DOI: https://doi.org/10.14710/jai.v0i0.70958

Anesthesia for ASD Closure in Robotic-Assisted Cardiac Surgery: A Case Report

1Harapan Kita National Cardiovascular Center, Jakarta, Indonesia

2Department of Cardiovascular Surgical Anesthesia, Harapan Kita National Cardiovascular Center, Jakarta, Indonesia

Received: 2 Sep 2025; Revised: 4 Nov 2025; Accepted: 11 Nov 2025; Available online: 9 Jan 2026.
Open Access Copyright 2026 JAI (Jurnal Anestesiologi Indonesia)
Creative Commons License This work is licensed under a Creative Commons Attribution 4.0 International License.

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Abstract

Background: Minimally invasive cardiac surgery (MICS) utilizes small chest incisions without sternotomy, offering faster recovery, reduced physiological stress, shorter hospitalization, and better cosmetic results. Robotic-assisted surgery is a modern approach within MICS that provides enhanced precision. However, literature on anesthesia management in robotic-assisted atrial septal defect (ASD) closure remains limited. This case report aims to provide clinical insights and support the safe adoption of such techniques.

Case: A 51-year-old male with an ASD secundum and a left-to-right (L-R) shunt measuring 22x29 mm, without comorbidities, was scheduled for general anesthesia. The patient was classified as American Society of Anesthesiologists (ASA) physical status III. Monitors applied included electrocardiogram (ECG), nasopharyngeal thermometer, arterial line, central venous pressure (CVP), EtCO₂, near-infrared spectroscopy (NIRS), and transesophageal echocardiography (TEE). The patient was placed in a supine position and intubated with a 37 Fr left-sided double-lumen endotracheal tube (DLT) at a depth of 31 cm, followed by one-lung ventilation. General anesthesia was induced using midazolam 5 mg, sufentanil 10 mcg, propofol 50 mg, and rocuronium 50 mg, maintained with 1% sevoflurane and rocuronium at 10 mg/hour. A regional block was performed using a deep serratus anterior plane block (DSAPB) with a regimen of 10 ml of 0.5% isobaric bupivacaine (50 mg), 5 ml of 10% lignocaine (500 mg), and epinephrine 1:200,000, with a total volume of 40 ml. The surgery was performed on a beating heart with right femoral artery, right femoral vein, and right jugular vein cannulation. The procedure lasted 12 hours.

Discussion: Robotic-assisted cardiac surgery enhances surgical accuracy but presents unique anesthetic challenges due to patient positioning, limited access, and cardiopulmonary dynamics. Anesthesiologists must optimize monitoring and maintain close team coordination.

Conclusion: Robot-assisted MICS represents a significant advancement in MICS. However, anesthesiologists must pay close attention to preoperative, intraoperative, and postoperative assessments to ensure patient safety and optimal outcomes.

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Keywords: atrial septal defect; cardiac robotic surgery; deep serratus anterior plane block; minimal invasive robotic cardiac surgery; one lung ventilation

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Section: Case Reports
Language : EN
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  1. Bernstein W, Walker A. Anesthetic issues for robotic cardiac surgery. Ann Card Anaesth. 2015 Jan 1;18(1):58–68
  2. Parnell A, Prince M. Anaesthesia for minimally invasive cardiac surgery. Vol. 18, BJA Education. Elsevier Ltd; 2018. p. 323–30
  3. Erol G, Kubat E, Sicim H, Kadan M, Bolcal C. An unexpected complication of robotic cardiac surgery: Pneumomediastinum. J Saudi Heart Assoc. 2019 Apr 1;31(2):106–8
  4. Ramchandani M, Al Jabbari O, Abu Saleh WK, Ramlawi B. Cannulation Strategies and Pitfalls in Minimally Invasive Cardiac Surgery. Methodist Debakey Cardiovasc J [Internet]. 2016 Jan 1;12(1):10. Available from: https://journal.houstonmethodist.org/article/10.14797/mdcj-12-1-10/
  5. Choi YS, Kwak YL, Jeon DH, Hong YW, Park HK. Anesthesia for Robotic Repair of the Atrial Septal Defect - A case report -. Korean J Anesthesiol [Internet]. 2007;52(3):371. Available from: http://ekja.org/journal/view.php?doi=10.4097/kjae.2007.52.3.371
  6. Fernandes RM, Pontes JPJ, Rezende Borges CE, de Brito Neto DR, Pereira A de J, Carvalho VP, et al. Multimodal Analgesia Strategies for Cardiac Surgery: A Literature Review. Hearts. 2024 Aug 21;5(3):349–64
  7. Xiao C, Chen F, Cao L, Yang M, Tan Y, Lin G, et al. Effects of ultrasound-guided serratus plane block combined with general anesthesia on postoperative early quality of recovery and analgesia in patients undergoing transapical transcatheter aortic valve implantation surgery: study protocol for a randomized controlled trial. Trials. 2024 Dec 1;25(1)
  8. Ashok V, Francis J. A practical approach to adult one-lung ventilation. Vol. 18, BJA Education. Elsevier Ltd; 2018. p. 69–74
  9. Sandoval E, Muro A, Navarro R, García-Álvarez A, Castellà M, Pereda D. Implementation and clinical impact of a robotic heart surgery program. Revista Española de Cardiología (English Edition). 2023 Sep 1;76(9):739–41
  10. Kone J. Anesthetic Management of an Atrial Septal Defect in Adult-Case Report. J Anesth Crit Care. 2015 Dec 14;3(5)
  11. Madaan V, Gupta R. Anaesthetic management of a case of large ASD with severe pulmonary hypertension—case presentation. Ain-Shams Journal of Anesthesiology. 2022 Dec;14(1)
  12. Hardman G, Zacharias J. Minimal-Access Atrial Septal Defect (ASD) Closure. Vol. 10, Journal of Cardiovascular Development and Disease. MDPI; 2023
  13. Wu W, Ding R, Chen J, Yuan Y, Song Y, Yan M, et al. Effect of body mass index on clinical outcomes after robotic cardiac surgery: is there an obesity paradox? BMC Cardiovasc Disord. 2023 May 23;23(1):271
  14. Argenziano M, Oz MC, Kohmoto T, Morgan J, Dimitui J, Mongero L, et al. Totally Endoscopic Atrial Septal Defect Repair With Robotic Assistance. Circulation. 2003 Sep 9;108(10_suppl_1)
  15. Rubino TE, Jackson A, Winter M, Punu K, Ashraf SF, Dufendach K, et al. Small cuts, big questions: the impact of incision length in minimally invasive robotic cardiac surgery. Front Cardiovasc Med. 2025 Jun 26;12
  16. Trejos AL, Patel R V., Ross I, Kiaii B. Optimizing port placement for robot‐assisted minimally invasive cardiac surgery. The International Journal of Medical Robotics and Computer Assisted Surgery. 2007 Dec 14;3(4):355–64
  17. Chauhan S, Sukesan S. Anesthesia for robotic cardiac surgery: an amalgam of technology and skill. Ann Card Anaesth. 2010;13(2):169–75
  18. Hendriks KDW, Castela Forte JN, Kok WF, Mungroop HE, Bouma HR, Scheeren TWL, et al. Mild hypothermia during cardiopulmonary bypass assisted CABG is associated with improved short- and long-term survival, a 18-year cohort study. PLoS One. 2022 Aug 25;17(8):e0273370
  19. Xiao C, Gao C. Peripheral Cardiopulmonary Bypass Establishment for Robotic Cardiac Surgery. In: Robotic Cardiac Surgery. Dordrecht: Springer Netherlands; 2014. p. 49–60
  20. Ramchandani M, Al Jabbari O, Abu Saleh WK, Ramlawi B. Cannulation Strategies and Pitfalls in Minimally Invasive Cardiac Surgery. Methodist Debakey Cardiovasc J. 2016 Jan 1;12(1):10
  21. Bernstein W, Walker A. Anesthetic issues for robotic cardiac surgery. Ann Card Anaesth. 2015;18(1):58
  22. Fitzgerald MM, Bhatt H V., Schuessler ME, Guy TS, Ivascu NS, Evans AS, et al. Robotic Cardiac Surgery Part I: Anesthetic Considerations in Totally Endoscopic Robotic Cardiac Surgery (TERCS). J Cardiothorac Vasc Anesth. 2020 Jan;34(1):267–77
  23. Inoue K, Hiraoka A, Chikazawa G, Totsugawa T, Nakajima K, Masuda M, et al. Preventive Strategy for Reexpansion Pulmonary Edema After Minimally Invasive Cardiac Surgery. Ann Thorac Surg. 2020 May;109(5):e375–7
  24. Yu S, Valencia MB, Roques V, Aljure OD. Regional analgesia for minimally invasive cardiac surgery. J Card Surg. 2019 Nov 23;34(11):1289–96
  25. Jayadeep I, Srinivasan G, Sethuramachandran A, Elakkumanan LB, Swaminathan S, Bidkar P. Comparison of the Analgesic Efficacy of Ultrasound-Guided Superficial Serratus Anterior Plane Block With Deep Serratus Anterior Plane Block in Patients Undergoing Modified Radical Mastectomy: A Randomized Clinical Trial. Cureus. 2022 Oct 29
  26. Weksler B, Sullivan JL, Schumacher LY. Randomized trial of bupivacaine with epinephrine versus bupivacaine liposome suspension in patients undergoing minimally invasive lung resection. J Thorac Cardiovasc Surg. 2021 May;161(5):1652–61
  27. Tschopp C, Tramèr MR, Schneider A, Zaarour M, Elia N. Benefit and Harm of Adding Epinephrine to a Local Anesthetic for Neuraxial and Locoregional Anesthesia: A Meta-analysis of Randomized Controlled Trials With Trial Sequential Analyses. Anesth Analg. 2018 Jul;127(1):228–39
  28. Li F, Yuan Y. Meta-analysis of the cardioprotective effect of sevoflurane versus propofol during cardiac surgery. BMC Anesthesiol. 2015 Dec 24;15(1):128
  29. Hemmerling T, Russo G, Bracco D. Neuromuscular blockade in cardiac surgery: An update for clinicians. Ann Card Anaesth. 2008;11(2):80
  30. Goodmanson MM, Latham GJ, Landsem LM, Ross FJ. The Year in Review: Anesthesia for Congenital Heart Disease 2022. Semin Cardiothorac Vasc Anesth. 2023 Jun 26;27(2):114–22

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