A case study on Minimally Invasive Cardiac Surgery (MICS) for Atrial Septal Defect (ASD) closure

Pushpa^1*, Sripreethi², Hemalatha³, Jaya Menon⁴

¹OT Incharge, Kauvery Hospital, Heart city, Trichy, Tamil Nadu

² Nursing educator , Kauvery Hospital, Heart city, Trichy, Tamil Nadu

³Assistant Nursing Superintendent, Kauvery Hospital, Heart city, Trichy, Tamil Nadu

⁴Nursing Superintendent, , Kauvery Hospital, Heart city, Trichy, Tamil Nadu

*Correspondence

Introduction

An Atrial Septal Defect (ASD) is a congenital heart condition characterized by a hole in the wall (septum) between the heart’s upper chambers. An ASD closure is a medical procedure or surgery designed to seal this opening, thereby preventing long-term complications such as pulmonary hypertension, heart enlargement, and stroke.

Case presentation

30 yrs old female during her infertility treatment diagnosed CAHD-OS advised for ASD Surgical closure. After Pre -Op evaluation done now the patient admitted for MICS ASD Closure. She was diagnosed with Congenital Acyanotic heart disease Ostium Secundum ASD with left to right Shunt.

History of past illness: There is no significant past history

On examination

Patient conscious, oriented

Temperature	98.6 F
PR	90 b/min
RR	18 b/min
CVS	S1S2+
RS	Clear.
P/A	Soft
BP	120/80mmhg
SpO2	98% at RA
Height	174cm
Weight	87.5kg

Previous surgery

Hernioplasty (2022) Laparoscopic Right Inguinal Hernia Mesh Repair done under GA on 11.1.2022

Lab investigations

S.no	Name of the investigation	O-pod	1st pod	2nd pod
1	Hb	10.9	9.5	7.8
2	PCV	28	28.3	23.2
3	Urea	-	20	19
4	Creatinine	-	0.6	0.7
5	Na	137	136	138
6	K	4.9	3.8	3.6
7	Ph	7.33	7.42	-
8	PO2	294	135	-
9	PCo2	33	31	-
10	HCO3	17.4	20.1	-
11	Glucose	258	173	-

Pre OP investigations

Hb	13.3g/dl
Urea	20mg/dl
Creatinine	0.8mg/dl
Blood grouping	O positive
Serology	Negative

ECG

Chest X-ray: Prominnat Pulmonary Artery dilatation

USG Abdomen: No significant changes

Echo report

Impression

Congenital acyanotic heart disease
Ostium secundum ASD with left to right shunt > 2:1
Good LV function
MVP-AML
MILD MR
Moderate TR / severe PAH

Diagnosis: ASD-OstiumSecundum

Operation done

MICS ASD closure using pericardial patch

Procedure

Under DLT + GA, Right anterolateral thoracotomy done. Pericardial stay taken.
Femoral exploration, femoral artery sutured with 8mm graft patient heparinized.
Femoral artery and vein cannulated. CPB instituted. Aorta cross clamped. SVC, IVC snugged. Cold blood del Nido cardioplegia heart arrested in diastole.
RA opened autologous pericardial patch closure of the ASD done. La deaired RA closed in two layers.
Patient rewarmed. Heart started to contract. Aorta cross clamp removed. Patient came off bypass in sinus rhythm protamine followed by sequential decannulation
hemostasis ensured.
RV pacing wire routine sternal closure wound closed in layers.

Procedure image

Post operative period

O-POD

Patient received from HCOT with AMBU bag ventilation then connected with mechanical ventilator.

Mode – SIMV(PRVC+PS)
Fio2 -100%, PEEP- 5cmof H2O, TV-450ml

Patient vitals were stable. She was managed with necessary support.

Adrenaline 5ml/hr
NTG 0.1ml/hr
Milrinone 8ml/hr
Vasopress 2ml/hr

Other Medications

Antibiotic Inj. Supacef 1.5mg IV -TDS administered.
Pan 20mg IV – od
Calcium 1 gm iv/st
Cefactum DS 1.5gm iv/bd
Sodium Bicarbonate 50 mg iv/st

Total ICD drain – 220 ml. Every 4h patient was given back care and ET suctioning

1st POD

Patient vitals are stable. Patient was managed with necessary supports

Adrenaline 5ml/hr
Milreonon 8ml/hr
Vasopress 2ml/hr
Fentanyl 2ml/hr
NTG support stop
Total ICD drain -170 ml
Extubation done.
Nebulization done.

2nd POD

Patient vitals are stable.
Remove Rt. Radial artery/ ICD/ Pacing Wire.
CVC removed.
Chest Physio Given.
Nebulization Given
Patient shift to ward with stable status and no complaints.

Nursing management

Pre-Procedure Management

Assessment and Preparation: Collect baseline blood work (CBC, electrolytes), explain the procedure, and ensure the patient’s consent is obtained.
NPO Status: Advise the patient to maintain a period of nothing by mouth (NPO) before the procedure.
Aseptic Technique: Insert intravenous (IV) lines and prepare the skin using strict aseptic techniques to prevent infection.

Post-Procedure & Long-Term Management

Monitoring: Continuously monitor the patient’s vital signs and hemodynamic status for any signs of complications.

Medication Administration

Beta-blockers: To control heart rate.

Anticoagulants: To reduce the risk of blood clots.

Diuretics: To reduce fluid buildup.

Lifestyle Adjustments

Diet: Advise patients to limit alcohol, sodium, and sugar intake.
Exercise: Encourage regular, moderate exercise (e.g., 30 minutes most days of the week) to increase aerobic capacity.
Activity Level: Gradually return to normal activities, with the possibility of a ~6-week recovery period for surgical recovery.
Symptom Management: Reduce exercise tolerance and treat symptoms that arise from the atrial septal defect.

Nursing Roles and Collaboration

Holistic Care: Provide care that considers both the physical and psychological needs of the patient and their family.
Interprofessional Team: Work closely with physicians and other healthcare professionals to provide comprehensive and high-level care.
Family Education: Educate the family on the condition, treatment, and ongoing care requirements to ensure their active participation.

Post procedure care

Maintain Wound Care: Keep surgical or catheterization sites clean and dry to prevent infection.
Pain Management: Administer prescribed medications for pain and monitor the child’s comfort level.
Activity Restrictions: Enforce activity limitations as advised by the cardiologist; typically, quiet activities like reading, watching TV, and resting are encouraged for several weeks after surgery.
Monitor for Complications: Be vigilant for signs of infection, bleeding, or other issues at the procedure site.

Health Education and Promotion

Educate the Family: Provide clear instructions on the ASD, self-care, medication adherence, and signs of postoperative complications.
Promote Healthy Lifestyle: Advise on healthy dietary habits, limit sodium and sugar intake, and encourage adequate hydration.
Exercise Guidance: Provide guidance on appropriate levels of exercise and activity, emphasizing the need for regular follow-ups with the cardiologist.
Prevent Infection: Educate the family on good dental care and hygiene practices to reduce the risk of infection.

Discharge Medication

Drug	Dose	Frequency	Days
Tab. Aspirin	75mg	OD	Until Review
Tab. Ultracet	-	TDS	5 Days
Tab. Dytor	10mg	OD	Until Review
Cap. Pan D	40mg	OD (Before Food)	Until Review
Cap. Becosules	-	OD	Until Review
Tab. Alprax	0.5mg	OD	Until Review
Tab. Gerbisa	5mg	OD	Until Review
Syp. Mucolite	10ml	TDS	Until Review
Syp. Gelusil	10ml	TDS (Before Food)	Until Review
Tab. Cepodem Xp	325mg	BD	7 Days

Conclusion

Patients with ASD should be educated that elective closure reduces the risk of pulmonary hypertension. The nurse should help ensure the patient has regular follow-up appointments. During follow-up after the procedure, the nurse should monitor the patient for changes in vital signs, new murmurs, or unexplained fever. Open communication between the interprofessional teams is recommended to achieve the best outcomes with minimal complications.

Reference

.Liu Y., Chen S., Zühlke L., Black G.C., Choy M.K., Li N., Keavney B.D. Global birth prevalence of congenital heart defects 1970–2017: Updated systematic review and meta-analysis of 260 studies. Int. J. Epidemiol. 2019; 48:455–463. doi: 10.1093/ije/dyz009.
Moons P., Bovijn L., Budts W., Belmans A., Gewillig M. Temporal trends in survival to adulthood among patients born with congenital heart disease from 1970 to 1992 in Belgium. Circulation. 2010;122:2264–2272. doi: 10.1161/CIRCULATIONAHA.110.946343.
Baumgartner H., De Backer J., Babu-Narayan S.V., Budts W., Chessa M., Diller G.-P., lung B., Kluin J., Lang I.M., Meijboom F., et al. 2020 ESC Guidelines for the management of adult congenital heart disease: The Task Force for the management of adult congenital heart disease of the European Society of Cardiology.
Hoffman J.I., Kaplan S. The incidence of congenital heart disease. J. Am. Coll. Cardiol. 2002; 39:1890–1900. doi: 10.1016/S0735-1097(02)01886-7.

A case study on Minimally Invasive Cardiac Surgery (MICS) for Atrial Septal Defect (ASD) closure

A case study on Minimally Invasive Cardiac Surgery (MICS) for Atrial Septal Defect (ASD) closure

Pushpa1*, Sripreethi2, Hemalatha3, Jaya Menon4

Nightingale Journals

Pushpa^1*, Sripreethi², Hemalatha³, Jaya Menon⁴