THE CLAMSHELL APPROACH FOR THE SURGICAL-TREATMENT OF COMPLEX CARDIOPULMONARY PATHOLOGY IN INFANTS AND CHILDREN

Background: The surgical approach to children with complex cardiovascu lar and pulmonary anomalies is still controversial. Staged operations through multiple incisions are often performed in this setting. Object ive: The different applications and clinical advantages of a bilateral thoracosternotomy approach to complex cardiothoracic disease requirin g surgical repair were reviewed retrospectively. Methods: Between Janu ary 1993 and June 1995, 33 patients, aged between 2 months and 17 year s (mean 7.8 +/- 5.3) underwent surgical treatment of complex cardiovas cular or pulmonary disease using a clamshell approach. Twenty-one pati ents (64%) had undergone 1-5 previous surgical procedures (mean 2.5 +/ - 1.0/patient). The technique involved supine position placement, subm ammary incision, access to the pleural space bilaterally through the f ourth intercostal space and transverse division of the sternal body. R esults: Four groups of patients were operated on via this approach: (1 ) patients undergoing lobar, lung or heart-lung transplantation (40%); (2) patients undergoing repair of tetralogy of Fallot/pulmonary atres ia (36%); (3) patients with previously corrected miscellaneous conotru ncal congenital heart defects requiring extracardiac conduit replaceme nt (12%); and (4) patients undergoing miscellaneous procedures (12%), including completion of Fontan, one-stage repair of left main bronchia l stenosis and atrial septal defect, one-stage repair of partial anoma lous pulmonary venous connection and aortic coarctation, and repair of congenital pulmonary venous stenosis. There were two early (< 30 days ) deaths, giving a perioperative mortality of 6% for the entire series . Complications included postoperative hemorrhage in 4 patients (12%), prolonged ventilation time due to mechanical failure in 4 (12%). Ther e were no wound infections. Analysis of complications by group showed the lung transplant group to be more affected (18% of patients experie nced complications). Except for 2 infants undergoing complete unifocal ization and presently awaiting completion of repair of tetralogy of Fa llot/pulmonary atresia, in the remaining 31 (94%) a definitive surgica l treatment could be performed in one-stage. Conclusions: The bilatera l thoracosternotomy allows optimal exposure of all intrathoracic anato mic structures making one-stage surgical repair possible in a variety of complex cardiovascular and pulmonary anomalies. Early mortality and technique-related morbidity do not differ from those reported with th e conventional approaches to the different disease conditions. A wider application of the clamshell approach for the management of complex i ntrathoracic pathology in infants and children is advocated. (C) 1997 Elsevier Science B.V.