy to avoid potentials for additional complications. Special consideration must be taken into account for the age of the patient and the size of the defect involved. Surgical closure is indicated for patients with primum, sinus venosus and coronary sinus type of atrial septal defects. However, ostium secundum atrial septal defects are commonly treated by percutaneous closure. With uncomplicated atrial septal defect, (without pulmonary hypertension and other comorbidities) the post-surgical mortality is as low as 1%

Surgery

Mechanisms of benefit

Surgical closure involves closing the defect either by putting a pericardial patch or via direct suture closure. The decision for suture closure or patch closure depends on the morphology and size of defect. The closure of the defect prevents the left-to-right shunting of blood across the atrium and thus improving the circulation in heart. It is not recommended that synthetic patches be used for primary closure..

Indication

Surgical closure is indicated for patients with primum, sinus venosus and coronary sinus type of atrial septal defects. Whereas, ostium secundum atrial septal defects are commonly treated by percutaneous closure.

Contraindications

Surgery is contraindicated in patients with severe irreversible pulmonary artery hypertension, eisenmenger's syndrome and no evidence of a left-to-right shunt. Also, for uncomplicated cases with ostium secundum defects percutaneous closure is preferred.

General considerations during surgery

• Small to moderate defects with oval shape, can be closed with the help of sutures.

• Direct suture closure of large round defects may cause distortion of the atrium and aortic annulus. Thus, a patch closure is preferred in these cases.

• The patch can be made up of either natural (made out of the patient's pericardium) or artificial polytetrafluoroethylene, (dacron).

• Other operations that are done for anomalies associated with atrial septal defects are tricuspid valve repair for significant tricuspid regurgitation, repair for anomalous pulmonary venous drainage, Warden procedure (translocation of the superior vena cava to the right atrial appendage) for sinus venosus ASD when the anomalous pulmonary venous drainage enters the mid or upper superior vena cava and maze procedure for intermittent/chronic atrial fibrillation/flutter.

• Considerations in an ostium primum repair:

• Surgical closure is more complicated compared to other atrial septal defect repairs.
• The patch should be attached to the septum at the juncture of the mitral and tricuspid valves.
• Mitral valve repair, closure of the cleft mitral leaflet, annuloplasty and mitral valve replacement may be required to repair mitral insufficiency.

• Devices used are:
  • Amplatzer septal occluder
  • STARFlex septal occluder
  • PFO Star
  • HELEX