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Ann Thorac Surg 2001;72:1645-1649
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Correction of simple congenital heart defects in infants and children through a minithoracotomy

^a Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt an Main, Germany
^b Department of Pediatric Cardiology, Johann Wolfgang Goethe University, Frankfurt an Main, Germany

Accepted for publication May 16, 2001.

* Address reprint requests to Dr Abdel-Rahman, Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, D-60590 Frankfurt am Main, Germany
e-mail: abdel-rahman{at}gmx.de

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Minimally invasive surgical techniques in pediatric cardiac surgery have evolved throughout the last 10 years. Advantages of minimally invasive procedures include excellent cosmetic results and superior postoperative outcome. However, safety of minimally invasive techniques has to be proven.

Methods. In 21 female infants and children, a right anterolateral thoracotomy was performed. Mean age was 7.1 years (0.5 to 16.6 years) and mean body weight was 20.8 kg (8.3 to 56 kg). The following defects were repaired: atrial septum defect type II (n = 14); partial atrioventricular septum defect (n = 3); partial anomalous pulmonary venous connection (n = 2); ventricular septum defect (n = 2); mitral valve insufficiency (n = 1); and resection of an embolized atrial septum defect occluder (n = 1). In two cases, aortic cross-clamping was performed by using a transthoracic clamp. In 5 patients, femoral cannulation was performed. Skin incisions were limited to 4 to 7 cm.

Results. There was no operative or late mortality. Mean operation time, bypass time, and aortic cross-clamp time were 138 (95 to 275), 72 (32 to 179), and 35 (12 to 120) minutes, respectively. Mean postoperative mechanical ventilation time, mean intensive care unit stay, and mean hospital stay were 3.9 hours (1 to 12 hours), 1.4 days (1 to 3 days), and 12 days (8 to 18 days), respectively. Postoperative complications included hemorrhage in 1 patient requiring surgical intervention. Mean follow-up period was 13.3 months (1 to 36 months). All patients were in New York Heart Association class I postoperatively. Trivial mitral insufficiency was evident in 1 patient operated for partial atrioventricular septum defect.

Conclusions. A small right anterolateral thoracotomy as a minimally invasive technique in pediatric cardiac surgery is a safe and suitable alternative in the operative management of simple congenital heart defects. Cosmetic results are superior, however, improved postoperative outcome has to be proven.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
The introduction of minimally invasive surgical techniques in adult cardiac surgery has resulted in enhanced public demand for similar approaches in the pediatric population. In the past 10 years, these techniques have evolved continuously for the correction of congenital heart defects in infants and especially in female patients [1–5]. In this particular population, the cosmetic and psychological implications of a conventional median sternotomy have to be considered, and may play an important role in the postoperative morbidity. Due to minimal skin incisions, the operative trauma can be reduced. However, it is still controversially discussed whether minimally invasive approaches lead to reduced postoperative pain, limited blood loss, and improved respiratory function [2, 6].

With the advent of percutaneous devices for closure of atrial septum defects, the efficiency of minimally invasive cardiac procedures has to be proven. The risk profile of intraoperative complications of minimally invasive surgery compared with the traditional sternotomy approach has not been conclusively studied.

Retrospectively, this study reviews the experience and technique of anterolateral thoracotomies for surgical repair of congenital heart defects in 21 female infants and children treated at our department.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
From May 1997 to February 2000, 21 female infants and children presenting with congenital heart defect were admitted to our department for surgical correction. Patients age ranged from 6 months to 16.6 years (mean, 7.1 years). Mean body weight was 20.8 kg (range, 8.3 to 56 kg). Baseline characteristics, type of defect, and surgical procedures are listed in Table 1.

In patients whose breasts were developed, the submammarian groove was used for the anterolateral incision. Skin incision was 4 to 7 cm (Fig 1A). In case of undeveloped breasts, the incision was made at least on top of the seventh intercostal space anteriorly and in the sixth lateral intercostal space to avoid deformity of the breast and the pectoral muscle [7]. Essentially, a musculocutaneous flap was developed from the overlying skin, breast organ, and pectoral muscle, avoiding its incision. Care was taken to preserve the long thoracic and thoracodorsal nerve, and the right internal mammary vessels. The chest was preferably entered in the fourth intercostal space. Thereafter, the pericardium was opened anterior to the phrenic nerve and suspended posteriorly, avoiding injury to the phrenic nerve.

View larger version (68K): [in this window] [in a new window]   Fig 1. (A) Minithoracotomy; (B) groin incision.

View larger version (105K): [in this window] [in a new window]   Fig 2. Transthoracic aortic cross-clamp (arrow).

In 8 patients, a secundum type atrial septum defect (ASD) was closed by direct sutures, and in six cases, the use of a pericardial patch was necessary. The ASD as a component of the partial atrioventricular septum defect (AVC) is closed in a similar fashion by using a pericardial patch. One of the two ventricular septum defects (VSDs) was closed directly, the second one by using a Dacron patch. The partial anomalous pulmonary venous connections (PAPVCs) were corrected by creating a pericardial tunnel patch redirecting the pulmonary venous blood flow into the left atrium. A 16-year-old girl had a mitral valve insufficiency based on a pathomorphology of the mitral valve described by Barlow and associates [8], but with additional leaflet degeneration. In this case, a reconstruction of the valve was impossible, and the valve was replaced by a prosthesis. In another patient, an occluder dislocation into the left atrium was diagnosed [9]. We resected the occluder and closed the ASD directly.

Intracardiac suction was used carefully to avoid emptying the blood level in the left atrium. The usual deairing procedures via the atrial incision and the aortic root were employed. The atriotomy was then closed, the caval snares released, ventilation was reestablished, and an aortic needle vent was connected to suction. Cardiopulmonary bypass was gradually discontinued. The pericardium was partially closed and a pleural drain was placed. Before closing the chest, an intercostal block was performed in the third, fourth, and fifth intercostal spaces. Finally, the chest was closed in a routine fashion and finished by an intradermic continuous skin suture.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
There were no early or late deaths. Mean operating time was 138 minutes (range 95 to 275 minutes), bypass time was 72 minutes (range 32 to 179 minutes), and aortic cross-clamp time amounted to 35 minutes (range 12 to 120 minutes) (Table 2). In 2 patients, in whom electrical fibrillation was used, the fibrillation time was 25 and 37 minutes. Mean postoperative mechanical ventilation time was 3.9 hours (range 1 to 12 hours), time spent in the intensive care unit was 1.4 days (range 1 to 3 days), and mean hospital stay was 12 days (range 8 to 18 days) (Table 2). Two postoperative complications were observed: bleeding from an intercostal vessel requiring surgical intervention in 1 patient, and one postcardiotomy syndrome with pericardial effusion, which resolved spontaneously. Wound healing problems have not been observed.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Since the first successful closure of an ostium secundum defect by Gibbon in 1953, median sternotomy has been the standard approach for correction of congenital heart defects. However, there is a growing interest in minimally invasive surgical techniques in cardiac surgery in general, and there is a legitimate desire to introduce minimally invasive approaches for the pediatric population.

Comparing complete sternotomy and anterolateral thoracotomies, the anterolateral approach seems to de superior to conventional sternotomy, particularly in young patients [10]. Chang and associates have shown that an anterolateral approach for correction of ASD was associated with significantly better clinical outcome; however, the bypass time is markedly longer in the minimally invasive group [6]. A group from Beijing, China recently published their experience with correction of more complex defects (eg, transpositions of the great arteries, tetralogy of Fallot) through a right thoracotomy in infants and children [11].

In the present study, a transthoracic aortic cross-clamp was used in 2 patients. The rationale is to limit the number of instruments that need to be introduced directly through a small incision beneath the operative field. However, we used the transthoracic clamp only in the oldest patients, aged 14 and 16 years, because transthoracic clamps for smaller children are not yet available. Another possibility to limit the number of instruments in the operative field is to perform a femoral cannulation for cardiopulmonary bypass. We used this approach in 5 patients aged 7 to 16 years. In two cases, both arteria and vena femoralis were cannulated, in the remaining three cases, only a femoral cannulation was performed, whereas venous cannulation was established through the thoracotomy.

By employing these two techniques, it was possible to reduce operative trauma, to improve the surgical exposure through the limited incision, and to correct a more complex defect in one case of partial AVC with mitral valve repair. In the cases of mitral valve repair, the quality of reconstruction did not differ from mitral valve repair through a conventional sternotomy.

Myocardial protection is a very controversial point in this context. Despite additional effort and cost, we strongly believe that cardioplegic arrest is the safest method, particularly for a new operation technique. It is well known that fibrillatory arrest is possible for short operating times, however, a fibrillating heart represents a high-energy state. In the present cohort, we had to employ fibrillation in 2 patients, because the standard method in our institution, cardioplegic arrest, was not effective.

In male children and adolescents, we prefer a partial lower sternotomy as an alternative minimally invasive approach [12]. In a prospective randomized study, Luo and associates found a significantly increased operating time but markedly less drainage and shorten hospital stay in the lower sternotomy group in children operated on for ASD or VSD [13]. Nicholson and associates recently reported about 104 children with tetralogy of Fallot, AVC, mitral valve diseases, and other defects corrected via a minimal sternotomy. Compared with similar lesions repaired through a conventional sternotomy, they did not find a significant difference in operating time, however, the length of hospital stay tended to be shorter in the minimal sternotomy group [14].

We believe that even in female patients, a lower sternotomy is cosmetically less satisfying than a small anterolateral thoracotomy. Therefore, we recommend a small thoracotomy in female patients.

In the present series, there was no early or late mortality. A similar postoperative outcome has been reported by other authors [2, 3, 14]. Thus, minimally invasive approaches in infants and children can be considered a safe and feasible alternative to conventional techniques. Postoperative pain scores or respiratory function tests have not been used in this study because there is no objective method to evaluate these parameters in infants and children. In our clinic, the pediatric cardiologists prefer a hospital stay up to 12 days in order to exclude postcardiotomy syndrome with relevant pericardial effusion, and for reimbursement reasons.

An important cosmetic aspect is the future development of the breast and pectoral muscle in children that have undergone thoracotomies, especially in females [15]. Cherup and associates described maldevelopment of these organs after antero- and posterolateral thoracotomies in childhood [16]. Dietl and associates recommend a subpectoral instead of a transpectoral approach in order to avoid maldevelopment and paraesthesia of the breast [7]. It should be mentioned that those operations were performed with large incisions and extended medially with subluxation of the chondrosternal junction [17]. It is also known that after extensive thoracotomies, scoliosis can occur [18]. Nowadays, the incisions range from 4 to 7 cm, minimizing musculoskeletal trauma and pain sensation [19]. Furthermore, in our institution, the skin incision is generally performed at least 3 cm below the nipple in infants and children with undeveloped breasts to avoid future maldevelopment. In spite of these limited muscle-sparing approaches, the cosmetic results have to be analyzed continuously in a long-term follow-up. In terms of postoperative neurological and psychological disorders, an objective pain score should be established comparing conventional and minimally invasive operation techniques.

In conclusion, a small right anterolateral thoracotomy in pediatric cardiac surgery represents a safe and feasible approach in the operative management of simple congenital heart defects. Compared with conventional techniques, the operation and bypass times are slightly prolonged. Cosmetic results are superior due to markedly smaller skin incisions.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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