Asian Cardiovasc Thorac Ann 1999;7:46-48
© 1999 Asia Publishing EXchange Pte Ltd
Right Anterolateral Thoracotomy for Repair of Atrial Septal Defects in Young Female Patients
Tayyab Pasha, Fcps,
Masud Ahmad Cheema, FRCS, Fcps
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Department of Cardiovascular Surgery Punjab Institute of Cardiology Lahore, Pakistan
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For reprint information contact: Tayyab Pasha, FCPS Tel: 92 42 758 9721 Fax: 92 42 758 1227 email: pinst{at}paknet1.ptc.pk Department of Cardiovascular Surgery, Punjab Institute of Cardiology, Jail Road, Lahore, Pakistan.
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Abstract
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We performed a right anterolateral thoracotomy for atrial septal defect closure in young female patients to achieve a good cosmetic result. From December 1995 to June 1997, 25 female patients with a mean age of 10 ± 3 years (range, 4 to 22 years) underwent repair of atrial septal defects that comprised 24 ostium secundum and one sinus venosus. The length of the incision varied from 10 to 14 cm. The ascending aorta was used for arterial cannulation except in 2 cases where the external iliac artery was cannulated. Repairs were performed under crystalloid cardioplegia except in 2 patients where fibrillation was employed. In 5 patients, autologous glutaraldehyde-treated pericardial patch closure was used and the defects were closed directly in the other 20. All patients underwent echocardiography in the intensive care unit and 3 months after the repair. There was no operative or late mortality and no morbidity related to the thoracotomy approach. We concluded that a right anterolateral thoracotomy incision is a safe and effective alternative to a median sternotomy for repair of atrial septal defects and it provided a superior cosmetic result in these young female patients.
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Introduction
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Currently, atrial septal defect (ASD) repairs have become a routine safe procedure performed commonly in young asymptomatic patients. Because the incidence of ASD in female is twice that of male, it is natural that greater emphasis has been placed on the cosmetic results of the operation. The cosmetic and psychological implications of a median sternotomy must now be considered as a possible factor of morbidity. At this time of growing interest in percutaneous closure, surgeons must be able to propose an operation that can provide a cosmetically satisfying result while maintaining optimal surgical security. In this series, as well as using a right anterolateral thoracotomy, we also avoided a separate groin incision for aortic cannulation, except in 2 patients where the external iliac artery was cannulated.
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Patients and Methods
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From January 1996 to June 1997, 25 female patients with a mean age of 10 ± 3 years (range, 4 to 22 years) underwent ASD repair through a right anterolateral thoracotomy. Apart from 2 patients aged 4 to 5 years, the others had relatively developed breasts. After anesthetic induction and stabilization, the patients were positioned for anterolateral thoracotomy with the right side elevated by 30°. The right groin was prepared and draped to give access to the right femoral and iliac vessels. An anterolateral thoracotomy incision was made, using the inframammary groove in adults and 4 to 6 cm below the nipple in very young patients. The chest was entered through the 4th intercostal space in the older patients and through the 3rd intercostal space in the two youngest. The right internal mammary vessels were always respected and the pericardium was opened longitudinally anterior to the phrenic nerve. The right thymic lobe was resected routinely and the two topmost stitches were tied to the periosteum of the second rib to allow assess to the aorta. Aortic cannulation was carried out in all patients using curved aortic cannulae except in 2 cases where external iliac arterial cannulation was used.
A single pursestring suture was placed on the right atrial appendage and another on the inferior aspect of the right atrium. After cannulation and heparin administration, cardiopulmonary bypass was established with mild to moderate hypothermia and antegrade crystalloid cardioplegia for myocardial preservation except in 2 cases where the atrial septal defects were closed on a fibrillating heart. Excellent exposure of intracardiac anatomy was obtained with an oblique right atrial incision. Autologous pericardium was used for repair of the defects in 5 patients including one with a sinus venosus type and partial anomalous venous connection. The defect was closed directly in the other 20 patients. After weaning from cardiopulmonary bypass, the pericardium was closed with interrupted sutures, keeping one chest tube behind the heart and another in the right pleural cavity.
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Results
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The length of the incisions varied from 10 to 14 cm. All patients spent the first postoperative day in the intensive care unit and the mean hospital stay was 4 days. There was no operative or late mortality and no morbidity directly related to the thoracotomy approach.
Echocardiography was performed in the intensive care unit and 3 months after the repair. This demonstrated no residual defect or left-to-right shunt in any of the patients. The right anterolateral thoracotomy incision was found to be a safe and effective alternative to median sternotomy for repair of ASD.
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Discussion
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Operative closure of ASD is considered to be a high-benefit low-risk operation today. Technological advances have improved the outcome of this operation, resulting in decreased morbidity and mortality to an extent favoring the emergence of cosmetic consideration.1 This is particularly the case when the patient is a young woman in whom the resulting scar will detract from her physical appearance. Surgeons must be capable of responding to the desire for a cosmetic result, while maintaining maximum security. Minimally invasive techniques in congenital heart defect surgery have evolved steadily over the past 5 years. The safety and efficacy of video-assisted endoscopic techniques for repair of simple extracardiac anomalies such as ligation of a patent ductus arteriosus or division of a vascular ring have been established.2,3 While minimizing the invasiveness in general surgery has been equated with minimizing access, what constitutes minimally invasive intracardiac surgery remains controversial.4 Many surgeons doubt the benefits of minimizing access when the need for cardiopulmonary bypass cannot be waived. Recognizing that a median sternotomy does entail significant morbidity, we investigated the value of this alternative approach for ASD closure.
Our choice of repair via an anterolateral thoracotomy with aortic cannulation answers the imperatives of maintaining maximum safety while achieving the desired cosmetic result. The anterolateral thoracotomy approach was recently adopted as an alternative to repeat sternotomy for redo mitral valve operations as well as for congenital heart defect operations.5,6 In the beginning of our series, we prepared the groin for possible cannulation. There are a few technical points that made aortic cannulation easier: the right thymic lobe was routinely resected; the two top pericardial stitches were tied to the ribs, thus elevating the aorta that was also taped; and a metal iliac cannula was used for aortic cannulation. For venous cannulation, we used direct superior and inferior vena caval cannulation with right-angled metal cannulae. The technique is suitable for very young children including infants but the incision must be made 4 to 6 cm below the nipple to avoid later breast complications.7
Compared to the standard technique through a median sternotomy, this approach for ASD closure seems to be technically more difficult for aortic cannulation, it provides limited exposure, and can be more painful postoperatively. Younger patients may develop later breast complications if the incision is not well below the nipple.8 However, cosmetically and psychologically, an anterolateral thoracotomy gives more satisfying results.9 The mean hospital stay in our series was 4 days and this makes it also more cost effective.
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References
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Grinda J-M, Folliguet TA. Right anterolateral thoracotomy for repair of atrial septal defect. Ann Thorac Surg 1996;62:175–8.[Abstract/Free Full Text]
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Laborde F, Folliquet T, Batisse A, Dibie A, da-Cruz E, Carbognani D, et al. Video-assisted thoracoscopic surgical interruption: the technique of choice for patent ductus arteriosus. Routine experience in 230 pediatric cases. J Thorac Cardiovasc Surg 1995;110:1681–4.[Abstract/Free Full Text]
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Burke RP, Rosenfeld HM, Wernovsky G, Jonas RA. Video-assisted thorascopic vascular ring division in infants and children. J Am Coll Cardiol 1959;25:943–7.
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Izzat MB, Yim AP, El-Zufari MH. Limited-access atrial septal defect closure and the evolution of minimally invasive surgery. Ann Thorac Cardiovasc Surg 1989;4:56–8.
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Tribble CG, Killinger WA Jr, Harman PK, Crosby IK, Nolan SP, Kron IL. Anterolateral thoracotomy as an alternative to repeat median sternotomy for replacement of the mitral valve. Ann Thorac Surg 1987;43:380–2.[Abstract]
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Preager PI, Pooley RW, Moggio RA, Somberg ED, Sarabu MR, Reed GE. Simplified method for reoperation on the mitral valve. Ann Thorac Surg 1989;48:835–7.[Abstract]
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Massetti M, Babatasi G, Rossi A, Neri E, Bhoyroo S, Zitouni S, et al. Operation for atrial septal defects through a right anterolateral thoracotomy: current outcome. Ann Thorac Surg 1996;62:1100–3.[Abstract/Free Full Text]
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Cherup LL, Siewers RD, Futrell JW. Breast and pectoral muscle maldevelopment after anterolateral and posterolateral thoracotomies in children. Ann Thorac Surg 1986;41:492–7.[Abstract]
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Cherian KM, Pannu HS, Sankar NM, Agarwal SK, Basavaraj S, Rao SG, et al. Thoracotomy approach for congenital and acquired heart defects: its possible applications in the current era. J Cardiac Surg 1996;11:37–45.[Medline]
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Abstract
Introduction
