Table III. Distribution of patients in both groups based on postoperative outcomes
Follow-up
During the follow-up, atrial fibrillation was found in one (4.5%) case in Group 1 and two cases (9.1%) in Group 2. No case of stroke or renal failure was reported for either group. Moreover, no deep wound infection emerged in either group; however, superficial wound infections were found in one (4.5%) patient in Group 1 and two (9.1%) patients in Group 2. This study revealed the following echocardiography findings for the study population after one month of follow-up: the mean ejection fraction was 55.74 ± 4.03 for the right minithoracotomy and 54.27 ± 6.12 for the median sternotomy; the mean LA diameter was 46.32 ± 2.77 for the right minithoracotomy and 46.36 ± 2.77 for the median sternotomy; and the mean PASP was 36.24 ± 7.37 for the right minithoracotomy and 39.74 ± 8.91 for the median sternotomy. No residual shunt was found in patients of either group.
Discussion
Minimally invasive approach of ASD closure can be achieved by several techniques for instance partial sternotomy, right parasternal mini-incision, right anterolateral thoracotomy, right posterolateral thoracotomy, video-assisted mini-thoracotomy, robot-assisted surgery, and total thoracoscopic surgery without robotic assistance [1-4,6,7]. MICS reveals a cosmetic advantage. However, MICS has the negative aspects of a confined operative area and technical difficulties in peripheral cannulation and aortic cross-clamping. Several studies of MICS for ASD closure have been performed, and most effects have published similar outcomes between the 2 group [9-11]. Right anterolateral thoracotomy has the benefit of offering a direct field of vision to the right atrium, which may additionally be incised and approached for ASD. Therefore, the skin incision is minimized and adjusted to the measurement required for ASD closure.
Our results revealed that the MICS group experienced significantly longer operation times, CPB times, and ACC times. Contributing factors are variations in femoral vessel development, peripheral cannulation and restricted operative field. On the contrary post-operative recovery was faster because of less ICU stay, minimal pain and early mobility. There was no conversion to full sternotomy in the MICS group, which means there was no failure of the minimally invasive procedure. There were also no additional complications because of femoral cannulation such as seroma, lymphocele, wound infection, or pseudoaneurysm in the MICS group. No residual shunt was identified in either of the group.
Limitations
This study was limited due to the following factors: it was a single-centre study, it used a purposive non-random sampling method, its sample size was small, and no data was collected after the one-month follow-up. In fact, no information regarding the participants’ postoperative quality of life, including their satisfaction with the procedure, return to work, level of discomfort and performance of daily activities following their ASD closures through right minithoracotomy or median sternotomy, was even mentioned.
Recommendations
Based on the findings of this study, future research should involve
• A large-scale multicentre study.
• A long-term follow-up.
• Sufficient training for and expertise in using the minimally invasive right thoracotomy in cardiac surgery; and
• A modern surgical instrument for following the meticulous surgical procedure.
Conclusion
This study confirms that ASD closure can be performed using a right minithoracotomy without compromising the patient’s safety. In addition, its findings, and Group 1 in particular, suggest some advantages to using the right minithoracotomy, including the reduced length of incision, the shorter duration of endotracheal intubation, less postoperative blood loss, fewer transfusion requirements, minimal postoperative pain, and the shorter duration of hospital stay. Patients in Group 1 also reported smaller scars, as expected, which contributes to better overall patient satisfaction.
Key Clinical Message
ASD closure by minithoracotomy can be a safe and affordable option even for a developing country. Although it requires expertise.
Author Contribution
Conception and design of the research-
Dr. Sumsul Arif Mohammad Musa.
Dr. Mauin Uddin
Dr. Prasanta Kumar Chanda.
Collection of the data-
Dr. Mauin Uddin
Dr. Sumsul Arif Mohammad Musa.
Analysis and interpretation of the data-
Dr. Mauin Uddin
Dr. Saikat Das Gupta
Dr. Rubana Forhad
Dr. Mohammad Mostafizur Rahman
Statistical analysis-
Dr. Rubana Forhad
Dr. Saikat Das Gupta
Dr. Sumsul Arif Mohammad Musa.
Dr. Mohammad Mostafizur Rahman
Drafting the manuscript-
Dr. Mauin Uddin
Dr. Sumsul Arif Mohammad Musa
Dr. Mohammad Mostafizur Rahman
Dr. Syed Al Nahian
Critical revision of the manuscript-
Dr. Mauin Uddin
Dr. Mohammad Mostafizur Rahman
Dr. Saikat Das Gupta
Dr. Syed Al Nahian
Final approval of the manuscript-
Dr. Prasanta Kumar Chanda
Obtained funding-
Dr. Prasanta Kumar Chanda
Dr. Farooque Ahmed
Overall responsibility-
Dr. Sumsul Arif Mohammad Musa
Dr. Prasanta Kumar Chanda
Dr. Farooque Ahmed
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