Ann Thorac Surg 2005;80:676-677
© 2005 The Society of Thoracic Surgeons
Original article: Cardiovascular
Invited commentary
Roberto M. Di Donato, MD
Department of Pediatric Cardiac Surgery, Ospedale Bambino Gesu’, Dipartimento Medico, Chirurgico di Cardiol Ped, Piazza S. Onofrio 4, Rome, 00165 Italy
(Email: didonato{at}opbg.net).
Schreiber and colleagues propose a novel approach for minimally invasive surgical closure of atrial septal defects in prepubescent patients (ie, a horizontal midaxillary muscle-sparing mini-thoracotomy). The results of their small series are excellent and the method as described is very intriguing.
Interestingly, the Munich group switched to this approach after experiencing relevant problems of asymmetrical breast development after right anterolateral thoracotomy in prepubescent female patients. Frankly, I do not recall a single case of severely deformed breast development in our series of patients undergoing right submammary mini-thoracotomy since 1997. I wonder whether the "standard" incision 3 to 4 cm below the nipple that the authors describe in their previous publication [1], is in fact a bit too "high" and potentially impinging upon the mammary tissue. Instead we prefer to carry the incision strictly along the fifth intercostal space (or even the sixth rib), a very reliable anatomical landmark of the future site of the submammary groove according to Rosengart and Stark [2]. Nonetheless, we must admit that the midaxillary approach really avoids the risk of breast deformity, and by preserving all major thoracic muscles it also substantially minimizes the risk of postoperative discomfort and acquired scoliosis.
I am impressed by the ability of the authors to avoid femoral cannulations in all the patients. I suppose that the typical patient’s size targeted for the procedure (4 years of age; minimum weight, 15 kg) lends itself to an "easy" direct aortic and bicaval cannulation even through such a limited and "distant" approach. Yet, in the general experience, the aortic cannulation is the trickiest phase of these mini-invasive open-heart procedures and one would guess that it gets harder the farther away from the midline sternotomy it is performed.
Another debatable technical issue is the routine use of induced ventricular fibrillation during the intracardiac stage of even a simple procedure (eg, atrial septal defect closure). I agree that avoiding the placement of an aortic cross clamp may greatly simplify the procedure. However, even keeping the head of the patient down, the potentially patent aortic outflow may involve a somewhat increased risk of air embolism.
In conclusion, I commend the authors for their persistent search of a more effective and cosmetic mini-invasive technique for atrial septal defect closure. This is probably one of the finest mini-invasive techniques currently available, as long as it is carried out by experienced hands.
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References
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- Bleiziffer S, Schreiber C, Burgkart R, et al. The influence of right anterolateral thoracotomy in prepubescent female patients on late breast development and on the incidence of scoliosis J Thorac Cardiovasc Surg 2004;127:1474-1480.[Abstract/Free Full Text]
- Rosengart TK, Stark JF. Repair of atrial septal defect through a right thoracotomy Ann Thorac Surg 1993;55:1138-1140.[Abstract]
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