Right thoracotomy approach for open heart surgery

Abstract

INTRODUCTIONThough most cardiac operations are performed through median sternotomy because of its versatility and familiarity to surgeons, the fact is sternotomy is not without complications, and the problems of post sternotomy pain, dehiscence, mediastinitis, osteomyelitis and unstable sternum increases morbidity and mortality in these patients. Median sternotomy may also leave a bad scar which patients don't prefer. Alternative to median sternotomy are gaining popularity in cardiac surgery. As an alternative to median sternotomy, the heart may be approached by (i) right parasternal mini-incision, aortic and central venous cannulation, (ii) right submammary mini-incision, femoral arterial cannulation and central venous cannulation, (iii) right submammary mini-incision, femoral arterial cannulation, right atrial cannulation and percutaneous jugular vein cannulation, (iv) parasternal incisions, the (v) hemisternotomy, the (vi) minithoracotomy, (vii) upper half sternotomy and or (viii) lower half sternotomy, (ix) lower small midline skin incision with minimal sternotomy approach, (x) transxiphoid approach without sternotomy. At times horizontal submammary skin incisions are used to split sternum to get the best post-operative results. The concept of alternative approaches for cardiac surgery started only when safety of open heart surgery was ABSTRACT Background: Median sternotomy approach provides excellent exposure of all the chambers of heart for performing open heart surgery, but this approach is the most invasive used for any surgical procedure. Besides an ugly scar, median sternotomy not only increases the morbidity but at times mortality also. To have an acceptable postoperative scar and to avoid the morbidity and mortality associated with median sternotomy, the present study was conducted to find an alternative to median sternotomy in patients with atrial septal defect, mitral and tricuspid valve disease. Methods: Patients were positioned with right side elevated 30-45 degree, and heart was approached by right anterior thoracotomy, through 4th intercostals space. Pericardium was opened anterior to phrenic nerve, and upper end pericardial stay sutures given to get aorta more anterior. Aortic and bicaval cannulation was done and intracardiac procedures were performed as are done after standard median sternotomy. Results: Difficult aortic cannulation and fracture to costochondral junction was the problem observed in some patients. Repair of atrial septal defect was the most common operation performed. Sternotomy, rib resection and peripheral cannulation was not needed in any of these patients. Post-operative period was uneventful in majority. Conclusions: In all patients above 4 years of age, with normal aortic valve, without active lung disease / previous right thoracotomy, having isolated atrial septal defects, mitral and tricuspid valve disease the heart should be approached through right anterior thoracotomy.

Atrial myxoma: a review

“…The details of thoracotomy approach for intracardiac procedures, its advantages and disadvantages, have been discussed in detail in other studies. 77,78 In spite of functional class, approach, embolization, the overall mortality is less then 5%. 15,16,18,21,59 In conclusion atrial myxoma though rare, can present with a grim phenomenon, symptomatology and clinical features are not specific, diagnosis is made by transesophageal echocardiography, in case of doubt other modalities of investigation should be used, once a diagnosis of atrial myxoma is made, surgery should not be delayed, jugular cannulation should be avoided, heart should be approached by right anterior thoracotomy, cannulation should be done gently, cardioplegia should be started after aortic cross clamp, tumor should be approached through right atriotomy, should be excised along with its base, thorough irrigation, suction of all the chambers should be done, the defect so created should be closed by direct or patch repair.…”