right axillary thoracotomy chd repair usa grand rounds
TRANSCRIPT
Minimal Invasive Left and Right Axillary Thoracotomy for Epicardial Pacing and Transatrial Repair of Congenital Heart
Defects: more than just a cosmetic sales pitch
A. Dodge-Khatami, MD, PhDChief of Pediatric and Congenital Heart SurgeryChildren’s Heart CenterProfessor of Surgery, University of Mississippi Medical CenterJackson, MS, USA
New Trends and Innovations in treating Congenital Heart Disease at the Children’s
Heart Center of UMMC
Introduction
standard approach for repair of congenital heart defects: •median sternotomy + central aorto-bicaval cannulation for cardiopulmonary bypass (CPB)•advantages:
– access to every cardiac structure (R+L) – maximum room for cannulation under direct
vision– no additional incisions/routes for cannula
insertion necessary
•disadvantages: – large visible scar– sternum requires 4-6 weeks to heal in
babies/children, and 6-8 weeks in adolescents/adults
– limitations to certain physical activities during healing (care in lifting babies/infants, bicycle riding, shopping bags, putting on backpack, driving …)
ALTERNATIVES?
Introduction
standard approach to pacemaker / defibrillator insertion: •transvenous + infra-clavicular generator pocket•advantages:
– lesser invasive surgery– (can be performed by EP (electro-philosophical)
cardiologist) •disadvantages:
– hardware in SVC of a growing kid, multiple leads if lead failure, near fatal events at extraction?
– venous thrombosis, SVC syndrome, endocarditis– often compromise in smaller patients with a VVI
system and not dual chamber > un-physiologic and may lead to early onset cardiomyopathy!
– no access to the heart if single ventricle Fontan completion
– more potential for trauma to anteriorly located generator
ALTERNATIVES?
Minimal Invasiveness : true patient benefit?
Lessen Surgical Trauma
Physical: •reduce incision (muscle-sparing, endoscopy)•reduce or eliminate cardiopulmonary bypass (decrease inflammation, filtration strategies, myocardial protection, off-pump surgery)
Psychological:•fast tracking (early extubation, short ICU, allowing quicker functional recovery and return to a normal environment)•cosmetic / less visible to peers•losing the stigma of “a child with a heart condition” and its negative emotional burden>> think of long-term consequences
Minimal Invasiveness
Avoid Surgical Trauma?
Interventional Catheter Procedures: •avoids incision (femoral vessel puncture)•avoids cardiopulmonary bypass•allows much quicker functional recovery and return to a normal environment
VSD device closure Ebeid MR, Batlivala SP, Salazar JD, Eddine AC, Aggarwal A, Dodge-Khatami A, Maposa D, Taylor MB. Percutaneous Closure of Perimembranous Ventricular Septal Defects Using the Second-Generation Amplatzer Vascular Occluders. Am J Cardiol. 2016;117:127-30.
ASD device closure
Minimal Invasiveness
Avoid Surgical Trauma?
Interventional Catheter Procedures: •avoids incision (femoral vessel puncture)•avoids cardiopulmonary bypass•allows much quicker functional recovery and return to a normal environment
>> Complications - ConversionsHowever ! >> Duration of Results? >> Accept Residual Lesions?
current trend / demand to increasingly intervene with percutaneous techniques whenever possible
>> challenge the surgical community to step up
WITHOUT COMPROMISING THE QUALITY OF REPAIR!
Minimal Invasiveness
1. muscle-sparing left mid-axillary thoracotomy
Left Heart DDD Epicardial Pacemaker Insertion Zurich, Hamburg, Jackson: 2003-2008; n=114, 2009-2016; n=87
•can avoid high-risk redo sternotomy•no mortality or major morbidity•favorable pacing characteristics (left heart vs. right heart cardiomyopathy)•avoids intravenous leads in growing patients•optimal sensing thresholds at mid-term follow-up >> high probability of lead survival
M Tomaske, B Gerritse, L Kretzers, R Prêtre, A Dodge-Khatami, M Rahn, U Bauersfeld. A 12-year experience of bipolar steroid-eluting epicardial pacing leads in children. Ann Thorac Surg. 2008;85:1704-11
Minimal Invasiveness
Left Heart DDD Epicardial Pacemaker Insertion through a mini-incisionis safe and reliable
steroid-eluting bipolar leads left atrial appendage +
lateral wall (apex) of the left ventricle
Janoušek J, van Geldorp IE, Krupičková S, Rosenthal E, Nugent K, Tomaske M, et al; Working Group for Cardiac Dysrhythmias and Electrophysiology of the Association for European Pediatric Cardiology. Permanent cardiac pacing in children: choosing the optimal pacing site: a multicenter study.Circulation. 2013;127:613-23.
Minimal Invasiveness
2. muscle-sparing right mid-axillary thoracotomy
Open repair of a wide range of CHD with Cardiopulmonary Bypass
Aortic or right iliac artery+ Bicaval or iliac vein cannulationZurich, 2001-2007; n=123, Hamburg, Jackson; n=48
•ASD•VSD +/- subaortic membrane•Partial AV Canal with mitral valve cleft•PAPVD / Warden operation•DCRV, cor triatriatum
5.5 - 82kgHH Dave, M Comber, T Solinger, D Bettex, A Dodge-Khatami, R Prêtre. Mid-term results of right axillary incision for the repair of a wide range of congenital cardiac defects. Eur J Cardiothorac Surg. 2009;35:864-70.
Minimal Invasiveness
2. muscle-sparing right mid-axillary thoracotomy
incisions / approach
vs. right anterolateral thoracotomyBleiziffer et al. J Thorac Cardiovasc Surg 2004;127:1474–80
Minimal Invasiveness
2. muscle-sparing right mid-axillary thoracotomy
view / cannulation
Minimal Invasiveness
2. muscle-sparing right mid-axillary thoracotomy
ASD closure
Minimal Invasiveness
2. muscle-sparing right mid-axillary thoracotomy
VSD patch closure
VSD +/- subaortic membrane
Minimal Invasiveness
2. muscle-sparing right mid-axillary thoracotomy
partial AV canal with mitral cleftPAPVD / Warden operation
Minimal Invasiveness
2. muscle-sparing right mid-axillary thoracotomy
results
A Dodge-Khatami, J Salazar. Right axillary thoracotomy for transatrial repair of congenital heart defects: VSD, partial AV canal with mitral cleft, PAPVR/Warden, cor triatriatum and ASD. Oper Tech Thorac Cardiovasc Surg 2016; Spring: In Press.
Minimal Invasiveness
2. muscle-sparing right mid-axillary thoracotomy
Open repair of a wide range of CHD
•safety of procedure: learning curve!•completeness in correcting the primary defect (= no residual lesions)•reduced stay in ICU and hospital•faster recovery of right shoulder and arm function vs. sternotomy•superior cosmetic result with a vertical incision hidden underneath a resting arm•remote from breast tissue to avoid future asymmetric breast growth
Minimal Invasiveness
muscle-sparing left + right mid-axillary thoracotomy
open repair of a wide range of CHDDDD epicardial pacing for arrhythmia
•prolonged cure of CHD without need for reintervention or reoperation •avoids intra-venous hardware in growing kids
> long term good results > true patient benefit (not just a sales pitch)
New Operations / Concepts
3. Primary IVC-PA Connection: = Upside-down Glenn= “Southern Glenn”
•an alternative palliation in single ventricle physiology when the bidirectional Glenn is an unfavorable option•Presented at the CHSS, Chicago, USA, Oct 25-26, 2015, at the STSA, Orlando, USA, Nov 4-7, 2015, at the PCICS, Houston, USA, Dec 9-11, 2015•Film posted on CTSNet.org, Feb. 8, 2016-current: http://www.ctsnet.org/article/when-bidirectional-glenn-unfavorable-option-primary-extracardiac-inferior-cavopulmonary•A. Dodge-Khatami, A. Aggarwal, M.B. Taylor, D. Maposa, J.D. Salazar. When the Bidirectional Glenn is an Unfavorable Option: Inferior Cavopulmonary Connection as an Alternative Palliation. Cardiol Young 2015; April 28:1-3.
4. Ascending Aortic Slide for Interrupted Aortic Arch repair= “Mississippi sliiiide”
5. Right Ventricular Outflow Procedure for tetralogy and pulmonary atresia-VSD•an alternative palliation to a shunt procedure for neonatal cyanosis
New Operations / Concepts
4. Ascending Aortic Slide for Interrupted Aortic Arch repair
= “Mississippi sliiiide”
•biventricular / single ventricle repair •unfavorable anatomy challenges a tension-free primary connection:
– long distance between interrupted arch portions– aberrant right subclavian artery
options include: – direct arch or arch vessel native tissue
anastomosis, – interposition graft– subclavian reverse flap
a novel surgical technique in 5 neonates/infants using an ascending aortic slide bridging flap.
all with drawbacks! •high recurrence of arch stenosis•left bronchial compression•no growth, sacrifice left arm artery
New Operations / Concepts
4. Ascending Aortic Slide for Interrupted Aortic Arch repair
= “Mississippi sliiiide”
•no surgical or interstage mortality. •no neurologic or renal complications. •mean follow-up 20 months (range 2.1-49 months):
– 1 univentricular patient needed percutaneous balloon arch angioplasty at 4 months
– 1 biventricular repair a re-operation with supravalvar aortic patch augmentation 4 months post-operatively.
•no patients had airway compression. •one late death from Influenza pneumonia (2.3 years after the initial aortic slide/Norwood operation = 1.9 years after successful bidirectional Glenn).•safe and reproducible technique, providing a bridge of native tissue between the proximal and distal portions of the aorta. •likely has potential for growth
New Operations / Concepts
4. Right Ventricular Outflow Procedure for tetralogy and pulmonary atresia-VSD
•an alternative palliation to a shunt procedure for neonatal cyanosisshunt drawbacks:
– no pulsatile flow (better for PA growth)– shunt occlusion life-threatening, mortality (STS 5-10.5%)
•RVO Procedure = valvotomy-valvectomy, RVOT muscle bundle resection +/- short transannular patch
>> VSD physiology (with some PS)•n=16, 11 with branch PA stenosis, age 5-193 days•no mortality, median follow-up 15.3 months (range 4-47)•9 required reintervention (learning curve) prior to complete repair: catheter balloon dilatation of RVOT, branch PA balloon dilatation, RVOT stent.•safe, provides pulsatile flow for growing PA’s, further evaluation/experience required
Summary
• survival after treating congenital heart disease is excellent, and we’ve come a long way since ASD closure under inflow occlusion or VSD using cross-circulation …
• as the vast majority of patients undergoing surgery for CHD are surviving into adulthood, the focus is no longer only on in-hospital survival: the choices we make initially will impact a patient’s lifetime : think forward!
• for many forms of CHD, existing pathways or surgical strategies work well, but for others, grey zones still exist, and outcomes are suboptimal: opportunities!
• given the room for improvement in maximizing survival, minimizing morbidity, and enhancing functional capacity/quality of life, innovation must be encouraged and not smothered behind defensive litigation-fearing medicine, within acceptable safety limits!
Thank Y’All !
our team!