A HANDA, S GOUSY Surgical correction is the standard of care for ASDs other than secundum defects, such as ostium primum and sinus venosus ASDs. The surgical approach was previously the standard of care for even ostium secundum defects, proving to be both safe and effective. However, over the past few decades many devices have been developed to treat secundum ASD percutaneously, and the benefits of the percutaneous approach have been well demonstrated in both paediatric and young population.1 Most operators agree that the majority of secundum ASDs can be closed percutaneously. When it is not feasible, the surgical approach is still recommended. Issues such as a defect size of >40 mm and lack of adequate rims of tissue from the defects to important surrounding structures, atrial thrombus and contraindication to antiplatelet therapy are in this category.2 The presence of other congenital cardiac deformities such as anomalous pulmonary venous drainage, ostium primum, sinus venosus or coronary sinus ASD are also definite indications for surgical correction of the atria septal defects. Surgical closure was previously the standard treatment for ASD closure but has now been mostly replaced by the percutaneous approach, albeit in some conditions it still remains the only option as listed above. Also, the standard midline thoracotomy was the preferred approach in ASD surgery, but now most surgeons prefer the minimally invasive right thoracotomy. Patients are supported by a heart-lung machine intraoperatively, and the ASD is approached through an opening in the right atrium3 (Figure 10.1). Figure 10.1 ASD approached through an opening in the right atrium. (Illustration by Saranya Gousy.) Smaller ASDs can be closed by simply using a suture and overseeing the defect. For larger ASDs, a patch is usually used to close the defect. This patch can be taken from the pericardium or made from synthetic materials such as Dacron or Teflon3 (Figure 10.2). Figure 10.2 Closure of ASD using patch (pericardial patch or Dacron/Teflon patch) (Illustration by Saranya Gousy.) Most ASDs can be corrected using the minimally invasive surgical approach. Instead of the traditional large midline-incision followed by the division of sternum used in open surgery in the past era, surgeons now perform the procedure by making a small 4- to 5-cm incision on the right side of the chest, reducing the complications and making it a cosmetically feasible procedure (Figure 10.3). Figure 10.3 Illustration of the now commonly used small 4- to 5-cm incision on the right side of the chest, instead of the large midline incision and division of the sternum used previously in open surgery. (Illustration by Saranya Gousy.)
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Surgical closure techniques
SURGICAL CLOSURE
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