Comparison of 3 different incisions used for atrial-septal defect closure.
ABSTRACT Surgical closure of atrial-septal defects is now associated with low morbidity and mortality rates. We assessed surgical, cosmetic, and psychological results of 3 different surgical approaches to atrial-septal defect repair.
Study participants were 82 patients who underwent surgery for atrial-septal defect. Mean age was 21 +/- 8 years, and the female:male ratio was 23:59. Patients were divided into 3 groups according to the incision used; group 1 (n = 26), partial lower sternotomy; group 2 (n = 34), right anterolateral thoracotomy via a submammary incision, and group 3 (n = 22), conventional median sternotomy.
There was no operative or late mortality. No significant differences between groups were associated with the surgical technique used. Direct closure was the procedure of choice performed in 53 patients (64.6%). In the remaining patients the repair was performed with a pericardial patch (29 patients, 35.4%). One patient in group 1 required conversion to median sternotomy because transoesophageal echocardiography performed at the operating theater revealed a partial anomalous pulmonary venous connection of right pulmonary veins to the inferior vena cava. This patient was excluded from the study group. All patients were symptom free postoperatively, and control echocardiography revealed a trivial shunt in only 1 patient, with a Qp:Qs ratio of 1.3. Rhythm abnormalities, including atrioventricular block, atrial fibrillation, and flutter, were observed in 7 patients but were found to be unrelated to the surgical incision (P = .3). Cardiopulmonary bypass, cross-clamp, and operative times were longer with minimally invasive approaches; but these differences were not statistically significant. Intensive care unit and hospital stay periods were significantly shorter in groups 1 and 2. During the postoperative follow-up period, patients in groups 1 and 2 showed superior results in satisfaction with their cosmetic outcomes.
With the development of minimally invasive techniques that yield surgical results comparable to those of standard techniques, surgeons have changed their focus from survival to cosmetic and psychological outcomes, especially in the repair of simple cardiac defects. Operations performed via limited skin incisions are surgically safe and provide superior cosmetic and psychological results.
- SourceAvailable from: ejcts.ctsnetjournals.org[show abstract] [hide abstract]
ABSTRACT: The closure of atrial septal defects via sternotomy is a low-risk and high-benefit procedure. Limited right anterolateral thoracotomy is an alternative approach with regard to cosmetic aspects. However, it is discussed that a lateral approach is not appropriate for more complex lesions and is associated with an increased incidence of phrenic nerve damage. The perioperative and long-term outcomes (mean follow-up time: 73.2 months) of 87 female patients, mean age 20.4 years (range: 3-56 years), operated on for all types of atrial septal defects via limited right anterolateral thoracotomy between 1982 and 1993, were analysed retrospectively. Special features of the operation technique were a limited skin incision, protection of mammary gland tissue, prevention of phrenic nerve damage, and aortic cannulation in all patients. There were no intraoperative complications. Postoperative complications occurred in 12/87 patients including one rethoracotomy for postoperative bleeding and one late pericardial tamponade due to coumadine overdose. Follow-up was assessed by a survey obtained by the patients or their parents, and their family doctors in 79 patients (90.8%) Cardiac symptoms, mostly supraventricular arrhythmias, were observed in 13.9%. Echocardiography revealed mild tricuspid valve regurgitation (one patient) and mild mitral valve incompetence (one patient with ostium primum defect); there were no residual shunts. Cosmetic results were considered good and excellent in 87.3% and satisfactory in 8.9%. Three patients (3.8%) complained of a broad scar. Anaesthetic areas and optional scar pain were quite frequent (16.5%), whereas restriction of shoulder movement, breast asymmetry and scoliosis were rare. In summary, only one patient, suffering from intercostal neuralgia, would prefer sternotomy. Limited right anterolateral thoracotomy has a high cosmetic acceptance and was proven to be safe and effective for closure of any kind of atrial septal defects. Therefore, it is recommended as standard approach for atrial septal defects especially in female patients. reserved.European Journal of Cardio-Thoracic Surgery 02/1999; 15(1):18-23. · 2.67 Impact Factor
Background: Surgical closure of atrial-septal defects
is now associated with low morbidity and mortality rates.
We assessed surgical, cosmetic, and psychological results of
3 different surgical approaches to atrial-septal defect repair.
Methods: Study participants were 82 patients who
underwent surgery for atrial-septal defect. Mean age was 21 ± 8
years, and the female:male ratio was 23:59. Patients were
divided into 3 groups according to the incision used; group 1
(n = 26), partial lower sternotomy; group 2 (n = 34), right
anterolateral thoracotomy via a submammary incision, and
group 3 (n = 22), conventional median sternotomy.
Results: There was no operative or late mortality. No
significant differences between groups were associated with
the surgical technique used. Direct closure was the procedure
of choice performed in 53 patients (64.6%). In the remain-
ing patients the repair was performed with a pericardial
patch (29 patients, 35.4%). One patient in group 1 required
conversion to median sternotomy because transoesophageal
echocardiography performed at the operating theater
revealed a partial anomalous pulmonary venous connection
of right pulmonary veins to the inferior vena cava.
This patient was excluded from the study group. All patients
were symptom free postoperatively, and control echocardio-
graphy revealed a trivial shunt in only 1 patient, with
a Qp:Qs ratio of 1.3. Rhythm abnormalities, including
atrioventricular block, atrial fibrillation, and flutter, were
observed in 7 patients but were found to be unrelated to
the surgical incision (P = .3). Cardiopulmonary bypass,
cross-clamp, and operative times were longer with
minimally invasive approaches; but these differences were
not statistically significant. Intensive care unit and hospital
stay periods were significantly shorter in groups 1 and 2.
During the postoperative follow-up period, patients in
groups 1 and 2 showed superior results in satisfaction with
their cosmetic outcomes.
Conclusions: With the development of minimally
invasive techniques that yield surgical results comparable
to those of standard techniques, surgeons have changed
their focus from survival to cosmetic and psychological
outcomes, especially in the repair of simple cardiac defects.
Operations performed via limited skin incisions are surgi-
cally safe and provide superior cosmetic and psychological
Surgical closure of atrial-septal defect (ASD) is associated
with very low mortality rates, and since cardiac surgery
began in the early 1950s, countless patients have benefited
from this surgical procedure [Horvath 1992; Konstantinides
1995; Lange 2001; Doll 2003; Ryan 2003]. Conventional
standard median sternotomy is the incision most
commonly used by most surgeons, but this approach may
be troublesome postoperatively because of the midline scar,
especially for young patients. In addition to the achievement
of a satisfactory surgical outcome, we believe that cosmetic
aspects of surgery cannot be neglected in cardiac surgery.
Currently, minimally invasive approaches have gained
popularity in all areas of surgery, and various cardiac proce-
dures can be performed safely through limited incisions
[Barbero-Marcial 1998; Däbritz 1999; Houyel 1999; Bichell
2000; Abdel-Rahman 2001; Schreiber 2005; Ak 2007;
Mishaly 2008]. New approaches may improve postoperative
psychological status by increasing patient body-image
satisfaction. Numerous reported studies [Abdel-Rahman
2001; Doll 2003; Schreiber 2005; Mishaly 2008] have
focused on early morbidity and mortality rates of such
techniques. In these studies, the investigators have tried to
reveal the equivalency of these approaches to conventional
approaches with regard to morbidity, mortality, and efficacy.
A few authors, including Massetti and coworkers [Massetti
1996, 1999], evaluated the cosmetic and psychological
implications of minimally invasive incisions; a major limi-
tation of this study, however, was the absence of a control
group. In this retrospective study, we assessed the early
outcomes of 3 different approaches and also compared
the cosmetic and psychological results obtained with each
The Heart Surgery Forum #2008-1060
11 (5), 2008 [Epub October 2008]
Received June 29, 2008; accepted September 15, 2008.
Correspondence: Murat Basaran, Fahrettin Kerim Gokay Street, Goztepe Safak
Hospital, Cardiovascular Surgery Clinic, Istanbul, Turkey; 00 90 216 565 44 44;
fax: 00 90 216 566 16 16 (e-mail: firstname.lastname@example.org).
Online address: http://cardenjennings.metapress.com
Comparison of 3 Different Incisions Used for Atrial-Septal
Murat Basaran, MD, Ali Kocailik, MD, Cihan Ozbek, MD, Alper Ucak, MD,
Eylul Kafali, MD, Melih Us
Goztepe Safak Hospital, Cardiovascular Surgery Clinic, Istanbul, Turkey
© 2008 Forum Multimedia Publishing, LLC
Comparison of 3 Different Incisions Used for Atrial-Septal Defect Closure—Basaran et al
MATERIALS AND METHODS
From September 2000 to July 2005, 82 patients with
a diagnosis of ASD were included into this retrospective
study. Data were gathered by examining the surgical and
medical records of patients. Mean age was 21 ± 8 years, and
female:male ratio was 23:59. Preoperative diagnosis and type
of ASD were determined by transthoracic echocardiography,
and additional invasive diagnostic modalities were carried
out in patients with appropriate indications. Older patients
(>40 years) with known risk factors of coronary artery disease
and peripheral arterial disease were routinely evaluated by
coronary and peripheral arterial angiography, respectively.
Defect closure was considered in symptomatic patients and
in patients with a Qp:Qs ratio of 1.5 [Gatzoulis 1996].
To overcome any statistical bias, patients requiring additional
procedures such as coronary artery bypass or valve
repair/replacement were excluded from the study group.
Patients were divided into 3 groups according to the incision
used; group 1 (n = 26), partial lower sternotomy; group 2
(n = 34); right submammary incision, and group 3 (n = 22),
conventional median sternotomy. Preoperative demographics
of all patients are listed in Table 1.
Noninvasive monitoring by electrocardiogram, pulse
oximetry, and measurements of inspiratory and expiratory gas
concentrations were used as well as invasive monitoring of cen-
tral venous and arterial pressures. The induction of anesthesia
was achieved with intravenous fentanyl (3μg/kg), propofol
(2 mg/kg), and vecuronium (0.1 mg/kg). Intermittent fentanyl
and isoflurane were used for maintenance. Transesophageal
endoscopic echocardiography was performed in patients to
confirm the preoperative diagnosis.
In group 1, surgery was performed while the patient was in
a supine position, and a longitudinal incision was made in the
femoral region to prepare the femoral artery for later use.
After a skin incision of 6-8 cm was made, the surgeon
performed a J-shaped partial lower sternotomy extending
from the xiphoid process to the right third intercostal space.
After systemic heparinization (activated coagulation time
>480 seconds), cardiopulmonary bypass was established through
cannulations of the ascending aorta and both caval veins.
Superior and inferior vena cavae were encircled with silicone
rubber loops. In cases with difficult exposure of the ascending
aorta because of significant cardiomegaly, the femoral route was
used for inflow. After the application of a cross-clamp, a dose
of 20 mL/kg of cold crystalloid cardioplegia was initially
infused into the aortic root at a pressure of 30 mmHg to
achieve cardiac arrest. Via a right atriotomy incision, the ASD
was closed directly or with a pericardial patch, depending on
the size of the defect. Before declamping, deairing was
performed carefully by use of a standard method through the
aortic root. Weaning from cardiopulmonary bypass was com-
menced when the patient’s rectal temperature reached 37˚C,
and the chest and groin wounds were closed with subcuticular
sutures to optimize the cosmetic results (Figure, A).
In group 2, surgery was performed while the patient was in
a slightly oblique position at an angle of 45˚. A 5-cm sub-
mammary incision was performed, and the cavity was entered
via the right fourth intercostal space in female patients with
developed breasts. In patients with undeveloped breasts, the
position of the skin incision was slightly lower, at the level of
the seventh intercostal space. The pericardium was opened
anterior to the phrenic nerve, and retraction sutures were
placed to improve surgical field exposure. The rest of the
surgical procedure was carried out as in group 1 patients.
The heart was arrested with antegrade cardioplegia, and the
ASD was then closed either with previously harvested
pericardium or directly. Weaning from cardiopulmonary
bypass was commenced when the patient’s rectal temperature
reached 37˚C, and the wounds were closed with subcuticular
sutures to optimize the cosmetic results (Figure, B). In
group 3, conventional median sternotomy with direct aortic
and bicaval cannulations were performed. Cardioplegia was
delivered antegradely and the ASD was closed through a right
The primary outcomes assessed were early postoperative
parameters and pain scores. Prolonged mechanical ventilation
time was defined as the requirement of mechanical ventilatory
support for more than 24 hours. Other postoperative compli-
cations recorded were revision because of postoperative
bleeding, superficial sternal infection, femoral wound infection,
and pneumonia. Postoperative pain scores were quantified
at 24, 48, and 96 hours by use of a visual analog rating scale
ranging from 0 (no pain) to 10 (worst possible pain).
The recorded need of pain medications was quantified with
a numeric scale (analgesic scale) with 0 indicating no addi-
tional medication; 1, pain relieved with the use of diclofenac
sodium intramuscularly; 2, use of meperidine intramuscularly;
and 3, more than 2 doses of meperidine daily [Ogus 2007].
The secondary outcomes included cosmetic and psychological
impacts of intervention. The patients were asked to complete
a modification of a self-report questionnaire described by
Massetti and coworkers [1996, 1999]. The answers were
assessed to determine the impacts of their surgical scar on
their routine daily life.
Data are expressed as mean ± SD. Statistical analysis was
performed by one-way ANOVA test with the post-hoc Tukey
for comparison of pre- and postoperative variables between
groups. The comparison of 3 groups was performed with the
Table 1. Preoperative Demographics of All Patients*
(n = 26)
(n = 34)
(n = 22)
Sex (F/M), n
19.1 ± 3.5
1.9 ± 0.3
64.5 ± 8.1
2.3 ± 0.2
28.9 ± 6.5
21.7 ± 4.1
2.1 ± 0.4
66.3 ± 7.9
2.1 ± 0.4
25.6 ± 3.7
18.6 ± 2.9
2.3 ± 0.4
63.2 ± 9.4
2.4 ± 0.3
23.2 ± 4.1
*NYHA indicates New York Heart Association; EF, ejection fraction; PAP,
pulmonary artery pressure.
The Heart Surgery Forum #2008-1060
Kruskal-Wallis test, whereas differences between 2 groups
were analyzed with the Bonferonni-adjusted Mann–Whitney
U-test. Differences were considered statistically significant
for a P-value of <.05.
There were no deaths or major complications during the
early postoperative period. Skin incision lengths ranged
from 5 to 8 cm in groups 1 and 2. Mean femoral incision
length was 3.1 cm (range, 2 to 4 cm). One patient in group 1
required conversion to median sternotomy because
transoesophageal echocardiography performed at the time
of surgery revealed a partial anomalous pulmonary venous
connection of the right pulmonary veins to the inferior
vena cava. This patient was excluded from the study group.
In 53 patients (64.6%) the septal defect was closed directly,
whereas in the remaining 29 patients (35.4%) a pericardial
patch was used to close the defect. There was no significant
difference between groups in terms of surgical technique
used (pericardial patch vs direct closure). The number of
patients having direct closure in groups 1, 2, and 3, respec-
tively, were 17 of 26 (65.4%), 22 of 34 (64.7%), and 14 of
Intra- and postoperative patient data are presented in
Table 2. Cardiopulmonary bypass, cross-clamp, and skin-to-skin
operative times were longer with minimally invasive
approaches, but this difference was not statistically significant.
During the early postoperative period there were no significant
differences in mechanical ventilation time or postoperative
blood loss (Table 2). All patients were extubated within a few
hours after surgical intervention. No patient required revision
because of postoperative drainage. Intensive care unit and
hospital stays were significantly shorter in groups 1 and 2
(Table 2). Rhythm abnormalities, including atrioventricular
block, atrial fibrillation, and flutter, were noticed in
7 patients, but these findings were not related to the surgical
incision (P = .3). One patient in each group experienced atrial
fibrillation postoperatively, but all patients were converted to
normal sinus rhythm with medical treatment. Two patients in
group 1, 1 patient in group 2, and 1 patient in group 3 had
transient right or left bundle-branch block that resolved spon-
taneously. There were no wound-healing problems at sternal
and thoracic incision sites in any group. All patients who
underwent the operation via femoral cannulation were free
from complications except 2 patients who developed paresthe-
sia at the inguinal region. Extreme care was undertaken to
avoid the phrenic nerve during surgery, and there was no
phrenic palsy in any patient. More patients in group 3 required
analgesic medication postoperatively, and analgesic scores
were lower in groups 1 and 2 (Table 3). During the early
postoperative period, 1 patient in group 2 suffered from
intercostal neuralgia, which was treated with medical therapy.
All patients were symptom free postoperatively and
in New York Heart Association Class I. Postoperative
Photographs views of patients after partial lower sternotomy (A) and
right anterolateral thoracotomy via submammary incision (B).
Table 2. Intra- and Postoperative Data of All Patients
(n = 26)
(n = 34)
(n = 22)
bypass time, min
Blood loss, mL
unit stay, h
Hospital stay, d
149.4 ± 17.8153.6 ± 16.5 145.8 ± 14.2 .1
25.8 ± 4.924.9 ± 5.321.1 ± 3.2 .09
62.4 ± 13.660.4 ± 11.456.4 ± 14.7 .08
4.2 ± 1.23.9 ± 0.84.4 ± 1.6 .11
325 ± 56.7
347 ± 63.5
13.9 ± 4.1†
363.8 ± 48.1
18.2 ± 5.6
5.1 ± 0.8*5.4 ± 0.9† 7.2 ± 1.2.03
*Group 1 vs 3, P < .01.
†Group 2 vs 3, P < .01.
echocardiographic evaluation revealed a trivial shunt in only
1 patient, with a Qp:Qs ratio of 1.3. Among the patients
examined postoperatively, no changes in breast volume and
symmetry were observed. The results obtained from the
self-report questionnaires and the comparisons of the 3 groups
are presented in Table 4.
Previous investigations have revealed excellent outcomes
obtained with minimally invasive cardiac surgery performed
via approaches other than median sternotomy [Barbero-Marcial
1998; Däbritz 1999; Houyel 1999; Bichell 2000]. An important
limitation of such studies, however, is the underevaluation of
psychological aspects of surgical intervention. In our study, we
aimed to assess the early outcomes of 3 different approaches
and also to compare the cosmetic and psychological results
obtained with 3 different techniques. Our experience suggests
that ASD closure can be performed as safely with minimally
invasive surgical procedures as with the standard median
sternotomy incision. Furthermore, minimally invasive surgery
avoids the midline scar and positively affects the psychological
status of the patient.
Surgeons are currently using a variety of incisions to obtain
adequate exposure, and the decision of approach usually
depends on personal preference. Some conflicting results have
been reported in the medical literature. Some studies have
suggested that none of these approaches have specific
superiority over each other [Bichell 2000; Ryan 2003].
In contrast, other studies have demonstrated the advantage of
minimally invasive surgery, especially in regard to intensive
care unit and hospital stays [Abdel-Rahman 2001; Mishaly
2008]. Indeed, our patients who underwent surgery with
minimal incisions had shorter intensive care unit and hospital
stay periods. Short incisions undoubtedly reduce surgical
trauma, which in turn leads to better postoperative recovery;
but these approaches are not free of complications. The major
drawbacks for the use of these approaches include the poten-
tial for complications such as increased operative time and risk
of injury to cardiac structures, especially during the surgeon’s
learning-curve period, and difficulty in the achievement of
adequate exposure and deairing.
The midline skin incision may leave an unsightly scar,
which leads to psychological displeasure that modifies the
patient’s body image. At the beginning of minimally invasive
surgery, the main goal was a nearly invisible, cosmetically
acceptable scar along with successful ASD closure comparable
to that obtained with a conventional approach. Most surgeons
have thus tried to obtain acceptable results with surgery
performed via short incisions leaving an invisible scar.
But studies of these procedures have generally failed to inves-
tigate the psychological impacts of surgical scars. We totally
agree with Massetti [1996, 1999], who suggested that the
psychological sequelae of cardiac surgery have been generally
underevaluated by surgeons who focus only on the achieve-
ment of satisfactory surgical outcome. In the current surgical
era, however, one of the major aims should be the reduction
of surgical impact caused by a midline scar.
The performance of the surgical procedure through a small
incision requires established skill and experience. Limited
exposure of the ventricles requires specific strategies regarding
deairing, pacing-wire insertion, and defibrillation. Minimally
invasive surgery can be accomplished in various ways.
Encouraging results have been obtained with the use of
percutaneous transcatheter closure of ASD [Liang 2006;
Hongxin 2007], but the major limitation of such intervention
is the need for special equipment. Furthermore, the use of
percutaneous transcatheter closure is usually limited to cases
with a maximum defect size of 34 mm and an accessible neck.
© 2008 Forum Multimedia Publishing, LLC
Comparison of 3 Different Incisions Used for Atrial-Septal Defect Closure—Basaran et al
Table 3. Visual Analog Pain Scale (VAS) and Analgesic Scale
(n = 26)
(n = 34)
(n = 22)
1.3 ± 0.4*
1.1 ± 0.2*
1.0 ± 0.1*
0.3 ± 0.1*
1.1 ± 0.3†
0.9 ± 0.1†
0.9 ± 0.1†
0.45 ± 0.1†
5.2 ± 0.9
4.5 ± 0.7
4.3 ± 0.6
2.7 ± 0.8
*Group 1 vs 3, P < .01
†Group 2 vs 3, P < .01
Table 4. Answers to Self-Report Questionnaire
Group 1 (n = 26) Group 2 (n = 34) Group 3 (n = 22)
Perception of the scar
Evaluation of the cosmetic result
Absence of psychological problems when:
Dressings are removed
Wearing a bathing suit
Participating in sports
In addition, data are not yet available regarding the long-term
results of percutaneous transcatheter closure, so the risks of
endocarditis and thrombus formation are not clear.
In our series, both femoral and aortic cannulations were
used for arterial inflow. The introduction of all cannulas
through the chest incision may obscure the surgical field;
we thus did not hesitate to use a groin incision during the
operation. As mentioned by Schreiber and colleagues ,
a minimum weight requirement of approximately 10-15 kg is
required for the use of femoral-artery cannulation. Because
our patients were generally older than those of Schreiber
et al, we used the femoral artery more liberally and observed
no major postoperative complications related to the femoral
incision. Methods for myocardial protection are the subject of
considerable debate. Although fibrillatory arrest can be
considered as an alternative adjunct, in our cohort every
effort was made to administer cardioplegia through a needle
introduced into the aortic root.
Another controversial issue addressed in the literature
is the optimal approach for young female patients. Some
surgeons recommend the use of a small thoracotomy inci-
sion in young patients [Giamberti 2000]. Others question
the use of this type of incision in this patient group because
asymmetric development of the right breast has occurred in
female patients who underwent surgery through a right
anterolateral thoracotomy during the prepubescent period.
Because our patient group was older, with developed breast
tissue, we generally used a bikini-line incision, which can
be easily hidden by the patient. In 4 patients younger than
12 years, however, we chose a lower partial sternotomy
approach to avoid any future problem with breast
In conclusion, with the development of minimally invasive
techniques that yield comparable surgical results, surgeons
have changed their focus from survival to cosmetic and
psychological outcomes, particularly when repairing simple
cardiac defects. Minimally invasive approaches reduce
surgical trauma and postoperative pain and allow faster
postoperative recovery. Operations performed via limited skin
incisions are surgically safe and provide superior cosmetic and
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