Minimally invasive surgery minus cannulation safe, effective for CHD

Minimally invasive cardiac surgery without peripheral cannulation is both safe and effective for correcting a wide range of congenital heart defects, including mitral valve repair and pulmonary stenosis, according to research published in Heart, Lung and Circulation this week.

Suresh Babu Kale, MCh, DNB, and Senthilkumar Ramalingam, MD, both cardiologists in Tamil Nadu, India, are trying to “treat more and hurt less” when it comes to the complicated nature of correcting congenital heart problems, they wrote in the journal. While median sternotomy is the standard approach for correcting atrial and ventricular septal defects, mitral regurgitation, valve repair and fistula, among other cardiac malformations, it’s also known to leave sometimes “unsightly” scars on a patient’s chest.

“Chest scars have significant adverse psychological consequences and social impact on growing boys and girls, especially in this part of the world, where a visible scar may make one’s prospect of advancing in life difficult,” Kale and Ramalingam, of the Department of Cardiovascular Thoracic Surgery at Meenakshi Hospital, wrote. “Minimally invasive surgery is a good alternative but is limited to a small percentage of surgeons.”

Still, it’s an attractive prospect, the authors said, since smaller incisions could also mean earlier extubation, shorter hospital stays and minimized exposure to transfused blood products. But Kale and Ramalingam said the pressure surgeons feel to reduce surgical trauma and maintain a certain physical aesthetic has kept progress at a slow pace.

For their study, the pair extended the use of right anterior minithoracotomy (RAMT) to repair congenital heart defects that would have otherwise been repaired with median sternotomy. Between October 2015 and March 2017, Kale and Ramalingam analyzed 145 patients who underwent correction of congenital heart malformations with cardiopulmonary bypass through RAMT.

The authors said there was no operative mortality or major morbidities, and all patients were alive at follow-up. Cardiopulmonary bypasses took, on average, 65 minutes, while mean aortic cross clamp time was an average of 38 minutes. According to the study, 55 patients were extubated in the operating room; the remaining 90 were extubated in the ICU.

“Our study shows the feasibility of RAMT without peripheral cannulation in treating wider congenital cardiac lesions in a safe and reproducible way without compromising on the quality of the outcome,” Kale and Ramalingam wrote. “The long-term morbidities of extensive thoracotomy and sternotomy are avoided with better pain control and rapid return to normal activities.”

Another perk of the more minimally invasive surgery, the authors said, was that cosmetic outcomes were “excellent” across the board. 

“An additional benefit of RAMT was the less-visible scar that provides good cosmesis and psychosocial satisfaction,” they wrote. “Multidisciplinary coordinated teamwork comprising cardiac surgeons, perfusionists, intensivists, anesthesiologists, cardiologists, nurses and psychologists are needed at all stages of treatment with the goal to treat more and hurt less.”