Ann Thorac Surg 1998;66:1433-1435
© 1998 The Society of Thoracic Surgeons
How to Do It
Repair of secundum atrial septal defect: limiting the incision without sacrificing exposure
Junaid H. Khan, MDa,
Doff B. McElhinney, MDa,
V. Mohan Reddy, MDa,
Frank L. Hanley, MDa
a Division of Cardiothoracic Surgery, University of California, San Francisco, San Francisco, California, USA
Accepted for publication June 1, 1998.
Address reprint requests to Dr Reddy, Cardiac Surgery, UCSF, 505 Parnassus Ave, M593, San Francisco, CA 94143-0118
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Abstract
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A simple and effective technique for repair of secundum atrial septal defect is described. The heart is exposed through a limited midline skin incision and partial sternotomy, and the atrial septal defect is closed through a right atriotomy with ascending aortic and dual venous cannulation. This approach achieves a cosmetically superior result with standard instrumentation and cardiopulmonary bypass techniques, without compromising exposure or using peripheral incisions.
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Introduction
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A variety of approaches are employed for the repair of secundum atrial septal defect. In this report, we describe a simple and effective technique for open surgical closure of this common lesion. Our approach achieves a cosmetically superior result with use of standard instrumentation and cardiopulmonary bypass techniques, without compromising exposure or using peripheral incisions.
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Technique
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A limited midline vertical incision is performed starting at the nipple level and extending inferiorly across two to three interspaces (3 to 8 cm depending on the body size). Generous skin flaps are raised and retracted away to allow visualization of the entire sternum. A sternal saw is then used to perform a partial sternotomy, which spares the manubrium and completely preserves both the soft tissue and the bony geometry of the upper sternum and the sternal notch. The sternotomy is started at the xiphoid and continued to the sternomanubrial junction (Fig 1). A standard chest retractor is used to spread the sternum. In children the manubrium is usually pliable enough to allow some stretch. A small amount of bleeding from the crotch of the manubrium is controlled with bone wax.
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Fig 1. A small incision across two intercostal spaces is performed (3 to 8 cm). A partial sternotomy starting from the xiphoid and extending to the sternomanubrial junction is used (dashed line).
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Dual atrial pursestring sutures are placed: one in the tip of the appendage and one in the free wall. The pursestring suture in the appendage is used for retraction to expose the aorta (Fig 2). Aortic cannulation is performed just above the sinotubular junction with the aid of a side-biting partial occluding clamp. Two straight venous cannulas are placed through the atrial pursestring sutures into the superior and inferior venae cavae with the cannulas crossing in the atrium (Fig 3). Snares are placed around both cavae. A second pursestring suture is placed in the proximal aorta for a vent needle (see Fig 2). The aorta is not cross-clamped. Cardiopulmonary bypass with fibrillatory arrest is instituted in the standard manner. The patient’s temperature is allowed to drift with no active cooling.
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Fig 2. A pursestring suture in the right atrial appendage is used to retract the appendage inferiorly and provide exposure of the aorta. The upper aortic pursestring suture is for the cannula; the lower is for the vent needle.
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Fig 3. Standard aortic cannulation is used. Inferior vena caval (IVC) and superior vena caval (SVC) cannulas are advanced through pursestring sutures in the atrium. Both cavae are snared. The SVC cannula is placed through the lower pursestring and the IVC cannula through the upper. The cannulas cross in the atrium. The cannulas are not yet snared in this figure.
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The atrial septal defect is exposed via a right atrial incision (see Fig 3). The defect is closed primarily or with a pericardial patch harvested and fixed in glutaraldehyde at the beginning of the procedure (Fig 4). A vein retractor is used to elevate the crossing venous cannulas and provides good exposure. A cardiotomy suction catheter is placed in the coronary sinus. Care is taken to maintain a blood level in the left atrium to avoid air embolism. The patch is then sewn to the defect with continuous 5-0 polypropylene suture. Alternatively, the defect may be closed directly with suture.
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Fig 4. A vein retractor is placed under the crossing venous cannulas for retraction, and a cardiotomy suction catheter is placed in the coronary sinus. An autologous pericardial patch (P) is used to close the defect with a continuous suture technique.
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Standard deairing maneuvers are conducted, including complete filling of the left atrium before the final suture is placed in the defect, inversion of the left atrial appendage, and ventilation. A vent needle is placed in the aorta and the patient is placed in steep Trendelenberg position. The fibrillator is removed and defibrillation performed when necessary. Cardiopulmonary bypass is discontinued in the standard fashion. A single mediastinal drain and a single ventricular pacing wire are placed. No intracardiac lines are used. The sternum is rewired and the chest is closed in the standard fashion.
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Comment
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The term "minimally invasive" is a poorly defined but commonly used buzzword that is applied to a wide array of techniques ranging from catheter-based procedures to general surgical procedures that are still fairly invasive. It is important to keep in mind the objectives of minimizing the invasiveness of a procedure and to balance the benefits against the drawbacks. Surgical repair of an atrial septal defect via a median sternotomy is routinely performed with minimal morbidity and mortality at most centers. As the operation has become routine, secondary factors such as cost, convalescence time, and cosmetics of the operation (ie, size and location of the incision) assume greater importance. This has been the rationale for modified surgical approaches for repair of atrial septal defects, such as a submammary incision and anterolateral thoracotomy. It has also been one of the driving forces behind percutaneous device closure.
The gold standard for repairing a secundum atrial septal defect today remains surgical closure, with median sternotomy the prevalent approach at most centers. Various other approaches have been used as well. Bilateral submammary incisions (with median sternotomy) and right anterolateral thoracotomy with both femoral and aortic/atrial cannulation have been described. Video-assisted repair with femoral cannulation also has been reported [1–3]. These approaches are not necessarily less invasive or more benign than a modified median sternotomy. For example, breast and pectoral maldevelopment has been noted after thoracotomy, especially when the operation is carried out before the clear development of the submammary crease in children [4]. Moreover, all of these approaches require either specialized instrumentation or peripheral incisions. Most of these approaches were developed initially for coronary artery bypass grafting but are now being applied in congenital heart operations [1, 5–8].
Our limited-exposure approach to the repair of atrial septal defect uses standard instrumentation and cannulation techniques without any peripheral incisions, and simultaneously provides a cosmetically superior result for the patient while ensuring maximal surgical security. Security is provided by the ability to perform a full sternotomy expeditiously and to have complete access to the entire mediastinum if necessary. Since 1992, we have repaired secundum atrial septal defects through a limited midline incision with partial sternotomy in 101 patients; none of the procedures had to be converted to a full sternotomy. There has been no mortality and no significant morbidity (minor morbidity included transient junctional tachycardia in 2 patients, intraoperative aortic repair in 1, pneumothorax in 1, and increased chest tube output not requiring transfusion in 1).
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References
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- Massetti M., Babatasi G., Rossi A., et al. Operation for atrial septal defect through a right anterolateral thoracotomy: current outcome. Ann Thorac Surg 1996;62:1100-1103.[Abstract/Free Full Text]
- Laks H., Hammond G. A cosmetically acceptable incision for the median sternotomy. J Thorac Cardiovasc Surg 1980;79:146-149.[Abstract]
- Brutel de la Riviere A., Brom G., Brom A. Horizontal submammary skin incision for median sternotomy. Ann Thorac Surg 1981;32:101-104.[Abstract]
- Cherup L., Siewers R., Futrell J. Breast and pectoral muscle maldevelopment after anterolateral and posterolateral thoracotomies in children. Ann Thorac Surg 1986;41:492-497.[Abstract]
- Grinda J.M., Folliguet T.A., Dervanian P., Mace L., Legault B., Neveux J.Y. Right anterolateral thoracotomy for repair of atrial septal defect. Ann Thorac Surg 1996;62:175-178.[Abstract/Free Full Text]
- Rosengart T.K., Stark J.F. Repair of atrial septal defect through a right thoracotomy. Ann Thorac Surg 1993;55:1138-1140.[Abstract]
- Tsai F.C., Lin P.J., Chang C.H., et al. Video-assisted cardiac surgery: Preliminary experience in reoperative mitral valve surgery. Chest 1996;110:1603-1607.[Abstract/Free Full Text]
- Stevens J., Burdon T., Peters W., et al. Port-Access coronary artery bypass grafting: a proposed surgical method. J Thorac Cardiovasc Surg 1996;111:567-573.[Abstract/Free Full Text]
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Abstract
Introduction
