Minimally Invasive Midaxillary Muscle Sparing Thoracotomy for Atrial Septal Defect Closure in Prepubescent Patients

Abstract

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. 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. 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. 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.