Surgical closure of atrial septal defect. Minimally invasive cardiac surgery or median sternotomy?

Effect of right anterolateral thoracotomy versus median sternotomy on postoperative wound tissue repair in patients with congenital heart disease: A meta-analysis

Right anterolateral thoracotomy (RAT) and median sternotomy (MS) are two major methods for treatment of congenital cardiac disease. But there are various types of surgery that provide a better operative outcome for the patient. Therefore, we carried out a meta-analysis to investigate the effects of these two methods in the treatment of wound tissue, hospitalization and so on, to find out which surgery method could provide the best short-term effect. In this research, we chose an English controlled trial from 2003 to 2022 to evaluate the influence of right anterolateral thoracotomy and median sternotomy on the short-term outcome of Cardiopulmonary bypass (CPB), time of operation, time spent in the hospital, and the time of scar formation. Our findings suggest that the RAT method was associated with a shorter surgical scars for congenital heart disease operations compared to MS with respect to post-operation scars (WMD, 3.55; 95% CI, 0.04, 7.05; p = 0.05). The RAT method is better suited to the needs of patients who care about their injuries. Nevertheless, in addition to other surgery related factors which might affect post-operative wound healing, we discovered that MS took a shorter time to perform CPB compared with RAT surgery (WMD, - 1.94; 95% CI, -3.39, -0.48; p = 0.009). Likewise, when it comes to the time taken to perform surgery, MS needs less operational time compared to RAT methods (WMD, -12.84; 95% CI, -25.27, -0.42; p = 0.04). On the other hand, the time needed for MS to recover was much longer compared to the RAT (WMD, 0. 60; 95% CI, 0.02, 1.18; p = 0.04). This indicates that while RAT is advantageous in terms of shortening the duration of post-operative scar, it also increases the time needed for surgical operations and CPB.

Bleeding From Left Atrial Appendage During Atrial Septal Defect Closure Through Right Anterolateral Thoracotomy: An Unusual Complication

Anterolateral thoracotomy is frequently used for the closure of ostium secundum atrial septal defect (ASD). The cosmetic result has become an important feature. There are various complications of anterolateral thoracotomy like persistent postoperative pain, phrenic nerve injury, atelectasis, and bleeding. We report a case of ASD closure through anterolateral thoracotomy who had bleeding of the left atrial appendage (LAA), which is an unusual and rare complication.

Mini right axillary thoracotomy for congenital heart defect repair can become a safe surgical routine

OBJECTIVE

Owing to its obvious cosmetic appeal, minimal invasive repair of congenital heart defects (CHDs) through the mini right axillary thoracotomy is becoming routine in many centres. Besides cosmesis, and before becoming a new norm, it is important to establish its outcomes as safe compared to repairs through traditional median sternotomy.

METHODS

Between 2013 and 2021, 116 consecutive patients underwent defect repairs through mini right axillary thoracotomy. Patient, operative data, and hospital outcomes were compared to contemporary mini right axillary thoracotomy and sternotomy series.

RESULTS

There was no mortality or need for approach conversion (mean age 4.3 years, range 0.17-17, mean weight 18.6 kg, range 4.8-74.4) in 118 repairs for atrial septal defect, ventricular septal defect, partial anomalous pulmonary venous return, partial atrioventricular canal with mitral cleft, scimitar syndrome, double-chambered right ventricle, cor triatriatum, and tricuspid valve repair. Protocol included on-table extubation, achieved in 97 children, with 23 outliers leading to 0.7 average hours of mechanical ventilation (range 0-66 hours), indwelling chest drain time of 2.6 days (range 1-9 days), intensive care stay of 1.8 days (range 1-10 days), and hospital stay of 3.9 days (range 2-18 days). Late revisions were required in one patient after scimitar repair for scimitar vein stenosis at 2 weeks, and in another for repair of superior caval vein stenosis after a Warden operation at 2 months; reoperations (5/116 = 4.3%) were successfully performed through the same mini right axillary incision.

CONCLUSIONS

While providing obvious cosmetic advantages, the minimally invasive right axillary thoracotomy approach for the surgical repair of common CHDs yields excellent results and is safe compared to the benchmark median sternotomy approach.

Anterolateral minithoracotomy versus median sternotomy for the surgical treatment of atrial septal defects: a meta-analysis and systematic review

Background

To compare the short-term safety and efficacy of right anterolateral minithoracotomy (ALMT) and median sternotomy (MS) for the surgical treatment of atrial septal defects (ASDs).

Methods

The PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched for comparative studies focusing on surgical repair of ASDs via ALMT or MS published up to the end of April 27, 2020. We used random-effect or fixed-effect models to obtain pooled estimates.

Results

A total of 7 publications, including 665 patients (ALMT 296 and MS 369), were included. Age (WMD: 1.80 years, 95% CI 0.31–3.29), weight (WMD: − 0.91 kg, 95% CI − 5.57 to 3.75), sex distribution (OR: 1.00, 95% CI 0.74–1.35) and surgical type (patch or direct closure) (OR: 1.00, 95% CI 0.67–1.49) were comparable in the ALMT group and MS group. No significant differences in the success rate (OR 0.23; 95% CI 0.05–1.07) or severe complication rate (OR 1.46; 95% CI 0.41–5.22) were found between the ALMT group and the MS group. In addition, the differences in the cardiopulmonary bypass (CPB) time (WMD 6.33; 95% CI − 1.92 to 14.58 min, p = 0.13) and the operation time (WMD 5.23; 95% CI − 12.49 to 22.96 min, p = 0.56) between the ALMT group and the MS group were not statistically significant. However, the ALMT group had a significantly longer aortic cross-clamp time (2.37 min more, 95% CI 1.07–3.67 min, p = 0.0003). The intubation time was 1.82 h shorter (95% CI − 3.10 to − 0.55 h; p = 0.005), the intensive care unit (ICU) stay was 0.24 days shorter (95% CI − 0.44 to − 0.04 days; p = 0.02), and the postoperative hospital stay was 2.45 days shorter (95% CI − 3.01 to − 1.88 days; p < 0.00001) in the ALMT group than in the MS group. Furthermore, the incision length was significantly shortened by 8.97 cm in the ALMT group compared with the MS group (95% CI − 9.36 to − 8.58 cm; p < 0.00001).

Conclusions

In the surgical treatment of ASD, ALMT and MS are equally safe and effective in terms of success rates and severe complication rates. The surgical procedures are equally difficult, but ALMT is associated with a faster functional recovery and better cosmetic results. Compared to MS, ALMT is the better choice for select ASD patients.

Surgical Closure of Atrial Septal Defects in Young Children-A Review of Anesthesia Care in Sternotomy and Thoracotomy Approaches

OBJECTIVES

To review and compare the anesthetic management of atrial septal defect (ASD) closures via mini lateral thoracotomy and sternotomy approaches.

DESIGN

Retrospective analysis.

SETTING

Single- center pediatric quaternary care hospital.

PARTICIPANTS

Patients aged <8 years of age undergoing ASD closure.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Outcome measures included anesthetic technique, total amount and type of analgesics, pain scores, procedure duration, complications, blood transfusion requirements, and duration of stay. Each group had 15 patients. All patients in the sternotomy group received 0.25% bupivacaine subcutaneous infiltration. Eleven of the 15 thoracotomy patients received a fascial plane block, including serratus anterior and erector spinae blocks, and 3 received subcutaneous infiltration. There was no difference in opioid consumption intraoperatively or in the first 24 hours after surgery (0.28 ± 0.24 mg/kg morphine equivalents in thoracotomy group and 0.21 ± 0.12 mg/kg in sternotomy group). Duration of procedure and cardiopulmonary bypass duration were longer in the thoracotomy group. There was no difference in cross-clamp duration between groups. There was no difference in intensive care unit or hospital stay.

CONCLUSIONS

The authors reviewed perioperative pain management strategies used in surgical ASD closures. Different fascial plane blocks were used. This study has paved way to design a randomized control trial to compare various regional techniques for cardiac surgeries and identified opportunities for improved pain assessment scoring in children after cardiac surgery.

[Sinus septal defect closure with correction of partial anomalous pulmonary vein drainage through mini-thoracotomy]

Mini-thoracotomy is one of the most popular minimally invasive approaches. This approach is used in the treatment of congenital and acquired heart diseases and characterized less surgical trauma, intraoperative blood loss, pain syndrome severity, risk of infectious complications and better cosmetic results. Successful correction of atrial septal defect (ASD) through right-sided mini-thoracotomy is reported in the article.

Mini-thoracotomy versus median sternotomy for atrial septal defect closure: Should mini-thoracotomy be applied as a standard technique?

BACKGROUND

This study aims to compare outcomes of minithoracotomy versus median sternotomy for atrial septal defect closure.

METHODS

Between January 2012 and May 2017, a total of 44 patients (8 males, 36 females; mean age 33.86 years; range, 14 to 63 years) who underwent atrial septal defect repair through mini-thoracotomy or median sternotomy in our clinic were retrospectively analyzed. Pre-, intra-, and postoperative data of the patients were recorded.

RESULTS

There was no significant difference in the cardiopulmonary bypass and cross-clamp times between the groups, although the duration of operation was shorter in the mini-thoracotomy group (p=0.001). No significant difference was observed between the groups in terms of early mortality, neurological complications, and residual atrial septal defect. The mean mechanical ventilation time and length of intensive care unit and hospital stay were statistically significantly shorter, and the amount of bleeding was statistically significantly lower in the mini-thoracotomy group (p=0.001 for all).

CONCLUSION

Mini-thoracotomy should be kept in mind as a favorable alternative to sternotomy following a satisfactory learning curve period with less cost and higher patient benefit.

Minimal Invasive Technique in Atrial Septal Defect Surgery

Background

Median sternotomy with minimal skin incision (MSWMSI) and modified anterior mini-thoracotomy (MAMT) approach that both are innovative techniques modified from previous documented techniques are important alternative to conventional median sternotomy in atrial septal defect (ASD) repair. Our aim is to explain the details of two performed techniques in our center and explain the results.

Methods

Totally 54 children with ASD (20 female and 34 male) were operated with two different techniques i.e. MAMT and MSWMSI in Imam Ali heart surgery center between May 2010 and May 2013. Intra and postoperative variables such as cardiopulmonary bypass time and aortic cross-clamp time, intensive care unit stay time, length of incision, postoperative hematoma and seroma, dehiscence mortality, exploration for postoperative bleeding, neurologic complication, infection and amount of blood transfusion were recorded.

Results

Mean cardiopulmonary bypass time was 30 ± 11 min, and mean aortic cross-clamp time was 7 ± 2 min. The mean amount of blood transfusion was 150 ± 39 mL, and the mean chest tube drainage after surgery was 140 ± 57 mL. Superficial skin infection occurred in three patients. Subcutaneous hematoma and seroma were founded in six patients. In 50 cases the defect was secundum type, in two patients it was sinus venosus type, and in two with associated perimembranous ventricular septal defect repair.

Conclusion

Both approaches are safe and may be the surgical techniques of choice for secundum ASD repair in all age groups; and we can also utilize these techniques for more complicated kinds of surgery, for instance, sinus venosus type ASD with or without partial anomalous defect.

Experiences in surgical closure of atrial septal defect with anterior mini-thoracotomy approach

Introduction: Anterior mini-thoracotomy approach is a good alternative to median sternotomy in Atrial Septal Defect (ASD) repair. Our purpose is to explain the details of our technique and peresent the results.

Methods: Seventy five patients with ASD (52 female and 23 male) were operated with anterior mini-thoracotomy approach in our tertiary center between March 2012 and March 2014. The mean age was 14±10 ranged from 2 to 42 years. Outcomes were defined according to cardiopulmonary and aortic cross-clump time, intensive care unit stay time, morbidity, mortality, the size of incision, the amount of post-operative bleeding, need for blood transfusion and reoperation.

Results: Mean Cardiopulmonary bypass time was 49.62 minutes (26 to 105 minutes) and mean aortic cross clamp time was 22.29±6.77 minutes (11 to 47 minutes). The mean amount of blood transfusion was 47.49± 62.22 mm (0 to 200 cc) and the mean chest tube drainage after surgery was 80.17 ±121.06 mm (0 to 600 cc). One patient re-operated for dehiscence of ASD surgical sutures and there was no reoperation for surgical bleeding or tamponade drainage in these patients. In 74 cases the defect was secundum type, in 2 patients it was sinus venosus type and in one with associated partial Anomalous repair.

Conclusion: Anterior thoracotomy approach is safe and may be the surgical technique of choice for secundum ASD repair in all age groups and we can utilize this technique also for more complicated kinds of surgery for instance, sinus venosus type ASD with or without Partial Anomalous Defect.

Clinical outcomes of minimally invasive endoscopic and conventional sternotomy approaches for atrial septal defect repair

BACKGROUND

Concerns remain that minimally invasive atrial septal defect (ASD) repair may compromise patient outcomes. We compared clinical outcomes of adult patients undergoing ASD repair via a minimally invasive endoscopic approach versus a "gold standard" sternotomy.

METHODS

We retrospectively reviewed the clinical outcomes of consecutive patients who underwent ASD patch repair at our institution between 2002 and 2012. We compared in-hospital/30-day mortality, postoperative complications, length of stay in hospital and in the intensive care unit and blood product requirements between patients who underwent right mini-thoracotomy (MT) and those who underwent conventional sternotomy.

RESULTS

During the study period, 73 consecutive patients underwent ASD patch repair at our institution: 51 (age 47 ± 16 yr, 66.7% women) in the MT group and 22 (age 46 ± 21 yr, 59.1% women) in the sternotomy group. In-hospital mortality was similar between the 2 groups (MT 0% v. sternotomy 4.5%, p = 0.30). There were no significant differences in any postoperative complications or blood product requirements. No patients in the MT group suffered stroke, retrograde aortic dissection or leg ischemia. Mean intensive care unit (MT 1.2 ± 1.2 d v. sternotomy 1.7 ± 2.2 d, p = 0.26) and hospital length of stays (MT 5.1 ± 2.2 d v. sternotomy 6.3 ± 3.6 d, p = 0.17) were similar between the groups; however, there was a trend toward fewer patients requiring prolonged hospital stays (> 10 d) in the MT group (3.9% v. 18.2%, p = 0.06).

CONCLUSION

Repair of ostium secundum and sinus venosus ASD can be performed safely via MT endoscopic approach with similar outcomes as sternotomy. Patient preference for a more cosmetically appealing incision may be considered without concern of compromised outcomes.

Atrial septal defect closure: comparison of vertical axillary minithoracotomy and median sternotomy

BACKGROUND

This study aims to evaluate whether or not the method of right vertical axillary minithoracotomy (RVAM) is preferable to and as reliable as conventional sternotomy surgery, and also assesses its cosmetic results.

METHODS

Thirty-three patients (7 males, 26 females) with atrial septal defect were admitted to the Cardiovascular Surgery Clinic of Cukurova University from December 2005 until January 2010. The patients' ages ranged from 3 to 22. Patients who underwent vertical axillary minithracotomy were assigned to group I, and those undergoing conventional sternotomy, to group II. Group I and group II were compared with regard to the preoperative, perioperative and postoperative variables. Group I included 12 females and 4 males with an average age of 16.5±9.7. Group II comprised 14 female and 3 male patients with an average age of 18.5±9.8 showing similar features and pathologies. The cases were in Class I-II according to the New York Heart Association (NYHA) Classification, and patients with other cardiac and systemic problems were not included in the study. The ratio of the systemic blood flow to the pulmonary blood flow (Qp/Qs) was 1.8±0.2. The average pulmonary artery pressure was 35±10 mmHg. Following the diagnosis, performing elective surgery was planned.

RESULTS

No significant difference was detected in the average time of the patients' extraportal circulation, cross-clamp and surgery (p>0.05). In the early postoperative period of the cases, the duration of mechanical ventilator support, the drainage volume in the first 24 hours, and the hospitalization time in the intensive care unit were similar (p>0.05). Postoperative pains were evaluated together with narcotic analgesics taken intravenously or orally. While 7 cases (43.7%) in group I needed postoperative analgesics, 12 cases (70.6%) in group II needed them. No mortality or major morbidity has occurred in the patients. The incision style and sizes in all of the patients undergoing RVAM were preserved as they were at the beginning. Furthermore, the patients of group I were mobilized more quickly than the patients of group II. The patients of group I were quite pleased with the psychological and cosmetic results. No residual defects have been found in the early postoperative period and after the end of the follow-up periods. All of the patients achieved functional capacity per NYHA. No deformation of breast growth has been detected during 18 months of follow-up for the group I patients, who underwent RVAM.

CONCLUSION

To conclude, the repair of atrial septal defect by RVAM, apart from the limited working zone for the surgeon in these pathologies as compared to sternotomymay be considered in terms of the outcomes, and early and late complications. And this has accounted for less need of analgesics and better cosmetic results in recent years.

Anterolateral minithoracotomy versus median sternotomy for the treatment of congenital heart defects: a meta-analysis and systematic review

Background

Anterolateral Minithoracotomy (ALMT) for the radical correction of Congenital Heart Defects is an alternative to Median Sternotomy (MS) due to reduce operative trauma accelerating recovery and yield a better cosmetic outcome after surgery. Our purpose is to conduct whether ALMT would bring more short-term benefits to patients than conventional Median Sternotomy by using a meta-analysis of case–control study in the published English Journal.

Methods

6 case control studies published in English from 1997 to 2011 were identified and synthesized to compare the short-term postoperative outcomes between ALMT and MS. These outcomes were cardiopulmonary bypass time, aortic cross-clamp time, intubation time, intensive care unit stay time, and postoperative hospital stay time.

Results

ALMT had significantly longer cardiopulmonary bypass times (8.00 min more, 95% CI 0.36 to 15.64 min, p = 0.04). Some evidence proved that aortic cross-clamp time of ALMT was longer, yet not significantly (2.38 min more, 95% CI −0.15 to 4.91 min, p = 0.06). In addition, ALMT had significantly shorter intubation time (1.66 hrs less, 95% CI −3.05 to −0.27 hrs, p = 0.02). Postoperative hospital stay time was significantly shorter with ALMT (1.52 days less, 95% CI −2.71 to −0.33 days, p = 0.01). Some evidence suggested a reduction in ICU stay time in the ALMT group. However, this did not prove to be statistically significant (0.88 days less, 95% CI −0.81 to 0.04 days, p = 0.08).

Conclusion

ALMT can bring more benefits to patients with Congenital Heart Defects by reducing intubation time and postoperative hospital stay time, though ALMT has longer CPB time and aortic cross-clamp time.

Evolution of surgical techniques for atrial septal defect repair in adults: A 10-year single-institution experience

OBJECTIVE

We retrospectively analyzed our experience in atrial septal defect repair with varied minimally invasive surgical approaches.

METHODS

From 1997 to 2006, 64 patients underwent surgical repair of atrial septal defects in our center. Patients were grouped into four groups according to the approach used; group 1 (n = 16), partial lower sternotomy; group 2 (n = 20), right anterior small thoracotomy with transthoracic clamping; group 3 (n = 4), right anterior small thoracotomy with endoaortic balloon clamping; and group 4 (n = 24), totally endoscopic approach with the use of the da Vinci surgical system (Intuitive Surgical, Mountain View, Calif). Preoperative diagnosis was a large secundum type atrial septal defect in 60 patients, primum type in 3 patients, and sinus venosus type in 1 patient.

RESULTS

Complete atrial septal defect closure was verified by intraoperative transesophageal echocardiography in all patients. There was neither perioperative mortality nor major complication. Groups 3 and 4 had significantly longer aortic crossclamp, cardiopulmonary bypass, and skin-to-skin operative times than had groups 1 and 2 (P = .000). All groups had similar ventilation time, postoperative drainage, and intensive care unit and hospital stays. Only 2 patients in group 4 were converted to the minithoracotomy owing to endoaortic balloon failure. During the follow-up of 30 +/- 24.3 months, 1 patient in group 3 was reoperated on owing to significant residual shunting.

CONCLUSIONS

All types of atrial septal defects can be repaired via those four different approaches as safely as can be done by the conventional technique. General complications during surgical procedures are negligible. These approaches may be considered a standard treatment and an adjunct to transcatheter treatment options in atrial septal defect repair.

Correction of simple congenital heart defects in infants and children through a minithoracotomy

BACKGROUND

Minimally invasive surgical techniques in pediatric cardiac surgery have evolved throughout the last 10 years. Advantages of minimally invasive procedures include excellent cosmetic results and superior postoperative outcome. However, safety of minimally invasive techniques has to be proven.

METHODS

In 21 female infants and children, a right anterolateral thoracotomy was performed. Mean age was 7.1 years (0.5 to 16.6 years) and mean body weight was 20.8 kg (8.3 to 56 kg). The following defects were repaired: atrial septum defect type II (n = 14); partial atrioventricular septum defect (n = 3); partial anomalous pulmonary venous connection (n = 2); ventricular septum defect (n = 2); mitral valve insufficiency (n = 1); and resection of an embolized atrial septum defect occluder (n = 1). In two cases, aortic cross-clamping was performed by using a transthoracic clamp. In 5 patients, femoral cannulation was performed. Skin incisions were limited to 4 to 7 cm.

RESULTS

There was no operative or late mortality. Mean operation time, bypass time, and aortic cross-clamp time were 138 (95 to 275), 72 (32 to 179), and 35 (12 to 120) minutes, respectively. Mean postoperative mechanical ventilation time, mean intensive care unit stay, and mean hospital stay were 3.9 hours (1 to 12 hours), 1.4 days (1 to 3 days), and 12 days (8 to 18 days), respectively. Postoperative complications included hemorrhage in 1 patient requiring surgical intervention. Mean follow-up period was 13.3 months (1 to 36 months). All patients were in New York Heart Association class I postoperatively. Trivial mitral insufficiency was evident in 1 patient operated for partial atrioventricular septum defect.

CONCLUSIONS

A small right anterolateral thoracotomy as a minimally invasive technique in pediatric cardiac surgery is a safe and suitable alternative in the operative management of simple congenital heart defects. Cosmetic results are superior, however, improved postoperative outcome has to be proven.

"I" ministernotomy for aortic valve replacement

BACKGROUND

Minimally invasive surgical approaches have been applied recently in the management of valvular heart disease. In this report, we reviewed our preliminary experience of minimally invasive aortic valve replacement.

METHODS

Eighteen patients were operated on by means of an "I" ministernotomy, and 16 patients were operated on by means of a full median sternotomy during the same period. There was no difference between these two groups in term of age, sex, and preoperative left ventricular ejection fraction. In patients of the ministernotomy group, the operations were approached through an "I" median sternal split, from the second to the fifth intercostal space, 8 to 10 cm in length, with transverse division. Cardiopulmonary bypass was established through aorto-right atrial cannulation with aortic cross-clamping and antegrade or retrograde delivery of blood cardioplegia.

RESULTS

Under direct vision, aortic valve replacement was performed successfully in patients of both groups. The duration of cardiopulmonary bypass time and aortic cross-clamp time was significantly longer in the ministernotomy group than in the full sternotomy group. However, the length of incision, duration of endotracheal intubation, intensive care unit stay, pain score, postoperative length of stay, and return to normal activity interval were significantly shorter and lower in patients of the ministernotomy group than in those of the full sternotomy group. All patients recovered from the operation rapidly. Follow-up was complete in all patients with no late complications. Echocardiographic examination showed good function of aortic prostheses.

CONCLUSIONS

Our experience demonstrates that the "I" ministernotomy provides good exposure, reduced wound pain, enhanced recovery, shortened hospital stay, and good cosmetic healing. It may be a good alternative for surgical correction of aortic valve lesions.