Minimally invasive atrial septal defect closure using the subxyphoid approach.

BACKGROUND: Atrial septal defects in adults are associated with paradoxical emboli, atrial tachyarrythmias, and congestive heart failure. Surgical closure is highly efficacious with low operative mortality and morbidity. However, in young women sternotomy scars are unsightly reminders of an otherwise curative procedure. Alternatives such as lateral thoracotomy or extended transverse incisions are more cosmetic but associated with breast maldevelopment, numbness and other side effects. The authors are proposing a new surgical approach based on their observation that the right atrium and septum actually lie only 1 inch superior to the xyphisternal junction.
METHODS: A 4 inch transverse inframammary incision is used and the linea alba divided. The lower sternum is lifted forward with a commericial cable-pully retractor system (Rultract). Using femoral bypass augmented by a balloon tipped cannula in the superior vena cava, the septal defect is easily visualized and closed with conventional techniques and equipment.
RESULTS: Two young women have undergone closure of a patent foremen ovale (N=1) and a large ostium secundum (N=1) defect through this approach. One patient had minor fat necrosis in the incision which subsequently healed without incident.
CONCLUSIONS: Close anatomic proximity between the atrial septum and the lower sternum make it feasible to approach ostium secundum defects using a purely subxyphoid exposure. Visualization of the defect is excellent without the need for thoractomy and sternotomy. The use of a small transverse incision in the inframammary crease makes the result cosmetically invisible.