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Ann Thorac Surg 2001;71:1066
© 2001 The Society of Thoracic Surgeons

Correspondence

Lower ministernotomy for the repair of atrial septal defects: Reply

Michael D. Black, MDa

a Department of Pediatric Cardiac Surgery, Lucile Packard Children’s Hospital, Stanford University School of Medicine, Stanford, CA 94305-5407, USA

e-mail: michael.black{at}leland.stanford.edu

To the Editor

The preservation of the patient’s self-esteem with improved cosmetics, a successful surgical repair, and the maintenance of the overall safety of the surgical endeavor remain paramount goals for the development of any minimally invasive cardiac surgical program. Although several alternative incisions are currently available, some facilitated with femoral arterial or venous cannulation, we continue to believe that the hemisternotomy remains superior for most patients. We have previously demonstrated overall safety, reproducibility, improved hospital utilizations, and thus cost savings with no obvious increase in operative times [1, 2]. The excellent exposure of the mediastinum afforded by the hemisternotomy allows for the repair of a myriad of cardiac malformations distinct from atrial septal defects, ie, ventricular septal defects, fibromuscular obstruction to the right ventricular outflow tract, atrioventricular valvular abnormalities, and endocardial cushion defects.

During the past 16 months, our surgical philosophy has continued to evolve; the cornerstone remaining the limited hemisternotomy. Infants, children, and adults have undergone operations that routinely include epidural or spinal anesthesia, active venous suction, cardioscopy, and most recently robotics (Fig 1). The development of a specially designed robotic "pivot point" has permitted improved visualization, especially in the limited confines of a pediatric thorax without the current obligatory thorascopic ports [3]. Femoral cannulation has been avoided in all patients and so too has retrograde cerebral perfusion and the complications of groin dissections. Most patients (2 months to 41 years) have been successfully discharged from hospital within 2 or sometimes 3 days. To date, there has been no readmissions to hospital or extensions of the original incision.



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  		Fig 1. Demonstrates a hemisternotomy surgical repair of an atrial septal communication with robotic video assistance. The "pivot point" negates both thorascopic incisions or ports.

 
Direct access to the mediastinum via the hemisternotomy allows for the correction of defects not previously appreciated, the ability to easily extend the incision if required, and superior deairing of the cardiac chambers. The incision remains the least painful, as the manubrium remains intact and the divided sternum can be successfully stabilized. I concur with the sentiments of Dr Wanjun Luo [4] with regards to the advantages of the hemisternotomy incision but remain skeptical regarding the absence of long-term sequelae of femoral cannulation. After all, this common way of accessing the circulatory system was previously abandoned by many of our predecessors.

References

  1. Black M.D., Freedom R.M. Minimally invasive repair of atrial septal defects. Ann Thorac Surg 1998;65:765-767.[Abstract/Free Full Text]
  2. Rao V., Freedom R.M., Black M.D. Minimally invasive surgery with cardioscopy for congenital heart disease. Ann Thorac Surg 1999;68:1742-1745.[Abstract/Free Full Text]
  3. Black MD, Pike N, Koransky M, et al. Innovations and future directions in pediatric cardiac surgery. In: Cross J, ed. Seminars on Cardiothoracic and Vascular Anesthesia. Philadelphia: W.B. Saunders Company.
  4. Luo W. Lower ministernotomy for the repair of atrial septal defects. Ann Thorac Surg 2001;71:1065-1066.[Free Full Text]

Related Article

Lower ministernotomy for the repair of atrial septal defects
Wanjun Luo
Ann. Thorac. Surg. 2001 71: 1065-1066. [Extract] [Full Text] [PDF]



This article has been cited by other articles:


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Ann. Thorac. Surg., November 1, 2001; 72(5): 1800 - 1801.
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