Gerard M. Guiraudon1, Douglas L. Jones2, Daniel Bainbridge3, John T. Moore4, Christopher Wedlake5, Cristian Linte6, Andrew Wiles7, Terrence M. Peters8.
1CSTAR LHSC LHRI. Robarts Research Institute. Department of Surgery. Schulich Medical school. UWO., London, ON, Canada, 2Department of Physiology and Pharmacology. CSTAR LHSC LHRI. Robarts Research Institute. Schulich Medical School. UWO., London, ON, Canada, 3CSTAR LHSC LHRI. Department of Anesthesiology. Schulich Medical School. UWO., London, ON, Canada, 4Robarts Research Institute. UWO., London, ON, Canada, 5Robarts Research Institute. UWO., London, ON, Canada, 6Robarts Research Institute. Department of Biophysics. Schulich Medical School. UWO., London, ON, Canada, 7Robarts Research Institute. Department of Biophysics. Schulich Medical School. UWO., London, ON, Canada, 8Robarts Research Institute. CSTAR LHSC LHRI.Department of Biophysics. Schulich Medical School. UWO., London, ON, Canada.
OBJECTIVE: Optimal ASD closure should combine off-pump techniques with the effectiveness and versatility of open heart techniques. We report our experience of off pump ASD closure using the Universal Cardiac Introducer® (UCI) in a porcine model. The UCI is comprised of an attachment cuff and a versatile, interchangeable airlock introductory chamber for instruments. The goal was to create an ASD over the fossa ovale, and position a patch over the ASD. Direct vision was substituted by real time ultrasound (US) imaging and multi-image modalities displayed on a single virtual reality (VR) platform.
METHODS: A US probe (tracked with a magnetic tracking system) was positioned into the oesophagus (TEE) for real time image guidance. The right atrium (RA) of 5 pigs was exposed via a right lateral thoracotomy. The UCI was attached to an excluded segment of the RA free wall. A custom made punch tool (15 mm diameter) was introduced via the UCI, navigated and positioned, under US guidance, over the fossa ovale (FO). Then its cutting tip was pushed through the fossa and the membrane excised and removed. A patch with its holder and a stapling device were introduced into the RA via the UCI. The patch was positioned on the ASD. Occlusion of the ASD was determined using US and Doppler imaging.
RESULTS: The FO membrane was excised successfully in all animals. One pig died of acute failure immediately after ASD construction. US image-guidance provided excellent visualization. The patch was positioned in all cases with complete occlusion of the ASD. Doppler imagining allowed for fine positioning of the patch. The standard laparoscopic stapling device proved too bulky and collided with the patch holder, precluding circumferential positioning of its active tip.
CONCLUSIONS: Using the Universal Cardiac Introducer®, ASD closure was safe and feasible in the off pump, beating heart. US imaging, combined with virtual and augmented reality provided accurate navigating and positioning. This study also provided valuable information on the future design of anchoring devices for intra-cardiac procedures. This ASD repair will combine effectiveness, safety and durability with minimal risk and side effects.
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