The Right Axillary Incision: A Potential New Standard of Care for Selected Congenital Heart Surgery

Superior cavopulmonary shunt via right vertical axillary mini-thoracotomy

We present 2 cases of patients with univentricular heart physiology of different anatomic variants who successfully underwent minimally invasive bidirectional cavopulmonary anastomosis via the right vertical axillary mini-thoracotomy.

Current treatment outcomes of congenital heart disease and future perspectives

China has the largest number of individuals with congenital heart disease (CHD) in the world and a heavy burden of CHD. Therefore, understanding current CHD treatment outcomes and patterns in China will contribute to global progress in CHD treatment and be a valuable experience. Generally, CHD treatment in China has satisfactory outcomes owing to the joint efforts by all relevant stakeholders across the country. However, efforts are needed to overcome the remaining challenges: management of mitral valve disease and paediatric end-stage heart failure needs to be improved; cohesive paediatric cardiology teams should be established and collaboration between hospitals enhanced; CHD-related medical resources need to be more accessible and equitable; and nationwide CHD databases should be enhanced. In the second paper of this Series, we aim to systematically summarise the current CHD treatment outcomes in China, discuss potential solutions, and provide future perspectives.

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.

Can Right Infra-Axillary Vertical Thoracotomy Make a Big Difference in Surgical Technique Preference?

AIM

Minimally invasive techniques in the surgical treatment of congenital heart diseases have gained popularity recently. Right infra-axillary vertical thoracotomy (RIAVT) is one of these techniques. The aim of this study is to investigate the postoperative morbidity and cosmetic results of the right infraaxillary thoracotomy technique and compare them with the results in the literature.

METHOD

All patients who had undergone cardiac surgery using RIAVT at the Ankara City Hospital Pediatric Cardiovascular Surgery Clinic between 2019 and 2021 were enrolled in the study. Pre-operative echocardiographic diagnoses, intraoperative surgical data and post-operative morbidity data of the patients was obtained. In addition, surgical incision length was measured and recorded for the evaluation of cosmetic outcome. This data was then compared with data from similar studies in the literature.

RESULT

Between January 2019 and December 2021, 59 patients were operated using RIAVT. Of the RIAVT patients, 45 (76%) were female and 14 (24%) were male. The mean weight of the patients was 22.38±12.48 kg. Although the youngest patient was a 5-month-old infant weighing 4 kg, the oldest one was 15-years-old weighing 57 kg. Isolated secundum atrial septal defect (ASD) repair (primary or patch) was performed in 47 patients. 1 patient with Primum ASD and mitral cleft, 1 patient with secundum ASD and perimembranous ventricular septal defect (VSD) repair, 9 patients with high venosum ASD and PAPVC, and 1 patient with a discrete subaortic membrane were operated on. The surgical incision length was between 4 to 5 cm.

CONCLUSION

RIAVT is an important surgical alternative to median sternotomy in selected cases with certain pathologies. It can be performed safely in various congenital heart anomalies and provides excellent functional and cosmetic results in the long-term when compared to other surgical methods.

Mini right axillary thoracotomy for congenital heart defect repair can become a safe surgical routine

OBJECTIVE

Owing to its obvious cosmetic appeal, minimal invasive repair of congenital heart defects (CHDs) through the mini right axillary thoracotomy is becoming routine in many centres. Besides cosmesis, and before becoming a new norm, it is important to establish its outcomes as safe compared to repairs through traditional median sternotomy.

METHODS

Between 2013 and 2021, 116 consecutive patients underwent defect repairs through mini right axillary thoracotomy. Patient, operative data, and hospital outcomes were compared to contemporary mini right axillary thoracotomy and sternotomy series.

RESULTS

There was no mortality or need for approach conversion (mean age 4.3 years, range 0.17-17, mean weight 18.6 kg, range 4.8-74.4) in 118 repairs for atrial septal defect, ventricular septal defect, partial anomalous pulmonary venous return, partial atrioventricular canal with mitral cleft, scimitar syndrome, double-chambered right ventricle, cor triatriatum, and tricuspid valve repair. Protocol included on-table extubation, achieved in 97 children, with 23 outliers leading to 0.7 average hours of mechanical ventilation (range 0-66 hours), indwelling chest drain time of 2.6 days (range 1-9 days), intensive care stay of 1.8 days (range 1-10 days), and hospital stay of 3.9 days (range 2-18 days). Late revisions were required in one patient after scimitar repair for scimitar vein stenosis at 2 weeks, and in another for repair of superior caval vein stenosis after a Warden operation at 2 months; reoperations (5/116 = 4.3%) were successfully performed through the same mini right axillary incision.

CONCLUSIONS

While providing obvious cosmetic advantages, the minimally invasive right axillary thoracotomy approach for the surgical repair of common CHDs yields excellent results and is safe compared to the benchmark median sternotomy approach.

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.

Kinesio taping to address post-sternotomy scars in pediatric patients: A case report

Introduction

The role of postoperative scar tissue adhesion and its impact on motor control in infants with congenital heart disease has not been explored in the literature. Elastic therapeutic tapes, such as Kinesio tape, are designed to affect the integumentary system. This case report aims to demonstrate the safety and present the observations following use of Kinesio tape to treat scar tissue in a pediatric patient after open-heart surgery in conjunction with standard rehabilitation.

Method

This retrospective case report presents observations of an infant's sternotomy scar adhesion and gross motor development after six applications of Kinesio tape. The sternotomy and drain tube scars were treated with Kinesio tape fascia applications in addition to standard physical therapy (PT).

Discussion

Several domains showed positive changes. The scar mobility and appearance improved. The patient's motor skills improved, possibly due to skin stretch's role in motor learning. The taping application did not cause discomfort, and there were no adverse reactions.

Conclusion

In this infant, the three-month-old sternotomy scar improved in adherence and appearance after six applications of Kinesio Fingerprint tape; motor skills also increased in the presence of standard PT. There were no adverse reactions noted with the protocol. Kinesio tape may provide a safe adjunct to treat scar tissue adhesion in infants with median sternotomy scars.

Lay Summary

Issue being explored Sternotomy scars can cause physical and psychological harm. Sensors (receptors) in the skin help with movement and balance responses. The impact of scar stiffness (adhesion) on developing motor control has not been reported in infants. Treating the scar in the remodelling phase with elastic tape may improve the scar's appearance and ability to move, thereby improving development.

Intrapleural pocket for pediatric epicardial pacemaker via right axillary incision

Congenital and acquired complete heart block (CHB) are serious conduction abnormalities that may necessitate permanent pacemaker placement. Small patient size and anatomy preclude transvenous pacemaker insertion and risk subcutaneous generator pocket complications. We describe placement of a pediatric bipolar epicardial pacemaker via right axillary incision with an intrapleural polytetrafluoroethylene (PTFE) membrane pocket to facilitate future generator exchange.

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.

Minimal Right Vertical Infra-axillary Incision for Repair of Congenital Heart Defects

BACKGROUND

This study evaluated the surgical results of a diverse array of congenital heart defects through minimal right vertical infra-axillary incision (RVIAI).

METHODS

We performed a retrospective review of consecutive patients using minimal RVIAI for congenital heart defects between 2015 and 2019. The study included 1672 patients and minimal RVIAI was used for 13 primary procedures. The incision was 2.0 to 4.0 cm in all patients.

RESULTS

Median age was 2.3 years (range, 0.2-6.0 years) and median weight was 12.5 kg (range, 5.0-34.0 kg). There were no in-hospital deaths or conversions to median sternotomy. Five patients underwent early reoperations (0.3%; 3 had postoperative bleeding, 1 had coarctation of ascending aorta owing to cannulation, and 1 had a major residual shunt). Other postoperative complications included a trivial residual shunt in 16 patients (1.0%), pleural effusion in 3 (0.2%), and wound infection in 4 (0.2%). Median follow-up was 3.2 years (range, 0.2-4.9 years). There were no late deaths or late reoperations. During follow-up, no surgery-related thoracic deformity or breast asymmetry was noted. One patient had mild scoliosis. We randomly chose 100 patients to complete a questionnaire regarding patient satisfaction with minimal RVIAI. Results showed that all patients and their parents were satisfied with the cosmetic results.

CONCLUSIONS

Minimal RVIAI can be safely performed for a wide range of congenital heart defects with excellent cosmetic results. It may serve as a good alternative to median sternotomy, especially for young female patients.