Asian Cardiovasc Thorac Ann 2002;10:228-230
© 2002 Asia Publishing EXchange Pte Ltd
Video-Assisted Thoracoscopic Surgery for Congenital Heart Disease
Yu Shi Qiang, MD,
Cai Zhen Jie, MD,
Cheng Yun Ge, MD,
Duan Da Wei, MCh,
Xu Xue Zheng, MD,
Chen Wen Sheng, MD,
Zhou Gen Xu, MD
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Institute of Cardiovascular Surgery Xijing Hospital The Fourth Military Medical University Xian, Shaanxi, People’s Republic of China
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For reprint information contact: Yu Shi Qiang, MD Tel: 86 29 337 3938 Fax: 86 29 324 4986 email: ysq2002{at}21cn.com Institute of Cardiovascular Surgery, Xijing Hospital, The Fourth Military Medical University, 15 Changlexi Road, Xian, Shaanxi 710032, People’s Republic of China.
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ABSTRACT
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We report our experience with video-assisted thoracoscopy in the surgical closure of heart septal defects. Nine patients, aged 10 to 26 years, underwent operation for closure of an atrial septal defect; and 3, aged 10 to 22 years, for closure of a ventricular septal defect. Three minithoracotomies with a diameter of 2 to 3 cm were made in the fourth intercostal space of the right parasternum and the fourth and seventh intercostal spaces of the right middle axillary line, respectively. Through the openings and guided by a thoracoscope, a catheter was inserted into the superior vena cava, femorofemoral extracorporeal circulation was built, the aorta was crossclamped, and the myocardium was protected by cold cardioplegia. The right atrium was opened, and the defect was exposed with a traction suture. Primary closure of defects was performed successfully in all patients. The duration of aortic crossclamping and extracorporeal circulation ranged from 11 to 56 minutes and from 50 to 168 minutes, respectively. Postoperatively, cardiac murmur disappeared and echocardiograms showed no residual shunt. Repair of heart septal defects can be completely done with the assistance of video-assisted thoracoscopy, offering a new option with minimal incision.
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INTRODUCTION
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Following the development of endoscopic techniques and their utilization in abdominal and thoracic surgery, thora-coscopy has been applied in cardiac surgery to provide a clearer view of intracardiac structures. We report our experience with video-assisted thoracoscopic surgery (VATS) in the closure of atrial and ventricular septal defects.
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PATIENTS AND METHODS
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Twelve patients were operated on to repair heart septal defects from April to September 2000. Only patients without other cardiovascular anomalies were selected. Nine patients, 3 males and 6 females, had an atrial septal defect (ASD). They ranged in age from 10 to 26 years (mean, 18 ± 6 years) and in weight from 27 to 67 kg (mean, 44 ± 12 kg). Echocardiograms showed that 3 cases were mixed-type ASD and 6 were secundum type. Three patients, 1 male and 2 females, had a ventricular septal defect (VSD). They were aged 10 to 22 years (mean, 17 ± 6 years) and weighed 27 to 67 kg (mean, 47 ± 20 kg). Echocardiograms showed that they were membranous-type VSD. No other anomalies were found in any of the patients.
The patients were anesthetized, and double-lumen tracheal cannulation (Mallinckrodt Medical, Athlone, Ireland) and femorofemoral cannulation were made. A 2-cm-long incision was made in the seventh intercostal space of the right middle axillary line (Figure 1
). A trocar was put in, through which the thoracoscope (Contec Medical, Ramat Hasharon, Israel) was inserted. Another 2-cm incision was made in the fourth intercostal space of the right parasternum for the insertion of surgical instruments and the inferior vena caval (IVC) snare. A 3-cm third incision was made in the fourth intercostal space of the right middle axillary line for the insertion of surgical instruments, the superior vena caval (SVC) snare, cannula for cold perfusion, and the aortic clamp. In patients over 40 kg, a double-lumen femoral vein catheter of 24/29F or 30/33F was placed in the SVC through the femoral vein. Left lung unilateral ventilation was employed. Oxygen saturation was monitored; if it fell below 90%, whole lung ventilation was installed. The position, focus, and brightness of the thoracoscope were modulated. The right phrenic nerve was identified, and the pericardium was incised from the IVC to the ascending aorta. Two traction sutures were made anterior to the phrenic nerve and pulled via the third incision. The SVC and IVC snares were inserted. A ligature was made at the apex of the right auricle via the first incision and pulled to expose the aortic root. A pursestring suture was placed around the root of the right auricle, through which the caval catheter was inserted into the SVC. Care was taken to avoid injury to the sinoatrial node. Extracorporeal circulation (ECC) was started. A pursestring suture was placed directly on the aortic root for holding the cold perfusion cannula. When temperature reached 30°C, the aorta was crossclamped, and hypothermic cardiac arrest was induced. The right atrium (RA) was opened and slung. The ASD was closed with a 3/0 Ticron running suture. During VSD repair, a disposable sump tip sucker was introduced into the left atrium through the foramen ovale or a small intraatrial defect created in the fossa ovalis. The VSD was exposed via the tricuspid valve and repaired with a 3/0 Dacron mattress suture without patch. The sucker was then placed in the right thoracic cavity, and the intraatrial defect or the fossa ovalis was sutured. The lungs were held in the inflated position to deair the left atrium before the suture was tied under blood. The aorta was unclamped while the orifice of the right coronary artery was compressed. Any residual shunt was investigated by transesophageal echocardiography. The SVC and IVC were released. The patient was changed to a head-down position. Air was evacuated via the aortic root by compressing the left atrium and ventricle. The RA was closed, and cardiac action resumed automatically. No atrioventricular block was found. ECC was terminated after the patient was rewarmed to 37°C. All catheters were extracted. The incision on the femoral vein was closed with a continuous 7/0 polypropylene suture. The pericardium was closed with an interrupted suture. The first thoracotomy opening was used for a pleural tube. Catheters in the femoral artery were extracted, and the vessel was closed with interrupted sutures. Hemostasis and closure of the other incisions were achieved.
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Figure 1. Three incisions (1, 2, and 3) were made in the seventh and fourth intercostal spaces of the right middle axillary line and the fourth intercostal space of the right parasternum, respectively. A drainage tube was inserted into the first opening after the operation.
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RESULTS
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No patch was used for repairing the ASD or VSD. The duration of aortic crossclamping and ECC was 11 to 56 minutes (mean, 30 ± 12 minutes) and 50 to 168 minutes (mean, 76 ± 33 minutes), respectively. All the patients were transferred from the intensive care unit to the general ward the next day and were discharged 5 to 7 days later. One patient with VSD was found with residual shunt after cardiac action resumed. The residual shunt was sutured on a beating heart while keeping the patient’s blood pressure above 8 kPa. Postoperatively, no murmur was heard and no residual shunt was shown by echo-cardiography in the other patients.
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DISCUSSION
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Minimally invasive procedures are the trend in cardio-vascular surgery. With experience in median sternotomy and minimal incision, a surgeon can perform VATS on the heart.1–3 Chang and Lin’s team repaired ASD in 8 patients4 and VSD in 14 patients5 with minimal anterolateral incision. They used video-assisted endoscopy to overcome the problem of inadequate view of intracardiac structures. In our procedure, the 10-mm 30-degree thoracoscope is inserted into the pectoral cavity via the opening in the seventh intercostal space of the right middle axillary line, providing a clear view of the entire right pectoral cavity, the root of the IVC, and the RA. With downward traction of the right auricle, the root of the SVC and the ascending aorta can also be seen clearly, making cardiac surgery feasible. Through three minithoracotomies on the right chest wall, we can perform dissection, incision, suture, and hemostasis with dexterity after several months of training. There were no problems with aortic crossclamping, coronary perfusion, and other surgical procedures.
The conventional method of air evacuation is to insufflate the lungs and change the patient to the head-down position. Transesophageal echocardiography is performed to ensure there are no air emboli in the heart chambers before cardioversion is performed. We evacuate air from the aortic root, another conventional method.
In conclusion, this surgical method offers many advantages: all surgical procedures can be carried out conveniently; intracardiac structures can be viewed clearly; air evacuation from the aortic root is reliable; and the incision is minimal. The duration of the surgery will be reduced with practice. In our opinion, it is a feasible and reliable method.
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REFERENCES
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- Lin PJ, Chang CH, Chu JJ, Liu HP, Tsai FC, Su WJ, et al. Minimally invasive cardiac surgical techniques in the closure of ventricular septal defect: an alternative approach. Ann Thorac Surg
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ABSTRACT
INTRODUCTION
