Minimal-access surgery for congenital heart defects.

Improved results with lower operative mortality and morbidity for corrective surgery for many congenital cardiac defects has stimulated a renewed interest in the use of surgical approaches other than a full midline sternotomy. In an effort to decrease pain and discomfort, shorten the recovery period, and improve the cosmetic result, several alternative approaches have been proposed and implemented, with varying results. Anterior thoracotomy in the inframammary area has been the most widely used incision and is most applicable to females patients past puberty, in whom the extent of breast tissue can be assessed more accurately. Complications with this approach including phrenic nerve injury and breast and chest wall deformities have been reported, although most reports describe satisfactory cosmetic results. We have used a midline approach limiting the incision over the xyphoid process either without a sternal incision (infants) or with division of the lower segment (patients younger than 3 to 4 years) with cephalad retraction to expose the heart and great vessels. From May 1996 to June 1997, 54 children had repair of a secundum-type atrial septal defect using a transxyphoid or ministernotomy approach. In 29, arterial cannulation was performed through the ascending aorta, and in 25 via the femoral artery. There were no instances in which conversion to full sternotomy was required, and complete repair with comparable ischemic and bypass time to full sternotomy was achieved in all patients. We have also used the same technique for repair of other congenital cardiac lesions, including ventricular septal defect and partial or complete atrioventricular canal defects, and in selected infants with tetralogy of Fallot. With this approach, cardioplegia for myocardial protection and left ventricular venting to prevent distention and to remove air from the heart can be used routinely. The adaptability of this technique to various cardiac defects and the ability to extend the incision if necessary make it an attractive alternative to other approaches for minimal-access cardiac surgery for congenital defects. Copyright 1998 by W.B. Saunders Company