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Ann Thorac Surg 2001;71:473-475
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Ministernotomy versus full sternotomy in congenital heart defects: a prospective randomized study

^a Department of Cardiothoracic Surgery, Xiang Ya Hospital, Hunan Medical University, Changsha, People's Republic of China

Accepted for publication September 14, 2000.

Address reprint requests to Dr Luo, Department of Cardiothoracic Surgery, Xiang Ya Hospital, Hunan Medical University, Changsha, P.R.China 410008
e-mail: wj103612{at}public.cs.hn.cn

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Background. Although the ministernotomy is extensively used in the repair of congenital heart defects all over the world, whether this approach has additional advantages over the conventional full sternotomy is not well established. This prospective study was designed to evaluate the effects of lower ministernotomy in the repair of congenital heart defects.

Methods. One hundred patients who underwent repair of atrial or ventricular septal defects were randomly divided into two groups: lower ministernotomy group (n = 50), and full sternotomy group (n = 50). The clinical indexes of each procedure were recorded and analyzed.

Results. The age, sex, and types of cardiac defects were comparable between the two groups. Ischemic times, bypass times, intensive care unit stay, and ventilation duration were similar in both groups. The procedure time (from skin to skin) was longer in the lower ministernotomy group than in the full sternotomy group (p < 0.001). There was less drainage in the lower ministernotomy group than in the full sternotomy group for the first 24 hours after operation (186 ± 99 mL/m² versus 237 ± 134 mL/m², p = 0.03) but no significant difference in transfusions between the two groups. The hospital stay was shorter in the lower ministernotomy group than in the full sternotomy group (6.5 ± 1.2 days versus 7.5 ± 1.8 days, p = 0.02).

Conclusions. Ministernotomy is as safe and effective as a full sternotomy in the repair of simple congenital heart defects in older children and adults. Furthermore, this small incision reduces the postoperative drainage, shortens hospital stay, and provides better cosmetic results. Operative times are longer.

	Introduction

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Although minimally invasive cardiac surgical procedures are performed all over the world, skepticism remains [1]. One of the major reasons for this debate is lack of a prospective, randomized study comparing minimally invasive cardiac procedures with conventional cardiac procedures. The lower sternotomy is a commonly used minimally invasive approach for repair of congenital heart defects [2–5]. Whether this ministernotomy has additional advantages over the full sternotomy is not well established. There are ever fewer prospective, randomized trials of minimally invasive procedures in the repair of congenital heart defects. This study was designed to evaluate the clinical effects of lower ministernotomy in the repair of congenital heart defects in older children (age > 7 years) and adults compared with conventional full sternotomy.

	Material and methods

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One hundred consecutive patients with acyanotic simple congenital heart defects who were undergoing repair procedures were randomized into two groups with 50 patients in each group. The patients were randomized to a ministernotomy group versus a full sternotomy group. The consent was from the patient or their parents (in the case of children). This study was approved by our hospital ethics medical committee.

All operations were performed using the same anesthesia protocol, moderate hypothermic cardiopulmonary bypass (30°C to 32°C), and 4:1 cold blood cardioplegia with epicardial ice slush. In some patients with atrial septal defects, hypothermic ventricular fibrillation arrest was used. All operations were performed by the same surgeon (W.L.) from May 1998 to December 1999.

In the full sternotomy group, the procedures were performed in the conventional manner. In the ministernotomy group, the midline skin incision was 6 to 12 cm (depending on the size of the patients), and the lower right-sided sternotomy was performed. This technique has been reported previously [6, 7]. The great vessels were then exposed. Ascending aortic cannulation was used in all patients with a thin-wall femoral artery cannula. If the ascending aorta was short or superior and deep with poor exposure, retrograde cardioplegia was used instead of antegrade cardioplegia. After the procedure, the chest incisions in both groups were covered with the same size of chest dressing for 48 hours, so that the individuals caring for the patients postoperatively were blinded as to the type of incisions.

Morbidity, mortality, duration of procedure (skin to skin), ischemic time (aortic cross-clamp or fibrillatory arrest), bypass time, postoperative chest tube drainage for 24 hours, blood transfusion, time of ventilation, length of intensive care unit, and length of hospital stay were recorded. The condition of incisional pain after discharge was also evaluated. Echocardiography was used to assess the effect of procedures 1 month after operation in all patients. Follow-up was at least 3 months postoperatively.

The data are reported as mean ± standard deviation. Differences of variables between both groups were analyzed with the Student’s t test, and ² or Fischer’s exact test (SPSS 8.0 for Windows). Values of p less than 0.05 were considered statistically significant.

	Results

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Tables 1 to 3 showed the perioperative data. There were no early or late deaths in either group. There were no significant differences with respect to age, sex, and type of septal defects between the two groups (Table 1). There was no morbidity in either group, and all patients recovered without event. There was no readmission and no residual shunt by echocardiography. Three children in the full sternotomy group had deformed healing of sternotomy during the follow-up.

The duration of procedure in the ministernotomy group was longer than that in the full sternotomy group (p < 0.001), but there were no significant differences between the two groups with respect to the bypass time, aortic cross-clamping time, ventilation duration, and intensive care unit stay. The drainage for 24 hours in the ministernotomy group was less than in the full sternotomy group (p = 0.03), but the number of patients requiring blood transfusion and the mean volume of blood transfusion in both groups were similar. There was a shorter hospital stay in the ministernotomy than in the full sternortomy group (p = 0.02). Although the number of patients complaining about incisional pain 1 month after operation in the ministernotomy group was decreased, this did not reach significant difference compared with the full sternotomy group (p = 0.18).

	Comment

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Surgical repair of simple congenital heart defects is both efficacious and safe using full sternotomy, cardioplegia, and cardiopulmonary bypass. With the development of minimally invasive cardiac surgical procedures in recent years, many minimal incisions have been used to perform operations on patients with congenital heart defects. Among them, the lower sternotomy is the most commonly used approach [2–5], but whether this small incision really does have additional advantages over the conventional full sternotomy has not been defined.

In the present study, we found three advantages of lower sternotomy versus conventional full sternotomy. First, less postoperative chest tube drainage occurred. Second, there was a shorter stay in the hospital. Third, the procedure provides a better cosmetic effect, especially in young women. Our results further support other reports from minimally invasive valve procedures [8] as well as minimally invasive repair of congenital heart defects [5]. Among the present significant findings, the cosmetic effects of the ministernotomy may be the major advantage over the full sternotomy, which has been well established in cardiac operations. Although the present study showed there was statistically decreased drainage in the ministernotomy group, this did not correlate with decreased requirements for transfusion in this group. Postoperative bleeding in cardiac operations is multifactorial, and the small incision was only one of the factors contributing to decreased bleeding postoperatively. Furthermore, there was no prominent clinical significance in reducing transfusion postoperatively with respect to a reduction of mean 50 mL of drainage in the ministernotomy group.

Another goal of minimally invasive cardiac procedures is to decrease the hospital stay. The length of hospital stay in the ministernotomy group was shorter when compared with that in the full sternotomy group. Because most of our patients come from areas far from our hospital, and the patients returned to rural areas with limited medical facilities, we were conservative in our discharge policy. However, there is no doubt that the size of the incision is one of the factors that determine the postoperative recovery of the patients. In this clinical experience, the postoperative recovery of the patients in the ministernotomy group were relatively faster not only physically but psychologically than those in the full sternotomy group. These clinical impressions need to be evaluated using more objective measurements.

There are several minimally invasive approaches for the repair of congenital heart defects, such as minithoracotomy [9], lower sternotomy [2–5], and subxyphoid approach [10] However, ministernotomy is the most commonly used approach in practice. Compared with the other approaches, this incision has at least three advantages. First, no peripheral artery cannulation was needed. Second, it is easy to convert to full sternotomy if necessary. Third, the distance between the incision and the cardiac septum is the shortest, which make it much easier to repair heart defects. In our study, only 3 patients (6%) required conversion to sternal transection to improve the exposure of the aorta for cannulation. However, because of the small space of the operative field and the learning curve in ministernotomy, the difficulty of manipulation was increased, and the speed of the procedure was slowed. The total time of the procedure was delayed, and this extra time (15 to 25 minutes) was mainly spent on aortic cannulation. This was especially true for adults owing to the their inflexible thorax. Aortic cross-clamping time and cardiopulmonary bypass duration were not delayed significantly.

With respect to myocardial protection used in the present study, it is noteworthy that some patients in the ministernotomy group received only retrograde cardioplegia delivery because of the very limited access to the ascending aorta (deep and short ascending aorta). Although there is a potential possibility of inadequate myocardial protection of the right ventricle, there was no evidence of right ventricular dysfunction in the group receiving retrograde cardioplegia. The local topical hypothermia from ice slush on the pericardium may enhance the right ventricular protection. In addition, simple procedures, no high-risk patients, and short aortic cross-clamping time may also contribute to the safety of retrograde cardioplegia when the ministernotomy is used.

In conclusion, from this prospective and randomized clinical trial, we showed that the lower ministernotomy is as safe and effective as a full sternotomy in the repair of simple congenital heart defects in older children and adults. Although it requires a longer operative time, this small incision reduces the postoperative drainage, decreases hospital stay, and provides a superior cosmetic result.

	Acknowledgments

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
We thank Jim Burdine, MD, with the Minnesota Thoracic Associates, for reviewing this revised manuscript.

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Wanjun Luo Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Luo, W. Articles by Chen, S. Search for Related Content PubMed PubMed Citation Articles by Luo, W. Articles by Chen, S. Related Collections Congenital - acyanotic Congenital - cyanotic Minimally invasive surgery