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Transverse Sternal Split: A Safe Mini-Invasive Approach for Repair of Tetralogy of Fallot
Arvind Kumar Bishnoi, Pankaj Garg, Chandrasekaran Ananthanarayanan, Malkesh Tarsaria, Pranav Sharma, Amber Malhotra, Jigar Patel, Himani Pandya.
U.N.Mehta Institute of Cardiology and Research Center, Ahmedabad, India.

Transverse Sternal Split: A Safe Mini-Invasive Approach for Repair of Tetralogy of Fallot
Objective: Right minithoracotomy or lower partial sternotomy have been used as an alternative approach for mini-invasive repair of congenital cardiac defects with a better cosmetic outcome. However, these approaches restrict the exposure of right ventricular outflow tract (RVOT) and pulmonary arteries. We performed transverse sternal split to improve the exposure of heart with advantage of mini incision for surgical correction of patients with tetralogy of Fallot (TOF).
Methods: From January 2015 to September 2015, 11 pediatric patients (7 male) with mean age 1.5 years (11 months- 3 years) and mean weight 9 Kg(7.5 - 14) underwent surgical correction for TOF. Surgery was performed through transverse sternal split in 3rd intercostals space involving a 3-5cm skin incision and cervical (right common carotid artery and right internal juglar vein) and inferior vena cava cannulation for conduct of cardiopulmonary bypass. In 7 patients, infundibular muscle resection was performed through right atrium and small right ventriculotomy. In these patients ventricular septal defect (VSD) was repaired through right atrium. In rest 4 patients transannular patch was inserted for hypoplastic pulmonary artery annulus. In these patients, infundibular muscle resection and closure of VSD was performed through the ventriculotomy.
Results: There was no mortality or significant morbidity in the postoperative period or during follow up. Mean cross clamp time was 98±27 minutes (range 75 to 169) and mean cardiopulmonary bypass time was 137±25 minutes (range, 103 to 205). All patients were weaned off mechanical ventilation within 16 hours of surgery. Cosmetic result was satisfactory in all patients with no incidence of sternal mobility or dehiscence. There was no neck wound related or neurological complication. There was significant residual defect in any patient. Two patients had tiny flow across VSD patch. During follow-up, two patients had residual gradient of 45 mmHg across right ventricular outflow tract without symptoms.
Conclusions: The transverse sternal split incision with cervical cannulation for cardiopulmonary bypass is a safe and effective alternative to a median sternotomy for surgical repair of TOF in selected group of patients with satisfactory cosmetic results.

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