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Ann Thorac Surg 2001;71:469-472
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Minimal sternotomy approach for congenital heart operations

^a Department of Cardiovascular Surgery, Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA

Accepted for publication August 21, 2000.

Address reprint requests to Dr del Nido, Department of Cardiovascular Surgery, Children’s Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115
e-mail: delnido{at}cardio.tch.harvard.edu

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. In recent years, minimal access cardiac operations have increased in application in both the adult and pediatric population. As our experience has grown with these approaches to atrial septal defect closure, we have expanded the same approach to the repair of more complex congenital heart disease.

Methods. At the Children’s Hospital in Boston, from August 1996 to November 1999, a minimal sternotomy approach was used to surgically correct 104 children with congenital heart defects other than atrial septal defect. The approach, in most patients, consisted of a skin incision based over the xiphisternum, 3.5 to 5 cm in length, with division of the xiphoid only and elevation of the sternum by fixed retractor. All patients underwent cannulation for cardiopulmonary bypass through the great vessels in the chest using this same incision. The lesions corrected included ventricular septal defect in 41 patients, tetralogy of Fallot in 27, common atrioventricular canal in 15, mitral valve operation in 3.5, and other defects in 18 patients. There were 53 male and 51 female patients. Mean age at operation was 1.4 years (range, 2 weeks to 11 years).

Results. There were no deaths. The mean cardiopulmonary bypass time was 71 minutes (standard deviation, 19 minutes), mean cross-clamp times 40.8 minutes (standard deviation, 13 minutes), and length of stay 4.5 days (standard deviation, 1.9 days). Complications included transient atrioventricular block in 2 patients, pleural effusion requiring drainage in 4, and pericardial effusion in 3 patients. When compared to similar lesions repaired using a full sternotomy approach there was no difference in operating times and length of stay tended to be shorter in the minimal sternotomy group.

Conclusions. A minimal sternotomy approach can be used to repair congenital cardiac lesions other than atrial septal defects. It gives good exposure, particularly for transatrial repairs, does not prolong ischemic times, and may lead to shorter hospital stay.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Minimally invasive surgical approaches used in cardiac operations have been reported widely in the literature both in the adult and pediatric populations [1–4]. The potential advantages are both in cosmesis and comfort for the patient and a shorter hospital stay, which has implications for cost [5]. Approaches in the pediatric population have largely involved anterior thoracotomy [6–9] and minimal sternal division [2, 4, 10], either upper or lower with or without video assistance [8, 11, 12]. Issues for the surgeon, particularly in congenital heart disease, are adequate exposure for a precise intracardiac repair, safe application of cardiopulmonary bypass through a central or peripheral site, adequate myocardial protection, and effective de-airing before resumption of cardiac ejection. After increasing experience in the application of a minimal sternotomy approach to atrial septal defect repair, this same approach has been expanded for the repair of more complex congenital heart disease at the Children’s Hospital in Boston. This technique uses standard great vessel cannulation techniques for application of cardiopulmonary bypass, allows direct visualization through routine cardiac incisions, and does not require the use of "special" instrumentation to perform a variety of repairs.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Patient characteristics
Between August 1996 and November 1999, 104 patients underwent repair of congenital heart disease other than atrial septal defect. This approach was selected by three surgeons at Children’s Hospital as the surgical approach of choice if a transatrial repair was possible for the particular lesion. There were 53 male and 51 female patients. Mean age at operation was 1.4 years (2 weeks to 11 years). Lesions corrected were ventricular septal defect in 41 patients, Tetralogy of Fallot in 27, atrioventricular septal defect in 15, mitral valve lesions in 3, and other defects in 18 patients (Table 1). Repair of additional lesions was performed in 59 patients (patent ductus arteriosus, 28; pulmonary artery plasty, 13; cleft mitral, 6; and right ventricular outflow tract obstruction, 12). There were no reoperations in this group.

View larger version (82K): [in this window] [in a new window]   Fig 1. Diagram showing site of sternotomy, cannulation of great vessels, and surgical exposure.

The aorta was cross-clamped through the incision using either an angled cross-clamp or a Gregory profunda clamp (Pilling-Weck), and cardioplegia given antegrade through the aortic root. The repair was performed through the right atriotomy, and exposure was adequate to perform patent ductus arteriosus ligation and right ventricular outflow reconstruction if necessary in some patients.

After the patient was separated from cardiopulmonary bypass, a pericardial window was made to the right pleural space and a single chest drain was placed that traverses the right pleural space to lie in the anterior mediastinum. Pericardium was loosely approximated overlying the great vessels. This drain exits the skin at the inferior vena cava cannula site. If the lower sternum was divided, it was approximated using a single stainless steel wire, but in the majority of patients only an absorbable suture is used to approximate the xiphisternum.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
There were no deaths in this series of 104 patients repaired using the lower minimal sternotomy approach. No patient required conversion to full sternotomy and there were no reoperations for complications or residual lesions. The mean cardiopulmonary bypass time for all patients was 71 minutes (standard deviation, 19 minutes) and cross-clamp time 40.8 minutes (standard deviation, 13 minutes). Mean length of stay in hospital was 4.5 days (standard deviation, 1.9 minutes). When compared to a similar number of patients treated for the same lesions with a full sternotomy over the same time period there was no obvious difference in cardiopulmonary bypass or cross-clamp times or in length of hospital stay (Table 2), which has been our experience in the atrial septal defect group of patients. It is difficult, however, to compare small groups of patients with a heterogeneous group of lesions treated by different surgeons. Hospital stay was not prolonged by wound complication and importantly, there were no abdominal or diaphragmatic hernias noted in follow-up.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
The main aspects of changing an operative approach for congenital heart disease away from the standard full sternotomy fall in to three main areas. First is the impact on the chest wall of the incision, both in terms of cosmesis, including pectus deformity, and postoperative discomfort and its possible positive impact on pulmonary mechanics. Second is the application of cardiopulmonary bypass in terms of the site of safe cannulation and duration of support and ischemic times. Third is the adequacy of exposure and the impact on the precision of the repair and effects of the incisions and retraction of the myocardium itself.

The cosmetic effect of the surgical incision is dependent on its site on the chest wall and size. The inframmary skin fold has been used as an alternative approach either for median sternotomy [13] or thoracotomy [6–9], particularly in the female patient, and with video assistance even smaller incisions are possible in the pediatric population [8]. These approaches do not always allow for central cannulation for cardiopulmonary bypass or for the use of cardioplegic arrest for intracardiac repair [8]. There is also the concern, particularly in the prepubescent girls, of distorting growing breast tissue [14]. It may, however, be possible in younger children to avoid potential pectoral distortion by performing the skin incision more laterally on the chest wall and sparing the overlying muscle [9].

The improved patient comfort and recovery from a minimal invasive approach seen in the adult population [5] is not as easily measured in pediatric patients with congenital cardiac defects. The type of cardiac defect, duration and management of cardiopulmonary bypass, cardiac protection, and postoperative intensive care management are important determinants of postoperative recovery. The impact of the thoracic incision on the recovery of a small heterogeneous group of patients is difficult to determine and we have seen no significant difference in the length of stay when compared to a similar number of patients having a full sternotomy. However, intuitively, having an intact thoracic cage postoperatively should offer an advantage in pulmonary mechanics and pain management in these patients and a larger cohort of patients may reveal a measurable difference in recovery time.

The minimal sternotomy approach to the repair of a number of congenital cardiac defects is an extension of our experience using this technique in the repair of atrial septal defects. The incision is more cosmetic than a full sternotomy, and does not have the growth implications of a thoracotomy, and therefore, can be used at any age. Variations of partial upper or lower sternotomies have been reported both in the adult and pediatric population for a wide spectrum of cardiac surgical applications [1, 2, 3, 10, 15]. A lower minimal sternotomy approach divides the xiphisternum only and leaves the sternum intact in the majority of patients. As the patient gets older, however, it has been our observation that the heart elongates in the chest and that using this approach may require the division of the lower extent of the body of the sternum to safely cannulate the aorta through the incision. We did not cannulate the femoral artery in this series. In the infant the heart can be exposed through the xiphisternal division only, particularly for transatrial repairs, and access to the great vessels allows routine cannulation and right ventricular outflow procedures to be performed. It also allows cardioplegic arrest and direct visualization of defects through traditional access incisions. All instruments are standard and widely available and nondisposable. In our experience this has led to cardiopulmonary bypass times, ischemic times, and operative times equivalent to a full sternotomy approach. There has been no compromise in intracardiac technique or precision of repair. The incision can easily be converted to a full sternotomy at any time during the procedure if necessary.

The minimal sternotomy approach allows for a predictable exposure with improved cosmesis, and can be used to repair congenital cardiac lesions other than atrial septal defects. It does not require changes in the management of cardiopulmonary bypass or prolong ischemic time, and can be applied to all age groups for repair of a wide range of congenital cardiac defects.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ian A. Nicholson David P. Bichell Emile A. Bacha Pedro J. del Nido Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Nicholson, I. A. Articles by del Nido, P. J. Search for Related Content PubMed PubMed Citation Articles by Nicholson, I. A. Articles by del Nido, P. J. Related Collections Congenital - acyanotic Congenital - cyanotic Minimally invasive surgery