Technique
In the current study, we report the cases of two female patients who underwent surgical re-intervention for residual SV ASD after initial repair in childhood (at the age of 4 years for Patient 1 and 10 months for Patient 2). Both index procedures were uneventful, and patients were discharged in good clinical conditions with no suspicion of residual intra-cardiac defects.
At follow-up, patients were asymptomatic. However, persistent right ventricular dilation with a significant residual ASD located at the junction between the right atrium and IVC was demonstrated. Both patients were scheduled for elective surgery considering that a percutaneous approach was not deemed feasible.
At the time of surgery, at the age of 32 years for patient 1 and 20 years for Patient 2, after surgical cannulation of the femoral vessels and percutaneous cannulation of the internal jugular vein, a peripheral CPB was started. A right postero-lateral mini-thoracotomy (or sub-axillary approach) was performed through a 4 cm incision in the fourth intercostal space just below the corner of the right scapula. Right lung exclusion was achieved in order to gain better surgical exposure.
After isolation of the mediastinal structures, with the aid of induced ventricular fibrillation (IVF), a right atriotomy was performed. While the SVC was snared before opening the atrium, the IVC was left unsnared to allow optimal visualization of the residual intra-cardiac shunt (Figure 1, Video 1). The residual ASD was closed with a heterologous pericardial patch (Figure 2). Total CPB time was 98 minutes for Patient 1 and 63 minutes for Patient 2. IVF time was 75 minutes and 24 minutes, respectively. The ventricular fibrillation was converted to sinus rhythm by direct current cardioversion shock in both, and the left cavities were cautiously deaired.
Surgical results were carefully reviewed by 2D-transesophageal echocardiography and confirmed through a bubble test. The postoperative course was uneventful, and patients were discharged home on postoperative day 7 (Patient 1) and 6 (Patient 2).