BACKGROUND: Type 1 ventricular septal defects (VSD) are difficult to visualize with a traditional minimally invasive approach from the right side. Therefore, many centers still use median sternotomy for type 1 VSD repair. We present a minimally invasive method combining a peri-areolar incision and left anterior thoracotomy to repair type 1 VSD in adult patients.
METHODS: The patient is prepared in a supine position, with the left axillary area exposed. A 3cm incision is made along the cranial-medial border of the left areolar. The subcutaneous fat layer is dissected from the underlying tissue to create a tunnel between the peri-areolar incision and the second sternocostal joint. In a female patient, extra caution has to be taken not to damage the mammary gland. Once the second rib is reached, a small thoracotomy is created through the second intercostal space. Cardiopulmonary bypass is initiated via peripheral cannulation, and the left-side venting catheter is introduced through the left atrial auricle. Introducing the aorta cross-clamp through a separate incision at the axillary area can significantly reduce the congestion around the small peri-areolar incision. After the heart is stopped, a transverse incision at the main pulmonary artery provides a clear view of the pulmonary valve and right ventricle outflow tract (RVOT). Patch closure of the defect can be performed without difficulty.
RESULTS: Our first case was a 24-year-old female. The original VSD was quite large and extended towards the tricuspid valve. It took several attempts to properly expose and suture the precise margin, resulting in a longer cross-clamp time than anticipated. The second case was an 18-year-old male, and with the experience of the first case, we could significantly reduce the operation time. Both patients were discharged without complications.
CONCLUSIONS: A minimally invasive approach combining a peri-areolar incision and left anterior thoracotomy can provide easy access to the RVOT area while achieving fast recovery and superior cosmetic results. This approach can be useful for managing type 1 VSDs or simple RVOT procedures in adult patients.
