Asian Cardiovasc Thorac Ann 2003;11:226-228
© 2003 Asia Publishing EXchange Ltd
Comparison of Different Approaches for Pediatric Congenital Heart Diseases
Wu Qingyu, MD,
Luo Guohua, MD,
Li Shoujun, MD,
Shen Xiangdong, MD,
Lu Feng, MD
Department of Cardiac Surgery, Fuwai Hospital & Cardiovascular Institute, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China
For reprint information contact: Wu Qingyu, MD Tel: 86 01 68332376 Fax: 86 01 68332176 email: wuqingyu{at}public.bta.net.cn Department of Cardiac Surgery, Fuwai Hospital & Cardiovascular Institute, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, People’s Republic of China.
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ABSTRACT
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To compare the clinical results of different surgical approaches for congenital heart disease in pediatric patients, 1,669 cases of atrial septal defect, ventricular septal defect, or tetralogy of Fallot, which were corrected from January 1999 to December 2001, were classified according to approach (sternotomy, ministernotomy, or minithoracotomy). In cases of ventricular septal defect, the incidence of pulmonary complications was significantly higher in the minithoracotomy group than in the full sternotomy or ministernotomy groups. In patients with tetralogy of Fallot, hemoglobin concentration was higher, oxygen saturation was lower, and more patients required a transanular patch in the sternotomy group than in the other groups, but the clinical results were similar. Patients with complex defects or severe pulmonary hypertension should undergo a full sternotomy.
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INTRODUCTION
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With the development of minimally invasive cardiac surgical procedures and greater emphasis on the cosmetic results of cardiac operations, different approaches for correction of pediatric congenital heart diseases have been reported. These approaches have mainly involved a minithoracotomy or ministernotomy.1–3 The effects of various approaches on the clinical results are unclear, and the most appropriate approach for each of the diverse pediatric congenital heart diseases has not yet been established. The aim of this study was to compare the clinical outcome of three approaches in various types of congential heart surgery.
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PATIENTS AND METHODS
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From January 1999 to December 2001, 294 patients with atrial septal defect (ASD), 1,815 with ventricular septal defect (VSD), and 482 with tetralogy of Fallot (TOF) were operated upon. The percentage of patients with ASD, VSD, and TOF complicated by other anomalies was 16.7% (49/294), 36.5% (663/1815), and 13.1% (63/482), respectively. Preoperative cardiac catheterization showed 147 of the 1,815 VSD patients had severe pulmonary hypertension. To compare groups, patients with severe pulmonary hypertension or septal defects associated with other cardiac anomalies were excluded from the analysis. Thus, there were 1,669 patients in the study: 245 with ASD, 1,005 with VSD, and 419 with TOF. They underwent correction of their cardiac defects by different surgeons; the approaches were decided by the individual surgeons based on their experience. Each category of patient was grouped according to whether the approach was via a full sternotomy, a ministernotomy, or a minithoracotomy. In the full sternotomy groups, the procedures were carried out in the conventional manner. In the ministernotomy groups, the midline skin incision was 5–7 cm long (depending on the size of the patient) and a lower partial sternotomy was performed. In the minithoracotomy groups, the patient was placed in the lateral decubitus position with the right side elevated 60–80 degrees. A skin incision of 6–10 cm in length was made obliquely between the anterior and posterior axillary folds. The upper border was the 3rd intercostal space, and the lower border was the 6th space. The chest cavity was entered through the 4th or 3rd intercostal space. The pericardium was opened longitudinally 2-cm anterior to the phrenic nerve. In all groups, cardiopulmonary bypass was established via ascending aortic and bicaval cannulation. The operative technique for correction of the intracardiac anomaly was similar in each category of disease. Data recorded included age, sex, body weight, cardiothoracic ratio, hemoglobin concentration and oxygen saturation in patients with TOF, the need for a transanular patch in patients with VSD, ischemic time, cardiopulmonary bypass time, duration of ventilation, intensive care unit stay, morbidity, mortality, and medical costs. All data are reported as mean ± standard deviation. Differences between groups were analyzed with Student’s t test or the chi-squared test. Values of p less than 0.05 were considered statistically significant.
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RESULTS
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There were no significant differences in age, sex, body weight, or preoperative cardiothoracic ratio between groups within each category of patient. In the VSD category, the percentage of patients with a large or moderate-sized VSD in the full sternotomy group was significantly greater than in the ministernotomy and the minithoracotomy groups (p < 0.05). The incidence of pulmonary complications including pulmonary exudation, atelectasis, pleural effusion, pneumothorax, and pulmonary infection in VSD patients was significantly higher in the minithoracotomy group than the ministernotomy or minithoracotomy groups. In TOF patients, hemoglobin concentration was higher, oxygen saturation was lower, and the percentage requiring a transanular patch was significantly greater in the full sternotomy group than the other 2 groups, but the clinical results including duration of ventilation, intensive care unit stay, morbidity, and mortality were no different between groups. The results are summarized in Tables 1
, 2, and 3.
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DISCUSSION
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There is no doubt that the cosmetic result is important for pediatric patients who undergo cardiac surgery, but the most important factors are optimal correction of the cardiac anomaly and avoidance of postoperative complications. As different approaches have been used over the years to correct congenital heart defects in the pediatric population, it is necessary to review their effects on the clinical results and to reconsider their indications.4 This study showed that the 3 different approaches used in patients with a simple ASD or VSD had no effect on bypass time, ischemic time, duration of ventilation, intensive care unit stay, mortality, or cost. This supports previous findings that the minithoracotomy and ministernotomy approaches could be used safely in cases of simple ASD or VSD.5,6 The use of a limited incision is preferable in such patients because of the superior cosmetic results. However, in patients with a VSD complicated by other anomalies such as patent ductus arteriosus, right ventricular outlet tract stenosis, or mitral valve insufficiency, the poor exposure afforded by a minithoracotomy might make it difficult to thoroughly explore for additional intracardiac defects. Some anomalies might be overlooked if they have not been diagnosed preoperatively.
The higher incidence of pulmonary complications in the minithoracotomy group of VSD patients suggests that this approach might be disadvantageous in those with severe pulmonary hypertension. The percentage of patients with a large or moderate-sized VSD in the sternotomy group of VSD patients reflects the decision to perform a full sternotomy in most cases of a large or moderate shunt.
The differences in hemoglobin levels, oxygen saturation, and use of a patch in the sternotomy group of TOF patients indicates more severe defects than in the other two groups, but the clinical results were similar with each approach. As TOF is a more complex anomaly, there may be a greater discrepancy between the preoperative diagnosis and intraoperative findings. In some cases, the diagnosis may be found to be erroneous, there may be an important coronary artery crossing the right ventricular outlet tract, or there may be bleeding within the transanular patch, which would contraindicate a limited incision. It is recommended that patients with TOF should be considered mainly for a full sternotomy or a ministernotomy that can be converted into a full sternotomy if necessary.
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REFERENCES
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- Doty DB, DiRusso GB, Doty JR. Full-spectrum cardiac surgery through a minimal incision: mini-sternotomy (lower half) technique. Ann Thorac Surg 1998;65:573–7.[Abstract/Free Full Text]
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- Laussen PC, Bichell DP, McGowan FX, Zurakowski D, DeMaso DR, del Nido PJ. Postoperative recovery in children after minimum versus full-length sternotomy. Ann Thorac Surg 2000;69:591–6.[Abstract/Free Full Text]
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ABSTRACT
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