Closure of a Paramembranous Ventricular Septal Defect Via Vertical Right Axillary Thoracotomy in an 8-Year-Old Girl
This is an 8-year-old girl who presented with at least moderate size paramembranous ventricular septal defect (VSD) and large left-to-right shunt. The procedure was performed via a vertical right axillary thoracotomy (VRAT) under general anesthesia and selective lung isolation. The patient was positioned in the left lateral decubitus with the right hip rotated 40 degrees to expose the right groin. The incision is a vertical one in the midaxillary line, extending from the 2nd to the 5th ribs. Generous subcutaneous flaps are created using electrocautery, and the latissimus dorsi muscle is partially mobilized and the digitations of the serratus anterior muscle is separated to expose the intercoastal space. For VSD closure, we entered the right Chest through the right 4th intercostal space. The right lung is then retracted to expose the pericardium which is incised 1-2 cm anterior to the right phrenic nerve. Stay sutures are placed and the thymic lobes can be either separated or resected to facilitate exposure. Heparin is then administered and the ascending aorta and both cavae are cannulated and normothermic cardiopulmonary bypass (CPB) is initiated. Ascending aortic cardioplegia needle is then placed and the ascending order is cross clamped and antegrade cardioplegia is administered. Both cavae are snared and an oblique right atriotomy is performed parallel to the right atrioventricular grove and the intracardiac anatomy is evaluated. Two or three pledgeted prolene sutures are placed in a horizontal mattress fashion at the base of the septal leaflet of the tricuspid valve to facilitate visualization of the VSD. All crossing tricuspid valve chordae are retracted with vessel loops to facilitate further exposure. It is important to completely visualize the entire margin of the defect and its relation to the aortic cusps prior to closure to avoid any residual shunts. An appropriately sized bovine pericardial patch is then used to close that defect using running prolene suture starting at the papillary muscle of Lancisi towards the posteroinferior margin of the defect, followed by the superior margin. Administration of antegrade cardioplegia can be helpful to test the aortic valve and to ensure its competence during the procedure. Once the defect is closed, all vessel loops are removed, and the tricuspid valve is tested with saline to ensure its competence. The right atriotomy is then closed and the heart is de-aired, followed by removal of the aortic cross clamp. The patient is then weaned off CPB. Once transesophageal echocardiogram confirms satisfactory repair, the patient is decannulated and heparin is reversed. The pericardium is partially closed, and a single drain is placed in the right chest with its tip directed into the pericardial space. The incision is then closed in the standard fashion. In the current case, the patient was extubated in the operating room, received no transfusion, and was discharged two days after the surgery and continued to do well during her follow up. We believe that VRAT is a valuable technique that's cosmetically superior and is suitable for repair of varieties of congenital heart defects.
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