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Interact CardioVasc Thorac Surg 2008;7:130-132. doi:10.1510/icvts.2007.164517 © 2008 European Association of Cardio-Thoracic Surgery
Completely endoscopic removal of a dislocated Amplatzer atrial septal defect closure device
a Department of Cardiac Surgery, Innsbruck Medical University, A-6020 Innsbruck, Austria Received 6 August 2007; received in revised form 26 September 2007; accepted 28 September 2007
*Corresponding author. Tel.: +43 512 504 80631/23806; fax: +43 512 504 22528.
Surgical treatment of residual shunts after transcatheter occlusion of atrial septal defect or patent foramen ovale is reported in approximately one to two percent of these percutaneous interventions. Minimally invasive surgery on the atrial septum is getting more and more common but little data is available on Amplatzer device explantation through limited access. No completely endoscopic device removal has been described previously. We report a case of a 57-year-old woman in whom an Amplatzer device was removed in a robotic totally endoscopic fashion through ports only using the daVinci telemanipulation system.
Key Words: Atrial septal defect; Persistent foramen ovale; Closure device; Removal; Endoscopic surgery; Robotic surgery
Transcatheter treatment of atrial septal defect (ASD) and patent foramen ovale (PFO) has become routine therapy and a minority of these defects is presently treated surgically. The rate of significant residual shunts after implantation of percutaneous closure devices lies in the one to two percent range [1–3]. The majority of these shunts will be treated surgically with open device removal and patch closure of the atrial septal defect. Conventional techniques of surgical explantation of AmplatzerTM occluders have been described [4, 5]. Minimally invasive methods in surgery for pathology on the atrial septum are getting more and more common. If transcatheter treatment fails, the patient will probably prefer such a limited access version of complication management. To our knowledge no completely endoscopic explantation of such a device has been carried out. We describe the first case so far reported in the literature.
A 57-year-old female patient had undergone ASD repair using an AmplatzerTM device seven months prior to admission to our unit. On echocardiography the implant was found to be tilted (Fig. 1) thereby leading to a large residual shunt and considerable thrombogenic risk. Totally endoscopic robotic removal of the device was scheduled.
The patient was placed on the operating table in a 30° left lateral decubitus position. The right femoral artery and vein were exposed. After heparinization and placement of a pursestring suture, a 25 F venous drainage cannula was inserted transfemorally into the right atrium under TEE control. A venous drainage cannula had been placed percutaneously into the superior vena cava after induction of anesthesia. A 23 F Cardiovations Heartport Cannula was inserted through the femoral artery and an endoaortic occlusion balloon catheter was inserted through its side arm. The daVinci telemanipulation system was positioned above the patient's chest. Under right lung collapse a camera port was inserted through the right 4th intercostal space in the mid clavicular line. The ports for the left and right robotic instrument arms were placed in the 3rd and 6th intercostal spaces on the anterior axillary line. Two 5 mm ports were additionally used for transthoracic assistance maneuvers. Endoscopic opening of the pericardium was carried out approximately 2 cm anterior to the right phrenic nerve. Both venae cavae were encircled. Cardiopulmonary bypass was started and the patient was cooled to 32 °C rectal temperature. After inflation of the endoaortic occlusion balloon the heart was arrested using an aortic root injection of 3 mg of adenosine and cold crystalloid cardioplegia. The venae cavae were completely occluded and the right atrium was opened endoscopically. Stay sutures which tack the atrial wall to the pericardium were placed. This resulted in good exposure of the AmplatzerTM device (Fig. 2, Video 1). The device was completely covered with neoendothelium. A suture was placed directly on the device for holding and manipulating purposes. Using robotic endoscopic scissors the device was cut out of the atrial septum. A suction line was inserted into the left atrium through the defect. Nests of residual organized thrombus were retrieved in several segments from the left atrial wall at the anchoring site of the device. The left atrial wall of the septum was also inspected for thrombus. For removal through one of the assistance ports the device had to be cut into two pieces.
A 20 mmx10 mm Dacron patch was brought into the operative field and sutured into the defect using several segments of 4/0 Gore-Tex sutures. The heart was vented through the balloon catheter and the endoaortic occlusion balloon was deflated. The heart spontaneously regained sinus rhythm. The atriotomy was sutured endoscopically on the beating heart again using 4/0 Gore-Tex. After reperfusion the patient was weaned from cardiopulmonary bypass. Perfusion cannulae were removed and protamin was given. The endothoracic operative field was inspected thoracoscopically for adequate hemostasis. A chest tube was inserted and the ports were closed. Aortic endo-occlusion time was 89 min, cardiopulmonary bypass time was 150 min, and total operative time was 288 min. Postoperative ventilation time was 6 h and the patient stayed in the recovery room for 19 h. Ambulation was without problems and the chest tube was removed on the second postoperative day. A postoperative transesophageal echocardiogram showed no residual shunt on the reconstructed atrial septum. The patient was discharged home six days postop. She resumed light sporting activities during the second postoperative week.
With this operation we demonstrate that a closure device on the atrial septum can be removed through ports only without any type of thoracotomy. The first totally endoscopic ASD repairs using the daVinci telemanipulation system have been described by Torracca and coworkers of Milano [6]. Few surgical teams worldwide have further applied and developed this technique [7, 8]. Our team has recently shown that robotic totally endoscopic ASD repair or PFO closure can be carried out with minimal chest trauma and an attractive cosmetic result [9]. Twenty-five cases of robotic atrial septal defect repair had been performed before the case of endoscopic AmplatzerTM device removal. AmplatzerTM device dislocations and surgical reinterventions are currently reported in the 1.0–1.9% range [2, 3]. Du and coworkers, in a large series of catheter based atrial septal defect closure, describe a 1.4% rate of moderate to large residual shunts and a 1.1% rate of surgical reintervention [1]. Our current case exhibited new insights into management of atrial septal closure device failures. First, we experienced the most direct view on the implantation site that probably was ever achieved. Looking on the atrial septum using more than 10-fold magnification revealed pictures of the high endothelialization grade of the device. Second, excision was enhanced by the multidimensional movements of the robotic instruments. Our group has experience with removal of an AmplatzerTM device through minithoracotomy and regards the totally endoscopic version as an ergonomically much more comfortable option from the primary surgeon's perspective and as the operative method that maximally preserves the patient's integrity. Third, we demonstrate that the device can be directly extracted from the thoracic cavity through a 5 mm port. It may, however, be necessary to cut the device in pieces for proper removal. These maneuvers can easily be accomplished using robotic instrumentation. We conclude that completely endoscopic explantation of an atrial septal defect occluder is feasible using robotic technology. This intervention represents a new attractive technique in the armamentarium for minimally invasive treatment of pathology on the atrial septum.
We acknowledge Drs. Thomas Schachner, Christian Kolbitsch, Otmar Pachinger, and Günther Laufer for their continued support of the robotic cardiac surgery program at Innsbruck Medical University.
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Abstract
1. Introduction
