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Minimally Invasive Approach for the Warden Procedure in Children: is it Really Safe?
Alexey Arkhipov, Alexander Omelchenko, Yuriy Gorbatykh, Alexey Zubritskiy, Timur Khapaev, Alexander Bogachev-Prokophiev, Alexander Karaskov.
Academician Meshalkin State Research Institute of Circulation Pathology, Novosibirsk, Russian Federation.

OBJECTIVE: At present right minithoracotomy is a routine surgical approach for atrial septal defect (ASD) repair in patients with contraindications for transcatheter procedure. But in cases of sinus venosus defect with partial anomalous pulmonary venous connection (PAPVC) to the upper superior vena cava (SVC) many surgeons prefer sternotomy relying on the risk of limited exposure, sinus node disfunction or veins obstruction. The aim of this study was to evaluate the safety and efficiency of the Warden procedure through midaxillary minithoracotomy as an alternative to the conventional approach.
METHODS: From June 2012 to December 2014, we performed the minimally invasive Warden procedure in 21 patients with PAPVC to the SVC. The skin incision 3-4 cm is performed in the midaxillary line in 4th intercostal space. Aorta and caval veins are cannulated directly. Our surgical approach is based on redirection of the PAPVC blood flow through the SVC and the sinus venosus defect to the left atrium with the bovine pericardial patch performed on ventricular fibrillation, followed by SVC-right atrial appendage anastomosis.
RESULTS: Mean age was 6,3 ± 4,1 years (range, 2-16 years) and mean body weight was 25,7 ± 18,8 kg (range, 9,9-68 kg). 9 patients had indications for the surgical enlargement of the restrictive sinus venosus defect to prevent obstruction. Mean cardiopulmonary bypass time for all patients was 52,1 ± 10,3 minutes (range, 38-79 minutes). Mean ventricular fibrillation time in all patients was 18,5 ± 6,7 minutes (range, 12-37 minutes). The total procedure “skin to skin” time ranged from 122 to 180 minutes. No patient required conversion to a sternotomy or incision enlargement to complete the repair. All patients had been discharged from the ICU the next day with mean ventilation time for 3,1 ± 0,9 hours after surgery. There was no mortality, bleeding, rhythm disturbances or phrenic nerve damage.
CONCLUSIONS: The Warden procedure for the sinus venosus defect with PAPVC to the superior caval vein is safe and simple technique preserving the function of the sinus node. Performed through the midaxillary minithoracotomy the procedure provides an acceptable exposure along with the optimal cosmetic benefit, particularly in prepubescent female patients.

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