Individualized Strategy of Minimally Invasive Cardiac Surgery in Congenital Cardiac Septal Defects

Abstract Background: Intracardiac septal defect tends to be repaired by minimally invasive surgery in both children and adults. This study summarized our strategy of minimally invasive therapy using various lateral mini-thoracotomies in patients with congenital septal defect. Methods: Four hundred and seventy-two patients who underwent minimally invasive repair of intracardiac septal defects (Atrial septal defect, ASD; ventricular septal defect, VSD; atrioventricular septal defect, AVSD) between January 2012 and June 2020 were retrospectively reviewed. Those who underwent device closure were excluded. The minimally invasive strategy included three groups. First, right sub-axillary vertical incision group (RSAVI group, N=335, 192 ASDs, 135 VSDs and 8 AVSDs; Second, right anterolateral thoracotomy group (RALT group, N=132, 77 ASDs, 51 VSDs and 4 AVSDs; Third, left anterolateral thoracotomy group (LALT group, N=5, all of them were sub-pulmonary VSDs).Results: Concomitant surgeries included 9 cases of right ventricular outflow tract obstruction relief, 9 mitral repairs and 37 tricuspid repairs. There was one transition from thoracotomy to sternotomy. Three patients required second pump run for residual lesions (2 residual shunts and 1 mitral regurgitation). The age and body weight of RSAVI group were significantly lower than those of RALT and LALT groups. The mean cardiopulmonary bypass time was 67.3±11.3 min and cross clamp time was 38.1±8.9 min. There was no post-operative death, and complications included 1 chest exploration for bleeding, 1 redo operation due to patch dehiscence during the same admission, 1 transient neural dysfunction, 3 diaphragmatic paresis and 13 atelectasis. The median stay in ICU was 2 days, while the median post-operative hospitalization was 6 days. The echocardiography results before discharge indicated no significant residual lesions. There was no reoperation, no new onset of chest deformities and no sclerosis during the follow up. Conclusions: The commonly seen intracardiac septal defects can be safely and effectively repaired by minimally invasive surgery with good cosmetic results. Right sub-axillary vertical incision is suitable in infants and young children, while right anterior mini-thoracotomy is more commonly used in adolescents and adults. Left anterior mini-thoracotomy is an alternative incision to repair sub-pulmonary artery VSD.