March

Minimally Invasive Surgery vs Device Closure for Atrial Septal Defects: A Systematic Review and Meta-analysis

Minimally Invasive Surgery vs Device Closure for Atrial Septal Defects: A Systematic Review and Meta-analysis   Mylonas KS, Ziogas IA, Evangeliou A, Hemmati P, Schizas D, Sfyridis PG, Economopoulos KP, Bakoyiannis C, Kapelouzou A, Tzifa A, Avgerinos DV. Pediatr Cardiol. 2020 Mar 11. doi: 10.1007/s00246-020-02341-y. [Epub ahead of print] Review. PMID: 32162027 Similar articles Select item 32162026   Take Home Points: Device closure of secundum ASDs has become the first-line treatment, but surgical closure of ASDs, often via minimally invasive techniques, is still often performed This study performed a meta-analysis of reports comparing ASD device closure vs. closure via minimally invasive surgical techniques and revealed that the two techniques compare favorably.     Commentary from Dr. Timothy Pirolli (Dallas), section editor of Congenital Heart Surgery Journal Watch: Closure of secundum atrial septal defects is often performed in the cardiac catheterization lab using a variety of devices. Surgical closure is often reserved for large defects, defects for insufficient rims, patients with small left atriums and non-secundum ASDs or need for concomitant procedures. Some surgeons have transitioned to closing ASDs via minimally invasive techniques (various versions of right thoracotomy approaches or partial sternotomies). The authors of this study sought to examine existing published studies that compare repair of ASDs via these two approaches (percutaneous vs. minimally invasive cardiac surgery) through a systematic review and meta-analysis.   The authors selected two independent reviewers from their group to scour PubMed and the Cochrane databases to select articles that focused on comparing percutaneous and minimally invasive surgical repair of ASDs. The inclusion criteria involved randomized control trials, non-randomized prospective studies and retrospective clinical studies and excluded meta-analyses, reviews, editorials and studies involving conventional full sternotomy for surgical repair. Out of a total of 780 potentially relevant articles, only 20 reports were deemed sufficient to be evaluated for inclusion in this meta-analysis. From this cohort, only six studies (all retrospective) were found to meet all criteria and be of sufficient quality for inclusion in this review (Table 1).   From those six studies, a total of 1577 patients were included. Data was extracted from the studies for meta-analysis, the statistical analysis of which is explained in detail in the report. The patient demographics are depicted in Table 2 below. It is notable that the median age of the majority of cohorts in this study is in the late 30’s, suggesting few children were included in this meta-analysis. The majority of types of MICS performed involved right anterior mini-thoracotomies. Only one study involved partial sternotomies. Figure 1 depicts forest plots comparing MCIS repair vs. device closure for treatment efficacy, overall complications and length of hospital stay. The overall trend was that patients who underwent device closure had less complications and shorter hospital stays, but the success rate of closure with surgery was higher. Of note, not all studies included in report could be utilized in each segment of data analysis due to insufficient or incomplete data. Figure 2 compares the two techniques for femoral complications and pericardial effusions, both analyses of which favor device closure. Figure 3 compares the two techniques for post-operative headaches and residual shunts, both analyses of which favor surgical closure. There were no differences between the two techniques in terms of pulmonary complications, new-onset atrial fibrillation, wound infection, major bleeding, transfusion requirements, cardiac tamponade, pacemaker placement and re-operation rates. There were no fatalities reported in any of the studies.   The authors discuss the risks and benefits of each technique and also the controversy of what, in fact, defines a “successful closure” of an ASD. They opted to define the term as complete closure of the ASD with no residual shunt. There were no glaring new revelations from this analysis. MCIS techniques are shown to have a more consistently complete repair, but at the expense of longer hospital stay at the expense of a larger scar and bypass run. Their meta-analysis between the two modalities is reassuring though that many of the potential complications (listed above) were not found to be more prevalent in the MCIS cohorts. Device embolization, a possibly devastating complication of percutaneous closure, was only reported in one patient in all the studies.   It is fair to say that the authors did their best to compare these two techniques through an exhaustive literature review and detailed data extraction, but there are many notable limitations to this report. All were included studies were non-randomized retrospective analyses and not all studies reported the outcomes that the authors sought to evaluate. There was no analysis of ASD morphology and there was very little data to be extracted on the pediatric population. The authors’ final conclusion that MICS closure for ASDs is a safe and reproducible procedure and compares favorably to percutaneous closure is valid. It is also fascinating that none of the studies included in this meta-analysis were from the United States. As always, a randomized controlled trial would be ideal, but that does not exist and likely never will. Also, any pediatric practitioner who reads this report and extrapolates to meaning the pediatric population should be cautious since the majority of patients included in this meta-analysis are full-grown adults in whom MCIS closure (especially through right thoracotomy) of ASDs is more feasible due to patient size.   Tables and Figures        

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Grown-up Congenital Heart Surgery in 1093 Consecutive Cases: A “Hidden” Burden of Early Outcome

Grown-up Congenital Heart Surgery in 1093 Consecutive Cases: A "Hidden" Burden of Early Outcome Haapanen H, Tsang V, Kempny A, Neijenhuis R, Kennedy F, Cullen S, Walker F, Kostolny M, Hsia TY, Van Doorn C. Ann Thorac Surg. 2020 Mar 5. pii: S0003-4975(20)30338-6. doi: 10.1016/j.athoracsur.2020.01.071. PMID: 32147413 Similar articles Select item 32131918   Take-Home Points: This retrospective study from Great Ormond Street Hospital retrospectively analyzes over 1,000 ACHD surgeries and possible risk factors for adverse outcomes over a 17-year period. The 30-day mortality outcome was overall low but increased by 6 months following CHD surgical procedures. The increasing complexity of CHD patients may be associated with longer ICU lengths of stay. Further consideration for updating standard outcomes metrics may be needed to accurately account for the extended window of postoperative risk beyond 30 days.     Commentary from Dr. Jeremy Herrmann (Indianapolis), section editor of Congenital Heart Surgery Journal Watch: Recognizing that surgical outcomes for adult congenital heart disease (ACHD) have progressively improved over the past two decades, the authors questioned whether the metric of 30-day postoperative mortality remains valid. Specifically, they aimed to determine whether prolonged ICU stay (>7 days) and 6-month mortality are more appropriate for assessing postoperative risk. The authors retrospectively reviewed over 1,000 consecutive ACHD surgeries performed over a 17-year period at Great Ormond Street Hospital in London. Surgical procedures spanned the full ACHD spectrum with the top three procedures being pulmonary procedure, aortic procedure, and ASD repair. Over half (55%) were reoperations and over one-third (36.8%) included concomitant procedures.   Overall, the mortality at 30 days was very low at 1.5% but increased to 2.4% at the 6-month mark. Forward stepwise regression analyses revealed several parameters associated with prolonged ICU stay (>7 days) OR 6-month mortality: sex, NHYA class III or greater, EF 50% or less, renal failure, multiple sternotomies, CHD complexity, urgent operation, preoperative ventilator support, CPB time, DHCA use, and concomitant procedures. Of these, higher NHYA class, complex CHD, preoperative ventilator support, CPB time, and concomitant procedures were significant associated with prolonged ICU stay (>7 days) OR 6-month mortality using multivariate logistic regression. Repeat sternotomy was not a risk factor, though the authors highlight discrepant information in the literature. The distribution of CHD complexity was similar across 4 eras of the study period, though the 6-month mortality decreased from 5.0% in the first era to 1.4% in the two most recent eras. The frequency of prolonged ICU stay increased during the study period possibly due to a greater degree of CHD complexity in the latter eras.   The authors conclude that 30-day mortality may be too short to fully account for the postoperative morbidity and mortality. This could also result from sicker patients receiving ICU-level care and surviving beyond 30 days but not for 6 months. This could be an important consideration for patient care given that patients will typically be home during most of the immediate 6-month postoperative window. This may also be an important consideration for outcomes data gathering and reporting. Regardless, it is gratifying to know that as a field, we have been able to elevate the standard of care for these potentially complex patients such that mere 30-day survival is an insufficient estimation of outcomes.    

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