Successful repair of chronic instability of anterior chest wall following right parasternal approach for closure of atrial septal defect in
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《血管的通路杂志》
a Department of Cardiothoracic Surgery Unit – I, Christian Medical College & Hospital, Vellore – 632004, Tamil Nadu, India
b Department of Orthopaedic Surgery Unit – III, Christian Medical College & Hospital, Vellore – 632004, Tamil Nadu, India
Abstract
Chronic instability of anterior chest wall is a known complication following the minimally invasive right parasternal approach for valvular heart operations. The exact incidence of this condition, as well as the need for reoperation, has not been well documented. We report the first case of successful correction of unstable anterior chest wall in a 33-year-old lady after she underwent atrial septal defect closure through right paramedian approach eight years ago. The repair consisted of interposing iliac crest bone graft in the defect created by deficiency of the 3rd and 4th costal cartilages and anchoring the graft using steel wires.
Key Words: Minimally invasive surgery; Incisions; Chest wall; Reoperation
1. Introduction
Minimally invasive right parasternal approach for heart valve operations was introduced by Cosgrove et al. in 1996 [1,2]. This approach suited septal defect closures as well [3,6]. Though early results were encouraging [4–6], the technique became less popular in view of certain disadvantages [5,7]. One of the complications reported has been the occurrence of chronic instability of the anterior chest wall [4]. This has been attributed to poor healing capacity in spite of replacement of the resected third and fourth costal cartilages [4,5].
We report the case of a young lady who presented with such a complication eight years following atrial septal defect closure through a right paramedian approach. This problem crippled her personal life causing a psychiatric illness and marital disharmony. After providing psychiatric counseling she was taken up for reoperation. Interposition of iliac crest bone graft resulted in satisfactory healing and a stable, symmetric chest wall.
2. Clinical summary
A 33-year-old lady presented with a history of chronic pain, dyspnoea and instability of the right anterior chest wall. Eight years ago she had undergone dacron patch closure of ostium secundum type of atrial septal defect through a right paramedian approach. She had developed superficial wound infection in the postoperative period and needed secondary suturing. She was also mentally disturbed and had recently separated from her husband. On examination of the right chest there was palpable discontinuity between the medial ends of the third and fourth ribs and the sternum. There was abnormal mobility to the extent that the patient could compress her chest wall posteriorly and then bring it back. Psychiatric evaluation led to a diagnosis of bipolar affective disorder. Chest radiology and computed tomography (CT scan) ruled out any intrathoracic pathology such as a lung hernia. Transthoracic echocardiogram showed intact interatrial septum with good cardiac function.
Following a session of psychiatric treatment she was scheduled for reoperation. Intraoperatively we found that the medial ends of the third and fourth ribs were lying free from the sternum with deficiency of the corresponding costal cartilages (Fig. 1). With assistance from the orthopedic surgeon, the left iliac crest bone graft was harvested and positioned between the freshened edges of the ribs and the sternum. The graft was held in place using No.5 stainless steel wires (Ethicon, Inc., Somerville, NJ). Postoperative recovery was uneventful and psychiatric treatment was continued. Follow up at six months interval revealed a symmetric chest wall with no abnormal mobility. Spiral CT scan (Fig. 2) and bone scan confirmed satisfactory healing.
3. Discussion
The right parasternal incision as described by Cosgrove et al. provides a minimally invasive and safe approach to performing heart valve operations and septal defect closures [1–3]. Though the early results were impressive, the technique has become less favored due to certain drawbacks [4–6]. Additional groin incision, vascular complications related to femoral cannulation, sacrifice of one or both internal thoracic arteries, suboptimal exposure in certain aortic valve surgeries, vertical transseptal atriotomy causing sinus node dysfunction, poor healing, chest wall instability and lung hernias were some of the disadvantages [4]. Various modifications were made to overcome some of them [6–8].
However, the occurrence of chest wall instability has been a subject of concern. Though there are anecdotal reports [4,5], the exact incidence of this complication is unknown. In Cosgrove's series some patients were noticed to have slight bulging of the chest wall during coughing but none of them were disabled enough to require reoperation [4]. The cause for this problem appears to be multifactorial [6,9,10]. Failure to replace the costal cartilages in their original position can lead to chest wall deformity [6,9]. Resection of the costal cartilage jeopardizes blood supply at either end and restoration takes a longer time. Stripping of the perichondrium or damage due to excessive use of electrocautery can devitalize the cartilages. It is also essential to put the cartilages in saline to preserve their viability [6]. The continuous movement of the chest wall secondary to respiratory excursion also interferes with healing. This is exaggerated by the differential movement between the ribs and the costal cartilages during inspiration [10].
In the case of our patient, the occurrence of postoperative wound infection interfered with healing and facilitated the development of unstable chest wall. The problem had significantly affected her physical and mental wellbeing forcing us to intervene as early as possible. The factors of concern were the mentally disturbed state of the patient and the need to provide a stable, symmetric and compliant chest wall in the only available opportunity. Our strategic technique of interposition iliac crest bone graft resulted in attaining satisfactory healing as well as chest wall integrity. Iliac crest was preferred to rib graft from the opposite side in order to exclude further complications in the chest. Contributions by the psychiatrist and the orthopedic surgeon were vital in effecting a good overall clinical outcome.
In conclusion, chronic chest wall instability following right paramedian approach can be surgically corrected easily if indicated.
Acknowledgements
We thank Mrs I. Famitha Banu for her secretarial assistance.
References
Navia JL, Cosgrove DM. Minimally invasive mitral valve operations. Ann Thorac Surg 1996; 62:1542–1544.
Cosgrove DM, Sabik JF. Minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996; 62:596–597.
Cremer JT, Boning A, Anssar MB, Kim PY, Pethig K, Harringer W, Haverich A. Different approaches for minimally invasive closure of atrial septal defects. Ann Thorac Surg 1999; 67:1648–1652.
Cosgrove DM, Sabik JF, Navia JL. Minimally invasive valve operations. Ann Thorac Surg 1998; 65:1535–1539.
Mihaljevic T, Cohn LH, Unic D, Couper GS, Byrne JG. One thousand minimally invasive valve operations – early and late results. Ann Surg 2004; 240:529–534.
Lazzara RR, Kidwell FE. Right parasternal incision: a uniform minimally invasive approach for valve operations. Ann Thorac Surg 1998; 65:271–272.
Arom KV, Emery RW. Minimally invasive mitral valve operations. Ann Thorac Surg 1997; 63:1219–1220.
Weinschelbaum E, Stutzbach P, Machain A, Favaloro R, Caramutti V, Bertolotti A, Fraguas H. Valve operations through a minimally invasive approach. Ann Thorac Surg 1998; 66:1106–1109.
Ohara K, Nakamura K, Ohta E. Chest wall deformities and thoracic scoliosis after costal cartilage graft harvesting. Plast Reconstr 1997; 99:1030–1036.
Thomson HG, Kim TY, Ein SH. Residual problems in chest donor sites after microtia reconstruction: a long term study. Plast Reconstr 1995; 95:961–968.(Murugu Sundara Pandiyan, )
b Department of Orthopaedic Surgery Unit – III, Christian Medical College & Hospital, Vellore – 632004, Tamil Nadu, India
Abstract
Chronic instability of anterior chest wall is a known complication following the minimally invasive right parasternal approach for valvular heart operations. The exact incidence of this condition, as well as the need for reoperation, has not been well documented. We report the first case of successful correction of unstable anterior chest wall in a 33-year-old lady after she underwent atrial septal defect closure through right paramedian approach eight years ago. The repair consisted of interposing iliac crest bone graft in the defect created by deficiency of the 3rd and 4th costal cartilages and anchoring the graft using steel wires.
Key Words: Minimally invasive surgery; Incisions; Chest wall; Reoperation
1. Introduction
Minimally invasive right parasternal approach for heart valve operations was introduced by Cosgrove et al. in 1996 [1,2]. This approach suited septal defect closures as well [3,6]. Though early results were encouraging [4–6], the technique became less popular in view of certain disadvantages [5,7]. One of the complications reported has been the occurrence of chronic instability of the anterior chest wall [4]. This has been attributed to poor healing capacity in spite of replacement of the resected third and fourth costal cartilages [4,5].
We report the case of a young lady who presented with such a complication eight years following atrial septal defect closure through a right paramedian approach. This problem crippled her personal life causing a psychiatric illness and marital disharmony. After providing psychiatric counseling she was taken up for reoperation. Interposition of iliac crest bone graft resulted in satisfactory healing and a stable, symmetric chest wall.
2. Clinical summary
A 33-year-old lady presented with a history of chronic pain, dyspnoea and instability of the right anterior chest wall. Eight years ago she had undergone dacron patch closure of ostium secundum type of atrial septal defect through a right paramedian approach. She had developed superficial wound infection in the postoperative period and needed secondary suturing. She was also mentally disturbed and had recently separated from her husband. On examination of the right chest there was palpable discontinuity between the medial ends of the third and fourth ribs and the sternum. There was abnormal mobility to the extent that the patient could compress her chest wall posteriorly and then bring it back. Psychiatric evaluation led to a diagnosis of bipolar affective disorder. Chest radiology and computed tomography (CT scan) ruled out any intrathoracic pathology such as a lung hernia. Transthoracic echocardiogram showed intact interatrial septum with good cardiac function.
Following a session of psychiatric treatment she was scheduled for reoperation. Intraoperatively we found that the medial ends of the third and fourth ribs were lying free from the sternum with deficiency of the corresponding costal cartilages (Fig. 1). With assistance from the orthopedic surgeon, the left iliac crest bone graft was harvested and positioned between the freshened edges of the ribs and the sternum. The graft was held in place using No.5 stainless steel wires (Ethicon, Inc., Somerville, NJ). Postoperative recovery was uneventful and psychiatric treatment was continued. Follow up at six months interval revealed a symmetric chest wall with no abnormal mobility. Spiral CT scan (Fig. 2) and bone scan confirmed satisfactory healing.
3. Discussion
The right parasternal incision as described by Cosgrove et al. provides a minimally invasive and safe approach to performing heart valve operations and septal defect closures [1–3]. Though the early results were impressive, the technique has become less favored due to certain drawbacks [4–6]. Additional groin incision, vascular complications related to femoral cannulation, sacrifice of one or both internal thoracic arteries, suboptimal exposure in certain aortic valve surgeries, vertical transseptal atriotomy causing sinus node dysfunction, poor healing, chest wall instability and lung hernias were some of the disadvantages [4]. Various modifications were made to overcome some of them [6–8].
However, the occurrence of chest wall instability has been a subject of concern. Though there are anecdotal reports [4,5], the exact incidence of this complication is unknown. In Cosgrove's series some patients were noticed to have slight bulging of the chest wall during coughing but none of them were disabled enough to require reoperation [4]. The cause for this problem appears to be multifactorial [6,9,10]. Failure to replace the costal cartilages in their original position can lead to chest wall deformity [6,9]. Resection of the costal cartilage jeopardizes blood supply at either end and restoration takes a longer time. Stripping of the perichondrium or damage due to excessive use of electrocautery can devitalize the cartilages. It is also essential to put the cartilages in saline to preserve their viability [6]. The continuous movement of the chest wall secondary to respiratory excursion also interferes with healing. This is exaggerated by the differential movement between the ribs and the costal cartilages during inspiration [10].
In the case of our patient, the occurrence of postoperative wound infection interfered with healing and facilitated the development of unstable chest wall. The problem had significantly affected her physical and mental wellbeing forcing us to intervene as early as possible. The factors of concern were the mentally disturbed state of the patient and the need to provide a stable, symmetric and compliant chest wall in the only available opportunity. Our strategic technique of interposition iliac crest bone graft resulted in attaining satisfactory healing as well as chest wall integrity. Iliac crest was preferred to rib graft from the opposite side in order to exclude further complications in the chest. Contributions by the psychiatrist and the orthopedic surgeon were vital in effecting a good overall clinical outcome.
In conclusion, chronic chest wall instability following right paramedian approach can be surgically corrected easily if indicated.
Acknowledgements
We thank Mrs I. Famitha Banu for her secretarial assistance.
References
Navia JL, Cosgrove DM. Minimally invasive mitral valve operations. Ann Thorac Surg 1996; 62:1542–1544.
Cosgrove DM, Sabik JF. Minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996; 62:596–597.
Cremer JT, Boning A, Anssar MB, Kim PY, Pethig K, Harringer W, Haverich A. Different approaches for minimally invasive closure of atrial septal defects. Ann Thorac Surg 1999; 67:1648–1652.
Cosgrove DM, Sabik JF, Navia JL. Minimally invasive valve operations. Ann Thorac Surg 1998; 65:1535–1539.
Mihaljevic T, Cohn LH, Unic D, Couper GS, Byrne JG. One thousand minimally invasive valve operations – early and late results. Ann Surg 2004; 240:529–534.
Lazzara RR, Kidwell FE. Right parasternal incision: a uniform minimally invasive approach for valve operations. Ann Thorac Surg 1998; 65:271–272.
Arom KV, Emery RW. Minimally invasive mitral valve operations. Ann Thorac Surg 1997; 63:1219–1220.
Weinschelbaum E, Stutzbach P, Machain A, Favaloro R, Caramutti V, Bertolotti A, Fraguas H. Valve operations through a minimally invasive approach. Ann Thorac Surg 1998; 66:1106–1109.
Ohara K, Nakamura K, Ohta E. Chest wall deformities and thoracic scoliosis after costal cartilage graft harvesting. Plast Reconstr 1997; 99:1030–1036.
Thomson HG, Kim TY, Ein SH. Residual problems in chest donor sites after microtia reconstruction: a long term study. Plast Reconstr 1995; 95:961–968.(Murugu Sundara Pandiyan, )