Interact CardioVasc Thorac Surg 2009;9:819-821. doi:10.1510/icvts.2009.209593
© 2009 European Association of Cardio-Thoracic Surgery
Institutional report - Congenital |
Ministernotomy for repair of congenital cardiac disease
Vinod A. Sebastiana,*,
Kristine J. Guleserianb,
Steven R. Leonardb and
Joseph M. Forbessb
a Department of Cardiothoracic Surgery, UT Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd. HA9.134, Dallas, TX 75390, USA
b Children's Medical Center Dallas, Dallas, TX, USA
Received 21 April 2009;
received in revised form 27 July 2009;
accepted 29 July 2009
 Abstract presented at The International Society for Minimally Invasive Cardiothoracic Surgery, Eleventh Annual Meeting, Boston, MA, June 14th 2008.
*Corresponding author. Tel.: +1-973-9307030; fax: +1-214-6459708.
E-mail address: VASEBA{at}parknet.pmh.org (V.A. Sebastian).
 |
Abstract
|
|---|
We report our experience with repair of a variety of congenital heart defects utilizing a ministernotomy incision. A ministernotomy was used in 79 patients with a variety of congenital heart diseases from November 2004 to August 2007. Patients included 36 males and 43 females with ages ranging from 1 month to 122 months (median age, 22 months). The weight ranged from 3.5 kg to 40 kg (median weight, 10.9 kg). There were no deaths, and one conversion to full median sternotomy (1/79, 1.3%). The median cardiopulmonary bypass time was 59 min, and median aortic cross-clamp time was 38 min. One patient underwent atrial septal defect (ASD) repair with fibrillatory arrest time of 35 min. The operating time ranged from 103 min to 312 min (median operating time, 168 min). The intensive care unit (ICU) stay ranged from 1 to 21 days (median ICU stay, 1 day) and the hospital stay ranged from 2 to 56 days (median hospital stay, 4 days). There were no reinterventions for residual cardiac defects. We demonstrate the safety and efficacy of ministernotomy for the correction of a range of congenital heart defects with improved cosmetic results.
Key Words: Atrial septal defect; Mini-sternotomy; Minimally invasive congenital cardiac surgery
|
1. Introduction
|
|---|
Minimally invasive cardiac surgery has been advocated for both adults and children in an effort to reduce costs related to hospital stay and to improve cosmetic results. Some of these techniques may require expensive equipment that may raise the cost of some procedures beyond that of conventional approaches. An inferior partial sternotomy, or ‘ministernotomy’ through a subxiphoid skin incision does not require any specialized or expensive equipment. This approach was first reported for repair of atrial septal defect (ASD) [1]. As experience with ministernotomy for ASD repair has grown, this approach has been used in the treatment of other congenital cardiac defects. We report our experience with ministernotomy in the surgical treatment of congenital cardiac defects. Our approach has been through a 3–6 cm subxiphoid skin incision with minimal sternal split. Aortic and bicaval cannulation, aortic cross-clamping with aortic root cardioplegia is achieved.
|
2. Materials and methods
|
|---|
From November 2004 to August 2007, 79 patients underwent ministernotomy for the correction of a variety of congenital heart diseases at Children's Medical Center, Dallas. Thirty-six male and 43 female patients with age ranging from 1 month to 122 months (median age, 22 months) were included. The weight ranged from 3.5 kg to 40 kg (median weight, 10.9 kg). The defects treated included partial AV canal, total anomalous pulmonary venous return, ASD, VSD and associated lesions (Table 1).
2.1. Operative technique
After induction of general anesthesia, transesophageal echocardiography is performed routinely. The patient is placed in a supine position. A 3–6 cm midline chest incision, typically terminating at or below the nipple line is made. The lower portion of the sternum is divided with the saw and the apex of the sternal incision retracted with an Army-Navy retractor (Pilling-Weck, Research Triangle Park, NC). In infants, a small Army-Navy retractor is attached tightly to either screen. In patients above 10 kg, this was accomplished with a Bookwalter retractor system (Codman, Randolph, MA). A subtotal thymectomy is routinely performed which improves exposure of the ascending aorta and superior vena cava. The ascending aorta is cannulated in a conventional fashion. The superior vena cava is cannulated either directly, or via the right atrial appendage. The inferior vena cava is similarly cannulated directly at the cavo-atrial junction (Video 1). This inferior vena caval cannula is usually brought out through a small skin incision, which is rightward and inferior to the caudal extent of the sternal incision. This serves to hold the cannula in a more inferior location, improving exposure (Video 2). At the conclusion of the operation, this small incision is used to place the chest tube. Lower profile ECMO venous cannula, placed via the right atrium, are frequently used in large patients (>15 kg). Left ventricular venting is performed via the right superior pulmonary vein, or directly with transeptal vent placement once the right atrium is opened. Cardiopulmonary bypass and cardioplegia delivery are performed according to the usual practice in our institution. The ascending aorta is cross-clamped directly via the ministernotomy. One patient underwent ASD closure with fibrillatory arrest. Carbon dioxide is routinely insufflated into the operative field at 500 ml/min to reduce the presence of intracavitary air.
View larger version (132K):
[in this window]
[in a new window]
|
Video 1. This video shows arterial and venous cannulae in position during an atriotomy through a ministernotomy.
|
|
View larger version (135K):
[in this window]
[in a new window]
|
Video 2. This video shows closure of atrial septal defect with ministernotomy. To improve exposure, the inferior vena caval cannula can be brought through the chest tube incision.
|
|
During cardioplegic arrest, the right atriotomy is easily centered in the incision. Conventional techniques are utilized to effect intracardiac repair. The patent ductus arteriosus can be most easily approached after the initiation of cardiopulmonary bypass, as the decompression of the pulmonary artery improves exposure. Subarterial ventricular septal defects can be approached via the proximal main pulmonary artery.
|
3. Results
|
|---|
Patient demographics and postoperative data are shown in Table 2. There were no deaths, with one conversion to full median sternotomy (1/79, 1.3%) in a patient with a left-sided superior vena cava. The median cardiopulmonary bypass time was 59 min, median aortic cross-clamp time was 38 min. One patient underwent ASD repair with fibrillatory arrest time of 35 min. The operating time ranged from 103 min to 312 min (median operating time, 168 min). The ICU stay ranged from 1 to 21 days (median ICU stay, 1 day) and the hospital stay ranged from 2 to 56 days (median hospital stay, 4 days). Complications included post-pericardiotomy syndrome requiring medical treatment in two patients, pericardial effusion requiring pericardiocentesis in one patient, hemothorax needing chest tube drainage in three patients, pleural effusion requiring thoracentesis in one patient, reintubation in one patient, pneumothorax requiring chest tube in one patient and three readmissions (Table 3). There were no reoperations for bleeding or residual defects.
|
4. Discussion
|
|---|
Minimally invasive cardiac surgical procedures have increased in popularity in adult cardiac surgery in the last two decades. These approaches have been applied to pediatric cardiac surgery in a limited fashion. A minimally invasive cardiac surgical approach for a cardiac surgeon must provide adequate exposure for an accurate repair, safe institution of cardiopulmonary bypass, adequate myocardial protection, effective deairing techniques and safe decannulation. We feel that our series demonstrates that ministernotomy can achieve these goals for many young patients.
Though minimally invasive surgery has traditionally been associated with faster patient recovery, a prospective study of ministernotomy vs. full-length sternotomy for repair of ASD in children, failed to demonstrate a significant difference in patient recovery including their stress response, pain scores, frequency of emesis, analgesic requirements, respiratory rate, ICU stay and hospital stay. It is important to note, however, that the limited access with a ministernotomy was not associated with increased operative or postoperative morbidity and the primary advantage in this prospective study seemed to be an improved cosmetic result [2]. Our retrospective review has no full sternotomy group for comparison but an examination of the operative times shows them to be well within what would be considered ‘routine’.
Alternative minimally invasive access techniques, such as, inframammary incisions or right thoracotomy have been described [3–6]. These approaches have been advocated especially in the female patients where the inframammary crease helps conceal the incision. Cosmetic results of these alternative approaches have been reported to be satisfactory but specific complications related to the incision have been reported. Pectoral muscle and breast maldevelopment after a transverse inframammary incision, along with paresthesia around breast tissue has been reported [7]. Dabritz et al. have used a limited right anterolateral thoracotomy for ASD closure in 87 female patients [8]. This technique included a limited skin incision, protection of mammary gland tissue and aortic cannulation. The mean age of patients in this study was 20.4 years compared to our study population whose mean age was 34.34 months. With the thoracotomy or inframammary incision, cosmetic concerns about the predictability of breast tissue development may delay some surgeries until after puberty [9]. Ying-long et al. have adapted the thoracotomy approach in >350 pediatric cases and avoid pectoral deformity by incising between the anterior and posterior axillary folds and sparing all muscle and overlying breast tissue [10]. Cosgrove and Sabik introduced the parasternal approach by resection of one or more costochondral cartilages producing reproducible exposures of cardiac structures and reducing pain and length of recovery [11–13]. This approach can lead to disruption of costochondral growth foci in the pediatric population and may lead to rib and chest wall deformity.
The advantages of a median sternotomy include a pericardial incision that parallels the course of the phrenic nerve and the avoidance of extensive myocutaneous flaps. The disadvantage of a full midline sternotomy is primarily cosmetic, due to the length of the scar. Variations of partial upper and lower sternotomy have been applied in pediatric and adult series. We question the value of the partial upper sternotomy as this is just as visible at the neckline as a full sternotomy.
The pliable thoracic cage in children, especially infants, can facilitate transatrial exposure through a lower sternal split ministernotomy and also minimize the length of the scar. This approach also does not encourage delay in repair until puberty like the inframammary approach.
Limitations of this study include the retrospective method of data collection. Another limitation is the lack of data in our series about level of pain, which remains difficult to measure in the pediatric population. The effect of a smaller incision and partial splitting of the sternum on the recovery of a small heterogeneous group of patients is difficult to measure. One can speculate, however, that a nearly intact sternum and ribcage will enhance early postoperative respiratory mechanics.
In summary, we demonstrate the safety and efficacy of a ministernotomy in the repair of a variety of congenital defects that require transatrial exposure. The cosmetic result of the ministernotomy is acceptable. There has been no compromise in technical repair and conversion to full median sternotomy can be done at any time during the procedure. The ministernotomy has become our approach of choice for a wide range of congenital defects requiring transatrial exposure.
|
References
|
|---|
- Bichell DP, Geva T, Bacha EA, Mayer JE, Jonas RA, del Nido PJ. Minimal access approach for the repair of atrial septal defect: the initial 135 patients. Ann Thorac Surg 2000;70:115–118.[Abstract/Free Full Text]
- 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;69:591–596.[Abstract/Free Full Text]
- Rosengart TK, Stark JF. Repair of atrial septal defect through a right thoracotomy. Ann Thorac Surg 1993;55:1138–1140.[Abstract]
- Luciani GB, Piccin C, Mazzucco A. Minimal access median sternotomy for repair of congenital heart defects. J Thorac Cardiovasc Surg 1998;116:357–358.[Free Full Text]
- Massetti M, Babatasi G, Rossi A, Neri E, Bhoyroo S, Zitouni S, Maragnes P, Khayat A. Operation for atrial septal defect through a right anterolateral thoracotomy: current outcome. Ann Thorac Surg 1996;62:1100–1103.[Abstract/Free Full Text]
- Brutel de la Riviere A, Brom GH, Brom AG. Horizontal submammary skin incision for median sternotomy. Ann Thorac Surg 1981;32:101–104.[Abstract]
- Cherup LL, Siewers RD, Futrell JW. Breast and pectoral muscle maldevelopment after anterolateral and posterolateral thoracotomies in children. Ann Thorac Surg 1986;41:492–497.[Abstract]
- Dabritz S, Sachweh J, Walter M, Messmer BJ. Closure of atrial septal defects via limited right anterolateral thoracotomy as a minimal invasive approach in female patients. Eur J Cardiothoracic Surg 1999;15:18–23.[Abstract/Free Full Text]
- Grinda JM, Folliguet TA, Dervanian P, Mace L, Legault B, Neveux JY. Right anterolateral thoracotomy for repair of atrial septal defect. Ann Thorac Surg 1996;62:175–178.[Abstract/Free Full Text]
- Ying-long L, Hong-jia Z, Han-shong S, Shou-jun L, Jun-wu S, Cun-tao Y. Correction of cardiac defects through a right thoracotomy in children. J Thorac Cardiovasc Surg 1998;116:359–361.[Free Full Text]
- Cosgrove DM, Sabik JF. Minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996;62:596–597.[Abstract/Free Full Text]
- Cosgrove DM, Sabik JF, Navia JL. Minimally invasive valve operations. Ann Thorac Surg 1998;65:1535–1539.[Abstract/Free Full Text]
- Cohn LH, Adams DH, Couper GS, Bichell DP, Rosborough DM, Sears SP, Aranki SF. Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair. Ann Thorac Surg 1997;226:421–428.
Related Articles
-
eComment: Re: Ministernotomy for repair of congenital cardiac disease
- Leo A. Bockeria, Alexey I. Kim, and Tigran R. Grigoryants
Interactive CardioVascular and Thoracic Surgery 2009 9: 822.
[Full Text]
[PDF]
-
eComment: Minimally invasive access for congenital heart disease repair
- Jamshid H. Karimov and Mattia Glauber
Interactive CardioVascular and Thoracic Surgery 2009 9: 822.
[Full Text]
[PDF]
This article has been cited by other articles:
|
|
|
|
 
L. A. Bockeria, A. I. Kim, and T. R. Grigoryants
eComment: Re: Ministernotomy for repair of congenital cardiac disease
Interactive CardioVascular and Thoracic Surgery,
November 1, 2009;
9(5):
822 - 822.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. H. Karimov and M. Glauber
eComment: Minimally invasive access for congenital heart disease repair
Interactive CardioVascular and Thoracic Surgery,
November 1, 2009;
9(5):
822 - 822.
[Full Text]
[PDF]
|
|
|
|
|
Top
Abstract
1. Introduction
