DISCUSSION
Minimally invasive ASD closure and TVR through a right mini-thoracotomy
in the 4th intercostal space is a widely accepted
surgical option [1, 2]. We report the use of the presence of a large
ASD to access the left-sided heart structures in order to close the LAA
and to perform a MAZE radiofrequency ablation procedure.
Although utilization of this access route may appear (and it probably
is) obvious, to the best of our knowledge, performance of this set of
procedures through a right mini thoracotomy and single atriotomy has not
been previously reported in the literature.
Cleary, a median sternotomy in this case would have been a simpler
approach that would enable the surgeon to readily access the left atrium
via the “natural” transeptal route provided by the ASD. Another option
for those practising MICS would have been to perform a right mini
thoracotomy and to accomplish the described sets of procedures through
separate right and left atriotomies. In this patient, we elected to use
the large ASD as a gate to reach and close the LAA and to perform left
atrial “box” lesions. In this way, it was possible to simplify the
operation avoiding either a bi-atrial MICS or a median sternotomy
approach.
The left atrium was adequately visualised through the large ASD,
allowing for a straightforward suturing and obliteration of the LAA from
within. This could have been also done externally using the AtriClip
[3], however, the exposure afforded through a mini-thoracotomy alone
might not have guaranteed a safe and effective application of the
AtriClip down to the base of the LAA.
The left atrial “box” lesion was comfortably created (Fig 1) [4]
using a linear cryoablation probe behind the left pulmonary veins,
across the lateral ridge, connecting the floor and roof lesions. The
same linear probe was used to make an endocardial lesion to the mitral
annulus.
Management of ASD in adult patients remains controversial, however,
appropriately selected patients can derive symptomatic and prognostic
benefit regardless of their age at the time of the diagnosis and repair
of ASD [5]. We believe in individualisation of treatment following
discussion in a multidisciplinary cardiology-cardiac surgical meeting.
Repair of tricuspid valve is superior to tricuspid valve replacement
[6] and our priority is to repair rather than replace intracardiac
valves if feasible. However, on this occasion, presence of calcification
and fibrosis of anterior and posterior leaflets in this patient dictated
the need for replacement of the native tricuspid valve with a
bioprosthesis.