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.

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.

Doubly committed subarterial ventricular septal defect closure through tricuspid approach: a clinical analysis

BACKGROUND

The research was to introduce the experience of doubly committed subarterial ventricular septal defect (DCVSD) repaired through tricuspid approach.

METHODS

From January, 2015 to September, 2019, 86 consecutive DCVSD paediatrics underwent repair via right subaxillary vertical incision (RAVI) through tricuspid approach. Perioperative and follow-up data were collected.

RESULTS

The age and weight at operation were 28.1 ± 18.5 (range: 7-101) months and 12.2 ± 4.2 (6-26.5) kg. There were two patients combined with discrete subaortic membrane, two patients with patent ductus arteriosus, one patient with atrial septal defect, and two patients with abnormal muscle bundle in right ventricular outflow tract. The mean size of ventricular septal defect was 7.0 ± 2.4 (3-13) mm. The defect was repaired with a piece of Dacron patch in 68 patients or directly with 1-2 pledgetted polypropylene sutures in 18 patients. The cardiopulmonary bypass time and aortic cross-clamp time were 46.2 ± 13.3 (23-101) minutes and 29.2 ± 11.5 (12-84) minutes. After 3.1 ± 2.4 (0-14) hours' ventilator assist and 23.2 ± 32.1 (0-264) hours' ICU stay, all patients were discharged safely. At the latest follow-up (27.9 ± 14.6 months), echocardiography showed trivial residual shunt in two patients. There was no malignant arrhythmia occurred and there was no chest deformity or asymmetrical development of the breast was found.

CONCLUSIONS

DCVSD repaired via right subaxillary vertical incision through tricuspid approach was safe and feasible, providing a feasible alternative to median sternotomy, and it can be performed with favourable cosmetic results.

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.

Effects of repairing ventricular septal defects with right vertical infra-axillary mini-incision on lung function and postoperative analgosedation

The present study aimed to assess the effects of repairing ventricular septal defects (VSDs) with right vertical infra-axillary mini-incision (RVAI). A total of 116 patients with VSDs were prospectively enrolled and underwent cardiac surgery between June 2017 and December 2018 at the cardiac intensive care unit of Shanghai Children's Medical Center (Shanghai, China). Of these, 58 patients underwent the RVAI procedure and 58 patients matched 1:1 underwent the standard median sternotomy incision (MSI) procedure and were designated as the control group. The demographic data and clinical outcomes intra- and postoperatively were compared. A bedside lung ultrasound was performed to evaluate the degree of lung injury and the number of B-lines was quantified and compared between the two groups. The sedation and analgesia levels were also assessed after the operation. No significant difference was identified between the two groups regarding the overall cardiopulmonary bypass or aortic cross-clamp time. All patients were extubated within 8 h. The RVAI group had shorter incision lengths (median, 4.6 cm) and less drainage (median, 15 ml) than the MSI group. Furthermore, compared to the MSI group, the RVAI group had a significantly higher number of B-lines in the right lung regions immediately after surgery and at 12 h postsurgery (24.1 and 5.2%, respectively) but eventually exhibited no differences at 24 and 36 h postsurgery; by contrast, there were no differences in the left lung regions. The bedside bispectral index score and the Face, Legs, Activity, Cry, Consolability scale score exhibited no significant differences after the operation. In conclusion, the RVAI procedure appears to be a safe alternative for repairing VSDs in addition to satisfactory cosmetic results and the incision does not interfere with postoperative analgosedation.

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.

Through Tricuspid Closure for Doubly Committed Subarterial Ventricular Septal Defect with Right Vertical Subaxillary Mini-incision: A Matched-Pair Analysis

To evaluate the feasibility and efficacy of the right subaxillary vertical mini-incision (RAVI) used for the closure of doubly committed subarterial ventricular septal defect (SAVSD) through tricuspid approach only. From June 2015 to September 2016, 32 SAVSD patients (mean age 2.4 ± 1.9 years, range 0.7-8 years) underwent surgical repair with either RAVI (incision length 3-4 cm) through tricuspid (group A, n = 16) or conventional median sternotomy incision through the main pulmonary artery approach (group B, n = 16). A retrospective 1:1 matched-pair analysis was performed with the group B matched for defect size, body weight, gender, patching, and operation year. The demographic characteristics in both groups were similar. No patient died and only 1 patient in group B needed reoperation for sternal infection. The mean cardiopulmonary bypass (CPB) time and aortic cross-clamp time were 48.6 ± 12.6 min, 29.3 ± 8.5 min in the group A and 57.8 ± 14.1 min (p = 0.03), 34.3 ± 12.1 min ( p = 0.18) in the group B. There was no significant difference between the two groups in the ICU stay (17.8 ± 8.9 h in group A, 18.7 ± 9.5 h in group B, p = 0.79), mechanical ventilation support time (2.7 ± 1.7 h in group A, 3.6 ± 1.5 h in group B, p = 0.11), postoperative hospital stay (6.3 ± 1.5 days in group A, 7.4 ± 1.7 days in group B, p = 0.06), and chest tube drainage (6.4 ± 4.3 ml/kg in group A, 8.5 ± 3.8 ml/kg in group B, p = 0.16). No significant residual defects were found in both groups. The post-operation pressure gradient across the right ventricular outflow tract (RVOT) was significantly different between the two groups with 4.6 ± 1.8 mmHg in group A and 10.0 ± 6.8 mmHg in group B (p = 0.004) even if no significant difference was found between both groups before operation. No arrhythmia was found after operation. All the patients or the parents (100%) in the group A were satisfied with the cosmetic results, while the number in B group was 7 (43.8%) in questionnaire. The RAVI through tricuspid approach to repair doubly committed subarterial ventricular septal defect is a safe and feasible procedure with better hemodynamic performance of RVOT and less CPB time because of keeping pulmonary artery intact comparing to conventional approach. More importantly, the RAVI through tricuspid approach can be performed with favorable cosmetic results.

Anatomical visualization of neural course and distribution of anterior ascending aortic plexus

The aim of this study was to document the detailed anatomy of neural course and distribution on the anterior ascending aorta, to identify the high and low density areas of the anterior ascending aortic plexus for further understandings in cardiovascular surgery. The embalmed hearts of 42 elderly individuals were submacroscopically and microscopically examined, after excluding any that were macroscopically abnormal. With its origins in the anterior ascending aortic plexus, the right coronary plexus substantially innervated the right coronary artery, the right atrium and ventricle, and the sinus node. The intensive neural area extending from 10 mm lateral to the interatrial groove below the pericardial reflection as far as the right coronary artery opening contained almost all the right coronary plexus in 61.3% of patients, and more than 40.9% of the total nerve volume of the anterior ascending aortic plexus. Our findings suggest that the most superior and lateral area on the ascending aorta show the lowest neural density of right coronary component in the anterior ascending aortic plexus and the high density areas are invisible in right lateral field of view as seen in the right trans-axillary MICS approach.

The arrowhead ministernotomy with rigid sternal plate fixation: a minimally invasive approach for surgery of the ascending aorta and aortic root

Background. Ministernotomy incisions have been increasingly used in a variety of settings. We describe a novel approach to ministernotomy using arrowhead incision and rigid sternal fixation with a standard sternal plating system. Methods. A small, midline, vertical incision is made from the midportion of the manubrium to a point just above the 4th intercostal mark. The sternum is opened in the shape of an inverted T using two oblique horizontal incisions from the midline to the sternal edges. At the time of chest closure, the three bony segments are aligned and approximated, and titanium plates (Sternalock, Jacksonville, Florida) are used to fix the body of the sternum back together. Results. This case series includes 11 patients who underwent arrowhead ministernotomy with rigid sternal plate fixation for aortic surgery. The procedures performed were axillary cannulation (n = 2), aortic root replacement (n = 3), valve sparing root replacement (n = 3), and replacement of the ascending aorta (n = 11) and/or hemiarch (n = 2). Thirty-day mortality was 0%; there were no conversions, strokes, or sternal wound infections. Conclusions. Arrowhead ministernotomy with rigid sternal plate fixation is an adequate minimally invasive approach for surgery of the ascending aorta and aortic root.