Facile minimally invasive cardiac surgery via ministernotomy.

BACKGROUND: The public's and surgeons' perception of minimally invasive operations are frequently at odds. Nevertheless, real or perceived benefits may result from limiting skin and skeletal trauma. METHODS: Beginning in January 1996, we began approaching most infant and pediatric open heart procedures through an upper sternal split incision using a 1- to 3-inch skin opening and then extended this technique using a 2.5- to 3.5-inch incision for adult aortic and mitral valve replacement. RESULTS: A total of 82 patients, 57 infants and children and 25 adults, have been operated on using this approach (age range, newborn to 81 years). Operations accomplished through ministernotomy have included aortic valvotomy, arterial switch, tetralogy of Fallot, atrial or ventricular septal defect closure, aortic valve replacement, mitral valve replacement and repair, redo aortic or mitral valve replacement, double valve replacement, aortic root replacement, and complex arch reconstruction. In adults, the sternum was divided and then a T incision was made at the second, third, or fourth intercostal space. The mitral valve was reached through the roof of the left atrium. In children, a lower sternal split was used for atrial septal defect repairs. All cannulas were introduced through the ministernotomy incision, eliminating femoral cannulation. No new instruments, retractors, or ports were used. Mediastinal drainage was accomplished through a Blake drain connected to Heimlich-valved grenade suction. All but 2 patients were extubated immediately. Hospital stay was from 1 to 20 days (median 2 days). Patient and family acceptance is very high. CONCLUSIONS: On the basis of this initial experience, we attempt all congenital cardiac and isolated adult valve operations through ministernotomy.

The use of transesophageal echocardiography to guide sternal division for cardiac operations via mini-sternotomy.

Cardiac surgery utilizing the mini-sternotomy technique offers many advantages, including lessened pain and hospitalization. Mid-line upper sternotomy (or mini-sternotomy) can provide adequate exposure of the ascending aorta, the aortic root, the right atrial appendage and the dome of the left atrium. Inherent in providing adequate exposure is the level at which the sternum is "T'd" off. The lower aspect of the sternotomy is "T'd" off at the second, third, or fourth intercostal space depending on the patient's anatomy. We describe a technique that uses transesophageal echocardiography to determine the precise location for "T'ing" off the sternotomy, rather than approximating the sternotomy site by physical exam and chest radiograph. This technique will reliably delineate the sternotomy site, irrespective of a patient's body size and habitus.