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J Thorac Cardiovasc Surg 1999;117:1040-1041
© 1999 Mosby, Inc.

LETTERS TO THE EDITOR

Correction of cardiac defects through a right thoracotomy in children

Unit of Cardio-Thoracic Surgery
La Timone Children's Hospital
Bd Jean Moulin
Cedex 5
13885 Marseilles, France

Correction of cardiac defects through a right thoracotomy in children

To the Editor:

Liu and coauthors describe in the Journal (1998;116:359-61) an approach to correct cardiac defects through a right lateral thoracotomy in children. They have a large experience of 351 patients without early or late mortality. The concept they advocate of minimally invasive surgery with good cosmetic results is very attractive. However, we believe this important and stimulating paper needs some words of discussion and caution.

Cosmetic approach
Several years after successful repair of a congenital cardiac defect, the cosmetic impact on an adolescent, particularly a girl, is one of the main concerns, if not the most important. For this reason many operations, mostly atrial septal defect closures, have reportedly been performed through a submammary incision or, more recently, a ministernotomy.

However, the submammary approach presents some uncertainty, especially in young female patients before breast development. Even though the incision is made at distance from the nipple and in the supposed area of the submammary groove in young girls, one is never absolutely certain of how the gland will grow. Asymmetry in the two breasts would be a catastrophic cosmetic result. In addition, disturbances of sensitivity of the breast have been described. For this reason a more posterior approach such as the one used by the authors may be cosmetically better and deserves interest. However, the authors mention that a "flap of breast tissue is mobilized." This could also have late cosmetic consequences, and more than 3 years' follow-up would be needed to identify these consequences.

Selection of patients
The authors are to be congratulated for using this lateral approach to repair not only secundum atrial septal defect (for which, curiously, they used more patches than direct closures) but also more complex defects including, in particular, ventricular septal defect (n = 211), tetralogy of Fallot (n = 27), and pulmonary artery stenosis (n = 34).

Tetralogy of Fallot is generally considered to be a serious surgical problem even if not complex. Inasmuch as the authors advocate surgery through this approach (excluding forms with stenosis of the origin of the left pulmonary artery), it would be interesting to know whether this small proportion of their cases (27/351) was consecutive or selected. Owing to their large experience, they have certainly treated many more cases of tetralogy of Fallot than are mentioned in their article. The question also arises about the increased risk of leaving a residual defect with such an approach, in particular a pulmonary artery distortion or a residual pulmonary stenosis, with some uncertainty on the late result of correction. Offering an alternative surgical approach for tetralogy of Fallot would need a demonstration that the anatomic result is as good as that obtained with the more usual midline approach.

The authors report a very small number of cases of partial atrioventricular canal (3/351). One wonders why this number is so small, since it would seem extremely convenient to use this approach to operate on this defect.

The authors also mention that a patent ductus arteriosus or a left superior vena cava, generally considered as contraindications for the right-sided approach, are not a problem. They should describe how they solved the problem.

In summary, we think that more comments should be made on the selection of patients.

An alternative approach
In the past 2 years, we have used in 40 cases an even more cosmetic approach, the right posterolateral thoracotomy through the fourth or fifth intercostal space. In fact, through a 7- to 10-cm skin incision posterior to the midaxillary line, the access to the heart is excellent. The ascending aorta and the right atrium are easily exposed, and all cardiopulmonary bypass catheters can be inserted through this posterior approach, as done by the authors through a purely lateral approach. The younger the patients, in fact, the easier it is to obtain a good view, since with pericardial retraction the heart is easily moved owing to the elasticity of structures. It may seem paradoxic, but the ascending aorta becomes one of the closest structures through this posterior approach after adequate exposure. Aortic crossclamping, cardioplegia, and deairing before releasing the crossclamp are easily performed, as is also true with the lateral approach advocated by Liu and colleagues.

Through this approach we have operated on babies under 1 year of age, as well as on young adults. Ostium secundum has been the most common indication, but ostium primum, single atrium, and ventricular septal defect (above 1 year of age without pulmonary artery hypertension) have also been repaired in this way.

This approach was introduced by the group from Marie-Lannelongue Hospital in Paris. They ¹ recently reported having done 140 cases, but their recommendation, with which we agree fully, is that more left-sided structures or lesions such as left superior vena cava, pulmonary stenosis, or tetralogy of Fallot are contraindications to this approach.

In conclusion, the report by Liu and colleagues is an important paper, but we would add the following suggestions:

•The lateral approach the authors advocate for better cosmetic results can be moved even more posteriorly, thereby causing no scar whatsoever in the anterolateral aspect of the chest. Standard cardiopulmonary bypass can be applied with adequate myocardial protection through a posterior access.

•Deairing of the heart, a concern frequently arising when such approaches are reported, can be very well done, as reported by Dr. Liu, although there is no access to the apex of the heart.

•However, patients must be selected very carefully. We would question statements that a left superior vena cava and tetralogy of Fallot can be easily repaired through this route, because immediate and long-term safety cannot be sacrificed to cosmetic advantages and the operation should not become dangerous for the patient.

Great caution must be exercised in repairing all but simple congenital defects in children through the use of "minimally invasive surgery." We think, as Georges Pompidou, former President of the French Republic, said once, paraphrasing a humorist: "When the bounds are crossed there are no more limits!"

12/8/97045

References

1. Planché C. The use of small incisions for congenital heart surgery. European Association for Cardio-Thoracic Surgery. Brussels: September 1998.
   

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				S. Bleiziffer, C. Schreiber, R. Burgkart, F. Regenfelder, M. Kostolny, P. Libera, K. Holper, and R. Lange The influence of right anterolateral thoracotomy in prepubescent female patients on late breast development and on the incidence of scoliosis J. Thorac. Cardiovasc. Surg., May 1, 2004; 127(5): 1474 - 1480. [Abstract] [Full Text] [PDF]

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