European Journal of Cardio-thoracic Surgery 16 (Suppl. 2) (1999) S86±S88 www.elsevier.com/locate/ejcts
Port Accesse surgery for congenital heart disease q Utz Kappert, Florian M. Wagner, Vassilios Gulielmos, Mohammad Taha, Jens Schneider, Stephan Schueler* Cardiovascular Institute, University Dresden, Fetscherstrasse 76, D-01307 Dresden, Germany
Abstract Objectives: Minimally invasive surgical techniques have been introduced into cardiac surgery in order to avoid median sternotomy related complications. Surgical trauma to the patient can be signi®cantly reduced without compromising the safety. In addition, a small lateral chest incision results in improved cosmesis, especially in female patients. Methods: Thirteen patients (median age 39 ^ 14 years, ranged from 17± 61 years) with atrial septal defect were treated with a minimally invasive surgical method using a modi®ed Port Accesse technique. In all patients access to the heart was achieved via a small (4±8 cm) right lateral chest incision in the 4th intercostal space. In these patients the selection of the Port Accesse system was used for cardiopulmonary bypass via the femoral vessel and for the application of cardioplegic solution. Results: No deaths or intraoperative complications were observed in any of the patients. The postoperative course was uneventful and only minor complications were observed postoperatively. The median hospital stay was 8:0 ^ 1 days (median ^ SEM). Conclusion: This minimally invasive surgical technique for the treatment of atrial septal defects represent a safe alternative to conventional treatment of ASD using median sternotomy and standard cardiopulmonary bypass. The exposure of the right atrium via the 4th intercostal space is ideal and can be performed with excellent cosmetic results. q 1999 Elsevier Science B.V. All rights reserved. Keywords: Atrial septal defect; Minimally invasive cardiac surgery; Port Accesse system
1. Introduction After the introduction of various minimally invasive surgical (MIS) techniques for the treatment of coronary artery disease (CAD) and valvular heart disease a limited number of reports for the treatment of congenital heart disease can be found [1±6]. The present paper represents our experience between January 1998 and February 1999 with a carefully selected patients group. After the ®rst clinical European trial with Port Accesse surgery [7±8], this technique was applied for the treatment of CAD at our institution in March 1997. 2. Methods Between January 1998 and February 1999, 13 patients with atrial septal defects were referred in this study for minimally invasive surgical treatment. Ten patients with q Presented at the International Symposium `Present State of Minimally Invasive Cardiac Surgery ± Meet The Experts', Dresden, Germany, December 3±5, 1998. * Corresponding author. Tel.: 149-351-450-1801; fax: 149-351-4501802. E-mail address:
[email protected] (S. Schueler)
ASD II, two patient with ASD I and mitral valve insuf®ciency, one patient suffered from partial av-canal. The patients age ranged between 20 and 60 years (median 37 ^ 13 years). There were nine female and four male patients. Small or calci®ed femoral vessels, overweight (more than 130% BMI), impaired left ventricular function (LVEF , 35%), other cardiac diseases (CAD etc.) were used as exclusion criteria [9]. Before surgery, Doppler ultrasound was performed to rule out peripheral vascular disease of the pelvic and femoral vessels. Cardiac catheterization revealed a mean left ventricular ejection fraction of 67% (median 67 ^ 12:3%), with no evidence of coronary artery disease in any patient. In addition, transesophageal echocardiography demonstrated normal aortic valve functioning and the absence of major aortic atherosclerosis. After induction of anesthesia the patient was placed in supine position with a rubber cushion under the right shoulder in order to elevate the right half of the body. The right arm was positioned to the body dorsally to the posterior axillary line. The patient was draped with the right chest wall accessible as well as the sternum, in case the patient needed to be converted to median sternotomy. Both groins were prepared for surgical access. The right groin was
1010-7940/99/$ - see front matter q 1999 Elsevier Science B.V. All rights reserved. PII: S10 10-7940(99)0027 8-X
U. Kappert et al. / European Journal of Cardio-thoracic Surgery 16 (Suppl. 2) (1999) S86±S88
dissected for arterial and venous cannulation for institution of CPB. A 1-cm skin incision right above the 4th rib in the submammarian groove was made for insertion of the thoracoscope in the 4th intercostal space after retracting the breast cranially. Thoracoscopical inspection of the operative ®eld was made to con®rm the correctness of the chest incision and the skin incision was enlarged up to 6±8 cm. The pericardium was opened longitudinally about 2 cm medially to the right phrenic nerve. Stay sutures were used to secure the pericardium to the skin margins. After systemic heparinisation the femoral vessels were cannulated for institution of CPB. A 23 F-Y-shaped femoral arterial cannula was used together with a 28 F-venous cannula (Port-Accesse Technique, Heartport, Inc., Redwood City, CA). Before initiation of cardiopulmonary bypass the endoclamp was positioned in the ascending aorta 2±3 cm above the aortic valve. The correct position was monitored using transesophageal echocardiography (TEE). The right radial artery pressure was continuously monitored in order to identify occlusion of the brachiocephalic trunk in case of balloon migration. On bypass the endoclamp was in¯ated thus occluding the ascending aorta. Balloon pressure was continuously monitored with a normal range from 280 to 340 mmHg. Cold antegrade crystalloid cardioplegic solution was administered and aortic root venting was applied during cardioplegic arrest. The aortic root pressure was monitored simultaneously. Neither an endosinus catheter nor an endopulmonary vent catheter was used. During cardioplegic arrest the venous drainage catheter was drawn back from the right atrium into the inferior cava vein (ICV). The ICV was occluded using an umbilical tape. After incising the right atrium the superior cava vein (SCV) was intubated with a low pressure ventilation cuff tube connected to the reservoir of the heart lung machine (HLM) for additional venous drainage of the upper body. The low pressure cuff of the ventilation tube was in¯ated (15 cc), thus enabling total drainage of the SCV. The right atrium was opened through an oblique incision. Four stitches were placed to retract the atrial wall. Atrial anatomy was carefully studied. In four patients (30.7%) a direct closure of the ASD was performed using a continuous 4-0 polypropylene suture. A bovine pericardial patch was used in nine (69.2%) patients. Simultaneously, in one (7.7%) a mitral valve replacement, in one further case (7.7%) a mitral valve repair and in one case (7.7%) a resection of atrial membrane was performed. Before the sutures were tied, careful deairing was performed, the endoaortic balloon was de¯ated, and cardiac reperfusion was started. The low pressure cuff was de¯ated and the ventilation tube was removed from the right atrium. As the right atrium was closed, the snare of the ICV was released and the femoral venous drainage catheter was placed back into the right atrium for better drainage. During
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reperfusion routinely used temporary pacemaker wires were placed. After rewarming the patient was weaned from CPB. Arterial and venous cannulae were removed and protamin was administered. A single soft thoracic catheter (Soft thoracic catheter, Cleve Gmbh, Germany) was left in place and both incisions were closed in layers. 3. Results There were no deaths. None of the patients needed inotropic support. No conversion to median sternotomy was necessary in any patient. Two patients received reexploration for bleeding using the same incision. The operative technique could be carried out with excellent view and without dif®culty in all patients. Table 1 shows duration of operation, CPB time, crossclamp time, intensive care unit stay, and hospitalization of all procedures. The hospital stay was smooth in all patients and there were no wound infections or neurological de®cits. Transthoracic echocardiography did not show any residual shunt and revealed good left ventricular function. Complains about surgical pain were minimal, and postoperative cosmesis was excellent (Fig. 1). Pain assessment revealed pain in one patient, who claimed to have some pain during body exercise, combined with an irritation of the proximal wound end. At present all patients are alive and well. 4. Comment The various new techniques for a less invasive treatment of CAD and mitral valve disease have gained signi®cant Table 1 Patients, postoperative data and complications a Data
Patients
Age (years) Sex Weight (kg) Height (cm) LVEF (%)
37.2 ^ 13.7 (20±60) Male (n 4), female (n 9) 67 ^ 6.3 (53±75) 168 ^ 7.3 (178±153) 67.8 ^ 13.8 (44±90)
Operation time (min) Cross clamp (min) CPB time (min) ICU stay (h) Hospitalization (day)
199 ^ 69.3 76 ^ 22.9 132 ^ 33.3 18 ^ 1.1 8^1
Death LCO Conversion Bleeding
0 0 0 2 (15.4%)
a PA-group, Port Accesse-group; HF-group, hypothermic ®brillation group; LVEF, left ventricular ejection fraction; CPB, cardiopulmonary bypass; ICU, intensive care unit; LCO, low cardiac output.
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There was no disadvantage compared to standard surgery and the convalescence and cosmesis was excellent. To improve the cosmetic outcome alternative incisions have been proposed. Levinson et al. [4] describe the use of a subxiphoidal approach. The right lateral approach, however, allows the treatment of other cardiac diseases such as cardiac tumors or mitral valve diseases. The experience with the latter technique encouraged us to extend this technique by the application of a complete robotic guided system. This may allow further reduction of the surgical trauma, thus improving the convalescence of the patient. References
Fig. 1. Cosmetic outcome after a minimally invasive surgical closure of an ASD using a small skin incision right above the 4th rib in the submammarian groove.
acceptance in the community of cardiac surgeons. Improved convalescence and a better cosmesis were major goals. The application of these techniques for the treatment of congenital heart disease is in process and a number of case reports have been published [1±6]. Our experience with these patients groups is based on 13 patients and represent a part of a program for MIS techniques including 450 patients. After an initial trial with Port Accesse systems in CAD patients, this approach was applied in patients with congenital heart disease.
[1] Chang CH, Pyng LJ, Chu JJ, Liu HP, Tsai FC. Video-assisted cardiac surgery and closure of atrial septal defect. Ann Thorac Surg 1996;62:697±701. [2] Grindja JM, Folloguet TA, Dervanian P, Mace L, Legault B, Neveaux JY. Right anterolateral thoracotomy for repair of atrial septal defect. Ann Thorac Surg 1996;62(1):175±178. [3] Izzat MB, Yim ACP. Minimally invasive direct atrial septal defect closure. Ann Thorac Surg 1997;63(6):1831±1834. [4] Levinson MM, Fonger J. Minimally invasive atrial septal defect closure using the subxiphoidal approach. Presented at: First World Congress of Minimally Invasive Cardiac Surgery, Palais deÁ Paris, France, May 1997. Heart Surg Forum 1998;1:132±138. [5] Reichenspurner H, Boehm DH, Welz A, Schulze C, Zwissler B, Reichart B. 3 D video- and robot-assisted minimally invasive ASD closure using the Port Accesse technique. Presented at: The Second World Congress of the International Society for Minimally Invasive Cardiac Surgery, Minneapolis, Minnesota, June 1998. Heart Surg Forum 1998;1:104-106. [6] Shetty F, Dixit MD, Gan MD, Das MB, Harish R, Kapoor L, Surendranath K. Video-assisted closure of atrial septal defect. Ann Thorac Surg 1996;62:940. [7] Reichenspurner H, Gulielmos V, Daniel WG, Schueler S. Minimally invasive coronary artery bypass surgery (CABS) with the safety of cardiopulmonary bypass and cardioplegic arrest. New Engl J Med 1997;336:67±68. [8] Reichenspurner H, Gulielmos V, Wunderlich J, Dangel M, Wagner FM, Karbalai P, SchroÈder C, Pompili M, Stevens J, SchuÈler S. Port Accesse coronary artery surgery with the use of cardiopulmonary bypass and cardioplegic arrest ± clinical experience with 42 cases. Ann Thorac Surg 1997;65:413±419. [9] Gulielmos V, Knaut M, Cichon R, Brandt M, Jost Th, Matschke K, Schueler St. Minimally invasive surgical treatment of coronary artery multivessel disease. Ann Thorac Surg 1998;66:1018±1021.
