Closure of a Paramembranous Ventricular Septal Defect Via Vertical Right Axillary Thoracotomy in an Eight-Year-Old Female

 

An eight-year-old female presented with at least a moderate size paramembranous ventricular septal defect (VSD) and large left-to-right shunt. This closure procedure was performed via a vertical right axillary thoracotomy (VRAT) under general anesthesia and selective lung isolation.

The patient is positioned in the left lateral decubitus with the right hip rotated forty degrees to expose the right groin. The incision is a vertical one in the midaxillary line, and it extends from the second to fifth ribs. Generous subcutaneous flaps are created using electrocautery. Also, the latissimus dorsi muscle is partially mobilized, and the digitations of the serratus anterior muscle are separated to expose the intercoastal space. For VSD closure, we entered the right chest through the right fourth intercostal space. The right lung is then retracted to expose the pericardium, which is incised 1 to 2 cm anterior to the right phrenic nerve. Stay -sutures are placed, and the thymic lobes can be either separated or resected to facilitate exposure. Heparin is then administered, the ascending aorta and both cavae are cannulated, and normothermic cardiopulmonary bypass (CPB) is initiated. The ascending aortic cardioplegia needle is then placed, the ascending order is cross- clamped, and antegrade cardioplegia is administered. Then, both cavae are snared, an oblique right atriotomy is performed parallel to the right atrioventricular grove, and the intracardiac anatomy is evaluated. Two or three pledgeted Prolene sutures are placed in a horizontal mattress fashion at the base of the septal leaflet of the tricuspid valve to facilitate visualization of the VSD. All crossing tricuspid valve chordae then are retracted with vessel loops to facilitate further exposure. It is important to completely visualize the entire margin of the defect and its relation to the aortic cusps prior to closure to avoid any residual shunts.

An appropriately sized bovine pericardial patch is then used to close the defect using running Prolene sutures starting at the papillary muscle of Lancisi toward the posteroinferior margin of the defect, followed by the superior margin. Administration of antegrade cardioplegia can be helpful to test the aortic valve and to ensure its competence during the procedure. Once the defect is closed, all vessel loops are removed, and the tricuspid valve is tested with saline to ensure its competence. The right atriotomy is then closed, and the heart is de-aired. This is followed by removal of the aortic cross- clamp. The patient is then weaned off CPB.

Once transesophageal echocardiogram confirms a satisfactory repair, the patient is decannulated and heparin is reversed. The pericardium is partially closed, and a single drain is placed in the right chest with its tip directed into the pericardial space. The incision is then closed in the standard fashion.

In the current case, the patient was extubated in the operating room, received no transfusion, and was discharged two days after the surgery. She continued to do well during her follow- up. We believe that VRAT is a valuable technique that is cosmetically superior and is suitable for repairing a variety of congenital heart defects.

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References

1. Yaliniz H, Topcuoglu MS, Gocen U, Atalay A, Keklik V, Basturk Y, Gunes Y, Turktan M, Salih OK. Comparison between minimal right vertical infra-axillary thoracotomy and standard median sternotomy for repair of atrial septal defects. Asian J Surg. 2015 Oct;38(4):199-204
2. Hu CX, Tan J, Chen S, Ding H, Xu ZW. Comparison of clinical outcomes and postoperative recovery between two open heart surgeries: minimally invasive right subaxillary vertical thoracomy and traditional median sternotomy. Asian Pac J Trop Med. 2014 Aug;7(8):625-629
3. Kadner A, Dodge-Khatami A, Dave H, Knirsch W, Bettex D, Prêtre R. Closure of restrictive ventricular septal defects through a right axillary thoracotomy. Heart Surg Forum. 2006;9(6):E836-9

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