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

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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.
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