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The Right Axillary Incision: a Potential New Standard of Care for Selected Congenital Heart Surgery
Timothy Lee, Aaron J Weiss, Elbert E Williams, Shinobu Itagaki, Khanh H Nguyen
Icahn School of Medicine at Mount Sinai, New York, NY

OBJECTIVES: Congenital heart surgery is traditionally performed through a median sternotomy. However, for adolescent patients and their families, the prospect of having their sternum divided is understandably a source of major apprehension. Furthermore, the large, central scar may be psychologically and emotionally detrimental to many children. At our center, the solution has been to adopt the right axillary incision as the default approach for most patients. This technique is safe, versatile and provides an unsurpassed cosmetic result. Here we provide our experience with the axillary incision for a diverse array of congenital cardiac lesions.
METHODS: Data was retrospectively collected on all patients receiving an axillary incision for congenital cardiac surgery between 2005-2016. A brief technique description - the patient is placed in left lateral decubitus with the right arm abducted. A horizontal incision is made through the fourth intercostal space between the anterior and posterior axillary lines sparing the latissmus dorsi and serratus anterior (Figure 1a). The right lung is deflated using single lung ventilation if possible, and central cannulation is performed (Figure 1b). The heart is fibrillated for simple defects or arrested for complex procedures, and repair proceeds in standard fashion. Intercostal nerve block is performed routinely prior to completion, and the patient is extubated in the operating room.
RESULTS: The right axillary incision was utilized in 358 patients (225 female, 63%) for 24 primary procedures (Table 1). The most common procedures were atrial septal defect repairs (n=244, 68%) and ventricular septal defect repairs (n=72, 20%); other surgeries included left ventricular assist device (LVAD) placement (n=3, 1%), Tetralogy of Fallot repair (n=7, 2%), mitral valve repair (n=2, 1%), and subvalvular aortic membrane resection (n=10, 3%). Median age was 5 years (range, 1 month to 60 years), and median weight was 17 kg (range, 4-124 kg). Cardiopulmonary bypass was instituted in 353 patients (98.6%) for a median time of 49 minutes (range, 5-386 minutes); bypass was not instituted for LVAD placement (n=3, 1%), pericardial window (n=1, 0.3%) or vascular ring division (n=1, 0.3%). Median surgery time was 174 minutes (range, 37-433 minutes). Extubation in the operating room occurred in 342 (96%) patients. There were no intra-operative deaths, surgical conversions to sternotomy, or takebacks to repair residual defects. Median length of post-operative hospital stay was 3 days (range, 2 to 44 days). In-hospital complications included death in a patient with acute myocarditis and pre-operative multi-organ failure requiring emergency LVAD (n=1, 0.3%), bleeding requiring surgical correction (n=3, 1%), pneumothorax or pleural effusion requiring surgical/invasive intervention (n=9, 3%) and need for permanent pacemaker (n=5, 1%).
CONCLUSIONS: The axillary incision allows safe, effective repair for a diverse array of congenital cardiac defects and is a potential new standard of care for many patients.

Operative characteristics of congenital heart repairs conducted via a right axillary incision
Primary procedureNo. patients (female)Age, yrs, median (IQR)Weight, kg, median (IQR)Surgery time, min, median (IQR)CPB time, min, median (IQR)LOS, days, median (IQR)
ASD repair244 (156)5 (3-12)18 (12-39)156 (121-195)27 (10-55)3 (2-3)
VSD repair72 (31)3 (1-6)13 (7-12)200 (176-236)89 (77-110)3 (3-4)
Subaortic membrane resection10 (8)7 (2-9)29 (14-47)175 (161-206)66 (55-78)3 (3-3)
Tetralogy of Fallot repair7 (3)0.3 (0.2-0.4)6 (5-7)292 )226-324)144 (93-163)6 (4-11)
DCRV resection, RVOT patch4 (3)9 (4-14)25 (14-52)208 (156-263)54 (48-79)3 (3-4)
LVAD implantation3 (1)2 (0.2-7)18 (9-24)162 (114-287)-15 (13-19)
Mitral valve repair2 (2)12 (1-22)29 (7-51)223 (198-248)131 (123-139)5 (4-6)
Warden procedure2 (1)24 (1-49)40 (12-67)151 (38-263)198 (136-259)5 (3-7)
Other14 (9)11 (1-21)38 (8-62)245 (185-296)122 (75-143)5 (3-7)


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