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Ann Thorac Surg 1999;67:1648-1652
© 1999 The Society of Thoracic Surgeons

Original Articles

Different approaches for minimally invasive closure of atrial septal defects

Jochen T. Cremer, MDa, Andreas Böning, MDa, Marcel B. Anssar, MDa, Peter Y. Kim, MDa, Klaus Pethig, MDa, Wolfgang Harringer, MDa, Axel Haverich, MDa

a Division of Thoracic and Cardiovascular Surgery, Surgical Center, Hannover Medical School, Hannover, Germany

Accepted for publication November 24, 1998.

Address reprint requests to Dr Cremer, Department of Cardiac and Vascular Surgery, Christian-Albrechts-University, D-24105 Kiel, Germany


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 
Background. To improve the acceptance of cosmetic results after closure of atrial septal defects, anterior or lateral thoracotomies are preferred rather than median sternotomies. Along with the availability of minimally invasive techniques, a further reduction in incision length appeared feasible while preserving thoracic stability.

Methods. Various minimally invasive approaches differing in the type of incision and mode of cannulation have been applied under conditions of normothermic ventricular fibrillation. In technique 1 (n = 5), a right parasternal mini-incision was combined with a central aortic and bicaval cannulation. Technique 2 (n = 2) was composed of an anterior submammary mini-incision with femoral arterial and central bicaval cannulation. To optimize the surgical access, the transincisional cannulation of the superior vena cava was replaced by a percutaneous cervical cannulation (technique 3, n = 17).

Results. Effective atrial septal defect closure assessed by intraoperative echocardiography was achieved in all patients. Central neurologic complications were completely absent. Besides temporary atrial fibrillation in one case, no other cardiac complications occurred. There were no cases with complicated wound healing.

Conclusions. Along with modified cannulation techniques and intraoperative echocardiography, minimally invasive techniques can be safely applied for atrial septal defect closure. Submammary incisions were highly accepted and allowed for adequate surgical exposure.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 Acknowledgments
 References
 
Several attempts have been made to alleviate the psychologic sequelae of atrial septal defect (ASD) closure by unsatisfactory cosmetic results when applying conventional complete sternotomy approaches in otherwise absolutely healthy individuals. Thus, right thoracotomies have been considered for several years, especially for female patients [1–4]. The incision may be located more anterior [5] or more lateral [6], allowing for adequate opening of the fourth intercostal space. Depending on the approach, aortic or femoral-iliac arterial cannulation may be applied under ventricular fibrillation or cardioplegic arrest. Even a combination of bilateral submammary skin incisions and median sternotomy [7] requiring extensive mobilization of the subcutaneous tissue has been attempted to gain cosmetically acceptable results. With the aid of new retractors designed for minithoracotomies and specially adapted cannula designs, minimally invasive techniques have become applicable for this diagnosis.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 Acknowledgments
 References
 
Since October 1996, three different surgical approaches with incisional lengths between 6 and 8 cm were evaluated in 24 individuals (13 men, 11 women; 35 ± 11 years) with uncomplicated ASD (Table 1). Significant atrial shunts were present in 23 patients, and 6 patients had previous neurologic events from paradoxic embolization through a patent foramen ovale. Preoperative pulmonary artery pressure was elevated in 1 patient.


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  		Table 1. Patients and Procedure-Related Data

 
The principal differences among these techniques involve different incisions and different modes of cannulation. All procedures were performed under normothermic (33° to 35°C) electrically induced ventricular fibrillation with conventional anesthesia (etomidate, fentanyl, pancuronium bromide) and double-lumen intubation. Patients were positioned with 30° elevation of the right hemithorax and draped to allow conversion to sternotomy as well as bilateral exposure of groin vessels. External defibrillation pads were placed and intraoperative transesophageal echocardiography (TEE) served for assessment of complete removal of air and effective ASD closure. The different procedures were limited to adolescents or adults, whereas a subxiphoidal approach was used in children by another team.

Technique 1: right parasternal mini-incision, aortic and central venous cannulation
Thoracic access was achieved by a right parasternal incision above the third and fourth ribs (Fig 1). In the first 2 patients, a small cartilaginous part of both ribs was removed before inserting the retractor (Cardiothoracic Systems, Cupertino, CA). Ligation of the right internal mammary artery was not necessary. After exposure and longitudinal incision of the pericardium, pledgeted traction sutures were placed to displace intrapericardial structures more anteriorly and laterally, allowing for better access to the aorta and right atrium. After encircling the inferior vena cava (IVC) and superior vena cava (SVC), full heparinized cardiopulmonary bypass was instituted by direct cannulation of the aorta (21F or 24F, Jostra, Hirrlingen, Germany) and SVC (V122, Stöckert, Munich, Germany). The IVC cannula (28F or 32F, Polystan, Vaerlose, Denmark) was guided through a separate lateral incision, which was used later for placement of a single drainage tube. On total bypass, the right atrium was entered through a conventional incision, and direct or patch closure was performed with over-and-over (4-0 polypropylene) sutures with superficial suction through the defect and continuous coronary sinus suction. Before tying the suture, air was removed from the left atrium under TEE guidance. Decannulation was performed after defibrillation using either external or internal pediatric pads. The pericardial edges were then reapproximated. In cases without removal of the cartilaginous parts, the ribs were repositioned with absorbable sutures before regular wound closure.



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  		Fig 1. Technique 1: right parasternal mini-incision, aortic and central venous cannulation.

 
Technique 2: right submammary mini-incision, femoral arterial cannulation, and central venous cannulation
An anterior submammary 6- to 8-cm-long incision served for thoracic access through the fourth interspace (Fig 2). An additional oblique 3-cm groin incision within the inguinal fold allowed adequate exposure and subsequent cannulation (A252, Stöckert) of the common femoral artery. After longitudinal pericardial incision (about 3 cm above the phrenic nerve) and positioning of stay sutures, the SVC was encircled, which occasionally was a difficult maneuver. In contrast, encircling of the IVC was usually easy. Both venae cavae (V122, Stöckert, or inflatable 37F, DLP, Grand Rapids, MI) were cannulated through the right atrium, and again the IVC cannula (Polystan) was guided through a different port incision. Closure of the ASD, removal of air, and decannulation were similar to technique 1. Wound closure was performed in the regular fashion.



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  		Fig 2. Technique 2: right submammary mini-incision, femoral arterial and central venous cannulation.

 
Technique 3: right submammary mini-incision, femoral arterial cannulation, right atrial cannulation, and percutaneous jugular vein cannulation
The thoracic and inguinal incisions were the same as in technique 2. In contrast, a previously placed central venous catheter through the right jugular vein was used to cannulate the SVC (15F Medtronic percutaneous Biomedicus Cannula, Minneapolis, MN) by the Seldinger technique (Figs 3, 4). Thus, encircling the SVC was avoided, and instead a suitable vascular clamp was placed when going on total bypass. To improve venous return from the SVC through the small 15F cannula, an additional centrifugal pump was added to the routine heart-lung machine set. This allowed active venous suction, thereby increasing venous drainage up to 2 to 3 L/min through the applied 15F cannula. For drainage of the IVC a newly designed, flat, low-profile, right-angled cannula (34F single-stage venous cannula oval, DLP) became available and was introduced through the incision itself. Atrial incision and ASD closure were similar to technique 1. After heparin reversal the jugular vein was decannulated, and local compression was applied until the bleeding stopped. Wound closure was similar to technique 2.



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  		Fig 3. Technique 3: right submammary mini-incision, femoral arterial cannulation, right atrial cannulation, and percutaneous jugular vein cannulation.

 


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  		Fig 4. Surgeon’s view in technique 3.

 

   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 Acknowledgments
 References
 
Complete ASD closure without the presence of residual shunts was assessed by TEE before coming off bypass. Tension-free direct closure was possible in 18 patients, whereas patch closure became necessary in the remaining 6 patients, implanting pericardial (n = 3) or prosthetic patches (n = 3, Table 1). The required period of ventricular fibrillation varied between 10 and 43 minutes (26.1 ± 8.6 minutes) (Table 1). Levels of creatine kinase and its myocardial isoform creatine kinase-MB peaked at 540 ± 344 U/L and 20.8 ± 7.1 U/L, respectively, whereas maximal creatine kinase-MB level represents 3.9% of total creatine kinase release. All patients maintained sinus rhythm and neither cardiac nor neurologic complications occurred. Local femoral artery dissection required conversion to a conventional midsternotomy approach and a femoral vascular repair in 1 patient. Rupture of a breast implant occurred in 1 woman after submammary incision. Thoracic wall herniation was not observed in any of the patients regardless of the type of incision. Cases of wound dehiscence or infections were completely absent. None of the patients presented with arteriosclerotic femoral lesions. Because of the maintained standard anesthesia protocol, the average postoperative ventilation had to be extended to 8.2 ± 2.8 hours, and patients were kept in the intensive care unit for 1 day and were discharged after 8.7 ± 2.9 days, which appears to be a relatively short period in terms of usual policies in our current health system. Intermittent atrial fibrillation occurred in 1 patient. All patients were satisfied with the cosmetic result, especially when applying technique 3 (Fig 5).



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  		Fig 5. Cosmetic postoperative result in a 28-year-old woman after atrial septal defect patch closure applying technique 3.

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
Acknowledgments
 References
 
Various attempts have been made to correspond to the desire of especially younger and otherwise healthy individuals with ASDs for cosmetically satisfying incisions. Until recently, submammary anterior or lateral thoracotomies have been favored in this situation. Along with the introduction of new minimally invasive concepts in the field of coronary and valvular surgery, reduced incisional lengths have also been discussed for ASD closure.

Respecting that surgical ASD closure requires total cardiopulmonary bypass, the mode of cannulation and the access to the SVC and IVC represents one key issue of minimally invasive ASD closures. Because femoral venous cannulation is associated with the risk of iliofemoral vein thrombosis, central cannulation of the IVC was preferred. Among different cannula types, a specially designed low-profile right-angled prototype cannula (DLP), introduced through the incision itself, appeared to be superior in handling and presentation of the surgical field. Cannulas inserted through separate port holes (technique 1) did not perform better and impaired the efficacy of pericardial traction sutures. Additional cannulation of the SVC through the same incision limited operative exposure and was technically difficult, even when using cannulas with an inflatable cuff (DLP 91037). In this situation, a high-flow small-diameter cannula (Biomedicus percutaneous cannula, Medtronic), placed through the jugular vein by Seldinger’s technique, represented the most attractive option. The potential risk of local thrombosis was estimated to be acceptably low secondary to the extensive experience and proved safety of regular central venous catheterization. This was confirmed by postoperative Doppler sonography of the jugular vein in our patients.

Preferring a submammary mini-incision over a right parasternal minithoracotomy, direct aortic cannulation appeared to be hazardous and femoral arterial cannulation was used instead. However, as in one of our patients, small vessel size may complicate the procedure but the risk of sclerotic embolization should be negligible in patients with ASDs. Complete aortic dissection, as reported in minimally invasive mitral valve operations [8], using specially designed transfemoral arterial cannulas functioning additionally as endoclamps (Heartport Inc, Redwood City, CA), has not been observed thus far.

The different procedures have not been applied on an alternating basis but rather represent a continuous development of approaches in discussion with advancing minimally invasive techniques and instrumentation.

The use of a right parasternal incision as in our first series of patients (group 1) requires dissection of at least two ribs, and possible ligation of the right internal mammary artery may be required. As the incision is asymmetrical and easily visible, the cosmetic results may not be satisfying even though incision length is short. In contrast, a submammary incision avoids some principal disadvantages of parasternal incisions inasmuch as rib destruction and internal mammary artery injury are avoided. However, in adolescent patients the future breast development has to be respected, just as in other anterior perimammary incisions [9].

The exposure of ASDs through mini-incisions with a fibrillating heart is not absolutely easy but is manageable with superficial suction that allows for direct or patch closure of the defect. Along with a left atrial suction, the completeness of air removal is a critical point of the procedure and should be controlled by intraoperative TEE as already described for other heart procedures [10]. None of our patients experienced neurologic complications with this technique. The completeness of the ASD closure was also assessed by TEE. Additional thoracic CO2 insufflation was not applied.

In addition to these more technical problems, the question arises whether fibrillation times of up to more than 40 minutes are tolerable under normothermic conditions. In this context, the investigations of Cox and colleagues [11] indicate that normothermic fibrillation appears safe under comparable circumstances. Thus, a significant release of the myocardial isoform of creatine kinase or deterioration of ventricular function has not been observed in our groups.

After evaluating different surgical approaches using mini-incisions for ASD closure, a safe and effective method is feasible. Small anterior submammary minithoracotomies are currently favored. Compared with conventional surgical procedures, a sophisticated adaptation of cannulation techniques is required to gain optimal access through mini-incisions. Because of the restricted exposure and limited air-removing procedures, a reliable means of assessing operative results is mandatory, preferably by TEE. Thus, adequate surgical results at a low complication rate can be expected, associated with a major benefit for these usually younger individuals in terms of superior cosmetic appearance, accelerated postoperative recovery, and improved exercise tolerance.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
References
 
We sincerely appreciate the professional expertise of Mrs Hannelore Laue and Mrs Bärbel Bornholdt-Dudler in preparing the manuscript. In addition, we are especially grateful to Mr Helmut Kreczik and Mrs Susanne Czichos for contributing the drawings and illustrations.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Kirklin J.W., Barratt-Boyes B.G. Atrial septal defect and partial anomalous pulmonary venous connection. In: Kirklin J.W., Barratt-Boyes B.G., eds. Cardiac surgery, 1st ed. New York: Churchill Livingstone, 1988.
  2. Lancaster L.L., Mavroudis C., Rees A.H., Slater A.D., Ganzel B.L., Gray L.A. Surgical approach to atrial septal defect in the female. Am Surg 1990;56:218-221.[Medline]
  3. Rosengart T.K., Stark J.F. Repair of atrial septal defect through a right thoracotomy. Ann Thorac Surg 1993;55:1138-1140.[Abstract]
  4. Grinda J.M., Folliguet T.A., Dervanian P., Macé 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]
  5. 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]
  6. Dietl C.A., Torres A.R., Favaloro R.G. Right submammarian thoracotomy in female patients with atrial septal defects and anomalous pulmonary venous connections. J Thorac Cardiovasc Surg 1992;104:723-727.[Abstract]
  7. Laks H., Hammond G.L. A cosmetically acceptable incision for the median sternotomy. J Thorac Cardiovasc Surg 1980;79:146-149.[Abstract]
  8. Mohr F.W., Falk V., Diegeler A., Walther T., van Son J.A.M., Autschbach R. Minimally invasive port-access. Mitral valve surgery. J Thorac Cardiovasc Surg 1998;115:567-576.[Abstract/Free Full Text]
  9. Cherup L.L., Siewers R.D., Futrell J.W. Breast and pectoral muscle maldevelopment after anterolateral and posterolateral thoracotomies in children. Ann Thorac Surg 1986;41:492-497.[Abstract]
  10. Falk V., Walther T., Diegeler A., et al. Echocardiographic monitoring of minimally invasive mitral valve surgery using an endoaortic clamp. J Heart Valve Dis 1996;5:630-637.[Medline]
  11. Cox J.A., Anderson R.W., Pass H.A., et al. The safety of induced ventricular fibrillation during cardiopulmonary bypass in nonhypertrophied hearts. J Thorac Cardiovasc Surg 1977;74:423-432.[Medline]

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