Correction of congenital heart defects and mitral valve operations using limited anterolateral thoracotomy

Median sternotomy, which generally is used as a standard access for atrial septal defect (ASD) and mitral valve operations, has a significant risk of postoperative instability/osteomyelitis of the sternum. Moreover, especially in young women, the resulting large scar is a poor cosmetic result that may have adverse psychological consequences. Our presentation suggests that these difficulties may be avoided by the use of a less invasive approach consisting of a limited anterolateral thoracotomy with standard cannulation.

From June 1997 until December 1999, 13 women, mean age 31.9 +/- 9.2 years, with atrial septum defect (n = 8), sinus venosus defect with partial anomalous pulmonary venous connection (n = 1), left atrial myxoma (n =1) or mitral valve regurgitation (n = 3), were scheduled for less invasive operation. In all cases a double lumen tube was used for ventilation. After a submammarian skin incision of about 10 cm a limited anterolateral thoracotomy was performed in the fifth right intercostal space. For cannulation of the ascending aorta a trochar cannula was used. Both caval veins were cannulated by angled vena cava catheters. Standard cardiopulmonary bypass was established using normothermia in all patients undergoing operations with correction of congenital heart defects and mild hypothermia (32 degrees C) in the three patients undergoing mitral valve operation. Surgery was performed in cardioplegic arrest using Bretschneider's solution. All corrections of congenital heart defects were performed by Goretex patches. Mitral valve reconstruction was carried out in two patients, and one patient underwent mitral valve replacement.

No complications occurred in any of the 13 patients peri- or postoperatively. Total time of operation was 211.9 +/- 36.0 minutes, the perfusion time was 77.0 +/- 25.8 minutes, and the aortic cross-clamp time was 51.8 +/- 21.9 minutes. Mean stay in ICU was 1.2 +/- 0.4 days (total hospital stay: 7.8 +/- 2.2 days). Postoperative thoracic x-ray and cardiac echocardiography/dopplersonography revealed no pathological findings in any patients.

Atrial septal defect operations, including partial anomalous pulmonary venous connection, left atrial myxoma and mitral valve operations, can be performed safely and effectively using a limited anterolateral thoracotomy and standard cannulation technique with excellent cosmetic results.