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Ann Thorac Surg 2000;69:982
© 2000 The Society of Thoracic Surgeons
a Cardiovascular Surgery, University Hospital Kiel, Arnold-Heller-Straße 7, D-24105 Kiel, Germany
e-mail: jcremer{at}kielheart.uni-kiel.de
To the Editor
The letter of Bauer and associates and the most recent publication of Daebritz and associates [1] indicate that there is an ongoing discussion on techniques of ASD closure aiming towards superior cosmetic results but simultaneously applying safe surgical approaches.
The basic question behind all of this is how far should we go and what amount of sophisticated technology makes sense to close a so-called simple ASD. The whole spectrum of techniques extends between a conventional full sternotomy approach and endoclamp technology eventually combined with robotics.
Regarding the concept introduced by Bauer and associates, I think a few comments should be made. They mention two principally different approaches assumingly based on the age of the patient. Thus, in the one group (n = 29, mean age 17 years), a limited anterior thoracotomy is applied, in contrast to the other group (n = 13, mean age 7 years), who received a partial inferior sternotomy. Central cannulation and cardioplegic arrest are common in both groups.
Regarding the central aortic cannulation in the elderly group (anterior thoracotomy), they admit that the handling of the aorta is at least tough, and what we would expect from our own experience (including a similar approach) requires an adequately incision to do it safely. In this content, it is not our experience that the length of the incision is meaningless for the patient because the scar is not at all barely visible hidden in the submammary fold, truly not in young men, who have no particularly expressed fold.
Concerning femoral artery cannulation, it has long been proven that it is safe unless atherosclerosis is absent, as is regular in younger aged patients. The one local dissection we had was due to an attempt to introduce an oversized cannula into the vessel.
The conventional aortic clamp also needs some (avoidable) space for the incision, which can be safely obviated applying ventricular fibrillation in such procedures.
Like Bauer and associates, we also in the meanwhile use pericardial patches more liberally, primarily not for reasons of distortion of the septum but for reasons of a better visualization of the defect margins.
Coming to their group of younger individuals, it may be debatable whether a supposed inversed L-incision or T-incision is a good solution. Asymmetric sternal growth may develop and injury of at least one internal mammary has to be expected. Why not do a limited posterior thoracotomy (P. Vouhe, meeting comment) or apply a transxiphoid approach, as proposed by van de Wal and associates [2] in these children.
Even though the numbers of ASDs subjected to surgery in times of interventional ASD closure become increasingly low, the interest for debating sophisticated technical means still remains unbroken.
References
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