Minimally Invasive Transaxillary Repair of Supravalvar Aortic Stenosis

The minimally invasive approach for pediatric cardiac surgery is increasingly advocated. This video demonstrates how the authors use the right vertical axillary incision to perform repair of severe supravalvar aortic stenosis. To their knowledge, there is no report of minimally invasive supravalvar aortic stenosis repair in the literature (1). 

The patient was a 5-year-old boy, a known case of Williams syndrome, who presented with dyspnea on exertion. 

An echocardiography revealed severe supravalvar aortic stenosis (AS) with a pressure gradient of 80 mmHg, and the angiogram confirmed the characteristic hourglass appearance of the ascending aorta, with severe stenosis located at the sinotubular junction. 

The procedure was performed through a small right vertical axillary incision, which is the incision that the authors use for most minimally invasive pediatric surgeries. 

The ascending aorta and aortic root were exposed and carefully dissected. The stenotic "waist" at the sinotubular junction was clearly visible. After initiating cardiopulmonary bypass and infusing cardioplegia, a longitudinal incision was made as high as possible on the ascending aorta. 

The incision was extended to the sinotubular junction and configured in a Y-shape, with two limbs directed toward the noncoronary and right coronary sinuses. 

The incisions stopped 2–3 mm above the annular attachment of the leaflets. Fibrotic tissue, commonly present at the sinotubular junction and exacerbating stenosis, especially in the left coronary sinus, was delicately excised. 

A pantaloon-shaped bovine pericardial patch was prepared to reconstruct the aortic root. The patch was designed to generously enlarge the sinotubular junction and extend deeply into the sinuses. 

Once suturing was completed, the aortic clamp was removed, and the reconstructed aortic root was inspected, revealing generous enlargement of the sinotubular junction. 

The patient was weaned off bypass without difficulty, maintaining stable hemodynamics. Postoperative echocardiography showed no residual aortic stenosis or aortic insufficiency. 

Conclusion 

The vertical axillary incision may provide satisfactory exposure for the minimally invasive approach for surgical repair in these patients. 

References

1. Deo, S. V., Burkhart, H. M., Dearani, J. A., & Schaff, H. V. (2013). Supravalvar aortic stenosis: current surgical approaches and outcomes. Expert Review of Cardiovascular Therapy, 11(7), 879–890. https://doi.org/10.1586/14779072.2013.811967

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.