Minimally invasive cardiac surgery for intracardiac congenital lesions

Inferior Partial Sternotomy for Surgical Closure of Isolated Ventricular Septal Defects in Children

BACKGROUND

Surgical closure of isolated ventricular septal defect (VSD) through partial inferior sternotomy offers the advantages of a much shorter, cosmetically superior skin incision, potentially improved sternal stability, a lower rate of infection, and less postoperative pain. We report our technique and results of use of inferior partial sternotomy for closure of isolated VSD in children.

PATIENTS AND METHODS

From July 2002 to July 2003, 24 consecutive patients with a median age of 4.5 months (range, 1 month-4.5 years) underwent partial inferior sternotomy for isolated VSD closure. The length of the incision ranged from 4 to 6 cm. Special features of the approach included T incision of the lower sternum (from the fourth intercostal space to the xiphoid), establishment of cardiopulmonary bypass with central cannulation, aortic cross-clamping, and cardioplegic arrest. All VSDs were approached through right atriotomy. Perimembranous VSDs were exposed after detachment of the anterior leaflet of the tricuspid valve and were closed with a continuous suture. Muscular VSDs were approached directly. Perioperative and postoperative echocardiographic findings were available for all patients. Follow-up was complete.

RESULTS

There was no mortality or significant surgical morbidity. Median cross-clamping and cardiopulmonary bypass times were 43 and 103 minutes, respectively. All patients were in sinus rhythm. Perioperative and postoperative echocardiography confirmed the absence of any residual defects in perimembranous VSDs and the presence of a trace residual VSD in 4 patients with muscular VSDs. Optimal healing of the partial sternotomy was obtained in all patients.

CONCLUSIONS

Inferior partial sternotomy is less invasive than and cosmetically superior to full sternotomy. It provides excellent results when applied to isolated VSD with standard surgical techniques.

[Comparative study of thoracic approaches in atrial septal defect closure]

Our early experience in approaching ASD by right thoracotomy as opposed to midline sternotomy is presented. Between July 2000 and December 2001, 15 patients (group A) were operated by right thoracotomy. Mean age of patients was 8.6 years and mean weight was 31.6 kg. In the same period, midline sternotomy was used in 16 patients (group B). Mean age was 4.7 years and weight was 16.5 kg. The duration of the procedure, by-pass, and aortic cross-clamping were similar. Bleeding was 265 ml (8.4 ml/kg) in group A, and 152 ml (9.2 ml/kg) in group B. The duration of the ICU stay and time of discharge were 2.4 days and 6 days in group A, and 2.23 days and 6.87 days in group B, respectively. No significant differences were found in ASD closure by thoracotomy and sternotomy. The cosmetic appearance acceptance of right thoracotomy was excellent.

Fast-track congenital heart operations: a less invasive technique and early extubation

BACKGROUND

Many novel techniques have been described for "minimally invasive" congenital cardiac operations to achieve an improved cosmetic result. There is little information on incorporation of such techniques into fast-track congenital heart operations.

METHODS

We have developed an approach to fast-track congenital heart operations, which includes a cosmetic approach for repair of congenital heart defects without sacrificing adequate exposure or requiring specialized equipment, along with a simple approach to intraoperative anesthetic management that allows extubation in the operating room. The heart is exposed through a short midline skin incision and a full median sternotomy. The conventional technique of cannulation is performed. Between October 1997 and January 1999, 88 patients were operated on with this method. Cardiac anomalies included simple and complex ostium secundum atrial septal defect, sinus venous atrial septal defect, partial atrioventricular septal defect, simple and complex ventricular septal defect, and bicuspid aortic valve stenosis.

RESULTS

There were no operative or late deaths. The majority of patients were extubated in the operating room or within 2 hours of operation. No patient underwent reoperation and the mean length of hospital stay was 3.9 days. Sternal instability or wound infection were not observed.

CONCLUSIONS

We believe that our approach to fast-track congenital heart operation is safe and effective. The surgical technique provides good exposure and has excellent cosmetic results. Moreover, it is easy to learn and, if necessary, the surgeon can quickly gain direct access to the heart. The anesthetic management facilitates early tracheal extubation and a shorter duration of postoperative stay.

A 5-year experience with surgical repair of atrial septal defect employing limited exposure

BACKGROUND

There has been a trend in recent years towards less invasive therapy for many congenital cardiac malformations. For the past 5 years, we have employed a technique of limited surgical exposure when repairing atrial defects within the oval fossa.

METHODS

Over the 5-year period from July 1992 to August 1997, 115 consecutive patients underwent surgical repair of an isolated atrial septal defect in the region of the oval fossa by a single surgeon. The patients had a limited midline skin incision starting at the line of the nipples and extending inferiorly across 2 to 3 intercostal spaces. A partial sternotomy was performed, sparing the manubrium. Standard instruments and cannulation techniques were used for cardiopulmonary bypass and fibrillatory arrest.

RESULTS

There were no deaths and no major complications. The median time to extubation after leaving the operating room was 3 hours (30 minutes to 8 days). Mediastinal drains were removed the morning after surgery. The median stay in the intensive care unit was 7 hours (3 hours to 10 days), and patients were discharged from the hospital a median of 4 days postoperatively (2 to 23 days).

CONCLUSIONS

This approach using limited exposure can be applied safely without any new instruments and without peripheral incisions or sites of vascular access, while providing a comfortable exposure for the surgeon and achieving a cosmetically superior result for the patient.

Video-assisted minimal access in excision of left atrial myxoma

BACKGROUND

Minimal access surgery with video-assisted endoscopy has been applied to the correction of intracardiac lesions. We report our experience using this technique in surgical excision of left atrial myxoma in 3 patients.

METHODS

From November 1995 to March 1997, 3 female patients, ages 45 to 80 years (mean, 62.7 years), received emergency operations for excision of left atrial myxoma. These operations were performed through a right anterior submammary minithoracotomy or right parasternal incision with the assistance of endoscopy during femoro-femoral cardiopulmonary bypass. The myocardium was protected by continuous coronary perfusion with fibrillatory arrest or cardioplegic arrest with aortic cross-clamping.

RESULTS

All the tumors were excised completely through the right atrial approach. The bypass time was 92 to 148 minutes (mean, 111 minutes). The operation time was 3.2 to 4.4 hours (mean, 3.7 hours). There were no hospital deaths. Follow-up, which ranged from 6 to 19 months (mean, 10.5 months), was complete in all patients. Transthoracic echocardiographic examination showed good ventricular function without any residual tumors. Patients were found to be in New York Heart Association functional class I or II. They were satisfied with the good cosmetic healing of the incision.

CONCLUSIONS

Our experience demonstrates that minimal access surgery is a technically feasible, safe, and effective procedure in surgical excision of left atrial myxoma.