Right axillary incision: A cosmetically superior approach to repair a wide range of congenital cardiac defects

Minimally Invasive Surgical Repair of Simple Congenital Heart Defects Using the Right Vertical Infra-Axillary Thoracotomy Approach

OBJECTIVE

To evaluate the safety and efficacy of surgical repair for patients diagnosed with simple congenital heart defects (CHD) using the minimally invasive right vertical infra-axillary minithoracotomy (RVIAT) approach.

METHODS

We retrospectively reviewed the clinical data of consecutive patients who underwent minimally invasive RVIAT for repair of CHD between August 2019 and August 2022. There were 382 patients who underwent 8 primary procedures and were included in this study.

RESULTS

The median age of the patients was 16.2 (interquartile range [IQR], 7.2 to 41.9) months, and the median weight of the patients was 8.8 (IQR, 6.5 to 14) kg. The preoperative diagnoses were as follows: ventricular septal defect, atrial septal defect, partial anomalous pulmonary venous return, partial atrioventricular septal defect, cor triatriatum, complete atrioventricular septal defect, and myxoma. The mean aortic cross-clamp time, bypass time, and operation time were 45.4 ± 19.3 min, 65.6 ± 23.1 min, and 154.5 ± 29.7 min, respectively. There was no in-hospital mortality or conversion to median sternotomy. Two patients (0.5%) required early reoperation; 1 due to postoperative bleeding and 1 for permanent pacemaker implantation. Other complications included trivial residual shunts (23 of 382, 6%), pleural effusion (3 of 382, 0.8%), pneumothorax (0.8%), and wound infection (4 of 382, 1%). There were 2 late noncardiac deaths. Late reoperation was performed on 1 patient with progressive aortic valve regurgitation who required aortic valvuloplasty.

CONCLUSIONS

RVIAT is a minimally invasive approach that can be safely performed on patients with simple CHDs. RVIAT may be a good alternative approach for median sternotomy and cardiac intervention.

Minimally Invasive Surgery for Simple Congenital Heart Defects: Preserving Aesthetics without Jeopardizing Patient Safety

Minimally invasive surgeries for pediatric patients have been proposed for decades, with different approaches in mind. Minimal right axillary thoracotomy (MRAT), proposed two decades ago, allows the preservation of patients' safety alongside faster aesthetic and functional recovery. The MRAT did not become widely adopted due to the prejudice that to follow a minimally invasive approach, safety and efficacy must be compromised. With this study, we aim to compare MRAT to the standard median sternotomy approach with a focus on safety and clinical outcomes. Between January 2017 and April 2021, 216 patients diagnosed with ASD, pAVSD, or PAPVD underwent surgical repair with different approaches in the same period. MRAT was used for 78 patients, and median sternotomy was used for 138 patients. In this last group, standard median sternotomy (SMS) was used for 116 patients, while a minimal skin incision (SMS mini) was used for 22 patients. There were no major complications overall nor in each specific approach. MRAT enabled the successful repair of simple heart defects, providing similar post-operative and cardiological recovery. MRAT does not compromise patients' safety and does not prolong the duration of surgery once the learning curve is overcome, which is generally after 15-20 consecutive operations.

Doubly committed ventricular septal defect: Is it safe to perform surgical closure through the pulmonary trunk approached by right vertical axillary thoracotomy?

Objective

This study investigated the safety of performing surgical repair for doubly committed ventricular septal defects by right vertical infra-axillary minithoracotomy (RVIAT).

Methods

A retrospective comparative study was performed to evaluate the outcomes of patients who underwent doubly committed ventricular septal defects closure from January 2019 to May 2022. Seventy-four patients were enrolled in the study and treated with either the median sternotomy approach (MSA: n = 37) or the RVIAT approach (RVIAT: n = 37).

Results

The median weight and age in the MSA group were significantly lower than those in the RVIAT group (MSA: 6.0 kg [interquartile range] (IQR), 5.2 to 8.7 kg] vs RVIAT: 7.5 kg [IQR, 5.6-14 kg]; P = .034 and MSA: 4.9 months [IQR, 3.6-9.4 month] vs 9.6 months [IQR, 5.0-60.4 months]; P = .0084). No patients died, and no patients in the RVIAT group required conversion to the MSA approach. The mean prebypass surgical time was longer in the RVIAT group (36.1 ± 8.2 minutes vs 31.8 ± 5.6 minutes; P = .03). There were no significant differences between the 2 groups in cardiopulmonary bypass time, aortic crossclamp time, or operation time. Significantly shorter ventilation times were observed in the RVIAT group (11.9 ± 8.2 hours vs 15.4 ± 6.3 hours; P = .006).

Conclusions

Closure of doubly committed ventricular septal defects through the pulmonary trunk by the RVIAT approach is feasible and safe, and does not increase the risk of bypass-related complications.

Safety and Efficacy of Right Axillary Thoracotomy for Repair of Congenital Heart Defects in Children

BACKGROUND

Minimally invasive repair of congenital heart defects in children has not gained wide popularity yet compared to minimally invasive approaches in adults. We sought to review our experience with this approach in children.

METHODS

This study included a total of 37 children (24 girls, 64.9%) with a mean age of 6.5 ± 5.1 years, who underwent vertical axillary right minithoracotomy for repair of a variety of congenital heart defects between May 2020 and June 2022.

RESULTS

The mean weight of these children was 25.66 ± 18.3 kg. Trisomy 21 syndrome was present in 3 patients (8.1%). The most common congenital heart defects that were repaired via this approach were atrial septal defects (secundum in 11 patients, 29.7%; primum in 5, 13.5%; and unroofed coronary sinus in 1, 2.7%). Twelve patients (32.4%) underwent repair of partial anomalous pulmonary venous connections with or without sinus venosus defects, while 4 patients (10.8%) underwent closure of membranous ventricular septal defects. Mitral valve repair, resection of cor triatriatum dexter, epicardial pacemaker placement, and myxoma resection occurred in 1 patient (2.7%) each. No early mortality or reoperations. All patients were extubated in the operating room, and the mean length of hospital stay was 3.3 ± 2.04 days. Follow-up was complete (mean 7 ± 5 months). No late mortality or reoperations. One patient required epicardial pacemaker placement due to sinus node dysfunction 5 months after surgery.

CONCLUSIONS

Vertical axillary right thoracotomy is a cosmetically superior approach that is safe and effective for repair of a variety of congenital heart defects in children.

Surgical Maneuver for Ventricular Septal Defect Exposure During Congenital Heart Surgery Through the Right Axillary Transverse Minithoracotomy

Right axillary transverse minithoracotomy is not conventionally used for ventricular septal defect (VSD) repair because of complicated VSD exposure and the need for a temporary tricuspid valve leaflet detachment to facilitate VSD exposure. Recently, our team developed a new, not previously described surgical maneuver that markedly facilitates perimembranous VSD exposure without any need for tricuspid valve leaflet detachment. The above-mentioned VSD exposure maneuver was used in 21 patients with a median age of 5 months (range, 1.5 to 132 months) and a median body weight of 7 kg (range, 4 to 47 kg). The length of the incision varied from 3 to 4.5 cm over the fourth intercostal space within the anterior and posterior axillary lines. Central cardiopulmonary bypass cannulation and antegrade blood cardioplegia were performed in all patients. Bent/angled instruments were used throughout the procedure to facilitate the surgeon’s view. Pericardial sutures and suspension of tricuspid valve chords were used as general exposure maneuvers. A special surgical maneuver aimed at changing the general plane of the ventricular septum was used. It consisted of one intraventricular exposing suture. Sufficient exposure of perimembranous VSD was obtained in all patients and was comparable with what is usually obtained through the median sternotomy. With the use of this new maneuver, all perimembranous VSDs could be safely exposed and repaired with the conventional suturing technique through the right axillary transverse minithoracotomy starting from 2 months of age.

Rightvertical axillary incision for atrial septal defect: a propensity score matched study

Background

Atrial septal defect is one of the most common types of congenital heart disease. This study aims to explore the surgical and cosmetic effects of open-heart surgery with right vertical axillary incision for simple congenital heart disease in infants.

Methods

From June 2018 to October 2021, children who underwent direct surgery of atrial septal defect in our department were selected for a propensity score matched study. Those with direct surgery through the right vertical axillary incision were included in the right vertical axillary incision group. According to age and weight, propensity score matching method was employed to match children from the right vertical axillary incision group with those undergoing direct surgery through median sternotomy (median sternotomy group) at a 1:2 ratio. Surgery outcomes between two groups were compared to evaluate the effectiveness and safety of right vertical axillary incision group.

Results

The median incision length (median, [interquartile range]) in right vertical axillary incision group (4.8 cm, [4.0–5.0]) was shorter than that in median sternotomy group (p < 0.001). The median drainage volume of drainage tube of the right vertical axillary incision group (117.5 ml, [92.8,152.8]) was smaller than that of median sternotomy group (p = 0.021). While no residual bubbles cases in the left and right ventricles and outflow tract were present in the right vertical axillary incision group, 44% of residual air bubble rate in right ventricular outflow tract was detected in median sternotomy group (p = 0.001). Additional sedation and analgesia (p = 0.003), wound infection or poor healing (p = 0.047), thoracic deformity healing (p = 0.029) and appearance satisfaction questionnaire (p = 0.018) in the right vertical axillary incision group were better than those in the median sternotomy group.

Conclusion

Right axillary vertical incision can effectively reduce surgical trauma, accelerate postoperative rehabilitation. This surgical approach also provides better cosmetic effect, which is easily accepted by children’s families and worthy of further clinical application.

Advantages of a mini right axillary thoracotomy for congenital heart defect repair in children

OBJECTIVES

The mini right axillary thoracotomy is an alternative surgical approach to repair certain congenital heart defects. Quality-of-life metrics and clinical outcomes in children undergoing either the right axillary approach or median sternotomy were compared.

METHODS

Patients undergoing either approach for the same defects between 2018 and 2020 were included. Demographic details, operative data, and outcomes were compared between both groups. An abbreviated quality of life questionnaire based on the Infant/Toddler/Child Health Questionnaires focused on the patient's global health, physical activity, and pain/discomfort was administered to all parents/guardians within two post-operative years.

RESULTS

Eighty-seven infants and children underwent surgical repair (right axillary thoracotomy, n = 54; sternotomy, n = 33) during the study period. There were no mortalities in either group. The right axillary thoracotomy group experienced significantly decreased red blood cell transfusion, intubation, intensive care, and hospital durations, and earlier chest tube removal. Up to 1 month, parents' perception of their child's degree and frequency of post-operative pain was significantly less after the right axillary thoracotomy approach. No difference was found in the patient's global health or physical activity limitations beyond a month between the two groups.

CONCLUSIONS

With the mini right axillary approach, surrogates of faster clinical recovery and hospital discharge were noted, with a significantly less perceived degree and frequency of post-operative pain initially, but without the quality of life differences at last follow-up. While providing obvious cosmetic advantages, the minimally invasive right axillary thoracotomy approach for the surgical repair of certain congenital heart lesions is a safe alternative to median sternotomy.

Individualized strategy of minimally invasive cardiac surgery in congenital cardiac septal defects

Background

Intracardiac septal defect is repaired using median sternotomy in most centers; however, there are several reports using minimally invasive surgery in both children and adults. This study summarized our strategy of minimally invasive therapy using various lateral mini-thoracotomies in patients with congenital septal defect.

Methods

In this study, 472 patients who underwent minimally invasive repair of intracardiac septal defects (atrial septal defect, (ASD), ventricular septal defect, (VSD), and atrioventricular septal defect, (AVSD)) from January 2012 to June 2020 were retrospectively reviewed. Those who underwent device closure were excluded. The minimally invasive strategy included three groups: the right sub-axillary vertical incision (RSAVI) group (N = 335, including192 ASDs, 135 VSDs and 8 AVSDs); the right anterolateral thoracotomy (RALT) group (N = 132, including 77 ASDs, 51 VSDs and 4 AVSDs); and the left anterolateral thoracotomy (LALT) group (N = 5, all subpulmonary VSDs).

Results

Concomitant surgeries included nine cases of right ventricular outflow tract obstruction relief, nine cases of mitral repairs and 37 cases of tricuspid repairs. There was one transition from thoracotomy to sternotomy. Three patients required second pump run for residual lesions (two residual VSD shunts and one mitral regurgitation). The age and body weight of the RSAVI group were significantly lower than those of the RALT and LALT groups (all P < 0.01). No postoperative death was observed. Postoperative complications included one case of chest exploration for bleeding, one case of reoperation due to patch dehiscence during the same admission, one case of transient neural dysfunction, three cases of diaphragmatic paresis and 13 cases of atelectasis. The median stay in the intensive care unit was two days, while the median postoperative hospitalization duration was six days. The echocardiography results before discharge indicated no significant residual lesions. No reoperation, no new onset of chest deformities and no sclerosis were observed during the follow-up.

Conclusions

Intracardiac septal defects can be safely and effectively repaired by minimally invasive surgery with good cosmetic results. RSAVI is suitable in infants and children, while RALT is more commonly used in adolescents and adults. LALT is an alternative incision to repair subpulmonary VSD.

Transaxillary Approach for Surgical Repair of Simple Congenital Cardiac Lesions: Pitfalls, and Complications

BACKGROUND

In the treatment of simple congenital cardiac lesions, percutaneous and cosmetic surgical approaches have steadily gained prominence. Surgically, right vertical axillary approach is sparsely used despite superior cosmesis and less pain and blood product usage. Knowledge of potential pitfalls could lead to its more widespread acceptance.

METHODS

We retrospectively analyzed perioperative outcomes of 104 consecutive patients who underwent surgery by this technique between mid-2016 and December 2019, including ostium secundum (67), sinus venosus (34), coronary sinus (1), and ostium primum (1) atrial septal defects and hemianomalous pulmonary venous connection (1). Perioperative variables, surgical times, complications, and follow-up data were analyzed.

RESULTS

Patient weight ranged from 6.8 to 41 kg. Incision length ranged from 4 to 6 cm. There was no mortality. All cannulation was central. Difficulty in cannulation (inferior vena cava) was seen in two patients. Morbidity included pneumothorax in 2 (1.9%) patients and subcutaneous emphysema necessitating prolonged intercostal drain retention in 20 (19.2%) patients. Surgical time increased linearly (r = 0.567; P < .001) with increasing patient weight but cardiopulmonary bypass (CPB) time remained unaffected. No chest deformities or paresthesia were noted on follow-up. Scar size decreased in some patients.

CONCLUSIONS

Right vertical axillary approach can be safely employed to treat simple congenital cardiac lesions with adequate awareness of potential pitfalls. Increasing patient weight increases the surgical time but does not affect CPB times. Incidence of pneumothorax and subcutaneous emphysema is similar to other thoracotomy approaches. It is cosmetically superior.

Right mini-thoracotomy approach for grown-up congenital heart disease

BACKGROUND

Right mini-thoracotomy cardiac surgery has been recognized as a safe and effective procedure, with remarkable early and long-terms outcomes. However, most of the literature is focused on mitral valve surgery and few studies report on the minimally invasive approach applied to congenital disease. Aim of this study was to review our experience on patients with grown-up congenital heart (GUCH) undergoing right mini-thoracotomy cardiac surgery.

METHODS

Data of patients with GUCH undergoing right mini-thoracotomy cardiac surgery from 2006 to 2019 were retrospectively analyzed. Inclusion criteria were atrial septal defect, partial anomalous pulmonary venous return, partial atrioventricular septal defect, and mitral or tricuspid valve dysfunction in congenital heart diseases.

RESULTS

During the study period 127 patients with GUCH underwent right mini-thoracotomy cardiac surgery. Mean age was 43.6 years and more than 60% were females; diagnosis was atrial septal defect in 57 cases (44.9%); 24 patients were redo (18.9%). No cases of stroke and major vascular complications were reported. Conversion to sternotomy was required in one case (0.8%). No residual shunts or valves dysfunction were recorded at the postoperative echocardiographic evaluation. Perioperative mortality was 1.6%.

CONCLUSIONS

Right mini-thoracotomy cardiac surgery in selected patients with GUCH allows to avoid the big scar of the sternotomy approach and to accelerate the recovery in a young population. Moreover, in redo cases, it allows the surgeon to reach the heart and the aorta avoiding the well-known risks of a re-sternotomy procedure.

Borrowing from Adult Cardiac Surgeons-Bringing Congenital Heart Surgery Up to Speed in the Minimally Invasive Era

The majority of congenital and adult cardiac surgery is performed through a median sternotomy. For surgeons, this incision provides excellent exposure; however, for patients, a median sternotomy confers a poorer cosmetic outcome and the possibility of postoperative respiratory dysfunction, chronic pain, and deep sternal wound infections. Despite the advances in adult cardiac surgery, the use of minimally invasive techniques in pediatric patients is largely limited to small case series and less complex repairs. In this article, we review the risks, benefits, and limitations of the minimally invasive congenital cardiac approaches being performed today. The interest in these approaches continues to grow as more data supporting reduced morbidity, decreased length of stay, and faster recovery are published. In the future, as the technology and surgical familiarity improve, these alternative approaches will become more common, and may someday become the standard of care.

Toward Routine Minimally Invasive Ventricular Septal Defect Closure Via Right Lateral Minithoracotomy

Background: Improving the surgical results and recent advancement of transcatheter techniques for closure of ventricular septal defect (VSD) increased the demand for minimally invasive approaches. In this study, we analyzed the results of the patients who underwent VSD closure with right lateral minithoracotomy (RLMT). Methods: Between September 2014 and February 2021, 24 patients underwent minimally invasive VSD closure with RLMT. The median age of the patients was 16 months (range, 4-84 months). Fifteen patients (62.5%) were female. The median weight of the patients was 9.75 kg (range, 4.6-30 kg). The types of VSD were perimembranous in 19 patients, subaortic in three patients, inlet in one patient, and subpulmonic in one patient. Five patients had low-lying pulmonary stenosis in addition to VSD. Results: No perioperative death or major complication occurred during follow-up. All defects were repaired through RLMT. The median cardiopulmonary bypass time was 81 min (range, 44-163 min), and the aortic cross-clamp time was 65 min (range, 33-131 min). The median hospital stay was 6 days (range, 5-21 days). One patient had minimal (2 mm) residual left-to-right shunt. All families were satisfied with the cosmetic results during the follow-up. Conclusions: The RLMT method is a safe and effective alternative to standard median sternotomy for VSD closure and can be performed with favorable cosmetic and clinical results.

Comparative Study between Surgical Repair of Atrial Septal Defect via Median Sternotomy, Right Submammary Thoracotomy, and Right Vertical Infra-Axillary Thoracotomy

Objective

To compare the results of surgical repair via median sternotomy, right submammary thoracotomy, and right vertical infra-axillary thoracotomy for atrial septal defect (ASD).

Methods

This is a retrospective analysis of the relative perioperative and postoperative data of 136 patients who underwent surgical repair for ASD with the abovementioned three different treatments in our hospital from June 2014 to December 2017.

Results

The results of the surgeries were all satisfactory in the three groups. No statistically significant difference was found in operative time, duration of cardiopulmonary bypass, blood transfusion amount, postoperative mechanical ventilation time, duration of intensive care unit, length of hospital stay, and hospital costs. However, the median sternotomy group had the longest incision. Meanwhile, there was no significant difference in postoperative complications.

Conclusion

All three types of surgical incisions can be safely and effectively used to repair ASD. The treatments via right submammary thoracotomy and right vertical infra-axillary thoracotomy have advantages over the treatment via median sternotomy in cosmetic results and should be the recommended options.

Correction of simple congenital heart defects by right axillary thoracotomy in adults

BACKGROUND

Right axillary thoracotomy has been performed for open-heart procedures as a more aesthetic alternative to standard median sternotomy. This study aimed to evaluate the efficacy and safety of right axillary thoracotomy for the correction of simple congenital heart defects in adults.

METHODS

Between January 2014 and December 2017, the clinical data of 180 adults who underwent right axillary thoracotomy for simple congenital heart defects were compared with the data of a paired group of 192 adults who underwent median sternotomy.

RESULTS

Compared with the median sternotomy group, the right thoracotomy group showed shorter operative time, postoperative mechanical ventilation time, and postoperative hospitalization duration, as well as less drainage and transfusion volumes (P < .05). Aortic cross-clamping time, cardiopulmonary bypass time, and length of intensive care unit stay were similar between groups. No mortality or significant residual defects were reported in either group during follow-up. In total, 172 patients (95.6%) in the right thoracotomy group and 134 patients (69.8%) in the median sternotomy group were satisfied with their cosmetic results (P < .01).

CONCLUSIONS

A right axillary thoracotomy is as safe and effective as a median sternotomy for the correction of simple congenital heart defects in adults. With lower trauma and better cosmetic results, this procedure provides a good alternative to the standard median sternotomy.

How to set-up a program of minimally-invasive surgery for congenital heart defects

BACKGROUND

Mid-line sternotomy is the commonest incision for cardiac surgery. Alternative approaches are becoming fashionable in many centres, amidst some reluctance because of learning curves and overall complexity. Our recent experience in starting a new program on minimally invasive pediatric cardiac surgery is presented. The rationale for a stepwise onset and the short-medium term results for a three-year span are displayed.

METHODS

A three-step schedule is planned: First, an experienced surgeon (A) starts performing simple cases. Second, new surgeons (B, C, D, E) are introduced to the minimally invasive techniques according to their own proficiency and skills. Third, the new adopters are enhanced to suggest and develop further minimally invasive approaches. Two quality markers are defined: conversion rate and complications.

RESULTS

In part one, surgeon A performs sub-mammary, axillary and lower mini-sternotomy approaches for simple cardiac defects. In part two, surgeons B, C, D and E are customly introduced to such incisions. In part three, new approaches such as upper mini-sternotomy, postero-lateral thoracotomy and video-assisted mini-thoracotomy are introduced after being suggested and developed by surgeons B, C and E, as well as an algorithm to match cardiac conditions and age/weight to a given alternative approach. The conversion rate is one out of 148 patients. Two major complications were recorded, none of them related to our alternative approach. Four minor complications linked to the new incision were registered. The minimally invasive to mid-line sternotomy ratio rose from 20% in the first year to 40% in the third year.

CONCLUSIONS

Minimally invasive pediatric cardiac surgery is becoming a common procedure worldwide. Our schedule to set up a program proves beneficial. The three-step approach has been successful in our experience, allowing a tailored training for every new surgeon and enhancing the enthusiasm in developing further strategies on their own. Recording conversion-rates and complications stands for quality standards. A twofold increase in minimally invasive procedures was observed in two years. The short-medium term results after three years are excellent.

[15 years of minimally invasive paediatric cardiac surgery; development and trends]

INTRODUCTION

The minimally invasive approach is seldom reported in paediatric cardiac surgery. Teams gathering experience are scarce, with programs focused on simple cases. The experience is presented on a series of over 200 cases operated on in the past 15 years.

MATERIAL AND METHODS

A sub-mammary approach program was started in 2000, which was gradually extended to include more complex and younger patients. The axillary incision was adopted in 2009, following the same steps. In 2013, the mini-sternotomy incision was introduced, increasing our armamentarium. From July 2000 until December 2014, 203 patients were operated on. The sub-mammary approach was used in 102 cases, axillary in 50 patients, mini-sternotomy in 44, postero-lateral thoracotomy in 4 cases, and upper mini-sternotomy in 3.

RESULTS

By diagnosis, ostium secundum atrial septal defect was the most common (128), followed by sinus venosus (20), ventricular septal defect (20), ostium primum (16), and others (19). One patient was converted to sternotomy. No neurological events were detected. The mean age was 7.8/3.7 and 1.8 years, and the mean weight was 28.1/16.1 and 9.4 Kg. in the sub-mammary, axillary and mini-sternotomy approaches, respectively. The aesthetic results were excellent.

CONCLUSIONS

Based on our 15 years of experience, minimally invasive surgery is safe and yields excellent cosmetic results. The gradual introduction of alternative approaches (sub-mammary, axillary, mini-sternotomy) allowed us to set-up guidelines and learning curves. The wide range of incisions enables the most appropriate one to be selected depending on age/weight and cardiac condition.

Horizontal right axillary minithoracotomy: aesthetic and effective option for atrial and ventricular septal defect repair in infants and toddlers

INTRODUCTION

Congenital heart defects treatment shows progressive reduction in morbidity and mortality, however, the scar, resulting from ventricular (VSD) and atrial septal defect (ASD) repair, may cause discomfort. Right axillary minithoracotomy approach, by avoiding the breast growth region, is an option for correction of these defects that may provide better aesthetic results at low cost. Since October 2011, we have been using this technique for repairing VSD and ASD defects as well as associated defects.

OBJECTIVES

To evaluate the efficacy of this method in children undergoing correction of VSD and ASD, to compare perioperative clinical outcomes with those repaired by median sternotomy, and to evaluate the aesthetic result.

METHODS

Perioperative clinical data of 25 patients submitted to axillary thoracotomy were compared with data from a paired group of 25 patients with similar heart defects repaired by median sternotomy, from October 2011 to August 2012.

RESULTS

Axillary approach was possible even in infants. There was no mortality and the main perioperative variables were similar in both groups, except for lower use of blood products in the axillary group (6/25) vs. control (13/25), with statistical difference (P =0.04). The VSD size varied from 7 to 15 mm in axillary group. Cannulation of the aorta and vena cavae was performed through the main incision, whose size ranged from 3 to 5 cm in the axillary group, with excellent aesthetic results.

CONCLUSION

The axillary thoracotomy was effective, allowing for a heart defect repair similar to the median sternotomy, with more satisfactory aesthetic results and reduced blood transfusion, and it can be safely used in infants.

Left ventricular assists device insertion via small right axillary incision in a pediatric patient

We report the use of a right axillary skin incision to institute a ventricle assist device support in a two-year-old 14 kg male with fulminant myocarditis. The ease of conversion to a long-term support, avoidance of a sternotomy, and a less visible incision made this approach an attractive option in this group of sick patients.

Strictly-posterior thoracotomy: a minimal-access approach for construction of the modified Blalock-Taussig shunt in West African children

Introduction

In resource-poor settings, the modified Blalock-Taussig shunt (MBTS) is often performed for symptomatic relief of Fallot's tetralogy. From September 2011, we adopted the strictly posterior thoracotomy (SPOT), a minimal-access technique for the MBTS and report the cosmetic advantages in this communication.

Methods

We retrospectively analyzed the records of consecutive patients in whom the SPOT approach was used to construct the MBTS. Study end-points were early mortality, improvement in peripheral oxygenation, morbidity, and the cosmetic appeal.

Results

Between September 2011 and January 2013, 15 males and 8 females, median age 4 years (1.3 - 17 years) and weight 13 kg (11 - 54 kg) underwent the MBTS through the SPOT approach. The polytetrafluoroethylene grafts used ranged from sizes 4 - 6mm (median 5mm). The median preoperative SpO2 was 74% (55% - 78%), increasing to a postoperative median value of 84% (80% - 92%). Shunts were right-sided in 22 patients and left-sided in one. There were no shunt failures. Hospital stay ranged from 7 - 10 days. There was one early death (4.3%), and two postoperative complications (re-exploration for bleeding and readmission for drainage of pleural effusion). The surgical scars had excellent cosmetic appeal: they ranged from 5-10 cm in length; all were entirely posterior and imperceptible to the patient.

Conclusion

The SPOT approach represents a safe and cosmetically superior alternative to the standard posterolateral thoracotomy, the scar being imperceptible to the patient. The excellent cosmetic appeal and preservation of body image makes this approach particularly attractive in children and young adults.

Complete muscle-sparing technique in axillary closure of atrial septal defects

Minimally invasive cardiac surgery is gaining wide acceptance. The midaxillary approach hides the incision under the right arm. Concerns may arise regarding functional recovery should the latissimus dorsi and serratus anterior muscles be affected by this maneuver. A modified technique that spares both muscles, without splitting their fibers, is described. Six patients have been operated on, with excellent functional and cosmetic results, and no side-effects.

[Axillary approach for surgical closure of atrial septal defect]

Mid-line sternotomy is the routine approach for surgical repair of congenital heart diseases. However, its noticeable scar is a constant reminder of having undergone heart surgery. Several alternative approaches have been developed for simple cardiac conditions to hide the scar. Our series, consisting of 26 patients with axillary closure of atrial septal defect, is presented. The median age was 5.45 years (range 3-13), and median weight was 19.84 Kg. (range 13-37). The defect was closed directly in 13 cases, and with an autologous pericardial patch in the other 13. The number of surgical steps and time taken were the same as in median sternotomy. Functional recovery, intensive care unit stay, and hospital discharge were also standard. The cosmetic result, assessed both by patients and relatives, was excellent.

Minimally invasive pediatric cardiac surgery. Atrial septal defect closure through axillary and submammary approaches

INTRODUCTION AND OBJECTIVES

Minimally invasive approaches in less-complex cardiac procedures can avoid unpleasant cosmetic results. Moreover, surgery can be scheduled in younger patients. In previous papers, we compared submammary and midline sternotomy. We present our initial experience with an axillary, compared to submammary, approach to repair atrial septal defects under extracorporeal circulation.

METHODS

20 patients are included: 10 in the submammary group (7 ostium secundum, 2 sinus venosus, 1 ostium primum) and 10 in the axillary group (7 ostium secundum, 3 sinus venosus). Mean age and weight are 6.4±3.62 years (range 3-13) and 23.5±8.74 Kg (range 12-38) in the submammary group, and 5.5±2.04 years (range 3-9) and 19.7±5.88 Kg (range 14-29) in the axillary one, respectively. Muscles are spared (pectoralis in submammary and latissimus in axillary). The whole procedure (cannulation and correction) is performed through a single incision, with no side ports.

RESULTS

No residual defects were found at discharge. Surgical approach maneuvers are more cumbersome through the axillary than the submammary approach. In a peer comparison, extracorporeal circulation and cross-clamp time were similar in both groups (P>.05).

CONCLUSIONS

1. Axillary approach is as safe as submammary access in selected patients and for defects approached through the atrium. 2. Cosmetic result is excellent.

Continuous positive airway pressure and lung separation during cardiopulmonary bypass to facilitate congenital heart surgery via the right thorax in children

We describe a fast track anesthesia technique that facilitates congenital heart surgery via right axillary thoracotomy in children. Continuous positive airway pressure on the dependent lung, before and during cardiopulmonary bypass, approximates the heart towards the chest wall incision, and significantly improves the surgeon's access to the heart.

Closure of Restrictive Ventricular Septal Defects through a Right Axillary Thoracotomy

OBJECTIVE

To report the midterm results of an alternative minimally invasive approach for closure of ventricular septal defects (VSD) through a muscle-sparing minithoracotomy at the right midaxillary line.

MATERIAL AND METHODS

From September 2003 to December 2005, 22 patients (median age, 5 years; range, 1.5-12 years) underwent a right lateral axillary thoracotomy for closure of a perimembranous VSD. Special features of the approach included an incision between the anterior and posterior axillary fold, a muscle-sparing preparation over the fourth intercostal space, and the establishment of cardiopulmonary bypass with inguinal and superior vena cava cannulation. The ascending aorta was cross clamped and cardioplegic arrest was instituted. The VSDs were all approached through a right atriotomy and closed directly (17 patients) or with a patch (5 patients). Three patients underwent concomitant aortic valve repair.

RESULTS

There was no mortality or significant surgical morbidity. Median cross-clamp and cardiopulmonary bypass times were 46 and 104 min, respectively. Follow-up was complete and ranged from 2 to 22 months (median, 20 months). All patients were in sinus rhythm. Echocardiography revealed no residual defects with competent aortic and tricuspid valves. The length of the incision ranged from 4 to 6 cm, was away from the mammary gland, and remained entirely covered by the adducted arm. All children recovered right shoulder function within days, and cosmetic results were very satisfying. One patient developed iliac artery stenosis following inguinal artery cannulation.

CONCLUSION

Closure of perimembranous VSDs in older children can be safely performed through a right axillary thoracotomy without compromising the accuracy of the repair. The cosmetic results are excellent.

Congenital mitral valve surgery: techniques and results

PURPOSE OF REVIEW

Congenital lesions of the mitral valve are rare. Conservative surgery is recognized as the best option. In complex anatomy, however, replacement is the only solution to achieve an acceptable result. This review aims to study the long-term follow-up of classical treatments, conservative or replacement, and to examine new technical advances.

RECENT FINDINGS

The long-term results of conservative surgery are confirmed with a low incidence of reoperation except in mitral valve stenosis. The Ross II operation using a pulmonary autograft is a difficult technique that may be useful in the youngest patient group when prosthetic devices cannot be used.

SUMMARY

In the last few years, surgery of congenital mitral valve lesions has gained from echocardiography, which shows the exact function and anatomy of the mitral valve. The tendency is to avoid multistage operations. Valve replacement by biologic material (Ross II) is still under clinical evaluation.