Ann Thorac Surg 2008;85:199-203. doi:10.1016/j.athoracsur.2007.08.049
© 2008 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Comparison of Incisions and Outcomes for Closure of Ventricular Septal Defects
Jianrong Li, PhD*,
Yinglong Liu, MD,
Cuntao Yu, MD,
Bin Cui, MD,
Ming Du, MD
Cardiovascular Institute and Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Laboratory of Congenital Heart Disease, Fuwai Cardiovascular Disease Hospital, Beijing, China
Accepted for publication August 22, 2007.
* Address correspondence to Dr Li, Laboratory of Congenital Heart Disease, Fuwai Cardiovascular Disease Hospital, 167 Beilishi St, Xicheng District, Beijing, 100037, China (Email: leejianrong{at}126.com).
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Abstract
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Background: Repair of ventricular septal defects (VSD) through a shorter right lateral thoracotomy has evolved for 10 years. However, outcomes of this surgery and patients’ health-related quality of life have not been evaluated so far.
Methods: Four hundred eighty-eight patients aged 6 to 15 years who had undergone repair of VSD through a right thoracotomy were surveyed (right group) and 185 patients of the same age were surveyed who had undergone the repair through a median sternotomy (median group). Cardiopulmonary bypass, arotic cross-clamping and mechanical ventilation time, amount of drainage, postoperative hospital stay, and in-hospital mortality and morbidity were measured as short-term outcomes. Symptoms, physical signs, ultrasonic cardiogram, chest film, and electrocardiogram were followed up as long-term outcomes; and the patients’ TNO-AZL Children’s Quality of Life (TACQOL) were studied to evaluate their health-related quality of life. The TNO-AZL Children’s Quality of Life (TACQOL) questionnaire is a 56-item child quality of life questionnaire designed by the TNO Institute of Prevention and Health and the Leiden University Hospital (TNO-AZL).
Results: Compared with the median group, the right group’s short- and long-term outcomes were more satisfactory, with less drainage (106.71 ± 85.20 mL versus 146.70 ± 75.63 mL) and no pigeon chest (0 versus 3). The right group’s TACQOL were higher than that of the median group in physical complaints (29.58 ± 2.8 versus 28.07 ± 2.95), motor functioning (31.23 ± 1.09 versus 30.53 ± 1.60), and cognitive functioning (29.93 ± 3.22 versus 26.87 ± 4.24).
Conclusions: Repair of VSD through a right thoracotomy can provide more satisfactory outcomes and better health-related quality of life.
Over the past 10 years, a revolution has occurred in cardiac surgery allowing many cardiac procedures to be performed through small incisions, including shorter right lateral and anterolateral thoracotomy, partial upper, mid, and lower sternotomy, and parasternal incision. But the question whether these small-incision surgeries are indeed minimally invasive remains in debate. In this report, we reviewed the patients’ short- and long-term outcomes and health-related quality of life (HRQOL) after repair of ventricular septal defect (VSD) through a shorter right lateral thoracotomy for the purpose of evaluating the whole effects of this surgery.
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Material and Methods
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From January 2005 to May 2005, all 488 patients aged 6 to 15 years with isolated congenital VSD who had undergone repair surgery through a shorter right lateral thoracotomy between October 1994 and April 2004 in Fuwai Hospital were surveyed (right group) and compared with 185 patients randomly selected from a total of 5,863 patients who had undergone this repair through a median sternotomy (median group) at the same time. There were no differences between the two groups in sex and age and weight at operation (Table 1).
Cardiopulmonary bypass time, arotic cross-clamping time, postoperative mechanical ventilation time, amount of drainage, postoperative hospital stay, and in-hospital mortality and morbidity were reviewed as short-term outcomes. Questionnaires completed by local cardiologists about symptoms and physical signs related with primary diseases and results of ultrasonic cardiogram, chest x-ray film, and electrocardiogram within 1 month of receiving follow-up letters were surveyed as long-term outcomes and meanwhile the patients’ TNO-AZL Children’s Quality of Life (TACQOL) questionnaires completed by their parents were studied to evaluate their HRQOL. The TNO-AZL Children’s Quality of Life (TACQOL) questionnaire is a 56-item child quality of life questionnaire designed by the TNO Institute of Prevention and Health and the Leiden University Hospital (TNO-AZL).
The TACQOL is a multidimensional instrument with seven domains concerning physical complaints, motor functioning, autonomy, cognitive functioning, social functioning and positive and negative emotions with eight items on each domain. Scores range from 0 to 32 on the first five domains, and from 0 to 16 on the other two emotional domains. Higher scores indicate better quality of life. In this study we used the parent form of TACQOL [1, 2]. The items of the TACQOL Parent Form are presented in Table 2.
Measurement data are presented as mean with standard deviation. Comparisons between the two groups were performed using the independent t test (equal variance) or t’test (unequal variance). Comparisons between two qualitative variables were performed using the 
2 test (with the Yates’ correction when necessary). A p value of 0.05 or less was considered significant.
Our study was approved by the Medical Ethics Committee of Fuwai Cardiovascular Disease Hospital, and they gave us their approval to waive the need for patient consent for publishing follow-up data about these patients.
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Results
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Short-Term Outcomes
The mean amount of drainage of the right group was significantly less than that of the median group. There were no significant differences in cardiopulmonary bypass time, aortic cross-clamping time, postoperative mechanical ventilation time, and postoperative hospital stay between the two groups. There were no significant differences in in-hospital mortality and morbidity between the two groups. These data are shown in Table 3. The cause of in-hospital death was severe pulmonary infection in the right group and pulmonary hypertensive crisis in the median group.
The in-hospital complications of the right group included atelectasis in 2 patients, residual shunt in 1, transient second-degree atrioventricular block in 2, and excessive secondary hemorrhage requiring surgical revision in 2. The complications of the median group were transient third-degree atrioventricular block in 1 and excessive secondary hemorrhage requiring surgical revision in 2. All these patients of both groups recovered before discharge.
Long-Term Outcomes
The general follow-up data are shown in Table 4. Three cases of pigeon chest were reported in the median group whereas no any symptoms and signs related with primary diseases were reported in the right group. There were no any abnormal findings in ultrasonic cardiogram examination in both groups except some cases of mild mitral, tricuspid, or pulmonary insufficiency without requiring treatment. Electrocardiographic examination found a patient with first-degree atrioventricular block and frequent premature ventricular contractions in the right group. He was diagnosed as having viral myocarditis without any relation to the primary operation and was being treated in his local hospital. The other findings of electrocardiograms in both groups were incomplete and complete right bundle branch block (30.5% in the right group and 28.7% in the median group), the most common electrocardiogram findings without requiring treatment after VSD repair. There were no significantly abnormal findings in chest films requiring treatment in either group.
The TACQOL Questionnaire
Compared with the median group, the scores of TACQOL of the right group were significantly higher in domains of physical complaints, motor functioning, and cognitive functioning. There were no significant differences in domains of autonomy, social function, positive emotions, and negative emotions between the two groups (Table 5).
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Comment
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The conventional criteria used to evaluate the effect of minimally invasive heart surgery include short-term outcome measures (including size of incision, cardiopulmonary bypass time, aortic cross-clamping time, postoperative mechanical ventilation time, amount of drainage, postoperative hospital stay, and in-hospital mortality and morbidity) and long-term outcome measures (including occurrence of residual malformation, late death, and late complication, and so on) [1–4]. However, these outcome measures only focus on the patient’s postoperative physical outcomes and health but do not reflect the operation’s impacts on the patient’s psychological and social health. We think that an indeed minimally invasive cardiac surgery can provide not only better physical outcomes, such as smaller incisions, shorter time of cardiopulmonary bypass, aortic cross clamping, and postoperative mechanical ventilation, less drainage, shorter postoperative hospital stay, and less mortality and morbidity, but also more satisfactory status of long-term physical, psychological, and social health for patients. We think that it is very important and even indispensable to measure the patients’ general physical, psychological, and social health when evaluating a minimally invasive surgery.
Health-related quality-of-life questionnaires are often used to evaluate a person’s or a certain group’s general health including physical, psychological, and social health. The TACQOL is such a HRQOL questionnaire constructed to enable a description of HRQOL of children aged 6 to 15 years by their parents or by the children themselves and often is used to compare the effects of different treatment modalities. In this study, we used the parent form of TACQOL. It has recently been translated into Chinese and validated on a large sample of Chinese school-going children with good reliability and validity (Cronbach’s 
= 0.8995, Spearman’s correlation coefficient 
= 0.289 to 0.790; p < 0. 05) [5], which is regarded as satisfactory for our study.
In this report, we review the short- and long-term outcomes of repair of congenital VSD through a shorter right lateral thoracotomy and its impacts on the patients’ TACQOL for the purpose of evaluating the whole effects of this surgery. Because of the age range of the TACQOL, we selected patients aged 6 to 15 years as our subjects.
Compared with the median group, the right group’s short- and long-term outcomes were more satisfactory, with less mean amount of drainage and no incidence of pigeon chest whereas 3 cases of pigeon chest were reported in the median group. Bleeding from the sternal marrow cavity is always one of the most crucial factors of postoperative drainage after sternotomy, and the most usual method to control this bleeding is to cover the sternal marrow cavity with bone wax. The bone wax used to cover the sternal marrow cavity must be sufficient, otherwise the bleeding would reoccur because the marrow cavity might absorb large quantities of wax; however, it would result in some new problems when too much bone wax was used. The adverse effects related to bone wax including sternotomy dehiscence and infection and even embolization of bone wax from sternotomy incisions to the lung have been reported repeatedly [6–8]. These factors might be partly responsible for our findings of more mean amount of drainage and high incidence of pigeon chest in the median sternotomy group.
In the right lateral thoracotomy group, a skin incision about 6 to 8 cm in length was made obliquely between the intersection of the posterior axillary fold and the third intercostals space and that of the anterior axillary fold and the sixth intercostals space. A flap of breast tissue and pectoralis muscle was dissected from the underlying chest wall and retracted cephalad, so that the chest cavity could be entered through the fourth or third intercostals space easily. It would not impact on the development of the breast and pectoralis muscle, as the incision was far from these tissues [9–11]. Good exposure and cannulation of aorta were the key steps, and could be performed safely. Selection of the correct intercostal space was critical to obtaining adequate exposure. The pericardium was opened longitudinally 1 to 2 cm anterior to the phrenic nerve. The pericardial incision was extended superiorly and inferiorly, giving adequate exposure to the aorta and the inferior vena cava. After the ascending aorta was placed with two concentric pursestring sutures and cannulated with the right-angled cannula, the superior vena cava was cannulated in the right atrial appendage with the rightangle cannula through a pursestring. The inferior vena cava cannula was inserted through a stab wound at the cavoatrial junction. Cardiopulmonary bypass was established through these cannulas, and core cooling was begun. When the body temperature was between 24°C and 32°C, the aorta was cross-clamped and cold crystalloid cardioplegic solution was infused into the ascending aorta. Acceptable exposure of the intracardiac anatomy could be obtained with a standard oblique right atriotomy or a vertical right ventriculotomy incision. The procedures for correcting the heart anomalies were almost the same as those for median sternotomy.
In contrast to the median sternotomy, the right lateral thoracotomy kept the integrity of the sternum, eliminated the bleeding from the sternal marrow cavity, and avoided the occurrence of some long-term complications after sternotomy.
In this report, we also found that the TACQOL scores of the right group were higher than that of the median group in domains of physical complaints, motor functioning, and cognitive functioning. In the right group, the patients’ thoracic motor function would not be damaged to a great extent as the right lateral thoracotomy kept the integrity of the bony thorax and avoided the occurrence of pigeon chest. In addition, the incision of the right lateral thoracotomy was located between the anterior and posterior axillary fold, and it would be covered easily by the right arm, especially when the arm hung loosely, so the patients and their parent’s memories of the operations would not be recalled frequently and intensely and thus their worries about the child’s health would decrease unconsciously. We think these factors would be responsible for the differences of TACQOL in physical complaints and motor functioning between the two groups.
School is usually the most important living environment for children aged 6 to 15 years. Any unhealthy or subhealthy conditions of children in physical, psychological, or social aspects seem to be more severe in the setting of school, and as a result, the difference in cognitive functioning between the two groups may reflect the differences in other physical, psychological, or social aspects more than the difference in intellectual ability even though these differences were undetectable in their own domains.
Missing at random owing to undelivered mail was the main cause of missing questionnaires in our study. It can be regarded as ignorable because missing at random leads to unbiased parameter estimates. The proportion of nonrandom missing in our study was less than 16% in the right group and 15% in the median group, which were acceptable.
In conclusion, the repair surgery of VSD through a shorter right lateral thoracotomy can provide more satisfactory short- and long-term outcomes and better HRQOL for pediatric patients.
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Acknowledgments
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We thank all participating children and parents without whom our research would not have been possible. We thank Prof. Nie Shaofa of Tongji Medical College for providing the Chinese version of TACQOL.
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References
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Abstract
Introduction
