Minimally invasive midaxillary muscle sparing thoracotomy for atrial septal defect closure in prepubescent patients
Christian Schreiber1, Sabine Bleiziffer, Martin Kostolny
1Clinic of Cardiovascular Surgery, Munich, Germany. schreiber@dhm.mhn.de
Insights
The midaxillary approach offers a safe, cosmetic alternative for pediatric atrial septal defect repair, avoiding muscle damage and improving outcomes in young patients.
Area of Science:
- Pediatric Cardiac Surgery
- Minimally Invasive Cardiac Surgery
- Thoracic Surgery
Background:
- Traditional thoracotomies for pediatric cardiac lesions can lead to impaired breast development in females and significant muscle group damage.
- The midaxillary approach presents a potential alternative to mitigate these adverse effects and enhance cosmetic outcomes.
Purpose of the Study:
- To evaluate the safety and efficacy of the midaxillary approach for correcting atrial septal defects in prepubescent children.
- To assess the cosmetic benefits and potential complications associated with this surgical technique.
Main Methods:
- A horizontal midaxillary incision was utilized, followed by mobilization of the latissimus dorsi and splitting of the serratus anterior muscles.
- Direct cannulation of the aorta and caval veins was performed, with atrial septal defect closure during electrically induced ventricular fibrillation.
- The technique was applied to prepubescent patients with atrial septal defects not suitable for catheter closure.
Main Results:
- The midaxillary approach was successfully applied in 36 prepubescent patients (30 girls, 6 boys) without requiring conversion to other methods.
- Mean cardiopulmonary bypass and ventricular fibrillation times were 31 and 21.2 minutes, respectively, with skin incisions ranging from 4.5 to 6.0 cm.
- No phrenic nerve damage was observed, and 28 patients received a patch for defect closure.
Conclusions:
- The midaxillary approach is a safe and effective alternative to lateral thoracotomies for pediatric atrial septal defect closure, offering improved cosmetic results.
- The study suggests limiting its application to specific patient groups (prepubescent) and avoiding more complex cardiac lesions or younger children.
- Further research into variations of cosmetically favorable partial sternotomy techniques is recommended for more complex cases or younger pediatric patients.
Background:
Partial sternotomy, as well as posterolateral or anterolateral right-sided thoracotomy, are used for correction of selected cardiac lesions in children. However, in female patients impaired breast development after an anterolateral thoracotomy is reported, and for both the posterolateral and the anterolateral approach, partial transection of large muscle groups is required. The midaxillary approach may help to avoid these side effects and improve the cosmetic result.
Methods:
Beginning in April 2003, our institutional policy changed toward a midaxillary approach in prepubescent patients with an atrial septal defect, in whom criteria for catheter closure were not fulfilled. Thoracotomy was performed after a horizontal midaxillary incision and mobilization of the latissimus dorsi and splitting of the serratus anterior. Aorta and caval veins were cannulated directly. The atrial septal defect was closed during electrically induced fibrillation of the heart.
Results:
Until August 2004, this technique was applied in 36 patients (30 girls, 6 boys), with no need for conversions to another approach. Mean patient age was 6.9 +/- 2.6 years (range, 4 to 14 years), with a mean weight of 23.8 +/- 11.2 kg (range, 15 to 69 kg). Skin incision ranged from 4.5 to 6.0 cm. Mean cardiopulmonary bypass time was 31 +/- 13 minutes (range, 13 to 73 minutes), with a mean ventricular fibrillation time of 21.2 +/- 7.4 minutes (range, 10 to 42 minutes). In 28 of 36 patients a patch was used. No phrenic nerve damage occurred.
Conclusions:
The midaxillary approach is a safe alternative to lateral thoracotomies frequently used in cardiac surgery for atrial septal defect closure. It helps to improve the cosmetic result in the prepubescent patient group. We believe that its application should not be expanded to include repair of more complex lesions or to patients below the age of 3 to 4 years. For these, variations of cosmetically favorable partial sternotomy techniques should be applied.
