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Right Axillary Thoracotomy for Repair of a Wide Variety of Congenital Heart Defects in Infants and Children—Should This Be the New Standard: Webinar Audience Q&A

Wednesday, October 25, 2023

Prof. Sameh Said wrapped up his congenital heart surgery Guest Editor Series, “Right Axillary Thoracotomy for Repair of a Wide Variety of Congenital Heart Defects in Infants and Children—Should This Be the New Standard?” by moderating a live webinar. Series contributors Dr. Paul Philipp HeinischProf. Ali Dodge-Khatami, and Dr. Oleksandr Babliak discussed tips and pitfalls of completing various congenital cardiac surgeries via vertical and horizontal right axillary thoracotomy. 

Because of time limitations, during the Q&A portion of the webinar, the panelists answered several insightful questions from the audience off-video. Those questions, along with the webinar panelists’ and Prof. Said’s answers, are outlined below. 

Rewatch the webinar to refresh your knowledge, then browse the Q&A below for any lingering questions you may have.

Do you see a potential need for opening an additional rib space in some cases?

Paul Phillipp Heinisch: Yes, that can happen. Especially in cases with poor exposure to the aorta where the upper space can be used for the aortic and superior vena caval cannulation and the lower space for inferior vena caval cannulation and the repair itself.
Sameh Said: This, in my opinion, is an additional advantage for the vertical compared to the horizontal version of the right axillary thoracotomy. The vertical incision gives the surgeon access to multiple rib spaces if needed.  

How would you ensure this approach will not interfere with the breast development in young girls in the future? And do you spare the muscles underneath?

Phillipp Heinisch: The muscles are mostly spared in the approach. Regarding the breast development, the incision should be as posterior as possible. That is why the vertical incision is advantageous.
Babliak: This method will not cause breast asymmetry as long as you don’t go beyond the anterior axillary line.
Said: This is one of the myths regarding the axillary approach. There are long-term data showing no risk of breast asymmetry or disfigurement, especially with the vertical incision that is limited to the midaxillary line. 

What’s your opinion regarding closing atrial septal defects (ASD) with beating heart using CO2 insufflation?

Phillipp Heinisch: CO2 insufflation is used to minimize risk of air embolism; however, I never close the ASD on a beating heart. Mostly, it is done with induced ventricular fibrillation. This strategy is used for secundum ASD and sinus venosus defects. 
Said: There is absolutely no need to increase the risk of a straightforward operation like an ASD by using a beating heart technique. There is no advantage in a case like this where the aortic cross-clamp time is short, and exposure is sufficient to place a cross-clamp and close the defect. 

Is the venous drainage vacuum assisted?

Phillipp Heinisch: Yes, in most cases.
Babliak: Always at our center.

When it comes to deairing of the left heart chambers, are there any specific maneuvers that can help? Did you notice greater difficulty with this approach compared to standard sternotomy?

Babliak: There is no difference compared to sternotomy. Deairing is easily done through the aortic root vent without noticeable difficulties.
Said: Deairing is done in a similar fashion to sternotomy. As we mentioned, the procedure should not differ from standard sternotomy, except from the approach standpoint, but all other steps are done in the same fashion, which guarantees safety and excellent outcomes. In terms of deairing, we use a combination of aortic root and left ventricular vents. Transesophageal echocardiogram is done routinely to ensure complete elimination of intracardiac air prior to patient separation from cardiopulmonary bypass.
What is the weight range you consider for this approach?

Ali Dodge-Khatami: Any baby above 4.5 kg.

Do you follow the same technique when closing atrial or ventricular septal defects in older patients and adults?

Babliak: In older patients and in adults, femoral cannulation is used, for sure. Also, with developed breasts the surgeon has more options regarding where to position the minithoracotomy.
Said: The challenge in older patients and adults is that the ascending aorta moves farther away from the chest wall in these patients, which makes aortic cannulation challenging through an axillary approach and necessitates alternate arterial access, like the femoral artery. 

Can we use the chest tube incision to pass the inferior vena caval (IVC) cannula to give better exposure, or it will be difficult?

Phillipp Heinisch: Yes, that is possible.
Said: We do this routinely in cases where we feel the exposure is limited and the space is tight with all cannulas. It is important to pass the IVC cannula prior to heparinization to minimize the risk of bleeding from the intercostal space if this is to be done in the routine fashion after heparinization. 

Any experience with aortic valve and/or subvalvular stenosis?

Babliak: Yes. It is very straightforward with right axillary thoracotomy. Consider the third intercostal space for this.
Said: Yes, this is possible. We have resected subaortic membranes through this approach and agree with Dr. Babliak; we use the third intercostal space for this procedure. 

Do you have any advice, tips, and tricks for TOF repair?

Babliak: Start in a stepwise fashion with simple right ventricular outflow tract (RVOT) procedures and ventricular septal defect closure prior to moving to tetralogy of Fallot.
Said: This can be quite challenging as the limiting factor can be the RVOT management through the right thoracotomy. Also, it depends on the age and size of the patient at the time of repair, which differs between institutions and surgeons. 

Dr. Babliak, can you talk again about the role of the pulmonary artery snare?

Babliak: To prevent the back bleeding from the PA, there is no extra space to put a pump sucker through the tricuspid valve.

I observed a complete heart block after ASD closure via right thoracotomy. Could you comment on the risk of this complication?

Phillipp Heinisch: The risk in general is very low. However, it has been described in literature as well.
Said: The risk of heart block through this approach is no different from sternotomy, whether with ASD or VSD closure. An important point to consider is that the surgeon needs to be familiar with the way the intracardiac anatomy is seen through the axillary approach. 


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