1. Right Axillary Thoracotomy for Transatrial
Repair of Congenital Heart Defects: VSD,
Partial AV Canal With Mitral Cleft, PAPVR or
Warden, Cor Triatriatum, and ASD
Ali Dodge-Khatami, MD, PhD, and Jorge D. Salazar, MD
For transatrial repair of congenital heart defects and wanting to avoid a sternotomy, the
muscle-sparing right axillary thoracotomy has the advantage over other thoracic incisions to
be far from breast tissue, allowing faster functional recovery, and being more cosmetic.
Initially limited to closure of an atrial septal defect, extended application using either
induced ventricular fibrillation or aortic cross-clamping with cardioplegic arrest expanded
the approach to repair of ventricular septal defects (with or without a subaortic membrane),
partial atrioventricular canal with a mitral valve cleft, partial anomalous pulmonary venous
return (including the Warden procedure), and more recently cor triatriatum through left and
right atrial incisions. The technique is repro.ducible and safe, the quality of repair
uncompromised (no residual defects or complications), and the morbidity reduced with
shorter hospital stays and faster return to functional capacity, not to mention superior
cosmetic results with a vertical scar hidden underneath a resting arm.
Operative Techniques in Thoracic and Cardiovasculary Surgery 20:384-401 r 2016
Elsevier Inc. All rights reserved.
KEYWORDS Congenital Heart Disease (CHD), Thoracotomy, Surgery/incisions/exposure/
techniques
Introduction
Surgical repair of simple to moderate complexity con-
genital heart defects (CHD) is currently achieved with an
expected mortality and morbidity approaching zero. Tech-
nological advances and less invasive approaches toward
minimizing or altogether avoiding surgical scars, reducing
physical and psychological trauma, and achieving faster
recovery with minimized costs for health care have
significantly affected the way these elective procedures are
managed. Accordingly, percutaneous catheter-based device
closure of simple CHD such as patent foramen ovale, atrial
septal defect (ASD), or restrictive ventricular septal defect
(VSD) are becoming routine, and slowly, but surely
replacing the prior gold standard of surgical repair through
median sternotomy.1,2
As the pressure for minimally
invasive or more cosmetic techniques increases, percuta-
neous approaches are sometimes preferred by cardiologists
or patients, even at the expense of optimal results or leaving
residual albeit hemodynamically insignificant defects.3
When percutaneous techniques are deemed technically
difficult, contraindicated, or when significant residual
defects are anticipated,1
surgery is reliably offered, although
at the “cost” of a median sternotomy with cardiopulmonary
bypass. Therefore, by popular demand, peer pressure and
perhaps common sense, the surgical community has
increasingly been challenged to become more “minimally
invasive,” avoiding a median sternotomy to repair CHD not
amenable to catheter intervention, without compromising
the quality of repair.3-7
Various incisions include anterior,
anterolateral (or submammary), posterolateral, or as is
described here, the muscle-sparing axillary right thoracot-
omy.3-7
Problems with the anterolateral or submammary
approach include rib deformation and atrophy of severed
pectoral muscles, and asymmetrical breast development later
in life after breast tissue growth has occurred, resulting in
suboptimal cosmetic results, thereby negating the initial
purpose of the approach.3
The suggested advantages of the axillary incision include
(1) the muscle-sparing nature of the approach with
resultant shorter recovery time and return to functional
capacity of the right arm and shoulder, as only longi-
tudinal muscle fibers of the serratus anterior are split
parallel to the ribs, (2) being far away from breast tissue,
which is especially important in young females (infants
384 1522-2942/$-see front matter r 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1053/j.optechstcvs.2016.04.003
Children’s Heart Center, University of Mississipi Medical Center, Jackson,
MS
Address reprint requests to Ali Dodge-Khatami, MD, PhD, Children’s Heart
Center, University of Mississipi Medical Center, 2500 N State St, Room
S345, Jackson, MS 39216 E-mail: adodgekhatami@umc.edu

2. and small children), given the absence of any visible
landmark, and (3) a completely hidden scar by the resting
arm, resulting in superior cosmetic results compared with
other more visible thoracic incisions.
The axillary approach was initially used for closure of the
most straightforward of defects, an ASD, on a beating heart.7
Expanding the approach to repair more complex defects
such as VSD closure or partial atrioventricular (AV) canal
involved a certain learning curve, and gaining confidence
and surgical comfort to proceed with longer operations in a
limited space. Adding first induced ventricular fibrillation,
and then finding room for an aortic cross-clamp and a
cardioplegia needle, René Prêtre et al3
in Zurich, Switzer-
land promoted the technique, where I learned it. In his
midterm review of 123 patients operated between 2001
and 2007, there was no mortality or prolonged hospital
stay, no conversions to another incision, no residual
defects in 116 patients and minor residuals in 7, and no
breast or chest wall deformity in any patient, with perfectly
healed incisions. Importantly, he stresses the necessity to
strive for perfect results, without compromising what may
be achieved by a standard median sternotomy, if the
approach is to be justified and the technique perpetrated6
(Figs. 1-13).
Right axillary thoracotomy 385

3. A
B
Figure 1 The right groin vessels are always left free without any anesthesia access lines in case peripheral cannulation becomes necessary for
bypass. With the patient positioned in a left lateral decubitus, the torso almost perpendicular to the table and the hips at approximately 450,
important landmarks (tip of the scapula, anterior border of the latissimus dorsi muscle, nipple, third and fourth ribs, femoral artery, and vein)
and the proposed incision are marked out before prepping and draping.
Operative Technique
A. Dodge-Khatami and J.D. Salazar386

4. Long thoracic N.
Latissimus dorsi
retracted
Posterior
Lateral thoracic
A & V
3rd rib
Serratus
anterior
Anterior
Figure 2 After skin incision, flaps are developed in the subcutaneous tissue to allow incision mobility relative to the chest spreaders. A plane is
made between the spared latissimus dorsi muscle, lateral thoracic vessels, and long thoracic nerve, which are retracted posteriorly with the
spreader.The third rib or fourth rib is exposed after going through fibers of the serratus muscle parallel to the rib. When cannulating through
the thoracotomy incision in infants and small children and anticipating repairs in front of the AV valves (such as for the repair of high sinus
venosus ASD, or partial anomalous pulmonary venous return [PAPVR] in view of a Warden procedure), access to the aorta and superior vena
cava (SVC) are better through the third intercostals space. Anesthesia is asked to stop positive end-expiratory pressure before pleural entry to
allow easier lung decompression and give the surgeon more space. In larger adolescents and young adults, aortic cannulation may be difficult
as the aorta is very remote, and placing a cross-clamp or inserting a cardioplegia needle is quite challenging. Accordingly, peripheral arterial
cannulation (and sometimes venous) is performed using the prepped right groin vessels, and induced ventricular fibrillation is anticipated. In
these cases, as with any repair involving structures behind the AV valves (VSD with or without subaortic membrane, partial AV canal with
mitral valve cleft), approaching the heart through the fourth intercostals space gives better access. In larger patients, consideration may be
given to asking anesthesia if lung isolation can be used to facilitate chest entry and lung retraction.
Right axillary thoracotomy 387

5. Thymus
Ao root
Right atrial
border
RV
RAA
Ao
SVC
IVC
Figure 3 The pericardium is grabbed and incised 1-2 cm anteriorly to the phrenic nerve, and opened longitudinally (cranio-caudally), with
pericardial stay sutures gradually keeping the lungs posteriorly behind a wet sponge, and exposing the right atrium, the SVC, and the aortic
root with a glimpse of the right ventricle (RV). The first 2 pericardial stay sutures are the most challenging, but each subsequent stay gradually
opens the field. The thymus is peeled off the pericardium and mobilized anteriorly without resecting anything, and the last pericardial stay
suture is tacked to the anterior internal chest wall near the internal mammary artery and knotted inside, thereby lifting the thymus out of the
way in a contained pocket, with adequate exposure to the ascending aorta. Occasionally, before this last exposing stay suture, it is necessary to
make an additional atypical “T” incision in the pericardium anteriorly to reduce tension, and better expose the aorta.
A. Dodge-Khatami and J.D. Salazar388

6. RAAAo
Figure 4 After intravenous heparin, before standard aortic cannulation, a stay suture is placed on the right atrial appendage (RAA), which is
retracted caudally, giving better exposure to the ascending aorta. The SVC is cannulated with an angled cannula, and bypass commenced.
Only at this point does the heart decompress with the right atrium collapsing, finally revealing more RV, and most importantly, the inferior
vena cava (IVC). Suggested right atrial incision is shown with dotted lines.
Right axillary thoracotomy 389

7. Proposed Ao
clamp placement
LV vent
Figure 5 With the heart decompressed, IVC cannulation is performed with a straight venous cannula that can be easily guided down into the
IVC. Going around the IVC with a snare before cannulation helps guide the cannula properly into the IVC beyond the junction at the
diaphragm. The cannula tip could otherwise inadvertently be sitting in the right atrium and difficult to assess with digital palpation, given the
effect of gravity and the vertical position of the patient’s chest in this position. Inadvertent and catastrophic venous air lock and bypass pump
shutoff may thus be avoided upon right atrial opening. A left heart vent is routinely placed through the right superior pulmonary vein if
anything more than an ASD closure is anticipated, in which case right atrial opening and venting of the left heart are achieved through the
defect. Proposed aortic clamp and cardioplegia needle sites are shown, which we have performed in routine fashion as during a median
sternotomy approach. No effort is made to dissect out the interadventitial fatty space between the great vessels to avoid unnecessary bleeding,
but care is given not to clamp the pulmonary artery. Although some groups have used a separate intercostal space (above) for the aortic
cross-clamp, or a separate future chest drain site (below) through which the IVC cannula may be brought out, we have not needed it, but
acknowledge its usefulness in certain situations.
A. Dodge-Khatami and J.D. Salazar390

8. Proposed Ao
clamp placement
ASD patch
TV
CS
Figure 6 After right atrial access, standard ASD closure is performed primarily or with a patch as indicated.
Right axillary thoracotomy 391

9. Ao valve
VSD
TV,
anterior leaflet
VSD border
Cut edge of annulus,
anterior leaflet
Figure 7 VSD closure—after right atrial access, 3 stay sutures are placed at 9, 12, and 3 o’clock of the tricuspid valve annulus. The anterior
leaflet of the tricuspid valve is unhinged from 2 o’clock back all the way to about 7 o’clock or where the rim of the VSD meets the tricuspid
valve (whichever comes first), at which point the leaflet falls forward toward the surgeon without any traction or tension, thus avoiding leaflet
or chordal injury. The borders of the VSD become visible, as does the aortic valve in typical perimembranous defects.
A. Dodge-Khatami and J.D. Salazar392

10. Anchor stitch
Patch
BA
2
1
Figure 8 VSD patch closure is performed, starting by anchoring at the deepest point (12 o’clock), closing the inferior border first, and coming
through the lowest unhinged portion of the anterior tricuspid leaflet into the right atrium (1). Given the effect of gravity and the VSD being in
a more vertical position compared with the patient’s position when supine, this order seems crucial. Once the patch is anchored inferiorly in
this fashion, the superior border can be exposed by asking the assistant to pull gently on each stitch as the surgeon is closing cranially,
allowing progressive, but complete visualization of the superior VSD border (2). The final stages involve reanchoring the anterior leaflet,
which on the inferior border involves sandwiching the 3 layers of the tricuspid annulus, the VSD patch, and the tricuspid leaflet, and on the
superior edge, suturing the leaflet back to the annulus. Valve competency is checked with a flush of cold saline.
Right axillary thoracotomy 393

11. Interatrial crest
MV, posterior
leaflet
TV, septal
leaflet
MV, anterior
leaflet
BA
Figure 9 Repair of partial AV canal with a mitral valve cleft. A traction stitch is placed at the deepest point of the 2 half portions of the left AV
valve, passed through the rim of the primum ASD, and pulled toward the surgeon. This allows the cleft to come out of the deep, and be
appropriately aligned for a running suture of fine 6 or 7-0 prolene to close the cleft.
A. Dodge-Khatami and J.D. Salazar394

12. Proposed incision in
rt. atrial appendage
for SVC anastomosis
SA node
Figure 10 For a Warden-type repair of PAPVR, the essential points are to cannulate the SVC as high as possible, after doubly clipping and
transecting the azygous vein for maximal mobility of the SVC toward the RAA. The anticipated anastomosis site of the SVC in the RAA is
shown.
Right axillary thoracotomy 395

13. Subaortic membrane
Figure 11 During VSD closure, in the presence of a nonrestrictive VSD with a subaortic membrane, the protruding ridge on the left side of the
interventricular crest can be excised through the VSD before closing it with a patch. Unhinging of the anterior leaflet of the tricuspid valve as
described in Figure 7 has already been performed to enhance access.
A. Dodge-Khatami and J.D. Salazar396

14. Scar
A
B
Figure 12 Closed incision underneath the right arm with a combined pericardial or right pleural chest drain, and the resulting hidden scar
underneath a resting arm in a standing child.
Right axillary thoracotomy 397

15. A
Figure 13 Postoperative pictures of the healed right axillary incision in a 2-year-old patient after repair of partial AV canal with a mitral valve
cleft closure, showing a hidden scar underneath the resting right arm.
A. Dodge-Khatami and J.D. Salazar398

16. B
Figure 13 (continued)
Right axillary thoracotomy 399

17. C
Figure 13 (continued)
A. Dodge-Khatami and J.D. Salazar400

18. Results and Comments
In the era of percutaneous catheter device closure of more
straightforward CHD, increasing parent and referring
cardiology demand is encountered to treat patients with
“minimally invasive” approaches. Most often, this includes
avoiding cardiopulmonary bypass and a standard median
sternotomy. Furthermore, in the eyes of parents and peers,
the stigma of a sternotomy scar implies having a heart
condition, an ostracizing situation from which many
children never fully recover, with its inherent negative
psychological burden. Therefore, it seems legitimate for the
surgical community to rise to the challenge and respond to
the demand, provide a less “invasive” approach and a
cosmetically superior result, without compromising safety or
quality.3
Together with the combined experience of
2 surgeons in 123 patients referred to by Prêtre et al,6
the
current series since 2008 includes another 45 patients (26
ASD, 7 VSD [including 1 with double-chambered RV], 8
Warden operations for PAPVR, 3 partial AV canals with
mitral valve cleft, and 1 cor triatriatum), with no residual
defects or perioperative complications. Availability of a
perioperative epidural catheter with optimized pain control
has allowed immediate postoperative extubation in the
operating room, thereby leading to shorter intensive care
unit and hospital lengths of stays, and faster functional
recovery with arm and shoulder mobility. As no sternal or
rib healing needs to occur, patients are encouraged to
augment physical activity as tolerated, with no restrictions.
The cosmetic results have been excellent, with very high
patient and parent satisfaction (Fig. 13).
The choice to proceed with induced ventricular fibrilla-
tion at normothermia or slight hypothermia, or an aortic
cross-clamp with cardioplegia at moderate hypothermia, is at
the discretion of the surgeon. Variables influencing this
decision are the type and length of operation to be
performed, the size and constitution of the patient that
determine the depth at which the aorta lies in the chest and
the relative ease or difficulty in placing a cross-clamp, and
the speed of the surgeon. Induced fibrillation times of more
than 30 minutes are probably best avoided, in which case
planning on cardioplegia is preferred. If performed with
induced ventricular fibrillation at normothermia or only
slight (drifting to 341C) hypothermia without a cross-clamp,
spontaneous defibrillation would occur as soon as the
fibrillator is turned off, and the surgeon should have already
closed intracardiac shunts to avoid unwanted air embolism.
It is a good idea to have a pitcher of sterile ice-cold saline
available so as to drown the surgical field under water,
should unplanned defibrillation suddenly occur. As this
phenomenon was once encountered, systematic tacking of
the fibrillatory electrode to the right ventricular epicardial
surface with a single stitch has been effective in preventing
unplanned spontaneous defibrillation.
Although the approach has been used in patients as small
as 6 kg, the patient’s body configuration is an important
variable for the same weight, the surgery is easier to do in a
thin and long patient, rather than in a short and chubby one,
using standard surgical instruments. Performing all cannu-
lation that is done in a standard fashion (as per median
sternotomy) through the thoracotomy using 1 intercostal
space, including the aorta, is easier in patients from 6-30 kg,
as opposed to larger patients in whom the aorta lies far away
from the chest wall, making peripheral groin vessel
cannulation wiser. Until now, the indications for the
approach have been repair of defects accessible through
the right atrium, with 1 repair of cor triatriatum through an
additional left atriotomy, and 1 patient with double-
chambered RV needing work in the right outflow. Currently,
the approach is not offered to typical left-sided lesions of the
heart, nor those involving the right infundibulum or
pulmonary valve.
Summary
The muscle-sparing right axillary approach is a safe,
reproducible, and teachable technique to repair CHD
typically accessible through the right atrium, including
VSD’s, partial AV canal with mitral valve clefts, PAPVR, and
of course ASDs. Compared with other thoracic incisions, the
approach is far away from breast tissue, which is easily
spared and thereby avoids future asymmetrical breast
growth, no muscles are sacrificed with rapid functional
recovery of the right arm and shoulder, and the cosmetic
results highly appreciated by parents and patients alike.
With gained experience and surgeon comfort, perfect results
are achieved without compromising repair quality compared
with a median sternotomy approach.
References
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amplatzer vascular occluders. Am J Cardiol 117:127–130, 2016
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