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Ann Thorac Surg 2005;80:673-676
© 2005 The Society of Thoracic Surgeons

Original article: Cardiovascular

Minimally Invasive Midaxillary Muscle Sparing Thoracotomy for Atrial Septal Defect Closure in Prepubescent Patients

Christian Schreiber, MD a , * , Sabine Bleiziffer, MD a , Martin Kostolny, MD a , Jürgen Hörer, MD a , Andreas Eicken, MD b , Klaus Holper, MD, PhD a , Peter Tassani-Prell, MD, PhD c , Rüdiger Lange, MD, PhD a

a Clinic of Cardiovascular Surgery, Munich, Germany
b Department of Pediatric Cardiology and Congenital Heart Disease, Munich, Germany
c Department of Anesthesiology, German Heart Center Munich at the Technical University, Munich, Germany

Accepted for publication March 3, 2005.

* Address reprint requests to Dr Schreiber, Clinic of Cardiovascular Surgery, German Heart Center Munich, Technical University of Munich, Lazarettstrasse 36, 80636 Munich, Germany (Email: schreiber{at}dhm.mhn.de).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
BACKGROUND: Partial sternotomy, as well as posterolateral or anterolateral right-sided thoracotomy, are used for correction of selected cardiac lesions in children. However, in female patients impaired breast development after an anterolateral thoracotomy is reported, and for both the posterolateral and the anterolateral approach, partial transection of large muscle groups is required. The midaxillary approach may help to avoid these side effects and improve the cosmetic result.

METHODS: Beginning in April 2003, our institutional policy changed toward a midaxillary approach in prepubescent patients with an atrial septal defect, in whom criteria for catheter closure were not fulfilled. Thoracotomy was performed after a horizontal midaxillary incision and mobilization of the latissimus dorsi and splitting of the serratus anterior. Aorta and caval veins were cannulated directly. The atrial septal defect was closed during electrically induced fibrillation of the heart.

RESULTS: Until August 2004, this technique was applied in 36 patients (30 girls, 6 boys), with no need for conversions to another approach. Mean patient age was 6.9 ± 2.6 years (range, 4 to 14 years), with a mean weight of 23.8 ± 11.2 kg (range, 15 to 69 kg). Skin incision ranged from 4.5 to 6.0 cm. Mean cardiopulmonary bypass time was 31 ± 13 minutes (range, 13 to 73 minutes), with a mean ventricular fibrillation time of 21.2 ± 7.4 minutes (range, 10 to 42 minutes). In 28 of 36 patients a patch was used. No phrenic nerve damage occurred.

CONCLUSIONS: The midaxillary approach is a safe alternative to lateral thoracotomies frequently used in cardiac surgery for atrial septal defect closure. It helps to improve the cosmetic result in the prepubescent patient group. We believe that its application should not be expanded to include repair of more complex lesions or to patients below the age of 3 to 4 years. For these, variations of cosmetically favorable partial sternotomy techniques should be applied.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Secundum atrial septal defect accounts for 6% to 10% of congenital heart disease at birth and is the most common congenital heart defect in adulthood [1]. The first successful atrial septal defect closure was performed through an anterolateral thoracotomy by F J Lewis in 1952 [2]. Over the years, the operative mortality and morbidity decreased dramatically [3, 4].

Today, the catheter-based closure devices have become accepted alternatives to surgery in selected cases [5, 6]. However, limitations for the interventional closure are defect size, insufficient rim, and complex anatomy. New minimally invasive approaches, such as ministernotomy [7–9], transxiphoid approach without sternotomy [10, 11], anterolateral thoracotomy [12], and posterolateral thoracotomy [13, 14] have gained in popularity. Most recently, Yang and colleagues [15] and our group [16] have described initial results using a midaxillary approach.

Prebubescent patients represent a special group in regard to surgical treatment. Our long-term follow-up in prepubescent female patients after right anterolateral thoracotomy revealed significantly impaired unilateral breast development [17]. Based on these findings, we abandoned our routine anterolateral approach in this subgroup of patients. In the present report, our surgical experience in 36 consecutive patients with the minimally invasive midaxillary muscle-sparing thoracotomy is described, and the current literature regarding other surgical approaches is reviewed.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Patients
Between April 2003 and August 2004 our institutional policy changed toward a midaxillary approach in prepubescent patients with an atrial septal defect, in whom criteria for catheter closure were not fulfilled. Of the 36 patients, 30 were girls and 6 were boys. Mean patient age was 6.9 ± 2.6 years (range, 4 to 14 years), with a mean weight of 23.8 ± 11.2 kg (range, 15 to 69 kg). Operative notes and discharge summaries were reviewed to ascertain patient characteristics and surgical outcome. All patients had intraoperative transesophageal echocardiography routinely performed, and another transthoracic echocardiography before discharge.

Surgical Technique
The patient is placed in an oblique position at an angle of 90 degrees, with the arm suspended at a right angle. The skin incision is performed in the midaxillary line. Beginning at the height of the mammary areola, it passes posteriorly toward the tip of the scapula. The subcutaneous attachments of the latissimus dorsi muscle are mobilized with electrocautery by dissecting just superficially to the fascia. The entire anterior border of the muscle is freed (Fig 1). The muscle can then be retracted posteriorly, exposing the serratus anterior muscle. This muscle is split in a longitude manner and the thorax opened in the bed of the fourth rib. The heart is exposed adequately by opening the pericardium, avoiding incision near the phrenic nerve. Suitable stay sutures are placed, and the pericardium retracted through the thoracal cavity to the skin. Tapes are passed around the caval veins. Two standard purse-string sutures are placed on the ascending aorta, and direct cannulation is performed. After placing two more standard purse-string sutures at the junctions of the caval veins with the right atrium, bicaval cannulation is performed (Fig 2). Cardiopulmonary bypass is instituted under normothermia. The operating table is then tilted, keeping down the head of the patient. The caval venous tapes are snared, fibrillation is induced electrically, and the right atrium is opened. A vertical incision in the midportion of the atrium is performed. In our experience, this facilitated access in contrast to the standard oblique atrial incision. Two pump suckers, of which one is placed in the coronary sinus, allow clear exposure of the right atrial cavity. The intraatrial defect is either closed with direct suture or patch material. The pericardial stay-sutures are then removed before gradually inflating the lungs for removal of air. Simultaneously, blood is withdrawn with a needle and a syringe from the left atrium and the aorta. Then, the heart is defibrillated. After a short period of reperfusion, the patient is weaned from bypass. For closure, pericostal sutures are placed, and the muscles are allowed to return to their normal position.



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  		Fig 1. The skin is incised and the subcutaneous tissue dissected right down to the latissimus dorsi muscle with the midaxillary incision line beginning at the height of the mammary areola and passing posteriorly toward the tip of the scapula.

 


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  		Fig 2. The thorax is opened, suitable stay sutures are placed, and the pericardium retracted through the thoracal cavity to the skin. Direct cannulation of the aorta and of the superior caval vein is performed. The inferior caval vein is cannulated through the right atrium.

 

   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
Skin incision ranged from 4.5 to 6.0 cm. No patient operated upon with the limited access required conversion to a larger skin incision. Femoral or iliac cannulation was not used in any patient. Mean cardiopulmonary bypass time for all patients was 31 ± 13 minutes (range, 13 to 73 minutes). In 28 of 36 patients a patch (knitted polytetrafluoroethylene) was used. Mean fibrillation time for all patients was 21.2 ± 17.4 minutes (range, 10.0 to 42 minutes), with a mean fibrillation time for direct closure of 17.5 ± 10.5 minutes (range, 10.0 to 42 minutes), and 22.2 ± 6.1 minutes (range, 11.0 to 35 minutes) for patch closure.

All patients were extubated within the first few hours after surgery. Mean stay at the intensive care unit was 3 ± 1 days (range, 1 to 4 days). In two patients, a pneumothorax after drainage removal resolved after conservative treatment. All patients were discharged after a mean of 12 ± 1 days (range, 10 to 14 days). One patient presented with a right pleural effusion after two months, which resolved with antiphlogistic therapy. One patient had a trivial residual shunt at the border of the patch on predischarge echocardiography. At follow-up, no shunt could be detected on atrial level. Sustained rhythm disturbances, bleeding, or phrenic nerve damage were not observed. No neurologic sequelae were found.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
In recent years, cosmetic sequelae of operations have gained relatively more importance, even in heart surgery. The median sternotomy is the universal method of exposure for most cardiac procedures. However, especially in patients with simple cardiac defects, a prominent midline scar remains an unsightly and lifelong reminder of an otherwise low-risk and successful procedure. Alternative approaches with the aim of a nearly invisible scar remain a surgical goal. It is accepted that standard posterolateral or anterolateral thoracotomy incisions provide good exposure of the intrathoracic structures. These lateral thoracotomies are also used in children [7, 12, 18–20] as an alternative access to anterior approaches such as full sternotomy, ministernotomy, or the transxiphoid approach.

In our recently published study, 72 female patients with right anterolateral thoracotomy, who had corrective operations when they were younger than 12 years of age, were examined after a mean follow-up time of 23.1 years [17]. Breast volume measurement showed a volume difference greater than 20% (left side larger than right) in 55% of the patients. Using indexed measurements, asymmetry in the lower part of the right breast was shown in 61%. Therefore, these findings question the use of an anterolateral thoracotomy in prepubescent female patients. Most other studies about the results after an anterolateral thoracotomy [18, 20–25] did, however, not differentiate between children before breast development and female patients with defined submammary grooves in an adequately large long-term cohort.

To avoid impaired development of the female breasts, we have successfully employed the modified midaxillary technique in 36 consecutive patients undergoing closure of a defect in the oval fossa between the ages of 4 and 14 years. The midaxillary incision is not even close to the site of future breast tissue and therefore any impairment of mammary development should be avoided. Apart from the intercostal musculature, the approach obviates the need to divide or incise any other muscles. Reduced acute and late pain, and morbidity, after the muscle-sparing alternative are well reported [26–28]. Likewise, thoracic surgeons have long considered the axillary thoracotomy as an optimal approach for pulmonary and mediastinal lesions [29–31]. We have, furthermore, preferred to use a short horizontal midaxillary incision in the skin, as this does not compromise any axillary glands, and does cross Langer's lines in perpendicular fashion.

In our practice, a minimum weight of 15 kg is required to employ the midaxillary approach. This body weight usually represents a patient group of about 4 years of age, as found in the weight-for-age percentiles. This minimum weight allows direct cannulation through the chest with optimal cosmetic benefit. The passage of all cannulas through the incision itself obviates any groin cannulation. Likewise, the groups around Bichell [7], Däbritz [12], Giamberti [18], and Abdel-Rahman [20] mainly favored direct cannulation of the heart. Giamberti [18] used groin cannulation in only 8 of 100 patients, and Bichell [7] in 40 of 135 patients, the smallest weighing 9.4 kg. In a large radiographic study, Steinberg and colleagues [32] provided blood vessel dimensions in infants and children. Four-year-old patients have a mean femoral vein and artery diameter of 0.7 cm (range, 0.4 to 1.15 cm). This confirms that cannulation may put the femoral vessels at risk in this patient group. In children under the age of four years, we and others [8, 33] consider the limited lower sternotomy as the preferred approach.

Whereas Helps and colleagues [34] observed phrenic nerve damage in an unusually high rate of 31% (5 of 16 patients), our group and Däbritz and associates [12] (87 patients) found no evidence of nerval damage. The exact operative techniques that are known to affect nerve function may be multifactorial (direct injury, electrocautery used near a nerve, extensive thymus dissection, placement of pericardial stay sutures and traction, internal jugular vein cannulation, and topical cooling). In our opinion, the midaxillary approach can be used safely by appreciating the course of the nerve, pulling adequately on the pericardial traction sutures, and avoiding topical cooling. Likewise, our preferred technique of fibrillatory arrest and normothermia obviates any cooling at all.

Especially today, where percutaneous closure of an atrial septal defect is becoming an accepted technique, substantial scarring or deformity ought to be avoided at any surgical intervention. Our described surgical approach in prebubescent patients with a minimum weight of 15 kg represents a favorable surgical alternative. For reasons outlined above, we regard a full sternotomy, or an anterolateral or posterolateral approach, as not adequate in this patient group.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

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