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Ann Thorac Surg 1998;65:771-774
© 1998 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Transxiphoid Approach Without Median Sternotomy for the Repair of Atrial Septal Defects

Heart Institute, University of São Paulo Medical School, Hospital Sírio Libanês, São Paulo, Brazil

Accepted for publication September 29, 1997.

Dr Barbero-Marcial, Instituto do Coração, HC, Faculdade de Medicina, USP, Av Dr Enéas de Carvalho Aguiar, 44, Caixa Postal 8091, CEP 05403-000, São Paulo, Brazil.

	Abstract

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Background. Interest in minimally invasive procedures has recently increased because it results in less surgical trauma, decreased patient discomfort, short hospital stay, reduced costs, and better cosmetic appearance. Based on these facts, we have been using the transxiphoid process approach without sternotomy for the correction of atrial septal defects.

Methods. From July 1996 to January 1997, the xiphoid process window approach was performed in 10 patients with ostium secundum atrial septal defect. Ages ranged from 6 months to 14 years (mean, 5.3 years). In all patients, extracorporeal circulation was carried out by means of cannulation of the femoral artery and both caval veins and of aortic cross-clamping. Videothoracoscopy was used to improve visualization of the aorta.

Results. There were no intraoperative or postoperative complications, and in all but 1 patient, extubation was possible while in the operating room.

Conclusions. The xiphoid process window, with no median sternotomy, permitted closure of the atrial septal defects with good results and could be used as a less invasive technique for their correction.

	Introduction

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Surgical repair of atrial septal defects (ASDs) and other similar anomalies should ideally be carried out with minimal surgical trauma, extubation in the operating room, and less pain and respiratory discomfort during the postoperative period, as well as the shortest possible hospital stay. As a consequence, a significant decrease in hospital costs would take place.

Closure of ASDs through cardiac catheterization has been performed in several centers [1][2][3][4]. There are still limitations with regard to the type and the size of the defect as well as to the vascular access for the introduction of the catheter in patients with low weight. Despite the numerous types of devices and the major endeavors of the hemodynamic specialists, this method has not proved to be the best for the closure of most ASDs without risk of immediate and late complications in patients of all ages.

Here we present our experience with a minimally invasive surgical technique, without median sternotomy, for correction of ASD in young patients.

	Material and Methods

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During a period of 6 months, 10 children (9 boys and 1 girl) whose ages ranged from 6 months to 14 years (mean age, 5.3 years) underwent operation (Table 1).

Resection of the xiphoid process and a 1-cm opening of the cartilaginous base of the supraxiphoid portion of the sternum were performed using an electrocautery. A specially designed deep-profile retractor, developed by the Heart Institute Bioengineering Division (Instituto do Coração, São Paulo, Brazil), was then positioned to provide about 2-cm superior and 2-cm anterior traction; to place the "xiphoid process window" in front of the right atrium, a metallic arm of adjustable length fixed to the operating table was used (Fig 1).

View larger version (1K): [in this window] [in a new window]   Position of the specially designed deep-profile sternal retractor with a metallic arm with adjustable length fixed at the operating table. This retractor was developed by the Heart Institute’s Bioengineering Division to provide anterosuperior traction and thereby to position the xiphoid window in front of the right atrium.

The cannulation of the common femoral artery began with an oblique incision over the femoral vessels. The common femoral artery and its proximal branches were dissected free and a tape was placed around the artery. After the patient had been heparinized (4 mg/kg of body weight), the femoral artery was clamped with a fine vascular clamp and opened with a no. 11 blade. The arterial cannula (dlp, Inc, Grand Rapids, MI) was gently inserted and advanced about 4 cm. The cannula was secured on the skin and connected to the arterial line of the pump oxygenator. The internal diameter of the arterial cannulas ranged from 8 to 12F.

After cannulation of the left femoral artery, two pursestring sutures for cannulation of the venae cavae were placed on the anterior face of the inferior vena cava and on the lateral wall of the right atrial appendage for cannulation of the superior vena cava. To place a tape around the superior vena cava, retraction of the lateral wall of the right atrium was performed with a special spatula. The pericardial reflection over the right pulmonary artery was incised and a right-angled clamp, in addition to the tape, was passed around the superior vena cava. To place the tape around the inferior vena cava, the surgeon incised the pericardial reflection and dissected it free. These maneuvers permitted the exposure of the vena and consequently facilitated the placement of the pursestring suture and the passage of the tape around the inferior vena cava.

With the same large spatula, the right atrium and the anterosuperior aspect of the right ventricle were retracted and the anterior wall of the ascending aorta was visualized. Next, resection of 1 cm of the adventitia was performed, allowing further infusion of cardioplegia as well as removal of the air from the left cavities.

A right-angled cannula (Biotecno, São Paulo, Brazil) for the inferior vena cava was directly inserted. To facilitate the cannulation of the superior vena cava, the right atrial wall was tractioned and the right-angled cannula was introduced into the right atrium and then guided to reach the orifice of the superior vena cava.

Cardiopulmonary bypass circulation was initiated, and after hemodynamic stabilization, the aorta was cross-clamped. Because of the limited incision, the aortic clamp had to be positioned by the right side of the aorta, with its inferior arm on the posterior wall of the ascending aorta, passing the transverse sinus, and the other arm in the anterior position. In the majority of the cases the pulmonary trunk was also included. The tapes were snugged around the cavae, the right atrium was transversely opened, and the edges of the right atrial wall were repaired and tractioned.

Closure of the ASD was performed in the conventional manner with running sutures or a patch of bovine or autologous pericardium. The blood was suctioned, avoiding emptying of the left atrium. Before closure of the ASD, a stab wound was made in the previously dissected anterior wall of the aorta and a pursestring suture was passed at the edges of the stab incision, to be tied later. Saline solution was infused into the left atrium until it flowed freely from the orifice of the aorta, and then the anesthesiologist inflated the lungs to help the removal of any residual air. At the same time, the anterior wall of the left ventricle was compressed several times with a forceps to eject the saline solution and the blood through the orifice of the aorta. After these maneuvers, the stitches of the ASD were tied and the right atrium was closed after deairing of the right cavities.

The aortic clamp was removed, and after recovery of the normal heart rate, the lungs were fully expanded and the venous line of the pump oxygenator was temporarily occluded to drive blood to the heart and to generate pressure in the left ventricle. During this process, the orifice in the ascending aorta remained open.

Finally, the running stitches of the ascending aorta stab were tied, cardiopulmonary bypass was discontinued, and all cannulas were removed. The femoral arteriotomy was closed with interrupted 7-0 PDS (Ethicon, Somerville, NJ) sutures. The remaining surgical steps were completed as usual.

One 30-degree Storz Endoscope SN 10/30/1419 (Karl Storz GmbH, Tuttlingen, Germany) sterilized for 60 minutes in a solution of 2% glutaraldehyde was used in the operation to improve the visualization of the aorta.

The time of extracorporeal circulation ranged from 17 to 31 minutes (mean, 23 minutes) and the aortic cross-clamp time ranged from 5 to 20 minutes (mean, 12.6 minutes).

	Results

Top Abstract Introduction Material and Methods Results Comment Addendum Acknowledgments References

 
In the 10 patients we operated on, the xiphoid process approach allowed surgical repair of the ASD. All patients but 1 were extubated in the operating room and did not exhibit complications during the postoperative period, being discharged from the hospital between the second to the fifth postoperative day. Postoperative transthoracic echocardiography showed good left ventricular function and the absence of residual shunts. At physical examination the femoral arterial cannulation did not cause alterations in the palpable pulse or a gradient between the upper and lower extremity blood pressures. Patients did not report any discomfort with regard to the groin approach or gait disturbances.

	Comment

Top Abstract Introduction Material and Methods Results Comment Addendum Acknowledgments References

 
In cardiac surgery, some procedures designed as minimally invasive have been performed in coronary artery bypass grafting without using extracorporeal circulation [5] and in aortic and mitral valve replacement [6]. Video-endoscopic operations have been used for biopsy and pericardium drainage, closure of the patent ductus arteriosus, and division and suture of the pulmonary vascular ring [7][8].

In pediatric cardiac surgery, some difficulties must be considered when carrying out minimally invasive procedures because of the complexity of the encontered anomalies, the low body weight, and the manipulation of extremely delicate anatomic structures. Chang and associates [9] have recently published data on the closure of ASDs using video-assisted right anterolateral minithoracotomy, the defect being corrected but with deep hypothermia and long periods of extracorporeal circulation (47 to 126 minutes). Although all patients had a favorable outcome, the described technique turns a simple and safe operation into one that entails greater difficulties, longer bypass circulation time, and potential risks of air embolism.

The transxiphoid process window is a feasible and secure approach for the repair of ASDs. The possibility of correcting other abnormalities such as perimembranous ventricular septal defects should be subject to investigation in the near future. The advantage of not opening the sternum is most evident in the postoperative period. Patients undergo a much more rapid recovery, as less postoperative pain and discomfort are observed. Discharge from the hospital can take place on the third postoperative day, with almost immediate resumption of normal physical activities. For the first 6 patients, the hospital stay was extended until the fourth or fifth postoperative day for better follow-up, although it would also have been possible to discharge the patients on the third day. The cosmetic appearance is another positive factor (Fig 2).

View larger version (1K): [in this window] [in a new window]   One-year-old patient 8 months after the operation, showing the length of the transxiphoid incision.

It is valid to point out that the restrictive exposure of the heart through this small incision turns this simple operation into a technically demanding procedure, which requires expertise on the part of the surgeon. In this preliminary study a similar relation between level of difficulty and the progressive age of the children was encountered. Moreover, when anatomic variations exist, as when the right atrium is very small and deeply positioned or when there is intraoperative suspicion of another associated anomaly such as partial anomalous pulmonary venous drainage, it would be advisable to extend the incision. In case of hemorrhage the conventional sternotomy should immediately be performed. Extreme care must also be taken during the other surgical steps, such as when placing the tape around the superior vena cava and during aortic cross-clamping. It is important to emphasize that the most fundamental step of this operation is the complete and careful deairing of the left cavities. If all the above-described maneuvers are followed, the possibility of any air remaining should be remote, which can be confirmed by using intraoperative transesophagic echocardiography.

For a long time, the approach to these defects has been performed through an anterolateral thoracotomy at the level of the fourth intercostal space [10]. This approach is adequate for correction of perimembranous ventricular septal defects and of ASDs, although it presents some inconveniences such as the opening of the pleural space, which could provoke a greater incidence of atelectasia and other pulmonary complications, as well as greater postoperative pain because of trauma to the intercostal nerves. Furthermore, it can be difficult to determine the exact position of the inframammary groove in children less than 1 year old, because with thoracic development its position changes, and also in girls, because of the development of the breasts. In certain infants, in our experience, the disjointment or rupture of the intercostal cartilage provoked by the thoracic retractor has afterward led to a difference in the growth of the ribs and the previously damaged cartilage. This may cause a permanent thoracic deformity, although it is rare in older children and adults.

Other approaches have been developed for the repair of intracardiac defects using minimally invasive operations such as reduced sternotomy with partial opening of the sternum, as described by Tatebe and associates [11], Wilson and colleagues [12], Komai and coworkers [13], and Del Nido and associates (personal communication, 1996), although these approaches included opening of the sternum.

In conclusion, the xiphoid process window, without opening of the sternum, permitted repair of the ASD with good results and with no complications in the 10 patients studied and could be used as a less invasive technique for the correction of such defects.

	Addendum

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Up to November 1997 another 14 patients with ASDs were submitted to surgical correction using the transxiphoid process window approach. The described technique was used with some technical modifications, and the results are similar to those already described. In 1 patient with situs inversus totalis and ASD, the surgeon performed the operation at the opposite side of the right atrium, ie, from the left side of the patient, because the exposure was easier. In 3 patients we had difficulties in placing a tape around the superior vena cava because of the dilated right atrium, and we preferred doing it after initiating the cardiopulmonary bypass when we had better exposure of the superior vena cava.

	Acknowledgments

Top Abstract Introduction Material and Methods Results Comment Addendum Acknowledgments References

 
We thank Mr Wilson Pereira da Silva and the Bioengineering Division of the Heart Institute, University of São Paulo, for the development of the retractor with an adjustable metallic arm.

	References

Top Abstract Introduction Material and Methods Results Comment Addendum Acknowledgments References

 

1. King TD, Mills NL Secundum atrial septal defect: nonoperative closure during cardiac catheterization. JAMA 1976;235:2506-2509.[Abstract/Free Full Text]
2. Latson LA, Hofschire PJ, Kugler JD, et al. Residual shunts after transcatheter closure of patent ductus arteriosus. A major concern of benign "techno-malady"?. Circulation 1991;84:2591-2593.[Free Full Text]
3. Rome JJ, Keane JF, Perry SB, et al. Double-umbrella closure of atrial septal defects. Initial clinical applications. Circulation 1990;82:751-758.[Abstract/Free Full Text]
4. Rao PS, Wilson AD, Chopra PS Transcatheter closure of atrial septal defect by "buttoned" devices. Am J Cardiol 1992;69:1056-1061.[Medline]
5. Benetti FJ, Ballester C Use of thoracoscopy and a minimal thoracotomy, in mamary–coronary bypass to left anterior descending artery, without extracorporeal circulation. Experience in 2 cases. J Cardiovasc Surg 1995;36:159-161.[Medline]
6. Lin PJ, Chang CH, Chu JJ, et al. Video-assisted mitral valve operations. Ann Thorac Surg 1996;61:1781-1787.[Abstract/Free Full Text]
7. Burke RP, Wernovsky G, van der Velde M, Hansen D, Castañeda AR Video-assisted thoracoscopy surgery for congenital heart disease. J Thorac Cardiovasc Surg 1995;109:499-508.[Abstract/Free Full Text]
8. Burke RP, Chang AC Video-assisted thoracoscopic division of a vascular ring in an infant: a new operative technique. J Thorac Cardiovasc Surg 1993;8:537-540.
9. Chang C-H, Lin PJ, Chu J-J, et al. Video-assisted cardiac surgery in closure of atrial septal defect. Ann Thorac Surg 1996;62:697-701.[Abstract/Free Full Text]
10. Rosengart TK, Stark JF Repair of atrial septal defect through a right thoracotomy. Ann Thorac Surg 1993;55:1138-1140.[Abstract]
11. Tatebe S, Eguchi S, Miyamura H, et al. Limited vertical skin incision for median sternotomy. Ann Thorac Surg 1992;54:787-788.[Abstract]
12. Wilson WR, Jr, Ilbawi MN, DeLeon SY, et al. Partial median sternotomy for repair of heart defects: a cosmetic approach. Ann Thorac Surg 1992;54:892-893.[Abstract]
13. Komai H, Naito Y, Fujiwara K, et al. Lower mid-line skin incision and minimal sternotomy—a more cosmetic challenge for pediatric cardiac surgery. Cardiol Young 1996;6:76-79.

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