right axillary thoracotomy CHD repair USA grand rounds

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


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!


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


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.


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.



incisions / approach

vs. right anterolateral thoracotomyBleiziffer et al. J Thorac Cardiovasc Surg 2004;127:1474–80



view / cannulation



ASD closure



VSD patch closure

VSD +/- subaortic membrane



partial AV canal with mitral cleftPAPVD / Warden operation



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.



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


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

http://www.ctsnet.org/article/when-bidirectional-glenn-unfavorable-option-primary-extracardiac-inferior-cavopulmonary




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


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


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!

right axillary thoracotomy CHD repair USA grand rounds

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