Repair of partial atrioventricular septal defect through a minimal right vertical infra-axillary thoracotomy

OBJECTIVE: To report a new minimally invasive and cosmetic approach for partial atrioventricular septal defect (PAVSD) repair. METHODS: From November 1997 to January 2000, six patients with a mean age of 19.2 +/- 7.7 years underwent minimal right vertical infra-axillary thoracotomy for PAVSD repair. Left atrioventricular (AV) valve regurgitation was assessed on the beating heart before and after valvuloplasty. Commissuroplasty of the left AV valve and atrial septum repair were done in all patients. RESULTS: There were no operative or late mortality, and no morbidity directly related to the thoracotomy approach. The average length of the incision was 8.3 +/- 131 cm. The arrest times averaged 32.8 +/- 8.3 minutes, and the cardiopulmonary bypass times averaged 66.0 +/- 9.0 minutes. One patient had a mild to moderate left AV valve regurgitation postoperatively. All patients were free of symptoms during the follow-up. CONCLUSION: The minimal right vertical infra-axillary thoracotomy is a safer, more cosmetic and less invasive approach than median sternotomy for the repair of PAVSD.     

右腋下小切口部分型心内膜垫缺损修补术——6例报告

目的　报道经右侧腋下小切口 ,修补部分型心内膜垫缺损的手术方法及结果。　方法　1997年 11月至 2 0 0 0年 1月 ,6例部分型心内膜垫缺损患者经右侧腋下小切口 ,完成了二尖瓣成形 (心脏跳动下观察二尖瓣返流情况及成形效果 )加Ⅰ孔房缺修补术。其中 1例解剖性单心房 ,1例过渡型心内膜垫缺损。 6例均有二尖瓣前叶裂 ,其中 3例合并二尖瓣中度关闭不全 ,1例重度关闭不全 ,1例三尖瓣中度关闭不全。　结果　切开长度 (8 3± 1 3)cm ,循环阻断时间 (32 8± 8 3)分钟 ,体外循环时间 (6 6 0± 9 0 )分钟。 1例术后二尖瓣仍有少 -中量返流 ,其余患者二尖瓣关闭良好 ,无房水平残余分流。 6例均顺利康复出院。术后随访 (1 1± 0 7)年 ,患者心功能良好 ,无死亡及并发症。　结论　经右侧腋下小切口行部分型心内膜垫缺损修补术 ,是一种安全、微创的手术方法。其中心脏跳动下观察二尖瓣返流情况 ,可为瓣膜成形提供可靠依据。     

Repair of atrial septal defect through a minimal right vertical infra-axillary thoracotomy in a beating heart

We present a minimally invasive and cosmetic approach to repair atrial septal defect. Fifty-five atrial septal defects were successfully repaired through a minimal right vertical infra-axillary thoracotomy. Every repair was performed on the beating heart with continuous suction through aortic needle vents and with the head of the patient lowered. This approach can be used not only in adults but also in young girls.     

Aortopulmonary window with subaortic fibrous stenosis and septal defect: surgery through a minimal right vertical infra-axillary thoracotomy

Aortopulmonary window with subaortic stenosis and ventricular septal defect is an uncommon congenital cardiac malformation that is repaired using cardiopulmonary bypass. The authors describe a 3-year-old patient on whom we performed surgery through a minimal right vertical infra-axillary thoracotomy. This minimally invasive surgery is likely to be applicable in a few cases.     

微创心脏不停跳下房间隔缺损修补术（附46例报告）

目的报告经右侧腋下小切口,在心脏不停跳下修补房间隔缺损的手术方法及结果。方法1997年1月至2000年3月,为46例房间隔缺损经右侧腋下小切口,在心脏不停跳下完成了缺损修补术,其中1例功能性单心房,2例部分型肺静脉(右侧)畸形引流,3例中度肺动脉高压。结果平均切口长度(7.2±1.1)cm。平均体外循环时间(30.3±7.8)分钟。术后所有患者无房水平分流及手术相关并发症,37例随访3月～2.4(1.3±0.6)年。所有患者心功能良好,无并发症。结论右侧腋下小切口心脏不停跳下房间隔缺损修补术,是一种安全、可靠、美观、微创的手术方法。     

Repair of atrial septal defect through a right posterolateral thoracotomy: a cosmetic approach for female patients

Background. Because the operation for atrial septal defect is considered a low-risk procedure, the cosmetic result has become an important issue. Principally for cosmetic reasons, anterolateral thoracotomy is frequently used for closure of atrial septal defect in young female patients. However, in anterolateral thoracotomy, the skin incision frequently crosses the future breast line, which may cause breast and pectoral muscle maldevelopment.

Methods. We review the long-term results of a consecutive series of 126 patients in whom the atrial septal defect was closed through a right posterolateral thoracotomy. The mean age at operation was 7.1 years (range, 1 to 15 years), and the mean body weight was 23.9 kg (range, 6.9 to 56 kg). Defects repaired included 121 ostium secundum (central type), 3 sinus venosus, and 2 ostium secundum without inferior margin.

Results. The average cardiopulmonary bypass time was 65 minutes (range, 37 to 130 minutes), with an average fibrillation time of 41 minutes (range, 23 to 70 minutes). There was no operative or late mortality. A majority of patients were pleased with their cosmetic results. There were no other late complications.

Conclusions. Atrial septal defect can be safely repaired through a right posterolateral thoracotomy approach. This approach offers the benefit of a total absence of scarring and cosmetic disfigurement of the anterior chest wall.     

Surgical repair of mitral valve prolapse through a minimal right vertical infraaxillary thoracotomy

Abstract Background: Minimally invasive mitral valve surgery has been proven a safe and cosmetic alternative to the conventional median sternotomy approach. The aim of this study is to retrospectively evaluate the clinical outcome of mitral valve repair for leaflet prolapse through a minimal right vertical infraaxillary thoracotomy (RVIAT). Methods: From January 2003 to December 2011, 68 patients with mitral regurgitation (MR) due to leaflet prolapse underwent mitral valve repair through a RVIAT approach. There were 37 males and 31 females. The mean age of the patients was 37.8 ± 10.5 years. Of the 68 patients, 45 had posterior leaflet prolapse and 23 had anterior leaflet prolapse. Results: The mean incision length was 7.3 ± 1.8 cm (range 5.5 to 10.0 cm). Mitral valve repair technique included quadrangular resection with or without sliding repair (40 cases), edge to edge technique (six cases), artificial chordae (18 cases), chordal transfer (four cases), and ring annuloplasty was performed in all 68 patients. There was no severe morbidity and operative mortality. Echocardiography after operation demonstrated absence or trivial mitral regurgitation in 52 patients and mild regurgitation in 16 patients. During the 3 months ～8 years' follow-up period, one patient (1.5%) underwent mitral valve replacement through the median sternotomy due to recurrent severe MR. Other patients were in good condition. Conclusion: Surgical repair of mitral valve prolapse can be successfully performed through the RVIAT approach achieving excellent cosmetic and clinical results. (J Card Surg 2012;27:533-537).     

部分型房室管畸形的外科治疗

目的探讨部分型房室管畸形的外科治疗方法。方法在52例部分型房室管畸形中,以自体心包修补、缝合瓣裂、乳头肌劈开及延长等方法矫正房室瓣关闭不全,分别采用Kirklin法和McGoon法修复原发房间隔缺损(PASD)42例、10例。结果手术死亡率3.8%,McGoon方法修补组发生Ⅲ度房室传导阻滞30%(3/10),而Kirklin法则无一例发生。47例术后随访2个月～22年,远期死亡率2.2%,5例心脏听诊心尖区可闻SMⅡ/6级,2例Ⅱ～Ⅲ/6级。结论根据二尖瓣畸形的病变解剖差异,选择个体化处理方法;用Kirklin法修复PASD比较安全。     

Bridging annuloplasty for left atrioventricular valve of partial atrioventricular septal defect

Residual left atrioventricular valve regurgitation after conventional repair technique for partial atrioventricular septal defect most commonly occurs in the central position. We describe here the technique for bridging annuloplasty on the opposing anterior and posterior annuli of the atrioventricular valve in selected patients with short leaflets.     

Residual postmyocardial infarction ventricular septal defect repair through right atrium with right thoracotomy on beating heart technique

Abstract   Background and Aim: The incidence of residual opening after repair of postmyocardial infarction ventricular septal defect (VSD) was reported to be 10% to 25%. Redo surgery with remedian sternotomy is more complex than primary surgery and is consequently associated with higher mortality and morbidity due to the myocardial and patent coronary grafts injury during pericardial dissection. Methods: A 59-year-old female patient had coronary artery bypass grafting and closure of post myocardial infarction ventricular septal defect with patch 10 months earlier in a different cardiac center. She was admitted to the hospital for severe congestive heart failure. Results: She was operated because of the residual opening after repair of post myocardial infarction ventricular septal defect. Post myocardial infarction ventricular septal defect closure was performed through the right atrium by on-pump beating heart technique via the right thoracotomy. Conclusions: Closure of post myocardial infarction ventricular septal defect with this technique offers an alternative and safe approach to repair of the residual VSD when the coronary bypass grafts are patent.     

Repair of complete atrioventricular septal defect with tetralogy of Fallot

Repair of complete atrioventricular canal with tetralogy of Fallot was performed in 9 patients. Ventricular septal defect was closed through the right atrium using a single polytetrafluoroethylene patch with ample anterior extension to avoid subaortic obstruction. The atrial septal defect was closed with a separate patch. Undivided atrioventricular valve leaflets were sandwiched between the two patches. Right ventricular outflow tract stenosis was relieved by pulmonary valvotomy and an infundibular patch in 7, a supravalvar patch (none transannular) in 6, and right ventricle-to-pulmonary artery conduit in 2. There was one hospital death (1/9, 11%) in a patient with persistent clinically significant postoperative pulmonary stenosis and low cardiac output requiring reoperation and right ventricle-to-pulmonary artery conduit insertion. There was no late mortality. All patients are asymptomatic 0.3 to 5.6 years after operation. Follow-up right ventricular outflow tract gradient ranged from 11 to 43 mm Hg and was 70 mm Hg in 1 patient who later had successful relief of obstruction. Three patients had mitral valve insufficiency; 1 needed reoperation. Aggressive relief of right ventricular outflow tract stenosis with maintenance of pulmonary valve competence and use of two separate patches for closure of the septal defects contribute to optimum immediate and long-term results after repair of this lesion.     

Surgery for partial atrioventricular septal defect in the adult

BACKGROUND: We sought to determine the clinical profile, operative results, and long-term outcome for adult patients undergoing operations for partial atrioventricular septal defects. METHODS: Between 1976 and 1996, 50 adults (mean age, 36.6 +/- 13.2 years) underwent surgery for partial atrioventricular septal defects. Thirty-nine of them underwent primary repair for a substantial left-to-right shunt (> or =1.8), associated with symptoms in 29. The remaining 11 patients had previous atrioventricular septal defect repair in childhood, but required reoperation as adults for severe left atrioventricular valve regurgitation (6), subaortic (3) or mitral (1) stenosis, and a residual atrial shunt (1). RESULTS: No patients died in hospital. Of the 39 patients first repaired in adulthood, left atrioventricular valve repair was performed in 37, valve replacement in 1, and no repair in 1. In contrast, left atrioventricular valve replacement was necessary in 2 of the 6 adults undergoing reoperation for left atrioventricular valve regurgitation. At 7 years median follow-up, 8 patients have died (2 from noncardiac causes). Of 42 patients alive in 1997, 39 are New York Heart Association class I or II, and 3 were class III (class improved in 81%). Two patients required left atrioventricular valve replacement (1 week and 5 years after repair, respectively) for valvar failure. CONCLUSIONS: Low operative risk and excellent long-term results support repair of partial atrioventricular septal defect in adults.     

Atrial septal defect repair through limited lateral thoracotomy in children

Objective We have developed a surgical method for atrial septal defect repair through a limited right lateral thoracotomy in which the incision line begins 2 cm caudal from the lower angle of the scapula and ends at the midaxial line, thereby improving patient satisfaction with the cosmetic results of treatment. Methods We performed a retrospective review of 28 patients who underwent isolated atrial septal defect repair through a limited right lateral thoracotomy between January 2002 and August 2004. The mean age and mean body weight at the time of the operation were 85.8 months (range 9–236 months) and 23.0 kg (range 8.0–56.0 kg), respectively. All repaired defects were the ostium secundum type. Results There was no operative or late mortality and no late morbidity after a mean follow-up of 26 months (range 12–41 months). Echocardiography showed no residual shunt in any of the patients. The mean length of the skin incision was 7.8 cm (range 5.0–11.0 cm), and almost all the patients had satisfactory cosmetic results. Conclusion The atrial septal defect repair through a limited right lateral thoracotomy in pediatric patients showed satisfactory surgical results and excellent cosmetic results.     

Modification of the radial procedure in a patient with partial atrioventricular septal defect

We successfully cured atrial fibrillation while preserving internodal conduction in a patient with a partial atrioventricular septal defect. Because the anterior and middle internodal tracts are interrupted by the defect, the lower right atrial incision of either the maze or the radial procedure may interrupt the remaining posterior tract, resulting in internodal conduction block. We deleted the posterior septal incision from the radial procedure and replaced it with a right-side left atriotomy. The patient resumed normal sinus rhythm with significant contraction of the right and left atria. The preserved internodal pathway through the posterior interatrial septum was confirmed by electrophysiologic study.     

Partial closure of the atrial septal primum defect and biventricular repair for a case of hypoplastic right ventricle with partial atrioventricular canal defect

An eight-year-old girl with partial atrioventricular canal defect and hypoplastic right ventricle was treated successfully by a palliative open-heart surgery. The preoperative right ventricular pressure was 58/7 mmHg (RVP/LVP = 0.67) and morphology of the right ventricle showed severe tricuspid stenosis and small outflow portion. The preoperative RVEDVI was 31 (41% of normal and tricuspid annulus was 17 mm (47% of normal). The right ventricular outflow was reconstructed with insertion of MVOP and the ASD was partially left open (the amplitude of the interatrial communication was 7 mm). Angiocardiogram two and half years after the operation demonstrated significant right ventricular growth with no right to left shunt through interatrial communication. The RVEDVI was 46 (56% of normal) and tricuspid annulus was 36 mm (90% of normal). This technique can be a procedure of choice in patient with right ventricular hypoplasia, who is not candidate for simple right ventricular reconstruction nor Fontan procedure, as the growth of the right ventricule is expected in the future.     

Repair of partial atrioventricular septal defect in children less than five years of age: late results.

BACKGROUND: Presently, surgical correction of partial atrioventricular septal defects is an extremely viable option giving good results. An aggressive approach toward operating on these patients at an early age may be warranted given the otherwise unfavorable natural history. METHODS: A retrospective study was done in 38 consecutive patients from 3 to 58 months of age, who underwent correction between 1981 and 1997. Preoperatively, moderate to severe mitral regurgitation was present in 45% of the patients. Congestive cardiac failure was noted in 41% of the cases. Closure of the left atrioventricular valve cleft was performed in 92% of the cases. A need for mitral annuloplasty was felt in 28% of the cases. Majority of the ostium primum defects in our series were closed by a pericardial patch. RESULTS: The early, 30 day mortality was 7.9%. A significantly low incidence of late mitral regurgitation (0.9%) was noted on a follow-up extending up to 14 years. There was only one reoperation during late follow-up. On their last follow-up, 87% of the patients are asymptomatic. CONCLUSION: An aggressive approach toward operating at an early age on children with this malformation is safe, effective, and yields excellent long term results.