Vertical Right Axillary Minithoracotomy: Extending the Spectrum from ASD to CAVSD

Objectives: Vertical right axillary minithoracotomy (VRAMT) is the standard approach for the correction of congenital heart defects at our institution. With growing experience and achieving comparable surgical results, VRAMT was extended to more complex heart defects. This report aims to investigate the safety and effectiveness of VRAMT. The study further includes an analysis of percutaneous femoral venous cannulation and extracorporal circulation (ECC) performance in relation to bodysurface area in children.

Methods: Patients up to 16 years of age who underwent corrective cardiac surgery by VRAMT for ASD, VSD, partial atrioventricular septal defects (PAVSD), complete atrioventricular septal defects (CAVSD: Rastelli’s type A), partial anomalous pulmonary venous connection (PAPVC) starting from January 2010 until October 2018 were included. The surgical technique involved a 3 to 5 cm vertical incision parallel to the anterior axillary fold, central arterial, and bicaval cannulation for institution of mild hypothermic ECC. Since 2016, the inferior caval vein was cannulated in all patients with a femoral percutaneous-venous cannula. The study was approved by the ethics committee (Approval No. 2016-01484).

Results: A total of 110 patients were included in this study with the following cardiac diagnoses: ASD secundum (35), VSD (44), CAVSD (12), PAVSD (7), PAPVC (9), Cor triatriatum (2), and DCRV (1). Mean age of patients at surgery was 3.56 (± 3.73) years, mean body weight was 13.18 (± 9.09) kg. Mean ECC time was at 70.52 (± 28.74) minutes with a mean cross- clamping time of 42.52 (± 15.73) minutes. Mean ICU stay was 84.03 (± 68.54) hours, while overall hospital stays was 8.36 (± 4.37) days. For patients with percutaneous femoral venous cannulation (n = 39, 35.5%), thrombosis at the cannulation site in the right femoral vein was recorded in five (13.5%) cases. There was no early or late mortality. There was no need for open conversion in any case. No wound infection nor thoracic deformities were observed. The mean echocardiographic follow-up time was 11.57 (± 14.90) months.

Conclusion: VRAMT can be considered as a safe and feasible access for the repair of a wide range of congenital heart defects. This minimally invasive technique has become the standard approach for the correction of congenital heart defects at our institution. For selected patient groups, it can be expanded to more complex heart defects without compromising the outcome. Percutaneous femoral venous cannulation provides sufficient ECC performance and can be safely applied even in infants with early postoperative heparin prophylaxis.