| Objective To summarize and analyse the clinical outcome of the right vertical axillary midline incision(RVAMI)used for the closure of doubly committed subarterial ventricular septal defect(SAVSD)through right atrium and tricuspid approach only,and evaluate the feasibility and efficacy of this method by comparing RVAMI through tricuspid orifice with the conventional median sternotomy incision surgery through pulmonary artery pathway in clinical outcome and the degree of satisfaction of patients’parents.Methods We retrospectively collect the clinical data from 1st June,2015 to 31st October,2016 of 32 patients who underwent surgical repair through RVAMI via tricuspid orifice and conventional median sternotomy incision via pulmonary artery approach for doubly committed subarterial ventricular septal defect in our Hospital.We divide the 32 patients into two groups.Sixteen children who were treated by RVAMI though right atrium and tricuspid orifice approach were selected to group A.After matching the sex,age,body weight,size of VSD,patch or not,experience of surgeon and the year of operation,we selected 16 children who were treated by the traditional median sternotomy incision through pulmonary artery approach in the same period to group B.By retrospective 1:1 paired analysis,aortic occlusion time,the cardiopulmonary bypass time(CPB),mechanical ventilation time,intensive care unit(ICU)stay,hospital stay,VSD residual shunt rate,pressure gradient across the right ventricular outflow tract(RVOT)and the incidence of arrhythmia were compared between the two groups.We also did a survey to evaluate the cosmetic satisfaction of two groups of children’s families after the operation by questionnaire.Results Thirty two children aged 7 months to 8 years(mean 2.4 years)were enrolled.The ratio of male and female in both groups was 1:1,No death during hospital stay and follow-up.1 patient in group B need reoperation cause of sternal infection.The average length of right axillary midline incision was 3-4 cm in group A.The cardiopulmonary bypass(CPB)time of group A and group B was 48.6±12.6 and 57.8±14.1 minutes(p=0.03),which significantly less in group A.The aortic cross-clamp time was 29.3±8.5 and 34.3±12.1 minutes(p=0.18).There was no significant difference in aortic cross-clamp time.The ICU stay in group A is 17.8±8.9 hours and 18.7±9.5 hours in group B;(p=0.79)Mechanical ventilation time is 2.7±1.7 hours in group A and 3.6±1.5 hours in group B(p=0.06).Postoperative hospital stay is 6.3±1.5 days in group A and 7.4±1.7 days in group B(p=0.18).Postoperative thoracic tube drainage in group A is 6.4±4.3 ml/kg and 8.5±3.8 ml/kg in group B(p=0.16).There was no significant difference between the two groups and no parent residual defects in both groups.There was no significant difference in pressure gradient across the right ventricular outflow tract between the two groups before operation.The pressure gradient across DVOT postoperatively is 4.6±1.8 mm Hg in group A and 10.0±6.8 mm Hg in group B(p=0.004),which was significantly lower in group A than group B.No arrhythmia was found in all patients after operation.The questionnaire shows,all parents in group A were satisfied with the cosmetic effect of the surgical incision,and only 7 cases(43.8%)from group B were satisfied.Conclusions It is safe and feasible to treat doubly committed subarterial ventricular septal defect through right vertical axillary midline incision via right atrial and tricuspid orifice approach.Compared with the traditional median sternotomy incision through pulmonary artery approach,the RVAMI approach can ensure the integrity of the pulmonary valve and main pulmonary artery and reduce the possibility of postoperative pulmonary stenosis in RVOT.RVAMI approach also has less cardiopulmonary bypass time.In addition,this surgical technique can obtain better cosmetic result and achieve real minimally invasive outcome and improve the prognosis of SAVSD patients. |
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