Right thoracotomy approach for open heart surgery

Ishtyak Ahmed Mir, A. G. Ahangar


Background: Median sternotomy approach provides excellent exposure of all the chambers of heart for performing open heart surgery, but this approach is the most invasive used for any surgical procedure. Besides an ugly scar, median sternotomy not only increases the morbidity but at times mortality also. To have an acceptable postoperative scar and to avoid the morbidity and mortality associated with median sternotomy, the present study was conducted to find an alternative to median sternotomy in patients with atrial septal defect, mitral and tricuspid valve disease.

Methods: Patients were positioned with right side elevated 30-45 degree, and heart was approached by right anterior thoracotomy, through 4th intercostals space. Pericardium was opened anterior to phrenic nerve, and upper end pericardial stay sutures given to get aorta more anterior. Aortic and bicaval cannulation was done and intracardiac procedures were performed as are done after standard median sternotomy.

Results: Difficult aortic cannulation and fracture to costochondral junction was the problem observed in some patients. Repair of atrial septal defect was the most common operation performed. Sternotomy, rib resection and peripheral cannulation was not needed in any of these patients. Post-operative period was uneventful in majority.

Conclusions: In all patients above 4 years of age, with normal aortic valve, without active lung disease / previous right thoracotomy, having isolated atrial septal defects, mitral and tricuspid valve disease the heart should be approached through right anterior thoracotomy.



Right thoracotomy, ASD repair

Full Text:



Barrat Boyes BG. Right anterolateral thoracotomy for cardiopulmonary bypass. In: Kirklin JW, Barrat Boyes BG, Eds. Cardiac Surgery Is ted. New York: Churchill Livingstone. 1988: 29-92.

Lancastar LL, Mavroudis C, Rees AH, Slater AD, Gansel BL, Gray LA. Surgical approach to atrial septal defect in the female: Right Thoracotomy versus sternotomy. Ann Surgery. 1990;56:218-21.

Dietl CA, Torres AR, Favaloro RG. Right submammary thoracotomy in females patients with atrial septal defects and anomalous pulmonary venous connections. Comparison between the transpectoral and sub pectoral approachs. J Thorac Cardiovasc Surg. 1992;104:723-27.

Massetti M, Babatasi G, Rossi A, Neri E, Bhoyroo S, Zitouni S et al. Operation for atrial septal defect through a right anterolateral thoracotomy, current outcome. Ann Thorac Surg. 1996;62:1100-3.

Grinda JM, Folliguet TA, Dervanian P, Mace L, Legault B, Neveux JY. Right anterolateral thoracotomy for repair of atrial septal defect. Ann Thorac Surg. 1996;62:175-8.

Cohn LH, Peigh PS, Sell J, Disesa VJ. Right thoracotomy, femoro femoral bypass and deep hypothermia for re-replacement of mitral valve. Ann Thorac Surg. 1989;48:69-71.

Muralidharan S, Krishnan WA, Verma SK, Nagarajan M. Atrial septal defect closure in young females by an anterolateral thoracotomy. IJTCVS. 2004;20:129-31.

Rosengart TK, Stark JF. Repair of atrial septal defect through right thoracotomy. Ann Thorac Surg. 1993;55:1138-40.

Molavipour A, Dastani M, Abdollahi A, Karamroudi A. Repair of atrial septal defect through a right anterolateral thoracotomy: A cosmetic and safe approach. J Cardiovasc Thorac Res. 2009;1(2):29-31.

Praeger PI, Pooly RW, Moggio RA, Somberg ED, Sarabu M, and Reed GE. Simplified method for reoperation on mitral valve. Ann Thorac Surg. 1989;48:825-7.

Chitwood WR, Elbeery JR, Moran JF. Minimally invasive mitral valve repair using transthoracic aortic occlusion. Ann Thorac Surg. 1997;63:1477-9.

Grossi EA, Lapietra A, Ribakove GH, Delianides J, Esposito R, Culliford AT, et al. Minimally invasive versus sternotomy approaches for mitral reconstruction: comparison of intermediate term results. J Thorac Cardiovas Surg. 2001;121:708-13.

Laks H, Hammond GL. A cosmetically acceptable incision for the median sternotomy. J Thorac Cardiovasc Surg. 1980;79:146-9.

Brutel de La Riviere A, Brom GHM, Brom AG. Horizontal submammary skin incision for median sternotomy. Ann Thorac Surg. 1981;32:101-4.

Bedard P, Keon WJ, Brais M, Goldstein W. Submammary skin incision as a cosmetic approach to median sternotomy. The Annals of Thoracic Surgery. 1986;41(3):339-41.

Navia JL, Cosgrove DM. Minimally invasive mitral valve operations. Ann Thorac Surg. 1996;62:1542-4.

Mohr FW Falk V, Diegeler A, Walther T, Van Son JA, Autschbach R. Minimally invasive port-access mitral valve surgery. J Thorac Cardiovasc Surg. 1998;115:567-76.

Richard A Hopkins, Arthur A, Bryan Buchholz,Kathleen Guarino, and Merry Meyers. Surgical patch closure of ASD defect. Ann Thoracic Surgery. 2004;77:2144-50.

Loulmet DE, Carpentier A, Cho PW, Berribi A, d’Attellis N, Austin CB, et al. Less invasive techniques for mitral valve surgery. J Thorac Cardiovasc Surg. 1998;115:772-9.

Cremer JT, Boning A, Ansaar MB, Kim PY, Pethig K, Harringer W, et al. Different approaches for minimally invasive closure of atrial septal defects. Ann Thorac Surg. 1999;67:1648-52.

Ramsankar P, Sadanandan R, Abdul Rashid MH, Nampooththiri MNY, Dinakaran KG, Nair PB. Right postero-lateral thoracotomy for atrial septal defect closure; a comparative analysis with median sternotomy. IJTCVS. 2005;21:24-8.

Tribble CG, Nolan SP, Kron IL. Anterolateral thoracotomy as an alternative to repeat median sternotomy for replacement of mitral valve. Ann Thorac Surg. 1995;59:255-6.

Shivaprakasha K, Murthy KS, Coelho R, Agarwal R, Rao SG, Planche C, et al. Role of limited posterior tthoracotomy for open heart surgery in current era. Ann Thoracic Surg. 1999;68:2310-3.