Evaluation of different minimally invasive techniques in pediatric cardiac surgery - Is a full sternotomy always a necessity?

Study objectives: A variety of minimally invasive techniques have been recently introduced in adult cardiac surgery. Experiences with children and newborns are, however, limited. In this report, we present our first experiences with different methods of ministernotomies for closure of atrial septum defect (ASD) and ventricular septum defect (VSD) in pediatric cardiac patients. Also, the current literature for different surgical approaches is reviewed. Patients and methods: Twenty-five pediatric patients (range, 4 months to 12 years old) underwent elective ASD or VSD closure. Surgical access was either without division of the sternum (group A, n = 5), with partial inferior sternotomy (group B, n = 5), total sternotomy with limited skin incision (group C, n = 5), or total sternotomy with full skin incision (group D, n = 10). Results: There were no severe intraoperative complications regarding exposure, cannulation, or bleeding. Conversion to full sternotomy was not necessary in any patient. Bypass time and cross-clamp time in groups A, B, and C were comparable to the standard operation (group D). However, preparation time was significantly increased in one minimally invasive group (group A vs group D, p < 0.05). Despite general feasibility, the transxiphoidal access without sternotomy compromises exposure of the ascending aorta, resulting in impaired administration of cross-clamping, cardioplegia, and especially de-airing. Conclusions: Transatrial pediatric cardiac operations can be performed without or with limited sternotomy. The partial sternotomy allows uncompromised exposure of the great vessels and should be favored over the transxiphoidal approach. The operative access and perioperative risk is comparable to a classical standard surgical approach. Advantages include improved cosmetic I results in combination with a high degree of safety.