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Ann Thorac Surg 1999;67:1652
© 1999 The Society of Thoracic Surgeons
a Cardiothoracic Surgery, Erie County Medical Center, 462 Grider St, Buffalo, NY 14215 USA
Invited commentary
Cremer and associates describe 3 surgical techniques for closure of atrial septal defects (ASD) using minithoracotomy approaches. The aim of their article is to address the evolving stages in developing a satisfactory technique for minimally invasive ASD closure. Currently, their preferred approach is technique 3, which consists of a mini right submammary incision (6 to 8 cm in length), right femoral artery cannulation, direct inferior vena cava cannulation, and percutaneous jugular vein cannulation.
There is an obvious trend in all areas of cardiac surgery to make incisions smaller and smaller. Techniques 2 and 3, described in this article, are especially intended for young women, to avoid an unsightly sternotomy scar. No doubt, a 6- or 8-cm submammary incision may be more appealing to our patients, and to our referring physicians, than a more conventional 12-cm submammary incision. However, from the cosmetic point of view, it seems to be a minor improvement, at the cost of potentially serious complications, which may be associated with cannulation of the femoral artery, as occurred in 1 patient in their series of 24 patients, and has also been reported by other authors.
It is also my impression that, despite the changes introduced in technique 3, the authors may still have great difficulty with exposure, because the fibrillating times are excessive (mean, 26.1 minutes), considering that most ASDs were direct closures (18 of 24 patients). Closure with a patch was seldom used in their series. I suspect that their fibrillating times would double or triple if they encounter an anomalous pulmonary venous connection. Why struggle through such a small incision?
It seems to me that a slightly longer submammary incision (ie, 12 cm in length) may have an equally satisfying cosmetic result, while enhancing exposure considerably. A conventional 12-cm submammary incision offers several advantages over a 6- or 8-cm incision: first, groin cannulation is avoided, because direct cannulation of the ascending aorta and of the superior and inferior venae cavae can be easily accomplished [1]; second, improved exposure results in shorter cross-clamp times (or shorter fibrillating times); third, it is easier to remove all the air, and defibrillate the heart; and fourth, other coexisting defects, such as anomalous pulmonary venous connections, can be easily repaired through a 12-cm submammary incision [1]. My colleagues and I have also used this approach for more than 20 mitral valve repairs and replacements, with excellent exposure in all cases.
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