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

Abstract

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.

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

“…The right transverse (horizontal) axillary incision for atrial septal defect repair was introduced to us by Schreiber et al 1 We prefer this incision, because in contrast to median sternotomy and other small thoracotomy incisions, transverse axillary minithoracotomy provides a nice cosmetic result, less postoperative pain, quick postoperative recovery, and a quicker return to normal activities, while avoiding potential chest deformities or problems with mammary gland development. 4–7…”

“…The right transverse (horizontal) axillary incision for atrial septal defect repair was introduced to us by Schreiber et al 1 We prefer this incision, because in contrast to median sternotomy and other small thoracotomy incisions, transverse axillary minithoracotomy provides a nice cosmetic result, less postoperative pain, quick postoperative recovery, and a quicker return to normal activities, while avoiding potential chest deformities or problems with mammary gland development. [4][5][6][7] Since then, several groups have reported the right axillary transverse (horizontal) approach for the repair of VSD and other congenital heart defects that include VSD. [4][5][6] To our knowledge, the main problem during these procedures was the VSD exposure, which required temporary septal leaflet detachment.…”

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

“…We do believe and agree with Dodge-Khatami and colleagues that it is critical in any minimal access approach not to compromise or change the repair technique for the sake of a cosmetically better incision. 17,18 Two patients in our series required a second run of CPB to close residual shunts. The first patient was a teenager who had a large ASD and underwent transcatheter ablation of supraventricular tachyarrhythmia 48 h prior.…”

“…15,16 There are several advantages to this approach as previously outlined by Dodge-Khatami and colleagues. 17,18 It has a superior cosmetic result as the incision is completely hidden under the right arm, and due to its vertical nature, it is away from any developing breast tissue so the risk of any future breast disfigurement is extremely low. 19 The muscle-sparing nature of the incision allows rapid recovery of the arm and shoulder movements and rapid return to full activity.…”

“…It will remain to be determined if the benefits of the VRAT extend beyond cosmesis and if it will be actually superior to MS in terms of better pain control, less transfusion requirements, shorter length of hospital stay, and quicker return to full activity. 17,18 We have standardized a protocol for pain management in all our VRAT patients which included performing an erector spinae or paravertebral block prior to the skin incision and this catheter stays in till prior to hospital discharge. All patients were extubated in the operating room and received no transfusions apart from the routine blood prime in smaller infants.…”