Minimally Invasive Resection of Subaortic Membrane via Vertical Right Axillary Thoracotomy

A three-year-old 14.6 kg child presented with a severe left ventricular outflow tract (LVOT) obstruction secondary to a subaortic membrane. Prebypass echocardiogram showed that the membrane was below the aortic valve with significant flow acceleration into the LVOT. 
 
The Surgery 

The procedure was performed through a vertical right axillary thoracotomy (VRAT). The right chest was entered, and the right lung was retracted. The pericardium was entered anterior to the right phrenic nerve. Cardiopulmonary bypass (CPB) was initiated via central aortic and single atrial cannulation. A cardioplegia needle was then placed, and the aortic cross-clamp was applied. 
 
A hockey stick aortotomy was performed and the membrane was visualized. It was then completely resected in a circumferential fashion. A limited septal myectomy was performed to minimize recurrence of the membrane. A 12 mm Hegar dilator was placed inside the LVOT, which corresponds to a Z score of 0. 
 
The aortotomy was then closed in a two-layer fashion and the patient was weaned off CPB without difficulty. Post-bypass transesophageal echocardiogram showed no residual subaortic membrane and no significant LVOT gradient. The patient was decannulated and the remainder of the procedure was performed in the typical fashion. 
 
Aortic cross-clamp and CPB times were 37 and 58 minutes, respectively. The patient was extubated in the operating room, received no transfusions, and the remainder of his postoperative course was uneventful. He was discharged less than 48 hours later. 

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
2. Atalay A, Yilmaz M, Turkcan BS, Ecevit AN, Ozler B, Azak E, Ozisik K. Can Right Infra-Axillary Vertical Thoracotomy Make a Big Difference in Surgical Technique Preference? Heart Lung Circ. 2022 Oct;31(10):1419-1424.

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