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Ann Thorac Surg 2008;85:831-835. doi:10.1016/j.athoracsur.2007.11.068
© 2008 The Society of Thoracic Surgeons
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Original Articles: Cardiovascular

Minimally Invasive Congenital Cardiac Surgery Through Right Anterior Minithoracotomy Approach

David Mishaly, MDa,*, Probal Ghosh, MDb, Sergey Preisman, MDc

a Department of Pediatric Cardiac Surgery, Sheba Medical Center, Tel Hashomer, Israel
b Department of Cardiac Surgery, Sheba Medical Center, Tel Hashomer, Israel
c Department of Anesthesiology, Sheba Medical Center, Tel Hashomer, Israel

Accepted for publication November 26, 2007.

* Address correspondence to Dr Mishaly, Department of Pediatric Cardiac Surgery, Sheba Medical Center, Tel Hashomer, 52621, Israel (Email: dmishaly{at}sheba.health.gov.il).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background: Median sternotomy has been the conventional approach for correction of congenital cardiac defects despite poor cosmetic results at times. Right anterior minithoracotomy was, therefore, assessed as an alternative procedure with a better cosmetic outcome.

Methods: From October 2002 through February 2007, 75 patients underwent correction of congenital cardiac malformations with the use of cardiopulmonary bypass through right anterior minithoracotomy involving a short incision through the fifth intercostal space and the minimally invasive cannulation. Of them, 18 patients were infants, 42 were children, and 15 were adult. The average age was 9.26 ± 14.1 years (range, 1.2 to 56). The average weight was 19.59 ± 24.3 kg (range, 8.5 to 118 kg). The corrected defects included atrial septal defect type II, sinus venosus atrial septal defect with partial anomalous pulmonary venous drainage, atrial component of atrioventricular septal defect, perimembranous ventricular septal defects with patent foramen ovale, mitral valve repair (complex), repair of cleft mitral valve, cor triatum atrial septal defect, repair of double-chambered right ventricle and extraction of atrial septal defect closure device. Skin incisions were as long as 5 cm.

Results: There was no operative or late mortality or major morbidity. The mean cardiopulmonary bypass time was 58.67 ± 35.11 minutes (range, 32 to 263). Sixty-five patients were extubated in the operating room; the remaining 10 patients were extubated within 4 hours. Cosmetic result was very satisfactory in all patients. Two adult patients complained of some right chest musculoskeletal discomfort.

Conclusions: The right anterior minithoracotomy incision is a safe and effective alternative to a median sternotomy for correction of congenital heart defects. Cosmetic results are highly satisfactory.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
Median sternotomy has been the conventional approach for correction of congenital cardiac defects for many years, but it often yields poor cosmetic results. Unsightly midline scars arouse displeasure and psychological distress, especially in young female patients. As the safety of cardiac operation has increased, more emphasis has been now put on cosmetic results after operation. Thus, the minimally invasive cardiac surgical techniques through a right anterior minithoracotomy (RAMT) were introduced. The aesthetic result was preferable and accepted by many people. In the past 10 years, these aesthetic techniques have also evolved to correction of congenital heart defects in infants and children as well [1–5].

We used RAMT to repair congenital heart defects for patients weighing at least 9 kg, and for defects that can be approached through the right or the left atrium. This retrospective study reviews our experience and results using this minimally invasive technique.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
From October 2002 through February 2007, 75 patients underwent open heart operations through a RAMT approach. Age ranged from 1.2 to 56 years (mean, 9.26). Sixty of them were younger than 18 years. Mean body weight was 19.59 ± 24.3 kg (range, 8.5 to 118 kg). Baseline characteristics, type of defect, and surgical procedures are listed in Table 1. Institutional Review Board approval was obtained for the study.


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  		Table 1 Baseline Characteristics, Types of Defect, and Surgical Procedures
 
Operative Technique
The patient was placed on the right side elevated 20 to 30 degrees. The arms were positioned beside the body; the right groin was prepared and draped to allow access to the right femoral vessels. The induction of anesthesia included midazolam (0.1 mg/kg) and fentanyl (5 µg/kg). Muscle relaxation was achieved by pancuronium (0.1 mg/kg). A regular cuffed endotracheal tube was inserted. Maintenance of anesthesia was tailored to achieve early extubation and included moderate doses of fentanyl (total dose of 15 to 20 µg/kg) with the addition of isoflurane. After the induction of anesthesia, external defibrillation pads were placed. Invasive monitoring included the use of a 21G arterial catheter placed in the right radial artery and a 4F double-lumen central venous catheter inserted through the left internal jugular vein after the induction of anesthesia. Comprehensive transesophageal echocardiographic examination was performed to confirm the diagnosis and obtain more precise information concerning underlying pathology and anatomy.

In all patients, the superior vena cava was cannulated by an anesthesiologist through the internal jugular vein using the Seldinger technique with a 12F to 18F Fem Flex II femoral arterial cannula (Edwards Lifesciences, Irvine, California). In 6 patients undergoing complex mitral valve repair, the internal jugular vein was used for the insertion of the special catheter into the coronary sinus (EndoPlege catheter; Heartport, Redwood City, CA). Venous or coronary sinus cannulae were carefully positioned by the anesthesiologist using transesophageal echocardiographic guidance (Fig 1).


Figure 1
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  		Fig 1. Patient before the beginning of the surgery.

 
Cannulations of the right femoral artery (12F to 18F cannula) and the inferior vena cava (IVC) through the right femoral vein (12F to 21F cannula [Femoral Cannulae Placement Kit; Medtronic, Minneapolis, Minnesota]) were then performed through a 2-cm incision in the groin. The Seldinger technique was used. The cannula in the IVC was positioned under transesophageal echocardiographic guidance by the anesthesiologist. The vascular cannulation sites were closed with pursestring suture after the end of the surgery.

In patients with developed breasts, the submammary groove was used for the skin incision. In case of undeveloped breasts, the incision was made in the fifth intercostal space anteriorly to avoid deformity of the breast and the pectoral muscle [6]. The anterior skin incision was 4 to 5 cm length. Essentially, a musculocutaneous flap was avoided. The chest was preferably entered in the fifth intercostals space. Care was taken to preserve right internal mammary vessels. While entering the intercostal space, care was taken to avoid trauma to the rib periosteum, and the incision was made in the intercostal muscles. Thereafter, the pericardium was opened anterior to the phrenic nerve and suspended posteriorly, avoiding injury to the phrenic nerve. If necessary, an autologous pericardial patch was harvested and prepared for further procedures.

After systemic administration of heparin, cardiopulmonary bypass (CPB) was initiated through the neck and groin cannulae. Most of the procedures were performed on a fibrillating heart in normothermic conditions. The fibrillation was achieved by the application of the electrodes of a conventional fibrillator directly on the epicardial surface of the heart. In 11 patients (closure of ventricular septal defects, correction of double-chamber right ventricle, and repair of complex mitral valve), a Chitwood-type aortic cross-clamp (Scanlan International, St. Paul, Minnesota) was inserted through a separate port in the chest wall. In these patients, retrograde crystalloid cardioplegia was delivered through the coronary sinus cannula inserted by the surgeon in 5 patients and by the anesthesiologist in 6 patients (accessed through internal jugular vein). During CPB, conventional hemofiltration was performed. Although use of CPB in port-access surgery enables the performance of modified hemofiltration, it was not used in the patients in the current study.

Through a standard oblique right atriotomy or a longitudinal left atrial incision, or both, an acceptable exposure of the intracardiac anatomy could usually be obtained. The procedures for correcting the heart anomalies were almost the same as used in the median sternotomy approach. Special "port-access" instruments were used in all cases. Primary continuous suture (13 patients) or pericardial patch was used (22 patients) for the closure of secundum type, IVC type, and coronary sinus type atrial septal defect (ASD). The ASD component of the partial atrioventricular septal defect was closed in a similar fashion by using a pericardial patch. The cleft mitral valve in these patients was repaired by using interrupted 6-0 polypropylene sutures to close the cleft, and a comissuroplasty suture was added in the posterior commissure (11 patients). The ventricular septal defects were closed with a pericardial patch. The partial anomalous pulmonary venous connections (PAPVD) were corrected by creating a pericardial patch tunnel redirecting the pulmonary venous blood return into the left atrium (13 patients). In another patient with an ASD occluder dislocation into the left atrium, the occluder was retrieved and the ASD was closed with a pericardial patch. In 8 patients, various pathologies of the mitral valve were repaired using standard repair techniques. One patient underwent repair of Scimitar syndrome with right pulmonary vein draining into the IVC by direct anastomosis of the vein to the right atrium, atrial septectomy, and creating a pericardial patch tunnel redirecting the pulmonary venous blood flow into the left atrium.

The air in the heart could be evacuated easily when the aortic clamp was released slowly and the aortic needle vent was connected to suction. The absence of intracardiac air and the quality of repair were evaluated by transesophageal echocardiographic. Pediatric external pads were used for defibrillation in 22 patients. Sinus rhythm was restored spontaneously in rest of the patients. The CPB was gradually discontinued. The pleuropericardial drain was placed. Before closing the chest, an intercostal block was performed in the fourth, fifth, and sixth intercostal spaces. The chest was then closed in a routine fashion with an intradermal continuous suture for the skin.

Caudal morphine (50 to 70 µg/kg) and rectal paracetamol (40 to 50 mg/kg) were administered for postoperative pain control before extubation. Pain control in the postoperative period consisted of oral administration of oxycodone in syrup (0.1 to 0.2 mg/kg every 6 hours) and ibuprofen in syrup (10 mg/kg every 8 hours).


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
There were no deaths in this series of 75 patients. No patient required conversion to full sternotomy. The mean CPB time was 58.67 ± 35.11 minutes (range, 32 to 263). In 11 patients in whom we used aortic cross-clamp, the mean aortic cross-clamping time was 35.03 ± 24.84 minutes (range, 13 to 142). Sixty-five patients were extubated in the operating room, and the remaining 10 patients were extubated within 4 hours.

Postoperative electrocardiogram showed normal sinus rhythm in all patients. Postoperative echocardiograms revealed no residual shunt. All wounds healed well. The mean hospital stay was 3.98 ± 0.92 days (range, 3 to 7; Table 2).


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  		Table 2 Operative and Postoperative Data
 
Two patients had early complications. In 1, a recurrent ASD developed 24 hours later owing to a tear of the ASD stitch. In the second patient, IVC had been directed to the left atrium during ASD closure because of anomalous insertion of IVC to the left atrium. Both were promptly reoperated on using the same minimally invasive approach, and have been doing well since then.

The follow-up was 12.3 ± 10.4 months (range, 6 to 45) for 75 patients. Echocardiography performed on all the patients before discharge showed no residual shunts, and was reconfirmed in the follow-up echocardiography.

The advantage of this technique included absence of any pericardial effusion in the RAMT group, as the creation of a pericardial window was a part of the procedure. The skin incision scar was barely discernible. All patients had gratifying cosmetic results at longer follow-up. No deformity of the chest or the breast was noted, nor was any pigeon chest or scoliosis noted. None of the patients had breast asymmetry (Fig 2). Two adult patients complained of some right chest musculoskeletal discomfort, which resolved after 6 months.


Figure 2
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  		Fig 2. Scar, 3 months postoperatively, in a postpubertal girl.

 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
Chest scars have significant adverse psychological consequences and social impact on growing boys and girls. The impact is more significant for them than for adult patients. In the current era of a growing interest in minimally invasive surgical techniques in cardiac surgery in general, there is a legitimate desire to adopt these approaches for the pediatric population.

During the last decade, several minimally invasive surgical techniques with or without cardioscopy have been introduced to achieve superior cosmetic results. These included ministernotomy (lower and upper) [7, 8], transxiphoidal approach without sternotomy [9–12], and anterior left [13], right [14], or posterior lateral [15–17] thoracotomy. Several authors have used RAMT similar to our approach but with larger incision [18, 19]. Currently the patients tend to be younger in age and smaller in body weight. Moreover, now there are wider indications for RAMT approach than for only ASD secundum closure.

Compared with a complete sternotomy, small lower partial sternotomy or bilateral submammary incision, we consider the anterolateral thoracotomy incision to be preferable, particularly for young patients. We believe that an almost obscure, small, lower anterior thoracotomy scar in the skinfold just below the breast is more cosmetic than even a short midline scar, as a midline scar is always visible. As the RAMT scar is less visible, the cosmetic result can meet patient expectations.

Cosmetically, we believe that the RAMT approach also appears to be superior to standard posterolateral thoracotomy. Cherup and associates [6] described maldevelopment of the breast and pectoral muscle in children who had undergone thoracotomies in early childhood. Those deformities developed after large incisions that were extended medially with subluxation of the chondrosternal junction [20]. Scoliosis is also known to occur after extensive thoracotomies [21]. In the present RAMT series, the incision ranged from 4 to 5 cm. To avoid distortion of the growing breast tissue, particularly in the prepubescent girls, we accented the minianterior thoracotomy as low as the fifth intercostal space below the future development of the breast tissue, which would not impede the future growth of the breast tissue and the pectoralis muscle (Fig 2).

No scoliosis or breast asymmetry has developed in the patients in our follow-up. There has been no compromise in intracardiac technique or precision of repair in this series. The RAMT approach allowed for a predictable exposure and improved cosmetics, and also could be used for repair of a wide variety of congenital cardiac lesions (other than ASD secundum), as long as the approach was through right or left atrium, or both. Presence of persistent left superior vena cava is not a contraindication to this approach.

Good exposure is the key to the feasibility of this minimally invasive approach. Both arterial and venous canulations were kept out of the operative field. We always established CPB through femoral artery, vein, and superior vena cava (percutaneously accessed through internal jugular vein) cannulations. We had no complication related to the femoral canulations, and the exposure to the intracardiac anatomy was very satisfactory. We were able to cannulate the groin and the jugular vein in infants weighing as low as 9 kg. Currently, through a 4-cm incision, we used this method exclusively for every patient who underwent repair of congenital cardiac defects that could be approached through the right or the left atrium or both and weighed at least 9 kg. We are not aware of any other group who has adopted a similar policy of percutaneous cannulations in small infants.

In conclusion, we believe that the right anterior minithoracotomy can be performed safely in children for repair of common congenital heart defects, including ASD, ventricular septal defect, partial anomalous pulmonary venous connection, mitral valve repair, and so forth. This method of minimally invasive surgery through RAMT confers upon patients psychological and social satisfaction and quality of life.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

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