Atrial septal defect can remain undiagnosed until
adulthood. In most asymptomatic patients, symptoms
occur after the fourth decade, including reduced
functional capacity, exertional shortness of breath,
palpitations, and less frequently right heart failure. If
pulmonary hypertension has not developed, surgical
repair has low mortality and good long-term outcome.
However, if pulmonary hypertension has developed,
these patients must be carefully evaluated. Atrial
septal defect closure is contraindicated in patients
with Eisenmenger physiology, a PVR ≥5 WU
(despite targeted PAH treatment), or desaturation on
exercise.[
4] Nonetheless, there is a gray zone where it is
still controversial to close ASD, particularly in patients
whose PVR is in the range of 4-5 WU.
According to the European Society of Cardiology
guidelines for the management of adult congenital
heart disease, patients who have ASD with a significant shunt (signs of right ventricular volume overload),
PVR <5 WU, and Qp/Qs >1.5 should undergo ASD
closure regardless of symptoms.[5] If PVR is ≥5 WU,
fenestrated ASD closure may be considered when
PVR falls below 5 WU after targeted PAH treatment
and a significant shunt is present (Qp:Qs >1.5). The
guidelines also conclude that a decision regarding
lesion correction should be based upon individual
patient evaluation at a tertiary center with expertise in
PH-CHD.[5] In our case, although the first measured
PVR was 4.74, we assessed that it would be risky
to completely close the ASD in this patient after
hemodynamic evaluation.
There are three commonly used classes of
medications that have shown efficacy in PAH
treatment: phosphodiesterase-5 inhibitors,
prostanoids, and endothelin receptor antagonists.
These medications have different pathway targets,
mechanisms of action, indications, delivery routes,
and side-effect profiles.[6] In our patient, we chose
macitentan (as an endothelin receptor antagonist) for
this purpose.
Percutaneous fenestrated ASD closure is
undoubtedly an alternative in these patients. However,
if it is not feasible to implant the device secondary to
a lack of rims (even if it is complete or fenestrated),
a surgical valved pericardial patch could be a good
choice.
There are some papers about unidirectional
valved patch closure of septal defects with good
results.[7,8] With this option, most of the patients
who had high surgical risk secondary to complete
closure of the ASD could be operated. Rosic et al.[7]
reported their surgical technique with a Dacron
patch, which was similar to our technique. It is
well-known that autologous pericardium has a
stronger ability to resist calcification without any
foreign or synthetic material. In our center, we
primarily choose autologous pericardium whenever
possible, and in this case, we used an autologous
pericardium patch instead of a bovine or Dacron
patch.
There are several options available to patients for
ASD surgery. Percutaneous interventions are less
invasive; however, in patients with an insufficient
rim of defect, these techniques cannot be used. Shunt
recurrency, infections, and occluder dislodgment are
other complications of percutaneous techniques.[9]
Therefore, surgeons should continue to prefer safe and feasible surgical procedures while utilizing less
invasive, less traumatic, and most cosmetically
appealing techniques. In our center, we do most of
the ASD closure surgery with the da Vinci robotic
system or minimally invasive techniques. Merits of
robotic surgery are mainly less pain, complication,
and trauma as in all minimally invasive techniques,
with surgeon-friendly instruments’ improved
mobility and visualization capability.[9,10] In this
regard, robot-assisted valved pericardial ASD closure
can be preferred as a cosmetically compelling and
effective method for patients with borderline PAH
after good hemodynamic evaluation and appropriate
medical therapy in a tertiary center.
In conclusion, robot-assisted ASD closure with
a valved pericardial patch is an effective and feasible
method in pulmonary hypertensive patients after a good
hemodynamic evaluation and patient management.
Patient Consent for Publication: A written informed
consent was obtained from the patient.
Data Sharing Statement: The data that support the
findings of this study are available from the corresponding
author upon reasonable request.
Author Contributions: Acquisition, analysis,
and interpretation of data. Drafting and revising the
manuscript: M.K.; Acquisition, analysis, and interpretation
of data. Drafting and revising the manuscript: G.E.;
Drafting and revising the manuscript: E.K.; Acquisition
of the data. Drafting and revising the manuscript: M.E.İ.;
Acquisition, analysis, and interpretation of the data.
Drafting and revising the manuscript: T.D.; Acquisition of
the data: C.B.
Conflict of Interest: The authors declared no conflicts
of interest with respect to the authorship and/or publication
of this article.
Funding: The authors received no financial support for
the research and/or authorship of this article.
){kind=link}