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Dodge-Khatami J, Dodge-Khatami A, Nguyen TD, Rüffer A. Minimal invasive approaches for pediatric & congenital heart surgery: safe, reproducible, more cosmetic than through sternotomy, and here to stay. Transl Pediatr 2023; 12:1744-1752. [PMID: 37814714 PMCID: PMC10560358 DOI: 10.21037/tp-23-282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 08/22/2023] [Indexed: 10/11/2023] Open
Abstract
Minimal invasive approaches through small thoracic incisions for the isolated repair of the most common congenital heart defects have been around for decades. However, the lack of belonging in established surgical training curriculums compared to the traditional median sternotomy, the requirement for more technical expertise and a certain learning curve, has limited their use, being routinely performed only by certain surgeons in specialized centers. More recently, through cumulated and increasingly mediatized shared experience, remote teaching potential through universally accessible surgical videos and simulation, the approach has gained traction and acceptance, and even established itself as the new norm in many centers. In this review, we present technically focused aspects of our own experience and protocols which have evolved over time, along with a brief overview of the literature pertaining to other right thoracic approaches, and some comparison to established results using the traditional median sternotomy. An increasing body of literature, produced more frequently and across all continents, seems to suggest that repairs of congenital heart defects through a minimal invasive right thoracic approach are becoming the new norm, as they are reported to be safe and reproducible, with excellent surgical results, and an obvious superior and more desirable cosmetic result. This comes at a cost of additional training and learning curve by surgeons, who are not offered the technique as part of their standard professional training curriculum.
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Affiliation(s)
- Jannika Dodge-Khatami
- Pediatric Cardiology, Department of Pediatrics, Faculty of Health, Helios University Medical Center Wuppertal, Witten/Herdecke University, Witten, Germany
| | - Ali Dodge-Khatami
- Clinic for Pediatric & Congenital Heart Surgery 2, Children’s Heart Center, University Hospital RWTH Aachen, Aachen, Germany
| | - Thai Duy Nguyen
- Clinic for Pediatric & Congenital Heart Surgery 2, Children’s Heart Center, University Hospital RWTH Aachen, Aachen, Germany
| | - André Rüffer
- Clinic for Pediatric & Congenital Heart Surgery 2, Children’s Heart Center, University Hospital RWTH Aachen, Aachen, Germany
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Abstract
OBJECTIVE Owing to its obvious cosmetic appeal, minimal invasive repair of congenital heart defects (CHDs) through the mini right axillary thoracotomy is becoming routine in many centres. Besides cosmesis, and before becoming a new norm, it is important to establish its outcomes as safe compared to repairs through traditional median sternotomy. METHODS Between 2013 and 2021, 116 consecutive patients underwent defect repairs through mini right axillary thoracotomy. Patient, operative data, and hospital outcomes were compared to contemporary mini right axillary thoracotomy and sternotomy series. RESULTS There was no mortality or need for approach conversion (mean age 4.3 years, range 0.17-17, mean weight 18.6 kg, range 4.8-74.4) in 118 repairs for atrial septal defect, ventricular septal defect, partial anomalous pulmonary venous return, partial atrioventricular canal with mitral cleft, scimitar syndrome, double-chambered right ventricle, cor triatriatum, and tricuspid valve repair. Protocol included on-table extubation, achieved in 97 children, with 23 outliers leading to 0.7 average hours of mechanical ventilation (range 0-66 hours), indwelling chest drain time of 2.6 days (range 1-9 days), intensive care stay of 1.8 days (range 1-10 days), and hospital stay of 3.9 days (range 2-18 days). Late revisions were required in one patient after scimitar repair for scimitar vein stenosis at 2 weeks, and in another for repair of superior caval vein stenosis after a Warden operation at 2 months; reoperations (5/116 = 4.3%) were successfully performed through the same mini right axillary incision. CONCLUSIONS While providing obvious cosmetic advantages, the minimally invasive right axillary thoracotomy approach for the surgical repair of common CHDs yields excellent results and is safe compared to the benchmark median sternotomy approach.
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Affiliation(s)
- Jannika Dodge-Khatami
- Division of Pediatric Cardiology, Southshore University Hospital, Bay Shore, NY, USA
| | - Rabia Noor
- Division of Pediatric Cardiology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Kyle W Riggs
- Department of Cardiovascular and Thoracic Surgery, Northwell Health, Manhassett, NY, USA
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Dodge-Khatami J, Adebo D. Evaluation Of Complex Congenital Heart Disease In Infants Using Ultra-low Dose Cardiac Computed Tomography. J Cardiovasc Comput Tomogr 2020. [DOI: 10.1016/j.jcct.2020.06.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Chen PC, Dodge-Khatami J, Hanfland RA, Sinha R, Salazar J, Dodge-Khatami A. Resuscitating the Chimney Graft to Innominate Artery for Straightforward Cannulation During Infancy. Ann Thorac Surg 2020; 109:e379-e381. [PMID: 31987822 DOI: 10.1016/j.athoracsur.2019.11.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 11/20/2019] [Accepted: 11/23/2019] [Indexed: 10/25/2022]
Abstract
Arterial cannulation with a chimney polytetrafluoroethylene graft to the innominate artery is commonly used for antegrade cerebral perfusion during neonatal aortic arch surgery. When properly retained and prepared before sternal closure, resuscitation of the polytetrafluoroethylene graft to innominate artery can be performed months later during sternal reentry. It is a safe and reproducible technique for expeditious arterial cannulation at stage II palliation in single-ventricle patients or complete intracardiac repair of biventricular lesions. We report our experience utilizing this technique successfully during reoperation in 90 of 92 patients, with no adverse thromboembolic events identified.
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Affiliation(s)
- Peter C Chen
- Division of Congenital Heart Surgery, Children's Heart Center, Children's Memorial Hermann Hospital, University of Texas Health Science Center at Houston, Houston, Texas
| | - Jannika Dodge-Khatami
- Division of Pediatric Cardiology, Children's Heart Center, Children's Memorial Hermann Hospital, University of Texas Health Science Center at Houston, Houston, Texas
| | - Robert A Hanfland
- Division of Congenital Heart Surgery, Children's Heart Center, Children's Memorial Hermann Hospital, University of Texas Health Science Center at Houston, Houston, Texas
| | - Raina Sinha
- Division of Congenital Heart Surgery, Children's Heart Center, Children's Memorial Hermann Hospital, University of Texas Health Science Center at Houston, Houston, Texas
| | - Jorge Salazar
- Division of Congenital Heart Surgery, Children's Heart Center, Children's Memorial Hermann Hospital, University of Texas Health Science Center at Houston, Houston, Texas
| | - Ali Dodge-Khatami
- Division of Congenital Heart Surgery, Children's Heart Center, Children's Memorial Hermann Hospital, University of Texas Health Science Center at Houston, Houston, Texas.
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Dodge-Khatami J, Simpson SA, Dodge-Khatami A. A Severe Form of Arterial Tortuosity Syndrome Presenting With Significant Airway Obstruction in an Infant. World J Pediatr Congenit Heart Surg 2019; 11:238-240. [PMID: 31088211 DOI: 10.1177/2150135119829009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
We describe a severe form of arterial tortuosity syndrome in a newborn, in which the tortuous course of the aorta masqueraded as a pulmonary artery sling on fetal echocardiogram. The newborn presented with respiratory distress after birth. The clinical course was complicated by extrinsic airway obstruction requiring cardiopulmonary resuscitation. Timely diagnostic work-up in patients with arterial tortuosity syndrome is necessary to plan eventual intervention, and hopefully to prevent complications related to the abnormal vasculature.
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Affiliation(s)
- Jannika Dodge-Khatami
- Department of Pediatrics, Pediatric Cardiology, Children's Heart Center, Children's Memorial Hermann Hospital, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Scott A Simpson
- Pediatric Cardiology, Children's Heart Center, University of Mississippi Medical Center, Jackson, MS, USA.,Pediatric and Fetal Cardiology, Children's Heart Center, University of Mississippi Medical Center, Jackson, MS, USA
| | - Ali Dodge-Khatami
- Division of Pediatric and Congenital Heart Surgery, Children's Heart Center, Children's Memorial Hermann Hospital, The University of Texas Health Science Center at Houston, Houston, TX, USA
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Batlivala SP, Hood MK, Dodge-Khatami J, Shakti D, Taylor MB, Ebeid MR, Salazar JD, Dodge-Khatami A. Staged Palliation of Cyanotic Obstructive Lesions With a Modified Right Ventricular Outflow Procedure. World J Pediatr Congenit Heart Surg 2018; 9:68-73. [PMID: 29310560 DOI: 10.1177/2150135117738007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Traditional palliation for biventricular cyanotic congenital heart lesions often involves staging with systemic-to-pulmonary arterial shunts to secure pulmonary blood flow (PBF) in the newborn period prior to complete repair. However, shunts may lead to life-threatening events secondary to shunt occlusion or acute coronary steal. They may be associated with morbidity secondary to diastolic runoff, systemic steal and volume loading, and do not provide pulsatile flow which has the potential to promote pulmonary artery (PA) growth. We have alternatively performed modified right ventricular outflow (mRVO) procedures by establishing antegrade right ventricle-to-PA flow. METHODS Retrospective review of data on all patients who underwent the mRVO procedure from 2013 to 2016, including anatomy, number of interstage catheterizations, reoperations, intensive care unit admissions, hypercyanotic episodes, interval to complete repair, and mortality. RESULTS Seventeen nonconsecutive patients included tetralogy of Fallot (n = 14), pulmonary valve stenosis (n = 2), and 1 with pulmonary atresia-intact septum; 14 had significant branch PA stenosis. Median age of first mRVO procedure was 14 days (range 5-193), and median duration of follow-up was 15.3 months (range 4-47 months). No patients had post-palliation acute hypercyanotic episodes. Nine were admitted to the ICU for persistent interstage hypoxemia, 7 of whom required reintervention prior to complete repair, which was achieved in 11 patients. Two late deaths unrelated to mRVO occurred. CONCLUSIONS The mRVO procedure is a potential option with satisfactory results. It avoids potential shunt-related sudden death. The physiology of the mRVO palliation may provide unique benefits by providing antegrade pulsatile PBF, facilitates catheter interventions, and avoids branch PA distortion and stenosis.
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Affiliation(s)
- Sarosh P Batlivala
- 1 School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA.,2 Division of Pediatric Cardiology, Batson Children's Hospital, University of Mississippi Medical Center, Jackson, MS, USA
| | - Mary K Hood
- 1 School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jannika Dodge-Khatami
- 1 School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA.,2 Division of Pediatric Cardiology, Batson Children's Hospital, University of Mississippi Medical Center, Jackson, MS, USA
| | - Divya Shakti
- 1 School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA.,2 Division of Pediatric Cardiology, Batson Children's Hospital, University of Mississippi Medical Center, Jackson, MS, USA
| | - Mary B Taylor
- 1 School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA.,2 Division of Pediatric Cardiology, Batson Children's Hospital, University of Mississippi Medical Center, Jackson, MS, USA
| | - Makram R Ebeid
- 1 School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA.,2 Division of Pediatric Cardiology, Batson Children's Hospital, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jorge D Salazar
- 4 Department of Cardiac Surgery, Boston Children's Hospital, Harvard University, Boston, MA, USA
| | - Ali Dodge-Khatami
- 1 School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA.,3 Division of Pediatric and Congenital Heart Surgery, Batson Children's Hospital, University of Mississippi Medical Center, Jackson, MS, USA
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Dodge-Khatami J, Gottschalk U, Eulenburg C, Wendt U, Schnegg C, Rebel M, Reichenspurner H, Dodge-Khatami A. Prognostic Value of Perioperative Near-Infrared Spectroscopy During Neonatal and Infant Congenital Heart Surgery for Adverse In-Hospital Clinical Events. World J Pediatr Congenit Heart Surg 2012; 3:221-8. [DOI: 10.1177/2150135111426298] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Perioperative monitoring with multisite near-infrared spectroscopy (NIRS) for congenital cardiac surgery with cardiopulmonary bypass may aid in predicting adverse clinical outcomes. Methods: Forty-one consecutive neonates and infants undergoing bypass were monitored with right + left cerebral and renal NIRS. Near-infrared spectroscopy and lactate were measured at 20 time points, from baseline 1 day preoperatively, during bypass and modified ultrafiltration (MUF; 10 minutes), until 24 hours postoperatively. Adverse events were extracorporeal membrane oxygenation (ECMO)/death, prolonged intensive care unit (ICU) or length of hospital stay. Results: Perioperative mean renal NIRS remained higher than baseline (n = 41) as did cerebral NIRS in all undergoing biventricular repair. During bypass (n = 41), mean right and left cerebral NIRS were equal. During MUF, cerebral and renal NIRS values increased ( P < .001). Cerebral NIRS and lactate inversely correlated during the first six postoperative hours. Extracorporeal membrane oxygenation /death occurred in four patients, correlating with cerebral and renal NIRS below 45% ( P = .030) and 40% ( P = .019) at anytime, respectively, and with mean lactate levels >9.3 mmol/L in the first postoperative 24 hours ( P < .001). Among survivors, renal NIRS below 30% at any time predicted a longer ICU stay. Conclusions: At bypass conclusion, 10 minutes of MUF does not adversely affect cerebral or renal NIRS. Left and right cerebral NIRS are equal, so that biparietal cerebral NIRS monitoring is probably not warranted. Perioperative cerebral and renal NIRS readings, respectively, below 45% and 40% correlate with ECMO/death and renal NIRS below 30% with prolonged ICU stay. Cerebral NIRS and lactate levels showed a strong inverse correlation during the first six postoperative hours.
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Affiliation(s)
- Jannika Dodge-Khatami
- Division of Congenital Cardiovascular Surgery, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Urda Gottschalk
- Division of Pediatric Cardiology, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Eulenburg
- Institute of Medical Biometry and Epidemiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Ulrike Wendt
- Division of Pediatric Cardiology, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Clivia Schnegg
- Division of Pediatric Cardiology, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Marcus Rebel
- Division of Congenital Cardiovascular Surgery, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Hermann Reichenspurner
- Division of Congenital Cardiovascular Surgery, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Ali Dodge-Khatami
- Division of Congenital Cardiovascular Surgery, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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