doi:10.1093/mmcts/mmu014 published online 4 August 2014.



Robotic atrial septal defect closure Sahin Senaya,*, Ahmet Umit Gullua, Muharrem Kocyigitb, Aleks Degirmenciogluc, Hasan Karabuluta and Cem Alhana Department of Cardiovascular Surgery, Acıbadem University School of Medicine, Istanbul, Turkey Department of Anesthesiology and Reanimation, Acıbadem University Vocational Schools, Istanbul, Turkey c Department of Cardiology, Acıbadem University School of Medicine, Istanbul, Turkey a


*Corresponding author. Acibadem Maslak Hastanesi, Maslak, Istanbul, Turkey. Tel: +90-212-3044444; fax: +90-212-3044440; e-mail: [email protected] (S. Senay). Received 16 April 2014; received in revised form 2 July 2014; accepted 7 July 2014

Summary Atrial septal defect (ASD) is one of the most common congenital cardiac diseases. This pathology can be treated with percutaneous devices. However, some of the ASDs are not suitable for device closure. Also, there may be device-related late complications of transcatheter ASD closure. Currently, robotic surgical techniques allow surgeons to close ASDs in a totally endoscopic fashion with a high success rate and a low complication rate. This study demonstrates the basic concepts and technique of robotic ASD closure. Keywords: Minimally invasive surgery • Robotic surgery • Atrial septal defect

INTRODUCTION Atrial septal defect (ASD) is one of the most common congenital cardiac diseases [1]. This pathology can be treated with percutaneous devices with a low rate of early post-procedural complications [2]. However, ASDs with unfavourable anatomy and the type of ASD other than the secundum are not suitable for transcatheter closure. Moreover, there are important device-related late complications of transcatheter ASD closure including device migration, device malposition, cardiac erosion or perforation leading to tamponade and death, atrioventricular block and bacterial endocarditis [1–4]. Currently, robotic surgical techniques allow surgeons to close ASDs in a totally endoscopic fashion with a high success rate and a low complication rate [1]. The robotic technique can be applied to ASDs with different anatomical sizes and also to both secundum and sinus venosus types. Moreover, since this technique does not require implantation of any prosthetic material, it may offer patients a safe long term that is free from any device-related complications. This study demonstrates the basic concepts and technique of totally endoscopic robotic ASD closure.

SURGICAL TECHNIQUE Patients should undergo preoperative evaluation by transthoracic echocardiography, coronary angiography and vascular ultrasound or computed tomographic angiographic examination (if necessary) of the femoral vessels. The operation can be performed for secundum or sinus venosus type ASDs and can be combined with right-sided robotic operations including mitral or tricuspid valve pathologies. The exclusion criteria for this operation are

r­ ecommended as primum-type ASD as well as extensive coronary artery disease, severe peripheral vascular disease and previous median sternotomy or right thoracotomy.

Anaesthesia, patient positioning and cardiopulmonary bypass set-up A double-lumen endotracheal tube is placed along with a multiplane transoesophageal echocardiography (TOE) probe after induct­ ion of general anaesthesia. The size of the ASD should be determined with TOE before cross-clamping for preparation of a pericardial patch. A chest roll is placed under the right shoulder, the right arm is placed at the side of the operation table and the table is rotated 20° to be right side up. The incision sites are marked (Fig. 1). A 15- or 17-Fr venous cannula (Medtronic Bio-Medicus, Eden Prarie, MN, USA) is inserted percutaneously via the right internal jugular vein and placed into the superior vena cava with its tip being at least 2–3 cm superior to the cavoatrial junction under TOE guidance. The common femoral artery is cannulated with a 17- or 19-Fr aortic cannula (Medtronic Bio-Medicus). A 21- or 24-Fr venous cannula (Medtronic Bio-Medicus) is inserted into the right common femoral vein and placed into the inferior vena cava, with its tip being 2–3 cm inferior to the cavoatrial junction. Unlike the set-up for robotic mitral operations, the reason for leaving a space of 2–3 cm at both venae cavae is the need for clamping for bicaval occlusion. The space at the superior vena cava should be even longer in sinus venosus-type defects.

Port implantation, cardioplegia and cross-clamping A 20-mm working port is placed in the right fourth intercostal space, 3 cm laterally to the nipple. The camera port is placed 1–2 cm

© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

S. Senay et al. / Multimedia Manual of Cardio-Thoracic Surgery

Figure 1:  ​Patient positioning (small picture), marking of port sites (main picture).


Video 2:  ​Placement of a cross-clamp.

Figure 2:  ​General set-up after placement of the ports (small picture) and after docking (main picture).

Video 3:  ​Administration of cardioplegia.

Video 1:  ​Pericardial stay sutures and external fixation.

­ edially to the working port at the same intercostal space. In usual m set-up, a 30° camera is used. However, since the atrial septum is horizontally visualized intraoperatively, a 0° camera may be a better choice, at least in some cases. Insufflation of carbon dioxide is used with 8 mmHg pressure and a flow rate of 6 l/min. The right-arm port

is placed two intercostal spaces inferior to the thoracotomy, and the left-arm port is placed one or two intercostal spaces above. The atrial retractor port is placed approximately 3 cm medially to the camera port in the fourth or fifth intercostal space. After port implantation, the robotic arms are connected to the ports (Fig. 2). Cardiopulmonary bypass (CPB) is instituted. The pericardium is opened 2–3 cm anteriorly to the phrenic nerve and the pericardial edges are suspended on stay sutures, which are then snared and pulled through the lateral chest wall inferior to the thoracotomy. These sutures are fixed externally (Video 1). Given that the magnification of the endocamera system may mislead the precise sizing intraoperatively, a pericardial patch is prepared in sizes according to the TOE measurements of the ASD. The ascending aorta is cross-clamped with a transthoracic clamp, which is inserted through one intercostal space above the working port in the direction of the transverse sinus. The position of this clamp should be arranged to pass through the upper side of the junction of the atrium and superior vena cava, leaving a space of 1–2 cm for the caval bulldog clamp (Video 2). The heart is arrested using cold crystalloid cardioplegia delivered into the aortic root with a transthoracic cannula through the thoracotomy (Video 3). Crossclamping and cardioplegia delivery should be confirmed using TOE.


S. Senay et al. / Multimedia Manual of Cardio-Thoracic Surgery

Bicaval occlusion, exposure and pericardial patch closure The inferior and superior venae cavae are occluded with bulldog clamps delivered through the working port [5] (Video 4). Alter­ natively, both venae cavae can be snared. After bicaval occlusion, the right atrium is opened through a classical incision and the exposure of the ASD is established by proper placement of the atrial retractor (Video 5). In most of the cases, the ASD is closed with pericardial patch material pretreated with glutaraldehyde (Video 6). Knots are tied with a knot pusher through the working port. After patch closure, the inferior vena cava clamp is released partially to allow Video 7:  ​Release of bulldog clamps.

Video 4:  ​Occlusion of both venae cavae with endoscopic bulldog clamps.

Video 8:  ​Deairing.

Video 5:  ​Right atriotomy and right atrial exposure.

deairing and control of the inferior caval orifice flow. The ­atriotomy is closed using a premade loop suture. Both bulldog clamps are released (Video 7). A suture is placed at the cardioplegia needle site and a vent is placed through this. The left lung is ventilated. TOE is performed for intracardiac air control. After deairing, the aortic cross-clamp is released (Video 8). Adequate haemostasis is achieved. The robotic arms are removed and the drainage tube is placed through the right port incision. After decannulation, heparin is reversed and all incisions are closed in layers (Fig. 3).


Video 6:  ​Patch closure of the defect.

From March 2010 to April 2014, a total of 92 patients underwent robotic cardiac procedures using the da Vinci Si HD surgical ­system (Intuitive Surgical, Inc., Sunnyvale, CA, USA). Among this group, 16 of them were robotic ASD closure with or without an additional procedure. Perioperative variables are presented in Table 1. No conversion to mini-thoracotomy or sternotomy was needed. Four patients had an additional cardiac procedure (Table 2). No operative and hospital mortality was observed. There was no reoperation, intensive care unit readmission or hospital readmission. No intraoperative devicerelated complications were observed. The mean follow-up period was 20 ± 11 months. During the mid-term follow-up,


S. Senay et al. / Multimedia Manual of Cardio-Thoracic Surgery

Table 2: ​Operations performed Operation type


ASD closure ASD closure + mitral valve repair ASD closure + mitral valve replacement

12 1 3

ASD: atrial septal defect.

Table 3: ​Postoperative variables Cross-clamp time (min) CPB time (min) Postoperative inotropic use (%) Mean drainage (ml) Intubation time (h) ICU stay time (h) Early reoperation for bleeding (%) Early mortality (%) ICU readmission (%) Postoperative surgical site infection (%) Postoperative new onset of atrial fibrillation (%) Postoperative stroke (%) Mortality at the mid-term follow-up (%) Hospital readmission (%) Need for reintervention/reoperation at the mid-term follow-up (%) Figure 3:  ​Postoperative view.

65 ± 25 121 ± 43 6.2 270 ± 240 6.4 ± 4.1 20 ± 8 0 0 0 0 6.2 0 0 0 0

CPB: cardiopulmonary bypass; ICU: intensive care unit.

Table 1: ​Basic demographics of the patients N Age (years) EuroSCORE (%) Body mass index (kg/m2) Gender (female/male) NYHA Class Preoperative creatinine (mg/dl) Preoperative EF (%)

16 36 ± 14 (range: 12–68) 2.6 ± 1.2 21.7 ± 6.5 9/7 2.4 ± 0.8 0.9 ± 0.3 58 ± 9

EF: ejection fraction; NYHA Class: New York Heart Association Classification.

there was no mortality and no need for reoperation or reintervention (Table 3).

DISCUSSION An ASD can be closed with transcatheter device implantation or surgical treatment. Transcatheter therapy is widely used with very low early postoperative complications [2]. However, this ­technique is not feasible for ASDs with unsuitable anatomy or ASD type other than secundum, by which we mean a large diameter (>36 mm), inadequate atrial septal rims or proximity of the defect to AV valves, coronary sinus or venae cavae [1]. Robotic ASD closure is safe and effective and can be offered, at least for this group of patients, as a minimally invasive technique. The device-related late complications of transcatheter therapy raise some questions regarding the safety of this technique in the long term. Since surgical therapy with a robot does not require

implantation of any prosthetic material, the long-term benefit may be superior to that of transcatheter therapy. There are several technical issues to be considered regarding robotic ASD closure. First, all intraoperative measurements including the size of the pericardial patch should be done with a ruler. The magnified robotic images may mislead one to improper sizing. Second, the need for bicaval occlusion necessitates some changes regarding the strategy for cannulation. Unlike robotic mitral operations, the venous cannulae at the superior and inferior venae cavae should not reach the right atrium but be away, leaving at least 1–2 cm of open space for endoscopic bulldog clamps. Third, the anatomical position of the interatrial septum may necessitate the use of a 0° endocamera unlike robotic mitral operations. ASD closures can also be performed with minimally invasive video-assisted techniques. Both techniques offer acceptable safety and feasibility. However, the main benefit of robotic ASD closure compared with a mini-video-assisted or totally endoscopic non-robotic ASD closure may be the better visualization and exposure of the anatomy and also better practical suture handling in difficult anatomies. There are several case series regarding robotic ASD closure reported in the literature with acceptable results [1, 6–10]. These are briefly summarized with the inclusion of our results in Table 4. In conclusion, robotic ASD closure is technically feasible and safe with a high success rate and a low complication rate. This technique can be offered at least for patients with ASD that is not suitable for transcatheter closure. The long-term results of the robotic technique should be investigated to make a comparison with transcatheter device therapy.


S. Senay et al. / Multimedia Manual of Cardio-Thoracic Surgery

Table 4: ​Results from different reports of robotic ASD closure Study

Patients Gender (n) (M/F)

Mean age (years)

Robotic system

CPB/CC time (min)

ICU stay (h)

Complications and comments

Yang et al. [10]



da Vinci

Sixty-one operations performed on beating hearts; postoperative outcome was similar for patients operated on- or off-pump Two patients were converted to mini-thoracotomy One recurrent shunt (detected at postoperative day 5), 1 right leg compartment syndrome and 1 postoperative atrial fibrillation One residual shunt, 1 right femoral artery dissection (required interposition of the graft and bare metal stent implantation) – Two cases of postoperative atrial fibrillation (both patients with concomitant mitral valve procedure)

Ak et al. [6] Argenziano et al. [7]

24 17

10/14 3/14

45.5 ± 17.0 47 ± 12

da Vinci da Vinci

135/63 122/32

23 20

Bonaros et al. [8]



35 (15–55)

da Vinci



Torracca et al. [9] Senay et al. [this study]

7 16

2/5 7/9

41 ± 13 36 ± 14

da Vinci da Vinci

101/63 121/65

– 20

CPB/CC time: cardiopulmonary bypass/cross-clamp time.

Conflict of interest: none declared.

REFERENCES [1] Yao DK, Chen H, Ma LL, Ma ZS, Wang LX. Totally endoscopic atrial septal repair with or without robotic assistance: a systematic review and metaanalysis of case series. Heart Lung Circ 2013;22:433–40. [2] 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;7:377–85. [3] Kazmouz S, Kenny D, Cao QL, Kavinsky CJ, Hijazi ZM. Transcatheter closure of secundum atrial septal defects. J Invasive Cardiol 2013; 25:257–64. [4] Crawford GB, Brindis RG, Krucoff MW, Mansalis BP, Carroll JD. Percutaneous atrial septal occluder devices and cardiac erosion: a review of the literature. Catheter Cardiovasc Interv 2012;80:157–67.

[5] Gullu AU, Senay S, Kocyigit M, Alhan C. A simple method for occlusion of both venae cavae in total cardiopulmonary bypass for robotic surgery. Interact CardioVasc Thorac Surg 2012;14:138–9. [6] Ak K, Aybek T, Wimmer-Greinecker G, Ozaslan F, Bakhtiary F, Moritz A et al. Evolution of surgical techniques for atrial septal defect repair in adults: a 10-year single-institution experience. J Thorac Cardiovasc Surg 2007;134:757–64. [7] Argenziano M, Oz MC, Kohmoto T, Morgan J, Dimitui J, Mongero L et al. Totally endoscopic atrial septal defect repair with robotic assistance. Circulation 2003;108(Suppl 1):II191–4. [8] Bonaros N, Schachner T, Oehlinger A, Ruetzler E, Kolbitsch C, Dichtl W et al. Robotically assisted totally endoscopic atrial septal defect repair: insights from operative times, learning curves, and clinical outcome. Ann Thorac Surg 2006;82:687–93. [9] Torracca L, Ismeno G, Quarti A, Alfieri O. Totally endoscopic atrial septal defect closure with a robotic system: experience with seven cases. Heart Surg Forum 2002;5:125–7. [10] Yang M, Gao C, Xiao C. Robotic-assisted endoscopic atrial septal defect closure: analysis of 115 cases in a single center. Nan Fang Yi Ke Da Xue Xue Bao 2012;32:915–8.

Robotic atrial septal defect closure.

Atrial septal defect (ASD) is one of the most common congenital cardiac diseases. This pathology can be treated with percutaneous devices. However, so...
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