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Ann Thorac Surg 2003;75:1527-1530
© 2003 The Society of Thoracic Surgeons

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Original article: cardiovascular

Secundum ASD closure using a right lateral minithoracotomy: Five-Year experience in 122 patients

^a Heart Center, Department of Cardiac Surgery, University of Leipzig, Leipzig, Germany

Accepted for publication November 21, 2002.

^* Address reprint requests to Dr Walther, Herzzentrum, Klinik für Herzchirurgie, Universität Leipzig, Strümpellstrasse 39, 04289 Leipzig, Germany
e-mail: walt{at}medizin.uni-leipzig.de

	Abstract

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BACKGROUND: Surgical closure of secundum atrial septal defect (ASD) is a standard procedure associated with very low mortality and morbidity. We evaluated outcomes in the era of catheter-based interventional closure and minimally invasive techniques.

METHODS: From May 1996, February 2002, 177 patients with a body weight of more than 30 kg underwent surgical ASD closure. A right lateral minithoracotomy (LMT) was used in 122 patients and a conventional approach, in 55. Diagnoses included secundum ASD in 106 patients in the LMT group and 40 in the conventional group, sinus venosus ASD in 13 patients in each group, and status post interventional closure in 3 and 2 patients, respectively. Mean age was 37 ± 17 years in the LMT group and 43 ± 20 years, in the conventional group and mean body weight was 66 ± 17 kg and 70 ± 16 kg, respectively. In the LMT group, femoral cannulation was performed for cardiopulmonary bypass.

RESULTS: Direct ASD closure was carried out in 67.2% of patients in the LMT group and 58.2% of those in the conventional group. The remaining patients had pericardial patch closure. There was one death: A patient in the conventional group who required explantation of an Amplatzer device because of infection died postoperatively. Average stay in the intensive care unit was 1.2 ± 0.5 days. Two patients required reoperation for residual ASD after direct closure; 1 sustained a temporary neurological deficit that resolved completely. On postoperative echocardiography, a minimal residual shunt was seen in only 3 patients. All patients were in good clinical condition with improved functional status at discharge from the hospital.

CONCLUSIONS: Secundum ASD closure by LMT has become as standard and safe an operation as the conventional technique and achieves good perioperative results and satisfactory long-term outcomes. Thus LMT is an attractive option for patients who are not suitable for closure using catheter-based devices.

	Introduction

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For more than four decades, surgical closure has been the standard technique for patients with a relevant secundum atrial septal defect (ASD) [1–5]. This method is associated with very low morbidity and virtually no mortality and yields optimal long-term results[1–5]. Whereas a right lateral thoracotomy was frequently used in the early years, a median sternotomy later became the standard approach. However, over the past few years, there has been a change in the patient profile. Catheter-based interventional closure of defects has been introduced for select patients, and minimally invasive surgical techniques, that is, lateral minithoracotomy (LMT) plus femoral cannulation, have been developed. Because it is suitable for different pathological conditions, surgical closure is indicated for all patients who are not candidates for interventional device closure. The aim of this study was to evaluate current outcomes with the application of these new techniques.

	Material and methods

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Patient population
All patients with a body weight of more than 30 kg undergoing operation between May 1996 and February 2002 were prospectively evaluated. Indications for secundum ASD closure were based on standard criteria: the presence of clinical signs such as dyspnea, recurrent respiratory tract infections, arrhythmias, or both, and a major shunt on the atrial level leading to a pulmonary to systemic flow ratio greater than 1.5:1 [6].

A total of 177 patients were evaluated, 122 of whom underwent a right LMT and 55, a conventional approach. Paralleling a steady increase in the number of LMTs over the study period was a decline in the performance of conventional procedures. Mean age was 36.7 ± 17.2 years (range, 9 to 80 years) in the LMT group versus 43.1 ± 20.4 years (range, 6 to 75 years) in the conventional group (p < 0.05), and 71.3% (n = 87) and 50.9% (n = 28), respectively, of the patients were female. Five of the female patients in the LMT group were prepubescent; all of the others had developed breasts by the time of the operation. Mean body weight was 65.7 ± 16.6 kg in the LMT group and 69.6 ± 16.4 kg in the conventional group (p = not significant [NS]), and mean body surface area was 1.74 ± 0.3 m² versus 1.79 ± 0.3 m², respectively (p = NS). The underlying pathological condition was secundum ASD in 106 patients in the LMT group and 40 patients in the conventional group, sinus venosus ASD with partial anomalous pulmonary venous drainage in 13 patients in each group, and status post interventional closure using an occluder in 3 patients and 2 patients, respectively. Preoperatively, left ventricular ejection fraction was 0.67 ± 0.09 in the LMT group and 0.68 ± 0.11 in the conventional group (p = NS), pulmonary artery systolic pressure was 34 ± 18 mm Hg and 38 ± 13 mm Hg, respectively (p = NS), and the left-to-right shunt was 47% ± 25% and 46% ± 24%, respectively (p = NS). Sinus rhythm was present in 90.2% of the LMT group and 76.4% of the conventional group and right bundle-branch block, in 40.2% and 38.1%, respectively (p = NS).

Operative technique
Secundum ASD closure was performed using a right LMT and femoral-femoral cardiopulmonary bypass (18F arterial and 20 or 22F venous cannulas inserted using the Seldinger technique) with additional right jugular vein drainage (16F venous return cannula). Surgical access was gained through the fifth and occasionally the fourth intercostal space, and exposure was optimized with a soft tissue retractor, a specially designed rib spreader, and two pericardial stay sutures. The exact location of the LMT incision is shown in Figure 1.

View larger version (97K): [in this window] [in a new window]   Fig 1. Lateral minithoracotomy incision for closure of atrial septal defect. The incision is made in the skin fold just below the breast and the thoracotomy is usually performed in the fifth intercostal space.

Statistical analysis
Results are given as the mean ± the standard deviation. Absolute and relative frequencies were calculated. The Kolmogorov-Smirnow test was used to assess normal distribution, and then the Student t test was applied. Categorical variables were compared with the ² test or Fisher’s exact test where appropriate. A p value of less than 0.05 was considered significant.

	Results

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Intraoperative results
All operations were performed without incident. No conversions from the LMT to the conventional technique were required. Total duration of the operation was 126 ± 47 minutes in the LMT group and 117 ± 42 minutes in the conventional group (p = NS), and cardiopulmonary bypass averaged 67 ± 32 minutes versus 50 ± 29 minutes, respectively (p < 0.01). Closure of the defect was carried out using aortic cross-clamping in 35.2% of the LMT group versus 87.3% of the conventional group (p < 0.05) or during ventricular fibrillation in 64.8% versus 12.7%, respectively (p < 0.05). Mean cross-clamp duration was 28 ± 15 minutes versus 23 ± 11 minutes (p < 0.05) in the LMT and conventional groups, respectively, and mean duration of fibrillation, 26 ± 15 minutes versus 10 ± 6 minutes, respectively (p < 0.05).

Direct closure of the defect was performed in 67.2% of patients in the LMT group and 58.2% of patients in the conventional group. Autologous pericardial patch closure was alone in the remaining 32.8% and 41.8%, respectively. All patients undergoing an LMT since 1998 had carbon dioxide field flushing.

Postoperative results
Patients were extubated in the intensive care unit after 7.8 ± 11.7 hours (LMT group) versus 11.7 ± 21.4 hours (conventional group) (p < 0.05), drainage was 460 ± 320 mL and 515 ± 456 mL (p = NS), and total intensive care unit stay was 1.4 ± 0.9 days versus 2.0 ± 3.5 days, respectively (p < 0.05). At discharge, 93.4% of patients in the LMT group and 78.2% of patients in the conventional group—more than preoperatively—were in sinus rhythm. Wounds healed without complications, and at discharge, patients had improved clinical function. Echocardiography revealed no residual defect in all but 3 patients; 2 patients after an LMT and 1 patient after a conventional procedure showed a major residual defect, and each had had direct closure.

Morbidity and mortality
There were a few adverse perioperative events. Transient neurological deficit occurred in 2 patients in the LMT group and 1 patient in the conventional group (1.6% and 1.8%, respectively). A transitory ischemic attack without any remaining neurological deficit was encountered in 1 patient in each group (0.8% and 1.8%), paresthesia of the thigh in 2 patients after femoral cannulation (1.6% and 0%), phrenic nerve palsy in 1 patient after LMT (0.8% and 0%), and superficial wound infection in 1 patient after sternotomy (0% versus 1.8%). Because of residual defects, 2 patients in the LMT group and 1 patient in the conventional group required reoperation; all of them had undergone direct closure of the secundum ASD at the first operation and had patch closure at reoperation. One patient (conventional group) died: He had been referred with ongoing sepsis resulting from infected Amplatzer device after interventional ASD closure. Emergency explantation of the infected occluder was performed but the sepsis did not resolve. The patient died of bowel ischemia on the first postoperative day. All other patients were discharged and were well at last follow-up.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
Beginning in the 1950s, surgical closure of an ASD was performed using either a lateral thoracotomy or a conventional median sternotomy. Since the 1990s, interventional approaches for simple pathological conditions and minimally invasive surgical techniques have been increasingly applied. The aim of this study was to evaluate current outcome with the LMT approach and to compare it with results using the conventional approach. Our experience with a right LMT indicate that surgical ASD closure can be performed with the same safety as with the conventional sternotomy approach. The LMT for ASD closure is associated with low morbidity and no mortality, and our findings compare favorably with current standards.

In this series, femoral cannulation for cardiopulmonary bypass was carried out to allow performance of the surgical procedure through a minithoracotomy. We did not observe any major problems with this technique when small-sized cannulas were used. Femoral cannulation through a small incision together with percutaneous jugular vein drainage is advantageous in that it allows enough space through the minithoracotomy for the surgical intervention. Because of the good results with femoral cannulation in our series, other techniques such as direct aortic cannulation eventually facilitated by rib disarticulation are not our preferences.

Direct closure was performed in patients who had a longitudinal defect with sufficient overlapping tissue, which allowed a tension-free closure. However, in 3 patients with a good initial result by intraoperative transesophageal echocardiography, residual defects were diagnosed at echocardiographic control before discharge, and reoperations were necessary. On the basis of the disappointing results in these 3 patients, we believe that direct closure should be performed only in patients with thick tissue in whom closure can be performed without any tension. Patch closure should be the standard approach for most patients.

There is frequent discussion in the medical literature about what the term minimally invasive means. The invasiveness of a procedure comprises several main factors—the incision, the use of cardiopulmonary bypass, and the induction of ventricular fibrillation or cardiac arrest. Thus ideally when talking about ASD closure, we can describe a less invasive approach, as cardiopulmonary bypass will always be required. To avoid any constraints, we chose the term lateral minithoracotomy for the approach presented here, as this term best describes the morphological as well as the technical aspects of the procedure.

In patients with sinus venosus ASD and partial anomalous pulmonary venous drainage, the exact location of the pulmonary venous connection should be delineated preoperatively. This can usually be accomplished using transthoracic and transesophageal echocardiography. In addition, magnetic resonance imaging can yield valuable information. Thus cardiac catheterization is only rarely indicated. Sinus venosus defects have been a classical indication for a median sternotomy to gain sufficient access for patch implantation, pulmonary venous redirection, and occasionally, reconstruction of the superior vena cava. However, our results indicate that such patients can safely undergo operation using a less invasive approach through an anterolateral minithoracotomy in the fourth intercostal space. This provides sufficient access to the superior vena cava and the ascending aorta.

The advantages of performing ASD closure using a right anterolateral minithoracotomy can be summarized as follows: Because of the smaller incision, operative trauma is minimized. This may result in less pain and better postoperative recovery. Young female patients benefit from an improved cosmetic result. Recovery, discharge, and return to all activities of daily life should be faster. Last, a shorter hospital stay can be anticipated, and this leads to less resource utilization and reduced costs. All these findings seen in our study compare favorably with those in the current literature [7–9].

On the basis of the good results obtained with percutaneous occluding devices, patients having a patient foramen ovale or a small-sized secundum ASD will be candidates for interventional rather than surgical closure in the future [10, 11]. Surgical closure using a LMT will be indicated in patients with a large defect, especially those in whom there is not sufficient rim to anchor the device; in general, this occurs at the inferior aspect close to the inferior vena cava. Patients in whom interventional closure can be performed safely will not be referred for surgical intervention. However, it is important to remember that no long-term results of interventional closure are available to date and that those patients receiving a metal mesh are at higher risk for endocarditis or thrombus formation. Patients with a sinus venosus ASD are amenable to surgical closure only. Thus, surgical closure using a LMT remains the standard for patients with more complex ASD pathology.

In conclusion, surgical ASD closure using either a LMT or a conventional technique yields good results. The use of autologous pericardial patches for ASD closure is a definitive therapy with low risk of subsequent endocarditis. Given the safety, efficacy, and potential benefits of a less invasive operation, the LMT can be considered the standard approach and is our first choice for surgical ASD closure.

	References

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