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Ann Thorac Surg 2001;71:1065-1066
© 2001 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Xing Ya Hospital, Hunan Medical University, Changsha, Hunan, People's Republic of China
To the Editor
I read with interest the article by Cremer and associates [1] entitled "Different approaches for minimally invasive closure of atrial septal defects" and the invited commentary by Dietl. In their article, three different techniques were described in the repair of atrial septal defects (ASDs). In fact, they used one of the minimally invasive approaches, that is, minithoracotomy (right submammary mini-incision or right parasternal mini-incision). There are at least three cosmetic incisions to be reported in the repair of atrial septal defects: minithoracotomy, ministernotomy, and subxiphoid incision [1–4]. Among these minimal incisions, lower ministernotomy is another minimal access for the repair of ASDs [2, 4], which also has excellent cosmetic results. We herein report our experience with the lower ministernotomy in the closure of ASDs with femoral artery cannulation. The mean age of 20 patients was 21 ± 5 years with 13 women and 7 men. The anesthesia was carried out as conventional manner. The median skin incision was made from the level of the fourth intercostal space to the xiphoid process with a mean length of 6 cm. The lower sternotomy was made and right half sternum was transected at the fourth intercostal space. The pericardium was opened vertically, the right side of which was anchored to the sternum. The right iliac or femoral artery was cannulated via a 2- to 3-cm groin incision. Superior vena cava (SVC) was cannulated via the right appendage using an endotracheal tube with balloon. The inferior vena cava was taped and cannulated through the right atrium using a right-angled cannula. Hypothermic cardiopulmomary bypass was established (28° to 32°C). When ventricular fibrillation take place, the right atrium was opened. The ASDs were repaired by direct (9 patients) or patch closure (11 patients). The internal pediatric pads were used for defibrillation. All the patients recovered without adverse events. The hospital stay was 4 to 7 days (mean 5 days). The bypass time and fibrillating time were 48 ± 9 and 21 ± 4 minutes, respectively. The echocardiography showed no residual shuts 1 month after operation. Only 2 patients need narcotic postoperatively. All patients were satisfied with the small incision cosmetically.
ASD, especially in adults, is a common congenital heart defect in developing countries. My colleagues and I have used three approaches in closure of adult ASDs: full sternotomy (the length of incision was 18 to 25 cm), right minithoracotomy (10 to 12 cm) and lower right-sided sternotomy (10 to 12 cm). In the above three approaches, no femoral cannulation was used. Although the minithoracotomy and lower right-sided sternotomy are accepted cosmetically by our patients, there is much room for shorting the length of incisions. In our technique described above, two measurements were taken to make the incision shorter compared with previous reports [2, 4]. First, the femoral artery was cannulated. Second, the SVC was cannulated with a ballooned endotracheal tube. In our opinion, there were several advantages of lower mini-sternotomy over the mini-thracotomy except for its cosmetical effect. First, the right atrium usually lies under the lower sternum, so the distance between incision and atrial septum was shortest, which provides better exposure and makes manipulation more comfortable. Second, this incision is easier to convert to a full sternotomy if necessary. Third, lower mini-sternotomy maintains the same stability of the sternum as mini-thoracotomy does, without mobilization of the breast tissue. Fourth, this approach has potentially less pain than mini-thoracotomy based on our clinical observation. Most recently, my colleagues and I performed the closure of ASDs using video-assisted thoracoscopy combined with lower mini-sternotomy without peripheral cannulation; the results are under evaluation.
In conclusion, we think the lower sternotomy is another cosmetically accepted approach for closure of simple ASDs, and thank Cremer and colleagues for their informative article.
References
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  M. D. Black Lower ministernotomy for the repair of atrial septal defects: Reply Ann. Thorac. Surg., March 1, 2001; 71(3): 1066 - 1066. [Full Text] [PDF]
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