The use of the Scar Cosmesis Assessment and rating scale to evaluate the cosmetic outcomes of totally thoracoscopic cardiac surgery.

BACKGROUND: Conventional median sternotomy is widely used in cardiac surgery, while thoracoscopic cardiac surgery, which is considered to have aesthetic advantages, is being performed increasingly more often in China because patients' requests for minimally invasive procedures yielding aesthetically pleasing results have significantly increased. Few studies have been conducted to assess surgical scars after cardiac surgery. Compared to the median sternotomy approach, multiple-incision totally thoracoscopic cardiac surgery requires smaller but numerous and scattered incisions. In addition to two working ports on the upper and lower margins of the right breast, an inguinal incision and an axillary incision are made. Therefore, does totally thoracoscopic cardiac surgery truly have aesthetic advantages? This study has the following objectives: (a) to compare median sternotomy cardiac surgery and total thoracoscopic cardiac surgery in terms of the long-term cosmetic outcomes of post-operative scars and (b) to evaluate the effectiveness of the Scar Cosmesis Assessment and Rating scale in combination with the numeric rating scale in the assessment of surgical scars after cardiac surgery. METHODS: Consecutive patients who visited our institution from January 2019 to May 2019 for cardiac surgery via median sternotomy or the totally thoracoscopic approach and followed up for at least one year were included. Inter-rater reliability, internal consistency and convergent validity were evaluated for the Scar Cosmesis Assessment and Rating scale and the numeric rating scale. Clinical characteristics and the scores of the two scales were compared between the two groups using Student's t test or the Mann-Whitney U test. RESULTS: Thirty-one patients underwent cardiac surgery via the totally thoracoscopic approach, and 42 patients underwent cardiac surgery via the median sternotomy approach. No significant differences were found in the demographic or clinical data between the two groups. The validity and reliability of the two scales were satisfactory. For the Scar Cosmesis Assessment and Rating scale, the median sternotomy group scored statistically significantly higher than did the totally thoracoscopic group on the "overall impression" and "patient question" subscales (P < 0.05). The overall scores of the Scar Cosmesis Assessment and Rating scale and numeric rating scale were statistically significantly different (P < 0.05). CONCLUSIONS: The Scar Cosmesis Assessment and Rating scale in combination with the numeric rating scale is an effective tool for the assessment of scar aesthetics after cardiac surgery. Surgical scars of totally thoracoscopic cardiac surgery can yield desirable cosmetic outcomes in Chinese individuals, especially in susceptible individuals with a high risk of keloid and hypertrophic scars. Patients with appropriate indications can undergo cardiac surgery with the totally thoracoscopic approach and exhibit a satisfactory scar appearance.

Safety and feasibility of intra-operative device closure of atrial septal defect with transthoracic minimal invasion.

OBJECTIVE: The study aims to evaluate the safety and feasibility of intra-operative device closure of atrial septal defect with transthoracic minimal invasion. METHODS: From May 2006 to June 2009, 252 patients with secundum-type atrial septal defect closure were enrolled in our institution. The patients were divided into two groups, with 182 patients in group I with intra-operative device closure and 72 in group II with surgical closure. In group I, the patients' age ranged from 3 months to 62 years (mean±standard deviation, 19.0±16.7 years). This approach involved a transthoracic minimal invasion that was performed after full evaluation of the atrial septal defect by transthoracic echocardiography, deploying the device through the delivery sheath to occlude the atrial septal defect. RESULTS: In group I, 180 patients were occluded successfully under this approach. The size of the occluder device implanted ranged from 6 to 48 mm. Minor complications occurred, which included transient arrhythmias (n=23) and pleural effusion (n=15). Two patients with postoperative cardiac arrest were successfully cardiopulmonary resuscitated. Another two patients with occluder dislodged back into the right atrium were turned to surgical repair with cardiopulmonary bypass on the postoperative day. In group II, all patients were occluded successfully, and almost all patients needed blood transfusion and suffered from various minor complications. All discharged patients were followed up for 1-5 years. During this period, we found no recurrence, no thrombosis, even no device failure. In our comparative studies, group II had significantly longer intensive care unit (ICU) stay and hospital stay than group I (p<0.05). The cost for group I was less than group II (p<0.05). CONCLUSIONS: Intra-operative device closure of atrial septal defect with transthoracic minimal invasion is a safe and feasible technique. It had the advantages of cost savings, yielding better cosmetic results, and leaving less trauma than surgical closure.

Intraoperative device closure of atrial septal defects with inferior vena cava rim deficiency: a safe alternative to surgical repair.

OBJECTIVE: Our objective was to evaluate the safety and feasibility of intraoperative device closure of atrial septal defects with inferior vena cava rim deficiency. METHODS: From January 2005 to December 2008, we enrolled 65 patients who had a secundum atrial septal defect with inferior vena cava rim deficiency closure in our institution. Patients were divided into 2 groups: 35 patients in group I underwent intraoperative device closure with a right lateral minithoracotomy and 30 in group II underwent open cardiac repair with a right lateral thoracotomy and cardiopulmonary bypass. Intraoperative device closure involved a minimal intercostal incision that was performed after full evaluation of the atrial septal defect by transthoracic echocardiography and the insertion of the device through the delivery sheath to occlude the atrial septal defect. RESULTS: The procedure was successful in all patients. In group I, the diameter of the atrial septal defect ranged from 30 to 44 mm (mean, 35.3 ± 3.9 mm), and the size of the implanted occluder ranged from 34 to 48 mm (mean, 40 ± 2.1 mm). The total occlusion rate was 82.9% immediately after the operation, 97.1% at 3 months, and 100% at 12 and 24 months of follow-up. In group II, all patients had successful closure. A follow-up period of 12 to 24 months was obtained in both groups. During the follow-up, there was no recurrence, thrombosis, or device failure. In our comparative studies, group II had significantly longer operative time, intensive care unit stay, and hospital stay than group I (P < .001). The cost of group I was less than that of group II (20,450.9 ± 840.8 RMB vs 25,884.9 ± 701.8; P < .001). CONCLUSIONS: Intraoperative device closure of atrial septal defects with inferior vena cava rim deficiency is a safe and feasible technique. It has the advantages of cost savings, cosmetic results, and less trauma than surgical closure. Early and midterm results are encouraging.