Closure of atrial septal defects via limited right anterolateral thoracotomy as a minimal invasive approach in female patients.

OBJECTIVE: The closure of atrial septal defects via sternotomy is a low-risk and high-benefit procedure. Limited right anterolateral thoracotomy is an alternative approach with regard to cosmetic aspects. However, it is discussed that a lateral approach is not appropriate for more complex lesions and is associated with an increased incidence of phrenic nerve damage. METHODS AND RESULTS: The perioperative and long-term outcomes (mean follow-up time: 73.2 months) of 87 female patients, mean age 20.4 years (range: 3-56 years), operated on for all types of atrial septal defects via limited right anterolateral thoracotomy between 1982 and 1993, were analysed retrospectively. Special features of the operation technique were a limited skin incision, protection of mammary gland tissue, prevention of phrenic nerve damage, and aortic cannulation in all patients. There were no intraoperative complications. Postoperative complications occurred in 12/87 patients including one rethoracotomy for postoperative bleeding and one late pericardial tamponade due to coumadine overdose. Follow-up was assessed by a survey obtained by the patients or their parents, and their family doctors in 79 patients (90.8%) Cardiac symptoms, mostly supraventricular arrhythmias, were observed in 13.9%. Echocardiography revealed mild tricuspid valve regurgitation (one patient) and mild mitral valve incompetence (one patient with ostium primum defect); there were no residual shunts. Cosmetic results were considered good and excellent in 87.3% and satisfactory in 8.9%. Three patients (3.8%) complained of a broad scar. Anaesthetic areas and optional scar pain were quite frequent (16.5%), whereas restriction of shoulder movement, breast asymmetry and scoliosis were rare. In summary, only one patient, suffering from intercostal neuralgia, would prefer sternotomy. CONCLUSION: Limited right anterolateral thoracotomy has a high cosmetic acceptance and was proven to be safe and effective for closure of any kind of atrial septal defects. Therefore, it is recommended as standard approach for atrial septal defects especially in female patients. reserved.     

Anterolateral thoracotomy as an alternative to repeat median sternotomy for replacement of the mitral valve

Median sternotomy is the most common approach for repeat cardiac surgery despite the potential complications of cardiac injury. Right anterolateral thoracotomy has been recommended as an alternative for patients undergoing mitral valve replacement, but data supporting one approach over the other do not exist. To compare these procedures, the records of 43 patients who had had a previous median sternotomy and who underwent mitral valve replacement were reviewed. No statistically significant differences between patients undergoing repeat median sternotomy (33 patients) and those undergoing right anterolateral thoracotomy (10 patients) were demonstrable when compared for age, gender, New York Heart Association Functional Class, other diseased valves, urgency of operation, indication for operation, type of valve removed, type of valve implanted, length of postoperative hospitalization, length of operation, days of ventilatory support, length of intensive care unit stay, and survival (90% for thoracotomy group; 76% for median sternotomy group; p, NS). Significant differences between the two groups, favoring right anterolateral thoracotomy, were apparent when comparisons were made for length of perfusion (means, 94.8 min, thoracotomy group; 121.4 min, sternotomy group; p = .03), incidence of reexploration (0%, thoracotomy group; 13%, sternotomy group; p = .001), and blood transfusion (means, 5.3 units, thoracotomy group; 11.4 units, sternotomy group; p = .003). Right anterolateral thoracotomy is an effective alternative to repeat median sternotomy for replacement of the mitral valve in patients who have had a previous median sternotomy.     

Aortic valve replacement through right anterolateral thoracotomy for aortic stenosis after mediastinal radiation therapy

A 76-year-old woman had severe aortic stenosis on transthoracic echocardiography [aortic valve area (AVA): 0.7 cm2, max pressure gradient (PG): 108 mmHg]. Since she was on radiation therapy for breast cancer, we considered that median sternotomy was a risk factor for mediastinitis, and right thoracotomy was chosen for aortic valve replacement. The operation was performed through a right anterolateral thoracotomy. Cardiopulmonary bypass was established with right femoral artery cannulation, right atrial cannulation, and right superior pulmonary vein cannulation for venting. The patient's postoperative course was uneventful. This method appears to be an alternative approach for aortic valve replacement in patients that are not suitable candidates for median sternotomy.     

Surgical approach to atrial septal defect in the female. Right thoracotomy versus sternotomy

Repair of atrial septal defect (ASD) remains a high-benefit, low-risk procedure due to technologic improvements. From July 1981 to December 1986, 35 females (age, 7 months to 28 years) had repair of ASD; 20 by right thoracotomy and aortic cannulation (group 1) and fifteen by median sternotomy (group 2). In general, right thoracotomy was applied to patients with secundum ASD two years or older and without associated lesions, while median sternotomy was applied to patients with ostium primum lesions and/or associated lesions. Patients or their families perceived the cosmetic results superior to the right thoracotomy approach over the median sternotomy. We feel that a right thoracotomy and aortic cannulation is effective in females (2 years and older) with secundum ASD for a superior cosmetic result over median sternotomy. However, females with ostium primum and/or associated lesions should undergo median sternotomy for better cardiac access and safety.     

Right extrapleural pneumonectomy for malignant mesothelioma via median sternotomy or thoracotomy? Short- and long-term results.

OBJECTIVE: To examine the short- and long-term results of right extrapleural pneumonectomy (EPP) for malignant pleural mesothelioma (MM) via median sternotomy or thoracotomy. METHODS: We analysed the results of EPP in consecutive patients with early stage MM undergoing a radical surgery protocol for MM over a 7-year period. Initially thoracotomy, but later median sternotomy, was the incision of choice for right-sided tumours. The effects of the change of approach on perioperative course and survival were analysed. RESULTS: EPP was performed in 105 patients (50 left thoracotomy, 22 right thoracotomy, 28 sternotomy, 5 combined sternotomy and right thoracotomy). Operation time was faster with median sternotomy than right thoracotomy (p=0.008). Right thoracotomy was associated with higher epidural infusion volume in the first 3 days than median sternotomy (p<0.001). There were fewer postoperative complications in the sternotomy group (p=0.05). There were no differences in pathological stage, completeness of resection or duration of postoperative stay. Median survival following left thoracotomy, right thoracotomy and median sternotomy was 18.3, 8.5 and 17.7 months, respectively (p=0.02). Planned neoadjuvant or adjuvant chemotherapy was more common following median sternotomy than right thoracotomy (p=0.01). However, compared with the left thoracotomy and sternotomy groups, right EPP performed via thoracotomy was an independent predictor of poor prognosis (hazard ratio 2.3 (95% confidence intervals, CI 1.3-4.1), p=0.02). No wound complications or tumour recurrence have been observed following median sternotomy. CONCLUSIONS: Median sternotomy should be considered as an alternative approach to thoracotomy for right EPP.     

Surgical approach for pericardiectomy: a comparative study between median sternotomy and left anterolateral thoracotomy

Pericardiectomy is the definitive treatment for constrictive pericarditis but the best surgical approach remains controversial. In this study we compared the results of pericardiectomy performed on 36 patients with constrictive pericarditis between 1995 and 2001. Pericardiectomy was performed by median sternotomy in 15 patients and by left anterolateral thoracotomy in 21 patients. All patients were reviewed at 6 weeks post operatively. Both groups of patients were similar in age, sex distribution, NYHA shortness of breath status, aetiology, presenting symptoms and duration of symptoms. Mortality was similar in the two groups with three deaths (14.2%) in the thoracotomy group and two deaths (13.3%) in the median sternotomy group. NYHA status improved in both thoracotomy (3.0+/-0.8 to 1.6+/-0.7; P=3.3x10(-6)) and median sternotomy (2.9+/-0.7 to 1.5+/-0.6; P=2.8x10(-5)) groups. The degree of improvement was not significant between the two groups (P=0.63). In addition ionotropic support and postoperative hospital stay were similar between the two groups. There was a higher incidence of wound infections (23.8 versus 6.6%; P=0.13) and pulmonary complications (23.8 versus 13.3%; P=0.33) associated with thoracotomy. In conclusion pericardiectomy improves NYHA status in all patients and mortality rates are similar in both the approaches.     

Right axillary incision: a cosmetically superior approach to repair a wide range of congenital cardiac defects

OBJECTIVES: We sought to evaluate the safety of a right axillary incision, a cosmetically superior approach than anterolateral thoracotomy, to repair various congenital heart defects. METHODS: All the patients who were approached with this incision between March 2001 and October 2004 were included in the study. There were 80 patients (median age, 4 years) with atrial septal defect closure (38 patients), repair of partial abnormal pulmonary venous return (14 patients), partial atrioventricular canal (16 patients), and perimembranous ventricular septal defect (12 patients). The surgical technique involved peripheral and central cannulation for institution of cardiopulmonary bypass. Electrically induced ventricular fibrillation was used for defects located in front of the atrioventricular valves, and cardioplegic arrest was used for those located at the level or behind these valves. RESULTS: The repair was possible without need for conversion to another approach. One patient sustained a transient neurologic deficit. The patients were all in excellent condition after a mean follow-up of 14 months. The cardiac defect was repaired with no residual defect in 75 patients and with trivial residual defect in 5 patients (3 with mitral valve regurgitation, 1 with atrial septal defect, and 1 with ventricular septal defect). The incision healed properly in all, and the thorax showed no deformity. CONCLUSION: The right axillary incision provides a quality of repair for various congenital defects similar to that obtained by using standard surgical approaches. Because it lies more laterally and is hidden by the resting arm, it provides superior cosmetic results compared with conventional incisions, including the anterolateral thoracotomy. Finally, the incision is unlikely to interfere with subsequent development of the breast.     

Pericardial drainage prior to operation contributes to surgical repair of traumatic cardiac injury

We report on two cases of successful surgical repair of cardiac injury: one involving a left ventricular stab injury and the other a blunt rupture of the right atrium. Each patient underwent emergency surgical repair, the former via left anterolateral thoracotomy and the latter via median sternotomy, following pericardial drainage tube insertion from the subxiphoid area. The operative approach was chosen according to the color of drained blood, i.e., arterial bleeding indicated left anterolateral thoracotomy, while venous bleeding indicated median sternotomy. We conclude that pericardial drainage via the subxiphoid approach prior to induction of anesthesia is an easy and useful technique to perform, not only to release cardiac tamponade but to determine the operative approach in patients suffering from cardiac tamponade following cardiac injury.     

Pericardial drainage prior to operation contributes to surgical repair of traumatic cardiac injury.

We report on two cases of successful surgical repair of cardiac injury: one involving a left ventricular stab injury and the other a blunt rupture of the right atrium. Each patient underwent emergency surgical repair, the former via left anterolateral thoracotomy and the latter via median sternotomy, following pericardial drainage tube insertion from the subxiphoid area. The operative approach was chosen according to the color of drained blood, i.e., arterial bleeding indicated left anterolateral thoracotomy, while venous bleeding indicated median sternotomy. We conclude that pericardial drainage via the subxiphoid approach prior to induction of anesthesia is an easy and useful technique to perform, not only to release cardiac tamponade but to determine the operative approach in patients suffering from cardiac tamponade following cardiac injury.     

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.     

体外循环手术应用腋下及腋前外切口

自１９９５年３月至１９９６年８月作者应用腋下及腋前外切口进行体外循环手术５０例。房间隔缺损１７例，室间隔缺损２６例，二尖瓣狭窄及关闭不全３例，三房心、部分型心内膜垫缺损、双腔右心室、二尖瓣关闭不全各１例。全组手术顺利，主动脉阻断时间２２．５９±１１．０６分钟，体外循环时间４０．１９±１７．１７分钟。无手术死亡及并发症。创伤轻、出血少、恢复快、腋下切口看不见手术瘢痕、美容效果好。     

Spinal deformity after combined thoracotomy and sternotomy for congenital heart disease

Patients with congenital heart disease are at an increased risk to develop scoliosis. The purpose of this study was to determine the incidence of spinal deformity in patients after thoracotomy and sternotomy for congenital heart disease. METHODS: Sixty-eight patients underwent thoracotomy followed by a sternotomy and met inclusion criteria. The medical records were reviewed to gather demographic data and medical and surgical history. Serial radiographs were reviewed. RESULTS: Scoliosis developed in 26% of the patients (10 boys, 8 girls). The mean Cobb angle was 40 degrees (range, 15-78 degrees). The mean age at diagnosis of scoliosis was 10.7 years (range, 2.9-17 years). The mean follow-up was 14.9 years (range, 5-20 years). Twelve percent (8 patients) required posterior spinal fusion. A kyphotic deformity developed in 21% (14 patients). In patients with scoliosis, the mean kyphosis was 38 degrees (range, 2-88 degrees). Patients with a cyanotic cardiac condition had a 4-fold incidence of scoliosis. There was no correlation between the development of scoliosis or kyphosis and the age at time of procedures, number of surgeries, sex, heart size, or side of the aortic arch. CONCLUSIONS: The risk of developing scoliosis in children with congenital heart disease is more than 10 times that of idiopathic scoliosis. Spinal deformities, including scoliosis and/or hyperkyphosis, were found in 38% of the patients. Curves develop at a younger age, which increases the risk of progression. The sagittal alignment in scoliosis patients tends toward hyperkyphosis. The thoracic spine receives a "double hit" when both procedures are combined.     

微创、正中切口在间隔缺损修补中的血液保护对比研究

目的近年,尽管许多血液保护技术及药物应用于心脏外科手术,失血和输血却总是依然存在。我们假设微创切口能够减少青春期间隔缺损患者术后失血和输血。方法回顾性的分析了连续的、接受先天性房间隔缺损修补或室间隔缺损修补的42名青春期患者,27例胸部正中切口,15例胸部前外侧切口,即右侧腋下胸部小切口(经肋间隙)。为了评估微创切口对于减少失血及输血的功效,就手术时间、术后总引流量及输血几率等做了对比。结果15例胸部前外侧切口中有2例输血,27例胸部正中切口中有13例输血(P<0.05)。胸部前外侧切口术后引流量(215.93±188.62)ml,低于胸部正中切口(471.85±423.14)ml(P<0.05)。胸部前外侧切口术后引流管拔除时间(27.20±6.18)h,低于胸部正中切口(35.96±14.58)h(P<0.05)。结论微创切口能够明显地减少青春期先天性间隔缺损修补术病人的失血和输血。     

Surgical treatment of pulmonary hydatid disease in children: report of 122 cases

BACKGROUND/PURPOSE: The aim of this study was to review the authors' surgical experience in pediatric pulmonary hydatid disease focusing on clinical presentation, parenchyma saving operations, and long-term results. METHODS: One hundred twenty-two children with pulmonary hydatid cyst were treated surgically over the last 2 decades and were reviewed retrospectively. There were 66 boys and 56 girls with a mean age of 9 years. RESULTS: Pulmonary hydatid cyst was seen in 111 (91%) patients and pulmonary and hepatic cysts in 11 (9%). Lateral thoracotomy was performed in 106 (87%) patients, thoracotomy and laparotomy in 6 (5%), median sternotomy in 5 (4%), lateral thoracotomy with phrenotomy in 4 (3%), and median sternotomy with phrenotomy in 1 (0.8%). Parenchyma-saving procedures were performed in 114 patients (93%) and lung resection in 8 (7%). There was no mortality. Postoperative complication was seen in 5 patients (4%). CONCLUSIONS: Parenchyma-saving procedures without capitonnage are preferable. In patients with right or bilateral lung and coexisting cysts in the upper part of the liver, thoracotomy or median sternotomy and transdiaphragmatic approach allows the surgeon to remove the lung and liver cysts in a single operation. Median sternotomy is an alternative method for the bilateral lung hydatidosis compared with sequential thoracotomy.     

Radiation pericarditis and breast reconstruction: a surgical dilemma

OBJECTIVE: To discuss a case of radiation pericarditis and the physiology of the disease, and to discuss the left thoracotomy as an effective alternative to median sternotomy for pericardiectomy in the treatment of complicated radiation pericarditis. DESIGN: A case report with accompanying discussion of the disease and literature search. SETTING: Keesler Air Force Base Medical Center, a military training facility and general surgery residency program. PARTICIPANTS: A single case report with review of literature. RESULTS: Left thoracotomy is an effective alternative to median sternotomy for the surgical treatment of radiation pericarditis, with a mild increase in pulmonary-associated complications. CONCLUSIONS: With an increase in the use of mediastinal radiation for treatment of malignant disease as well as the increase in women having reconstructive procedures of the breast, one may expect complicated cases of radiation pericarditis that may not be amenable to median sternotomy. Left thoracotomy may be an alternative to median sternotomy for pericardiectomy in cases of pericarditis complicated by cosmetic constraints.     

Simultaneous resection of synchronous bilateral bronchogenic carcinoma using median sternotomy

Despite the increasing use of median sternotomy for pulmonary resection, only two successful cases of simultaneous resection of bilateral primary bronchogenic carcinoma by this approach have been reported. We report the third case of successful resection of synchronous primary bronchogenic carcinoma by median sternotomy, and the fourth successful case of simultaneous resection, as the first reported case of simultaneous resection was accomplished via bilateral anterolateral thoracotomy incisions. We believe at present that the ideal surgical approach for patients with bilateral primary bronchogenic carcinoma is simultaneous resection by median sternotomy.     

Two Different Minimally Invasive Techniques for Female Patients with Atrial Septal Defects: Totally Thoracoscopic Technique and Right Anterolateral Thoracotomy Technique

Background: To compare the outcomes of totally thoracoscopic technique (TTS) vs. right anterolateral thoracotomy technique (RALT) in female patients undergoing minimal invasive atrial septal defect (ASD) correction.Methods: From March 2011 to January 2013, 125 female patients underwent minimally invasive atrial septal defect closure, of whom 62 patients were in the TTS group and 63 were in the RALT group.Results: Procedures were performed successfully in all patients without in-hospital mortality or major complications. cardiopulmonary bypass (CPB) time were 48.95 ± 15.63 min in TTS group, 31.4 ± 8.04 min in RALT group (p <0.001); the cross-clamp time were 26.92 ± 11.84 min in TTS group and 18.51 ± 6.11 min in RALT group (p <0.001). The length of incision in RALT group (6.02 ± 1.03 cm) was longer than TTS group (5.31 ± 0.68 cm) and the difference was significant (p <0.001). The overall satisfaction rate for the cosmetic results of TTS was 100% and was 96.83% (61/63 patients) in RALT patients. During follow-up, all patients in TTS group were satisfied expect two patients complained that scar was too long at groin. Reasons for a lower score in RALT group included the long scar in the chest; a RALT incision that was located too medially (coming off the bra line) and asymmetrical breast development.Conclusions: Both TTS and RALT are valid and reliable cosmetic surgical techniques for repairing ASDs in female patients. Both techniques allow excellent cosmetic and functional results in most female patients. The totally thoracoscopic technique may gain shorter incision and cosmetic results compared with RALT.     

微创小切口心脏瓣膜手术134例

目的总结经微创小切口行心脏瓣膜手术的临床经验,探讨手术径路、方法、效果以及可能的危险因素。方法采用微创小切口行心脏瓣膜手术134例,其中经胸骨旁切口行主动脉瓣置换术5例,二尖瓣置换术2例;经右胸前外侧切口行二尖瓣手术46例,单纯三尖瓣手术15例;经胸骨上段小切口(反Z字形)行主动脉瓣置换术11例;经胸骨下段劈开加横断右半胸骨(倒L形)切口行二尖瓣手术55例。结果术后早期死亡3例,其中2例死于低心排血量综合征和右心功能不全,1例死于急性肝、肾功能衰竭。随访114例,随访时间2个月~7年,术后6个月患者的心功能均有不同程度的改善,切口疤痕隐蔽,复查心脏彩色超声心动图显示心瓣膜功能良好。结论微创小切口行心脏瓣膜手术可行,避免了完全劈开胸骨,维持胸廓的完整性,减少损伤,相对美观,有利于患者术后的恢复。     

Right postero-lateral thoracotomy for atrial septal defect closure; a comparative analysis with median sternotomy

Introduction In a low risk procedure like ASD closure Right Posterolateral thoracotomy approach aims at the cosmetic results as compared to median sternotomy. This paper illustrates our approach for a standardised Right Posterolateral thoracotomy in ostium secundum ASD repair and the analysis of the outcome. Methods Right Posterolateral thoracotomy (RPLT) was offered as a cosmetic alternative for atrial septal defect (ASD) closure in children, and selected adult patients below 30 years with lean body build. A retrospective study comparing these patients with median sternotomy approach during the same period (2000–2003) was performed. Exclusion criteria included preoperative diagnosis of complex ASD, obesity and chest wall deformity. Common variables were considered for analysis. Results There were 96 patients (66 females and 30 males) with an average age of 13yrs (range 3 to 27 years) in RPLT group and 225 patients (95 females and 130 males) with average age of 36 years (range 2 to 46 years) in sternotomy group. Extra corporeal time was 32 minutes (28 to 45) and aortic cross clamp time was 14 minutes (8 to 36) in RPLT while the values were 46 minutes (37 to 90) and 22 minutes (18 to 36) in Median sternotomy approach. Blood loss in postoperative period was 160 ml (20 ml to 400 ml) in thoracotomy group compared to 210 ml (40ml to 600 ml) in sternotomy group. There was no mortality or recurrence after repair of ASD during the follow-up. Significant postoperative morbidity was persisting pain and shoulder movement restriction in 12 patients. The scar was cosmetic in RPLT. Conclusion In selected patients with lean body build Right posterolateral thoracotomy is suitable for ostium secundum atrial septal defect closure. The final appearance has definite cosmetic advantage over sternotomy. Presented at the 50^th Annual Meeting of IACTS, New Delhi, Feb., 2004.     

Heart displacement during off-pump CABG: how well is it tolerated?

BACKGROUND: Heart displacement during off-pump coronary artery bypass grafting (CABG) is necessary to expose the anastomosic sites. We analyzed the hemodynamic changes in relation to the grafted arteries. METHODS: The relationship between surgical exposure and hemodynamic management was assessed in 150 consecutive patients undergoing off-pump CABG utilizing the Octopus Tissue Stabilization System (Medtronic, Minneapolis, MN). RESULTS: Surgical exposure by anterolateral thoracotomy showed no significant hemodynamic changes. Through sternotomy, stroke volume was significantly reduced by dislocation at all target sites: by 6% at the left anterior descending artery (LAD), 25% at the diagonal branch artery (D), 14% at the right coronary artery (RCA), and 21% at the obtuse marginal artery (OM). The application of head-down positioning (LAD, 56%; D, 74%; RCA, 90%; OM, 96%) increased not only surgical exposure but also preload, producing correction of ventricular filling pressures and output. In a minority of cases, dopamine (3 to 5 microg x kg(-1) x min(-1)) was added to maintain baseline hemodynamic values (LAD, 5%; D, 15%; RCA, 7%; OM, 28%). CONCLUSIONS: Revascularization during anterolateral thoracotomy was uneventful. The sternotomy approach with heart displacement induced right heart compression. Mainly fluid redistribution was sufficient to correct cardiac output. Once stabilized, systemic circulation remained unchanged during revascularization.