Minimally invasive approaches to atrial septal defect closure
2022; Elsevier BV; Volume: 14; Linguagem: Inglês
10.1016/j.xjtc.2022.02.037
ISSN2666-2507
AutoresIgor E. Konstantinov, Yasuhiro Kotani, Edward Buratto, Antonia Schulz, Yaroslav Ivanov,
Tópico(s)Cardiac Arrest and Resuscitation
ResumoCentral MessageMinimally invasive closure of atrial septal defects can be safely achieved with a range of techniques. Currently, partial sternotomy and right axillary thoracotomy are the most widely used approaches. Minimally invasive closure of atrial septal defects can be safely achieved with a range of techniques. Currently, partial sternotomy and right axillary thoracotomy are the most widely used approaches. Percutaneous device closure is currently the preferred treatment for children with secundum atrial septal defects (ASDs).1Bennhagen R.G. McLaughlin P. Benson L.N. Contemporary management of children with atrial septal defects: a focus on transcatheter closure.Am J Cardiovasc Drugs. 2001; 1: 445-454Crossref PubMed Scopus (10) Google Scholar However, there is a group of patients who are not suitable for device closure, due to insufficient margins or the large size of the defect, in whom surgical closure is required. Furthermore, there is an evolving understanding of significant adverse reactions to septal occlusion devices due to nickel allergy. In some patients, surgical removal may be required to alleviate symptoms attributed to nickel allergy.2Sharma V. DeShazo R.A. Skidmore C.R. Glotzbach J.P. Koliopoulou A. Javan H. et al.Surgical explantation of atrial septal closure devices for refractory nickel allergy symptoms.J Thorac Cardiovasc Surg. 2020; 160: 502-509Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 3Naimo P.S. Konstantinov I.E. Commentary: a nickel for your thoughts: an overlooked allergen in implantable devices?.J Thorac Cardiovasc Surg. 2020; 160: 512-514Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 4Wertman B. Azarbal B. Riedl M. Tobis J. Adverse events associated with nickel allergy in patients undergoing percutaneous atrial septal defect or patent foramen ovale closure.J Am Coll Cardiol. 2006; 47: 1226-1227Crossref PubMed Scopus (91) Google Scholar, 5Verma D.R. Khan M.F. Tandar A. Rajasekaran N.S. Neuharth R. Patel A.N. et al.Nickel elution properties of contemporary interatrial shunt closure devices.J Invasive Cardiol. 2017; 27: 99-104Google Scholar Although newer septal occlusion devices have been shown in vitro to have significantly lower nickel elution than the previously used devices,5Verma D.R. Khan M.F. Tandar A. Rajasekaran N.S. Neuharth R. Patel A.N. et al.Nickel elution properties of contemporary interatrial shunt closure devices.J Invasive Cardiol. 2017; 27: 99-104Google Scholar systemic allergic contact dermatitis to nickel has also been reported with these new devices.6Resor C.D. Goldminz A.M. Shekar P. Padera R. O'Gara P.T. Shah P.B. Systemic allergica contact dermatitis due to a Gore Carioform septal occlude device: a case report and literature review.JACC Case Rep. 2020; 2: 1867-1871Crossref PubMed Scopus (6) Google Scholar Given the ongoing need for surgical ASD closure in a significant proportion of patients, it would be reasonable to employ minimally invasive approaches to reduce surgical trauma and improve cosmesis. As experience with minimally invasive approaches has increased in pediatric cardiac surgery, its application has been extended from "simple" lesions such as ASD7Bichell D.P. Geva T. Bacha E.A. Mayer J.E. Jonas R.A. del Nido P.J. Minimal access approach for the repair of atrial septal defect: the initial 135 patients.Ann Thorac Surg. 2000; 70: 115-118Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar,8Konstantinov I.E. Buratto E. Atrial septal defect closure via ministernotomy in children.Heart Lung Circ. 2021; 30: e98-e100Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar to more complex lesions such as tetralogy of Fallot9Giamberti A. Mazzera E. Di Chiara L. Ferretti E. Pasquini L. Di Donato R.M. Right submammary minithoractomy for repair of congenital heart defects.Eur J Cardiothorac Surg. 2000; 18: 678-682Crossref PubMed Scopus (19) Google Scholar, 10Lee T. Weiss A.J. Williams E.E. Kiblawi F. Dong J. Nguyen K.H. The right axillary incision: a potential new standard of care for selected congenital heart surgery.Semin Thorac Cardiovasc Surg. 2018; 30: 310-316Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 11Liu Y. Zhang H. Sun H. Li S. Yan J. Su J. et al.Repair of cardiac defects through a shorter right lateral thoracotomy in children.Ann Thorac Surg. 2000; 70: 738-741Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar and mitral valve repair.12Dave H.H. Comber M. Solinger T. Bettex D. Dodge-Khatami A. Prêtre R. Mid-term results of right axillary incision for the repair of a wide range of congenital cardiac defects.Eur J Cardiothorac Surg. 2009; 35: 864-870Crossref PubMed Scopus (33) Google Scholar There appears to be a consensus that minimally invasive repair of ASD is a reasonable and safe alternative to conventional sternotomy.13Schreiber C. Bleiziffer S. Kostolny M. Hörer J. Eicken A. Holper K. et al.Minimally invasive midaxillary muscle sparing thoracotomy for atrial septal defect closure in prepubescent patients.Ann Thorac Surg. 2005; 80: 673-676Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar The improved cosmetic result is clearly the major advantage of minimally invasive surgery. This must be achieved without increase in surgical risk. The minimally invasive approaches appear to provide similarly excellent results to conventional sternotomy8Konstantinov I.E. Buratto E. Atrial septal defect closure via ministernotomy in children.Heart Lung Circ. 2021; 30: e98-e100Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,10Lee T. Weiss A.J. Williams E.E. Kiblawi F. Dong J. Nguyen K.H. The right axillary incision: a potential new standard of care for selected congenital heart surgery.Semin Thorac Cardiovasc Surg. 2018; 30: 310-316Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar,14Luo H. Wang J. Qiao C. Zhang X. Zhang W. Song L. Evaluation of different minimally invasive techniques in the surgical treatment of atrial septal defect.J Thorac Cardiovasc Surg. 2014; 148: 188-193Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar with potential benefits of decreased length of hospitalization,14Luo H. Wang J. Qiao C. Zhang X. Zhang W. Song L. Evaluation of different minimally invasive techniques in the surgical treatment of atrial septal defect.J Thorac Cardiovasc Surg. 2014; 148: 188-193Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar postoperative pain, and hospital cost.15Formigari R. Di Donato R.M. Mazzera E. Carotti A. Rinelli G. Parisi F. et al.Minimally invasive or interventional repair of atrial septal defects in children: experience in 171 cases and comparison with conventional strategies.J Am Coll Cardiol. 2001; 37: 1707-1712Crossref PubMed Scopus (74) Google Scholar In fact, it has been suggested that the minimally invasive approach should be adopted as a new "standard" for surgical ASD closure.10Lee T. Weiss A.J. Williams E.E. Kiblawi F. Dong J. Nguyen K.H. The right axillary incision: a potential new standard of care for selected congenital heart surgery.Semin Thorac Cardiovasc Surg. 2018; 30: 310-316Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar,13Schreiber C. Bleiziffer S. Kostolny M. Hörer J. Eicken A. Holper K. et al.Minimally invasive midaxillary muscle sparing thoracotomy for atrial septal defect closure in prepubescent patients.Ann Thorac Surg. 2005; 80: 673-676Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar,16Vida V.L. Tessari C. Fabozzo A. Padalino M.A. Barzon E. Zucchetta F. et al.The evolution of the right anterolateral thoracotomy technique for correction of atrial septal defects: cosmetic and functional results in prepubescent patients.Ann Thorac Surg. 2013; 95: 242-247Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar A great number of minimally invasive approaches have been described, including partial sternotomy,7Bichell D.P. Geva T. Bacha E.A. Mayer J.E. Jonas R.A. del Nido P.J. Minimal access approach for the repair of atrial septal defect: the initial 135 patients.Ann Thorac Surg. 2000; 70: 115-118Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar,8Konstantinov I.E. Buratto E. Atrial septal defect closure via ministernotomy in children.Heart Lung Circ. 2021; 30: e98-e100Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,17Black M.D. Freedom R.M. Minimally invasive repair of atrial septal defects.Ann Thorac Surg. 1998; 65: 765-767Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar,18Sebastian V.A. Guleserian K.J. Leonard S.R. Forbess J.M. Ministernotomy for repair of congenital cardiac disease.Interact Cardiovasc Thorac Surg. 2009; 9: 819-821Crossref PubMed Scopus (13) Google Scholar transxiphoid approach,19Barbero-Marcial M. Tanamati C. Jatene M.B. Atik E. Jatene A.D. Transxiphoid approach without median sternotomy for the repair of atrial septal defects.Ann Thorac Surg. 1998; 65: 771-774Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar,20van de Wal H. Cardiac surgery by transxiphoid approach without sternotomy.Eur J Cardiothorac Surg. 1998; 13: 551-554Crossref PubMed Scopus (20) Google Scholar anterolateral,16Vida V.L. Tessari C. Fabozzo A. Padalino M.A. Barzon E. Zucchetta F. et al.The evolution of the right anterolateral thoracotomy technique for correction of atrial septal defects: cosmetic and functional results in prepubescent patients.Ann Thorac Surg. 2013; 95: 242-247Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar,21Mishaly D. Ghosh P. Preisman S. Minimally invasive congenital cardiac surgery through right anterior minithoracotomy approach.Ann Thorac Surg. 2008; 85: 831-835Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar,22Grinda 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: 175-178Abstract Full Text PDF PubMed Scopus (60) Google Scholar and posterolateral23Yoshimura N. Yamaguchi M. Oshima Y. Oka S. Ootaki Y. Yoshida M. Repair of atrial septal defect through a right posterolateral thoracotomy: a cosmetic approach for female patients.Ann Thorac Surg. 2001; 72: 2103-2105Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar,24Houyel L. Petit J. Planché C. Sousa-Uva M. Roussin R. Belli E. et al.Right postero-lateral thoracotomy for open heart surgery in infants and children. Indications and results.Arch Mal Coeur Vaiss. 1999; 92 ([in French]): 641-646PubMed Google Scholar right-sided thoracotomy, right axillary approach,12Dave H.H. Comber M. Solinger T. Bettex D. Dodge-Khatami A. Prêtre R. Mid-term results of right axillary incision for the repair of a wide range of congenital cardiac defects.Eur J Cardiothorac Surg. 2009; 35: 864-870Crossref PubMed Scopus (33) Google Scholar, 13Schreiber C. Bleiziffer S. Kostolny M. Hörer J. Eicken A. Holper K. et al.Minimally invasive midaxillary muscle sparing thoracotomy for atrial septal defect closure in prepubescent patients.Ann Thorac Surg. 2005; 80: 673-676Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 14Luo H. Wang J. Qiao C. Zhang X. Zhang W. Song L. Evaluation of different minimally invasive techniques in the surgical treatment of atrial septal defect.J Thorac Cardiovasc Surg. 2014; 148: 188-193Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar,25Schreiber C. Horer J. Vogt M. Kuhn A. Libera P. Lange R. et al.The surgical anatomy and treatment of interatrial communications.Multimed Man Cardiothorac Surg. 2007; 2007 (mmcts.2006.002386)PubMed Google Scholar, 26Schreiber C. Bleiziffer S. Lange R. Midaxillary lateral thoracotomy for closure of atrial septal defects in pre-pubescent female children: reappraisal of an "old technique.".Cardiol Young. 2003; 13: 565-567Crossref PubMed Scopus (9) Google Scholar, 27Yan L. Zhou Z.-C. Li H.-P. Lin M. Wang H.-T. Zhao Z.-W. et al.Right vertical infra-axillary mini-incision for repair of simple congenital heart defects: a matched-pair analysis.Eur J Cardiothorac Surg. 2013; 43: 136-141Crossref PubMed Scopus (19) Google Scholar and video-assisted thoracoscopic surgery, albeit, the latter for adolescents and adults.28Wang F. Li M. Xu X. Yu S. Cheng Z. Deng C. et al.Totally thoracoscopic surgical closure of atrial septal defect in small children.Ann Thorac Surg. 2011; 92: 200-203Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar,29Zheng X.-X. Wang Z.-Y. Ma L.-Y. Liu H. Liu H. Qin J.-W. et al.Triport periareolar thoracoscopic surgery versus right minithoracotomy for repairing atrial septal defect in adults.Interact Cardiovasc Thorac Surg. 2021; 32: 313-318Crossref PubMed Scopus (1) Google Scholar These approaches may28Wang F. Li M. Xu X. Yu S. Cheng Z. Deng C. et al.Totally thoracoscopic surgical closure of atrial septal defect in small children.Ann Thorac Surg. 2011; 92: 200-203Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar or may not require special instrumentation.8Konstantinov I.E. Buratto E. Atrial septal defect closure via ministernotomy in children.Heart Lung Circ. 2021; 30: e98-e100Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,13Schreiber C. Bleiziffer S. Kostolny M. Hörer J. Eicken A. Holper K. et al.Minimally invasive midaxillary muscle sparing thoracotomy for atrial septal defect closure in prepubescent patients.Ann Thorac Surg. 2005; 80: 673-676Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar Reproducibility, learning curve, and transfer of surgical skills to trainees are also important aspects of minimally invasive ASD closure. In the modern era, 2 approaches appear to have gained the most widespread adoption: right thoracotomy and partial median sternotomy. Minimally invasive ASD closure through a midaxillary approach was initially reported by Schreiber and colleagues13Schreiber C. Bleiziffer S. Kostolny M. Hörer J. Eicken A. Holper K. et al.Minimally invasive midaxillary muscle sparing thoracotomy for atrial septal defect closure in prepubescent patients.Ann Thorac Surg. 2005; 80: 673-676Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar from Munich in response to unsatisfactory results from the right anterolateral thoracotomy.30Bleiziffer S. Schreiber C. Burgkart R. Regenfelder F. Kostolny M. Libera P. et al.The influence of right anterolateral thoracotomy in prepubescent female patients on late breast development and on the incidence of scoliosis.J Thorac Cardiovasc Surg. 2004; 127: 1474-1480Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar The midaxillary approach is appealing, as the area is least covered by chest wall muscles, is far away from the immature breast tissue, and provides a direct plane of vision to the atrial septum. Access may be achieved either through a transverse or vertical (Figure 1, A) midaxillary skin incision, allowing a muscle-sparing approach to the fourth intercostal space (Figure 1, B). A vertical incision is made in the pericardium and care is taken to avoid injury to the phrenic nerve (Figure 1, C). Direct vision of the aorta, superior vena cava, and right atrium is achieved with the use of soft-tissue retractors (Figure 1, D). In the majority of cases, it is possible to achieve aortic cannulation directly via the thoracotomy (Figure 1, E). However, when difficulties in cannulation occur via this approach, they can be difficult to manage due to the limited space and access.31Naimo P.S. Konstantinov I.E. Small incisions for small children: is right lateral thoracotomy a right approach in open heart surgery in infants?.Heart Lung Circ. 2016; 25: 104-106Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar As such, surgeons need to be prepared for alternative sites of arterial cannulation, such as the femoral artery. However, a body weight of less than 10 to 15 kg12Dave H.H. Comber M. Solinger T. Bettex D. Dodge-Khatami A. Prêtre R. Mid-term results of right axillary incision for the repair of a wide range of congenital cardiac defects.Eur J Cardiothorac Surg. 2009; 35: 864-870Crossref PubMed Scopus (33) Google Scholar,32Vida V.L. Tessari C. Putzu A. Tiberio I. Guariento A. Gallo M. et al.The peripheral cannulation technique in minimally invasive congenital cardiac surgery.Int J Artif Organs. 2016; 39: 300-303Crossref PubMed Scopus (4) Google Scholar is generally considered to be a relative contraindication to femoral artery cannulation. The vertical axillary incision is hidden by the adducted arm, providing excellent cosmesis (Figure 1, F). Myocardial protection may be achieved by either fibrillatory arrest or aortic crossclamping and cardioplegic arrest. Some institutions prefer fibrillatory arrest, however, it is crucial that the surgeon is extremely vigilant in ensuring that the fibrillation pads constantly maintain contact with myocardium and that the fibrillatory arrest is continuously assessed by electro and echocardiography.12Dave H.H. Comber M. Solinger T. Bettex D. Dodge-Khatami A. Prêtre R. Mid-term results of right axillary incision for the repair of a wide range of congenital cardiac defects.Eur J Cardiothorac Surg. 2009; 35: 864-870Crossref PubMed Scopus (33) Google Scholar Inadvertent defibrillation and ejection of air can result in massive air embolism and catastrophic neurologic complications.12Dave H.H. Comber M. Solinger T. Bettex D. Dodge-Khatami A. Prêtre R. Mid-term results of right axillary incision for the repair of a wide range of congenital cardiac defects.Eur J Cardiothorac Surg. 2009; 35: 864-870Crossref PubMed Scopus (33) Google Scholar This can be avoided by aortic crossclamping and cardioplegic arrest, which can be achieved directly via the thoracotomy (Figure 1, E). The result of surgical ASD closure must be nothing but perfect. Thus, we would always perform aortic crossclamping to eliminate any risk of air embolization. This technique has been used in 101 children in Okayama University Hospital without any mortality, morbidity or conversion to full thoracotomy. Schreiber and colleagues13Schreiber C. Bleiziffer S. Kostolny M. Hörer J. Eicken A. Holper K. et al.Minimally invasive midaxillary muscle sparing thoracotomy for atrial septal defect closure in prepubescent patients.Ann Thorac Surg. 2005; 80: 673-676Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar reported 36 patients who had minimally invasive ASD closure through the right midaxillary approach with excellent cosmetic outcomes. Nevertheless, they recommended restricting the approach to patients older than 3 or 4 years.13Schreiber C. Bleiziffer S. Kostolny M. Hörer J. Eicken A. Holper K. et al.Minimally invasive midaxillary muscle sparing thoracotomy for atrial septal defect closure in prepubescent patients.Ann Thorac Surg. 2005; 80: 673-676Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar Another series by Dave and colleagues12Dave H.H. Comber M. Solinger T. Bettex D. Dodge-Khatami A. Prêtre R. Mid-term results of right axillary incision for the repair of a wide range of congenital cardiac defects.Eur J Cardiothorac Surg. 2009; 35: 864-870Crossref PubMed Scopus (33) Google Scholar demonstrated that the midaxillary approach could be used not only for ASD closure, but also be expanded to more complex operations. Interestingly, in their series the youngest of their 62 patients undergoing ASD closure was 4.5 months and the minimum weight was 3.8 kg. Since then, there have been a number of reports of midaxillary approach for the minimally invasive ASD closure,10Lee T. Weiss A.J. Williams E.E. Kiblawi F. Dong J. Nguyen K.H. The right axillary incision: a potential new standard of care for selected congenital heart surgery.Semin Thorac Cardiovasc Surg. 2018; 30: 310-316Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar,14Luo H. Wang J. Qiao C. Zhang X. Zhang W. Song L. Evaluation of different minimally invasive techniques in the surgical treatment of atrial septal defect.J Thorac Cardiovasc Surg. 2014; 148: 188-193Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar,27Yan L. Zhou Z.-C. Li H.-P. Lin M. Wang H.-T. Zhao Z.-W. et al.Right vertical infra-axillary mini-incision for repair of simple congenital heart defects: a matched-pair analysis.Eur J Cardiothorac Surg. 2013; 43: 136-141Crossref PubMed Scopus (19) Google Scholar including one large series of 244 consecutive patients.10Lee T. Weiss A.J. Williams E.E. Kiblawi F. Dong J. Nguyen K.H. The right axillary incision: a potential new standard of care for selected congenital heart surgery.Semin Thorac Cardiovasc Surg. 2018; 30: 310-316Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar While similar access can be achieved via a right anterolateral thoracotomy,16Vida V.L. Tessari C. Fabozzo A. Padalino M.A. Barzon E. Zucchetta F. et al.The evolution of the right anterolateral thoracotomy technique for correction of atrial septal defects: cosmetic and functional results in prepubescent patients.Ann Thorac Surg. 2013; 95: 242-247Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar,21Mishaly D. Ghosh P. Preisman S. Minimally invasive congenital cardiac surgery through right anterior minithoracotomy approach.Ann Thorac Surg. 2008; 85: 831-835Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar,22Grinda 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: 175-178Abstract Full Text PDF PubMed Scopus (60) Google Scholar some cosmetically undesirable outcomes have been reported.30Bleiziffer S. Schreiber C. Burgkart R. Regenfelder F. Kostolny M. Libera P. et al.The influence of right anterolateral thoracotomy in prepubescent female patients on late breast development and on the incidence of scoliosis.J Thorac Cardiovasc Surg. 2004; 127: 1474-1480Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar,33Isik O. Ayik M.F. Akyuz M. Daylan A. Atay Y. Right anterolateral thoracotomy in the repair of atrial septal defect: effect on breast development: thoracotomy effect on breast.J Card Surg. 2015; 30: 714-718Crossref PubMed Scopus (5) Google Scholar Impaired breast development is of concern, as it is challenging to determine the appropriate length and position of the incision in a child with respect to the immature breast tissue. According to Bleiziffer and colleagues30Bleiziffer S. Schreiber C. Burgkart R. Regenfelder F. Kostolny M. Libera P. et al.The influence of right anterolateral thoracotomy in prepubescent female patients on late breast development and on the incidence of scoliosis.J Thorac Cardiovasc Surg. 2004; 127: 1474-1480Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar right breast asymmetry was reported in 61% of female patients who underwent ASD closure via right anterolateral thoracotomy before onset of puberty compared with no such events in standard full median sternotomy group. As a balancing argument, they reported that 76% of patients in the thoracotomy group perceived their cosmetic results as excellent in contrast to 39% of patients in standard full median sternotomy group. Similarly, Isik and colleagues33Isik O. Ayik M.F. Akyuz M. Daylan A. Atay Y. Right anterolateral thoracotomy in the repair of atrial septal defect: effect on breast development: thoracotomy effect on breast.J Card Surg. 2015; 30: 714-718Crossref PubMed Scopus (5) Google Scholar reported breast asymmetry occurrence in 60% and mild sensory deficit in the mammary area in 16% of women who underwent ASD closure in prepubertal age via anterolateral thoracotomy. Clearly, the anterolateral thoracotomy approach should be used cautiously, if at all, in prepubertal female patients. A limited midline sternotomy incision is an alternative minimally invasive approach for ASD closure. The patient is positioned and draped as for conventional midline sternotomy. A limited skin incision is placed over the inferior third of the sternum, and a limited sternotomy is performed (Figure 2, A). Cannulation is achieved directly and facilitated by initial placement of a right atrial purse-string suture to retract the right atrial appendage and expose the aorta (Figure 2, B). Superior vena cava cannulation can be simplified by using a malleable cannula inserted via the right atrial appendage (Figure 2, C). Standard placement of the inferior vena cava and cardioplegia cannulae can be achieved on cardiopulmonary bypass (Figure 2, D). A conventional right atriotomy is performed, allowing the ASD to be closed. With experience, the length of the incision can be decreased to only 3 to 4 cm (Figure 2, E). This technique has been performed in the Royal Children's Hospital in Melbourne in 77 children without any mortality, morbidity, or conversion to full sternotomy as previously reported.8Konstantinov I.E. Buratto E. Atrial septal defect closure via ministernotomy in children.Heart Lung Circ. 2021; 30: e98-e100Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Advantages of the partial sternotomy may include short learning curve,8Konstantinov I.E. Buratto E. Atrial septal defect closure via ministernotomy in children.Heart Lung Circ. 2021; 30: e98-e100Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar and same,8Konstantinov I.E. Buratto E. Atrial septal defect closure via ministernotomy in children.Heart Lung Circ. 2021; 30: e98-e100Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar or very similar, surgical equipment7Bichell D.P. Geva T. Bacha E.A. Mayer J.E. Jonas R.A. del Nido P.J. Minimal access approach for the repair of atrial septal defect: the initial 135 patients.Ann Thorac Surg. 2000; 70: 115-118Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar,18Sebastian V.A. Guleserian K.J. Leonard S.R. Forbess J.M. Ministernotomy for repair of congenital cardiac disease.Interact Cardiovasc Thorac Surg. 2009; 9: 819-821Crossref PubMed Scopus (13) Google Scholar used for conventional full median sternotomy. Most importantly, there is the advantage of rapid conversion to full median sternotomy if required; however, published series from Boston7Bichell D.P. Geva T. Bacha E.A. Mayer J.E. Jonas R.A. del Nido P.J. Minimal access approach for the repair of atrial septal defect: the initial 135 patients.Ann Thorac Surg. 2000; 70: 115-118Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar and Melbourne8Konstantinov I.E. Buratto E. Atrial septal defect closure via ministernotomy in children.Heart Lung Circ. 2021; 30: e98-e100Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar have demonstrated that such conversion was not required. Importantly, no increase in operative or postoperative morbidity has been reported with ministernotomy approaches.7Bichell D.P. Geva T. Bacha E.A. Mayer J.E. Jonas R.A. del Nido P.J. Minimal access approach for the repair of atrial septal defect: the initial 135 patients.Ann Thorac Surg. 2000; 70: 115-118Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar,8Konstantinov I.E. Buratto E. Atrial septal defect closure via ministernotomy in children.Heart Lung Circ. 2021; 30: e98-e100Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Anecdotally, a greater incidence of pericardial effusion in ministernotomy group was observed; therefore, routine creation of pericardial window has been recommended.7Bichell D.P. Geva T. Bacha E.A. Mayer J.E. Jonas R.A. del Nido P.J. Minimal access approach for the repair of atrial septal defect: the initial 135 patients.Ann Thorac Surg. 2000; 70: 115-118Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar Interestingly, although it was hoped that minimally invasive surgery would result in faster postoperative recovery, this has not been observed in series reporting the results of ministernotomy ASD closure.7Bichell D.P. Geva T. Bacha E.A. Mayer J.E. Jonas R.A. del Nido P.J. Minimal access approach for the repair of atrial septal defect: the initial 135 patients.Ann Thorac Surg. 2000; 70: 115-118Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar,8Konstantinov I.E. Buratto E. Atrial septal defect closure via ministernotomy in children.Heart Lung Circ. 2021; 30: e98-e100Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,18Sebastian V.A. Guleserian K.J. Leonard S.R. Forbess J.M. Ministernotomy for repair of congenital cardiac disease.Interact Cardiovasc Thorac Surg. 2009; 9: 819-821Crossref PubMed Scopus (13) Google Scholar Although right thoracotomy and partial sternotomy are the most widely used approaches, alternative techniques have also been reported. Several groups have reported trans-xiphoid approach.19Barbero-Marcial M. Tanamati C. Jatene M.B. Atik E. Jatene A.D. Transxiphoid approach without median sternotomy for the repair of atrial septal defects.Ann Thorac Surg. 1998; 65: 771-774Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar,20van de Wal H. Cardiac surgery by transxiphoid approach without sternotomy.Eur J Cardiothorac Surg. 1998; 13: 551-554Crossref PubMed Scopus (20) Google Scholar,34Hagl C. Stock U. Haverich A. Steinhoff G. Evaluation of different minimally invasive techniques in pediatric cardiac surgery.Chest. 2001; 119: 622-627Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar However, Hagl and colleagues34Hagl C. Stock U. Haverich A. Steinhoff G. Evaluation of different minimally invasive techniques in pediatric cardiac surgery.Chest. 2001; 119: 622-627Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar found that it compromised exposure of the ascending aorta, resulting in difficulties with crossclamping, administration of cardioplegia, and especially deairing. Perhaps, the difficulties with direct aortic cannulation may be alleviated with femoral vessels cannulation; however, this approach may not be feasible in smaller patients.32Vida V.L. Tessari C. Putzu A. Tiberio I. Guariento A. Gallo M. et al.The peripheral cannulation technique in minimally invasive congenital cardiac surgery.Int J Artif Organs. 2016; 39: 300-303Crossref PubMed Scopus (4) Google Scholar Although the transxiphoid approach may provide excellent cosmetic outcomes, it appears to introduce considerable technical complexity. Video-assisted thoracoscopic ASD closure allows the surgeon to achieve anatomical visualization without excessive tissue traction and extended incisions. While its safety and efficacy has been demonstrated in a large group of adult patients,29Zheng X.-X. Wang Z.-Y. Ma L.-Y. Liu H. Liu H. Qin J.-W. et al.Triport periareolar thoracoscopic surgery versus right minithoracotomy for repairing atrial septal defect in adults.Interact Cardiovasc Thorac Surg. 2021; 32: 313-318Crossref PubMed Scopus (1) Google Scholar the experience in the pediatric patients seems to be limited.28Wang F. Li M. Xu X. Yu S. Cheng Z. Deng C. et al.Totally thoracoscopic surgical closure of atrial septal defect in small children.Ann Thorac Surg. 2011; 92: 200-203Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar,35Yu S.Q. Cai Z.J. Cheng Y.G. Duan D.W. Xu X.Z. Chen W.S. et al.Video-assisted thoracoscopic surgery for congenital heart disease.Asian Cardiovasc Thorac Ann. 2002; 10: 228-230Crossref PubMed Scopus (5) Google Scholar Although Wang and colleagues28Wang F. Li M. Xu X. Yu S. Cheng Z. Deng C. et al.Totally thoracoscopic surgical closure of atrial septal defect in small children.Ann Thorac Surg. 2011; 92: 200-203Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar demonstrated the feasibility and safety of thoracoscopic surgical ASD closure in 26 children weighing 13.5 to 22 kg, they also highlighted that this type of surgery required meticulous surgical technique with careful surgical planning. Furthermore, crossclamp times are much longer in the thoracoscopic group compared with midaxillary access group, which reflects additional complexity of this surgery.14Luo H. Wang J. Qiao C. Zhang X. Zhang W. Song L. Evaluation of different minimally invasive techniques in the surgical treatment of atrial septal defect.J Thorac Cardiovasc Surg. 2014; 148: 188-193Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar In the end, it leaves the patient with 3 port incisions on the right chest wall.14Luo H. Wang J. Qiao C. Zhang X. Zhang W. Song L. Evaluation of different minimally invasive techniques in the surgical treatment of atrial septal defect.J Thorac Cardiovasc Surg. 2014; 148: 188-193Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar Again, the need for femoral arterial cannulation imposes limitations on the size of patients who are suitable for this approach.28Wang F. Li M. Xu X. Yu S. Cheng Z. Deng C. et al.Totally thoracoscopic surgical closure of atrial septal defect in small children.Ann Thorac Surg. 2011; 92: 200-203Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Irrespective of the approach chosen (Table 1), minimally invasive ASD closure should fulfill several criteria. Most importantly, the safety must be equivalent to the traditional full sternotomy approach.36Dodge-Khatami A. Salazar J.D. Right axillary thoracotomy for transatrial repair of congenital heart defects: VSD, partial AV canal with mitral cleft, PAPVR or Warden, cor triatriatum and ASD.Op Tech Thorac Cardiovasc Surg. 2016; 20: 384-401Abstract Full Text Full Text PDF Scopus (13) Google Scholar In ASD closure, any result short of perfection is unacceptable due to the high standards of safety set by device closure and conventional surgical approach. Learning curve, the need for additional training, and equipment are important factors when implementing a minimally invasive ASD program. Finally, the cosmetic result should be considered for each patient individually, and this includes the prominence of the location, the length of the incision and finally the impact on developing breast tissue.Table 1Summary of the literature on minimally invasive ASD closure in childrenAuthorYearsNumberAge rangeWeight rangeApproachMyocardial protectionCannulation strategyDefectsThoracotomy Yoshimura et al, 200123Yoshimura N. Yamaguchi M. Oshima Y. Oka S. Ootaki Y. Yoshida M. Repair of atrial septal defect through a right posterolateral thoracotomy: a cosmetic approach for female patients.Ann Thorac Surg. 2001; 72: 2103-2105Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar1983-20001261-15 y6.9-56 kgPosterolateral thoracotomyFibrillatory arrestCentralASD Liu et al, 200011Liu Y. Zhang H. Sun H. Li S. Yan J. Su J. et al.Repair of cardiac defects through a shorter right lateral thoracotomy in children.Ann Thorac Surg. 2000; 70: 738-741Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar1994-19996834 mo to 7 y5-40 kgRight thoracotomyCrossclamp and cardioplegiaCentralASD (403), ToF (65), pAVSD (16, VSD (24), MV repair (4), cor triatriatum (2) LVOTO (2), PS (2). LA myxoma (1), LCA to LV fistula (1) Formigari et al, 200115Formigari R. Di Donato R.M. Mazzera E. Carotti A. Rinelli G. Parisi F. et al.Minimally invasive or interventional repair of atrial septal defects in children: experience in 171 cases and comparison with conventional strategies.J Am Coll Cardiol. 2001; 37: 1707-1712Crossref PubMed Scopus (74) Google Scholar1996-199871Median 5.1Median 20.5 kgRight anterolateral thoracotomyCrossclamp and cardioplegiaCentralASD Giamberti et al, 20009Giamberti A. Mazzera E. Di Chiara L. Ferretti E. Pasquini L. Di Donato R.M. Right submammary minithoractomy for repair of congenital heart defects.Eur J Cardiothorac Surg. 2000; 18: 678-682Crossref PubMed Scopus (19) Google Scholar1997-199910017 mo to 16 y9-65 kgSubmammary thoracotomyCrossclamp and cardioplegiaCentralASD (78), VSD (7), ToF (6), pAVSD (5), DCRV (2), Fontan (1). Vida et al, 201316Vida V.L. Tessari C. Fabozzo A. Padalino M.A. Barzon E. Zucchetta F. et al.The evolution of the right anterolateral thoracotomy technique for correction of atrial septal defects: cosmetic and functional results in prepubescent patients.Ann Thorac Surg. 2013; 95: 242-247Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar1998-20131418 mo to 12 y7-45 kgRight anterolateral thoracotomyFibrillatory arrestPeripheralASD Dave et al, 200912Dave H.H. Comber M. Solinger T. Bettex D. Dodge-Khatami A. Prêtre R. Mid-term results of right axillary incision for the repair of a wide range of congenital cardiac defects.Eur J Cardiothorac Surg. 2009; 35: 864-870Crossref PubMed Scopus (33) Google Scholar2001-20071230.4-19.4 y3.8-62 kgRight axillary thoracotomyFibrillatory arrestMostly peripheralASD (84), pAVSD (19), and VSD (20) Mishaly et al, 200821Mishaly D. Ghosh P. Preisman S. Minimally invasive congenital cardiac surgery through right anterior minithoracotomy approach.Ann Thorac Surg. 2008; 85: 831-835Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar2002-2007751.2-56 y8.5-118 kgAnterior thoracotomyFibrillatory arrestPeripheralASD (37), pAVSD (11), VSD (4), DCRV (1), MV repair (8), PAPVD (14) Schreiber et al, 200513Schreiber C. Bleiziffer S. Kostolny M. Hörer J. Eicken A. Holper K. et al.Minimally invasive midaxillary muscle sparing thoracotomy for atrial septal defect closure in prepubescent patients.Ann Thorac Surg. 2005; 80: 673-676Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar2003-2004364-14 y15-69 kgRight axillary thoracotomyFibrillatory arrestCentralASD Yan et al, 201327Yan L. Zhou Z.-C. Li H.-P. Lin M. Wang H.-T. Zhao Z.-W. et al.Right vertical infra-axillary mini-incision for repair of simple congenital heart defects: a matched-pair analysis.Eur J Cardiothorac Surg. 2013; 43: 136-141Crossref PubMed Scopus (19) Google Scholar2003-2010520.8-34.9 y9-63 kgVertical axillary thoracotomyCrossclamp and cardioplegiaCentralASD (20), VSD (26), pAVSD (6)Mini-sternotomy Black and Freedom, 199817Black M.D. Freedom R.M. Minimally invasive repair of atrial septal defects.Ann Thorac Surg. 1998; 65: 765-767Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar1995-19962319 mo to 15 y11-62 kgMini-sternotomyCrossclamp and cardioplegia in majorityCentralASD Bichell et al, 20007Bichell D.P. Geva T. Bacha E.A. Mayer J.E. Jonas R.A. del Nido P.J. Minimal access approach for the repair of atrial septal defect: the initial 135 patients.Ann Thorac Surg. 2000; 70: 115-118Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar1996-19981356 mo to 25 yNot reportedMini-sternotomyCrossclamp and cardioplegiaMostly centralASD Sebastian et al, 200918Sebastian V.A. Guleserian K.J. Leonard S.R. Forbess J.M. Ministernotomy for repair of congenital cardiac disease.Interact Cardiovasc Thorac Surg. 2009; 9: 819-821Crossref PubMed Scopus (13) Google Scholar2004-2007791 mo to 10 y3.5-40 kgMini-sternotomyCrossclamp and cardioplegiaCentralASD (34), pAVSD (3), TAPVD (1), PV plasty (1), VSD (40) Konstantinov and Buratto, 20218Konstantinov I.E. Buratto E. Atrial septal defect closure via ministernotomy in children.Heart Lung Circ. 2021; 30: e98-e100Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar2010-2020556 mo to 16 yMean 22.8 kgMini-sternotomyCrossclamp and cardioplegiaCentralASDAlternative approaches Barbero-Marcial et al, 199819Barbero-Marcial M. Tanamati C. Jatene M.B. Atik E. Jatene A.D. Transxiphoid approach without median sternotomy for the repair of atrial septal defects.Ann Thorac Surg. 1998; 65: 771-774Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar1996-1997106 mo to 14 yNot reportedTransxiphoidCrossclamp and cardioplegiaPeripheralASD Van de Wal, 199820van de Wal H. Cardiac surgery by transxiphoid approach without sternotomy.Eur J Cardiothorac Surg. 1998; 13: 551-554Crossref PubMed Scopus (20) Google Scholar1996-1997266 mo to 14 yNot reportedTransxiphoidCrossclamp and cardioplegiaBoth central and peripheralASD Hagl et al, 200134Hagl C. Stock U. Haverich A. Steinhoff G. Evaluation of different minimally invasive techniques in pediatric cardiac surgery.Chest. 2001; 119: 622-627Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar1997-199854 mo to 10 yNot reportedTransxiphoidCrossclamp and cardioplegiaCentralASD Wang et al, 201128Wang F. Li M. Xu X. Yu S. Cheng Z. Deng C. et al.Totally thoracoscopic surgical closure of atrial septal defect in small children.Ann Thorac Surg. 2011; 92: 200-203Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar2009-2010284.5-8 y13.5-22 kgThoracoscopicCrossclamp and cardioplegiaPeripheralASDASD, Atrial septal defect; TOF, tetralogy of Fallot; pAVSD, partial atrioventricular septal defect; VSD, ventricular septal defect; MV, mitral valve; LVOTO, left ventricular outflow tract obstruction; PS, pulmonary stenosis; LA, left atrium; LCA, left coronary artery; LV, left ventricle; DCRV, double-chambered right ventricle; PAPVD, partial anomalous pulmonary venous drainage; TAPVD, total anomalous pulmonary venous drainage; PV, pulmonary valve. Open table in a new tab ASD, Atrial septal defect; TOF, tetralogy of Fallot; pAVSD, partial atrioventricular septal defect; VSD, ventricular septal defect; MV, mitral valve; LVOTO, left ventricular outflow tract obstruction; PS, pulmonary stenosis; LA, left atrium; LCA, left coronary artery; LV, left ventricle; DCRV, double-chambered right ventricle; PAPVD, partial anomalous pulmonary venous drainage; TAPVD, total anomalous pulmonary venous drainage; PV, pulmonary valve. A range of techniques can be used to achieve a cosmetic approach to ASD closure. In particular, partial sternotomy and midaxillary thoracotomy appear be the most widely adopted techniques, providing excellent cosmesis, allowing conventional approaches to bypass and myocardial protection as well as achieving outcomes with safety equivalent to traditional median sternotomy.
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