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Ann Thorac Surg 2000;70:115-118
© 2000 The Society of Thoracic Surgeons

Original articles: Cardiovascular

Minimal access approach for the repair of atrial septal defect: the initial 135 patients

David P. Bichell, MDa, Tal Geva, MDa, Emile A. Bacha, MDa, John E. Mayer, MDa, Richard A. Jonas, MDa, Pedro J. del Nido, MDa

a Departments of Cardiology and Cardiovascular Surgery, Children’s Hospital, Boston, Massachussetts, USA

Address reprint requests to Dr Bichell, Department of Cardiovascular Surgery, Children’s Hospital, 3030 Children’s Way, San Diego, CA 92123


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 References
 
Background. From May 1996 to August 1998 a minimal access approach was used for 135 of 200 consecutive surgical atrial septal defects closures in children through young adults ranging in age from 6 months to 25 years (median 5 years).

Methods. A 3.5- to 5-cm midline incision was centered over the xiphoid with division of the xiphoid alone (transxiphoid) or of the lower sternum (ministernotomy); both groups underwent bicaval venous cannulation through the incision. Cardioplegia and aortic cross-clamping were administered through the incision. Cephalad retraction of the sternum with a fixed-arm retractor aided exposure.

Results. There have been no early or late deaths and no bleeding or wound complications. No procedure required conversion to a full sternotomy, and no cannulation attempt was abandoned for an alternate site. Cross-clamp and cardiopulmonary bypass times were equivalent to those in the full sternotomy group. The mean length of hospital stay in the ministernotomy group was 2.7 days.

Conclusions. The closure of atrial septal defects can be performed through a transxiphoid or ministernotomy approach, conferring a satisfactory cosmetic result without compromising the safety or accuracy of the repair.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 References
 
Techniques and specialty equipment for so-called minimally invasive open heart procedures have proliferated in recent years, changing the approach to and sometimes the philosophy of proven conventional procedures. Ironically, with cost containment as one driving force, minimally invasive approaches to some of these procedures have spawned a proliferation of costly, often disposable specialty instrumentation, possibly raising the cost of some procedures beyond that of more conventional approaches. Although the new minimally invasive approaches are appealing to patients for the small scars that result and appealing to managed care organizations for the potential of diminished hospital stay and overall cost, the surgeon must be cautious in looking beyond market enthusiasm to assure that the new procedures are equivalent to conventional approaches in efficacy and safety.

To that end, we have examined the results of 200 consecutive surgical atrial septal defect (ASD) closures at our institution, performed by minimal access or full sternotomy approaches, according to surgeon’s preference. Of note, the full sternotomy group is becoming an historical control rather than a contemporary standard procedure; at present all uncomplicated ASDs are closed by a minimal access approach by all surgeons at this institution, in contrast with the first year studied. Our applications of the minimal access approach have expanded to include the repair of more complex congenital cardiac lesions.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 References
 
We reviewed 213 consecutive surgical ASD closures performed at the Children’s Hospital, Boston between May 1996 and August 1998. Thirteen patients who underwent reoperative sternotomy (n = 7), thoracotomy (n = 2) or complicating concomitant procedures (n = 4) were excluded, leaving 200 isolated nonreoperative ASD closures. Patient ages ranged from 1 month to 34 years (median 4 years). Diagnosis was made by preoperative echocardiogram. Included were 167 secundum ASDs, 14 primum ASDs, 17 sinus venosus ASDs, and 2 coronary sinus defects (Table 1). Defects were repaired by full sternotomy in 65 of 200 patients aged 1 month to 34 years (median, 3 years), and by ministernotomy in 135 patients aged 6 months to 25 years (median, 5 years), according to surgeon’s preference. Among the 135 patients with defects repaired by ministernotomy, arterial cannulation was aortic in 95 and femoral arterial in the remaining 40, again by surgeon’s preference. The smallest patient undergoing femoral artery cannulation weighed 9.4 Kg.


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  		Table 1. Anatomic Characteristics and Approach

 
Methods
We followed our current ASD closure procedure in this study: Patients are positioned supine with a transverse shoulder roll and extended neck. The skin incision is 3.5 to 5 cm, with its superior extent at or below the nipple level. Skin flaps are raised to mobilize the incision. The xiphoid and lower sternum or xiphoid alone (in patients < 5 years of age) is split in the midline. A pediatric sternal retractor spreads the partial sternotomy. The apex of the partial sternotomy is engaged by an Army-Navy retractor (Pilling-Weck, Research Triangle Park, NC), stabilized by a fixed-arm, table-based Bookwalter retractor system (Codman, Randolph, MA), used to retract the thorax cephalad and expose the aortic root and adjacent structures. The apex of the pericardotomy is also engaged behind the Army-Navy retractor blade or fixed by suture to the posterior table of the sternum to lift the aorta further into view, and pericardial suspension sutures on the right sie aid in exposing the right atrium, allowing the apex of the heart to fall unsuspended. Cannulation purse-string sutures are placed in the ascending aorta, the atrium–inferior vena caval junction, and the superior vena caval or right atrial appendage. After systemic heparinization, a thin-walled wire wound arterial cannula with rigid occluder (Medtronic-Biomedicus, Eden Prairie, MN) is introduced directly into the aortotomy or over a wire through a needle at the purse-string site. A metal-tipped right angle venous cannula (DLP, Grand Rapids, MI) is used for the inferior vena cava and for direct cannulation of the superior vena cava. Placement of arterial and venous cannulas through the small incision is facilitated by controlling the cannula near its point of insertion with a curved clamp. Alternatively, the superior vena cava can be cannulated with a straight venous cannula (Medtronic-Biomedicus) or a cuffed endotracheal tube (Mallinckrodt, St Louis, MO) advanced through the right atrial appendage. Tourniquetted caval tapes are placed, or, alternatively, a cuffed endotracheal tube in the superior vena cava is gently inflated. A vented cardioplegia cannula (DLP) placed in the proximal ascending aorta delivers cardioplegia and serves as an aortic root vent. Cardiopulmonary bypass is commenced and the patient cooled to 32°C to 34°C. The aorta is cross-clamped through the incision with an angled cross-clamp or Gregory profunda clamp (Pilling-Weck), and cardioplegic arrest is brought about. Closure of the ASD is carried out through atriotomy, using a suture or pericardial patch (Fig 1). The cross-clamp is removed after air is eliminated from the left heart, and the patient is rewarmed and separated from cardiopulmonary bypass. A single chest tube or silicone Jackson-Pratt drain with bulb suction reservoir (Baxter Healthcare, Deerfield, IL) is placed, traversing the right pleural space and a routinely created pericardial window. The lower sternum is reapproximated with a wire, and the soft tissues are closed in layers. Bupivicaine is infused subcutaneously around the incision.



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  		Fig 1. Parasagittal cutaway view of subxiphoid incision showing cephalad retraction of the sternum, bicaval and aortic cannulas, cardioplegia, and aortic cross-clamp through the incision. The skin incision is centered over the xiphoid and confined to the area below the nipples (inset). (IVC = inferior vena cava; SVC = superior vena cava.)

 
Femoral artery cannulation was the site of choice for all patients repaired by one surgeon early in the minimal access experience. Exposure of the femoral artery is accomplished by way of a 1-cm groin crease incision. Cannulation is done through a small transverse arteriotomy, using a thin-walled wire wound arterial cannula with rigid occluder (Medtronic-Biomedicus). Primary repair is performed after decannulation and before the administration of protamine.

Patients are extubated in the operating room or in the first postoperative hours in the intensive care unit.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 References
 
Two hundred consecutive ASD closures by full sternotomy (n = 65) or ministernotomy (n = 135) resulted in no hospital deaths, no bleeding or wound complications, and no reoperations for residual ASD. The decision to divide xiphoid only or xiphoid and lower sternum was made at the outset of each case, based largely on patient age and chest wall compliance, and no xiphoidotomy required later extension to achieve exposure. No ministernotomy approach required an extension to full sternotomy. No cannulation attempt, either aortic or femoral, was unsuccessful. Fifty-six of 135 ASDs were closed by pericardial patch, and the choice of patch or primary closure did not result in the extension of incision or sternotomy. Cardiopulmonary bypass and aortic cross-clamp times did not vary significantly between the ministernotomy and full sternotomy groups, although cross-clamp times tended to be longer in the full sternotomy group. Postoperative echocardiograms were obtained for 38 of the 135 ministernotomy patients (28%), and 28 of the 65 full sternotomy patients (43%), revealing no residual defects in either group. Five ministernotomy patients required readmission 11 to 28 days after discharge, including 4 (2.9%) admitted for pericardial effusion, of whom 2 (1.5%) required pericardiocentesis. The fifth ministernotomy readmission was for the treatment of noncardiac sequelae of cystic fibrosis. Five full sternotomy patients (7.7%) were readmitted, 1 (1.5%) for pericardiocentesis, 1 for medical treatment of pericarditis, 1 for repair of a regurgitant mitral valve cleft, and 2 (3%) for preexistent lung disease or the treatment of noncardiac disease. The mean length of hospital stay was 2.7 days for the ministernotomy group and 4.5 days for the full sternotomy group. Eliminating outliers whose stay was prolonged beyond 10 days for reasons unrelated to cardiac disease, the mean lengths of stay were 2.7 and 3.2 days in the ministernotomy and full sternotomy groups, respectively, revealing no significant difference (Table 2).


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  		Table 2. Treatment Course

 

   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
References
 
More than 300 recent articles address minimally invasive approaches to heart surgery. More than three fourths of those were published since 1996, reflecting the explosive recent interest in alternatives to conventional full sternotomy. Use of minimally invasive approaches has arrived last in the pediatric population, for whom constraints unique to the growing patient create a particular challenge.

Anterolateral thoracotomy modified for cardiac surgery in the 1980s has been advocated because its exposure of the heart is advantageous in peripheral cardiopulmonary bypass, particularly for mitral valve and reoperative procedures [1]. Anterolateral thoracotomy with skin incision concealed in the inframammary fold has been adapted to produce cosmetic advantages over median sternotomy for female patients [2–6]. The addition of videoscopic optical assistance and percutaneous transthoracic aortic cross-clamping permits adequate exposure through even smaller thoracotomy incisions [7, 8]. Critics of these initial minimally invasive approaches cite the needless introduction of complications inherent in peripheral cannulation for cardiopulmonary bypass, the suboptimal myocardial protection, and the risk of distorting breast tissue, all of which are particularly likely to affect the prepubescent age group[9]. Defibrillation and removal of air from ventricles can be more difficult, and individual variation in the spatial relationship of the cardiac structures to the chest wall may render thoracotomy or minithoracotomy a less reproducible exposure than sternotomy. Furthermore, cosmetic concerns about the predictability of breast tissue formation may prompt the needless and perhaps deleterious delay of some surgeries until after puberty, conferring a special disadvantage on this approach in the pediatric patient [6]. Ying-long and colleagues have adapted the thoracotomy approach in a series of more than 350 pediatric cases in such a way as to avoid pectoral deformity (by midterm follow-up); by incising between the anterior and posterior axillary folds, the approach spares all muscle and overlying breast tissue [10].

The parasternal approach, introduced by Cosgrove and Sabik, including resection of one or more costochondral cartilages and peripheral cannulation or cannulation through the incision, produces reproducible exposures of cardiac structures without physiologically violating chest wall integrity. This method demonstrably reduces pain and length of recovery [11–13]. Resultant chest wall deformity and lung herniation have, however, prompted some centers to abandon the approach, although some of its complications can be avoided by replacing the excised cartilage [12, 14, 15]. Importantly, the parasternal approach is impractical in the growing pediatric patient, in whom the disruption of costochondral growth foci may eventually lead to an exaggerated rib and chest wall deformity.

Variations of partial upper and partial lower sternotomy have been applied in adult and pediatric series with success [16–20]. The pliable infant thoracic cage permits exposures that are optimal in infancy, and the approach therefore does not encourage delay, as might inframammary approaches. In fact, in infants, the heart can be exposed for a majority of open heart repairs using a subxiphoid approach, leaving the body of the sternum completely intact.

Our minimally invasive approach to cardiac surgery in the infant and child began in May 1996 with ASD repairs only, approached through a xiphoidotomy or lower partial midline sternotomy, with exposure assisted by the cephalad retraction of the near-intact thoracic cage, bicaval venous cannulation through the incision, cannulation of the aorta directly through the incision or by way of the femoral artery according to surgeon’s preference, and cardioplegic arrest.

Early experience suggesting a higher prevalence of postoperative pericardial effusion in the ministernotomy group has prompted the routine formation of a pericardial window, allowing drainage into the right pleural space. Since this modification was adopted, the ministernotomy and full sternotomy groups have had equal incidences of postoperative pericaridal effusions.

Other morbidity, reflected in incidence of complications such as bleeding, residual lesions, reoperations, readmissions, or prolonged hospital stay, reveals no significant disadvantage imposed by the ministernotomy approach compared with the more conventional sternotomy, as performed at this institution. There is no conclusive evidence that the ministernotomy approach confers an advantage over the conventional approach in pain management, pulmonary physiology, or recovery time, and further study is warranted to examine these endpoints. Our series does suggest that the ministernotomy exposure is as safe and accurate as the same procedure performed through longer incisions that extend farther cephalad and that the procedure therefore constitutes a rational alternative to conventional approaches that imposes no special risks.

All instruments and retractors used in our procedures were standard, noncustom, nondisposable products that are part of an inventory for conventional cardiovascular procedures. Because our results show no demonstrable increase in time or resource use in the conduct of surgery or immediate convalescence, it seems reasonable to deduce that the ministernotomy approach imposes no significant added cost compared with the conventional approach, although objective measures of hospital costs are difficult to make and conclusions beyond inference are restricted by the limitations of this study.

One important limitation of this retrospective study is that advantages in pain and course of convalescence are elusive measurement targets, particularly in the pediatric age group. Further study of pain in the two patient groups is currently underway. A second limitation is the potential inaccuracy inherent in retroscopy introduced by the absence of routine intraoperative and postoperative echocardiograms to rule out residual lesions, dehiscence, or other abnormalities. A third limitation is that the distinction between xiphoidotomy and partial lower sternotomy is imprecise, particularly in reference to the cartilaginous infant sternum; distinguishing data cannot be extracted by chart review.

A minimal access approach using transxiphoid incision or ministernotomy provides exposure for safe and complete repair of simple and complex heart defects in the infant or child. Comparison of the ministernotomy with the conventional full sternotomy in contemporary patient groups demonstrates no significant difference in safety, efficacy of repair, bypass or aortic cross-clamp times, or length of hospital stay. The routine creation of a pericardial window into the right pleural space may decrease the incidence of postoperative pericardial effusion. The cosmetic result of the ministernotomy is acceptable; incisions are lower and shorter than those necessary for full sternotomy. At the time of this presentation, our institutional experience with the ministernotomy approach includes more than 140 ASD repairs and the repair of more than 50 complex defects, including ventricular septal defects, atrioventricular canals, cor triatriatum, and tetralogy of Fallot. Minimal access by transxiphoid incision or ministernotomy is our approach of choice for all ASD repairs.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 References
 

  1. Berreklouw E., Alfieri O. Revival of right thoracotomy to approach atrioventricular valves in reoperations. J Thorac Cardiovasc Surg 1984;32:331-333.
  2. Massetti M., Babatasi G., Rossi A., et al. Operation for atrial septal defect through a right anterolateral thoracotomy. Ann Thorac Surg 1996;62:1100-1103.[Abstract/Free Full Text]
  3. Laks H., Hammond G.L. A cosmetically acceptable incision for the median sternotomy. J Thorac Cardiovasc Surg 1980;79:146-149.[Abstract]
  4. Rosengart T.K., Stark J.F. Repair of atrial septal defect through a right thoracotomy. Ann Thorac Surg 1993;55:1138-1140.[Abstract]
  5. Dietl C.A., Torres A.R., Favaloro R.G. Right submammarian thoracotomy in female patients with atrial septal defect and anomalous pulmonary venous connections. J Thorac Cardiovasc Surg 1992;104:723-727.[Abstract]
  6. 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 Thorc Surg 1996;62:175-178.[Abstract/Free Full Text]
  7. Chitwood W.R., Wixon C.L., Elbeery J.R., Moran J.F., Chapman W.H.H., Lust R.M. Video-assisted minimally invasive mitral valve surgery. J Thorac Cardiovasc Surg 1997;114:773-782.[Abstract/Free Full Text]
  8. Lin P.J., Chang C.H., Chu J.J., et al. Minimally invasive cardiac surgical techniques in the closure of ventricular septal defect. Ann Thorac Surg 1998;65:165-170.[Abstract/Free Full Text]
  9. Cherup L.L., Siewers R.D., Futrell J.W. Breast and pectoral maldevelopment after anterolateral and posterolateral thoracotomies in children. Ann Thorac Surg 1986;41:492-497.[Abstract]
  10. Ying-long L., Hong-jia Z., Han-shong L., Jun-wu S., Cun-tao Y. Correction of cardiac defects through a right thoracotomy in children. J Thorac Cardiovasc Surg 1998;116:359-361.[Free Full Text]
  11. Cosgrove D.M., Sabik J.F. Minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996;62:596-597.[Abstract/Free Full Text]
  12. Cosgrove D.M., Sabik J.F., Navia J.L. Minimally invasive valve operations. Ann Thorac Surg 1998;65:1535-1539.[Abstract/Free Full Text]
  13. Cohn L.H., Adams D.H., Couper G.S., et al. Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair. Ann Thorac Surg 1997;226:421-428.
  14. Deeik R.K., Memon M.A., Sugimoto J.T. Lung herniation sec-ondary to minimally invasive direct coronary artery bypass grafting. Ann Thorac Surg 1998;65:1772-1774.[Abstract/Free Full Text]
  15. Lazzara R.R., Kidwell F.E. Right parasternal incision. Ann Thorac Surg 1998;65:271-272.[Abstract/Free Full Text]
  16. Del Nido P.J., Bichell D.P. Minimal-access surgery for congenital heart defects. Semin Thorac Cardiovasc Surg 1998;10(Suppl):75-80.
  17. Gundry S.R., Shattuck O.H., Razzouk A.J., del Rio M.J., Sardari F.F., Baily L.L. Facile minimally invasive cardiac surgery via ministernotomy. Ann Thorac Surg 1998;65:1100-1104.[Abstract/Free Full Text]
  18. Doty D.B., DiRusso G.B., Doty J.R. Full-spectrum cardiac surgery through a minimal incision. Ann Thorac Surg 1998;65:573-577.[Abstract/Free Full Text]
  19. Black M.D., Freedom R.M. Minimally invasive repair of atrial septal defects. Ann Thorac Surg 1998;65:765-767.[Abstract/Free Full Text]
  20. Tam R.K.W., Almeida A.A. Minimally invasive aortic valve replacement via partial sternotomy. Ann Thorac Surg 1998;65:275-276.[Abstract/Free Full Text]
Accepted for publication December 24, 1999.




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