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Ann Thorac Surg 2000;69:981-982
© 2000 The Society of Thoracic Surgeons
a Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
e-mail: mbauer{at}dhzb.de
To the Editor
We read with great interest the article by Cremer and associates with regard to three different approaches for minimally invasive closure of atrial septal defects (ASD) [1]. They treated a total of 24 patients (age 35 ± 11 years) with uncomplicated ASD. Most of the patients were treated by a right submammary incision (n = 19), and the others through a right parasternal incision. The length of the thoracotomy incision was between 6 and 8 cm. The operations were done with electrically induced ventricular fibrillation (26.1 ± 8.6 minutes). Each approach necessitated additional incisions for arterial and/or caval cannulation. In one patient, femoral artery dissection occurred. There are several reports in the literature about the correction of congenital heart defects through a right anterolateral submammary incision with [2] and without cannulation of peripheral vessels [3, 4].
We would like to present our experience of the treatment of patients with ASD by the use of, as we call it, less invasive approaches with special emphasis on complete central cannulation through the thoracotomy incision. From June 1996 to January 1999, we used less invasive techniques for the correction of ASD (n = 35) and ASD with partial anomalous pulmonary venous connection (PAPVC) (n = 7). We performed right anterior submammary thoracotomy (skin incision 6 to 12 cm) in 29 patients (average age 17 years) and partial inferior sternotomy (skin incision 4 to 7 cm) in 13 patients (average age 7 years). We preferred the submammary thoracotomy for patients who already manifested breast development in order to avoid breast deformities in growing adolescents and small children. The main point of our concept is to perform cannulation of the aorta and the great veins always through the thoracotomy. Aortic cannulation may prove to be rather difficult, and it is for this reason that the suture for the cardioplegic cannula should be applied first to enable better handling of the vessel. The cannula is inserted by grasping it with forceps and guiding it into the previously performed aortic incision.
In contrast to Cremer and associates, we always close ASD in adult patients with a pericardial patch to avoid distortion of the septum and the tricuspid valve. Apart from very small defects, which are directly closed, we used antegrade cold crystalloid cardioplegic solution for myocardial protection (n = 36). The aortic clamp time was 17 ± 8.7 minutes. The extracorporeal circulation was performed under normothermic conditions. De-aeration of the heart was done retrograde before complete closure of the septal defect and the atriotomy, and antegrade over the ascending aorta before and after release of the aortal clamp or defibrillation of the heart by connecting suction to the cardioplegic cannula. The peri- and postoperative course was uneventful in all patients.
We feel that our technique provides a safe and cosmetic approach for the correction of congenital heart defects in selected patient groups. The length of the submammarian skin incision does not matter, because it is hidden in the submammary fold. The operation is possible using standard instruments, cannulation, and heart-lung machines. Additional approaches for extracorporeal circulation are unnecessary and can be avoided.
References
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