1. Minimal Invasive Left and Right Axillary Thoracotomy
for Epicardial Pacing and Transatrial Repair of
Congenital Heart Defects: more than just a cosmetic
sales pitch
A. Dodge-Khatami, MD, PhD
Chief of Pediatric and Congenital Heart Surgery
Children’s Heart Center
Professor of Surgery, University of Mississippi Medical Center
Jackson, MS, USA

2. New Trends and Innovations in treating Congenital
Heart Disease at the Children’s Heart Center of
UMMC

5. Introduction
standard approach for repair of congenital heart
defects:
•median sternotomy + central aorto-bicaval
cannulation for cardiopulmonary bypass (CPB)
•advantages:
– access to every cardiac structure (R+L)
– maximum room for cannulation under direct vision
– no additional incisions/routes for cannula insertion
necessary
•disadvantages:
– large visible scar
– sternum requires 4-6 weeks to heal in
babies/children, and 6-8 weeks in
adolescents/adults
– limitations to certain physical activities during
healing (care in lifting babies/infants, bicycle riding,
shopping bags, putting on backpack, driving …)
ALTERNATIVES?

6. Introduction
standard approach to pacemaker / defibrillator
insertion:
•transvenous + infra-clavicular generator pocket
•advantages:
– lesser invasive surgery
– (can be performed by EP (electro-philosophical)
cardiologist)
•disadvantages:
– hardware in SVC of a growing kid, multiple leads if
lead failure, near fatal events at extraction?
– venous thrombosis, SVC syndrome, endocarditis
– often compromise in smaller patients with a VVI
system and not dual chamber > un-physiologic and
may lead to early onset cardiomyopathy!
– no access to the heart if single ventricle Fontan
completion
– more potential for trauma to anteriorly located
generator
ALTERNATIVES?

7. Minimal Invasiveness : true patient benefit?
Lessen Surgical Trauma
Physical:
•reduce incision (muscle-sparing, endoscopy)
•reduce or eliminate cardiopulmonary bypass
(decrease inflammation, filtration strategies,
myocardial protection, off-pump surgery)
Psychological:
•fast tracking (early extubation, short ICU,
allowing quicker functional recovery and return to
a normal environment)
•cosmetic / less visible to peers
•losing the stigma of “a child with a heart
condition” and its negative emotional burden
>> think of long-term consequences

8. Minimal Invasiveness
Avoid Surgical Trauma?
Interventional Catheter Procedures:
•avoids incision (femoral vessel puncture)
•avoids cardiopulmonary bypass
•allows much quicker functional recovery and return
to a normal environment
VSD device closure Ebeid MR, Batlivala SP, Salazar JD, Eddine AC, Aggarwal A, Dodge-Khatami A, Maposa D,
Taylor MB. Percutaneous Closure of Perimembranous Ventricular Septal Defects Using the
Second-Generation Amplatzer Vascular Occluders. Am J Cardiol. 2016;117:127-30.
ASD device closure

9. Minimal Invasiveness
Avoid Surgical Trauma?
Interventional Catheter Procedures:
•avoids incision (femoral vessel puncture)
•avoids cardiopulmonary bypass
•allows much quicker functional recovery and return to a normal environment
>> Complications - Conversions
However ! >> Duration of Results?
>> Accept Residual Lesions?
current trend / demand to increasingly intervene with percutaneous techniques
whenever possible
>> challenge the surgical community to step up
WITHOUT COMPROMISING THE QUALITY OF REPAIR!

10. Minimal Invasiveness
1. muscle-sparing left mid-axillary thoracotomy
Left Heart DDD Epicardial Pacemaker
Insertion
Zurich, Hamburg, Jackson:
2003-2008; n=114, 2009-2016; n=87
•can avoid high-risk redo sternotomy
•no mortality or major morbidity
•favorable pacing characteristics (left heart vs. right
heart cardiomyopathy)
•avoids intravenous leads in growing patients
•optimal sensing thresholds at mid-term follow-up >>
high probability of lead survival
M Tomaske, B Gerritse, L Kretzers, R Prêtre, A Dodge-Khatami, M Rahn, U
Bauersfeld. A 12-year experience of bipolar steroid-eluting epicardial pacing
leads in children. Ann Thorac Surg. 2008;85:1704-11

11. Minimal Invasiveness
Left Heart DDD Epicardial
Pacemaker Insertion
through a mini-incision
is safe and reliable
steroid-eluting bipolar leads
left atrial appendage +
lateral wall (apex) of the left
ventricle
Janoušek J, van Geldorp IE, Krupi ková S, Rosenthal E, Nugent K, Tomaskeč
M, et al; Working Group for Cardiac Dysrhythmias and Electrophysiology of
the Association for European Pediatric Cardiology. Permanent cardiac
pacing in children: choosing the optimal pacing site: a multicenter study.
Circulation. 2013;127:613-23.

12. Minimal Invasiveness
2. muscle-sparing right mid-axillary thoracotomy
Open repair of a wide range of CHD
with Cardiopulmonary Bypass
Aortic or right iliac artery
+ Bicaval or iliac vein cannulation
Zurich, 2001-2007; n=123, Hamburg, Jackson; n=48
•ASD
•VSD +/- subaortic membrane
•Partial AV Canal with mitral valve cleft
•PAPVD / Warden operation
•DCRV, cor triatriatum
5.5 - 82kg
HH Dave, M Comber, T Solinger, D Bettex, A Dodge-Khatami, R Prêtre.
Mid-term results of right axillary incision for the repair of a wide range of
congenital cardiac defects. Eur J Cardiothorac Surg. 2009;35:864-70.

13. Minimal Invasiveness
2. muscle-sparing right mid-axillary thoracotomy
incisions / approach
vs. right anterolateral thoracotomy
Bleiziffer et al. J Thorac Cardiovasc Surg 2004;127:1474–80

14. Minimal Invasiveness
2. muscle-sparing right mid-axillary thoracotomy
view / cannulation

15. Minimal Invasiveness
2. muscle-sparing right mid-axillary thoracotomy
ASD closure

16. Minimal Invasiveness
2. muscle-sparing right mid-axillary thoracotomy
VSD patch closure
VSD +/- subaortic membrane

17. Minimal Invasiveness
2. muscle-sparing right mid-axillary thoracotomy
partial AV canal with mitral cleft
PAPVD / Warden operation

18. Minimal Invasiveness
2. muscle-sparing right mid-axillary thoracotomy
results
A Dodge-Khatami, J Salazar. Right axillary thoracotomy for transatrial
repair of congenital heart defects: VSD, partial AV canal with mitral cleft,
PAPVR/Warden, cor triatriatum and ASD. Oper Tech Thorac Cardiovasc
Surg 2016; Spring: In Press.

20. Minimal Invasiveness
2. muscle-sparing right mid-axillary thoracotomy
Open repair of a wide range of CHD
•safety of procedure: learning curve!
•completeness in correcting the primary defect (=
no residual lesions)
•reduced stay in ICU and hospital
•faster recovery of right shoulder and arm function vs. sternotomy
•superior cosmetic result with a vertical incision hidden underneath
a resting arm
•remote from breast tissue to avoid future asymmetric breast
growth

21. Minimal Invasiveness
muscle-sparing left + right mid-axillary thoracotomy
open repair of a wide range of CHD
DDD epicardial pacing for arrhythmia
•prolonged cure of CHD without need for reintervention or
reoperation
•avoids intra-venous hardware in growing kids
> long term good results
> true patient benefit (not just a sales pitch)

22. New Operations / Concepts
3. Primary IVC-PA Connection:
= Upside-down Glenn
= “Southern Glenn”
•an alternative palliation in single ventricle physiology when
the bidirectional Glenn is an unfavorable option
•Presented at the CHSS, Chicago, USA, Oct 25-26, 2015, at the STSA, Orlando, USA, Nov 4-7,
2015, at the PCICS, Houston, USA, Dec 9-11, 2015
•Film posted on CTSNet.org, Feb. 8, 2016-current: http://
www.ctsnet.org/article/when-bidirectional-glenn-unfavorable-option-primary-extracardiac-inferior-cavopulmonary
•A. Dodge-Khatami, A. Aggarwal, M.B. Taylor, D. Maposa, J.D. Salazar. When the Bidirectional
Glenn is an Unfavorable Option: Inferior Cavopulmonary Connection as an Alternative Palliation.
Cardiol Young 2015; April 28:1-3.
4. Ascending Aortic Slide for Interrupted Aortic Arch repair
= “Mississippi sliiiide”
5. Right Ventricular Outflow Procedure for tetralogy and
pulmonary atresia-VSD
•an alternative palliation to a shunt procedure for neonatal
cyanosis

24. New Operations / Concepts
4. Ascending Aortic Slide for Interrupted Aortic Arch repair
= “Mississippi sliiiide”
•biventricular / single ventricle repair
•unfavorable anatomy challenges a tension-free primary
connection:
– long distance between interrupted arch portions
– aberrant right subclavian artery
options include:
– direct arch or arch vessel native tissue anastomosis,
– interposition graft
– subclavian reverse flap
a novel surgical technique in 5 neonates/infants using
an ascending aortic slide bridging flap.
all with drawbacks!
•high recurrence of arch stenosis
•left bronchial compression
•no growth, sacrifice left arm artery

25. New Operations / Concepts
4. Ascending Aortic Slide for Interrupted Aortic Arch repair
= “Mississippi sliiiide”
•no surgical or interstage mortality.
•no neurologic or renal complications.
•mean follow-up 20 months (range 2.1-49 months):
– 1 univentricular patient needed percutaneous balloon arch angioplasty
at 4 months
– 1 biventricular repair a re-operation with supravalvar aortic patch
augmentation 4 months post-operatively.
•no patients had airway compression.
•one late death from Influenza pneumonia (2.3 years after the
initial aortic slide/Norwood operation = 1.9 years after successful bidirectional
Glenn).
•safe and reproducible technique, providing a bridge of
native tissue between the proximal and distal portions of the
aorta.
•likely has potential for growth

26. New Operations / Concepts
4. Right Ventricular Outflow Procedure for tetralogy and
pulmonary atresia-VSD
•an alternative palliation to a shunt procedure for neonatal
cyanosis
shunt drawbacks:
– no pulsatile flow (better for PA growth)
– shunt occlusion life-threatening, mortality (STS 5-10.5%)
•RVO Procedure = valvotomy-valvectomy, RVOT muscle
bundle resection +/- short transannular patch
>> VSD physiology (with some PS)
•n=16, 11 with branch PA stenosis, age 5-193 days
•no mortality, median follow-up 15.3 months (range 4-47)
•9 required reintervention (learning curve) prior to
complete repair: catheter balloon dilatation of RVOT, branch
PA balloon dilatation, RVOT stent.
•safe, provides pulsatile flow for growing PA’s, further
evaluation/experience required

27. Summary
• survival after treating congenital heart disease is
excellent, and we’ve come a long way since ASD closure
under inflow occlusion or VSD using cross-circulation …
• as the vast majority of patients undergoing surgery for
CHD are surviving into adulthood, the focus is no longer
only on in-hospital survival: the choices we make
initially will impact a patient’s lifetime : think forward!
• for many forms of CHD, existing pathways or surgical
strategies work well, but for others, grey zones still
exist, and outcomes are suboptimal: opportunities!
• given the room for improvement in maximizing survival,
minimizing morbidity, and enhancing functional
capacity/quality of life, innovation must be encouraged
and not smothered behind defensive litigation-fearing
medicine, within acceptable safety limits!

28. Thank Y’All !
our
team!