Reprinted from Tue AMERICAN SURGEON Vol. 20, No. 3, March, 1954 Printed in U.S.A. _ SURGICAL CLOSURE OF ATRIAL SEPTAL DEFECT: THE RESPONSE IN A PATIENT WITH SEVERE PULMONARY HYPERTENSION S. Gitpert Biount, Jz., M.D. Matcotm C. McCorp, M.D. ~ . Henry Swan, , M.D. Denver, Colorado ‘xia septal defect is one of the common clnneisial vinigcraeesils of the heart. The lesion usually occurs in two locations depending upon ‘the nature, at : the embryologic arrest in the formation of the septum. The most frequent: loca- tion is in the area of the foramen ovale, thus a central location; less commonly the defect lies low in the septal wall in close Proximity to the atrioventricular a os ‘valves, Occasionally there are multiple openings; and in addition, frequently are associated anomalies of the pulmonary venous return. ‘When the. septal de-' fect occurs low, immediately above the atrioventricular. valves, the technical .. difficulties of chedire: abs greater than when the defect occurs higher in the sep- tum. Regardless of location the defect gives rise to a. left-to-right shunt’ of blood which results in an elevated pulmonary blood flow. Depending upon the magni- tude of this pulmonary blood flow varying degrees of enlargement: of the right . atrium, right ventricle and pulmonary vasculature result. Correspondingly the | natural history of patients with this defect shows wide variation in symptomatol- ogy and in their life span. It is recognized that many patients with smunbiek defects and lesser magnitudes of pulmonary blood flow may lead relatively normal ‘lives and live to middle age or beyond. Large defects may result in pulmonary flows of such a magnitude — that congestive failure develops early in life. In other instances the development of pulmonary hypertension is the: Sroiting factor as regards. the natural history eine _ of patients with this. defect. The factors leading to the development of pulmonary hypertension are ae ‘clearly understood, but may include the volume of pulmonary flow and, the: ce © velopment of obliterative pulmonary vascular changes. - Therefore, since this lesion is common and frequently results i in disability wd Be premature death it constitutes an important challenge mR the tee to {seit : safe and adequate technics for its closure. ns : SURGICAL BACKGROUND Pile The experimental approach to the solution of the ‘problews of Linas slegare : - of atrial septal defects was s initiated by Cohn? in. 1947. Since that time many From the Departments ‘of Medicine and Surgery, The University ‘of Colorado School ot Medicine, Denver, Colorado. a This study s was -mapporied in part by the United ‘States Public Health tar viee Research rant 1208 ee i) 305 306 BLOUNT, McCORD AND SWAN ingenious but indirect technics have been evolved to accomplish this purpose. These recently have been reviewed by Bailey and associates! and by Swan.® - Experience in this institution with several types of indirect technics for the closure of atrial defects led to the realization that, despite good results in the experimental laboratory, when applied to very large defects found in the clinical patient, indirect methods did not afford complete closure of the defect. Accord-— ; ingly, we have recently turned to the method first. described by Lewis and — Taufic! of direct vision closure with the aid of hypothermia and cardiac inflow occlusion. The technical aspects of this procedure have recently been ews by — Swan and associates.® Briefly, the body temperature of the anpethatited patient is ‘lowbiid to ap- proximately 30 C. in a tub of ice water. The patient is then removed to the operating room with a continued fall in body temperature to the neighborhood of 24 C. An anterior transverse sternum splitting bilateral thoracotomy is then done. At this temperature it is considered safe to totally ocelude circulation for periods up to 10 minutes. The right auricle is then opened arid the septal defect closed under direct vision with interrupted ‘silk sutures. It is of the utmost im- portance that measures be taken to prevent edronary air "embolism at the time of closure of the right atrium. CASE REPORT G.H., a 26 year old white woman had experienced ease of fatigue and exertional dyspnea since easly childhood. A cardiac murmur was first. detected at 5 years of age and bed rest was — instituted for one year. Dyspnea and fatigue progressed until at the age of 15 years the ex- ercise tolerance was limited to three bloeks. At age 20 years a diagnosis of congenital heart disease was:made and the patient was advised to avoid exertion and pregnancy. At age 26 years the patient was unable to walk one block without discomfort, and was forced to sleep. with three pillows because of shortness of breath. - The physical examination revealed enlargement of the heart to the left anterior axillary : line. There. was an over active precordium with a forceful cardiac impulse palpable in the left third and fourth intercostal spaces between the midsternal and midelavicular lines. A systolic thrust followed by a shock was palpable in ‘the left second intercostal space. Auscul- tation revealed a marked increase in the intensity of the second heart sound in the left second interspace with fine redupli¢ation. A grade ILI systolic murmur was present along the left sternal border with maximum, intensity in the left third intercostal space. This murmur was high pitched and rough in quality and was transmitted toward the apex. The blood pressure in the arm was 105/751 mm, Hg. The-lungs were clear and the liver was not enlarged. There was no “eee or clubbing, and. the femoral arterial pulsatiens were normal. The electrocardiogram (Gg. 1) demonstrated 1 anrs sR! hte in precordial position ‘V-1. The R’ wave was 18 mm. in‘amplitude and showed « delayed intrinsicoid deflection time of » .05 seconds. The total QRS duration was..10 seconds. There were prominent upright P waves in the right sided precordial leads, The tracing was interpreted as indicating right ventricu- lar hypertrophy. with incoaapeee right bundle branch block: ond probable right atrial en- largement. The fluoroscopic examination showed a considerable increase in the vascularity of the- lung fields. The main pulmonary artery and the left and right pulmonary arteries were greatly increased in size and showed significant increase in the amplitude of pulsations. The right atrium was greatly enlarged. The ventricular area was considerably enlarged with the configuration suggesting right ventricular enlargement (fig. 2). SURGICAL CLOSURE OF ATRIAL SEPTIC DEFECT 307 rae ora Fig. 1. The electrocardiogram demonstrates a pattern of right ventricular hypertrophy with incomplete right bundle branch block, and right atrial enlargement. Cardiac catheterization was done via a left basilic vein on March-5, 1953. The catheter pursued an abnormal course indicating the presence of a persistent left superior vena cava entering the right atrium through the coronary sinus. The catheter wag advanced into the “right ventricle and into the left atrium and left ventricle. Blood samples indicated no 8.9 liters/min./M?. There was a marked elevation of the pulmonary arterial pressure to average levels of 100/30 mm. Hg (table I). On April 15 a thoracotomy was done using a transternal approach under hypothermia at 308 BLOUNT, McCORD AND SWAN Fic, 2. The preoperative shah roentgenogram is shown on the left and four months operative on the right, Decrease in heart. size ot GeePoaaeS, ‘vascularity of the hung fie ds is i apparent. 21.5 C. Marked enlargement of the hina artery and viet atrium was apparent. on ex- a posure of the heart. The vena cavae were occluded, the lateral wall of the right atrium was Mica clamped and an incision wag made. The right’ atrium was openéd, and a 2.5 by 4:0 cm, atrial defeet: was closed and circulation re-established after occlusion of the circulation for 7.5 . Iinutes. Following closure of the chest wall and warming to. normal body ere shock presented. which responded to blood transfusion and pressor agents. Postoperatively a rapidly’ changing succession of supraventricular cardiac rhythms oc- curred. The postoperative course was further complicated by a transient partial aphasia which disappeared within 48 hours. The patient was Saas on ey 18, 1953... ot TABLE 1° nat ; Preoperative. Physiologic studies © : z ae = Catheter Position Sama S ee Content : Oxygen Saturation | /liter : ‘Per.cent Superior vena cava.............. ake oo Ae a5 104.0 54.9 Inferior vena cava. :......... Cee eed the past by several authors.': ?_ Once the diagnosis has been established the problem of the selection of suitable candidates for surgical correction arises. The : great variability in the natural history of patients with thi defect is well known. "Thus, at this stage in the development of the operative procedure it would be of great help could one predict those patients who will enjoy relative longevity as compared to those who will develop complications leading to serious disability — early in their lives. However, a review of the studies of our patients with atrial % 310 BLOUNT, McCORD AND: SWAN septal defects: reveals that such a prediction is difficult, if not impossible to ac- complish, ; Early in the history of any operative technic it is common to wait until the " patient is actually a very poor risk for the operative procedure before advising surgical intervention. The indications for operation are changed as experience —. patient, The criterion for operation. will thus be similar to that in patients with ( a patent ductus arteriosus, namely the diagnosis of the anomaly. = Seo ue. “f . CONCLUSIONS pt oi : Lass = The clinical course, the operative technic, and physiologic studies of a 26 year old woman with an atrial septal defect are presented. ree S ‘The postoperative course, the physical and fluoroscopic findings and the e physiologic data all indicate complete closure of the defect.” 2 “he _. This patient demonstrates that severe pulmonary artery hypertension does _ not constitute a contraindication to closure of an atrial septal defect: provided an. increased pulmonary blood flow. is present. OS es RPL ; REFERENCES 1. Bailey, C. P., and: others: Congenital interatrial communications: clinical and surgical considerations with deseription of new surgical technic : atrio-septo-pexy, Ann. Int. Med: 87: 888 (Nov.) 195: : : aera oS ; ; 2. Barber, J. M., Magidson; O., and Wood, P.: Atrial septal defect with special reference to electrocardiogram, pulmonary artery pressure and second heart sound, Brit. Heart J. de: 207 uly) 1950, See % n Am. Heart’ J, 33: 453: (April) 1947 4. Lewis, F. J., and Taufic, M.: Closure of atrial septal defects with aid of hypothermia; experimental accomplishments and report of one successful case, Surgery 33: 52 (Jan.) 1 ; , be Swan, H.: Surgical closure of interauricular septal defects, J -A.M.A. 161 2 792 (March 7) 6. Swan, H., Zeavin, I, Blount, §. G., Jr., and Virtue, R. W.: Visual surgery in open heart during hypothermia, J.A.M.A., to. be ‘published. te Experimental method for closure of interauricular septal defects in dogs, ee