Minimal Right Vertical Infra-axillary Incision for Subarterial Ventricular Septal Defect Closure in Children_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZHANGWei-hua , LUOHong , ZHANGXin , LIUDong-hai , MANing , ZHANGBo ,  QIAOChen-hui

Department of Cardiovascular Surgery, the First Affiliated Hospital, Zhengzhou University, Zhengzhou 450052, P. R. China;

Corresponding author：

QIAOChen-hui, Email: qchenhui@hotmail.com

Keywords：

Congenital heart disease; Right vertical infra-axillary incision; Subarterial ventricular septal defec

DOI：

10.7507/1007-4848.20140134

Video：

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Objective To summarize clinical results and experience of subarterial ventricular septal defect (sVSD) closure through a minimal right vertical infra-axillary incision in children, and evaluate the feasibility of this technique. Methods Clinical data of 27 sVSD patients who underwent surgical repair through a minimal right vertical infra-axillary incision from March 2009 to January of 2013 in the First Affiliated Hospital of Zhengzhou University were retrospectively analyzed. There were 20 male and 7 female patients with their age of 1.1-11.0 (4.4±2.8) years and body weight of 7.6-28.0 (14.6±5.3) kg. After induction of anesthesia, the patients were placed in a 90 degree left lateral position. The incision was performed along right midaxillary line vertically between the superior border of the third rib and inferior border of the fifth rib. The thoracic cavity was entered through the fourth intercostal space. The pericardium was opened 2 cm anterior to the phrenic nerve and suspended to elevate the heart and great vessels by the pericardial traction sutures. Cardiopulmonary bypass (CPB) was established after cannulation of the ascending aorta, superior vena cava and inferior vena cava. Closure of sVSD was performed through longitudinal pulmonary incision. After procedures under CPB finished, the aortic cannula was removed and the pericardium was closed with interrupted sutures. The thoracic drainage tube was placed through the sixth intercostal space. All the patients were followed up 3, 6 and/or 12 months after surgery. Satisfactory degree of the patients and their relatives were evaluated. Chest X-ray, electrocardiography and echocardiography were examined. Results Surgical repair of sVSD was performed in all the patients through this incision without any difficulty, incision prolongation or conversion to another incision. There was no in-hospital death, reexploration for bleeding, postoperative atelectasis, pulmonary infection, pleural effusion, impairment of central nervous system, phrenic nerve damage, poor wound healing, wound infection or pericardial effusion. Incision length was 4.4-7.0 (5.07±0.66) cm. Echocardiography before discharge showed no residual shunt in all the patients. All the patients were followed up 3, 6 and/or 12 months at the outpatient department or via the phone. During follow-up, there was no late death, residual shunt or chest asymmetry. The short incision under the armpit was obscured and provided favorable cosmetic results. All the patients and their relatives were satisfied with the cosmetic results. Conclusion Repair of sVSD through a minimal right vertical infra-axillary incision is feasible and safe for children. The advantages of this technique are favorable for children with sVSD.

Citation： ZHANGWei-hua, LUOHong, ZHANGXin, LIUDong-hai, MANing, ZHANGBo, QIAOChen-hui. Minimal Right Vertical Infra-axillary Incision for Subarterial Ventricular Septal Defect Closure in Children. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2014, 21(4): 473-476. doi: 10.7507/1007-4848.20140134 Copy

1.	Anzai T, Iijima T, Yoshida I, et al. The natural history and timing of the radical operation for subpulmonic ventricular septal defects. Jpn J Surg, 1991, 21 (5):487-493.
2.	de Leval MR, Pozzi M, Starnes V, et al. Surgical management of doubly committed subarterial ventricular septal defects. Circulation, 1988, 78 (5 Pt 2):Ⅲ40-Ⅲ46.
3.	Lue HC. Is subpulmonic ventricular septal defect an oriental disease? In:Lue HC, Takao A, eds. Subpulmonic ventricular septal defect. 1st ed. Tokyo:Springer-Verlag, 1986. 3-8.
4.	Ueda M, Fujimoto T, Becker AE. The infundibular septum in normal hearts and in hearts with isolated ventricular septal defect. A comp-arison between Japanese and Dutch hearts. Jpn Heart J, 1986, 27 (5):635-643.
5.	Chen Q, Chen LW, Wang QM, et al. Intraoperative device closure of doubly committed subarterial ventricular septal defects:initial experience. Ann Thorac Surg, 2010, 90 (3):869-873.
6.	Chungsomprasong P, Durongpisitkul K, Vijarnsorn C, et al. The results of transcatheter closure of VSD using Amplatzer^® device and Nit Occlud^® Lê coil. Catheter Cardiovasc Interv, 2011, 78 (7):1032-1040.
7.	Dave HH, Comber M, Solinger T, et al. Mid-term results of right axillary incision for the repair of a wide range of congenital cardiac defects. Eur J Cardiothorac Surg, 2009, 35 (5):864-870.
8.	Nguyen K, Chin C, Lee DS, et al. The axillary incision:a cosmetic approach in congenital cardiac surgery. J Thorac Cardiovasc Surg, 2007, 134 (5):1358-1360.
9.	Wang Q, Li QG, Zhang J, et al. Ventricular septal defects closure using a minimal right vertical infraaxillary thoracotomy:Seven-Year experience in 274 patients. Ann Thorac Surg, 2010, 89 (2):552-555.
10.	Yan L, Zhou ZC, Li HP, et al. Right vertical infra-axillary mini-incision for repair of simple congenital heart defects:a matched-pair analysis. Eur J Cardiothorac Surg, 2013, 43 (1):136-141.
11.	Prêtre R, Kadner A, Dave H, et al. Right axillary incision:a cosme-tically superior approach to repair a wide range of congenital cardiac defects. J Thorac Cardiovasc Surg, 2005, 130 (2):277-281.
12.	Kaneda T, Nishino T, Saga T, et al. Small right vertical infra-axillary incision for minimally invasive port-access cardiac surgery:a moving window method. Interact Cardiovasc Thorac Surg, 2013, 16 (4):544-546.
13.	何发明, 王平凡, 梁志强, 等.右腋下小切口心脏直视手术3012例的临床应用.中国胸心血管外科临床杂志, 2010, 17 (3):247-249.
14.	Liu YL, Zhang HJ, Sun HS, et al. Repair of cardiac defects through a shorter right lateral thoracotomy in children. Ann Thorac Surg, 2000, 70 (3):738-741.
15.	Hobbins SM, Izukawa T, Radford DJ, et al. Conduction disturbances after surgical correction of ventricular septal defect by the atrial app-roach. Br Heart J, 1979, 41 (3):289-293.
16.	Houyel L, Vaksmann G, Fournier A, et al. Ventricular arrhythmias after correction of ventricular septal defects:Importance of surgical approach. J Am Coll Cardiol, 1990, 16 (5):1224-1228.
17.	Vaksmann G, Fournier A, Chartrand C, et al. Arrhythmia disorders after repair of ventricular septal defects. Comparison of atrial and ventricular approaches. Arch Mal Coeur Vaiss, 1989, 82 (5):731-735.
18.	Miyake T, Shinohara T, Nakamura Y, et al. Spontaneous closure of ventricular septal defects followed up from < 3 months of age. Pediatr Int, 2004, 46 (2):135-140.
19.	Yip WC, Ho TF, Chan KY, et al. Comparison of spontaneous closure rate in children with different types of ventricular septal defects. J Paed Child Health, 1997, 33 (Suppl 1):S41.
20.	Erdem S, Ozbarlas N, Küçükosmanoğlu O, et al. Long term follow-up of 799 children with isolated ventricular septal defects. Turk Kardiyol Dern Ars, 2012, 40 (1):22-25.
21.	Sim EK, Grignani RT, Wong ML, et al. Outcome of surgical closure of doubly committed subarterial ventricular septal defect. Ann Thorac Surg, 1999, 67 (3):736-738.
22.	Cheung YF, Chiu CS, Yung TC, et al. Impact of preoperative aortic cusp prolapse on long-term outcome after surgical closure of subar-terial ventricular septal defect. Ann Thorac Surg, 2002, 73 (2):622-627.
23.	Lun K, Li H, Leung MP, et al. Analysis of indications for surgical closure of subarterial ventricular septal defect without associated aortic cusp prolapse and aortic regurgitation. Am J Cardiol, 2001, 87 (11):1266-1270.
24.	Ishikawa S, Morishita Y, Sato Y, et al. Frequency and operative correction of aortic insufficiency associated with ventricular septal defect. Ann Thorac Surg, 1994, 57 (4):996-998.
25.	Yildirim SV, Tokel K, Saygili B, et al. The incidence and risk factors of arrhythmias in the early period after cardiac surgery in pediatric patients. Turk J Pediatr, 2009, 50 (6):549-553.
26.	Chiu SN, Wang JK, Lin MT, et al. Progression of aortic regurgitation after surgical repair of outlet-type ventricular septal defects. Am Heart J, 2007, 153 (2):336-342.
27.	胡义杰, 钟前进, 陈建明, 等.右侧腋下小切口先天性心脏病直视手术的临床应用.中国胸心血管外科临床杂志, 2012, 19 (4):427-429.

1. Anzai T, Iijima T, Yoshida I, et al. The natural history and timing of the radical operation for subpulmonic ventricular septal defects. Jpn J Surg, 1991, 21 (5):487-493.
2. de Leval MR, Pozzi M, Starnes V, et al. Surgical management of doubly committed subarterial ventricular septal defects. Circulation, 1988, 78 (5 Pt 2):Ⅲ40-Ⅲ46.
3. Lue HC. Is subpulmonic ventricular septal defect an oriental disease? In:Lue HC, Takao A, eds. Subpulmonic ventricular septal defect. 1st ed. Tokyo:Springer-Verlag, 1986. 3-8.
4. Ueda M, Fujimoto T, Becker AE. The infundibular septum in normal hearts and in hearts with isolated ventricular septal defect. A comp-arison between Japanese and Dutch hearts. Jpn Heart J, 1986, 27 (5):635-643.
5. Chen Q, Chen LW, Wang QM, et al. Intraoperative device closure of doubly committed subarterial ventricular septal defects:initial experience. Ann Thorac Surg, 2010, 90 (3):869-873.
6. Chungsomprasong P, Durongpisitkul K, Vijarnsorn C, et al. The results of transcatheter closure of VSD using Amplatzer^® device and Nit Occlud^® Lê coil. Catheter Cardiovasc Interv, 2011, 78 (7):1032-1040.
7. Dave HH, Comber M, Solinger T, et al. Mid-term results of right axillary incision for the repair of a wide range of congenital cardiac defects. Eur J Cardiothorac Surg, 2009, 35 (5):864-870.
8. Nguyen K, Chin C, Lee DS, et al. The axillary incision:a cosmetic approach in congenital cardiac surgery. J Thorac Cardiovasc Surg, 2007, 134 (5):1358-1360.
9. Wang Q, Li QG, Zhang J, et al. Ventricular septal defects closure using a minimal right vertical infraaxillary thoracotomy:Seven-Year experience in 274 patients. Ann Thorac Surg, 2010, 89 (2):552-555.
10. Yan L, Zhou ZC, Li HP, et al. Right vertical infra-axillary mini-incision for repair of simple congenital heart defects:a matched-pair analysis. Eur J Cardiothorac Surg, 2013, 43 (1):136-141.
11. Prêtre R, Kadner A, Dave H, et al. Right axillary incision:a cosme-tically superior approach to repair a wide range of congenital cardiac defects. J Thorac Cardiovasc Surg, 2005, 130 (2):277-281.
12. Kaneda T, Nishino T, Saga T, et al. Small right vertical infra-axillary incision for minimally invasive port-access cardiac surgery:a moving window method. Interact Cardiovasc Thorac Surg, 2013, 16 (4):544-546.
13. 何发明, 王平凡, 梁志强, 等.右腋下小切口心脏直视手术3012例的临床应用.中国胸心血管外科临床杂志, 2010, 17 (3):247-249.
14. Liu YL, Zhang HJ, Sun HS, et al. Repair of cardiac defects through a shorter right lateral thoracotomy in children. Ann Thorac Surg, 2000, 70 (3):738-741.
15. Hobbins SM, Izukawa T, Radford DJ, et al. Conduction disturbances after surgical correction of ventricular septal defect by the atrial app-roach. Br Heart J, 1979, 41 (3):289-293.
16. Houyel L, Vaksmann G, Fournier A, et al. Ventricular arrhythmias after correction of ventricular septal defects:Importance of surgical approach. J Am Coll Cardiol, 1990, 16 (5):1224-1228.
17. Vaksmann G, Fournier A, Chartrand C, et al. Arrhythmia disorders after repair of ventricular septal defects. Comparison of atrial and ventricular approaches. Arch Mal Coeur Vaiss, 1989, 82 (5):731-735.
18. Miyake T, Shinohara T, Nakamura Y, et al. Spontaneous closure of ventricular septal defects followed up from < 3 months of age. Pediatr Int, 2004, 46 (2):135-140.
19. Yip WC, Ho TF, Chan KY, et al. Comparison of spontaneous closure rate in children with different types of ventricular septal defects. J Paed Child Health, 1997, 33 (Suppl 1):S41.
20. Erdem S, Ozbarlas N, Küçükosmanoğlu O, et al. Long term follow-up of 799 children with isolated ventricular septal defects. Turk Kardiyol Dern Ars, 2012, 40 (1):22-25.
21. Sim EK, Grignani RT, Wong ML, et al. Outcome of surgical closure of doubly committed subarterial ventricular septal defect. Ann Thorac Surg, 1999, 67 (3):736-738.
22. Cheung YF, Chiu CS, Yung TC, et al. Impact of preoperative aortic cusp prolapse on long-term outcome after surgical closure of subar-terial ventricular septal defect. Ann Thorac Surg, 2002, 73 (2):622-627.
23. Lun K, Li H, Leung MP, et al. Analysis of indications for surgical closure of subarterial ventricular septal defect without associated aortic cusp prolapse and aortic regurgitation. Am J Cardiol, 2001, 87 (11):1266-1270.
24. Ishikawa S, Morishita Y, Sato Y, et al. Frequency and operative correction of aortic insufficiency associated with ventricular septal defect. Ann Thorac Surg, 1994, 57 (4):996-998.
25. Yildirim SV, Tokel K, Saygili B, et al. The incidence and risk factors of arrhythmias in the early period after cardiac surgery in pediatric patients. Turk J Pediatr, 2009, 50 (6):549-553.
26. Chiu SN, Wang JK, Lin MT, et al. Progression of aortic regurgitation after surgical repair of outlet-type ventricular septal defects. Am Heart J, 2007, 153 (2):336-342.
27. 胡义杰, 钟前进, 陈建明, 等.右侧腋下小切口先天性心脏病直视手术的临床应用.中国胸心血管外科临床杂志, 2012, 19 (4):427-429.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Minimal Right Vertical Infra-axillary Incision for Subarterial Ventricular Septal Defect Closure in Children

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