right axillary operative techniques 2016

384 1522-2942/$-sehttp://dx.doi.or

Children’s Heart CenteMS

Address reprint requesCenter, UniversityS345, Jackson, MS

Right Axillary Thoracotomy for TransatrialRepair of Congenital Heart Defects: VSD,Partial AV Canal With Mitral Cleft, PAPVR orWarden, Cor Triatriatum, and ASD
Ali Dodge-Khatami, MD, PhD, and Jorge D. Salazar, MD
For transatrial repair of congenital heart defects and wanting to avoid a sternotomy, themuscle-sparing right axillary thoracotomy has the advantage over other thoracic incisions tobe far from breast tissue, allowing faster functional recovery, and being more cosmetic.Initially limited to closure of an atrial septal defect, extended application using eitherinduced ventricular fibrillation or aortic cross-clamping with cardioplegic arrest expandedthe approach to repair of ventricular septal defects (with or without a subaortic membrane),partial atrioventricular canal with a mitral valve cleft, partial anomalous pulmonary venousreturn (including the Warden procedure), and more recently cor triatriatum through left andright atrial incisions. The technique is repro.ducible and safe, the quality of repairuncompromised (no residual defects or complications), and the morbidity reduced withshorter hospital stays and faster return to functional capacity, not to mention superiorcosmetic results with a vertical scar hidden underneath a resting arm.Operative Techniques in Thoracic and Cardiovasculary Surgery 20:384-401 r 2016Elsevier Inc. All rights reserved.

KEYWORDS Congenital Heart Disease (CHD), Thoracotomy, Surgery/incisions/exposure/techniques

Introduction

Surgical repair of simple to moderate complexity con-genital heart defects (CHD) is currently achieved with an

expected mortality and morbidity approaching zero. Tech-nological advances and less invasive approaches towardminimizing or altogether avoiding surgical scars, reducingphysical and psychological trauma, and achieving fasterrecovery with minimized costs for health care havesignificantly affected the way these elective procedures aremanaged. Accordingly, percutaneous catheter-based deviceclosure of simple CHD such as patent foramen ovale, atrialseptal defect (ASD), or restrictive ventricular septal defect(VSD) are becoming routine, and slowly, but surelyreplacing the prior gold standard of surgical repair throughmedian sternotomy.1,2 As the pressure for minimallyinvasive or more cosmetic techniques increases, percuta-neous approaches are sometimes preferred by cardiologistsor patients, even at the expense of optimal results or leavingresidual albeit hemodynamically insignificant defects.3

e front matter r 2016 Elsevier Inc. All rights reserved.g/10.1053/j.optechstcvs.2016.04.003

r, University of Mississipi Medical Center, Jackson,

ts to Ali Dodge-Khatami, MD, PhD, Children’s Heartof Mississipi Medical Center, 2500 N State St, Room39216 E-mail: [email protected]

When percutaneous techniques are deemed technicallydifficult, contraindicated, or when significant residualdefects are anticipated,1 surgery is reliably offered, althoughat the “cost” of a median sternotomy with cardiopulmonarybypass. Therefore, by popular demand, peer pressure andperhaps common sense, the surgical community hasincreasingly been challenged to become more “minimallyinvasive,” avoiding a median sternotomy to repair CHD notamenable to catheter intervention, without compromisingthe quality of repair.3-7 Various incisions include anterior,anterolateral (or submammary), posterolateral, or as isdescribed here, the muscle-sparing axillary right thoracot-omy.3-7 Problems with the anterolateral or submammaryapproach include rib deformation and atrophy of severedpectoral muscles, and asymmetrical breast development laterin life after breast tissue growth has occurred, resulting insuboptimal cosmetic results, thereby negating the initialpurpose of the approach.3

The suggested advantages of the axillary incision include(1) the muscle-sparing nature of the approach withresultant shorter recovery time and return to functionalcapacity of the right arm and shoulder, as only longi-tudinal muscle fibers of the serratus anterior are splitparallel to the ribs, (2) being far away from breast tissue,which is especially important in young females (infants

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Right axillary thoracotomy 385

and small children), given the absence of any visiblelandmark, and (3) a completely hidden scar by the restingarm, resulting in superior cosmetic results compared withother more visible thoracic incisions.The axillary approach was initially used for closure of the

most straightforward of defects, an ASD, on a beating heart.7

Expanding the approach to repair more complex defectssuch as VSD closure or partial atrioventricular (AV) canalinvolved a certain learning curve, and gaining confidenceand surgical comfort to proceed with longer operations in alimited space. Adding first induced ventricular fibrillation,and then finding room for an aortic cross-clamp and a

cardioplegia needle, René Prêtre et al3 in Zurich, Switzer-land promoted the technique, where I learned it. In hismidterm review of 123 patients operated between 2001and 2007, there was no mortality or prolonged hospitalstay, no conversions to another incision, no residualdefects in 116 patients and minor residuals in 7, and nobreast or chest wall deformity in any patient, with perfectlyhealed incisions. Importantly, he stresses the necessity tostrive for perfect results, without compromising what maybe achieved by a standard median sternotomy, if theapproach is to be justified and the technique perpetrated6

(Figs. 1-13).

A

B

Figure 1 The right groin vessels are always left free without any anesthesia access lines in case peripheral cannulation becomes necessary forbypass. With the patient positioned in a left lateral decubitus, the torso almost perpendicular to the table and the hips at approximately 450,important landmarks (tip of the scapula, anterior border of the latissimus dorsi muscle, nipple, third and fourth ribs, femoral artery, and vein)and the proposed incision are marked out before prepping and draping.

Operative Technique

A. Dodge-Khatami and J.D. Salazar386

Long thoracic N.

Latissimus dorsiretracted

Posterior

Lateral thoracicA & V

3rd rib

Serratus anterior

Anterior

Figure 2 After skin incision, flaps are developed in the subcutaneous tissue to allow incision mobility relative to the chest spreaders. A plane ismade between the spared latissimus dorsi muscle, lateral thoracic vessels, and long thoracic nerve, which are retracted posteriorly with thespreader.The third rib or fourth rib is exposed after going through fibers of the serratus muscle parallel to the rib. When cannulating throughthe thoracotomy incision in infants and small children and anticipating repairs in front of the AV valves (such as for the repair of high sinusvenosus ASD, or partial anomalous pulmonary venous return [PAPVR] in view of a Warden procedure), access to the aorta and superior venacava (SVC) are better through the third intercostals space. Anesthesia is asked to stop positive end-expiratory pressure before pleural entry toallow easier lung decompression and give the surgeon more space. In larger adolescents and young adults, aortic cannulation may be difficultas the aorta is very remote, and placing a cross-clamp or inserting a cardioplegia needle is quite challenging. Accordingly, peripheral arterialcannulation (and sometimes venous) is performed using the prepped right groin vessels, and induced ventricular fibrillation is anticipated. Inthese cases, as with any repair involving structures behind the AV valves (VSD with or without subaortic membrane, partial AV canal withmitral valve cleft), approaching the heart through the fourth intercostals space gives better access. In larger patients, consideration may begiven to asking anesthesia if lung isolation can be used to facilitate chest entry and lung retraction.


Thymus Ao root

Right atrial border

RV

RAA

AoSVC

IVC

Figure 3 The pericardium is grabbed and incised 1-2 cm anteriorly to the phrenic nerve, and opened longitudinally (cranio-caudally), withpericardial stay sutures gradually keeping the lungs posteriorly behind a wet sponge, and exposing the right atrium, the SVC, and the aorticroot with a glimpse of the right ventricle (RV). The first 2 pericardial stay sutures are the most challenging, but each subsequent stay graduallyopens the field. The thymus is peeled off the pericardium and mobilized anteriorly without resecting anything, and the last pericardial staysuture is tacked to the anterior internal chest wall near the internal mammary artery and knotted inside, thereby lifting the thymus out of theway in a contained pocket, with adequate exposure to the ascending aorta. Occasionally, before this last exposing stay suture, it is necessary tomake an additional atypical “T” incision in the pericardium anteriorly to reduce tension, and better expose the aorta.


RAAAo

Figure 4 After intravenous heparin, before standard aortic cannulation, a stay suture is placed on the right atrial appendage (RAA), which isretracted caudally, giving better exposure to the ascending aorta. The SVC is cannulated with an angled cannula, and bypass commenced.Only at this point does the heart decompress with the right atrium collapsing, finally revealing more RV, and most importantly, the inferiorvena cava (IVC). Suggested right atrial incision is shown with dotted lines.


Proposed Aoclamp placement

LV vent Figure 5 With the heart decompressed, IVC cannulation is performed with a straight venous cannula that can be easily guided down into theIVC. Going around the IVC with a snare before cannulation helps guide the cannula properly into the IVC beyond the junction at thediaphragm. The cannula tip could otherwise inadvertently be sitting in the right atrium and difficult to assess with digital palpation, given theeffect of gravity and the vertical position of the patient’s chest in this position. Inadvertent and catastrophic venous air lock and bypass pumpshutoff may thus be avoided upon right atrial opening. A left heart vent is routinely placed through the right superior pulmonary vein ifanything more than an ASD closure is anticipated, in which case right atrial opening and venting of the left heart are achieved through thedefect. Proposed aortic clamp and cardioplegia needle sites are shown, which we have performed in routine fashion as during a mediansternotomy approach. No effort is made to dissect out the interadventitial fatty space between the great vessels to avoid unnecessary bleeding,but care is given not to clamp the pulmonary artery. Although some groups have used a separate intercostal space (above) for the aorticcross-clamp, or a separate future chest drain site (below) through which the IVC cannula may be brought out, we have not needed it, butacknowledge its usefulness in certain situations.


Proposed Aoclamp placement

ASD patch

TV

CS

Figure 6 After right atrial access, standard ASD closure is performed primarily or with a patch as indicated.


Ao valve

VSD

TV,anterior leaflet

VSD border

Cut edge of annulus,anterior leaflet

Figure 7 VSD closure—after right atrial access, 3 stay sutures are placed at 9, 12, and 3 o’clock of the tricuspid valve annulus. The anteriorleaflet of the tricuspid valve is unhinged from 2 o’clock back all the way to about 7 o’clock or where the rim of the VSD meets the tricuspidvalve (whichever comes first), at which point the leaflet falls forward toward the surgeon without any traction or tension, thus avoiding leafletor chordal injury. The borders of the VSD become visible, as does the aortic valve in typical perimembranous defects.



Anchor stitch

Patch

BA

21

Figure 8 VSD patch closure is performed, starting by anchoring at the deepest point (12 o’clock), closing the inferior border first, and comingthrough the lowest unhinged portion of the anterior tricuspid leaflet into the right atrium (1). Given the effect of gravity and the VSD being ina more vertical position compared with the patient’s position when supine, this order seems crucial. Once the patch is anchored inferiorly inthis fashion, the superior border can be exposed by asking the assistant to pull gently on each stitch as the surgeon is closing cranially,allowing progressive, but complete visualization of the superior VSD border (2). The final stages involve reanchoring the anterior leaflet,which on the inferior border involves sandwiching the 3 layers of the tricuspid annulus, the VSD patch, and the tricuspid leaflet, and on thesuperior edge, suturing the leaflet back to the annulus. Valve competency is checked with a flush of cold saline.

Interatrial crest

MV, posterior leaflet

TV, septal leaflet

MV, anteriorleaflet

BA

Figure 9 Repair of partial AV canal with a mitral valve cleft. A traction stitch is placed at the deepest point of the 2 half portions of the left AVvalve, passed through the rim of the primum ASD, and pulled toward the surgeon. This allows the cleft to come out of the deep, and beappropriately aligned for a running suture of fine 6 or 7-0 prolene to close the cleft.


Proposed incision in rt. atrial appendagefor SVC anastomosis

SA node

Figure 10 For a Warden-type repair of PAPVR, the essential points are to cannulate the SVC as high as possible, after doubly clipping andtransecting the azygous vein for maximal mobility of the SVC toward the RAA. The anticipated anastomosis site of the SVC in the RAA isshown.


Subaortic membrane

Figure 11 During VSD closure, in the presence of a nonrestrictive VSD with a subaortic membrane, the protruding ridge on the left side of theinterventricular crest can be excised through the VSD before closing it with a patch. Unhinging of the anterior leaflet of the tricuspid valve asdescribed in Figure 7 has already been performed to enhance access.


Scar

A

B

Figure 12 Closed incision underneath the right arm with a combined pericardial or right pleural chest drain, and the resulting hidden scarunderneath a resting arm in a standing child.


A

Figure 13 Postoperative pictures of the healed right axillary incision in a 2-year-old patient after repair of partial AV canal with a mitral valvecleft closure, showing a hidden scar underneath the resting right arm.


B

Figure 13 (continued)


C

Figure 13 (continued)



Results and CommentsIn the era of percutaneous catheter device closure of morestraightforward CHD, increasing parent and referringcardiology demand is encountered to treat patients with“minimally invasive” approaches. Most often, this includesavoiding cardiopulmonary bypass and a standard mediansternotomy. Furthermore, in the eyes of parents and peers,the stigma of a sternotomy scar implies having a heartcondition, an ostracizing situation from which manychildren never fully recover, with its inherent negativepsychological burden. Therefore, it seems legitimate for thesurgical community to rise to the challenge and respond tothe demand, provide a less “invasive” approach and acosmetically superior result, without compromising safety orquality.3 Together with the combined experience of2 surgeons in 123 patients referred to by Prêtre et al,6 thecurrent series since 2008 includes another 45 patients (26ASD, 7 VSD [including 1 with double-chambered RV], 8Warden operations for PAPVR, 3 partial AV canals withmitral valve cleft, and 1 cor triatriatum), with no residualdefects or perioperative complications. Availability of aperioperative epidural catheter with optimized pain controlhas allowed immediate postoperative extubation in theoperating room, thereby leading to shorter intensive careunit and hospital lengths of stays, and faster functionalrecovery with arm and shoulder mobility. As no sternal orrib healing needs to occur, patients are encouraged toaugment physical activity as tolerated, with no restrictions.The cosmetic results have been excellent, with very highpatient and parent satisfaction (Fig. 13).The choice to proceed with induced ventricular fibrilla-

tion at normothermia or slight hypothermia, or an aorticcross-clamp with cardioplegia at moderate hypothermia, is atthe discretion of the surgeon. Variables influencing thisdecision are the type and length of operation to beperformed, the size and constitution of the patient thatdetermine the depth at which the aorta lies in the chest andthe relative ease or difficulty in placing a cross-clamp, andthe speed of the surgeon. Induced fibrillation times of morethan 30 minutes are probably best avoided, in which caseplanning on cardioplegia is preferred. If performed withinduced ventricular fibrillation at normothermia or onlyslight (drifting to 341C) hypothermia without a cross-clamp,spontaneous defibrillation would occur as soon as thefibrillator is turned off, and the surgeon should have alreadyclosed intracardiac shunts to avoid unwanted air embolism.It is a good idea to have a pitcher of sterile ice-cold salineavailable so as to drown the surgical field under water,should unplanned defibrillation suddenly occur. As thisphenomenon was once encountered, systematic tacking ofthe fibrillatory electrode to the right ventricular epicardialsurface with a single stitch has been effective in preventingunplanned spontaneous defibrillation.Although the approach has been used in patients as small

as 6 kg, the patient’s body configuration is an important

variable for the same weight, the surgery is easier to do in athin and long patient, rather than in a short and chubby one,using standard surgical instruments. Performing all cannu-lation that is done in a standard fashion (as per mediansternotomy) through the thoracotomy using 1 intercostalspace, including the aorta, is easier in patients from 6-30 kg,as opposed to larger patients in whom the aorta lies far awayfrom the chest wall, making peripheral groin vesselcannulation wiser. Until now, the indications for theapproach have been repair of defects accessible throughthe right atrium, with 1 repair of cor triatriatum through anadditional left atriotomy, and 1 patient with double-chambered RV needing work in the right outflow. Currently,the approach is not offered to typical left-sided lesions of theheart, nor those involving the right infundibulum orpulmonary valve.

SummaryThe muscle-sparing right axillary approach is a safe,reproducible, and teachable technique to repair CHDtypically accessible through the right atrium, includingVSD’s, partial AV canal with mitral valve clefts, PAPVR, andof course ASDs. Compared with other thoracic incisions, theapproach is far away from breast tissue, which is easilyspared and thereby avoids future asymmetrical breastgrowth, no muscles are sacrificed with rapid functionalrecovery of the right arm and shoulder, and the cosmeticresults highly appreciated by parents and patients alike.With gained experience and surgeon comfort, perfect resultsare achieved without compromising repair quality comparedwith a median sternotomy approach.

References1. Thomson JD, Aburawi EH, Watterson KG, et al: Surgical and

transcatheter (Amplatzer) closure of atrial septal defects: A prospectivecomparison of results and cost. Heart 87:466–469, 2002

2. Ebeid MR, Batlivala SP, Salazar JD, et al: Percutaneous closure ofperimembranous ventricular septal defects using the second-generationamplatzer vascular occluders. Am J Cardiol 117:127–130, 2016

3. Prêtre R, Kadner A, Dave H, et al: Right axillary incision: A cosmeticallysuperior approach to repair a wide range of congenital cardiac defects. JThorac Cardiovasc Surg 130:277–281, 2005

4. Cremer JT, Böning A, Anssar MB, et al: Different approaches forminimally invasive closure of atrial septal defects. Ann Thorac Surg67:1648–1652, 1999

5. Bleiziffer S, Schreiber C, Burgkart R, et al: The influence of rightanterolateral thoracotomy in prepubescent female patients on late breastdevelopment and on the incidence of scoliosis. J Thorac Cardiovasc Surg127:1474–1480, 2004

6. Dave HH, Comber M, Solinger T, et al: Mid-term results of right axillaryincision for the repair of a wide range of congenital cardiac defects. Eur JCardiothorac Surg 35:864–869, 2009

7. Yang X, Wang D, Wu Q: Repair of atrial septal defect through a minimalright vertical infra-axillary thoracotomy in a beating heart. Ann ThoracSurg 71:2053–2054, 2001

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