title: Closure of restrictive ventricular septal defects through a right axillary thoracotomy.
abstract: OBJECTIVE
  To report the midterm results of an alternative minimally invasive approach for closure of ventricular septal defects (VSD) through a muscle-sparing minithoracotomy at the right midaxillary line.
  
  
  METHODS
  From September 2003 to December 2005, 22 patients (median age, 5 years; range, 1.5-12 years) underwent a right lateral axillary thoracotomy for closure of a perimembranous VSD. Special features of the approach included an incision between the anterior and posterior axillary fold, a muscle-sparing preparation over the fourth intercostal space, and the establishment of cardiopulmonary bypass with inguinal and superior vena cava cannulation. The ascending aorta was cross clamped and cardioplegic arrest was instituted. The VSDs were all approached through a right atriotomy and closed directly (17 patients) or with a patch (5 patients). Three patients underwent concomitant aortic valve repair.
  
  
  RESULTS
  There was no mortality or significant surgical morbidity. Median cross-clamp and cardiopulmonary bypass times were 46 and 104 min, respectively. Follow-up was complete and ranged from 2 to 22 months (median, 20 months). All patients were in sinus rhythm. Echocardiography revealed no residual defects with competent aortic and tricuspid valves. The length of the incision ranged from 4 to 6 cm, was away from the mammary gland, and remained entirely covered by the adducted arm. All children recovered right shoulder function within days, and cosmetic results were very satisfying. One patient developed iliac artery stenosis following inguinal artery cannulation.
  
  
  CONCLUSIONS
  Closure of perimembranous VSDs in older children can be safely performed through a right axillary thoracotomy without compromising the accuracy of the repair. The cosmetic results are excellent.
authors.affiliation: Division of Congenital Cardiac Surgery, Children's Hospital, University of Zurich, Zurich, Switzerland. a.kadner@web.de
authors.forename: Alexander
authors.initials: A
authors.lastname: Kadner
authors.forename: Ali
authors.initials: A
authors.lastname: Dodge-Khatami
authors.forename: Hitendu
authors.initials: H
authors.lastname: Dave
authors.forename: Walter
authors.initials: W
authors.lastname: Knirsch
authors.forename: Dominique
authors.initials: D
authors.lastname: Bettex
authors.forename: René
authors.initials: R
authors.lastname: Prêtre
mesh_terms: D002315:Cardiopulmonary Bypass / Q000379:methods*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006345:Heart Septal Defects, Ventricular / Q000601:surgery*; D006801:Humans; D007223:Infant; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D013908:Thoracotomy / Q000379:methods*; D016896:Treatment Outcome