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Perventricular Device Closure of Ventricular Septal Defect Using a Video - Assisted Thoracoscopic Approach
Alexander Y. Omelchenko, MD, PhD, Yuriy N. Gorbatykh, MD, PhD, Alexander M. Karaskov, MD, PhD, Gregory S. Zaitsev, MD, Marina A. Novikova, MD, Alexey N. Arkhipov, MD, PhD.
Academician E.N. Meshalkin State Research Institute of Circulation Pathology, Novosibirsk, Russian Federation.
OBJECTIVE: To describe a new technique of perventricular closure of a perimembranous ventricular septal defect using transesophageal echocardiography guidance and video-assisted thoracoscopy.
METHODS: The patient was in a 20° right lateral decubitus position. Trocars (3.5 and 3.9 mm) were set through punctures in the 3rd and 6th intercostal spaces along the midclavicular line, in the 4th intercostal space along the anterior axillary line to the left. The thoracoscopic ports were used: the right one for atraumatic forceps and a needle holder; the left one for micro scissors and exteriorization of the tourniquet using a purse-string suture.The central lower trocar was used for endoscopy. After the trocar for the endoscope was placed, insufflation of dioxide carbon (0.5 L/min) was started. The pericardium was opened widely. Using the Kelly forceps under TEE control, we detected the puncture site on the anterior wall of the right ventricle. The Prolene 4/0 purse-string suture was then placed. To close the defect, we used a tool, composed of a ventricular septal defect occlusion device, short occluder delivery system, and modified puncture needle. After direct puncture at the level of the sternocostal joint in the 4th intercostal space on the left, the delivery system was advanced into the anterior mediastinum. A puncture was then made in the anterior wall of the right ventricle through the purse-string suture. The VSD was closed using a standard perventricular device closure technique. A 3-mm drain was placed in the left pleural cavity through the lower puncture site. Extubation was performed in the operation room.
RESULTS: Three patients were treated with this approach (ages 4, 5 and 6 years; weight, 15-17.5 kg, one of them had subaortic VSD and we used eccentric occluder). The first operation was performed on August 15, 2013. The 3-month follow-up examination revealed excellent cosmetic results in all patients with no shunts, conduction disturbances, or valve complications in any patient.
CONCLUSIONS: Applying this technique we expect to achieve high cost-efficiency since this procedure is off-pump, avoids incisions, is effective and safe, and reduces operation time, and the patient’s length of stay.
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