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Ann Thorac Surg 1997;63:1831-1834
© 1997 The Society of Thoracic Surgeons
Department of Surgery, Prince of Wales Hospital, Shatin New Territories, Hong Kong
To the Editor:
We read with interest the recent reports by Chang and associates [1] and Shetty and colleagues [2], and the editorial comments of Dr Mavroudis [3], regarding video-assisted closure of atrial septal defects (ASDs). We share Dr Mavroudis' anxiety that the cosmetic results achieved by the described techniques do not justify the need for deep hypothermic systemic perfusion (22°C), prolonged extracorporeal circulation time, or the primary closure of large adult ASDs without a patch [1]. Although we share Dr Mavroudis' concerns about the techniques employed by both groups, we still believe that a less invasive form of surgical ASD closure is not only possible but is also equally safe and efficacious.
Over the past 6 months we have routinely employed a method that merely modifies the traditional technique without jeopardizing patients' safety. Our technique is as follows: The patient is anesthesized in the supine position, and isolated left lung ventilation is achieved using a Univent endotracheal tube (Fuji Systems Corp, Tokyo, Japan). A right parasternal incision is made extending from the lower edge of the third costal cartilage to the superior edge of the sixth costal cartilage. The fourth and fifth costal cartilages are exposed and totally excised, and the right pleural space is entered after incision of the intercostal muscles parallel to the edge of the sternum. The pericardium is incised vertically anterior to the phrenic nerve, exposing the right atrium, aorta, and superior vena cava, and a pericardial patch is excised and prepared for use in ASD closure.
Cardiopulmonary bypass is established through femoral arterial and venous cannulation, and the superior vena cava is cannulated directly through the minithoracotomy. Mildly hypothermic systemic perfusion (32°C) is used as this is our routine. Inflation of the left lung will bring the aorta into the operative field where direct cross-clamp application and cardioplegia introduction can be easily performed. To isolate the right atrium, the inferior vena cava is clamped at its junction with the right atrium using a long vascular clamp introduced through a stab incision lateral to the xiphisternum. These maneuvers are performed with video assistance through a thoracoscope inserted in the fourth intercostal space, midaxillary line.
Directly through the minithoracotomy, the right atrium is opened vertically and the atrial edges are retracted with stay sutures. With this approach, all types of atrial septal defects are readily accessible, and repair can be easily performed under direct vision employing the standard pericardial patch method. After the right atriotomy is closed, transesophageal echocardiography is used to assist in removing air from the heart chambers before removal of the aortic cross-clamp. After decannulation and hemostasis, the thoracoscope port site and the inferior vena cava clamp site are used for the insertion of a pleural and a pericardial drain, respectively.
The method described here is only a modification of the traditional technique without any alteration in cardiopulmonary bypass and myocardial protection routines, or compromising the surgical access to the septal defect. The smaller incision described has a number of potential advantages. Substantially less pain was reported by our patients, most likely due to the absence of rib retraction compared with median sternotomy. Patients therefore were able to be discharged from the hospital earlier (mean hospital stay, 3 days). The smaller incision is also cosmetically more acceptable to patients.
In conclusion, although we believe that the recently reported methods of totally endoscopic ASD closure are not to be recommended, traditional surgical ASD closure using a less invasive approach is, in our opinion, easy and effective, and deserves further investigation.
References
Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, 199, Tun-Hwa N Rd, Taipei, Taiwan
To the Editor:
We appreciate very much the interest expressed by Drs Izzat and Yim regarding our article on video-assisted cardiac operations for closure of atrial septal defect [1]. However, essential information and surgical results of Izzat and Yim's patients were not included in their correspondence. The minimally invasive techniques described by Drs Izzat and Yim is the method described by Drs Navia and Cosgrove [2] with slight modification. Isolated aortic or mitral valve replacements were performed by our group [3] frequently through the right parasternal incision described by Drs Navia and Cosgrove. This incision is not an ideal incision cosmetically. The patients occasionally complained of deformity and paradoxical movement of the chest wall during respiration. However, the incisional pain was significantly less than that from median sternotomy. In our opinion, minithoracotomy with submammary incision is the preferred incision cosmetically.
Deep hypothermia was only applied to the first 5 patients in our series of atrial septal defects to induce fibrillation of the heart [1]. The myocardium was well protected with fibrillatory arrest with continuous coronary perfusion, which is continuously applied in modern cardiac operations [4]. However, moderate hypothermia was used by our group, after the initial period, for all video-assisted or minimally invasive operations by using topical cooling of the heart to induce fibrillation and to enhance myocardial protection [3, 5, 6]. This shortens the duration of extracorporeal circulation and operating time significantly. The ventricular fibrillator is not available in Taiwan.
Prolonged extracorporeal circulation time resulted from deep hypothermia, inexperience in the video-assisted surgical techniques, and inadequate team work. With more experience and use of topical cooling, the duration of extracorporeal circulation was significantly shortened to the range of 30 minutes in our recent series of atrial septal defects [6].
Direct closure of the atrial septal defect is preferred to patch closure if the defect is not too large [7]. In our recent series, patch closure of the atrial septal defect was performed under direct vision by using the minimally invasive techniques in about 25% of the patients, including patients with sinus venosus or posterior inferior type of atrial septal defect, or patients with persistent left superior vena cava or partial anomalous pulmonary venous return [6].
Cross-clamping of the ascending aorta with antegrade infusion of the cardioplegia is technically feasible in minimally invasive operations on the cardiac lesions. It was applied in our institute combined with minimally invasive surgical techniques in aortic or mitral valve replacements in 15 patients, multiple coronary artery bypass grafting with an average of 3.7 distal anastomoses in 20 patients, closure of ventricular septal defect in 18 patients, and total correction of tetralogy of Fallot in 6 patients [3, 6]. However, manipulation of the aorta should be reduced to the minimum in minimally invasive cardiac operations, especially when the incision is short and far away from the aorta and the exposure of the ascending aorta needs the assistance of the thoracoscope, as in the techniques described by Drs Izzat and Yim. Hazardous complications of the ascending aorta might happen while immediate correction of these complications is impossible due to poor exposure. Fibrillatory arrest with continuous coronary perfusion under mild to moderate hypothermia without manipulation of the aorta, in our opinion, is the preferred method of myocardial protection in minimally invasive surgical correction of simple cardiac lesions, such as atrial septal defect.
The techniques used in video-assisted cardiac surgery or minimally invasive cardiac surgery are evolving rapidly. The video-assisted surgical techniques used in our institute to close atrial septal defects in more than 80 patients have been revised since our last publication [1]. The major changes are (1) use of topical cooling to induce fibrillation, which will significantly reduce the duration of extracorporeal circulation; (2) application of mild to moderate hypothermia with rectal temperature around 28° to 30°C; (3) more frequent use of direct vision, without the assistance of thoracoscope, to close the atrial septal defect; and (4) patch closure of large atrial septal defects in about 25% of the patients [6].
In our recent review [8] comparing the results of video-assisted or minimally invasive surgical closure of atrial septal defect in 80 patients with those of median sternotomy in 96 patients showed that video-assisted surgical closure of atrial septal defects could significantly decrease the amount of postoperative bleeding, enhance postoperative recovery, decrease the incidence of parenteral analgesic injection, provide excellent cosmetic healing, shorten the postoperative length of stay, lower the medical cost, and shorten the back to school or work interval. Our experience demonstrates that video-assisted cardiac surgery is one of the good options for repair of atrial septal defect. We are now using this video-assisted cardiac surgical technique to repair atrial septal defects routinely.
References
Division of Cardiovascular-Thoracic Surgery, The Children's Memorial Hospital, 2300 Children's Plaza, M/C #22, Chicago, IL 60614
To the Editor:
No one can rationally object to "minimally invasive direct atrial septal defect closure" as long as the techniques are safe, the exposure allows accurate execution with minimal effort, and the changes of incisions and cannulation methods result in no long-term disabilities.
In their letter, Drs Izzat and Yim have presented a technique for minimally invasive atrial septal defect closure that requires a right parasternal incision from the third to the sixth costal cartilage, femoral vessel (artery and vein) cannulation, and resection of the fourth and fifth costal cartilages. This appears to be a safe procedure in the short-term. In fact, as they correctly state, this procedure is "a modification of the traditional technique" of right thoracotomy for open heart operations (with or without femoral cannulation) that has been successfully implemented by a number of authors [1–3] for various open heart exposures. Doctors Izzat and Yim contend that their approach results in less pain owing to the lack of rib and sternal retraction. We are left with the idea that costochondral resection and femoral cannulation are better than median sternotomy and classic cannulation techniques.
For the sake of argument, let us consider the common case of a 4-year-old girl with a secundum atrial septal defect who is not a candidate for the transcatheter device closure technique (which at the present time is undergoing clinical trials in the United States). The technique described by Drs Izzat and Yim provides safe exposure in their hands and most likely will provide safe exposure for anyone willing to learn their techniques. However, one must consider whether the exposure will be adequate in the event of an undiagnosed left superior vena cava, or an undiagnosed patent ductus arteriosus, or for the repair of an unexpected case of partial anomalous pulmonary venous return [4]. Furthermore, what will be the incidence of femoral vessel cannulation complications, which can lead to dissection [5], ischemia [6], anterior tibial compartment syndrome [7], and defective limb growth [8]? Groin scars can also become unsightly in the event of contraction across a skin fold-an issue that may be of some concern to a maturing woman.
Routine femoral cannulation was widely used in the early days of open heart surgery [9]. This practice was quickly converted to aortic cannulation [10], reserving femoral cannulation for specific indications in an effort to limit femoral artery complications. Is routine femoral vessel cannulation for atrial septal defect closure safer now? Perhaps it is, owing to better clamps and suture material. It is unlikely, however, that the complication rate will be zero.
Minimally invasive techniques to achieve safe and effective operations are commendable and virtuous. Implementation of improved technology will eventually answer all these aforementioned questions and reservations. In the meantime, we should not forget the lessons of the past as we look to the future.
References
B.M. Birla Heart Research Centre, 1/1 National Library Ave, Calcutta 700027, India
To the Editor:
Doctors Izzat and Yim have described an interesting variation in technique for the closure of atrial septal defects (ASDs) with cosmetic considerations in mind.
The driving force behind innovative cosmetic procedures for benign heart problems like patent ductus arteriosus and ASDs is the social hurdle that heart surgery poses for thousands of little girls in our society. In a conservative society like ours, most weddings are arranged by the parents and finding a suitable boy for a girl with heart disease, irrespective of its nature, will be extremely difficult. The presence of an obvious scar does not help the overall situation. Herein lies the social face of our endeavor.
We have tried several approaches for repair of ASDs. The greatest disadvantage of the right parasternal incision is that it would go through the breast tissue, with the concern that the breast contour would be disfigured as the patient grows. In fact, we routinely use the right anterolateral thoracotomy approach, through a 15-cm submammary incision, for closure of ASDs in young girls with suitable anatomy [1]. We cannulate the vena cava and the aorta directly through the incision in this approach, unlike Drs Izzat and Yim and many other surgeons using the right anterolateral thoracotomy approach. Compared with the right paramedian incision, this is a cosmetically superior method as the scar heals excellently. It is after having sufficient experience with the excellent cosmetic results of anterolateral thoracotomies that we proceeded with the technique of groin cannulation and video-assisted technique described by us [2].
Over the last 7 years, we have performed 568 ASD closures at our center with no mortality, using a variety of techniques like midsternotomy, right anterolateral thoracotomy, fibrillatory arrest, crystalloid cardioplegia, blood cardioplegia, and groin cannulation. Although the video-assisted technique is not as easy as the other techniques we have used, we believe that the benefits of cosmesis and shortened hospital stay far outweigh the apparent technical complexity of our procedure.
At our center the classic methods of repair of ASDs through the midsternotomy and the right anterolateral thoracotomy are still the standard. We are using our video-assisted technique only for young girls with anatomically small defects amenable to direct closure, with no anomalous pulmonary venous drainage, no patent ducts, no left superior vena cava, and no pulmonary hypertension.
Since our report we have done the procedure on three more occasions. Our bypass time has been consistently less than 40 minutes. In 1 patient there was a transient rise in serum creatinine level postoperatively. The other patients did well. Adding Chang and associates' [3] 8 patients to our 4, we see that in 12 patients this procedure has been smoothly conducted.
Doctor Mavroudis, in his editorial, has made several very pertinent points about surgery for ASD. We agree with Dr Mavroudis [4] that these are still the "early days," but as the number of video-assisted procedures increases, we will be able to gauge the true utility of the procedure. Until trials satisfactorily prove the safety of the procedure, classic techniques should prevail.
We would like to mention in passing, however, that our center is an independent institution in Calcutta and is not affiliated with the University of Madras, which is about 1,800 km away.
References
This article has been cited by other articles:
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J.Q. Melo, J.P. Neves, M. Abecassis, and M.M. Pinto Cava endoluminal balloon occlusion as an adjunct technique to perform less invasive cardiopulmonary bypass procedures Eur. J. Cardiothorac. Surg., November 1, 1999; 16(suppl_2): S89 - S92. [Abstract] [Full Text] [PDF]
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 M. B. Izzat and A. P. C. Yim Minimal-access or minimally invasive surgery? J. Thorac. Cardiovasc. Surg., January 1, 1998; 115(1): 258 - 258. [Full Text]
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