HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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): Masahiro Yamaguchi Yoshihiro Oshima Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Yoshimura, N. Articles by Yoshida, M. Search for Related Content PubMed PubMed Citation Articles by Yoshimura, N. Articles by Yoshida, M. Related Collections Congenital - acyanotic

Ann Thorac Surg 2001;72:2103-2105
© 2001 The Society of Thoracic Surgeons

---

Original article: cardiovascular

Repair of atrial septal defect through a right posterolateral thoracotomy: a cosmetic approach for female patients

^a Department of Cardiothoracic Surgery, Kobe Children’s Hospital, Kobe, Japan

Accepted for publication June 28, 2001.

* Address reprint requests to Dr Yoshimura, Department of Cardiothoracic Surgery, Kobe Children’s Hospital, 1-1-1, Takakura-dai, Suma-ku, Kobe 654-0081, Japan
e-mail: y-naoki{at}za2.so-net.ne.jp

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Because the operation for atrial septal defect is considered a low-risk procedure, the cosmetic result has become an important issue. Principally for cosmetic reasons, anterolateral thoracotomy is frequently used for closure of atrial septal defect in young female patients. However, in anterolateral thoracotomy, the skin incision frequently crosses the future breast line, which may cause breast and pectoral muscle maldevelopment.

Methods. We review the long-term results of a consecutive series of 126 patients in whom the atrial septal defect was closed through a right posterolateral thoracotomy. The mean age at operation was 7.1 years (range, 1 to 15 years), and the mean body weight was 23.9 kg (range, 6.9 to 56 kg). Defects repaired included 121 ostium secundum (central type), 3 sinus venosus, and 2 ostium secundum without inferior margin.

Results. The average cardiopulmonary bypass time was 65 minutes (range, 37 to 130 minutes), with an average fibrillation time of 41 minutes (range, 23 to 70 minutes). There was no operative or late mortality. A majority of patients were pleased with their cosmetic results. There were no other late complications.

Conclusions. Atrial septal defect can be safely repaired through a right posterolateral thoracotomy approach. This approach offers the benefit of a total absence of scarring and cosmetic disfigurement of the anterior chest wall.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Currently, closure of atrial septal defect (ASD) has become a routine and safe procedure that is often performed in young, asymptomatic patients. The cosmetic result of this operation has become an important issue, especially for female patients. Surgical approaches include median sternotomy, the lower ministernotomy [1, 2], transxiphoid approach without sternotomy [3], and right thoracotomy [4–10]. A right anterolateral thoracotomy approach has gained acceptance owing to its cosmetic superiority with acceptable exposure and safety. However, anterolateral thoracotomy frequently crosses the future breast tissue, and results in breast and pectoral muscle maldevelopment associated with paresthesia [5–8]. We believe that these undesirable side effects can be avoided by using posterolateral thoracotomy restricted posterior to the anterior axillary line, because it offers the benefit of a total absence of scarring in the anterior chest wall (Fig 1A). In this study, we reviewed the long-term results of a consecutive series of 126 patients in whom the ASD was closed through a right posterolateral thoracotomy.

View larger version (103K): [in this window] [in a new window]   Fig 1. Skin incision in a 9-year-old girl. (A) Posterolateral thoracotomy approach offers the benefit of a total absence of scarring in the anterior chest wall and no disfigurement of the breast. (B) Anterior end of the skin incision (the right side arrow) is restricted not to cross over the anterior axillary line. The arrow on the left side indicates the location of the skin incision in relation to the scapula. The arrow on the right side indicates the anterior end of the skin incision.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

Follow-up was available in all patients through clinic visits. Five years after operation, follow-up was discontinued in patients without any problems.

Surgical technique
The patient is placed in the lateral decubitus position with the ipsilateral arm suspended by a well-padded holder in such a way as to expose the axilla. A posterolateral thoracotomy incision is made. The anterior end of the skin incision is restricted not to cross over the anterior axillary line (Fig 1B). The chest is opened in the fourth intercostal space. The lung is retracted posteriorly, and the pericardium is opened longitudinally 1 cm anterior to the phrenic nerve. Pericardial stay sutures are put on traction. The two top pericardial traction stitches are sutured to the costal cartilages to elevate the aorta into the operative field. Tapes are passed around the aorta, superior vena cava, and inferior vena cava in standard fashion. After full anticoagulation with heparin, the aorta is partially clamped and cannulated. An adequate aortotomy is made, and one pursestring suture is put around the aortotomy, then the aorta is cannulated. After bicaval cannulation, cardiopulmonary bypass is instituted and maintained with mild hypothermia (32°C to 33°C). Under electrical fibrillation, the right atrium is opened. Intracardiac suction is used carefully to avoid emptying the blood level in the left atrium. Atrial septal defect is closed with a patch in all patients. After the atriotomy is closed, the fibrillation electrode is removed and caval snares are released. If necessary, the heart is defibrillated. Air is removed using an aortic needle vent. Cardiopulmonary bypass is discontinued and all cannulas are removed. After the pericardial and pleural drains are placed, the thoracotomy is closed in a routine fashion with an intradermic continuous suture for the skin layer. The operation was performed on 25 patients by residents. Since August 1996, 34 of 36 (94.4%) patients did not require any blood products.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
The average bypass time was 65 minutes (range, 37 to 130 minutes), with an average fibrillation time of 41 minutes (range, 23 to 70 minutes). There was no operative or late mortality. In-hospital morbidity included third-degree atrioventricular block in 6 patients (recovered to normal sinus rhythm in 5 patients, and another patient did not need pacemaker implantation), transient paresis of the right hemidiaphragm in 4 patients, wound dehiscence at the skin level in 2 patients, epipleural hematoma in 1 patient, and paroxysmal supraventricular tachyarrhythmia in 1 patient. During the follow-up period, there were no readmissions to hospital. The standard 12-lead electrocardiogram showed 4 (3.2%) patients with a first-degree atrioventricular block. There was no atrial fibrillation in 126 patients. Echocardiographic study showed that there were no patients with residual ASD. There were no patients who had a complication of posterior thoracic asymmetry. A majority of the patients were pleased with their cosmetic results. There were no other late complications.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
The median sternotomy is the standard approach for most intracardiac operations. However, an unsightly midline scar can cause psychological distress in young female patients [11]. Principally for cosmetic reasons, alternative operative approaches have been developed with better aesthetic results. Komai and associates [2] described a lower small midline skin incision with minimal sternotomy approach. Barbero-Marcial and associates [3] recommended a transxiphoid approach without sternotomy for ASD closure. Both groups reported that all patients had a favorable outcome [2, 3], but the restrictive exposure of the heart through the small incision turns a simple and safe operation into a technically difficult procedure that entails potential risks such as injury to the great vessels and air embolism. Moreover, the long-term fate of skin scar formation and protrusion of the sternum, which was retracted strongly during operation, are unknown. Anterolateral thoracotomy is one of the most frequently used incisions for closure of ASD in young female patients [4–6, 9, 10]. This approach yields excellent visualization and cosmesis for adult female patients. However, it is very difficult to determine an adequate skin incision in prepubertal patients because the quantum of the breast growth in individuals cannot be predicted exactly. Therefore, anterolateral thoracotomy skin incision frequently crosses the future breast line, which may cause breast and pectoral muscle maldevelopment [5–7]. Decreased nipple sensitivity and permanent anesthesia of the lower part of the right breast have also been reported [4, 7, 8]. Grinda and associates [6] and Massetti and associates [5] recommended delaying the operation until puberty to avoid a too high incision on the breast with the potential risk of mammary atrophy.

We have used the posterolateral thoracotomy as a procedure of choice for ASD closure for more than 20 years. This approach has the advantage of a scar in the back that does not impair the future growth of breast tissue. Therefore, this approach is suitable for prepubertal patients. Surgical access to the ascending aorta and the venae cavae was adequate (Fig 2), and none of the patients required femoral cannulation. Although cardioplegic arrest with aortic clamping is possible, we prefer electrical fibrillation because the safety of a short period of fibrillation with acceptable perfusion pressures in the nonhypertrophied heart is well established [5, 9]. In our series, there were 6 patients whose fibrillation time exceeded 60 minutes. None of them had demonstrable decline in myocardial function. The mean body weight of these 6 patients was 34.6 kg (range, 14 to 55 kg). Our technique may be slightly more difficult for a patient who weighs more than 30 kg. The most important step in this operation is the complete and careful release of air from the left heart cavities. Intracardiac suction should be used carefully to avoid emptying the blood level in the left atrium. After the ASD is closed, an aortic needle vent is opened to remove air from the aortic root. No cerebral or myocardial infarction caused by air embolism were observed in our series. It is well known that electrical fibrillation is not safe to use in patients with aortic valve insufficiency because aortic valve insufficiency may cause irreversible left ventricular dilatation under ventricular fibrillation. Patients with aortic valve insufficiency should be operated on through a median sternotomy. The posterolateral thoracotomy approach has potential risks of pain and scoliosis compared with median sternotomy [1]. We presume that the incidence of postoperative pain is low in the younger patients, and that the pain can be controlled by low-dose analgesics. None of our patients had intractable pain after the operation. There were no patients who had a complication of posterior thoracic asymmetry, although we do not have a special manner to prevent scoliosis.

View larger version (122K): [in this window] [in a new window]   Fig 2. Surgical field, showing that the exposure of the ascending aorta is satisfactory.

	References

Top Abstract Introduction Patients and methods Results Comment 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. Komai H., Naito Y., Fujiwara K., et al. Lower mid-line skin incision and minimal sternotomy—a more cosmetic challenge for pediatric cardiac surgery. Cardiol Young 1996;6:76-79.
3. Barbero-Marcial M., Tanamati C., Jatene M.B., Atik E., Jatene A.D. Transxiphoid approach without median sternotomy for repair of atrial septal defects. Ann Thorac Surg 1998;65:771-774.[Abstract/Free Full Text]
4. Dietl C.A., Torres A.R., Favaloro R.G. Right submammarian thoracotomy in female patients with atrial septal defects and anomalous pulmonary venous connections: comparison between the transpectoral and subpectoral approaches. J Thorac Cardiovasc Surg 1992;104:723-727.[Abstract]
5. Massetti M., Babatasi G., Rossi A., et al. Operation for atrial septal defect through a right anterolateral thoracotomy: current outcome. Ann Thorac Surg 1996;62:1100-1103.[Abstract/Free Full Text]
6. Grinda J.M., Folliguet T.A., Dervanian P., Mace L., Legault B., Neveux J.Y. Right anterolateral thoracotomy for repair of atrial septal defect. Ann Thorac Surg 1996;62:175-178.[Abstract/Free Full Text]
7. Shivaprakasha K., Murthy K.S., Coelho R., et al. Role of limited posterior thoracotomy for open-heart surgery in the current era. Ann Thorac Surg 1999;68:2310-2313.[Abstract/Free Full Text]
8. Cherup L.L., Siewers R.D., Futrell J.W. Breast and pectoral muscle maldevelopment after anterolateral and posterolateral thoracotomies in children. Ann Thorac Surg 1986;41:492-497.[Abstract]
9. Rosengart T.K., Stark J.F. Repair of atrial septal defect through a right thoracotomy. Ann Thorac Surg 1993;55:1138-1140.[Abstract]
10. Helps B.A., Ross-Russell R.I., Dicks-Mireaux C., Elliot M.J. Phrenic nerve damage via a right thoracotomy in older children with secundum ASD. Ann Thorac Surg 1993;56:328-330.[Abstract]
11. Nakamura K., Irie H., Inoue M., Mitani H., Sunami H., Sano S. Factors affecting hypertrophic scar development in median sternotomy incision for congenital cardiac surgery. J Am Coll Surg 1997;185:218-223.[Medline]

This article has been cited by other articles:

				H. H. Dave, M. Comber, T. Solinger, D. Bettex, A. Dodge-Khatami, and R. Pretre Mid-term results of right axillary incision for the repair of a wide range of congenital cardiac defects Eur. J. Cardiothorac. Surg., May 1, 2009; 35(5): 864 - 870. [Abstract] [Full Text] [PDF]

				D. Mishaly, P. Ghosh, and S. Preisman Minimally Invasive Congenital Cardiac Surgery Through Right Anterior Minithoracotomy Approach Ann. Thorac. Surg., March 1, 2008; 85(3): 831 - 835. [Abstract] [Full Text] [PDF]

				C. Schreiber, J. Horer, M. Vogt, A. Kuhn, P. Libera, R. Lange, and R. H. Anderson The surgical anatomy and treatment of interatrial communications MMCTS, October 18, 2007; 2007(1018): 2386. [Abstract] [Full Text] [PDF]

				L. Hongxin, G. Wenbin, S. Lijun, W. Zhengjun, L. Hao, Z. Chengwei, D. Liang, and Y. Guidao Intraoperative device closure of secundum atrial septal defect with a right anterior minithoracotomy in 100 patients. J. Thorac. Cardiovasc. Surg., October 1, 2007; 134(4): 946 - 951. [Abstract] [Full Text] [PDF]

				C. Schreiber, S. Bleiziffer, M. Kostolny, J. Horer, A. Eicken, K. Holper, P. Tassani-Prell, and R. Lange Minimally Invasive Midaxillary Muscle Sparing Thoracotomy for Atrial Septal Defect Closure in Prepubescent Patients Ann. Thorac. Surg., August 1, 2005; 80(2): 673 - 676. [Abstract] [Full Text] [PDF]

				R. Pretre, A. Kadner, H. Dave, A. Dodge-Khatami, D. Bettex, and F. Berger Right axillary incision: A cosmetically superior approach to repair a wide range of congenital cardiac defects J. Thorac. Cardiovasc. Surg., August 1, 2005; 130(2): 277 - 281. [Abstract] [Full Text] [PDF]

				J. Resley, D. Fitzgerald, R. Albus, and P. Massimiano Pericardial patch closure of an atrial septal defect using endoscopic robotic technology Perfusion, December 1, 2003; 18(6): 365 - 367. [Abstract] [PDF]

				N. Yoshimura, M. Yamaguchi, S. Oka, M. Yoshida, and H. Murakami Alternative inferior vena cava cannulation facilitates ministernotomy procedures: Reply Ann. Thorac. Surg., April 1, 2003; 75(4): 1359 - 1360. [Full Text] [PDF]

				L. Mohanakrishnan, K. Vijayakumar, P. Sukumaran, N. Menon, and G. Santhanam Alternative inferior vena cava cannulation facilitates ministernotomy procedures Ann. Thorac. Surg., April 1, 2003; 75(4): 1358 - 1359. [Full Text] [PDF]

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): Masahiro Yamaguchi Yoshihiro Oshima Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Yoshimura, N. Articles by Yoshida, M. Search for Related Content PubMed PubMed Citation Articles by Yoshimura, N. Articles by Yoshida, M. Related Collections Congenital - acyanotic