Surgical ASD closure

Date
September 14, 2025
URL
https://x.com/WithAScalpel/status/1967203127192637870
Categories
ASDCardiac Surgery

Secundum ASD Closure — Operative Technique, Evidence, and Pearls

Where surgery fits alongside transcatheter therapy

For anatomically suitable secundum ASDs, contemporary meta-analyses consistently show transcatheter device closure (TCC) has lower all-cause mortality, fewer total/major complications, and a shorter length of stay than surgical closure (SC), while SC achieves a lower rate of residual shunt [1–3]. Surgical results remain excellent when TCC is not feasible; large series of patch closure report complete closure with no operative deaths and low perioperative morbidity [4]. Device-related complications are uncommon but include embolization, erosion, perforation, and conduction disturbances, occasionally requiring surgical rescue [5]. Recent reviews reinforce a “TCC-first when rims are adequate; surgery for unsuitable anatomy or concomitant repair” approach across pediatric and adult practice [6, 7].

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Indications and pre-operative essentials

  • Indication. Hemodynamically significant secundum ASD with right-sided volume overload or symptoms; choose surgery when device closure is unsuitable (deficient rims—especially posteroinferior/IVC—very large/multiple fenestrations, associated lesions), or when concomitant procedures are needed [1–3, 6].
  • Define the anatomy. Pre-op TTE/TEE (± CT/MRI) to confirm: defect at the fossa ovalis, number of fenestrations, rim adequacy (focus on the posteroinferior/IVC rim), pulmonary venous return (exclude PAPVC), integrity of the coronary sinus roof, and additional atrial shunts.
  • Plan the strategy. Decide on patch vs primary closure, need for a fenestration (severe pulmonary hypertension or impaired LV compliance), and arrested vs beating-heart repair (arrested heart is standard in pediatrics; a beating-heart approach is an adult option in selected centers).

Key landmarks to respect

  • Triangle of Koch. Bordered by the tendon of Todaro, tricuspid septal annulus, and coronary sinus orifice; the AV node sits at its apex—avoid deep bites near the anteroinferior rim.
  • IVC rim & eustachian valve. Do not incorporate the valve or IVC cannula; avoid stitches that could narrow the IVC or coronary sinus.
  • Aortic/superior rim. Near the aortic root, take tiny, superficial bites on firm tissue to prevent erosion.

Standard operative sequence

  1. Cannulation and myocardial protection

    2. Bicaval cannulation with snug snares; moderate hypothermia as needed. Aortic cross-clamp → cardioplegic arrest (beating-heart option: normothermic CPB with meticulous venting and air management).

  2. Right atriotomy and exposure

    3. Longitudinal RA incision parallel to the AV groove; stay sutures to elevate the interatrial septum. Confirm defect type (secundum vs sinus venosus/coronary sinus variants). Suction gently on the LA side—avoid over-suction that entrains air or distorts rims.

  3. Assessment and preparation

    4. Survey for multiple fenestrations, fragile septum primum, and adequacy of the IVC rim. Plan a suture path away from Koch’s triangle; mentally mark the coronary sinus ostium.

  4. Closure
    • Patch repair (preferred for most pediatric secundum ASDs): autologous glutaraldehyde-treated pericardium or ePTFE. Start at the posteroinferior rim with 5-0/6-0 polypropylene, then run continuously (or use interrupted stitches) around the defect. Keep bites small and on the LA side to protect conduction tissue.
    • Primary closure: reserve for small, firm-rim defects; use interrupted or running monofilament with the LA partially filled to avoid purse-stringing.
    • Optional fenestration: 3–4 mm fenestration in the patch when postoperative pulmonary hypertension or poor LV compliance is a concern.
  5. De-airing and hemostasis

    6. Maintain an LA vent (e.g., via the right superior pulmonary vein). Fill the LA before final knots; flood the field with CO₂ (if available), perform gentle lung inflation, and aspirate RA/LA. Close the RA with meticulous hemostasis.

  6. Separation from bypass and verification

    7. Remove the cross-clamp, rewarm, and wean from CPB. TEE: confirm complete closure, unobstructed SVC/IVC and coronary sinus inflows, no pulmonary venous obstruction, and preserved AV-valve function. Release caval snares after verifying caval patency and de-airing.

Pitfalls and how to avoid them

  • AV block or junctional rhythm: stay off the anteroinferior rim; keep bites shallow and on the LA surface; avoid crossing onto the tricuspid annulus.
  • IVC or coronary sinus obstruction: never include the eustachian valve or CS lip in the suture line; mind the IVC cannula when placing inferior stitches.
  • Residual shunt: search for accessory fenestrations; use a larger patch to span friable septum primum.
  • Air embolism: prevent LA over-suction, keep the LA filled during final ties, maintain active venting, and verify with TEE.
  • Misclassified defect: if PAPVC/sinus venosus anatomy is identified, convert to the appropriate operation (e.g., two-patch or Warden), not a simple ASD closure.

Postoperative considerations

  • Monitor for arrhythmias (transient JET/junctional rhythm common), AV block, or RA hypertension (suggesting caval/CS narrowing).
  • Early echocardiography to document closure and venous inflows; diuresis as needed for RA/RV volume unloading.
  • If a fenestration was created or pulmonary hypertension is present, plan staged fenestration closure after clinical improvement.

One-page checklist (OR card)

  • Bicaval cannulation → cross-clamp → cardioplegia (or beating-heart plan).
  • RAotomy; gentle LA suction; define rims and nearby structures.
  • Respect Koch’s triangle; protect the IVC rim and eustachian valve.
  • Patch (preferred) or primary closure with the LA filled.
  • Meticulous de-airing; RA closure → unclamp → TEE confirmation → wean from CPB.

References

[1] Villablanca PA, Briston DA, Rodés-Cabau J, Briceno DF, Rao G, Aljoudi M, et al. Treatment options for the closure of secundum atrial septal defects: A systematic review and meta-analysis. Int J Cardiol. 2017;241:149-155.

[2] Rigatelli G, Zuin M, Roncon L, Nanjiundappa A. Secundum atrial septal defects transcatheter closure versus surgery in adulthood: a 2000–2020 systematic review and meta-analysis of intrahospital outcomes. Cardiol Young. 2021;31(4):541-546.

[3] Butera G, Biondi-Zoccai G, Sangiorgi G, Abella R, Giamberti A, Bussadori C, et al. Percutaneous versus surgical closure of secundum atrial septal defects: a systematic review and meta-analysis of currently available clinical evidence. EuroIntervention. 2011;7(3):377-385.

[4] Hopkins RA, Bert AA, Buchholz B, Guarino K, Meyers M. Surgical patch closure of atrial septal defects. Ann Thorac Surg. 2004;77(6):2144-2149.

[5] Shimpo H, Hojo R, Ryo M, Konuma T, Tempaku H. Transcatheter closure of secundum atrial septal defect. Gen Thorac Cardiovasc Surg. 2013;61(11):614-618.

[6] Alkashkari W, Albugami S, Hijazi ZM. Current practice in atrial septal defect occlusion in children and adults. Expert Rev Cardiovasc Ther. 2020;18(6):315-329.

[7] Shaban Q, Hijazi ZM. Secundum atrial septal defects in adults: all you need to know with an emphasis on outcome. Expert Rev Cardiovasc Ther. 2025;23(4):165-178.