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

Abstract

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.

Repair of Scimitar Syndrome with Intact Atrial Septum in a Two-Year-Old Child Via Vertical Right Axillary Thoracotomy

“…We have previously reported our outcomes for repair of a wide variety of heart defects in infants and children using the VRAT approach. Others [5] have demonstrated the superiority of this approach as well which expands beyond the cosmetic aspect to the shorter length of hospital stay and quicker return to full activity [6]. More data will be needed prior to considering this approach as a new standard in such cases.…”

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.…”