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Ann Thorac Surg 1996;62:697-701
© 1996 The Society of Thoracic Surgeons
Divisions of Thoracic and Cardiovascular Surgery and Cardiology, Department of Pediatrics and Anesthesiology, Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Taiwan, Republic of China
Accepted for publication April 2, 1996.
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentReferences |
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Methods. Eight patients (3 male and 5 female) underwent operation for closure of an atrial septal defect. The patients ranged in age from 2.0 to 60.9 years (mean, 19.2 ± 19.0 years). The patients weighed 11 to 66 kg (mean, 41.3 ± 23.5 kg). The ratio of pulmonary blood flow to systemic blood flow ranged from 2.0 to 6.0 (mean, 3.4 ± 1.3). The mean pulmonary artery pressure was 19.7 ± 4.0 mm Hg (range, 13 to 24 mm Hg). The operations were performed through a right anterior minithoracotomy and guided by video-assisted endoscopic techniques under femorofemoral or femoral-right atrial extracorporeal circulation. The aorta was not cross-clamped, and the myocardium was protected by continuous coronary perfusion with hypothermic fibrillatory arrest (rectal temperature, 22.0° ± 2.0°C). Transesophageal echocardiographic monitoring was maintained during the operations. The right atrium was entered after pericardiotomy. Primary closure of the defect was performed successfully in all patients. Conventional nondisposable instruments were used for dissection, grasping, suturing, and hemostasis.
Results. The durations of extracorporeal circulation and operation ranged from 47 to 126 minutes (mean, 80 ± 31 minutes) and from 2.2 to 4.5 hours (mean, 3.1 ± 0.8), respectively. All patients recovered from the operation rapidly with an uneventful postoperative course.
Conclusions. Our experience demonstrates that video-assisted cardiac surgery is technically feasible and can be used with excellent results for the repair of congenital heart defects in general.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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) were operated on for the repair of an ASD of the ostium secundum, fossa ovalis type at Chang Gung Memorial Hospital, Taipei, Taiwan, from October to December 1995. There were 3 male and 5 female patients who ranged in age from 2.0 to 60.9 years (mean, 19.2 ± 19.0 years). The patients weighed from 11 to 66 kg (mean, 41.3 ± 23.5 kg). Transthoracic echocardiography and cardiac catheterization confirmed the diagnosis of ASD. The ratio of pulmonary blood flow to systemic blood flow ranged from 2.0 to 6.0 (mean, 3.4 ± 1.3). The pulmonary artery pressure ranged from 13 to 24 mm Hg (mean, 19.7 ± 4.0 mm Hg). Video-assisted techniques involving the use of an endoscope were used in an attempt to close the ASD through a right anterior minithoracotomy so that a median sternotomy could be avoided for cosmetic reasons and to ensure minimum postoperative discomfort.
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Encouraged by our excellent results from video-assisted thoracic surgery [5, 6], beginning in 1995 we performed animal experiments in the surgical closure of ASD on canine hearts using video-assisted endoscopic techniques. The operative policy to use VACS was approved by hospital authorities. Written consent was obtained from the family members before the operation.
The video-assisted techniques used in these patients have been previously described [4]. After the induction of general anesthesia, transesophageal echocardiographic monitoring was set up and the diagnosis of ASD confirmed (Figs 1A, 1B). The patient was put in a left semidecubitus position with the right groin exposed. Extracorporeal circulation was established through cannulation of the right femoral artery with an aortic cannula (THI aortic perfusion cannula; Argyle, St. Louis, MO) and cannulation of the right femoral vein with a chest tube (Thoracic catheter; Mallinckrodt Laboratories, Athlone, Ireland). A membranous oxygenator (Maxima Plus oxygenation system; Medtronic, Anaheim, CA) was used. Systemic hypothermia was begun immediately after the start of extracorporeal circulation. A 2-cm incision was made over the seventh intercostal space in the posterior axillary line (Fig 2). The chest was entered carefully through a stab incision. Bleeders from the intercostal muscle were checked meticulously. Digital palpation was performed to determine whether there was any adhesion of the lung to the chest wall, and none was found in any of the patients. An 11-mm nondisposable trocar was put in place, through which the endoscope (Stryker Endoscopy, San Jose, CA) was inserted. The entire thoracic cavity was then carefully explored to determine whether there was any adhesion of the pericardium to the lung, and none was found. A right anterior minithoracotomy (4 to 7 cm long; Fig 2) through the fourth intercostal space was made as the "manipulation incision" for the introduction of conventional surgical instruments into the chest and right atrium [4, 5]. Bleeders from the intercostal muscle were also checked meticulously.
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). Cannulation and then snaring of the inferior vena cava through the right atrium was performed in 3 patients (Nos. 4, 7, and 8) at this time for extracorporeal circulation because of the small diameter of their femoral vein. The aorta was not cross-clamped. The heart was protected with continuous coronary perfusion with hypothermic fibrillatory arrest. Topical cooling of the heart was used in the last 3 patients to facilitate fibrillation of the heart. After the heart fibrillated, a 4-cm stab incision was made on the right atrium, which was then entered. In our first 4 patients, a chest tube was inserted into the superior vena cava via the atriotomy and connected to the venous cannula of the extracorporeal circulation for drainage of the venous blood from the superior vena cava (Fig 3C). In our last 4 patients, the superior vena cava was clamped temporarily for 10 to 15 minutes during the procedure, without congestion or swelling of the head. The jugular venous pressure was monitored through the central venous line inserted via the right internal jugular vein and was found to be less than 15 mm Hg during clamping of the superior vena cava. The endoscope was advanced to enter the right atrium, and the entire right atrial cavity was carefully explored by means of projected images on the video monitor, where an ostium secundum, fossa ovalis-type ASD was found in all patients. It was closed primarily with 4-0 Prolene (Ethicon, Somerville, NJ) running suture (Fig 3B), and care was taken to make sure the left atrium was filled with blood. Blood from the superior vena cava, if it was not clamped, was helpful in filling the left atrium. The aspirator was not, and should not be, put into the left atrium. This is important for evacuating air and preventing air embolization. The air in the left atrium was carefully evacuated by rotating the operating table in all directions and by expanding both lungs before complete closure of the ASD. After closure of the ASD, the right atriotomy was closed with a 4-0 Prolene running suture (Figs 3C, 3D). Transesophageal echocardiography showed no obvious air bubble in the left atrium or ventricle. The patient was changed to a head-down position.
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). The pericardium was closed with interrupted sutures. Dobutamine and sodium nitroprusside were not used. A pacemaker was also not used. The thoracotomy used for insertion of the endoscope was then used for insertion of a pleural tube. Another thoracotomy was created in the seventh intercostal space in the anterior axillary line for insertion of the pericardial tube (see Fig 2). Hemostasis and closure of the incisions were easily achieved. |
Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Since the first report of the use of video-assisted techniques published by Lewis and associates [7] in 1991, these techniques have become a useful part of the surgical treatment of intrathoracic disease [1–4, 6, 8].
In the use of these techniques in the surgical repair of an ASD, cardiopulmonary bypass can be accomplished through cannulation of the femoral artery and vein [9, 10], with excellent results. In our patients, simple femorofemoral bypass via the right femoral artery and vein established satisfactory cardiopulmonary bypass with adequate perfusion of all vital organs, including the brain. For pediatric patients, the diameter of the femoral vein may be too small to permit cannulation, but the inferior vena cava can be easily cannulated via the right atrium. The blood from the superior vena cava can then be drained by another venous cannula inserted via the right atrium to the extracorporeal system. The superior vena cava could be clamped temporarily without complication, however. The blood could be drained to the lower half of the body via the azygos vein or other collateral veins. No organ failure occurred postoperatively, and the patients regained consciousness promptly after the operation, indicating tissue perfusion had been adequate during extracorporeal circulation. Although the duration of extracorporeal circulation in our series was longer than usual, the duration of the operation was not significantly long. With more experience, the duration of extracorporeal circulation can be shortened.
Infusion of the cardioplegic solution was difficult using VACS. However, continuous perfusion of the heart without cross-clamping of the ascending aorta can offer adequate myocardial protection [11, 12]. In our patients, in whom continuous coronary perfusion under hypothermic fibrillatory arrest was used for myocardial protection, there was no instance of low cardiac output postoperatively, indicating protection had been adequate.
The growing use of video-assisted techniques for the surgical treatment of thoracic or abdominal disease has been accompanied by the development and extensive application of expensive disposable endoscopic instruments. Nonetheless, we have found in our experience with such procedures [4–6] that conventional nondisposable instruments can be used routinely at a considerable savings, while still preserving the minimally invasive nature of video-assisted procedures. We did not use any expensive disposable endoscopic instrument in these procedures. Our creation of a manipulation incision made the use of conventional instruments for dissection, grasping, suturing, and hemostasis easy and smooth in the 8 patients described here.
Air embolization occasionally occurs after a smooth cardiac operation. To prevent this, care was taken to fill the left atrium with blood during the operation. Blood from the superior vena cava, if it is not clamped, is also helpful in filling the left atrium. The aspirator should not be put into the left atrium. We rotated the operating table in all directions and expanded both lungs during the removal of air. The patients were also kept in a head-down position. Transesophageal echocardiography showed no obvious air bubbles in the heart [13, 14] before the heart began beating. Our patients woke up from the anesthesia promptly after arriving in the intensive care unit; there was also no evidence of neurologic defect postoperatively.
Cardioversion was not a problem in our patients. Defibrillation was easily performed by putting the pads on the surface of the heart. Hemostasis of the atriotomy and pericardiotomy was easily established through the manipulation incision. Conventional hand suturing was used for closure of the atriotomy and was performed smoothly through the manipulation incision under endoscopic guidance. This reduced to a minimum the likelihood of bleeding from the suture lines; any bleeder could be easily controlled by hand sutures or electric cautery. Small incisions, without the need for sternotomy, with minimal mediastinal dissection, and with no incision or puncture on the high-pressure system of the heart (such as the aorta), were also helpful for establishing hemostasis.
The major advantage of VACS is the avoidance of sternotomy. The minimally invasive nature of VACS can lead to a reduction in the incidence of postoperative mediastinitis to a minimum. It may also have the advantages of being more expedient and safe than conventional procedures, causing minimal discomfort and less postoperative pain, and leading to rapid functional recuperation, excellent cosmetic healing, and shortened hospital stays, and therefore a savings in cost [6]. These advantages are particularly apparent in patients with simple intracardiac defects such as an ASD, as was the case in our patients.
In our experience, the use of VACS techniques in the closure of an ASD can be accomplished safely and easily with (1) femorofemoral or femoral-right atrial cardiopulmonary bypass, (2) continuous coronary perfusion with hypothermic fibrillatory arrest, and (3) conventional instruments placed through the manipulation incision. The removal of air and hemostasis were easily accomplished. The surgical techniques used in these procedures were very similar to those used in the usual open heart procedures. These initial results demonstrate that video-assisted endoscopy-guided cardiac surgical procedures are technically feasible and can be effectively executed in a minimally invasive manner. We believe that such video-assisted techniques can be used for the surgical repair of congenital heart defects in general and we anticipate the striking extension of their use in major cardiac procedures in the near future.
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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References |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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