Ann Thorac Surg 2000;70:730-737
© 2000 The Society of Thoracic Surgeons
Original articles: cardiovascular
Video-assisted cardioscopy for intraventricular repair in congenital heart disease
Kagami Miyaji, MDa,
Robert L. Hannan, MDa,
Jorge Ojito, BSa,
James M. Dygert, MDa,
Jeffrey A. White, MSa,
Redmond P. Burke, MDa
a Department of Cardiovascular Surgery, Miami Children’s Hospital, Miami, Florida, USA
Address reprint requests to Dr Burke, Department of Cardiovascular Surgery, Miami Children’s Hospital, 3200 SW 60 Ct, Suite 102, Miami, FL 33155-4069
e-mail: redmondlll{at}aol.com
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Abstract
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Background. Video-assisted thoracoscopic surgical techniques have been widely adopted as a means to reduce surgical trauma. By adapting pediatric thoracoscopic instrumentation, we have developed a technique for video-assisted cardioscopy (VAC). We report our experience and describe the technical feasibility of VAC.
Methods. Since June 1995, 409 consecutive patients underwent 431 intracardiac procedures (ventricular septal defect, 150; tetralogy of Fallot or double outlet right ventricle, 101; atrioventricular canal, 52; subaortic stenosis, 43; valve repair, 50; Rastelli procedure, 12; Konno or Ross Konno operation, 11; and miscellaneous, 12) using VAC at Miami Children’s Hospital. Using a prospective database, we tracked outcomes and operative events to delineate the usefulness and efficacy of this technique.
Results. VAC provided clear and precise imaging of small or remote intracardiac structures during repair of congenital heart defects without technical complications. Procedure times and aortic cross-clamp times using VAC were not prolonged. Intraoperative images were collected for every operation, documenting each patient’s cardiac anatomy before and after repair. Surgery through small incisions was facilitated. Operative mortality was 1.2% (5 of 409), and no patient required reoperation before discharge. At a mean follow-up interval of 22 months, the incidence of reoperation for residual or recurrent lesions was 1.2% (5 of 404).
Conclusions. Our experience demonstrates the technical feasibility and clinical utility of routine endoscopic imaging during open heart surgery for congenital heart repair.
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Introduction
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Video-assisted thoracoscopic surgical techniques are now commonly used to improve anatomic visualization and reduce surgical trauma in general thoracic [1] and cardiovascular surgery [2, 3]. Video-assisted endoscopic techniques in congenital heart surgery have been described for patent ductus arteriosus interruption [4–7] and vascular ring division [8–10]. These procedures demonstrate the efficacy of video-assisted thoracoscopy in providing pediatric thoracic access and exposure within confined and delicate anatomic spaces, ie, patent ductus interruption in premature newborns.
Open heart operations for congenital heart disease in neonates and infants also require clear visualization of small structures within confined spaces. By adapting pediatric thoracoscopic instrumentation, we developed a technique for routine video-assisted cardioscopy (VAC) during open heart repair of congenital heart disease [11]. This technique was initially used in selected operations to visualize remote intracardiac structures and to facilitate repairs while avoiding the need for extended cardiac incisions or vigorous cardiac retraction. We subsequently found that routine use of these techniques could be used to enhance operative visualization and precision.
Patient demand for less traumatic, more cosmetic surgery has increased, particularly for congenital heart surgery. Several authors have reported less-invasive procedures for repair of atrial septal defect (ASD) [12, 13] and ventricular septal defect (VSD) [14]. Many of these operations have come under scrutiny for violating key surgical tenets of exposure and precision. The VAC technique can provide clear and precise visualization of small intracardiac structures within a limited space. This technique is effective and necessary to achieve complete repair of more complex intraventricular lesions in minimally or less invasive congenital heart surgery.
Since June 1995, 409 consecutive patients underwent intracardiac repair using a VAC technique to expose remote or small intracardiac structures and facilitate surgical repair in Miami Children’s Hospital. Here, we report our experience and clarify the usefulness and efficacy of this technique.
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Material and methods
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Cardioscope equipment
Pediatric VAC was performed with the same equipment used in pediatric video-assisted thoracic operations [5–7]. Videoscopes (Smith and Nephew, Dyonics, Inc, Andover, MA) were chosen based on size (4-mm diameter with a 7-cm working length) and the angle at the camera face (30 degrees) and produced 4x magnification. Endoscopic instruments were not required. In all cases, the video equipment was on the operative field before cardiopulmonary bypass was initiated.
Patient characteristics
Between June 1995 and April 1999, 1,056 congenital cardiovascular operations were performed at Miami Children’s Hospital, Miami, Florida. The VAC technique was used for 431 consecutive intraventricular procedures in 409 patients (Table 1). The patients’ ages ranged from 2 days to 38 years (mean 3.4 years) and their weight ranged from 2.2 to 80.0 kg (mean 14.1 kg). All intraventricular repairs were classified into one of the following eight categories: (1) ventricular septal defect (VSD) closure; (2) tetralogy of Fallot (TOF) and pulmonary atresia with VSD (PA/VSD) repair including double outlet of right ventricle (DORV) repair; (3) atrioventricular canal (AVC) repair; (4) subaortic stenosis (SAS) repair; (5) valvuloplasty; (6) Rastelli and reparation à l’étage ventriculaire (REV) procedure; (7) Ross and Ross/Konno procedure; and (8) miscellaneous procedures.
VSD closure
VSD closure was performed in 150 patients. Patient age ranged from 4 days to 18 years (mean 2.9 years) and body weight ranged from 2.3 kg to 76.8 kg (mean 13.0 kg). The types of VSD and associated procedures are shown in Table 2. Once the heart was arrested, the cardioscope was inserted into the right ventricle through the right atriotomy, pulmonary artery, or right ventriculotomy. VAC was then used to expose and clearly define the bounds of the VSD and suture line for closure.
TOF and PA/VSD repair
TOF and PA/VSD repair was performed in 101 patients. Patient age ranged from 2 days to 22 years (mean 1.6 years) and body weight ranged from 2.7 kg to 46 kg (mean 9.4 kg). Types of TOF and associated procedures are shown in Table 3. The cardioscope was inserted into the right ventricle cavity through a ventriculotomy after heart arrest was achieved. The VAC was used to expose both the right ventricular outflow tract (RVOT) and the VSD, and to decide the resection of RVOT obstructed muscle and the suture line for VSD closure.
AVC repair
AVC repair was performed in 52 patients. Patient age ranged from 40 days to 13 years (mean 1.4 years) and body weight ranged from 2.7 kg to 52 kg (mean 8.2 kg). The types of AVC include complete AVC (36) and transitional AVC (16). Associated procedures were PDA ligation or division (16), atrioventricular valve repair (12), ASD secumdum closure (9), pulmonary artery plasty (5), RVOTR (4), and aortic arch repair (1). The cardioscope was inserted into the right ventricle through a right atriotomy after heart arrest was achieved. The VAC was used to expose the VSD component of AVC and AV valve apparatus including chordal structures in order to determine the dividing line of the anterior and posterior leaflets of the common AV valve and the suture line for VSD patch closure. Before closing the ASD component, we inserted the cardioscope into the left atrium through the ASD and a left-sided AV valve competence test using cold saline installation without any retraction was performed and used in all cases.
SAS repair
For SAS, resection of transaortic subaortic membrane was performed in 43 patients. A minimally invasive procedure using a partial upper sternotomy was performed in 15 patients [15], and a conventional approach using full median sternotomy was used in 28. Among these 28 patients, 14 underwent the following associated procedures: mitral valvuloplasty (6), VSD closure (5), aortic arch repair (2), aortic valvuloplasty (2), ASD closure (1), and PDA ligation (1). Patient age ranged from 2 months to 26 years (mean 6.3 years) and body weight ranged from 5.4 kg to 68 kg (mean 24.2 kg). After good exposure of the aortic valve leaflet, the VAC was applied to visualize the subaortic lesion. Inspection of the subaortic area using the VAC technique was performed to confirm the absence of any obstructive lesion.
Valvuloplasty
Valvuloplasty was performed in 50 patients (Table 4). Patient age ranged from 1 month to 28 years (mean 6.2 years) and body weight ranged from 3.5 kg to 80 kg (mean 21.2 kg). Before and after the valve repair procedure, a valve competence test using cold saline installation was performed without any retraction in all cases and the VAC technique was applied to check valve competence.
Rastelli and REV procedure
Rastelli and REV procedures were performed in 12 patients. Patient age ranged from 5 days to 8 years (mean 2.6 years) and body weight ranged from 2.2 kg to 31.2 kg (mean 12.0 kg). The Rastelli operation was performed in 9 patients and the REV procedure in 3 patients. Associated procedures were VSD closure (12), ASD closure (9), VSD enlargement (5), Damus-Kay-Stansel (DKS) anastomosis (1), RVOTR (1), PA plasty (1), and PDA ligation or division (1). The cardioscope was inserted into the right ventricle through a ventriculotomy after heart arrest was achieved. The VAC was then used to expose the anatomic relationships in the aortic valve, VSD and tricuspid valve apparatus including chordal structures. We determined the suture line for VSD closure and rerouting to the aortic valve, avoiding injuries to the aortic valve and conduction system. The VAC confirmed that stitches were in the proper position during the procedure and that the VSD was completely closed and the LVOT wide open after the procedure.
Konno and Ross/Konno procedures
The Konno aorticoventriculoplasty or Ross/Konno procedure was performed in 11 patients. Patient age ranged from 3 months to 38 years (mean 10.0 years) and body weight ranged from 5.4 kg to 64.8 kg (mean 29.8 kg). The Konno aorticoventriculoplasty was performed in 3 patients with subaortic stenosis, and 2 of them underwent aortic valve replacement. The Ross/Konno procedure was performed in 8 patients. The aorticoventriculoplasty was performed using a Dacron graft patch. The cardioscope was inserted into the left ventricle through the aortotomy, after heart arrest had been achieved. VAC was used to expose the subaortic lesion and define the incision line of the ventricular septum for ventriculoplasty. Inspection of the subaortic area was also performed to confirm the absence of any obstructive lesion after the procedure.
Miscellaneous procedures
A thrombectomy was performed in 4 patients (left atrium, 2; left ventricle, 1; and right atrium, 1). After aortic clamping, the cardioscope was inserted into the left ventricle through a transverse incision of the ascending aorta for left ventricle thrombectomy [16]. VAC was used to expose the intracardiac thrombus and to make sure that there was no remnant of thrombus. Video-assisted intraoperative stenting for branch pulmonary artery stenosis was performed in 6 patients and a pulmonary artery stent removal in 1. Associated procedures were PA plasty (7), RVOTR (6), VSD closure (5), ASD closure (1). VAC was used to expose the pulmonary stenosis and make sure that the stent was positioned properly during and after the procedure. Coronary artery fistula repair was performed in 1 patient.
Study protocol
We reviewed the postoperative transesophageal echocardiograms (TEE) and transthoracic echocardiograms (TTE) and mortality and morbidity related to the above-mentioned procedures. Procedure time and aortic cross clamp time were also reviewed to evaluate the influence of VAC upon the procedure itself. All data are expressed as mean ± standard deviation (SD).
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Results
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VSD closure
Intraoperative VAC provided clear vision of all VSDs in 150 patients (Fig 1). VAC was also used to make sure that stitches were in proper position during procedures, and the procedure made it easy to close the VSD without injury to the aortic valve or conduction system (Fig 1). After the procedure, VAC was used to make sure that the VSD was completely closed. Intraoperative TEE and postoperative TTE findings are shown in Table 5. Small residual VSDs were found in 12 patients (8%; 5 VSD type II and 7 multiple VSD). There were 2 hospital deaths (1.3%); 1 patient died of postoperative vascular thrombosis after ASO with VSD closure and the other of pulmonary hypertension. The procedure times and aortic cross clamp times are shown in Table 6 for 73 patients with simple VSD closure. The mean follow-up period was 22 months, and during this period no patient needed reoperation.
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Fig 1. Representative picture of perimembranous ventricular septal defect taken using video-assisted cardioscopy (VAC). The aortic valve can be seen clearly by inducing cardioplegia. The VAC confirmed that stitches were in the proper position during the procedure and made it easy to close the defect without injuring the aortic valve and conduction system.
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TOF and PA/VSD repair
Intraoperative VAC provided a clear view of malalignment VSD in all 101 patients. The VAC technique made it clear that stitches were in proper position during the procedure (Fig 2A), and made it easy to close the VSD without injuring aortic valve and conduction system. After the procedure the VAC was used to confirm that there was no right ventricular outflow tract obstruction (RVOTO) and that the VSD was closed completely. For DORV, in order to determine the absence of left ventricular outflow tract obstruction (LVOTO) and suture line placement of the left ventricle to aorta graft patch, the cardioscope was inserted inside of the Dacron graft tunnel (Fig 2B). Intraoperative TEE and postoperative TTE findings are shown in Table 5. Small residual VSDs were found in 4 patients. Mild RVOTO less than 25 mm Hg was found in 11 patients. There were no hospital deaths. The procedure times and aortic cross clamp times are shown in Table 6 for 66 patients with TOF including TAP and non-TAP repair. During a mean follow-up period of 21 months, 1 patient required reoperation. This patient underwent PA/VSD repair with RVOTR using a homograft. Postoperative echocardiography revealed no residual VSD and RVOTO, and the patient was discharged home. One month later, a residual VSD was found on the follow-up echocardiography and required VSD closure.
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Fig 2. (A) Representative picture of a malalignment ventricular septal defect (TOF type) taken using video-assisted cardioscopy (VAC). The overriding aortic valve can be seen clearly by inducing cardioplegia. The VAC confirmed that stitches were properly positioned during the procedure and made it easy to close the defect without injuring the aortic valve and conduction system. (B) Representative picture of the inside of the Dacron graft tunnel in double-outlet right ventricle repair. There was no left ventricular outflow tract obstruction, and the suture line of left ventricle to aorta graft patch was perfect.
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AVC repair
Intraoperative VAC was utilized in all 52 AVC patients and clearly exposed the VSD component of the AVC and AV valve apparatus including the chordal structures. This technique was very helpful in determining the dividing line of the anterior and posterior leaflets of the common AV valve and the suture line for VSD patch closure, preserving AV valve function and avoiding injury of the conduction system. The VAC also made sure that stitches were in the proper position during the procedure and that the AVC was completely repaired after the procedure. Before closure of the ASD component, a left-sided AV valve competence test was performed and visualized using the VAC technique. The VAC provided a clear view of valve competence without retraction of the right atrium (Fig 3). Valve incompetence was found in 12 patients, requiring valve repair. One patient needed a valve replacement because the VAC revealed severe left-sided valve regurgitation after valve repair. Intraoperative TEE and postoperative TTE findings are shown in Table 5. Minor residual VSDs were found in 3 patients, with 1 patient needing reoperation for residual VSD closure. One patient who had unbalanced AVC with a hypoplastic left ventricle and needed aortic arch repair died because of heart failure and infection. The procedure times and aortic cross clamp times are shown in Table 6. The mean follow-up period was 25 months, and during that period 1 patient needed reoperation (valve repair).
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Fig 3. Before closure of an atrial septal defect component, a left-sided atrioventricular valve competence test was performed, and video-assisted cardioscopy provided a clear view of valve competence without retraction of the right atrium.
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SAS repair
Intraoperative VAC provided a clear view of the SAS in all 43 patients. After exposing the aortic valve, the cardioscope clearly revealed the subaortic lesion. This technique was very useful to resect the subaortic fibromembrane using blunt and sharp dissection, while avoiding injury of the aortic valve and conduction system [15]. Inspection of the subaortic area using the VAC technique confirmed the absence of any obstructive lesion. Postoperative echocardiographic findings are shown in Table 5. Two patients had moderate residual SAS (35 mm Hg and 40 mm Hg), but there were no deaths. The procedure times and aortic cross clamp times are shown in Table 6. The mean follow-up period was 21 months, and during that period no patient required reoperation.
Valvuloplasty
The VAC provided an excellent view of the valve apparatus in 50 patients during the repair. After completion of the procedure, a valve competence test was performed, and the VAC technique was used to provide confirmation of valve competence without any retraction of the left and right atrium or aortic wall. Severe valve incompetence was found in 1 patient postoperatively, and a mitral valve replacement was performed. Intraoperative TEE and postoperative TTE findings are shown in Table 5. For valve stenosis, all patients had less than mild valvar stenosis. There were 2 hospital deaths. One patient who had critical aortic stenosis died of postoperative neurologic complication and another with severe Ebstein’s anomaly died of postoperative cardiac failure. The procedure times and aortic cross clamp times are shown in Table 6. The mean follow-up period was 22 months, during which no patient underwent reoperation.
Rastelli and REV procedure
The VAC was used to view the anatomical relationship of the aortic valve, VSD and tricuspid valve apparatus including chordal structures in 12 patients. In 5 patients, a VSD enlargement was needed due to restrictive VSD. This technique was useful in deciding on the suture line for the VSD closure and rerouting to aortic valve, while avoiding injuries to the aortic valve and conduction system. The VAC also confirmed that stitches were in the proper position during the procedure, and made it easy to close the VSD completely. After the procedure, the cardioscope was inserted into the buffle graft in order to check for LVOTO and the suture line of the buffle graft (Fig 4). Intraoperative TEE and postoperative TTE findings are shown in Table 5. There were no hospital deaths. Procedure times and aortic cross clamp times ae shown in Table 6. The mean follow-up period was 21 months, and during this period no patient needed reoperation.
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Fig 4. Representative picture of the inside of Dacron buffle graft patch in a reparation à l’étage ventriculaire procedure with ventricular septal defect enlargement. There was no left ventricular outflow tract obstruction.
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Konno and Ross/Konno procedure
The VAC provided a clear view of subaortic lesions and was helpful while determining the incision line of the ventricular septum for ventriculoplasty, avoiding the conduction system (Fig 5). The VAC also made sure that stitches were in the proper position during these procedures and that the ventriculopalsty patch was completely closed. Inspection of the subaortic area using VAC provided a picture clear and precise enough to verify that there was no obstructive lesion in the LVOT after the procedure. Intraoperative TEE and postoperative TTE findings are shown in Table 5. There were no hospital deaths. Procedure times and aortic cross clamp times are shown in Table 6. The mean follow-up period was 20 months, during which no patient needed reoperation.
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Fig 5. Representative picture of Konno ventriculoplasty. Video-assisted cardioscopy provided a clear view of the subaortic lesion and was used to determine the incision line of the ventricular septum, avoiding the conduction system, and mitral and tricuspid papillary muscles.
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Miscellaneous procedures
VAC provided a clear intracardiac view and was useful in removing the intracardiac thrombus. After the procedure, the VAC confirmed that there was no residual thrombus remnant [16]. Postoperative TTE also revealed that there was no intracardiac thrombus in these patients. VAC was also useful in removing the previous stent device from the left distal pulmonary artery. The cardioscope was also used during stenting of the pulmonary artery, providing a clear picture of the pulmonary stenosis and assuring proper position of the stent device. After the procedure, the cardioscope was inserted into the pulmonary artery distal to the stent and used to confirm that the device was positioned in the proper position and that the pulmonary stenosis lesion was dilated. The intraoperative TEE or postoperative TTE showed there was no residual pulmonary stenosis present in these patients. For coronary artery fistula repair, VAC provided a clear vision of the fistula and made it possible to find the discrete opening of the fistula into the right ventricle. After closure of the fistula, VAC was used to confirm the complete closure by means of cardioplegia through the coronary artery. The intraoperative TEE revealed no residual coronary fistula.
Overall results
The VAC technique was applied to a total of 409 patients and 431 procedures. There were 5 hospital deaths (1.2%). The mean follow-up period is 22 months, and during this period there were 6 late deaths (1.5%) and only 5 patients who needed reoperation (1.2%).
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Comment
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Experience with endoscopic techniques for PDA interruption and vascular ring division in neonates led us to consider using video assistance during congenital open heart operations when difficult anatomic situations were anticipated preoperatively or encountered intraoperatively. In 1994, we reported that video-assisted cardioscopy is feasible for imaging small, inaccessible structures during repair of complex congenital heart defects [11]. VAC allows atraumatic visualization and magnification of inaccessible structures while avoiding vigorous cardiac manipulation and extended incisions.
Since June 1995, the VAC technique has been applied to intracardiac procedures at Miami Children’s Hospital. VAC provided clear and precise imaging of intracardiac structures in all cases. This technique was also a very useful aid to understanding the anatomy of intracardiac lesions such as malalignment VSD and subaortic stenosis. The surgical results using VAC were excellent, and no patients needed reoperation before being discharged home, although 5 patients needed reoperation during the follow-up period (22 months). Potential problems with VAC include prolonged procedure time, prolonged cardiac arrest time, valve laceration, and ventricular or atrial wall perforation. To prevent trauma, the rigid videoscope must be advanced along a straight anatomic path avoiding cardiac distortion. The procedure time and aortic cross-clamping time using the VAC technique were acceptable in all cases. There were no valve lacerations and no ventricular or atrial perforations detected in our series.
Video-assisted minimally invasive cardiac surgery is becoming more and more common in adult cardiac surgery. This surgical technique has been applied in the management of intracardiac lesions, including mitral valve procedures, as well as coronary artery bypass grafting [2, 3, 17]. In congenital cardiac surgery, video-assisted thoracoscopic PDA interruption [4–7] and vascular ring division [8, 10] were reported as producing excellent results. Recently, since improved outcomes and less morbidity have been experienced, minimally invasive procedures for ASD [12, 13] and VSD [14] have been reported. As mentioned, the VAC technique allows atraumatic visualization and magnification of inaccessible structures without vigorous cardiac manipulation and extended incisions.
Minimally invasive surgery with this technique can be a sophisticated and useful procedure, especially in complex congenital cardiac surgery. Since March 1997 we have performed resection of the subaortic membrane via an upper sternotomy as a minimally invasive procedure. This approach is basically the same as minimally invasive aortic valve surgery in adults. However, as the operative field is limited and smaller than that of an adult, the VAC technique was used to expose the subaortic lesion. Recently, video-assisted robotic surgery was reported for a mitral valve procedure and coronary artery bypass grafting [18–20]. This new technology may be applied to congenital cardiac surgery in the near future, although there are several problems to be solved such as access for cardiopulmonary bypass in small children. We believe that VAC will play an important role in robot-assisted minimally invasive adult and pediatric cardiac surgery in the future.
In conclusion, 409 consecutive underwent intracardiac repair using the VAC technique. Our experience showed its technical feasibility for imaging small, inaccessible intracardiac structures and for obtaining excellent surgical results without any valve laceration or perforation. Long-term follow-up will be necessary to ensure that the excellent short-term results continue.
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Accepted for publication March 8, 2000.
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Abstract
Introduction
