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Eur J Cardiothorac Surg 1999;15:18-23
© 1999 Elsevier Science NL

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

S. Däbritz, J. Sachweh, M. Walter, B.J. Messmer

Department of Thoracic and Cardiovascular Surgery, University Hospital, Klinik für Thorax-, Herz- und Gefässchirurgie, Universitätsklinikum, Pauwelsstrasse 30, 52057 Aachen, Germany

Received 3 June 1998; received in revised form 26 October 1998; accepted 2 November 1998.

Corresponding author. Tel.: +49-241-808-9957; fax: +49-241-888-8454.


   Abstract
Top
 Abstract
Introduction
Materials and methods
Results
 Discussion
References
 
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.

Key Words: Atrial septal defect • Surgical treatment • Anterolateral thoracotomy • Congenital heart disease


   Introduction
Top
 Abstract
 Introduction
Materials and methods
Results
 Discussion
References
 
Atrial septal defects (ASD) are one of the most common cardiac malformations. Without the presence of severe symptoms, diagnosis is not always made in childhood and may be delayed to adolescence or adulthood. As the increased pulmonary blood flow may lead to pulmonary hypertension, closure of a significant ASD is generally recommended. Various transcatheter closure techniques have been developed, but are still restricted to selected cases because of certain complications [1] [2]. Thus, surgical closure remains the therapy of choice. It is usually performed using cardiopulmonary bypass (CPB) by a sternal approach. Currently, more and more emphasis is put on the cosmetic results of surgical interventions. Female patients especially, may suffer from the sternotomy scar. Right anterolateral thoracotomy seems to be an alternative approach; however, it is discussed that this approach is not safe enough for more complex lesions [3] [4] [5] [6] and that it is associated with an increased incidence of phrenic nerve damage [7]. The aims of this study were to investigate the safety of a limited right anterolateral thoracotomy for closure of all types of ASD and to evaluate the cosmetic and functional results of this approach.


   Materials and methods
Top
 Abstract
 Introduction
Materials and methods
Results
 Discussion
References
 
Between January 1982 and November 1993, 87 female patients, mean age 20.4 years (range: 3–56 years), mean weight 46.3 kg (range: 13.4–79.2 kg), were operated on any kind of ASD via limited right anterolateral thoracotomy (Table 1). Patient enrolment was terminated in November 1993 to guarantee true long-term follow-up in order to verify the cosmetic result also in adolescents. Preoperative diagnosis included ASD of secundum type with or without partial anomalous pulmonary venous return (PAPVR), persistent left caval vein, pulmonary valve stenosis, Scimitar syndrome, and ostium primum defect (ASD I) with mitral incompetence. Previous right thoracotomy for treatment of esophageal atresia (one patient) and previous attempt of transcatheter closure (two patients) were no contraindications for this approach.


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  		Table 1. Intracardiac diagnosis of 87 female patients operated by limited right anterolateral thoracotomy

 
Operation technique
The patient is positioned in a 45° anterior oblique position after the fourth rib has been marked anteriorly ( Fig. 1 ). The skin incision is limited from the sternum to the anterior axillary line and is placed in the submammary fold ( Fig. 2 ) or 4–5 cm below the nipple in children. The subcutis is cut straight down to the fascia to avoid injury of mammary gland tissue. Subcutaneous fat and the mammary gland tissue are dissected from the fascia up to the fourth rib. The pectoralis muscle is cut in horizontal direction. Alteration of the latissimus dorsi muscle is avoided. Subsequently, the thorax is opened in the bed of the fourth rib. After ligation of the mammary vessels, the cartilage of the fourth rib is cut near the sternum. The pericardium is opened longitudinally 2 cm above the phrenic nerve which is always visible. In children, thymus tissue has to be dissected cranially. An adequate exposure is achieved by traction on pericardial stay sutures. Cannulation and closure of the ASD is performed in the same way as in sternotomy with mild hypothermia and cardioplegic arrest. Exposure of the intracardiac structures is at least as good as in sternal approach ( Fig. 3 ). A persistent left caval vein can be cannulated separately before or after opening of the atrium or a sucker can be placed near the coronary sinus. Pulmonary valvulotomy or mitral valve reconstruction can be performed. Subsequently, the ASD is closed. In simple secundum defect the sucker is not inserted beyond the atrial septum to avoid entrance of air into the left atrium. In any other kind of ASD, it is mandatory to allow the left heart to fill with blood before the ASD is closed completely. Accordingly, the caval tapes are opened before the right atrium is closed completely. Only the aortic root is de-aired before the aortic cross-clamp is opened. A ventricular pacing wire is inserted during CBP, because of poor exposition of the ventricle. The following steps are identical to those in the sternal approach. Left atrial pressure is only measured in adults with impaired ventricular function. Pericardial and pleural drains are inserted and the pericardium is adapted almost completely. The thoracotomy is closed, the pectoralis muscle and subcutaneous tissue are adapted, and the skin is closed by an intracutaneous suture line.



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  		Fig. 1. Positioning and marking of skin incision for limited right anterolateral thoracotomy in a 7-year-old girl.

 


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  		Fig. 2. Scar 12 days after limited right anterolateral thoracotomy in a 29-year-old woman.

 


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  		Fig. 3. Exposure of intracardiac structures in limited right anterolateral thoracotomy.

 
Perioperative assessment and follow-up
CPB protocols, blood loss and blood transfusions, intra- and postoperative complications, intensive care and hospital stay were reviewed. A follow-up was assessed by a survey obtained by the patients or their parents, and the family doctors. Special regard was given to cosmetic results as the appearance of the scar and development of the mammae as well as to complaints concerning the surgical approach such as pain, numbness or thoracic asymmetries.


   Results
Top
 Abstract
 Introduction
Materials and methods
Results
Discussion
References
 
Perioperative assessment
Mean CBP time was 55 min (range: 25–131 min) and mean aortic cross-clamp time was 29 min (range: 9–81 min). There were no intraoperative complications; mortality was zero. After 1–3 days (mean: 1.26 days) patients were transferred to the regular ward and were discharged on day 10–26 (mean: 12.9 days).

Twelve patients had postoperative complications (Table 2), three of those (3.4%) required prolonged hospital stay: one patient had a postoperative bleeding requiring rethoracotomy, one had a late pericardial tamponade on the 12th day postoperatively secondary to an overdose of coumadine, and one patient developed pneumonia of the left lung. Four complications may be related to the approach, but do occur in sternotomy patients as well; these are right pleural effusion, right pneumothorax, and atelectasis of the right lung. None of the 87 patients had damage of the phrenic nerve.


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  		Table 2. Postoperative complications in 12 of 87 female patients after limited right anterolateral thoracotomy for closure of ASD

 
Overall mean blood loss was 318 ml (range: 0–1690 ml) including one severe bleeding with rethoracotomy. Blood transfusions were given to 29 patients (33.3%) from 1 to 7 units. In 17 patients, blood units were needed for priming, 14 of those had no blood after CPB. Postoperative blood transfusions were given to 14 of 50 patients (28%) between 1982 and 1988. In the following years only one of 37 patients (2.7%) received blood units postoperatively due to restricted transfusion politics and the establishment of autologous blood donation.

Follow-up
Follow up was assessed in 79/87 patients (90.8%) with a mean follow-up time of 73.2 months (10.1–151.4 months). The cosmetic result was considered good and excellent in 87.3% and satisfactory in 8.9%; three patients (3.8%) were not satisfied because of a broad scar. Nevertheless, all three would choose limited right thoracotomy again. Seventeen patients (21.5%) do not yet show breast development. In 61 (98.4%) of the remaining 62 patients the scar was concealed by the breast partly or completely. It was completely visible in one patient (1.6%). Three (4.8%) of the adult patients complained of breast asymmetry. They were operated at the age of 26, 24 and 15 years. Thirteen patients (16.5%) reported optional pain. It was specified as mild in nine (11.4%) cases and as disturbing in five patients (6.3%). In four of those five patients hyperesthetic areas of the breast and nipple were present; one had a sensitive scar and was unable to wear a bra. Anaesthetic areas were noticed by 13 patients (16.5%). They were described as trivial in 5 (6.3%) and as moderate in 8 (10.1%).

Remarkable restriction of shoulder movement was assessed in two (25%) patients and was caused by pain. In one of them, operated at the age of 56 years, clinical assessment and chest X-ray revealed thoracic asymmetry and scoliosis, which was already present prior to surgery. The only other patient with a remarkable scoliosis had a length difference of the legs.

Cardiac abnormalities were found in 11 patients (13.9%). Those were supraventricular tachycardias (nine patients), mild mitral valve incompetence (one patient with ostium primum defect), and tricuspid valve incompetence in one patient; none of the patients had a residual ASD. In patient's resumeés 75 (94.9%) would prefer limited right anterolateral thoracotomy to sternotomy, three (3.8%) would probably also choose this approach again. One patient (1.3%) suffers from intercostal neuralgia and, therefore, would rather accept the cosmetic disadvantage of a sternotomy scar.


   Discussion
Top
 Abstract
 Introduction
Materials and methods
Results
 Discussion
References
 
Right anterolateral thoracotomy for intracardiac surgery of the right and left atrium has been described several times [3] [4] [5] [6] [8] [9] [10]. The surgical closure of an ASD is a low-risk and high-benefit procedure. Although cosmetic advantage of right anterolateral thoracotomy particularly in women is undisputed, operative risk in complex lesions [3] [4] [5] [6] and the risk of phrenic nerve damage [7] is considered higher.

In 87 female patients who had a closure of any kind of ASD via limited right anterolateral thoracotomy no technical problems arose from the approach, from aortic and venous cannulation, or from de-airing. A persistent left caval vein can be drained by transatrial cannulation with a balloon occluding catheter before or after opening of the atrium by placing a sucker near the coronary sinus. Poor exposure of the ventricles requires specific strategies regarding de-airing, pacing-wire insertion, and defibrillation. In a simple secundum defect the sucker is not inserted beyond the atrial septum; in any other kind of ASD, it is mandatory to allow the left heart to fill with blood before the ASD is closed completely. Only the aortic root is de-aired before the aortic cross-clamp is opened. The ventricular pacing wire is inserted on the empty heart during CPB. Defibrillation can be performed with small, special designed internal paddles or with preoperatively fixed external paddles. Past experience has shown that external paddles are superior due to difficulties in placing internal paddles correctly in some patients.

The exposition of intracardiac structures was good; the surgical correction of complex lesions (e.g. ostium primum lesions) did not turn out to be more difficult than via the sternotomy approach. On the contrary, the exposure of the AV-valve area is better from a more lateral approach. There was no need to cannulate the femoral or iliac artery. Although this access is used to establish extracorporal circulation in combination with antero-lateral thoracotomy [10], troublesome complications may arise particularly in children [11].

The intraoperative complication rate was zero; the postoperative complications in our series do occur in sternotomy as well. Phrenic nerve damage, which is especially attributed to right anterolateral thoracotomy [7], was not seen in our series. Since the nerve is always easily visible, there should not be incidental damage.

Transfusion rate has significantly decreased in the last years due to changing politics. Currently, blood transfusion in ASD-closure is an exception, particularly as children in our institution undergo elective ASD-closure not under 15 kg of weight and, thus, do not need blood for priming. Furthermore, an isolated ASD does not represent an emergency nor an urgent case in early infancy. Prolonged CBP-times were related to the training of junior surgeons whereas prolonged hospital stay without complications was due to the health care system and patients attitude, respectively, which have recently changed.

Critical follow up reveals that the cosmetic and functional results are not always excellent. Mild breast asymmetries and scar pain do occur. Major sequalae as thoracic asymmetries, scoliosis, and diminished shoulder movement are rare. Quite frequent and disturbing are anaesthetic and hyperesthetic areas. However, the cosmetic perception of the scar is enormous; despite all complaints only one patient would choose a sternotomy instead.

Most complaints and complications after right anterior thoracotomy are related to soft tissue damage. Therefore, horizontal submammary skin incision with sternotomy [12] [13] would add to the complications without having advantages in surgery for ASD.

Certain guidelines can be assessed to avoid most of the above complications and improve the results. Skin incision should be rather too far away from the nipple than too near to it in order to safe the gland tissue in children. The incision should not be extended too laterally and latissimus dorsi muscle should not be divided. Thus, innervation of the lateral breast and nipple is saved and the functional result is improved. Division of mammary vessels can be avoided by separating pleural tissue from the fourth rib before it is cut.

In contrast to the literature [3] [4] [5] [6] we do not consider ostium primum defects, pulmonary valve stenosis, persistent left caval vein, prior anterolateral thoracotomy or prior insertion of an ASD-closure device as a contraindication for anterolateral thoracotomy approach for experienced surgeons. Especially in children and young patients it is easy to expose the pulmonary artery by traction sutures on the empty heart and to perform commissurotomy.

In conclusion, limited right anterior thoracotomy for closure of ASD of any kind has proven to be safe and effective. Poor ventricular exposure requires special strategies regarding de-airing, pacing-wire insertion and defibrillation. Cosmetic and functional results are good, but can be improved by subtle techniques. Further follow-up is required to ensure normal breast development in the pre-adolescent patients.

Finally, it has to be pointed out that patients with an anterolateral thoracotomy for ASD-closure have less adhesions in the case of secondary operations for acquired heart disease later in life. Furthermore, this approach has been recommended for repeat mitral valve surgery [9], but can also be used for primary mitral valve surgery.

Currently, cosmetic aspects are more and more emphasized and cannot be neglected in cardiac surgery either. This applies especially to malformations, which are completely healed. Thus, the scar is the only residue for a lifetime. We therefore consider limited right anterolateral thoracotomy as the standard approach for closure of any kind of ASD in females and are currently expanding it to male patients, too. In the latter a partial sternal split with limited midline skin incision might be a promising alternative [14]. To our mind there have to be additional pathology or special contraindications to justify a conventional sternotomy.


   References
Top
 Abstract
 Introduction
Materials and methods
Results
 Discussion
References
 

  1. Lloyd T.R., Rao P.S., Beekman R.H., Mendelsohn A.M., Sideris E.B. Atrial septal defect occlusion with the buttoned device: a multi-institutional US trial. Am J Cardiol 1994;73:286-291.[Medline]
  2. Perry S.B., Van der Velde M.E., Bridges N.D., Keane J.F., Lock J.E. Transcatheter closure of atrial and ventricular septal defects. Herz 1993;18:135-142.[Medline]
  3. Kumar A.S., Prasad S., Rai S., Saxena D.K. Right thoracotomy revisited. Texas Heart Inst J 1993;20:40-42.[Medline]
  4. Lancaster L.L., Mavroudis C., Rees A.H., Slater A.D., Ganzel B.L., Gray L.A. Surgical approach to atrial septal defect in female. Right thoracotomy versus sternotomy. Am Surg 1990;56:218-221.[Medline]
  5. 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]
  6. Schmid F.X., Wippermann C.F., Hake U., Mayer E., Kupferwasser I., Schranz D., Oelert H. Surgical closure of atrial septal defects via right-sided thoracotomy. Value with reference to the development of interventional closure techniques. Z Kardiol 1996;85(7):489-494.[Medline]
  7. Helps B.-A., Ross-Russel R.I., Dicks-Mireau C., Elliott M.J. Phrenic nerve damage via a right thoracotomy in older children with secundum ASD. Ann Thorac Surg 1993;56:328-330.[Abstract]
  8. Todd K., Rosengart T.K., Stark J.F. Repair of atrial septal defect through a right thoracotomy. Ann Thorac Surg 1993;55:1138-1140.[Abstract]
  9. Tribble C.G., Killinger W.A., Harman K., Crosby I.K., Nolan A.P., Kron I.L. Anterolateral thoracotomy as an alternative to repeat median sternotomy for replacement of the mitral valve. Ann Thorac Surg 1987;43:380-382.[Abstract]
  10. Grinda J.M., Folliguet T.A., Dervanian P., Macé L., Legault B., Neveux J.Y. Right anterolateral thoracotomy for repair of atrial septal defect. Ann Thorac Surg 1996;62:175-178.[Abstract/Free Full Text]
  11. Londe S., Sugg W.L. The challenge or reoperation in cardiac surgery. Ann Thorac Surg 1984;37:273.[Abstract]
  12. Brutel de la Riviere A., Brom G.H.M., Brom A.G. Horizontal submammary skin incision for median sternotomy. Ann Thorac Surg 1981;32:101-104.[Abstract]
  13. Laks H., Hammond G.L. A cosmetically acceptable incision for the median sternotomy. J Thorac Cardiovasc Surg 1980;79:146-149.[Abstract]
  14. Black M.D., Freedom R.M. Minimally invasive repair of atrial septal defects. Ann Thorac Surg 1998;65(3):765-767.[Abstract/Free Full Text]



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