Ann Thorac Surg 2001;71:1716-1718
© 2001 The Society of Thoracic Surgeons
How to do it
Transxiphoid approach for intracardiac repair using video-assisted cardioscopy
Kagami Miyaji, MDa,
Arata Murakami, MDa,
Jotaro Kobayashi, MDa,
Yoshihiro Suematsu, MDa,
Shinichi Takamoto, MDa
a Department of Cardiothoracic Surgery, University of Tokyo Hospital, Tokyo, Japan
Accepted for publication December 20, 2000.
Address reprint requests to Dr Miyaji, Department of Cardiothoracic Surgery, Kanagawa Children’s Medical Center, 2-138-4 Mutsukawa, Minami-ku, Yokohama, Japan 232-0066
e-mail: Kagami111{at}aol.com
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Abstract
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Video-assisted cardioscopy (VAC) is a novel tool for providing clear visualization of small intracardiac structures and achieving complete repair in minimally invasive surgery. Between July 1999 and July 2000, 12 patients with atrial septal defect and ventricular septal defect underwent surgical repair using a combined procedure with the transxiphoid approach and VAC in our institution. The mean skin incision was 5.4 cm, and the postoperative courses of all the patients were uneventful without any complications. The mean hospital stay was 8.3 days and 1 patient (8.3%) needed blood products. Our experience showed the technical feasibility and acceptable surgical results of transxiphoid approach using a VAC.
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Introduction
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Minimally invasive cardiac surgery is currently being performed for a wide variety of cardiothoracic procedures. Several authors have reported the usefulness of minimally invasive or less invasive procedures for atrial septal defect (ASD) [1] and ventricular septal defect (VSD) [2]. Open heart operations for congenital heart disease in neonates and infants require clear visualization of small structures within confined spaces. Intracardiac imaging using a cardioscopy [3] is a novel method to improve visualization during minimally invasive surgery [4]. This technique is effective and necessary to achieve complete repair of intraventricular lesion in minimally or less invasive congenital heart surgery.
Since August 1998, the transxiphod approach has been selected for ASD and VSD closure including double chamber of the right ventricle (DCRV) repair in our institution. Since July 1999 we have routinely used a video-assisted cardioscopy (VAC) for intracardiac repair. Here we report our initial experiences with a combined procedure using a transxiphoid approach and VAC for intracardiac repair.
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Technique
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Between July 1999 and July 2000, 12 patients underwent intracardiac repair using a combined procedure with a transxiphoid approach and VAC at the University of Tokyo Hospital (Tokyo, Japan). These 12 patients included ASD (n = 7), VSD (n = 4), and VSD with DCRV (n = 1). The mean age and body weight were 3.0 ± 1.8 years and 12.6 ± 4.2 kg, respectively.
Cardioscopic equipment
Pediatric video-assisted cardioscopy was performed with the same equipment used in pediatric video-assisted thoracic operations. Videoscopes (Karl Stolz GmbH, Tuttlingen, Germany) were chosen based on size (4-mm diameter with a 17-cm working length) and the angle at the camera face (30 degrees), and produced a fourfold magnification (Fig 1). In all cases the video equipment was focused on the operative field before cardiopulmonary bypass was initiated.
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Fig 1. Operative view of combined procedure with transxiphoid approach and video-assisted cardioscope. Kent retractor was positioned at upper edge of xiphoid process to provide superior and anterior traction. Arterial cannula is inserted into ascending aorta using the Seldinger method.
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Combined procedure with transxiphoid approach and VAC
The transxiphoid approach was performed according to the following technique [1,5]. About 1 cm above the base of the xiphoid process a longitudinal skin incision was made and extended to 1 cm below the tip of the xiphoid process. The lower part of the incision was carried through the linea alba. Resection of the xiphoid process and a 1-cm opening of the cartilaginous base of the supraxiphoid portion of the sternum were achieved using electrocautery. To place the "xiphoid process window" in front of the right atrium, a deep-profile retractor was used and the Kent retractor (Takasago Medical Industry Co, Ltd, Tokyo, Japan) was positioned at the upper edge of the xiphoid process to provide superior and anterior traction (Fig 1). After the patient was heparinized, a straight aortic cannula, 8 F to 12 F in diameter (Medtronic Biomedicus Inc, Eden Prairie, MN) was inserted using the Seldinger technique [5]. Venous cannulation was performed through the right atrial appendage and the inferior vena cava–atrial junction. We began cardiopulmonary bypass, and the SVC and IVC were controlled with tapes.
For ASD closure, a fibrillator was used to induce ventricular fibrillation. Under ventricular fibrillation, the right atrium was opened and the VAC inserted into the right atrium. We inspected the anatomy of the ASD and ensured the pulmonary venous returns to the left atrium using the VAC technique. The ASD was closed with running sutures or a patch of polytetrafluoroethylene (0.4 mm). After the procedure, the VAC was used to ensure that the ASD was completely closed.
For VSD closure the aorta was cross-clamped and antegrade blood cardioplegia was administered, with a good arrest achieved. The left atrium vent was inserted from the right upper pulmonary vein. The right atrium was opened and the cardioscope inserted into the right ventricle through right atriotomy. A VAC was then used to expose and clearly define the bounds of the VSD and the suture line for closure (Fig 2). The VSD was closed with a polytetrafluoroethylene patch (0.4 mm) using mattress or running sutures. The VAC was used to ensure that stitches were in proper position during procedures and to facilitate closing the VSD without injury to the aortic valve or the conduction system. After the procedure the VAC was used to ensure that the VSD was completely closed. For DCRV repair the VAC provided clear and precise visualization of the right ventricle cavity (Fig 3). We found the small ostium infundibulum surrounded by fibrous tissues and perimembranous VSD. The abnormal muscle bundles of the right ventricle were resected from the right atrium to avoid injury to the papillary muscle of the tricuspid valve under VAC and direct vision. We confirmed the wide opening of the right ventricular outflow tract using the cardioscope.
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Fig 2. Clear, precise visualization of right ventricular cavity provided by the video-assisted cardioscope in double chamber of right ventricle. The small ostium infundibulum surrounded by fibrous tissues and perimembranous ventricular septal defect (VSD) were observed.
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Fig 3. Perimembranous ventricular septal defect (VSD) shown using video-assisted cardioscopy. The cardioscope confirmed that stitches were in proper position during the procedure and facilitated closing the defect without injuring the aortic valve and conduction system.
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Results
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In the 12 patients we operated on, combined procedure with transxiphoid approach and VAC allowed surgical repair of the ASD and VSD (with DCRV). The mean procedure time was 211 ± 72 minutes. The cardiopulmonary bypass time and aortic cross-clamp time or ventricular fibrillation time were 87 ± 47 minutes and 49 ± 35 minutes, respectively. Intraoperative TEE revealed that there were no residual ASD and VSD, and no right ventricular outflow obstruction in DCRV. The mean size of skin incision was 5.4 cm (range 5.0 to 6.0 cm). Only 1 patient needed a blood transfusion (8.3%). The postoperative courses of all patients were uneventful without any complications. The mean duration of hospital stay was 8.3 ± 3.2 days.
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Comment
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In congenital heart surgery, patient demand for less traumatic, more cosmetic surgery has increased. In 1998, Barbero-Marcial and colleagues [1] reported transxiphoid approach without sternotomy for ASD closure with excellent results. They selected the left common femoral artery as an arterial cannulation site. Because an incision in the groin is contradictory to the demand for a more cosmetic surgery, we cannulated the ascending aorta directly using the Seldinger technique, resulting in a transxiphoid approach with one small (mean 5.4 cm) lower midline incision.
In 1994, Burke and colleagues [3] reported that video-assisted cardioscopy is feasible for imaging small inaccessible structures during repair of complex congenital heart defects. Video-assisted cardioscopy allows atraumatic visualization and magnification of inaccessible structures while avoiding vigorous cardiac manipulation and extended incisions. This technique was also very useful for understanding the anatomy of intracardiac lesions such as VSD and right ventricular outflow tract obstruction. Potential problems with VAC include prolonged cardiac arrest time, valve laceration, and ventricular or atrial wall perforation. In our series, the aortic cross-clamping time (49 ± 35 minutes) appeared to be longer than that of the conventional approach. These results might be caused by technical difficulty with the transxiphoid approach. In fact, our series included challenging cases such as VSD or DCRV repair. Nevertheless, because of good surgical results and cosmetic superiority, this combined procedure can be acceptable. To prevent trauma, the rigid videoscope must be advanced along a straight anatomic path avoiding cardiac distortion. There were no valve lacerations and no ventricular or atrial perforations detected in our series. Video-assisted cardioscopy is a valuable educational tool to ensure that surgical assistants including residents, fellows, and medical students are able to visualize and to become familiar with surgical anatomy and procedures, especially in minimally invasive cardiac surgery [3,4]. The transxiphoid approach accompanied with the VAC technique is a sophisticated procedure that can be useful in complex congenital cardiac surgery [6].
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References
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Barbero-Marcial M., Tanamati C., Jatene M.B., Atik E., Jatene A.D. Transxiphoid approach without median sternotomy for the repair of atrial septal defects. Ann Thorac Surg 1998;65:771-774.[Abstract/Free Full Text]
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Lin P.J., Chang C.H., Chu J.J., Liu H.P., Tsai F.C., Su W.J., et al. Minimally invasive cardiac surgical techniques in the closure of ventricular septal defect: an alternative approach. Ann Thorac Surg 1998;65:165-170.[Abstract/Free Full Text]
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Burke R.P., Michielon G., Wernovsky G. Video-assisted cardioscopy in congenital heart operations. Ann Thorac Surg 1994;58:864-868.[Abstract]
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Miyaji K., Ojito J., White J.A., Hannan R.L., Burke R.P. Minimally invasive resection of congenital subaortic stenosis. Ann Thorac Surg 2000;69:1273-1275.[Abstract/Free Full Text]
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Murakami A., Kaneko Y., Imanaka K., Takamoto S., Yahagi N. Easy aortic cannulation: A transxiphoid approach. Artif Organs 2000;24:156-157.[Medline]
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Rao V., Freedom R.M., Black M.D. Minimally invasive surgery with cardioscopy for congenital heart defects. Ann Thorac Surg 1999;68:1742-1745.[Abstract/Free Full Text]
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Abstract
Introduction
