IJTCVS 2004; 20: 129–131 Brief report
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Atrial septal defect closure in young females by an anterolateral thoracotomy Srinivasan Muralidharan, M.Ch, Viswanathan Anup Krishnan, M.Ch, Shashi Kumar Varma, M.Ch, Muthialu Nagarajan, MS G Kuppuswamy Naidu Memorial Hospital, Coimbatore 641 037, India Abstract There are many approaches for closure of atrial septal defects. We used an anterolateral thoracotomy for closure of atrial septal defects in 140 young females for cosmetic considerations. The technique was relatively simple and no extra equipment was needed. The outcome was excellent however breast development will need to be followed up as many of these were pre pubertal children. (Ind J Thorac Cardiovasc Surg, 2004; 20: 129–131) Key words: Atrial septal defect closure, Anterolateral thoracotomy for closure of atrial septal defect Introduction Atrial Septal Defect Closure surgically today carries almost no risk, consequently even asymptomatic patients are being operated. In young girls with this condition closure of the defect through a median sternotomy or lower mini sternotomy,1 often leaves an unsightly scar which is cosmetically unacceptable. Modifications to avoid this scar lead to the use of a right anterolateral thoracotomy, 2,3,4 a posterolateral thoracotomy,5,6 or a transxiphoid approach without a sternotomy7. We elected to use a right anterolateral thoracotomy approach as there was no need for additional equipment, it was safe and the cosmetic outcome was good. Our results using this technique in 140 young female patients operated upon between 1996 and February 2003 are being reported. Patients and Methods Between January 1996 and February 2003 140 young female patients underwent Atrial Septal Defect Closure Address for correspondence: Dr. S. Muralidharan Chief Cardio-thoracic Surgeon Department of Cardio-thoracic Surgery P.O. Box 6327 G Kuppuswamy Naidu Memorial Hospital Coimbatore 641037, India Tel.: 91 - 422 - 2211 000 Fax: 91 - 422 - 2213 509 E-mail :
[email protected] @IJTCVS097091342030904/035 Received - 23/09/03; Review Completed - 12/11/03; Accepted - 11/05/04.
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via a right antero lateral thoracotomy approach. All had Ostium Secundum Defects except for two who had a sinus venosus defect. The mean age was 10.85 yrs and this varied from 2 to 24 yrs. The mean weight and body surface area was 21.25 Kgs and 0.9 m2 respectively. The patients were positioned with the right side tilted by 45 degrees with a sandbag under the shoulder. The right arm was flexed at the elbow and suspended from the frame at the table top by the wrist. The skin incision was placed well below the 5th intercostal space when the breast was not developed or below the breast when this was present. The pleural cavity was however entered through the 4th intercostal space reflecting the breast and stretching the incision posteriorly. The lung was packed away and the pericardium opened anterior to the phrenic nerve and hitched up. The thymus if large was removed. Cardiopulmonary bypass was instituted using conventional cannulae, Aortic cannulation was sometimes demanding.8 Mild hypothermia and cold crystalloid cardioplegic arrest was used in all cases except in one where a short period of total circulatory arrest, under profound hypothermia was needed to circumvent venous drainage problems. An angled aortic clamp was placed in a caudal fashion with the handle placed towards the foot reducing the equipment clutter at the head end (Fig. 1). The Atrial Septal Defect was closed directly, with a pericardial patch or dacron patch as indicated. Deairing or defibrillation was not a problem. The right pleura was drained and invariably Bupivacaine 0.25% (Astra Zeneca Pharma India Ltd) was infiltrated in three intercostal spaces for pain relief.
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Fig. 1. The atrial septal defect is seen. Note the direction of the aortic cross clamp.
Extubation was either on the table or shortly after transfer to the Intensive care. Results The mean operating time was 120.5 mts (75-240 mts), the mean Cardiopulmonary Bypass time 40.83 mts, (20-168 mts) the mean Aortic Cross Clamp time was 20.3 mts (6-49 mts). Aortic cannulation was successful in all cases. Mean blood loss was 155.6 ml. (20-310 ml) and mean hospital stay 9.17 days (7 to 12 days). All patients were in NYHA Class I. There was no mortality. One patient was reexplored for bleeding and this was due to Right Internal Mammary Artery injury. One patient had wound dehiscence and a right sided empyema which needed decortication. There were no late complications. Since many were very young we are not able to report on breast development as yet as the follow-up period is too short. Discussions Anterolateral thoracotomy is one of the most frequently used incision for closure of Atrial Septal Defect in young female patients. This approach yields excellent visualisation and cosmesis for adult female patients. It is difficult to determine an adequate skin incision in prepubertal patients because the quantum of breast development cannot be predicted easily. Long term follow-ups do mention decreased nipple sensitivity and anaesthesia in the lower part of the breast9. Since most of our patients were very young and symptomatic we could not wait for breast development prior to surgery. Our incision was quite low down and we believe that breast development has not been compromised (Fig. 2). Since we have had hardly any
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Fig. 2. The final result. Note the location of scar.
complication we feel this approach can be used for other procedures like mitral and tricuspid valve surgery, besides closure of simple Ventricular Septal Defects when cosmesis was a consideration. Femoral or Iliac artery cannulation was not required in our series. The recovery time has been shorter and smoother. In the short term follow up breast development has not been compromised in these young children with the low incision practised by us. We have not used the midline mini sternotomy approach described by Komai and associates nor the transxiphoid approach described by Barbero–Marcial and associates as we felt they were quite demanding. The posterolateral thoracotomy approach was not favoured by us even though breast development was purportedly not compromised. Conclusions Anterolateral thoracotomy for Atrial Septal Defect Closure in young female patients has been the cosmetic
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procedure of choice in our series. With no extra equipment, this procedure can be accomplished safely with no increased risk. Long term follow-up will determine whether breast development is compromised inspite of our low incision. References 1. Komai H, Naito Y, Fujiwara K, et al. Lower midline skin incision and minimal sternotomy–a more cosmetic challenge for pediatric cardiac surgery. Cardiol Young 1996; 6: 76–79. 2. Massetti M, Babatasi G, Rossi A, et al. Operation for atrial septal defect through a right anterolateral thoracotomy current outcome. Ann Thorac surg 1996; 62: 1100–03. 3. Dabritz S, Sachwah J, et al. Closure of atrial septal defects via limited right anterolateral thoracotomy as a minimal invasive approach in female patients. Eur J Cardiothora Surg 1999; Oct. 16(4) 489–90.
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4. Rosengart TK, Stark JF. Repair of atrial septal defect through a right thoracotomy. Ann Thorac Surg 1993; 55: 1138–40. 5. Shivaprakasha K, Murthy KS, Coelho R, et al. Role of limited posterior thoracotomy for open heart surgery in the current era. Ann Thorac Surg 1999; 68: 2310–13. 6. Naoki Yoshimura, Masahiro Yamaguahi, Yoshihiro Oshima, et al. Repair of atrial septal defect through a right posterolateral thoracotomy; A cosmetic approach for female patients. Ann Thorac Surg 2001; 72: 2103–05. 7. Barbero–Marcial M, Tanamati C, Jatene MB, Atik E. Jatene AD, Trans xiphoid approach without median sternotomy for repair of atrial septal defects. Ann Thorac Surg 1998; 65: 771–74. 8. John W. Kirklin, Brian G Barratt Boyes. Cardiac Surgery 2nd Edition, Churchill Livingstone PP 477. 9. Cherup LL, Siewers RD, Futrell JW. Breast and pectoral muscle maldevelopment after anterolateral and posterolateral thoracotomies in children. Ann Thorac Surg 1986; 41: 492–97.
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