ASD Closure Through a Midaxillary Minithoracotomy

This article is part of CTSNet’s 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?” Guest Editor Dr. Sameh Said has curated a robust collection of content that shares the knowledge, techniques, and insights of several distinguished experts from around the world.

The patient is a twelve-month-old infant who was born premature with thirty-six weeks of gestation and a weight of 2,700 g. The patient suffered from two pneumonias which required hospitalization for treatment. At that time, a systolic murmur was found on physical examination. Furthermore, she had failed to thrive adequately over the last eight weeks.

An echocardiography revealed a secundum ASD sizing 20 by 10 mm in diameter and a left-to-right shunt. A thin floating membrane was found to partly cover the ASD. The right atrium and the right ventricle were dilated, and the left ventricular function was preserved. Because of the encountered pneumonias and the suppressed weight gain, a timely indication for ASD closure was considered. Although the patient’s age was younger than usual, her weight was 7.1kg.

Surgeons performed an ASD closure with a patch through a right midaxillary minithoracotomy in the fourth intercostal space.

The Surgery

To begin, general anesthesia with endotracheal intubation was performed in the usual manner. Intraoperative monitoring consisted of invasive arterial and central venous pressure, near-infrared spectroscopy, and transesophageal echocardiography. External defibrillation pads were placed.

The patient was positioned on her left side and the right axillary region was exposed by elevating the arm. The anterior and posterior axillary lines, the mammilla, and the tip of the scapula were delineated.

Next, a midaxillary incision was made over the fourth intercostal space. The subcutaneous tissue was then mobilized extensively in all directions. The serratus anterior muscle overlying the fourth intercostal space was identified, as was the latissimus dorsi muscle's lateral border. The long thoracic nerve and artery located posteriorly on the serratus anterior muscle were protected.

At the inferior margin of the fourth rib in the fourth intercostal space, a thoracotomy was performed. After retracting the lungs away, the pericardium was incised horizontally at some distance away from the phrenic nerve. To retain the lungs, stay sutures were applied along the margins of the pericardium and attached to the skin.

Extracorporeal circulation (ECC) was established by cannulating the ascending aorta and superior and inferior caval veins using curved cannulae. Around both veins, snares were put in place and ECC was started at normothermia. A fibrillator probe was inserted into the pericardium so that it would lie on the right ventricle. For optimal fibrillation and to reduce movements, a small gauze was laid on top of the fibrillator probe.

After snaring the caval veins, fibrillation was induced, and the right atrium was incised in a vertical fashion. Four retraction sutures were applied for optimal exposure. Next, the ASD was visualized, focusing on the size and the rims. As described in the echocardiography, a floating membrane was present, which was then excised.

After sizing the ASD, an ePTFE Gore-Tex patch was trimmed. The ASD was then closed using a continuous 5-0 Prolene suture. After insufflating the airways for deairing, the fibrillator probe was removed and a spontaneous sinus rhythm set in. The atriotomy was closed with a continuous polydioxanone suture.

Following decannulation, the pericardium was closed with two single stitches, allowing pericardial fluid to escape into the right pleural space. The chest was closed with absorbable sutures after insertion of a chest drain.

Postoperative Course

The postoperative course of the patient was unremarkable. The child was extubated two hours postoperatively and discharged home seven days after ASD closure. The echocardiography prior to discharge revealed no residual shunt and reduced size of the right heart.

Two months after the surgery, the patient had gained 2 kg of weight and made incredible steps in her development.
 

References

1. Schreiber C, Bleiziffer S, Lange R. Midaxillary lateral thoracotomy for closure of atrial septal defects in pre-pubescent female children: reappraisal of an "old technique". Cardiol Young. 2003 Dec;13(6):565-7.
2. Heinisch PP, Wildbolz M, Beck MJ, Bartkevics M, Gahl B, Eberle B, et al., Vertical Right Axillary Mini-Thoracotomy for Correction of Ventricular Septal Defects and Complete Atrioventricular Septal Defects. Ann Thorac Surg. 2018;106(4):1220–1227.
3. Prêtre R, Kadner A, Dave H, Dodge-Khatami A, Bettex D, Berger F., Right axillary incision: a cosmetically superior approach to repair a wide range of congenital cardiac defects. J Thorac Cardiovasc Surg, 2005;130(2):277–81.

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