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: email@example.com).
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