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J Thorac Cardiovasc Surg 1999;117:1041-1042
© 1999 Mosby, Inc.

LETTERS TO THE EDITOR

Reply

Department of Cardiovascular Surgery
Fu Wai Cardiovascular Institute and Cardiovascular Diseases Hospital
Chinese Academy of Medical Sciences
Peking Union Medical College
A 167, Beilishi Rd, Xicheng District
Beijing, 100037 People's Republic of China

Reply to the Editor:

My colleagues and I thank Metras and Kreitmann for their interest in our article. First we shall respond to their comment on the cosmetic approach. This approach was used not only in children, but also in adolescents and adults. About 30 adult patients, mainly young women from 18 to 38 years old, had their congenital cardiac defects corrected, including atrial and ventricular septal defects, through this approach. The follow-up showed no asymmetry or changes in sensitivity of the breasts. The follow-up for children was 4 years, and again there were no asymmetrical or sensitivity changes of the breasts.

Second, concerning the selection of patients, tetralogy of Fallot (TOF) has been corrected through this approach since January 1996. In the beginning, if pulmonary artery hypoplasia was suspected, the anomalies were corrected through a median sternotomy. With improvement in technique, the indications were increased. At this point, this approach has been used to repair congenital cardiac defects in about 560 patients, including more than 60 patients with TOF. Some patients also had coexisting patent ductus arteriosus, left superior vena cava, single coronary deformity, and maldevelopment of the pulmonary artery. However, if occlusion of systemic-pulmonary collateral vessels is needed before the operation, if the pulmonary artery is hypoplastic (aorta:pulmonary artery > 4:1), if the presence, size, and continuity of the native pulmonary arteries are not identified before the operation, or if the left pulmonary artery is abnormal as suggested by preoperative echocardiography, median sternotomy is also used. If a right thoracotomy is used in repair of TOF, a surgeon experienced in correcting TOF through a median sternotomy is needed who also has experience in repairing common congenital heart defects through this approach. Our results with this approach show that the rates of morbidity, residual defects, and residual pulmonary stenosis are almost the same as with a median sternotomy, because the exposure of the defect through the right ventricular outflow tract and the standard of correction of the pulmonary arteries are similar. About 30 TOF patients needed to have the right ventricular outflow tract and the main pulmonary artery enlarged with autologous pericardium or a homograft artery with a single valve across the pulmonary anulus. We have done 8 corrections of partial atrioventricular canal through this approach. Because of space limitations in our article, we did not describe the methods of dealing with a patent ductus arteriosus or left superior vena cava in detail. A patent ductus arteriosus can be sutured through the pulmonary artery incision with a lower body temperature and a lower rate of perfusion, and a left superior vena cava can be crossclamped intermittently if it is small or cannulated through the coronary sinus if it is large. We believe there is no difference in the procedure in correcting a patent ductus arteriosus or a left superior vena cava, whether done through a right lateral thoracotomy or through a median sternotomy.

Finally, we believe it may be easier to injure the long thoracic nerve and the thoracodorsal nerve through the posterior approach, affecting muscle development and thoracic symmetry. Thus we do not advocate using the posterior approach.

12/8/97044

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Ying-long, L. Search for Related Content PubMed Articles by Ying-long, L.