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Ann Thorac Surg 1996;62:1100-1103
© 1996 The Society of Thoracic Surgeons

Original Articles: Cardiovascular

Operation for Atrial Septal Defect Through a Right Anterolateral Thoracotomy: Current Outcome

Massimo Massetti, MD, Gerard Babatasi, MD, Antoine Rossi, MD, Eugenio Neri, MD, Satar Bhoyroo, MD, Samira Zitouni, MD, Pascale Maragnes, MD, Andre Khayat, MD

Departments of Thoracic and Cardiovascular Surgery and Cardiology, University Hospital, Caen, France

Accepted for publication April 29, 1996.


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
Background. Operative closure of atrial septal defect is today considered a high-benefit and low-risk operation. Patients are often young and sensitive to the cosmetic results of the procedure. The midline scar of median sternotomy may be unsightly and can provoke dissatisfaction and psychological distress. For cosmetic reasons, an alternative operative approach, such as right anterolateral thoracotomy, can be proposed, with better aesthetic results and without increasing operative risks.

Methods. Our study reviews retrospectively the long-term results of a consecutive series of 56 young patients in whom the atrial septal defect was closed through a right submammary approach. The indication for this approach was isolated atrial septal defect in female patients with complete development of the breasts.

Results. In-hospital morbidity included three postpericardiotomy syndromes with one operative drainage for a moderate pericardial effusion (subxiphoid approach); 6 patients had supraventricular tachycardia in the early postoperative period. One patient presented with a symptomatic supraventricular arrhythmia and was treated medically for atrial flutter or fibrillation. Follow-up ranged from 12 to 240 months and included 41 of 57 patients. There were no early or late deaths. All patients were in normal sinus rhythm and free of symptoms, in New York Heart Association functional class I. Electrocardiography results showed 4 patients with first-degree atrioventricular block and 5 with complete right bundle branch block. Echocardiographic study results showed 3 patients with a trivial residual shunt. There were no other late complications. Breast volume and symmetry and the character of the scar were evaluated objectively by a physician and subjectively by a multiple-choice questionnaire completed by the same patients. The answers suggested that the patients' subjective impressions were at least commensurate with the objective findings. Most of the patients perceived the cosmetic results as good or excellent. No serious psychological problems related to the scar were found.

Conclusions. Right thoracotomy incision is a safe alternative approach to median sternotomy to repair isolated atrial septal defect in young female patients.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
Operative closure of atrial septal defect (ASD) has been performed since the beginning of the cardiac surgery era. In patients who underwent operation early, long-term survival has proved to be similar to that of age- and sex-matched control populations [1]. Because the operation for ASD is considered a low-risk and high-benefit procedure, the aesthetic result has become an important issue. Median sternotomy is the standard approach, but the midline scar may be unsightly and, especially in young female patients, can easily provoke displeasure and psychological distress [2]. Principally for cosmetic reasons, alternative operative approaches can be proposed, with better aesthetic results and minimally increased operative risks. Brutel de la Riviere and associates [3] recommended bilateral submammary skin incisions followed by midline sternotomy; Kirklin and Barratt-Boyes [4] used a right thoracotomy approach in selected cases. The right anterolateral thoracotomy is well sited for access to both atria and is safely used in some cardiac procedures other than ASD closure [5, 6]. With this technique, several aspects must be emphasized to perform the operation safely and expeditiously. Our study reviews retrospectively the long-term results of a consecutive series of 56 patients in whom the ASD was closed through a right submammary approach. Both the aesthetic and cardiologic results are discussed.


   Patients and Methods
Top
 Footnotes
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Acknowledgments
 References
 
From January 1976 to December 1993, 56 female patients underwent ASD closure through a right anterolateral thoracotomy approach. At the time of operation, the mean age was 21.5 years (range, 13 to 46 years) (Fig 1Go) and the mean weight was 49 kg (range, 42 to 67 kg). The operation was performed by only one surgeon. In our practice, this approach was preferred for cosmetic reasons in female patients presenting with completed breast development. In 53 cases the ASD was an isolated ostium secundum and in 1 case the ASD was type ostium primum; in 3 cases the ostium secundum was associated with partial anomalous pulmonary venous connection, and in another case it was associated with left ventricle to right atrium fistula.



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  		Fig 1. . Age distribution of the 56 young female patients.

 
Operative Technique
The patient was placed in the 30-degree anterolateral position with the right arm positioned lateral to the chest; the right groin was usually draped for potential femoral cannulation. The skin incision was made along the right inframammary groove between the parasternal and midaxillary lines; the line incision was marked previously with the patient in the orthostatic position (Fig 2Go) to be sure of the anatomic limits. The breast and pectoralis major muscle were dissected en bloc from the chest wall, which was entered in the fourth intercostal space. Electrocautery was used with caution and was limited to the sources of bleeding. If access was inadequate, a subluxation of the chondrosternal junction was performed to the fourth rib after liberation of the internal mammary vessels. The lung was retracted posteriorly, the right lobe of the thymus was resected, and the pericardium was then opened longitudinally 2 cm anterior to the phrenic nerve. Pericardial stay sutures were put on traction to elevate the mediastinal structures in the operative field.



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  		Fig 2. . Right anterolateral thoracotomy: line of incision in the orthostatic position in a 24-year-old woman.

 
In our series, aortic cannulation was accomplished without problem in 44 cases, and femoral cannulation was performed at the beginning of our experience in 12 cases. After bicaval cannulation, cardiopulmonary bypass was instituted and maintained with mild hypothermia (32°C). For simple ASD and partial anomalous pulmonary venous connection (54 cases), we used electrical fibrillation, and for the 2 other cases, aortic cross-clamping with cardioplegia was required. The right atrium was opened using a standard oblique incision; intracardiac suction was used carefully to avoid emptying the blood level in the left atrium (Fig 3Go). In 35 patients, the secundum type ASD was closed directly by two continuous mattress sutures (4/0 nonabsorbable material), and in 21 patients, a Dacron patch was necessary. After the atriorrhaphy was completed, the aortic needle vent was connected to suction and the usual dearing techniques were used. The heart was defibrillated and cardiopulmonary bypass was gradually discontinued. The pericardium was closed, and one pleuropericardial drain was placed through the same skin incision in the submammary groove. The chest was then closed in a routine fashion with an intradermic continuous suture (4/0 absorbable material) for the skin layer.



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  		Fig 3. . Operative view of the right atrium opened from the right anterolateral thoracotomy incision. Direct aortic cannulation is performed (white arrow). Black arrow shows the atrial septal defect.

 
Operative data and in-hospital morbidity for all patients are reported. After approval was granted by the local medical ethical committee, 41 patients were evaluated postoperatively in the follow-up study; 15 patients refused or were lost to follow-up. The patients were evaluated by a cardiologist for both the cardiologic results (ASD closure) and the aesthetic results; participant confidentiality was protected.

Cardiologic results included a clinical examination with standard electrocardiogram, chest roentgenogram, and bidimensional Doppler echocardiography to assess the outcome of ASD repair. Aesthetic results were assessed both objectively by the physician and subjectively by a multiple-choice questionnaire completed by the same patients before the hospital examination. Photographs (frontal and oblique views) of the patients were obtained with a Yashika FX 50-mm lens (Fig 4Go).



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  		Fig 4. . Oblique view of a 24-year-old woman operated on 6 years before.

 
The breast volume and symmetry and the character of the scar were evaluated by the examiner visually; functional anomalies (trouble nursing, numbness, twinges of pain) were carefully researched in the interview. The questionnaire focused on the patients' evaluation of the aesthetic result and its psychological influences. A summary of the questions follows: (1) subjective impression regarding the volume and symmetry of the breasts; (2) description of the quality (color, dimensions, and visibility) of the scar; (3) unhappiness with the scar when clothing is removed, wearing a bathing suit, participating in sports, buying bras, or living with a spouse or partner; and (4) satisfaction or dissatisfaction with the operation.


   Results
Top
 Footnotes
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Acknowledgments
 References
 
The mean cardiopulmonary bypass time was 33 minutes (range, 14 to 84 minutes), with a mean fibrillation time of 20 minutes (range, 6 to 41 minutes). In the 2 patients in whom cardioplegic arrest was used, aortic cross-clamping times were 34 and 30 minutes. The average mechanical ventilation time was 7.5 hours (range, 4 to 24 hours), and the mean hospital stay was 10.7 days (range, 7 to 20 days). In-hospital morbidity included 3 (5.3%) postpericardiotomy syndromes with one operative drainage for a moderate pericardial effusion (subxiphoid approach). Six patients (10.7%) had supraventricular tachycardia in the early postoperative period; none of these received antiarrhythmic therapy. One patient (1.7%) presented with a symptomatic supraventricular arrhythmia and was treated medically for atrial flutter or fibrillation. Follow-up ranged from 12 to 208 months (mean, 84.7 months) and included 41 of the 56 patients. There were no early or late deaths.

Late Cardiologic Results
All patients were in normal sinus rhythm and free of symptoms, in New York Heart Association functional class I. The standard 12-lead electrocardiogram showed 4 (7.1%) patients with a first-degree atrioventricular block and 5 (8.9%) patients with complete right bundle branch block. Ectopic ventricular activity was recorded in 2 (3.5%) patients; both had monoform premature ventricular contractions. Echocardiographic study results revealed 3 patients (5.3%) with a trivial residual shunt without dilatation of the right ventricle. There were no other late complications. The presence of arrhythmias and evidence of residual shunt in the follow-up examination were not related to differences in localization of the ASD, baseline data (preoperative shunt size, age at the operation, or operative technique), age at follow-up, or duration of follow-up.

Among 41 patients examined, 2 (3.5%) had persistent numbness in the periareolar area; there were no instances of decreased nipple sensitivity or difficulty nursing in the women who were mothers.

Cosmetic Results
Among the 41 patients examined, there was no difference between the two sides of the chest; the breast volume and symmetry were considered unchanged after the operation. The scar length ranged from 19 to 24 cm (mean, 22 cm). The aesthetics and the psychological responses from the questionnaire are reported in Table 1Go.


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  		Table 1. . Objective and Subjective Results
 

   Comment
Top
 Footnotes
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Acknowledgments
 References
 
Operative closure of ASD has been performed successfully since 1952. Studies [1, 7] show that many years after operation, most patients consider themselves healthy and are free from any medical or operative interventions since the operation. Many of them are not followed up any longer by a cardiologist. Because the operation for ASD is now considered a safe and high-benefit procedure, more attention is dedicated to the aesthetic results of the operation [8, 9]. Median sternotomy remains the standard approach used by most surgeons, but the residual scar may be cosmetically unsatisfactory and a source of psychological displeasure modifying the patient's body image, particularly in young female patients [9–11].

Alternative approaches to median sternotomy have been developed over time to conceal the scar. Brom was the first to describe a bilateral transternal submammary incision in 1956. In 1960, Willman and Hanlon proposed a modified approach consisting of a bilateral submammary incision combined with a vertical sternotomy, after development of a superior flap to expose the suprasternal notch and an inferior flap extending beyond the xyphoid process [3, 10]. Certain complications may occur after the modified bilateral submammary incision; these include problems with wound healing in 3% to 23% of patients, hematomas in 3% to 11% and breast maldevelopment in 1% [10]. Right anterolateral thoracotomy can be considered a preferable alternative approach in selected cases, and is already used successfully in some reoperative mitral and other congenital heart operations [4–6, 11, 12]. Nevertheless, many studies have reported breast and pectoral muscle maldevelopment associated with paresthesias after the anterolateral and posterolateral chest approaches [4, 13]. The reason is that the breast tissue in a male or female infant lies in the areolar border by as much 1.5 cm. Although the areola and breast mass lie in the fourth interspace in the infant, the complex migrates down to the seventh interspace by the completion of female development. The pectoral muscle also spans the second through sixth interspaces and inserts medially on the sternum and on the sixth costal cartilage. The innervation of the pectoralis major comes from the medial and lateral pectoral nerves, and nutrient vessels run longitudinally above the muscle layer. Therefore, any transverse incision of the breast and pectoral muscle evolves gradually toward atrophy of the inferior segment. In the right anterolateral thoracotomy approach, it is mandatory to respect the breast tissue and the muscle layer. In our practice, the right anterolateral thoracotomy consists of a submammary incision without division of the breast tissue and pectoral muscle, as Cherup and colleagues [13] recommended. Complete development of the breasts is necessary to identify the anatomic limits. The exposure of the intracardiac anatomy is excellent, and direct aortic cannulation can be performed safely. Ostium secundum, sinus venosus, or primum defects can be repaired through this approach. Cardioplegic arrest with aortic clamping is possible, although ventricular fibrillation remains our preferred choice. Experience has proved that ventricular fibrillation, especially in nonhypertrophied hearts, under certain conditions (mild hypothermia during a half hour and maintained with acceptable perfusion pressure) results in no demonstrable decline in myocardial function or myocardial damage [1, 12]. Long-term cardiologic results in our series seem to be comparable to those of other literature reports [1, 7]: No early or late deaths were observed, morbidity was minimal, and assurance of complete ASD closure was about 93.5%. The presence of residual trivial shunt without ventricular dilatation, observed in 4 patients, seems to be clinically insignificant, but the evaluation remains to be determined in the future.

The major indication for this approach rather than median sternotomy was cosmetic reasons. An unsightly scar in the middle of the thorax may cause psychological disturbance, especially in young female patients [14–16]. The traditional operation heals the cardiac pathology, but it detracts from the body image; feelings of frustration result from buying bras and clothing, participating in sports, and having relationships [15, 16]. The experience of an operation for a patient who is doing well, as are the majority of ASD patients, has been widely regarded as a stressful life event that requires coping and adaptation. The emotional and psychological drawbacks of this experience lead the patient to evaluate more the symbolic value of the scar. The right anterolateral thoracotomy approach for ASD is a better alternative because of the limited extension of the scar.


   Acknowledgments
Top
 Footnotes
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
References
 
We are grateful for the contribution to our work provided by Dr Michel Iselin of the Pediatric Cardiology Department.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
Address reprint requests to Dr Massetti, Service de Chirurgie Thoracique et Cardiovasculaire, CHU, 14000 Caen Cedex, France.


   References
Top
 Footnotes
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Murphy JG, Gersh BJ, McGoon MD, et al. Long term outcome after surgical repair of isolated atrial septal defect. N Engl J Med 1990;323:1645–50.[Abstract]
  2. Laks H, Hammond GL. A cosmetically acceptable incision for the median sternotomy. J Thorac Cardiovasc Surg 1980;79:146–9.[Abstract]
  3. Brutel de la Riviere A, Brom GHM, Brom AG. Horizontal submammary skin incision for median sternotomy. Ann Thorac Surg 1981;32:101–4.[Abstract]
  4. Kirklin JW, Barratt-Boyes BG. Right anterolateral thoracotomy for cardiopulmonary bypass. In: Kirklin JW, Barratt-Boyes BG, eds. Cardiac surgery. 1st ed. New York: Churchill Livingstone, 1988:29–82.
  5. Praeger PI, Pooley RW, Moggio RA, Somberg ED, Sarabu MR, Reed GE. Simplified method for reoperation on the mitral valve. Ann Thorac Surg 1989;48:835–7.[Abstract]
  6. Tribble CG, Killinger WA, Harman PK, Crosby IK, Nolan SP, Kron IL. Anterolateral thoracotomy as an alternative to repeat median sternotomy for replacement of the mitral valve. Ann Thorac Surg 1987;43:380–2.[Abstract]
  7. Hanlon CR, Barner HB, Willman VL, et al. Atrial septal defect results of repair in adults. Arch Surg 1969;49:275–81.
  8. Lancaster LL, Mavroudis C, Rees AH, Slater AD, Ganzel BL, Gray LA. Surgical approach to atrial septal defect in the female: right thoracotomy versus sternotomy. Am Surg 1990;56:218–21.[Medline]
  9. Rosengart TK, Stark JF. Repair of atrial septal defect through a right thoracotomy. Ann Thorac Surg 1993;55:1138–40.[Abstract]
  10. Bedard P, Keon WJ, Brais MP, Goldstein W. Submammary skin incision as a cosmetic approach to median sternotomy. Ann Thorac Surg 1986;41:339–41.[Abstract]
  11. Dietl CA, Torres AR, Favaloro RG. Right submammarian thoracotomy in female patients with atrial septal defect and anomalous pulmonary venous connections. J Thorac Cardiovasc Surg 1992;104:723–7.[Abstract]
  12. Kirklin JW, Barratt-Boyes BG. Atrial septal defect and partial anomalous pulmonary venous connection. In: Kirklin JW, Barratt-Boyes BG, eds. Cardiac surgery. 1st ed. New York: Churchill Livingstone, 1988:463–97.
  13. Cherup LL, Siewers RD, Futrell JW. Breast and pectoral muscle maldevelopment after anterolateral and posterolateral thoracotomies in children. Ann Thorac Surg 1986;41:492–7.[Abstract]
  14. Folkman S, Lazarus RS, De Longis A. Appraisal, coping, health status, and psychological symptoms. J Pers Soc Psychol 1986;50:571–9.[Medline]
  15. Losken HW. Psychological aspects of breast surgery. Aesthetic Plast Surg 1990;14:107–9.[Medline]
  16. O'Hara MW, Ghoneim MM, Hinrichs JV, Mehta MP, Wright EJ. Psychological consequences of surgery. Psychosom Med 1989;51:356–70.[Abstract/Free Full Text]



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