Pitfalls in the Surgical Closure of Atrial Septal Defect

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SURGICAL closure of atrial septal defects was attempted first by external technics wherein the redundant wall of the right atrium was imbricated against the septal rim of the defect.1–4 The surgeon relied upon his index finger for orientation—that, and a preconceived mental picture of how a characteristic atrial defect should lie in relation to other structures. The imbrication technics reached their ultimate with the ingenious Sondergaard5 approach wherein the dissection was carried on within the plane of the septum itself. In effect, this technic resulted in a purse-string closure of the centrally located ostium secundum defect.

The limitations of the imbrication methods for closing septal defects at the atrial level soon became apparent. Atrial defects even in their simplest form are not standard in size and location. There is considerable variation in related anatomic features, and the need for a direct open approach was soon realized. The well technic of Gross4 was the first practical breakthrough in this direction.6 With this technic a surgeon could not see within the depths of the operative field, but his range of “digital visualization” and his surgical maneuverability were greatly increased (Fig. 1).

There is no doubt that by application of these earlier methods many patients were treated effectively and were relieved of their interatrial shunts. Unfortunately, some patients were not improved and others were made worse, as the surgeon could not cope with complex underlying problems that were beyond limitations imposed by these technics. In the light of present-day knowledge, the . . .



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