Atrial Septal Defect Closure by Anterior Mini Thoracotomy with Total Peripheral Cannulation: A Step towards Establishing Mini Invasive Cardiac Surgery in a Developing Nation

Background: Atrial Septal Defect (ASD) closure is a common cardiac surgical procedure performed worldwide. Due to favourable clinical outcome, minimal invasive approach is becoming popular. Hence this study was conducted to compare the outcome of two surgical approaches, median sternotomy and mini thoracotomy with total peripheral cannulation, in a developing country Nepal. Methods: A prospective study of 62 ASD patients, randomized to undergo surgical closure either via right anterior mini thoracotomy or median sternotomy was conducted and followed up over three years. The clinical outcome parameters like intensive care unit stay, hospital stay, post-operative duration of ventilation, cardiopulmonary bypass time, aortic cross clamp time, mediastinal drainage, size of scar and complication were compared between two groups. Results: Cardiopulmonary bypass time and aortic cross clamp time were significantly longer in right anterior mini thoracotomy group as compared to median sternotomy group (43.97 min ± 12.70 min vs 34.42 min ± 10.42 min and 25.13 min ± 7.82 min vs 19.48 min ± 6.93 min respectively, p-value < 0.05). There was no significant difference in duration of surgery (2.75 hrs ± 0.43 hrs vs 2.56 hrs ± 0.41 hrs, p-value = 0.09), post-operative ventilation (2.90 hrs ± 1.22 hrs and 2.88 hrs ± 1.07 hrs, p-value = 0.96) between two groups. Post-operative mediastinal drainage was significantly less in right anterior mini thoracotomy group (214.52 ml ± 91.79 ml vs 284.03 ml ± 158.91 ml, p-value = 0.04). There was no significant difference in How to cite this paper: Khakural, P., Baral, R., Bhattarai, A. and Koirala, B. (2020) Atrial Septal Defect Closure by Anterior Mini Thoracotomy with Total Peripheral Cannulation: A Step towards Establishing Mini Invasive Cardiac Surgery in a Developing Nation. World Journal of Cardiovascular Surgery, 10, 192-199. https://doi.org/10.4236/wjcs.2020.1010022 Received: August 24, 2020 Accepted: October 23, 2020 Published: October 26, 2020 Copyright © 2020 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access


Background
Atrial Septal Defect (ASD) is one of the common cardiac malformations, approximately 6.7% [1]. Although these malformations are often asymptomatic [2], if uncorrected, they may lead to irreversible pulmonary hypertension, progressively declining cardiac function and early death [3]. Median sternotomy (MS) has been the gold standard approach in cardiac surgery because almost all aspects of the heart can be reached and complex measures such as revascularization, valve surgery and procedures for arrhythmia can be executed. However, MS requires a large surgical wound around the sternum that can cause bleeding from bone marrow that occasionally requires blood transfusion and results in mediastinitis, which is often a critical complication although ASD itself is not a critical disease. In contrast, minimally invasive approaches like right anterior mini thoracotomy (RAMT) with cannulation of femoral artery, femoral vein and internal jugular vein delivers the benefits of smaller, less painful wounds, shorter hospital stay, more rapid postoperative recovery and cost reductions and has become a feature of cardiac surgery [4] [5]. Preferable results of minimally invasive ASD closure have been reported and Vida et al. had obtained excellent cosmetic results [6] [7] [8]. However, mini invasive cardiac surgery is in an early phase of development, in low resource countries. Hence this study was aimed to compare the clinical outcomes in ASD closure by RAMT with total peripheral cannulation and MS in a developing country like ours.

Methods
Sixty two patients of ostium secundum ASD, at Manmohan Cardiothoracic Vascular and Transplant Center, Kathmandu, Nepal from December 2014 to June 2016 were randomized into two groups (ASD closure via MS and ASD closure via RAMT with total peripheral cannulation), operated and followed prospectively. All the patients above 14 years of age, requiring ASD closure were included in the study. However, patients weighing less than 25 kg, those requiring other concomitant cardiac procedures and those with previous thoracic surgery/infection were excluded from study. Approval was obtained from institutional review committee for the study. In RAMT group, patients underwent standard general anesthesia, a right sub-mammary incision of 6 cm or less with anterior thoracotomy, internal jugular vein, femoral artery and femoral vein

Discussion
Atrial septal defect is more common in females as compared to males. Our study also showed a female preponderance (Female: male-2.2:1), which is a finding similar to that seen in a study Bigdelian et al. [9]. In our study, the mean age of  [12]. The smaller incision, limited working space increase the CPB time and ASD closure time. In a retrospective Japanese study, ACC time was longer in the right thoracotomy group than in the MS group (45 ± 17 min vs 23 ± 9 min, p = 0.004) [13]. Adhikary et al., found that the mean total operation time was 217.33 ± 21.65 min in ASD closure via thoracotomy [14]. lost by the right thoracotomy group than the MS group (89 ± 53 mL vs 209 ± 142 mL, p = 0.01) [13]. However, the total amount and duration of blood drainage did not significantly differ between the two groups. Thoracotomy patients have the advantages of small incision, less pain, early extubation, less mediastinal drainage, early drain removal, early ambulation and hence they tend to have a shorter ICU stay and hospital stay. However in our study, no significant difference was found in the ICU stay and hospital stay amongst the groups. One study showed, the mean length of stay in the intensive care unit was 2 days and the mean length of hospital stay was 4.5 days [9]. The length of stay in the ICU and hospitalization did not significantly differ between the two groups in other studies [13]. In our study, pain management in RAMT group was done with infu-

Limitations of the Study
This was a single hospital based study, done over a limited period with a small sample size. Quantification of pain is always a difficult matter. Although the use of numeric pain scale helps to quantify it, the subjective perception of intensity of pain varies amongst individuals.

Conclusion
We found a shorter surgical scar, less mediastinal drainage and lower pain score in RAMT group. There were no differences in postoperative ventilation duration, ICU stay and hospital stay. CPB and ACC time were significantly shorter in MS group. Although statistically insignificant, the operative time was less in MS group than RAMT group. Patients were satisfied with the smaller incision and P. Khakural et al.
perceived that they had the better cosmetic results, besides having less pain in immediate postoperative period as well as in long term follow up. There was no mortality, limb loss or any other major complication. Hence we conclude that ASD can be closed safely by mini thoracotomy incision with total peripheral cannulation with a better long term cosmetic result.