HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Thierry A. Folliguet Loïc Macé Jean-Yves Neveux Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Grinda, J.-M. Articles by Neveux, J.-Y. Search for Related Content PubMed PubMed Citation Articles by Grinda, J.-M. Articles by Neveux, J.-Y. Related Collections Related Article

Ann Thorac Surg 1996;62:175-178
© 1996 The Society of Thoracic Surgeons

---

Original Articles: Cardiovascular

Right Anterolateral Thoracotomy for Repair of Atrial Septal Defect

Département de Chirurgie Cardio-vasculaire et Cardiaque Pédiatrique, Hôpital Marie Lannelongue, Université Paris Sud, Paris, France

Accepted for publication February 19, 1996.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. To procure a cosmetic incision in female patients, we performed operation on atrial septal defects through a right anterolateral thoracotomy.

Methods. From 1984 to 1994, 80 female patients with a mean age of 24 ± 13 years (ranging from 12 to 62 years) underwent right anterolateral thoracotomy for atrial septal defect repairs. Defects repaired included 62 ostium secundum, 12 sinus venosus, 2 low septal defect, and 4 ostium primum. The right iliac external artery was systematically used for arterial cannulation, through a cosmetic incision. Repairs were always performed under fibrillation, except in the 4 ostium primum defects, for which cardioplegia was used.

Results. There was no operative or late mortality, and no morbidity directly related to the thoracotomy approach.

Conclusions. The right thoracotomy incision appears to be a safe and effective alternative to median sternotomy for repair of atrial septal defects.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
See also page 178.

Currently, atrial septal defect (ASD) repairs have become a common, routine, and safe procedure performed often in young, asymptomatic patients. The incidence being twice as great in female as in male patients, naturally more emphasis has been placed on the cosmetic results of the operation. In this particular population, the cosmetic and psychological implications of a median sternotomy must be considered as a possible factor of morbidity. At this time of growing interest in percutaneous closure, surgeons must be able to propose an operation that would provide a cosmetically satisfying result, as well as maintain optimal surgical security. This study reviews the indications, surgical techniques, and results of 80 female patients undergoing ASD repairs by right anterolateral thoracotomy (ALT) from 1984 to 1994.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
After anesthetic induction and stabilization, patients were positioned for a right ALT, with the right side elevated 30 degrees. The right arm was wrapped with adequate padding to avoid peripheral nerve injury and suspended over the head. The right groin was prepared and draped to allow access to the right iliac vessels. In all patients right iliac cannulation was used. The right external iliac artery was approached through a short (3-cm) incision parallel to the natural skin fold, facing the superior edge of the cruralis arcade, and dissected in the infraperitoneal space.

At this time, a small anterolateral thoracotomy incision was made, using the inframammary groove. The incision started approximately 2 cm anterior to the nipple and extended about 12 cm posteriorly. The serratus anterior and latissimus dorsi muscles were not divided. Care was taken to preserve both the long thoracic nerve of Bell and the thoracodorsal nerve. The chest was entered through the fourth or fifth intercostal space depending on the patient's physical characteristics and the type of lesion being treated. The right internal mammary vessels were always respected. The pericardium was opened longitudinally, anterior to the phrenic nerve, and suspended posteriorly. A single atrial pursestring was placed on the right atrial appendage and another on the inferior aspect of the right atrium. A single aortic pursestring was placed proximally on the ascending aorta to help in the deairing maneuver.

After heparin administration, iliac and bicaval cannulation was performed. Cardiopulmonary bypass under mild hypothermia (32°C) was started and the caval tapes were snared. In cases of an ostium primum defect, with the need of an associated revision of the mitral valve, aortic cross-clamping was performed and cold crystalloid cardioplegia was administered (n = 4). For all other patients, electrical fibrillation was used.

Excellent exposure of intracardiac anatomy was obtained with an oblique right atrial incision. Heterologous pericardium was generally used for repairs, as described in Table 1.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Between December 1984 and December 1994, 80 female patients ranging in age from 12 to 62 years (mean age, 24.9 ± 13 years) underwent ASD repair through a right ALT. Actually, patients undergo operation on the basis of preoperative transthoracic echocardiogram. Nevertheless, catheterization were performed in some instances, such as older age, incomplete preoperative transthoracic echocardiogram, and enrollment in a protocol of percutaneous closure. This approach was always used in female patients whose breasts were developed. With this in mind, operation was delayed 2 to 10 years (mean, 4.3 years) between the diagnosis and the date of surgical repair in 22 patients who were followed up with echocardiographic controls.

Anatomic types of ASD are summarized in Table 1. Sixty-two patients had a secundum-type ASD (77.5%), which all were closed with a heterologous pericardial patch. In 4 of these patients, the operation was performed after a prior percutaneous closure procedure. In 4 other patients, an aneurysm of the fossa ovalis was resected. Twelve patients had a sinus venosus type defect. Pulmonary venous inflow was redirected with a pericardial patch; enlargement of the fossa ovalis was necessary in 2 cases. An additional second enlargement patch of the atrium and the superior vena cava junction was performed in 6 patients. Two patients had a low septal defect, which was closed with a heterologous pericardial patch. Among these patients the average bypass time was 38 ± 12.3 minutes, with an average fibrillation time of 22.4 ± 8.6 minutes. Average recorded core temperature was 32°C (range, 28° to 34°C). Aortic cross-clamping and cold crystalloid cardioplegic solution were used in 4 patients who presented an ostium primum ASD. All defect repairs were performed with a heterologous pericardial patch positioning the coronary sinus in the right cavity (n = 3) or in the left cavity (n = 1). Clefts in the anterior leaflet of the mitral valve were sutured, with a double mitral valve orifice being respected in 1 patient.

There were no deaths in this series. Postoperative echocardiography was performed systematically for each patient. There has been no evidence of postoperative persistent ASD. Postoperative complications included one pericardial effusion and one pleural effusion requiring surgical drainage. Four moderate pleural effusions, two partial pneumothoraces, and one subcutaneous emphysema resolved spontaneously. Postoperative paresthesia of the right arm was observed in 1 patient with complete recovery at 6 weeks. An atrial flutter was reduced by internal electrical stimulation in 1 patient.

Extubation was accomplished after 5.1 ± 2.2 hours postoperatively. The average postoperative bleeding was 320 ± 140 mL. The average hospital stay was 9.4 ± 2 days, with an average intensive care unit stay of 1.4 ± 0.5 days. Patients who received an ATL approach experienced a greater degree of postoperative pain, requiring greater amounts of analgesic drugs than patients operated on via a sternotomy. All incisions healed well. The cosmetic result was judged satisfactory by all patients.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Since the use of ingenious methods such as inflow occlusion [1], the atrial well [2], and the first ASD repairs under cardiopulmonary bypass, technologic advances have improved the benefit of this operation, resulting in decreased morbidity and mortality to the extent of favoring the emergence of cosmetic considerations. This is particularly true when the patient is a young woman, because the resulting scar can be unsightly and detract from her physical appearance; the incision is quite often the only long-lasting reminder of a previous cardiac operation. Surgeons must be capable of responding to the legitimate desire for a cosmetic result, maintaining maximum security. Our choice of repair via an ATL under induced electrical fibrillation with the aid of right external iliac artery cannulation answers the imperatives of maintaining maximum security as well as the desired cosmetic result.

The ATL approach was recently updated as an alternative to repeat sternotomies for redo mitral valve operations [3–5] or congenital heart correction [6], as well as for cosmetic reasons [7–10]. The safety of the use of a short period of fibrillation with acceptable perfusion pressures in the nonhypertrophied heart has been well established [11]. Although direct aortic cannulation has been generally advocated [8–10], we have always performed external iliac cannulation without any complications in these young female patients unaffected by atherosclerotic pathology. Direct aortic cannulation appears to us as a delicate procedure. Peripheral arterial cannulation allows for better intercostal exposure depending on the patient's anatomic lesions and morphology. With peripheral cannulation, the surgeon was not inclined to compensate for potential technical difficulties encountered with direct aortic cannulation by enlarging the incision, which should not exceed 12 cm. We have found many advantages of performing iliac cannulation rather than the classic femoral approach. First, the incision above the crural arch is short and parallel to the natural skin fold, and is perfectly hidden by an undergarment. Second, the external iliac approach does not cross the lymph nodes, thus avoiding local complications. Third, the external iliac artery has a larger diameter, which is important in low-weight adolescents. We have found that these conditions provide the least surgical risk for ASD repairs with the least cosmetic compromise. This compromise is even less than that of a bilateral submammary skin incision described by Brom in 1956 and modified later by Willman and Hanlon [12, 13]. This approach is not without complications, which include healing difficulties, hematomas, seromas, extensive loss of sensation in the nipple and breast area, and poor breast development [13–16].

The different types of ASD, including those with associated partial anomalous pulmonary venous connections, are accessible by ATL. The partial atrioventricular canal defect should not be excluded as a type of repair suitable through an ATL, provided the mitral valve repair is not too complex. In these particular cases (n = 4), we have preferred use of aortic cross-clamping and cardioplegia over electrical fibrillation. On the other hand, associated abnormalities on the right or left outflow tracts and left superior vena cava draining in the left atrium contraindicate this approach, but we never encountered such a situation and were able to perform adequately all repairs of this series through an ATL. For the moment, we did not perform more complex repair through this approach, such as ventricular septal defect repair. At this point, we do not believe that it is appropriate to extend this approach to male patients for purely cosmetic reasons.

To avoid a too high incision on the breast with the potential risk of mammary atrophy [17], only female patients with perfectly defined submammary grooves benefited from an ATL approach in our series. In young children, in whom ASDs are well tolerated, our policy is to wait until puberty. The onset of puberty allows more precise definition of the submammary groove, which we believe is necessary for an ALT approach. In our series, 22 patients benefited from this cosmetic approach thanks to this voluntary waiting attitude. If operation was necessary earlier, repair was performed via a sternotomy by a very short longitudinal incision. In adult female patients, age limitations for an ATL approach are imposed in cases of pathophysiologic complications of older ASDs such as heart failure or pulmonary hypertension.

The ALT approach allows satisfactory cosmetic treatment of differing types of ASD with the utmost security. The onset of puberty permits all patients to benefit from this cosmetic approach. The quality of the cosmetic result justifies in young female patients the clinical and echocardiographic period awaiting pubescent definition of the submammarian groove, the precondition necessary for the ATL approach.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Neveux, Département de Chirurgie Cardiovasculaire et Cardiaque Pédiatrique, Hôpital Marie Lannelongue, 133 ave de la Résistance, 92350 Le Plessis Robinson, France.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Lewis FJ, Taufic M. Closure of atrial septal defects with the aid of hypothermia: experimental accomplishments and the report of one successful case. Surgery 1953;33:52–9.[Medline]
2. Gross RE, Watkins E Jr, Pomerane AA, Goldsmith EL. Method for surgical closure of interauricular septal defects. Surg Gynecol Obstet 1953;96:1–23.
3. Tribble CG, Killinger WA Jr, Harman PK, Crosby IK, Nolan SP, Kron IL. Anterolateral thoracotomy as an alternative to repeat median sternotomy for replacement of the mitral valve. Ann Thorac Surg 1987;43:380–2.[Abstract/Free Full Text]
4. Praeger PI, Pooley RW, Moggio RA, Somberg ED, Sarabu MR, Reed GE. Simplified method for reoperation on the mitral valve. Ann Thorac Surg 1989;48:835–7.[Abstract/Free Full Text]
5. Cohn LH, Peigh PS, Sell J, DiSesa VJ. Right thoracotomy, femorofemoral bypass, and deep hypothermia for re-replacement of the mitral valve. Ann Thorac Surg 1989;48:69–71.
6. Szarnicki RJ, Stark J, de Leval M. Reoperation for complications after inflow correction of transposition of the great arteries: technical considerations. Ann Thorac Surg 1978;25:150–4.[Abstract/Free Full Text]
7. Blondeau P. Exposition et exploration du coeur. In: Blondeau P, Henry E, eds. Nouveau traité de technique chirurgicale, Tome IV, coeur, gros vaisseaux, pericarde. Paris: Masson et Cie, 1972:45–54
8. Rosengart TK, Stark JF. Repair of atrial septal defect through a right thoracotomy. Ann Thorac Surg 1993;55:1138–40.[Abstract/Free Full Text]
9. Lancaster LL, Mavroudis C, Rees AH, Slater AD, Ganzel BL, Gray LA. Surgical approach to atrial septal defect in the female: right thoracotomy versus sternotomy. Am Surg 1990;56:218–21.[Medline]
10. Dielt CA, Torres AR, Favalero RG. Right submammarian thoracotomy in female patients with atrial septal defects and anomalous pulmonary venous connections: comparison between the transpectoral and subpectoral approaches. J Thorac Cardiovasc Surg 1992;104:723–7.[Abstract]
11. Cox JA, Anderson RW, Pass HA, et al. The safety of induced ventricular fibrillation during cardiopulmonary bypass in non hypertrophied hearts. J Thorac Cardiovasc Surg 1977;74:423–32.[Medline]
12. Amato JJ. The Brom submammarian incision for median sternotomy. J Thorac Cardiovasc Surg 1980;80:463–4.
13. Willman VL, Hanlon CR. Median sternotomy using a transverse submammary skin incision. Am J Surg 1960;100: 779–81.
14. Laks H, Hammond GL. A cosmetically acceptable incision for the median sternotomy. J Thorac Cardiovasc Surg 1980;79:146–9.[Abstract]
15. Brutel de la Rivière A, Brom GHM, Brom AG. Horizontal submammary skin incision for median sternotomy. Ann Thorac Surg 1981;32:101–4.[Abstract/Free Full Text]
16. Bedard P, Keon WJ, Brais MP, Goldstein W. Submammary skin incision as a cosmetic approach to median sternotomy. Ann Thorac Surg 1986;41:339–41.[Abstract/Free Full Text]
17. Cherup LL, Siewers RD, Futrell JW. Breast and pectoral muscle maldevelopment after anterolateral and posterolateral thoracotomies in children. Ann Thorac Surg 1986;41: 429–7.

This article has been cited by other articles:

				V. A. Sebastian, K. J. Guleserian, S. R. Leonard, and J. M. Forbess Ministernotomy for repair of congenital cardiac disease Interact CardioVasc Thorac Surg, November 1, 2009; 9(5): 819 - 821. [Abstract] [Full Text] [PDF]

				H. H. Dave, M. Comber, T. Solinger, D. Bettex, A. Dodge-Khatami, and R. Pretre Mid-term results of right axillary incision for the repair of a wide range of congenital cardiac defects Eur J Cardiothorac Surg, May 1, 2009; 35(5): 864 - 870. [Abstract] [Full Text] [PDF]

				K. S. Mohamed Minimally Invasive Right Posterior Minithoracotomy for Open-Heart Procedures Asian Cardiovasc Thorac Ann, December 1, 2007; 15(6): 468 - 471. [Abstract] [Full Text] [PDF]

				F P Casselman, H Dom, B De Bruyne, Y Vermeulen, and H Vanermen Thoracoscopic ASD closure is a reliable supplement for percutaneous treatment Heart, June 1, 2005; 91(6): 791 - 794. [Abstract] [Full Text] [PDF]

				K. Nishigaki, H. Nishi, Y. Kume, K. Kitabayashi, and K. Miyamoto Minimal Access via Lower Partial Sternotomy for Congenital Heart Defects Asian Cardiovasc Thorac Ann, March 1, 2005; 13(1): 42 - 46. [Abstract] [Full Text] [PDF]

				R. A. Hopkins, A. A. Bert, B. Buchholz, K. Guarino, and M. Meyers Surgical patch closure of atrial septal defects Ann. Thorac. Surg., June 1, 2004; 77(6): 2144 - 2149. [Abstract] [Full Text] [PDF]

				S. Bleiziffer, C. Schreiber, R. Burgkart, F. Regenfelder, M. Kostolny, P. Libera, K. Holper, and R. Lange The influence of right anterolateral thoracotomy in prepubescent female patients on late breast development and on the incidence of scoliosis J. Thorac. Cardiovasc. Surg., May 1, 2004; 127(5): 1474 - 1480. [Abstract] [Full Text] [PDF]

				N. Yoshimura, M. Yamaguchi, Y. Oshima, S. Oka, Y. Ootaki, and M. Yoshida Repair of atrial septal defect through a right posterolateral thoracotomy: a cosmetic approach for female patients Ann. Thorac. Surg., December 1, 2001; 72(6): 2103 - 2105. [Abstract] [Full Text] [PDF]

				U. Abdel-Rahman, G. Wimmer-Greinecker, G. Matheis, A. Klesius, U. Seitz, R. Hofstetter, and A. Moritz Correction of simple congenital heart defects in infants and children through a minithoracotomy Ann. Thorac. Surg., November 1, 2001; 72(5): 1645 - 1649. [Abstract] [Full Text] [PDF]

				J. M. Grinda, C. P. Latremouille, N. D'Attellis, A. Berrebi, and J. N. Fabiani Angioplasty balloon occlusion of internal thoracic artery in redo surgery in patients with coronary artery bypass operations J. Thorac. Cardiovasc. Surg., July 1, 2001; 122(1): 182 - 183. [Full Text] [PDF]

				X. Yang, D. Wang, and Q. Wu Repair of atrial septal defect through a minimal right vertical infra-axillary thoracotomy in a beating heart Ann. Thorac. Surg., June 1, 2001; 71(6): 2053 - 2054. [Abstract] [Full Text] [PDF]

				R. Formigari, R. M. Di Donato, E. Mazzera, A. Carotti, G. Rinelli, F. Parisi, L. Pasquini, and L. Ballerini Minimally invasive or interventional repair of atrial septal defects in children: experience in 171 cases and comparison with conventional strategies J. Am. Coll. Cardiol., May 1, 2001; 37(6): 1707 - 1712. [Abstract] [Full Text] [PDF]

				W. Luo, C. Chang, and S. Chen Ministernotomy versus full sternotomy in congenital heart defects: a prospective randomized study Ann. Thorac. Surg., February 1, 2001; 71(2): 473 - 475. [Abstract] [Full Text] [PDF]

				D. P. Bichell, T. Geva, E. A. Bacha, J. E. Mayer, R. A. Jonas, and P. J. del Nido Minimal access approach for the repair of atrial septal defect: the initial 135 patients Ann. Thorac. Surg., July 1, 2000; 70(1): 115 - 118. [Abstract] [Full Text] [PDF]

				M. Bauer, V. V. Alexi-Meskishvili, and R. Hetzer Less invasive correction of atrial septal defects with transthoracic cannulation Ann. Thorac. Surg., March 1, 2000; 69(3): 981 - 982. [Full Text] [PDF]

				V. Rao, R. M. Freedom, and M. D. Black Minimally invasive surgery with cardioscopy for congenital heart defects Ann. Thorac. Surg., November 1, 1999; 68(5): 1742 - 1745. [Abstract] [Full Text] [PDF]

				U. Kappert, F. M. Wagner, V. Gulielmos, M. Taha, J. Schneider, and S. Schueler Port AccessTM surgery for congenital heart disease Eur J Cardiothorac Surg, November 1, 1999; 16(Supplement_2): S86 - S88. [Abstract] [Full Text] [PDF]

				J. T. Cremer, A. Boning, M. B. Anssar, P. Y. Kim, K. Pethig, W. Harringer, and A. Haverich Different approaches for minimally invasive closure of atrial septal defects Ann. Thorac. Surg., June 1, 1999; 67(6): 1648 - 1652. [Abstract] [Full Text] [PDF]

				T. Pasha and M. A. Cheema Right Anterolateral Thoracotomy for Repair of Atrial Septal Defects in Young Female Patients Asian Cardiovasc Thorac Ann, March 1, 1999; 7(1): 46 - 48. [Abstract] [Full Text] [PDF]

				S. Dabritz, J. Sachweh, M. Walter, and B. J. Messmer Closure of atrial septal defects via limited right anterolateral thoracotomy as a minimal invasive approach in female patients Eur J Cardiothorac Surg, January 1, 1999; 15(1): 18 - 23. [Abstract] [Full Text] [PDF]

				J. H. Khan, D. B. McElhinney, V. M. Reddy, and F. L. Hanley Repair of secundum atrial septal defect: limiting the incision without sacrificing exposure Ann. Thorac. Surg., October 1, 1998; 66(4): 1433 - 1435. [Abstract] [Full Text] [PDF]

				W. R. Chitwood Jr., C. L. Wixon, J. R. Elbeery, J. F. Moran, W. H. H. Chapman, and R. M. Lust VIDEO-ASSISTED MINIMALLY INVASIVE MITRAL VALVE SURGERY J. Thorac. Cardiovasc. Surg., November 1, 1997; 114(5): 773 - 782. [Abstract] [Full Text]

				C. Minale and J.-M. Grinda Atrial Septal Defect Closure Through a Thoracotomy Ann. Thorac. Surg., March 1, 1997; 63(3): 913 - 914. [Full Text]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Thierry A. Folliguet Loïc Macé Jean-Yves Neveux Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Grinda, J.-M. Articles by Neveux, J.-Y. Search for Related Content PubMed PubMed Citation Articles by Grinda, J.-M. Articles by Neveux, J.-Y. Related Collections Related Article