International Society For Minimally Invasive Cardiothoracic Surgery

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Redo-minimally Invasive Asd Closure Without Cross-clamping In Beating-heart
Gökay Deniz, Evren Özçınar, Çağdaş Baran, Mehmet Çakıcı, Ali İhsan Hasde, Serkan Durdu.
Ankara University Heart Center, Ankara, Turkey.

OBJECTIVE: Our aim was to describe the case of a 62-year-old man with redo-ASD via minimally invasive incision. Due to previously CABG operation and using saphenous graft to RCA, it is so complicated to approach the right atrium. However, the absence of a cross-clamp area, adhesions in the aorta, heavily calcification in thorax ct images and some difficulties of maintaining cardiac arrest due to lima-lad bypass forced us to close ASD without cross clemping with beating heart.
METHODS: The plan was to perform ASD closure through 3th intercostal space. Bicaval cannulation was performed with femoral (23 F cannula) and jugular (17 F cannula) cannulation. We preferred a large cannula for comfortable emptying of heart. After the 19 F arterial cannulation, we performed the incision until the thorax cavity. Carefully, the pericardium was opened and the saphenous-RCA bypass graft was pulled up (Figure 1). We performed aortic root vent for removing air and cardiopulmonary bypass was begun. We filled the thorax cavity with carbon dioxide in order to prevent air embolism due to right-left air transition. When the patient was in trendelenburg position, right atrium was opened and the ASD was closed with primary sutures. During the procedure, aorta and left venticile were checked for air embolism with TEE. After the removal of the ASD leak, the operation was routinely continued and completed.
RESULTS: We used an extra-ordinary minimally invasive technique for ASD closure with redo-CABG. Although there was a risk in terms of air embolism when the patient was in the trendelenburg position, only a small portion of the air in the left ventricle was passed to the aorta in the beating-heart bypass, and the air was removed from the aortic vent canulla. The using carbon dioxide was so essential. After the operation, the patient woke up normally.
CONCLUSIONS: Redo minimally invasive asd closure is a feasible alternative despite being a high-risk redo procedure. New strategies are needed to address challenging cases and this case could show us how it is possible.


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