Ann Thorac Surg 2000;69:872-876
© 2000 The Society of Thoracic Surgeons
Original Articles
Fast-track congenital heart operations: a less invasive technique and early extubation
Stefano M. Marianeschi, MDa,
Francesco Seddio, MDa,
Doff B. McElhinney, MDa,
Luisa Colagrande, MDa,
Raul F. Abella, MDa,
Teresa de la Torre, MDa,
Marco Meli, MDa,
Fiore S. Iorio, MDa,
Carlo F. Marcelletti, MDa
a Department of Pediatric Cardiac Surgery, Hesperia Hospital, Modena, Italy
Address reprint requests to Dr Marcelletti, Department of Pediatric Cardiac Surgery, Hesperia Hospital, Via Arquà 80/A, 41100 Modena, Italy
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Abstract
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Background. Many novel techniques have been described for "minimally invasive" congenital cardiac operations to achieve an improved cosmetic result. There is little information on incorporation of such techniques into fast-track congenital heart operations.
Methods. We have developed an approach to fast-track congenital heart operations, which includes a cosmetic approach for repair of congenital heart defects without sacrificing adequate exposure or requiring specialized equipment, along with a simple approach to intraoperative anesthetic management that allows extubation in the operating room. The heart is exposed through a short midline skin incision and a full median sternotomy. The conventional technique of cannulation is performed. Between October 1997 and January 1999, 88 patients were operated on with this method. Cardiac anomalies included simple and complex ostium secundum atrial septal defect, sinus venous atrial septal defect, partial atrioventricular septal defect, simple and complex ventricular septal defect, and bicuspid aortic valve stenosis.
Results. There were no operative or late deaths. The majority of patients were extubated in the operating room or within 2 hours of operation. No patient underwent reoperation and the mean length of hospital stay was 3.9 days. Sternal instability or wound infection were not observed.
Conclusions. We believe that our approach to fast-track congenital heart operation is safe and effective. The surgical technique provides good exposure and has excellent cosmetic results. Moreover, it is easy to learn and, if necessary, the surgeon can quickly gain direct access to the heart. The anesthetic management facilitates early tracheal extubation and a shorter duration of postoperative stay.
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Introduction
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In the current era, "minimally invasive" cardiac operation has become increasingly used for the repair of both acquired and congenital heart disease. The term minimally invasive is used rather broadly to mean new or smaller incisions, modified approaches to cardiac access, operation on a beating heart, or specialized equipment. In patients with congenital heart disease, the primary benefits of less invasive surgical techniques are likely to be improved cosmetic results and possibly shorter periods of in-hospital convalescence. In conjunction with a "fast-track" strategy, such techniques may be used to decrease hospital stay and cost. These objectives, however, should not take precedence over safety and meticulous repair. In our institution, we have developed a simple method for performing a limited midline skin incision along with a conventional full median sternotomy, which allows us to achieve both a superior cosmetic result and optimal safety and exposure with standard techniques of cannulation and cardiopulmonary bypass and no specialized instrumentation. Furthermore, our patients were considered for a simple intraoperative anesthetic management that allows early tracheal extubation and shortening of the length of intensive care unit and hospital stays.
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Material and methods
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Patients
From October 1997 to January 1999, 88 patients with congenital heart disease underwent operation with our less invasive approach. At the time of operation, 14 patients were infants, with a median age of 6 months (range, 2 to 10 months), whereas the remaining 74 patients ranged in age from 1 to 43 years (median, 6 years). The median weights in infants and noninfants were 5.5 kg (range, 4 to 7 kg) and 20 kg (range, 8 to 74 kg), respectively. Informed consent was obtained for all patients.
The cardiac anomalies approached through our limited skin incision are summarized in Table 1 , and included simple and complex ostium secundum atrial septal defect, sinus venous atrial septal defect, partial atrioventricular septal defect, simple and complex ventricular septal defect, and bicuspid aortic valve stenosis. The clinical presentation varied according to the cardiac malformation. The diagnosis was made in all patients using cross-sectional and Doppler echocardiography.
Anesthetic management
Preanesthetic sedation is accomplished using rectal midazolam (0.5 mg/kg). Rapid induction of anesthesia requires administration of sevoflurane with the "single breath" technique consisting of a high concentration (8%) of gas for a few seconds to reach the desired state of anesthesia, after which the concentration of sevoflurane is reduced to a maintenance level of 2% to 3%. A bolus of sufentanyl (1 µg/kg) is administered with a weight-related dose of vecuronium bromide (0.15 mg/kg). After induction, anesthesia is maintained with a continuous infusion of sufentanyl 0.5 µg · kg-1 · h-1, sevoflurane (2% to 3%), and vecuronium bromide every 40 minutes. During cardiopulmonary bypass, the gas is stopped and midazolam 0.2 mg/kg is given. When bypass is off, the sufentanyl is decreased to 0.25 µg · kg-1 · h-1, and then to 0.10 to 0.15 µg · kg-1 · h-1, to provide maintenance analgesia. At the end of the operation, the sufentanyl is stopped and the effect of vecuronium bromide is reversed with administration of neostigmine and atropine. This anesthetic protocol permitted us to wean all patients from ventilator support on the day of operation.
Operative technique
The patient is prepared and draped in the usual manner. Depending on the age of the child, a 5- to 7-cm midline incision is made over the lower one-third of the sternum to the xiphoid process (Fig 1). The pectoralis major is separated from the sternum to allow for more extensive retraction with minimal tension once the median sternotomy has been performed later. The subcutaneous tissue is dissected away from the manubrium and upper sternum, up to the suprasternal notch, with electrocautery and skin retraction. A complete median sternotomy beginning from the xiphoid is performed with an oscillating saw. A standard sternal retractor is used to separate the sternal edges (Fig 2). After the thymus gland is removed, the pericardium is opened from the diaphragm to the aortic reflection. A portion of the pericardium is excised and treated in glutaraldehyde for possible use as patch material. The pericardial edges are then suspended with tacking sutures, thus exposing the heart and great vessels. A smaller sternal retractor is placed longitudinally to retract the superior and inferior apices of the midline skin incision. Cannulation is then performed as usual (Fig 3) , with mobilization and leftward retraction of the aorta to provide exposure for placement of a pursestring suture in the superior caval vein, and downward traction to facilitate cannulation of the ascending aorta by means of a partial occluding clamp. This procedure is more difficult and generally requires a longer time in young adults, because it is not as easy to mobilize the aorta in older patients than in children. The venous cannulas (Medtronic DLP Inc, Grand Rapids, MI) are inserted into the inferior and superior caval veins, with a straight cannula used for the superior caval vein and a right-angled cannula for the inferior caval vein. Cardiopulmonary bypass is initiated and maintained according to the cardiac anomaly and repair. Caval exclusion is achieved by snaring the cannulas around the vessels. In patients requiring cardioplegia, the pulmonary trunk is dissected free of the aorta, after which the aorta is clamped and cold crystalloid cardioplegia is given into the aortic root.
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Fig 3. Exposure is obtained with two retractors demonstrating the feasibility of standard cannulation.
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After completion of the operation, a single chest tube is inserted and the lower part of the sternum is closed in the usual fashion, whereas the upper part is easily reapproximated using Vicryl sutures instead of steel wires. Finally, the subcutaneous fascia and the skin are closed (Fig 4).
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Results
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All patients underwent complete repair according to the preoperative intent to treat. The average length of skin incision was less than 50% of the length of the sternum. In no patient was it necessary to convert the incision to full length. There were no operative death, no reoperation, and no complications related to the limited exposure technique. There were no cases of wound hematoma, wound infection, or sternal instability. The mean ± standard deviation cross-clamp and bypass times were 18 ± 10 and 42 ± 16 minutes, respectively. Operative time was not prolonged except in the learning period (3 to 4 months). The majority of patients (80%) were extubated in the operating room or within 2 hours of operation, and they were discharged from the intensive care unit an average of 10 hours after operation. Fifty-one patients (58%) with a median age of 7.5 years (range, 0.5 to 43 years) were extubated in the operating room, 19 patients (22%) with a median age of 5 years (range, 10 months to 37 years) were extubated within 2 hours, and the remaining 18 patients (20%), who ranged in age from 2 months to 8 years (median, 8 months), were extubated at more than 2 hours after the operation. There were no complications related to early extubation, and no patient required reintubation or readmission to the intensive care unit. Duration and volume of pleural drainage was no different from patients operated with standard incision. The average duration of hospital stay was 3.9 days.
At follow-up ranging from 1 to 14 months, there were no late deaths. No patient required treatment for wound or sternal complications, and all had good sternal stability at follow-up. The benefit in terms of cosmetic result was considerable (Fig 5) , and parental satisfaction was high.
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Fig 5. Second postoperative day. The length and location of the skin incision is shown in an 11-year-old boy.
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Comment
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In this report, we have described the results of our initial foray into the domain of fast-track congenital heart operations. Our strategy has been straightforward, with emphasis on a less invasive approach and a simple anesthetic approach that facilitates early extubation.
Various approaches have been developed to achieve an improved cosmetic result after pediatric cardiac operations, so-called minimally invasive or less invasive techniques [1]. Initially, such minimally invasive methods were applied to the repair of an atrial septal defect and other simple intracardiac anomalies. Several approaches for intracardiac repair without a midline skin incision have been used. For example, a submammary skin incision for a median sternotomy has been described, which offers the advantage of concealing the scar within the bikini line [2]. However, this technique requires a large subcutaneous flap, which may predispose to postoperative complications such as hematomas or hypesthesia of the breast tissue [3]. Another approach to the repair of intracardiac anomalies requiring a right atrial approach, which offers an alternative to sternotomy altogether, is a right thoracotomy. The disadvantages of this approach include reduced access to the mediastinum if complications should develop, as well as increased postoperative pain acutely, and a high likelihood of breast distortion as the child grows [4]. In a recent article, a technique was described to approach intracardiac lesions by means of projected images on the monitor through a thoracotomy incision, with femorofemoral cardiopulmonary bypass [5]. This technique requires peripheral incisions, specialized equipment, and does not allow ready access to the mediastinum in the event of an emergent complication. Moreover, these techniques are not necessarily less invasive than a midline approach, which is the quickest and most common method to approach the heart, and also provides optimal surgical exposure.
During the past several years, there has been an evolution in minimally invasive congenital heart operations toward the use of a ministernotomy approach. In 1992, Wilson and colleagues [4] developed a cosmetic approach consisting in a limited midline skin incision and an incomplete median sternotomy for repair of simple heart defects. More complex operations, however, required complete sternal transection and larger skin incision. Also in 1992, Tatebe and associates [6] described an alternative approach of a full median sternotomy with a short incision. Their technique, however, required a specific mechanical scapular retractor attached to the operating table to expose the sternal notch. Black and Freedom [7] found it unnecessary to use elaborate devices to enhance the exposure, performing a limited skin incision and a partial sternal split with an undersized sternal retractor and no specialized instruments. This technique was limited by restricted visualization of the extreme cephalad mediastinal structures, which allowed only repair of atrial septal defects.
In 1997, we developed a simple method for successfully performing a complete median sternotomy with limitation of the skin incision to less than 50% of the length of the sternum. It has been possible to gain good exposure by mobilizing the subcutaneous tissue in the manubrium sterni, along with downward traction on the ascending aorta to permit conventional techniques of cannulation without requiring any specialized equipment. Results with this technique have been excellent. The objective of minimally invasive cardiac operation is not simply to ensure a small scar, but also to minimize morbidity. In our experience, with the approach described in this report, we are able to provide a good cosmetic result without increasing the risk of complications or other morbidity. There are other advantages as well: the complete median sternotomy is routinely performed for other cardiac operations and the surgeon needs a short learning time to practice with a small operative field and to separate the sternal edges completely with a limited vertical skin incision. Moreover, given that the sternum is completely divided, the exposure is thorough, allowing excellent access even to the great vessels, permitting standard cannulation and the repair of congenital heart defects other than simple atrial septal defects. Although there is a complete median sternotomy, the sternum appears to heal quickly and well, and has been stable in all of our patients. Finally, in an emergency, more extensive access can be achieved quickly and easily, simply by extending the skin incision without losing time to complete the sternotomy. This may impart a higher level of safety to this approach compared with other less invasive techniques.
Gundry and colleagues [8] suggested that an easy approach to minimally invasive operation should allow a practicing surgeon to continue to use familiar tools and approaches for cardiac operations. Khan and associates [9] advanced the same opinion, describing a simple and effective method to repair atrial septal defects using standard equipment and cannulation techniques, with exposure through a limited midline skin incision and partial sternotomy. The concept that a conventional full median sternotomy is the main source of postoperative infections and blood loss has become widely accepted. Although reduction of these complications may eventually prove to be a benefit of partial sternotomy techniques, it is not clear whether such improvement will be countered by increased bypass times and less precise surgical technique, which may be a consequence of limited exposure in some patients. Nevertheless, in our experience there have been no sternal wound infections and no patient required reoperation for bleeding, and postoperative pain was well tolerated.
It has been demonstrated that the early extubation after cardiac operations for congenital heart disease has minimal risk in carefully selected patients, allowing reduced postoperative stays in the intensive care unit and hospital, as well as decreased cost of hospitalization [10–12]. Recently, Heinle and colleagues [12] reported excellent results using both intravenous and epidural opioids to accomplish early extubation in many neonates and young infants undergoing cardiac operation. No patient in this study required reintubation because of decreased ventilatory effort [12], although Valley and Bailey [13] reported a higher incidence of respiratory depression in patients who received supplemental intravenous opioids in addition to spinal axis morphine.
The anesthetic strategy that we use in our fast-track patients follows the philosophy of a simple method, using inhalational agents (sevoflurane) supplemented with modest doses of sufentanyl, which facilitates early tracheal extubation. Sufentanyl is used because of its shorter duration of action. We also used midazolam as a potent amnestic agent having a short half-life and no active metabolites. Finally, the pharmacologic reversal of any residual effect of muscle relaxants and complete rewarming before leaving the operating room led us to a significant reduction in the duration of mechanical ventilation and endotracheal intubation, avoiding the potentially deleterious effects of prolonged mechanical circulatory support.
In these exciting times of fast-track and minimally invasive cardiac operation creative new approaches to cardiovascular access have been developed, with varying results and flexibility of application. In addition, physicians are devoting increased efforts to the streamlining of perioperative care, in an effort to improve outcomes and patient satisfaction, while decreasing costs. In this evolving environment, we have developed a strategy that has been successful in these respects. We realize that there remains considerable room for progress, and more rigorous evaluation of the implications of such strategies, and plan to focus our efforts in this direction.
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References
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Akins C.W. Full sternotomy through a minimally invasive incision. Ann Thorac Surg 1998;66:1429-1430.[Abstract/Free Full Text]
-
Laks H., Hammond G.L. A cosmetically acceptable incision for the median sternotomy. J Thorac Cardiovasc Surg 1980;79:146-149.[Abstract]
-
Bédard P., Keon W.J., Brais M.P., Goldstein W. Submammary skin incision as a cosmetic approach to median sternotomy. Ann Thorac Surg 1986;41:339-341.[Abstract]
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Wilson W.R., Jr, Ilbawi M.N., DeLeon S.Y., Piccione W., Jr, Tubeszewski K., Cutilletta A.F. Partial median sternotomy for repair of heart defects. Ann Thorac Surg 1992;54:892-893.[Abstract]
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Wu Y.C., Chang C.H., Lin P.J., et al. Minimally invasive cardiac surgery for intracardiac congenital lesions. Eur J Cardiothorac Surg 1998;14(Suppl 1):154-159.
-
Tatebe S., Eguchi S., Miyamura H., et al. Limited vertical skin incision for median sternotomy. Ann Thorac Surg 1992;54:787-788.[Abstract]
-
Black M.D., Freedom R.M. Minimally invasive repair of atrial septal defects. Ann Thorac Surg 1998;65:765-767.[Abstract/Free Full Text]
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Gundry S.R., Shattuck O.H., Razzouk A.J., del Rio M.J., Sardari F.F., Bailey L.L. Facile minimally invasive cardiac surgery via ministernotomy. Ann Thorac Surg 1998;65:1100-1104.[Abstract/Free Full Text]
-
Khan J.H., McElhinney D.B., Reddy V.M., Hanley F.L. Repair of secundum atrial septal defect. Ann Thorac Surg 1998;66:1433-1435.[Abstract/Free Full Text]
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Schuller J.L., Bovill J.G., Nijveld A., Patrick M.R., Marcelletti C. Early extubation of the trachea after open heart surgery for congenital heart disease. Br J Anaesth 1984;56:1101-1108.[Abstract/Free Full Text]
-
Cheng D.C. Fast-track cardiac surgery. J Cardiothorac Vasc Anesth 1998;12:72-79.[Medline]
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Heinle J.S., Diaz L.K., Fox L.S. Early extubation after cardiac operations in neonates and young infants. J Thorac Cardiovasc Surg 1997;114:413-418.[Abstract/Free Full Text]
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Valley R.D., Bailey A.G. Caudal morphine for a postoperative analgesia in infants and children. Anesth Analg 1991;72:120-124.[Free Full Text]
Accepted for publication July 15, 1999.
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Abstract
Introduction
