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J Thorac Cardiovasc Surg 2007;134:1358-1360
© 2007 The American Association for Thoracic Surgery
Brief Communication |
a Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York, NY
b Department of Anesthesiology, Mount Sinai Medical Center, New York, NY
c Department of Pediatrics, Mount Sinai Medical Center, New York, NY
d Division of Pediatric Cardiology, St Joseph’s Medical Center, Paterson, NJ.
Received for publication June 8, 2007; accepted for publication June 21, 2007. * Address for reprints: Khanh H. Nguyen, MD, Mount Sinai Medical Center, Department of Cardiothoracic Surgery, 1190 Fifth Ave, Box 1028, New York, NY 10029. (Email: Khanh.Nguyen{at}mountsinai.org).
Surgery for congenital heart disease has made great advances, and the focus has shifted from simply surviving the operation to the quality of life after surgical repair, especially when dealing with simple lesions such as atrial septal defects (ASDs). In children and young women, the appearance of the incision has been a significant issue, with concern that it could have an impact on the patient’s psychological wellbeing and self esteem.
Several approaches have been described to avoid a visible midline scar. Most commonly, surgeons have tried using the anterolateral thoracotomy approach, originally described by Lewis and Taufic1
in 1952. In addition, there have been reports concerning the use of other access sites such as a short right lateral thoracotomy, posterolateral thoracotomy, ministernotomy, a subxiphoid approach without sternotomy, and, more recently, an axillary incision.2,3 The axillary incision scar is well concealed under the upper arm (Figure 1) and, in prepubescent female patients, poses less potential for subsequent breast tissue distortion.4 This article reports the use of the axillary incision at our institution in 34 patients with various congenital cardiac defects.
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Thirty-four consecutive patients were included in the report. Median age was 5 years, with a range from 5 months to 47 years. Median weight was 21 kg, with a range from 5.9 to 72 kg. Clinical and operative data regarding the 34 patients are shown in Table 1.
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Ministernotomy
The technique has been well described.5 A majority of patients had repair with the heart electrically fibrillated, and the defects were closed primarily. For larger lesions, the defects were closed with an autologous pericardial patch.
Right axillary incision
The patient was placed in the left lateral decubitus position. The right arm was elevated to expose the axilla. The slightly oblique incision was placed between the anterior and posterior axillary lines.
The incisions usually measured about 1.5 inches in a 10-kg infant to almost 3 inches in adults. The serratus anterior muscle was split along its fibers and the latissimus dorsi was retracted posteriorly. The pleural cavity was entered through the fourth intercostal space. Aortic and bicaval cannulations were then achieved, and cardiopulmonary bypass (CPB) was instituted. The conduct of the operation is similar to that of ministernotomy.
Statistical Methods
Data are described as percentages or median and range, as appropriate. Comparisons of categorical factors between the 2 procedures are by exact 
2 tests. Wilcoxon tests were used to compare continuous measures. Data analyses were implemented with SAS software, version 9.1 (SAS Institute Inc, Cary, NC).
There was 1 case of transient and 1 case of permanent atrioventricular block. One patient, who had first-degree heart block preoperatively, required a permanent pacemaker placed after closure of a ventricular septal defect. All but 1 patient were extubated in the operating room. Intraoperative and follow-up echocardiograms showed no residual lesions in any patient.
Intraoperative data from the patients who had an axillary incision are shown in Table 1. Data and statistical analysis on the 2 groups of patients with secundum ASDs are shown in Table 2. As can be seen from the table, the CPB times and the overall duration of surgery were significantly greater for the patients with axillary incisions.
The axillary incision has been commonly used for thoracic operations. Our goal to achieve a cosmetic result in surgery for congenital cardiac lesions had led us to the application of the axillary incision. Our experience showed that repair of certain congenital defects through an axillary incision using central cannulation is possible. Lesions at the atrial level, lesions close to the tricuspid valve, and those that can be visualized and reached from the unique angle dictated by the axillary incision seem amenable to the axillary approach. The smallest patient was 5.9 kg.
When compared with patients with ASD closed via a ministernotomy, there is clearly an increase in CPB and fibrillation times in patients with axillary incision, but the two groups had no differences in postoperative outcomes or length of stay. Because it was a new approach, there was a tendency to use a more complete open heart setup with mild hypothermia and crossclamping in the axillary incision group, as our data noted. Up to 44% of patients in the axillary group had aortic crossclamping, in contrast to 7% in the ministernotomy group, contributing to a longer duration of CPB. In fact, when only normothermia and fibrillation were used in patients with an axillary incision, the CPB and fibrillation times approached those of patients with the ministernotomy approach.
The study sample was small, but it did provide useful data when compared with that of the more commonly performed ministernotomy. The axillary incision is not suitable for many complex congenital cardiac lesions and the sternotomy is still the standard and most effective approach.
In conclusion, the axillary incision provides a superior cosmetic result in repairing a variety of congenital cardiac lesions. We anticipate its wider application in patients with mitral and aortic valve disease, as well as in surgery of the ascending aorta.
References
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