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would not want your surgeon to use a technique that leaves youwith three or four grafts, all with 50% stenosis, but claim that theoperation had a “perfect” result.
Gerald S. Weinstein, MD
Cardiothoracic and Vascular Surgical Associates4815 Liberty Ave, Suite 204Pittsburgh, PA 15224
References
1. Mack MJ, Magovern JA, Acuff TA, et al. Results of graftpatency by immediate angiography in minimally invasivecoronary artery surgery. Ann Thorac Surg 1999;68:383–90.
2. Webster’s New World Dictionary, Second College Edition.New York: Simon and Schuster, 1986:1055.
Stroke After Repair of Atrial Septal DefectTo the Editor:
I read with interest the report on incidence of atrial flutter/fibrillation in adults with atrial septal defect before and aftersurgery by Berger and associates [1]. The message seems to beclear: all atrial septal defects should be closed regardless of thepatient’s age in order to prevent atrial flutter/fibrillation andtheir devastating sequelae.
Thromboembolism after surgical repair of an atrial septaldefect in an adult can occur in the early postoperative period [2].Stroke after successful surgical closure of an atrial septal defectin an adult is unfortunate and can be debilitating. Whether ornot a right-sided Maze procedure should be employed at thetime of surgical repair of an atrial septal defect in an adult withatrial fibrillation, it is important to emphasize the longstandingpolicy of early postoperative anticoagulation of patients 35 yearsof age or older at the time of repair of an atrial septal defect andits continuation for at least 6 months [3].
Tsung O. Cheng, MD
George Washington University Medical Center2150 Pennsylvania Ave, NWWashington, DC 20037
References
1. Berger F, Vogel M, Kramer A, Alexi-Meskishvili V, Weng Y,Lange PE, Hetzer R. Incidence of atrial flutter/fibrillation inadults with atrial septal defect before and after surgery. AnnThorac Surg 1999;68:75–8.
2. Cheng TO. Early thromboembolism after atrial septal defectrepair. J Thorac Cardiovasc Surg 1990;99:758.
3. Kirklin JW. Early thromboembolism after atrial septal defectrepair [Editor’s comment]. J Thorac Cardiovasc Surg 1990;99:758.
ReplyTo the Editor:
We thank Dr Cheng for his comments on our paper. In ouropinion, there are three important reasons to close atrial septaldefects in all adults: (a) prevention of atrial flutter or fibrillation[1], (b) prevention of the development of pulmonary vasculardisease [2], and (c) improvement of quality of life. In our patientgroup, we also found patients who developed transient flutter orfibrillation after surgery. These patients were all older than 40
years and the tachycardia occurred 3 [2 to 5] days after surgery,when these patients were still on intravenous heparin and thuseffectively anticoagulated. Thus, we fortunately did not encoun-ter patients with a stroke in the immediate postoperative period.Among the 18 patients who developed atrial flutter/fibrillationde novo, 6 could be converted to sinus rhythm with intravenousverapamil, and 12 with cardioversion. The latter patient groupwas treated with sotalol for at least 1 year to prevent recurrenceof flutter. We did not continue anticoagulation in those patientswith transient flutter, who responded to electrical or pharmaco-logical conversion to sinus rhythm, but monitor these patientsclosely to detect recurrence of atrial flutter/fibrillation. While weanticoagulate all patients with persistent or intermittent atrialflutter/fibrillation [3], we are not sure whether routine anticoag-ulation of all patients over the age of 35 years who had under-gone closure of an atrial septal defect is warranted.
Felix Berger, MD
Department Congenital Heart DiseaseDeutsches HerzzentrumPostfach 650505D-13305 Berlin, Germany
Michael Vogel, MD, PhD
GUCH UnitMiddlesex HospitalMortimer StJules Thorn Building 5th FloorLondon W1N 8AA, Englande-mail: [email protected].
References
1. Gatzoulis MA, Freeman MA, Siu SC, Webb GD, Harris L.Atrial arrhythmia after surgical closure of atrial septal defectsin adults. N Engl J Med 1999;340:839–46.
2. Vogel M, Berger F, Kramer A, Alexi-Meskisvili V, Lange PE.Incidence of secondary pulmonary hypertension in adultswith atrial septal or sinus venosus defect. Heart 1999;82:30–3.
3. Berger F, Vogel M, Kramer A, Alexi-Meskishvili V, Weng Y,Lange PE, Hetzer R. Incidence of atrial flutter/fibrillation inadults with atrial septal defect before and after surgery. AnnThorac Surg 1999;68:75–8.
Less Invasive Correction of Atrial Septal Defects WithTransthoracic CannulationTo the Editor:
We read with great interest the article by Cremer and associateswith regard to three different approaches for minimally invasiveclosure of atrial septal defects (ASD) [1]. They treated a total of24 patients (age 35 6 11 years) with uncomplicated ASD. Most ofthe patients were treated by a right submammary incision (n 519), and the others through a right parasternal incision. Thelength of the thoracotomy incision was between 6 and 8 cm. Theoperations were done with electrically induced ventricular fibril-lation (26.1 6 8.6 minutes). Each approach necessitated addi-tional incisions for arterial and/or caval cannulation. In onepatient, femoral artery dissection occurred. There are severalreports in the literature about the correction of congenital heartdefects through a right anterolateral submammary incision with[2] and without cannulation of peripheral vessels [3, 4].
We would like to present our experience of the treatment ofpatients with ASD by the use of, as we call it, less invasiveapproaches with special emphasis on complete central cannula-tion through the thoracotomy incision. From June 1996 to Janu-ary 1999, we used less invasive techniques for the correction of
981Ann Thorac Surg CORRESPONDENCE2000;69:971–82
© 2000 by The Society of Thoracic Surgeons 0003-4975/00/$20.00Published by Elsevier Science Inc
ASD (n 5 35) and ASD with partial anomalous pulmonaryvenous connection (PAPVC) (n 5 7). We performed right ante-rior submammary thoracotomy (skin incision 6 to 12 cm) in 29patients (average age 17 years) and partial inferior sternotomy(skin incision 4 to 7 cm) in 13 patients (average age 7 years). Wepreferred the submammary thoracotomy for patients who al-ready manifested breast development in order to avoid breastdeformities in growing adolescents and small children. Themain point of our concept is to perform cannulation of the aortaand the great veins always through the thoracotomy. Aorticcannulation may prove to be rather difficult, and it is for thisreason that the suture for the cardioplegic cannula should beapplied first to enable better handling of the vessel. The cannulais inserted by grasping it with forceps and guiding it into thepreviously performed aortic incision.
In contrast to Cremer and associates, we always close ASD inadult patients with a pericardial patch to avoid distortion of theseptum and the tricuspid valve. Apart from very small defects,which are directly closed, we used antegrade cold crystalloidcardioplegic solution for myocardial protection (n 5 36). Theaortic clamp time was 17 6 8.7 minutes. The extracorporealcirculation was performed under normothermic conditions. De-aeration of the heart was done retrograde before completeclosure of the septal defect and the atriotomy, and antegradeover the ascending aorta before and after release of the aortalclamp or defibrillation of the heart by connecting suction to thecardioplegic cannula. The peri- and postoperative course wasuneventful in all patients.
We feel that our technique provides a safe and cosmeticapproach for the correction of congenital heart defects in se-lected patient groups. The length of the submammarian skinincision does not matter, because it is hidden in the submam-mary fold. The operation is possible using standard instruments,cannulation, and heart-lung machines. Additional approachesfor extracorporeal circulation are unnecessary and can beavoided.
Matthias Bauer, MDVladimir V. Alexi-Meskishvili, MD, PhDRoland Hetzer, MD, PhD
Department of Cardiothoracic and Vascular SurgeryDeutsches Herzzentrum BerlinAugustenburger Platz 113353 Berlin, Germanye-mail: [email protected].
References
1. Cremer JT, Boning A, Anssar MB, et al. Different approachesfor minimally invasive closure of atrial septal defects. AnnThorac Surg 1999;67:1648–52.
2. Grinda JM, Folliguet TA, Dervanian P, Mace L, Legault B,Neveux JY. Right anterolateral thoracotomy for repair of atrialseptal defect. Ann Thorac Surg 1996;62:175–8.
3. Dietl CA, Torres A, Favaloro RG. Right submammarian tho-racotomy in female patients with atrial septal defects andanomalous pulmonary venous connections. J Thorac Cardio-vasc Surg 1992;104:723–7.
4. Ying-long L, Hong-jia Z, Han-shong S, Shou-jun L, Jun-wu S,Cun-tao Y. Correction of cardiac defects through a rightthoracotomy in children. J Thorac Cardiovasc Surg 1998;116:359–61.
ReplyTo the Editor:
The letter of Bauer and associates and the most recent publica-tion of Daebritz and associates [1] indicate that there is an
ongoing discussion on techniques of ASD closure aiming to-wards superior cosmetic results but simultaneously applyingsafe surgical approaches.
The basic question behind all of this is how far should we goand what amount of sophisticated technology makes sense toclose a so-called simple ASD. The whole spectrum of techniquesextends between a conventional full sternotomy approach andendoclamp technology eventually combined with robotics.
Regarding the concept introduced by Bauer and associates, Ithink a few comments should be made. They mention twoprincipally different approaches assumingly based on the age ofthe patient. Thus, in the one group (n 5 29, mean age 17 years),a limited anterior thoracotomy is applied, in contrast to the othergroup (n 5 13, mean age 7 years), who received a partial inferiorsternotomy. Central cannulation and cardioplegic arrest arecommon in both groups.
Regarding the central aortic cannulation in the elderly group(anterior thoracotomy), they admit that the handling of the aortais at least tough, and what we would expect from our ownexperience (including a similar approach) requires an ade-quately incision to do it safely. In this content, it is not ourexperience that the length of the incision is meaningless for thepatient because the scar is not at all barely visible hidden in thesubmammary fold, truly not in young men, who have noparticularly expressed fold.
Concerning femoral artery cannulation, it has long beenproven that it is safe unless atherosclerosis is absent, as isregular in younger aged patients. The one local dissection wehad was due to an attempt to introduce an oversized cannulainto the vessel.
The conventional aortic clamp also needs some (avoidable)space for the incision, which can be safely obviated applyingventricular fibrillation in such procedures.
Like Bauer and associates, we also in the meanwhile usepericardial patches more liberally, primarily not for reasons ofdistortion of the septum but for reasons of a better visualizationof the defect margins.
Coming to their group of younger individuals, it may bedebatable whether a supposed inversed L-incision or T-incisionis a good solution. Asymmetric sternal growth may develop andinjury of at least one internal mammary has to be expected. Whynot do a limited posterior thoracotomy (P. Vouhe, meetingcomment) or apply a transxiphoid approach, as proposed by vande Wal and associates [2] in these children.
Even though the numbers of ASDs subjected to surgery intimes of interventional ASD closure become increasingly low,the interest for debating sophisticated technical means stillremains unbroken.
Jochen T. Cremer, MD, PhDAndreas Boening, MDJens K. W. Scheewe, MD
Cardiovascular SurgeryUniversity Hospital KielArnold-Heller-Straße 7D-24105 Kiel, Germanye-mail: [email protected].
References
1. Daebritz S, Saehweh J, Walter M, Messmer BJ. Closure ofartrial defects via limited right anterolateral thoracotomy as aminimal invasive approach in female patients. J Thorac Car-diovasc Surg 1999;15:18–23.
2. Van de Wal HJCM, Barbero-Marcial M, Hulin S, Lecompte Y.Cardiac surgery by transxiphoid approach without sternot-omy. Eur J Cardiothorac Surg 1998;13:551–4.
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