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Right Axillary Thoracotomy for Transatrial Repair of a Wide Range of Congenital Heart Defects

Tuesday, April 12, 2016

By

Ali Dodge-Khatami

The right axillary thoracotomy allows repair of a wide range of congenital heart defects. From 2008 to 2016, 48 patients* underwent surgical repair through the right chest. There were no mortalities, residual defects, or peri-operative complications. In the authors’ experience, the cosmetic results are highly appreciated, as the approach is far from breast tissue with minimal potential for asymmetrical breast growth. No muscles are sacrificed in this approach, which leads to rapid functional recovery of the right arm. With gained experience and surgeon comfort, a right axillary thoracotomy can achieve the same high standards and repair quality as a median sternotomy. This video shows the closure of a ventricular septal defect via a right axillary thoracotomy in a 10-month-old baby girl.

*The operations included: 26 ASD, 10 ventricular septal defects (3 with double-chambered right ventricle), 8 Warden operations for partial anomalous pulmonary venous return, 3 partial atrio-ventricular canals with mitral valve cleft, and 1 cor triatriatum. The patients ranged in age from 4 months to 18 years, and weighed 5.5 – 82kg.

Comments

Submitted by Juan-Miguel Gil-Jaurena on
Well done. It looks simple and easy to carry out. Our experience in axillary approach is the horizontal incision for simple cases, such as ostium secundum and sinus venosus atrial septal defects (50 patients, so far) Your example prompts us to explore new ways to expand the minimally invasive approaches. Congratulations.
Submitted by Ali Dodge-Khatami on
thank you for your comments/question: in a female with fully developed breasts with clear anatomical landmarks, probably not, as the sub-mammary incision will also be hidden, and trauma to breast tissue unlikely. since my practice is primarily pediatric, and the smallest patients in whom i use the approach have been 5.5kg, including males and females, there is no breast tissue to be seen, and where the actual landmarks to avoid trauma to breast tissue with a potential for future asymmetric breast growth are unknown. in female patients, infants to pre-pubescent, the axillary approach is remote enough from future breast tissue, so as to avoid complications as the patient grows older; the group from Munich illustrated this problem in their nice publication after follow-up of female patients that were operated upon at a younger age through an anterior/submamammary incision, and cautioned against it (Bleiziffer et al. J Thorac Cardiovasc Surg 2004;127:1474–80).
Submitted by Mohammad Sharifuzzaman on
Thank your for your nice video. you made it look like very simple. Can you warn us any real or potential problems in Aortic and IVC canulation. How you snare IVC and what is you advice to beginners?
Submitted by Ali Dodge-Khatami on
thank you for your interest. aortic cannulation is straightforward, i always put 2 purse-strings to be on the safe side; it is actually easier in infants from 6kg-children of 30kg. in bigger adolescents or adults, the aorta is too far away from the chest and femoral artery cannulation preferred. SVC cannulation is also easy, and once you are on bypass with one cannula (SVC), the heart decompresses, then i go around the IVC with the future snare, and then finally IVC (or right atrial with sliding the cannula down to the IVC) cannulation is possible. With the snare in place before cannulating, you ensure that the tip of your cannula is indeed in the IVC and not into the right atrium, so as to avoid air lock when you open the atrium. Check with your finger from the outside that your happy before atrial entry. i hope this helps.
Submitted by Xiaotao Deng on
good news for most kids with simply CHD, is it also suitable for child with PAPVC associated with SVC type of ASD? what's the best age to receive such kind of surgry?
Submitted by Ali Dodge-Khatami on
yes, we have done quite a few PAPVC's, and it is also possible to do the Warden operation through this approach. i find it easiest to use in infants/kids between 8-15kg, but i would use the regular timing you use to do your repairs based on the defect, not the approach. more details with regards to using the incision for various other repairs will be appear in the summer edition of "Operative Techniques in Thoracic and Cardiovascular Surgery: A Comparative Atlas" 2016.
Submitted by Xiaotao Deng on
thank you Dr.Dodge-Khatami for the information, another question that I would like to seek your advice is that can child with PAPVC plus ASD take regular vaccine immunization before surgery? does vaccine have any potential risk to increase his/her cardiac overload or cause myocarditis?
Submitted by Siraphop Thapmongkol on
In some situation, we miss diagnosis and found a doubly committed VSD intraoperation (axillary thoracotomy). What should we do?....Can closure through this approach or proper management?....Thank you.
Submitted by Siraphop Thapmongkol on
In some situation, we miss diagnosis and found a doubly committed VSD intraoperation (axillary thoracotomy). What should we do?....Can closure through this approach or proper management?....Thank you.
Submitted by Siraphop Thapmongkol on
In some situation, we miss diagnosis and found a doubly committed VSD intraoperation (axillary thoracotomy). What should we do?....Can closure through this approach or proper management?....Thank you.
Submitted by Siraphop Thapmongkol on
In some situation, we miss diagnosis and found a doubly committed VSD intraoperation (axillary thoracotomy). What should we do?....Can closure through this approach or proper management?....Thank you.
Submitted by Siraphop Thapmongkol on
In some situation, we miss diagnosis and found a doubly committed VSD intraoperation (axillary thoracotomy). What should we do?....Can closure through this approach or proper management?....Thank you.
Submitted by Siraphop Thapmongkol on
In some situation, we miss diagnosis and found a doubly committed VSD intraoperation (axillary thoracotomy). What should we do?....Can closure through this approach or proper management?....Thank you.
Submitted by Ali Dodge-Khatami on
thank you for your question and sorry for the late reply. i'm sure an intra-operative "discovery" of a doubly-committed VSD is an unpleasant surprise, as it may be very challenging to repair while needing visualization of both semi-lunar valves to avoid any damage to them. in general with that diagnosis going in, i wouldn't recommend the mini right axillary approach. in difficult situations regarding approach and visibility, i have needed to open both the ascending aorta as you would with an aortotomy for an aortic valve replacement, and also the RV outflow with a horizontal infundibular incision: placing swabs behind the heart may lift the RV towards you and enhance your exposure, but again, this is only anecdotal. i hope this helps. thank you for your interest.

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