Ventricular Septal Defects Closure Using a Minimal Right Vertical Infraaxillary Thoracotomy: Seven-Year Experience in 274 Patients

doi:10.1016/j.athoracsur.2009.11.026

The Annals of Thoracic Surgery

Volume 89, Issue 2, February 2010, Pages 552-555

https://doi.org/10.1016/j.athoracsur.2009.11.026 Get rights and content

Background

From December 2001 to February 2008, right vertical infraaxillary thoracotomy (RVIAT) was used to perform ventricular septal defect (VSD) closure in selected patients. This retrospective study reviews our results and experiences.

Methods

The study included 274 patients (143 females, 131 males) undergoing VSD closure through a RVIAT approach. Patients were a mean age of 10.5 ± 8.9 years (range, 0.5 to 43 years). Body weight was 37.8 ± 12.5 kg (range, 8 to 72 kg). The VSD was subpulmonary in 14 patients and perimembranous in 260.

Results

No perioperative or late deaths occurred during the follow-up. Cardiac defects were corrected in all patients through RVIAT. The mean incision length was 7.2 ± 2.9 cm (range, 4.1 to 8.9 cm). Cardiopulmonary bypass time was 61.6 ± 27.8 minutes (range, 29 to 187 minutes), and aortic clamp time was 33.4 ± 20.8 minutes (range, 5 to 139 minutes). The mean postoperative hospital stay was 4.9 ± 2.6 days (range, 2 to 14 days). Postoperative echocardiograms revealed 3 patients with residual shunt with later catheter intervention. The cosmetic advantage of the RVIAT is the short incision under the armpit that is often invisible. All patients were satisfied with the cosmetic results during the follow-up.

Conclusions

The RVIAT can be performed with favorable cosmetic and clinical results for VSD closure. It provides a good alternative to standard median sternotomy for VSD patients.

Section snippets

Material and Methods

This study included 274 selected patients (143 females, 131 males) who underwent VSD closure through a RVIAT approach from December 2001 to February 2008 (Table 1). Patients with right ventricular outflow tract obstruction detected by an ultrasonic cardiogram preoperatively or body mass index (BMI) greater than 30 kg/m² were not recommended for RVIAT. Mean age was 10.5 ± 8.9 years (range, 0.5 to 43 years; Fig 1), and body weight was 37.8 ± 12.5 kg (range, 8 to 72 kg).

Subpulmonary VSD was

Results

Cardiac defects were corrected in all patients through RVIAT (Table 2). Direct closure was used in 169 patients and patch closure in 105. The mean incision length was 7.2 ± 2.9 cm (range, 4.1 to 8.9 cm). Cardiopulmonary bypass time was 61.6 ± 27.8 minutes (range, 29 to 187 minutes), and aortic clamp-time was 33.4 ± 20.8 minutes (range, 5 to 139 minutes). The mean postoperative hospital stay was 4.9 ± 2.6 days (range, 2 to 14 days).

There were no perioperative or late deaths during the follow-up

Comment

Surgical treatment of most simple congenital heart defects can be performed with perfect results through a standard median sternotomy. However, the psychologic burden associated with unattractive scarring of a full sternotomy should be taken into consideration in evaluating the procedure, especially for children, teenagers, and young adults. As a result, nonsurgical transcatheter interventions with minimal invasiveness and favorable cosmetic results are more popular with patients, sometimes

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Cited by (40)

Doubly committed ventricular septal defect: Is it safe to perform surgical closure through the pulmonary trunk approached by right vertical axillary thoracotomy?
2023, JTCVS Open
This study investigated the safety of performing surgical repair for doubly committed ventricular septal defects by right vertical infra-axillary minithoracotomy (RVIAT).
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).
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).
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.
Can Right Infra-Axillary Vertical Thoracotomy Make a Big Difference in Surgical Technique Preference?
2022, Heart Lung and Circulation
Citation Excerpt :
For the last decade, the most popular surgical technique among these minimally invasive techniques is RIAVT. The advantages of this incision can be listed as follows: (1) as few serratus muscle fibres are transected longitudinally, this allows for the quick functional recovery of the right arm and the shoulder joint; (2) since it is an incision far from the breast tissue, it does not cause any potential breast development problems; (3) it provides very satisfactory cosmetic results with a 2 to 5 cm incision line, which is almost completely invisible under the arm in the free position; (4) compared to conventional median sternotomy, it causes less pain and discomfort for the first postoperative month after discharge; and (5) there is no need to use a special surgical instrument for the procedure [10,13]. In addition to all these advantages, in many studies comparing infra-axillary incision with median sternotomy and anterolateral thoracotomy in the repair of simple heart defects, no statistically significant differences were observed in total operation time, CPB time, and cross clamp times [11,14,15].
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.
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. Preoperative echocardiographic diagnoses, intraoperative surgical data and postoperative 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.
Between January 2019 and December 2021, 59 patients were operated on 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. One (1) patient with Primum ASD and mitral cleft, 1 patient with secundum ASD and perimembranous ventricular septal defect (VSD) repair, nine patients with high venosum ASD and PAPVC, and one patient with a discrete subaortic membrane were operated on. The surgical incision length was between 4 to 5 cm.
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.
Minimal Right Vertical Infra-axillary Incision for Repair of Congenital Heart Defects
2022, Annals of Thoracic Surgery
Citation Excerpt :
Our previous study12 showed that among patients with doubly committed subarterial VSD, the CPB and surgery time of minimal RVIAI were actually shorter than those of median sternotomy. Right vertical infra-axillary incision was introduced and used by several other centers7,9,11,13,14 (Table 3). Compared with those studies, an important feature of our technique is that it has been used for a broad range of congenital heart defects, not limited to ASD and VSD, and concomitant repair of 2 or more lesions can also be accomplished.
This study evaluated the surgical results of a diverse array of congenital heart defects through minimal right vertical infra-axillary incision (RVIAI).
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.
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.
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.
Vertical Right Axillary Mini-Thoracotomy for Correction of Ventricular Septal Defects and Complete Atrioventricular Septal Defects
2018, Annals of Thoracic Surgery
Vertical right axillary mini-thoracotomy (VRAMT) is the standard approach for correction of atrial septal defect and partial atrioventricular septal defect at our institution. This observational single-center study compares our initial results with the VRAMT approach for the repair of ventricular septal defect (VSD) and complete atrioventricular septal defect (CAVSD) in infants and children to an approach using standard median sternotomy (MS).
The perioperative courses of patients undergoing VSD and CAVSD correction through either a VRAMT or an MS were analyzed retrospectively. The surgical technique for the VRAMT involved a 4- to 5-cm vertical incision in the right axillary fold.
Of 84 patients, 25 (VSD, n = 15; CAVSD, n = 10) underwent correction through a VRAMT approach, whereas 59 (VSD, n = 35; CAVSD, n = 24) had repair through MS. VSD and CAVSD groups were comparable with respect to age and weight. No significant differences were observed for aortic cross-clamp duration, intensive care unit stay, hospital stay, and echocardiographic follow-up. There was no need for any conversion from VRAMT to MS in any case. Neither wound infections nor thoracic deformities were observed in both groups.
VRAMT can be considered as a safe and effective approach for the repair of VSD and CAVSD in selected patient groups, and the outcome data appear comparable to those of MS.
Mid-term Outcomes of Common Congenital Heart Defects Corrected Through a Right Subaxillary Thoracotomy
2017, Heart Lung and Circulation
Citation Excerpt :
Because of the extreme elasticity of the axillary skin, the access to the heart was identical to an incision parallel to the ribs within the skin folds (Figure 3). The cosmetic results of right vertical infraaxillary thoracotomy (RVIAT) is excellent [15] with the short incision under the armpit that is often invisible. To avoid distortion of the breast tissue in young girls, the incision never surpasses the preaxillary line and thus would not impede the future growth of the breast tissue and the pectoralis muscle.
To evaluate the mid-term outcomes of the correction of various congenital heart defects through a right subaxillary thoracotomy.
Between June 2004 and April 2014, all eligible patients were those with a common congenital heart defect corrected via an approach through a right subaxillary thoracotomy. There were 836 patients (male 417, female 419; median age, 3.5 years; median weight 13.6 kg) with ventricular septal defect (VSD) closure (523 patients), atrial septal defect (ASD) closure (235 patients), partial atrioventricular canal (PAVC) correction (55 patients), mild tetralogy of Fallot (TOF) (23 patients). Additional procedures involved tricuspid valvuloplasty (TVP) (68 patients), repair of partial anomalous pulmonary venous connection (PAPVC) (54 patients), mitral annuloplasty (42 patients), closure of patent ductus arteriosus (PDA) (35 patients), correction of cor triatriatum (eight patients). The median cardiopulmonary bypass (CPB) and aortic cross-clamp times were 67 (28∼217) and 23 (3∼116) min, respectively.
The procedures were performed successfully in all patients, and no in-hospital mortality occurred. There was no need for conversion to another approach in all procedures. The main complications involved arrhythmia in 21 patients, atelectasis in 18, pneumothorax in 17, subcutaneous emphysema in 15, pulmonary infection in 14, low cardiac output syndrome in eight, transient cerebral dysfunction in two. The patients were all in excellent condition after a mean follow-up of 34 months. The cardiac defect was repaired with no residual defect in 820 patients and with trivial to mild residual defect in 16 patients (10 with small VSD residual shunt, four with mild mitral regurgitation, two with mild residual right ventricular outflow tract obstruction). The incision healed properly in all, and the thorax showed no deformity.
Right subaxillary thoracotomy, providing an advantageous alternative, can be performed with favourable cosmetic and satisfactory clinical results for the correction of a wide range of common congenital heart defects.
Minimally Invasive Peratrial Device Closure of Perimembranous Ventricular Septal Defect Through a Right Infraaxillary Route: Clinical Experience and Preliminary Results
2017, Annals of Thoracic Surgery
Citation Excerpt :
Our new, minimally invasive surgery using a peratrial occlusion approach through the right infraaxillary route exhibits marginally better cosmetic results and no injury to the right ventricle. Once the device closure fails, the patient is converted to CPB operation by extending the original incision, and the incision remains hidden and cosmetic [13, 14]. The occurrence of complete atrioventricular block is one of the most serious complications related to device closure of PmVSD.
Both percutaneous and perventricular device closures of perimembranous ventricular septal defects (PmVSD) present certain drawbacks. We report our experiences with a new, minimally invasive surgery using a peratrial device closure of PmVSD through a right infraaxillary route.
Between January 2014 and October 2015, 145 patients (71 male, 74 female) with PmVSD, aged 0.5 to 9.7 years (mean 2.8 ± 2.2) and weighing between 6.1 kg and 43 kg (mean 14.0 ± 6.6 kg) were included in this study. In patients with left lateral position, a 2- to 3-cm incision was made along the right midaxillary line. The thoracic cavity was entered through the fourth intercostal space. With the help of transesophageal echocardiography guidance, a specially designed hollow probe was inserted into the right atrium. The probe was passed through the tricuspid valve into the right ventricle. The tip of the probe was adjusted to point to or cross the defect. A flexible guidewire was inserted into the left ventricle through the channel of the probe to establish a delivery pathway. Then, the device was deployed to close the defect.
A total of 142 cases (97.9%) were successfully occluded, whereas 3 cases failed and were converted to cardiopulmonary bypass operation through the original incision. The device size ranged from 4.0 to 10.0 mm (mean 5.1 ± 1.4 mm), and all devices were concentric. Follow-up in all patients ranged from 1.0 to 22.8 months (mean 9.9 ± 5.6) and revealed no evident valve regurgitation, no complete atrioventricular block, and no device dislocation.
This new minimally invasive technique of peratrial device closure through a right infraaxillary route under transesophageal echocardiography guidance was shown to be a safe, effective, feasible, and cosmetically superior treatment for PmVSD.

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Original articlePediatric cardiacVentricular Septal Defects Closure Using a Minimal Right Vertical Infraaxillary Thoracotomy: Seven-Year Experience in 274 Patients

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Results

Comment

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Am Coll Cardiol

Am Heart J

Ann Thorac Surg

J Am Coll Cardiol

Original article
Pediatric cardiac
Ventricular Septal Defects Closure Using a Minimal Right Vertical Infraaxillary Thoracotomy: Seven-Year Experience in 274 Patients