Minimally access via left anterior mini-thoracotomy for repair of adult subarterial ventricular septal defects

Liao et al. Journal of Cardiothoracic Surgery (2017) 12:48 DOI 10.1186/s13019-017-0611-7 RESEARCH ARTICLE Open Access Minimally access via left anterior mini-thoracotomy for repair of adult subarterial ventricular septal defects YunFei Liao†, Xiang Long†, ShuQiang Zhu†, Jun Tu, Hua Wen, JianJun Xu and YongBing Wu* Abstract Background: Minimally invasive cardiac surgical techniques are increasingly applied in the treatment and management of a variety of adult ventricular septal defects (VSDs). However, repair of adult subarterial VSDs via left anterior mini-thoracotomy is rarely reported. The present study aimed to determine the feasibility and safety of the left anterior mini-thoracotomy for the repair of adult subarterial VSDs. Methods: Twenty-seven adult patients underwent repair of subarterial VSDs via left anterior mini-thoracotomy. The approach includes two options for skin incision access, longitudinal and transverse skin incisions. The skin incision length was 4.1–6.1 cm (mean, 5.1 ± 0.6 cm). The closure of the VSDs was obtained through the main pulmonary artery under direct visualization. Results: Successful repair of the defects was achieved in all the patients. No patients died or converted to median sternotomy. Average durations of cardiopulmonary bypass (CPB) and aortic cross-clamp were 102.5 ± 13.6 min (range, 85–127 min) and 54.6 ± 6.9 min (range, 45–66 min), respectively. No patients required blood transfusion. The average postoperative hospital stay was 5.1 ± 0.7 days (range, 4–6 days). There were no postoperative complications related to the operative procedures or peripheral cannulation. During the follow-up of 5.4–32.3 months, no patients were found to have residual shunt, wound infections, pericardial effusion, neurologic or other complications. Conclusion: Our experiences demonstrate that minimally invasive cardiac surgical technique via left anterior mini-thoracotomy can be served as a novel, feasible and safe alternative for the repair of adult subarterial VSDs. Keywords: Minimally invasive cardiac surgical techniques, Left anterior mini-thoracotomy, Subarterial VSDs, Adults Background Conventional median sternotomy is the most common surgical access used for cardiac surgery; it is extensively applied in the repair of subarterial ventricular septal defects (VSDs). To date, intracardiac repair under direct visualization via median sternotomy is still considered the gold standard for treatment of VSDs [1]. However, the conventional surgery always accompanies by long midline or thoracotomy skin incisions, postoperative pain and poor cosmetic effects. Occasionally, mediastinitis and osteomyelitis may make the repair of VSD troublesome [2]. In the past few years, interventional * Correspondence: † Equal contributors Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province 330006, People’s Republic of China occlusion and minimally invasive cardiac surgery have gained popularity in the treatment of VSDs [3, 4]. However, though interventional occlusion has been extensively applied in the treatment of perimembranous and muscular VSDs, some controversies exist in its application due to its complexity and its potential to damage the aortic valve; thus its application to some extent has been limited [3]. By contrast, minimally invasive cardiac surgery has been increasingly applied to adult coronary revascularization, valvular surgery and congenital heart disease, especially in recent decades [5]. Minimally invasive cardiac surgery includes two primary accesses, right mini-thoracotomy and lower partial sternotomy [4, 6]. A novel alternative, left anterior mini-thoracotomy, is less commonly used in the repair of adult subarterial VSDs and is less frequently reported in previous studies. © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Liao et al. Journal of Cardiothoracic Surgery (2017) 12:48 The present series aimed to determine the feasibility and safety of minimally invasive cardiac surgical technique via left anterior mini-thoracotomy for the repair of adult subarterial VSDs. From June 2013 to October 2016, we performed minimally invasive repair of subarterial VSDs for 27 adult patients via the left anterior mini-thoracotomy. By analyzing the clinical data of these 27 patients, such as CPB time, cross-clamp time, postoperative drainage volume, mechanical ventilation time, intensive care unit (ICU) stay and postoperative hospital stay, etc., we concluded that minimally invasive cardiac surgery via left anterior minithoracotomy could be served as a novel, safe and feasible alternative for the repair of subarterial VSDs. Methods Inclusion and exclusion criteria This approach described herin is mainly applicable to the adult single subarterial VSDs patients without any other intracardiac lesions. The body weight of these patients should be controled in 35–80 kg (according to our exprimences). Some difficults exist in constructing an extracorporeal circulation for those too light patients (<35 kg), while for those who are too heavy (>80 kg), it has some trouble to expose the operative field for the thick cortex. In addition, patients who accompanied by moderate or severe aortic insufficiency are not the suitable cohort, for these patients should receive an extra aortic vulve replacement. Patients who simultaneously suffer severe pericardial adhesions are also not the suitable cohort, for it is difficult to expose the operative field. Patients Twenty-seven adult patients (12 male, 15 female) with subarterial VSDs were selected to undergo repair of subarterial VSDs by this minimally invasive cardiac surgical technique via left anterior mini-thoracotomy. Among these patients, the average age and body weight were 28.3 ± 9.7 years (range, 19–46 years) and 55.4 ± 10.6 kg (range, 40–73 kg), respectively. By preoperative examinations, such as transthoracic color doppler ultrasound or transesophageal echocardiography (TEE), all patients were confirmed to have isolated subarterial VSD and no other intracardiac malformations. The average VSD size was 7.9 ± 4.4 mm (range, 4.0–18.0 mm). According to New York Heart Association (NYHA) classifications, 16 were classified as grade I and others were grade II. The average ejection fraction was 58.5 ± 7.2% (range, 50–72%). 7 patients were found with aortic valve regurgitation (4 trivial / 3 mild). Mild pu (...truncated)