Eur J Cardiothorac Surg 1998;14:S154-S159
© 1998 Elsevier Science NL
Minimally invasive cardiac surgery for intracardiac congenital lesions 1
Yi-Cheng Wu,
Chau-Hsiung Chang,
Pyng Jing Lin*,
Jaw-Ji Chu,
Hui-Ping Liu,
Min-Wen Yang,
Hung-Chang Hsieh,
Feng-Chun Tsai
Division of Thoracic and Cardiovascular Surgery, Department of Anesthesiology, Chang Gung Memorial Hospital, Chang Gung University, 199, Tun-Hwa North Road, Taipei, Taiwan
* Corresponding author. Tel.: +886 3 3281200; fax: +886 3 3285818.
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Abstract
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Objective: Minimally invasive cardiac surgery has recently been applied to the correction of intracardiac lesions. This report reviews our experience of minimally invasive cardiac surgery in 119 patients with intracardiac congenital lesions. Methods: From October 1995 to April 1997, 119 patients (48 male and 71 female, aged 0.9–65 years old, 18.5±17.8) received elective minimally invasive cardiac surgery at Chang Gung Memorial Hospital, Taipei, Taiwan for repair of atrial septal defect (96 patients) or ventricular septal defect (23 patients). The operations were performed through right submammary incision (ASD) or left parasternal minithoracotomy (VSD), under femoro-femoral or femoro-atrial cardiopulmonary bypass with fibrillatory arrest. Results: All of the defects were repaired successfully. The bypass time was 25–125 min (46±18). The operation time was 1.5–5.2 h (2.8±0.8). The postoperative course was uneventful in all patients. Follow-up (1.0–18.2 months, mean 7.3) was complete, with no late deaths or residual shunt. All patients were found to be in NYHA functional class I or II. Conclusion: Our experience demonstrate that minimally invasive cardiac surgery is a technically feasible, safe, and effective procedure in surgical correction of selective simple intracardiac congenital lesions, yielding good short-term results.
Key Words: Minimally invasive cardiac surgery • Atrial septal defect
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1. Introduction
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Median sternotomy is the standard approach for surgical intervention of intracardiac congenital lesions [7]. However, the poor cosmetic effect and possible complications of median sternotomy are occasionally troublesome [7].
Minimally invasive cardiac surgical techniques have recently been utilized in correction of intracardiac lesions in order to lessen incisional pain and hospital stay [2, 4, 9–13, 17]. Our experience showed that closure of atrial septal defect and correction of mitral valve lesions could be performed safely by the use of minimally invasive video-assisted endoscopic techniques under femoro-femoral or femoro-right-atrial extracorporeal circulation. The minimally invasive nature of these surgeries can lessen incisional pain, minimize incisional length, enhance functional recovery, and shorten hospital stay.
In this review, we present our preliminary results with the use of minimally invasive cardiac surgical techniques in 119 patients with simple intracardiac congenital defects, atrial septal defect or ventricular septal defect at Chang Gung Memorial Hospital, Taipei, Taiwan.
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2. Material and methods
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2.1 Patients
From October 1995 to April 1997, 119 patients (48 male and 71 female) received elective minimally invasive cardiac surgery at Chang Gung Memorial Hospital, Taipei, Taiwan for surgical repair of atrial septal defect (ASD, 96 patients) or ventricular septal defect (VSD, 23 patients). (Table 1
and Table 2
). Their ages ranged from 0.9 to 65 years old (18.5±17.8). Body weight was 7.5–78.0 kg (35.1±19.7). Congestive heart failure was noted in eight patients with VSD. The diagnosis was established by transthoracic echocardiographic examination and cardiac catheterization.
In patients with ASD, fossa ovalis type was noted in 76 patients, posterior inferior type was found in 16 patients, and sinus venosus was diagnosed in four patients (Table 1). Catheter occlusion had been performed in one patient before operation. The ratio of systemic blood flow to pulmonary blood flow (Q
p/Q
s) was 1.5–5.2 (2.9±0.9). The mean pulmonary arterial pressure was 9–34 mmHg (21±7).
In patients with VSD, subarterial type was noted in 19 patients and perimembranous type was found in four patients (Table 2). The ratio of systemic blood flow to pulmonary blood flow (Q
p/Q
s) was 1.5–6.8 (2.1±0.4). The mean pulmonary arterial pressure was 15–54 mmHg (22±4). Prolapse of aortic cusp with mild aortic regurgitation was noted in 11 patients. A ruptured right sinus of Valsalva aneurysm into the right ventricle was noted in one patient.
Elective operation was arranged after the diagnosis confirmed. All the patients and/or their family members were informed that an median sternotomy might be necessary and all signed the operative consent form.
2.2 Operative techniques
The minimally invasive cardiac surgical techniques used in these patients has been previously described [4, 13]. Under general anesthesia with a single-lumen endotracheal intubation, patients were put in the left semidecubitus position in ASD patients or on supine position in VSD patients. Transesophageal echocardiographic monitoring was set up.
In patients with ASD, a right anterior submammary minithoracotomy (4–6 cm in length) through the fourth intercostal space was made without excision of the ribs (Fig. 1
).
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Fig. 1. Pictures of a 4-year-old boy taken in the operation room. Arrow indicates submammary incision (5 cm). Arrowhead indicates inguinal incision for femoro-femoral cardiopulmonary bypass.
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In patients with VSD, a left anterior submammary minithoracotomy was performed. The pleural space was entered through the third intercostal space in patients with subarterial VSD or through the fourth intercostal space in patients with perimembranous VSD. The cartilage portion of the third or fourth rib was divided without resection to promote exposure. Care was taken not to damage the underlying internal thoracic artery.
A small rib spreader was used in these incisions to facilitate instrumentation. An endoscope (Stryker Endoscopy, San Jose, CA) was inserted through the manipulation incision or through a separate thoracotomy incision (1–2 cm in length). The intracardiac lesion was approached by the endoscope after the heart arrested by means of projected images on the video monitor. In the later part of this series, the endoscope is only used for illumination and teaching. The intracardiac lesions can be repaired under direct vision with the illumination by the endoscope.
Cardiopulmonary bypass was established through cannulation of the femoral artery and femoral vein. The venous cannula was inserted up to the level of the retrohepatic inferior vena cava. A membranous oxygenator was used. Systemic hypothermia began immediately after the start of extracorporeal circulation with rectal temperature 26–36°C (28.1±1.8°C). Cannulation of the inferior vena cava through the right atrium was performed in patients with ASD whose body weight was smaller than 15 kg, because of the small size of the femoral vein.
The aorta was not cross-clamped and the heart was protected with continuous coronary perfusion with fibrillatory arrest, without infusion of cardioplegic solution. In some patients, topical cooling of the heart was applied to facilitate fibrillation of the heart, enhance myocardial protection, and avoid deep hypothermia. In one patient with subarterial VSD and ruptured right sinus of Valsalva aneurysm into the right ventricle, the distal part of the ascending aorta was cross-clamped by a vascular clamp inserted through the thoracotomy incision. Cardioplegic solution (Plegisol, Abbott, North Chicago, IL.) was infused into the coronary orifices after oblique aortotomy.
In patients with ASD, a 4-cm incision was made on the right atrium which was then entered when the heart fibrillated (Fig. 2
). The venous return from the superior vena cava was controlled by insertion of a venous cannula, by a pump sucker, or clamping the superior vena cava temporarily. The ASD was closed directly (Fig. 2) in 44 patients or with a patch in 52 patients (Table 1).
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Fig. 2. In a patient with ASD, (A) a 4-cm incision by an ordinary scissors was made on the right atrium. (B) Fossa ovalis type of ASD was found and was closed directly by running sutures using hand-suturing technique. (C) The right atriotomy was closed with running sutures. (D) The pericardium was closed with interrupted sutures.
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In patients with VSD, after the heart fibrillated, a 1–2 cm incision was made on the right ventricular outflow tract which was then entered. A cardiotomy suction tube was inserted into the right ventricle. The VSD was identified with the assistance of the endoscope. In patients with mild aortic regurgitation, a suction catheter was inserted through a stab incision on the apex of the left ventricle. A small suction tube was inserted into the left ventricle via VSD to outline the margin of the VSD. The VSD was closed directly with interrupted sutures in seven patients. In the other 16 patients, the VSD was closed with a patch. In one patient, with a ruptured right sinus of Valsalva aneurysm into the right ventricle, patch closure was performed from the aortic and right ventricular side. The hypertrophic infundibular muscle of the two patients was resected and the right ventricular outflow tract was patch recontracted. The right ventriculotomy of another 21 patients was then closed directly with a running suture.
After completion of the intracardiac procedures, the left ventricle and then the left atrium were filled with blood. The air was then carefully evacuated by rotating the operating table in all directions before complete closure of the ASD or VSD. There was no obvious air bubble noted by transesophageal echocardiographic examination [5, 15]. The patients were kept in a head-down position. A venting needle could be inserted into the right superior pulmonary vein in patients with ASD or could be inserted into the apex of the left ventricle in patients with VSD to evacuate the residual air, if any. Cardioversion was easily performed by putting the cardioverter (CodeMaster, Hewlett–Packard, McMinnville, OR) pads on the surface of the heart, through the minithoracotomy. Cardiopulmonary bypass was terminated after rewarming of the patients. In some patients with VSD, temporary epicardial pacemaker wires were set up. Hemostasis and closure of the incisions were easily achieved. The femoral arteriotomy and venotomy were carefully repaired with interrupted non-absorbable sutures.
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3. Results
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All of the septal defects were repaired successfully. The duration of cardiopulmonary bypass time was 25–125 min (46±18). The operation time was 1.5–5.2 h (2.8±0.8). Cardiotonic drugs and intra-aortic balloon pumping were not used. All patients regained consciousness in the early postoperative period and the endotracheal tubes were removed on the operative night or the first postoperative day. There was no wound or lower limb vascular complications. The postoperative length of stay was 3–16 days with a mean of 6.9 days. Follow-up (1.0–18.2 months, mean 7.3) was complete, with no late deaths. Transthoracic echocardiographic examination showed good ventricular function and no residual shunt. All patients were found to be in NYHA functional class I or II. They were satisfied with the good cosmetic healing of the incision.
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4. Discussion
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We report 119 patients with ASD or VSD who were operated on with the aid of minimally invasive cardiac surgery. They recovered rapidly from the operations, indicating that minimally invasive cardiac surgery can be applied in the surgical correction of simple intracardiac congenital lesions with good results.
Median sternotomy is the gold standard of a surgical approach in the repair of congenital heart disease [7]. However, long incision length, postoperative pain, a not-ideal cosmetic effect, and possible complications of sternotomy (mediastinitis, osteomyelitis, etc.) make repair of ASD or VSD troublesome occasionally. The major advantage of minimally invasive cardiac surgery is avoidance of sternotomy. The minimally invasive nature of this procedure will reduce the incidence of postoperative mediastinitis and wound pain to a minimum.
From previous experience of minimally invasive thoracic and cardiac surgeries, it can provide the promise of expediency, safety, minimal discomfort, less postoperative pain, quick functional recuperation, excellent cosmetic healing, shortened hospital stays, and therefore savings in cost [2, 4, 8–14, 17]. In this series, there was no morbidity and no mortality. All patients were satisfied with the cosmetic healing. These indicate that minimally invasive cardiac surgery is a safe procedure with the expectation of the above mentioned benefit of minimally invasive endoscopic surgeries.
In minimally invasive cardiac surgery, simple femoro-femoral or femoro-atrial cardiopulmonary bypass established satisfactory perfusion of all vital organs, including the brain [2, 4, 9–13, 17]. For ASD patients of pediatric age, the femoral vein may be too small to be cannulated. Cannulation with snaring of the inferior vena cava via right atrium through the manipulation incision could be performed easily. The blood from the superior vena cava could be cleared by the cardiotomy sucker, inserting cannula connected to the cardiopulmonary bypass system, or clamping the superior vena cava temporarily. In our series, there was no organ failure postoperatively and the patients regained consciousness promptly after the surgeries, indicating adequate tissue perfusion during cardiopulmonary bypass. The femoral artery and vein, although small in caliber in pediatric patients, could be easily repaired without stenosis. There were no vascular complications of the lower limbs in our patients within the 1–18.2 month (mean 7.3 months) follow-up period.
Cardioplegic arrest is the standard myocardial protection. However, continuous perfusion of the heart without cross-clamping the ascending aorta can also offer adequate myocardial protection [1, 2, 4, 9–13, 17]. In this series, using continuous coronary perfusion, there was no low cardiac output postoperatively. Cardiotonic drugs were not used. This indicated adequate myocardial protection.
Prevention of air embolization is one of the most important procedures in minimally invasive cardiac surgery, especially while the aorta was not cross-clamped. Using the de-airing procedures described in this report or previous reports, the air in the cardiac chambers could be effectively evacuated [2, 4, 9–13, 17]. Before the heart started beating, transesophageal echocardiographic examination was performed to detect any residual air [5, 15]. All our patients woke up rapidly. There was no evidence of neurological defect postoperatively indicating adequate de-airing.
Direct or patch closure of the ASD or VSD could be successfully achieved through right submammary incision under direct vision or guided by the video-assisted endoscope. In patients with the sinus venosus type of ASD, patch closure is also feasible.
The choice of approach for VSD repair varies significantly among surgeons or centers performing this type of surgery. Repair of subarterial VSD could be accomplished through the pulmonary valve [16]. The right atrial approach is the route of choice for closure of other type of VSD. Right atriotomy could reduce the prevalence of right bundle branch block but does not prevent late AV block [6]. Prevalence of ventricular arrhythmias increased with follow-up duration and age at evaluation whatever the surgical approach, right atrium or ventricle [6]. This indicates that the right atrial approach can not prevent the occurrence of ventricular arrhythmia. In our institute, subarterial or perimembranous septal defect is routinely closed through the transventricular route which provides excellent exposure [3]. We have not been able to document a significant adverse effect on mortality or morbidity from the use of the ventricular approached which is accomplished through an incision in the right ventricular outflow tract that avoids injury to coronary artery branches. The exposure of VSD through the right ventricular outflow tract, with the aid of video-assisted endoscope in this series is excellent and closure of the VSD could be easily accomplished.
The duration of cardiopulmonary bypass in this series, 46±18 min, is slightly longer, indicating the technically demanding nature of minimally invasive cardiac surgery. However, this seemed acceptable to most cardiac surgeons and patients. However, the operation time was short. This showed the advantage of minimally invasive nature of minimally invasive cardiac surgery. However, general application as a routine procedure needs further long-term analysis of a larger series with comparison with those approached through median sternotomy.
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Footnotes
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1 Presented at World Congress on Minimally Invasive Cardiac Surgery, under the auspices of the European Association of Cardiothoracic Surgery, Paris, May 30–31, 1997. 
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Abstract
1. Introduction
