Creating Opportunities From Challenging Anatomy: Left Axillary Thoracotomy for Closure of Ventricular Septal Defect in an Infant With Situs Solitus and Extreme Levoposition of the Heart

This unique case involved a 5-month-old, 6 kg infant who presented with failure to thrive secondary to a large membranous ventricular septal defect (VSD) with a large left-to-right shunt. The patient was born with a near absence of the left lung, and both the mediastinal structures and the heart were shifted to the left hemithorax (a condition known as levoposition). 

During the neonatal period, the infant underwent repair of esophageal atresia via a right thoracotomy. Preoperative imaging, including chest X-rays and cross-sectional imaging, showed significant displacement of the heart and great vessels into the left chest, along with compensatory hyperinflation of the right lung. The authors successfully performed a minimally invasive VSD closure through a left axillary thoracotomy, resulting in an uneventful recovery.  

This is the first case in literature in which left axillary thoracotomy has been utilized for VSD closure in a patient with situs solitus and levoposition of the heart. This challenging anatomy highlighted the potential for a minimally invasive approach, demonstrating the value of preoperative imaging in planning such a complex approach.