ASD (Atrial Septal Defect) Surgery

Listed below is the step by step procedure of atrial septal defect surgery:

1. What is ASD Surgery?
2. Why is ASD Surgery Required?
3. Pre-operative Preparations
4. Day Before Surgery
5. Procedure Day
6. Methods/Techniques of ASD Surgery
7. Post Procedure
8. Risks and Complications

What is ASD Surgery?

Operative methods employed by surgeons to treat a hole in the upper part of human heart are included in ASD surgery. ASD is the abbreviated form of Atrial Septal Defect. The heart is divided into four chambers. Each chamber is surrounded by a muscular wall. The upper two chambers of the heart are known as atrium. Between the right and left atria is a muscular wall. Sometimes continuity of this wall is disrupted by the presence of a perforation (hole). ASD Surgery is performed in such cases to seal the perforation by patching up or blocking it.

Why is ASD Surgery Required?

Function of the human heart is to receive deoxygenated blood from all over the body, purify it and pump oxygen rich blood back to all the organs. Deoxygenated blood from all over the body enters the right atrium from two large veins. The left atrium always received oxygenated blood from the lungs. A perforation in the wall separating the two atria will lead to mixture of oxygenated and deoxygenated blood. This could lead to serious health complications. Treatment is needed to repair this perforation.

A few indications are given below which suggest that surgery is needed to treat ASD.

• Medical Investigations: ASD is often asymptomatic and hence goes undiagnosed. Routine investigations like 2D Echocardiogram can often reveal presence of a septal defect. It is advisable to undergo surgery soon after the condition is detected. If left untreated, it could complicate and cause health problems.
• Symptoms: Atrial septal defect causes entry of blood from left atrium into the right atrium. This is because pressure is higher in the left atrium as compared to the right one. This leads to symptoms like elevated blood pressure in the pulmonary artery, breathlessness, palpitations, swelling of the body.
• Acquired Atrial Septal Defect: ASD is more commonly a defect present since birth. Rarely does it happen that is develops in adulthood. Though sometimes, it could occur later in life, if the wall between right and left atria is damaged due to some prevalent heart condition. Endocarditis is one such condition. In such cases, the defect can be operated upon to prevent development of symptoms.
• Pediatric cases: Most of the cases of ASD occur as a developmental disorder. They may be detected but may not require treatment if they are not a serious danger to the patient. However, as they grow, children with ASD may develop symptoms like breathing difficulties, poor appetite, inability to concentrate, fatigue. If there is increase in such symptoms, it is advisable to treat the condition with surgery to prevent further complications.
• Right Heart Overload: Pressure in the left atrium is always higher than the right atrium. Hence, in ASD, blood from left atrium always flows on the right side. Right atrium will thus end up having more than its capacity of blood. In turn, excess of blood will get pushed into the left ventricle and into the lungs via pulmonary artery. This adds to a lot of pressure on the right side of heart. It could cause right heart failure if left untreated.

Pre-operative Preparation

Factors which indicate that surgery is necessary for ASD have been mentioned in the previous section. However, there may be other indications too which could necessitate ASD surgery. Once the decision for proceeding with surgery has been taken, certain pre-operative procedures are advisable to be undertaken to clear any obstacles in the course of surgery. These have been mentioned below:

• Consent of Patient:

  Though the surgeon feels that operating on the atrial effect is essential, surgery cannot be started till the patient gives their consent. The entire procedure along with its pros and cons is explained to the patient and their close family. A signed consent form is taken from the patient before proceeding with the operation.

• Investigations:

  There are some pre-operative tests which the patient has to undergo prior to ASD surgery. Blood tests are done to determine if the white blood cell count is high. High white cell count indicates presence of infection. ASD surgery cannot be performed till the infection is controlled. High blood sugar levels are also a contraindication (sign to withhold) for surgery of atrial defect. In case the patient has high blood glucose levels, they are controlled first and then surgery is performed. ECG is done to assess the functioning of heart. Chest X-Ray will reveal the structure and size of heart.

  Blood tests are also done to determine the patient's blood group. Blood belonging to the same group and type as the patient's is arranged as a precaution against excessive blood loss during surgery. A 2D Echocardiogram could be done to check for the defect just prior to surgery.

• Pre-operative medication:

  Patients are given antacids before surgery. This is done to avoid regurgitation (back flow) of acidic contents from the stomach during surgery. They could enter the trachea and lungs and cause respiratory complications. Anti-biotics could be given in advance to prevent infections. It is common to develop infection internally or at the site of surgery. If the patient is on any blood thinning medications, the surgeon should be made aware about it. Their dosage may be changed for sometime before and after surgery. The surgeon should be aware about any other medication which patient might be on.

These pre-operative steps are usually advised to all patients undergoing ASD surgery. Depending on each case, the surgeon may suggest a few more things as well. It is essential for the patient to follow the surgeon's advise, as it is in the patient's best interest. Pre-operative procedures may begin a few days before the surgery as the surgeon sees fit. After they have been completed, there is assurance to the patient as well as surgeon that there are no obstacles in proceeding with the surgery.

Day Before Surgery

The day before surgery is always very important. Preparing the patient for surgery begins from this day.

• Admission to Hospital

  One night prior to surgery, patient is advised to get admitted into the hospital. This is done so that the patient gets used to the hospital environment where they are expected to stay for some days after ASD surgery. Arriving at the hospital on the day of surgery can prove quite tedious for the patient. This is another reason why it is advised to get admitted a day before the surgery.

• Physical Examination

  Before the surgery, a complete physical examination is done for the patient. Blood pressure, respiratory rate, pulse and body temperature (vitals) are monitored at regular intervals. For patients with atrial septal defect, a distinct 'murmur' can be heard. Heart sounds can be heard when the stethoscope is placed correctly on the chest. A murmur is an abnormal heart sound and indicates ASD.

• Fasting Before Surgery

  ASD surgery is performed under general anesthesia. The patient is completely unconscious during surgery. There is possibility that if the stomach is full, the contents may come out in the reverse direction. They may then enter the lungs and this can cause respiratory complications. Hence, it is advised to the patient not to consume any food from one night prior to the surgery. To keep the digestive tract clear, patients are given laxatives.

  The patient is advised to get adequate rest before the surgery. Physical exertion is not allowed. The patient is advised to relax mentally also and to avoid undue stress.

The patient is advised to get adequate rest before the surgery. Physical exertion is not allowed. The patient is advised to relax mentally also and to avoid undue stress.

Procedure Day

On the day of surgery, the patient is transferred to the operation theater. The room is made sterile before hand to rid it of all microorganisms. The patient is dressed in sterile surgical clothing. An anesthetist will monitor the patient's vitals and start administering the anesthetic medicine. This will be in the form of an injection given into the vein or respiratory fumes which are inhaled through nose.

Surgical incision is given on chest for ASD surgery. The skin over chest is cleaned and all hair is shaved from it. It is then washed with anti-septic solution. Betadine is the solution of choice in most cases, though other anti-septics can also be used. Once the anesthetist confirms that the patient is completely unconscious, surgery begins. Throughout the surgery, the patient's blood pressure, pulse, respiration and body temperature are monitored.

Methods/Techniques of ASD Surgery

• Repair with Sternotomy

  This is a open procedure in which the chest cavity is completely exposed. A single vertical incision is given at the center of the chest. The underlying muscles are cut. The sternum (breast bone) is divided and the rib cage is opened. A heart-lung machine is then connected to the patient which will perform the function of pumping oxygen rich blood to all the other organs. Heart temporarily ceases to move. This is done as it is difficult to operate on a beating heart.

  The right atrium is used to approach the defect. It is sutured using surgical thread, to maintain the continuity of the interatrial valve. If the defect is large, suturing might distort its shape. In such cases, tissue is taken from the patient themselves to be used as a patch to repair the defect. This patch is usually a part of the peri-cardial sac which is a protective covering of the heart.

  After the atrial defect is repaired, any air remaining in the heart chambers is removed and the patient is taken off heart-lung machine. The heart begins its function immediately. Tubes are placed inside the chest cavity to prevent accumulation of fluid in or around the heart. The sternum is replaced and the skin incision is closed.

• Minimally Invasive Procedure

  As the name suggests, these procedures involve minimum amount of surgical cuts and exposure of internal organs. Multiple small incisions are given on the skin over the chest. The sternum may or may not be removed. If it is removed, the removal is not complete. The further procedures are the same as described above for repairing the atrial defect.

• Percutaneous Transcatheter Closure

  This is a relatively new procedure and involves comparatively minimal invasion. A catheter is inserted inside the patient's body through the groin. It passes through a vein in the pelvic region known as femoral vein. The vein ultimately meets the heart. The catheter travels inside the vein up to the right atrium of the heart. Here a device which was attached to the catheter opens up and patches the perforation in the wall dividing the two atria. Use of heart lung machine is needed for this surgery.

The surgeon will choose a method out of the ones described above, depending on the patient's illness history, age and general health.

Post Procedure

Once the surgery is over, the patient will be transferred out of the operation theater. Successful completion of surgery does not mean end of treatment. After the surgery, the patient as well as the doctor must work together as a team towards achieving complete recovery. Some post operative care instructions are mentioned below:

• Immediately After Surgery

  The patient is transferred out of the operating room into ICU soon after surgery is over. It takes a while for patient to regain consciousness. An intravenous line inserted into a vein of the arm maintains the patient's nutritional status to normal. Chest tubes which are placed during surgery are retained for some time after surgery is over. After the patient regains consciousness, the surgeon performs a complete physical examination and checks if the surgical incision is healthy.

• Post-operative Medication

  Pain and infection at the site of surgical incision are commonly experienced after ASD surgery. Post operative pain killers and antibiotics are therefore included in post-operative care most of the times.

• Discharge from Hospital

  After remaining in ICU for a day or two, the patient is shifted into a normal recovery room. Discharge from hospital is usually 5-7 days after surgery. This duration may vary depending on the patient's response to treatment. After discharge too, the patient has to continue with home care for sometime. Complete recovery after ASD surgery will take about 4-6 weeks.

• Pediatric Care

  If the patient is a young child or a baby, special care has to be taken. They should be kept away from any kind of infection. Children should be disallowed from playing, running or jumping around. Physical exertion may disrupt the continuity of the interatrial wall again. If the patient is a new born child, then the pediatrician and the surgeon, both must be consulted for instructions regarding breast feeding after surgery.

• Adult Care

  Adult patients should take care to avoid lifting heavy weights or doing a lot of physical exertion. This can put extra pressure on the recuperating heart.

• Wound Care

  The surgical incision should be cared for well. It should be cleaned daily and the surgical dressing should be replaced. The patient may do it on their own or a nurse or doctor can help out with it.

• Cardiac Rehabilitation

  The surgeon may advise the patient to undergo cardiac rehabilitation. Exercises, relaxation techniques and diet to develop a healthier heart are included in this program.

• Light Physical Activity

  Exercising too much and not doing any physical activity at all, both are equally harmful after ASD surgery. Light physical activity like walking, gentle stretching exercises should be done following surgery but only after consulting with the surgeon. This prevents accumulation of fluids and swelling on the body which can happen after surgery.

Despite following all instructions for post operative care, there is possibility of some complications occurring in some cases. These however can be treated separately. If they are cared for well, they do not prove to be fatal.

Risks and Complications

• Infections:

  The surgical incision may get infected if not cared for properly. There could be swelling pain and even bleeding at the site of the cut. Antibiotics, use of antiseptic solution to clean the wound and pain killers help to curb this condition.

• Swelling:

  There could be swelling of the ankles, wrist, face or of the entire body due to accumulation of fluids. This can be treated with appropriate medicines, exercise and diet. The patients are advised to contact their doctor in case this happens.

• Risks of Surgery:

  During surgery, there could be bleeding due to accidental cutting of a blood vessel. Blood accumulation could occur in or around the heart. This needs to be drained to avoid complications. Severe blood loss will need to be treated with blood transfusion to the patient. There could be accidental damage to surrounding healthy organs like lungs, or some other part of the heart during surgery. This damage preferably will be repaired during the surgery itself. The patient may develop an allergic reaction to the anesthetic medicine used. There could be elevation of blood pressure due to the reaction. In such cases, the anesthetic medicine is changed or used in optimum quantity only. Reactions to the anesthetic agent are treated with appropriate medicines.

• Blood Clots:

  During surgery, there could be formation of blood clots. These clots could restrict the blood flowing through heart. They might even travel through blood vessels and block the arteries. This could reduce the blood supply to a particular organ and may damage it. Clots can be treated by blood thinning medications. Almost every patient undergoing ASD surgery is given blood thinners. However, close monitoring is then required. If the dosage of blood thinner is exceeded, there could be bleeding which will cause further complications.

The article gives patient a good understanding about ASD surgery with its risks and advantages. However, it is to be noted that not each case of ASD is the same. Hence, there may be variation for the procedures before, during and after surgery for every case. But the end result and aim of every surgery is the same, which is to provide complete relief to patient.