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Repeat Right Axillary Thoracotomy Is a Safe and Feasible Approach for Repair of Recurrent LAVVR After Previous AVSD Repair

Tuesday, September 23, 2025

By

Ali Mashadi

Mashadi A, Essa Y, Said S. Repeat Right Axillary Thoracotomy Is a Safe and Feasible Approach for Repair of Recurrent LAVVR After Previous AVSD Repair. September 2025. doi:10.25373/ctsnet.30190030

This case demonstrated the repair of a recurrent left atrioventricular valve regurgitation via a repeat right axillary thoracotomy in a two-year-old girl who had previously undergone repair of a partial atrioventricular (AV) canal 10 months prior.  

The patient was positioned in a modified left lateral decubitus position, with the right side up and the right arm abducted above the shoulder. The same midaxillary skin incision utilized during the previous procedure was employed.  

The previous intercostal space was not used for entry into the right chest. Careful adhesiolysis was performed with electrocautery. In case future reoperation is required, one should routinely close the pericardium after the right axillary thoracotomy by approximating the pericardial edges with a few interrupted sutures. 
 
Cardiopulmonary bypass (CPB) was then initiated with central aortic and bicaval cannulation. After this, the right atrium was then reopened, revealing the previously placed pericardial patch, which was scarred and thick. This patch was excised, and the left atrioventricular valve was seen. The cleft or zone of apposition was still defective, and that was where the regurgitation was coming from in the area closer to the interventricular septum. This was repaired with interrupted Prolene sutures, followed by reinforcement at the beginning of the cleft with pledgeted sutures. This completed the repair of the left atrioventricular valve, and a new pericardial patch was then used to close the atrial septal defect. The right atriotomy was then closed, and the rest of the procedure was completed in the standard fashion. 
 
CPB and aortic cross-clamp times were 90 and 65 minutes, respectively. The patient was extubated in the operating room and discharged 24 hours later. During her two-year follow-up, she was doing well. 

This case represents that redo right axillary thoracotomy can be performed safely and without difficulty. 

References

  1. Said SM, Greathouse KC, McCarthy CM, Brown N, Kumar S, Salem MI, Kloesel B, Sainathan S. Safety and Efficacy of Right Axillary Thoracotomy for Repair of Congenital Heart Defects in Children. World J Pediatr Congenit Heart Surg. 2023 Jan;14(1):47-54. doi: 10.1177/21501351221127283. PMID: 36847761.
  2. Mashadi AH, Said SM. Repair of Partial Atrioventricular Septal Defect via Vertical Right Axillary Thoracotomy (VRAT) in Eleven-Year-Old. January 2023. doi:10.25373/ctsnet.21821604.v1

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Comments

Submitted by Ali Dodge-Khatami on
congratulations, nice video, and an important point that the redo mini right thoracotomy is feasible and safe for residual lesions. for primary mini right axillary approaches, do you suggest the same precautions/attempts at minimizing adhesions for potential redos as we do through median sternotomy (PDS pursestrings and atrial closure, avoiding prolene, closing the pericardium, adhesion prophylaxis (if you believe in them, which ones?)? thank you for sharing.
Submitted by Sameh Said on
Dear Ali, Thank you for your insightful comments. I have not found the type of sutures makes a difference; however, I believe it is very important to close the pericardium which serves two purposes: (1) prevent adhesions between the right atrium and the lung which can be problematic if you decide to come back as we see sometimes through repeat median sternotomy, and (2) more importantly - in my mind- protect the right phrenic nerve and avoid retraction of the pericardium on that side. I put a couple of sutures to bring the pericardium together on that side and leave windows in between for drainage to also prevent tamponade/pericardial effusion. I submitted another video that will be shared soon about repeat right axillary thoracotomy for re-resection of recurrent subaortic membrane (was done by a different surgeon) in which the pericardium was not closed at the first operation, and you will see the difference between this video and the upcoming one. At the end of the case, I reconstructed the right side of the pericardium with Gore-Tex membrane to prevent separate the right atrium from the medial surface of the right lung in case that patient will require any future surgery. Thank you

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