Short-term outcomes of modified right vertical infra-axillary thoracotomy for doubly committed subarterial ventricular septal defect repair_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZHANG Heqi ¹ , CAO Hua ² ,  LIANG Weijie ¹ , DONG Haoju ¹ , LIANG Dong ¹ , XUAN Maozheng ¹ , LI Menghao ¹ , FAN Taibing ¹

1. Children’s Heart Center, Fuwai Central China Cardiovascular Hospital, Zhengzhou, 451464, P. R. China;
2. Department of Cardiac Surgery, Fuwai Central China Hospital, Zhengzhou University, Zhengzhou, 451464, P. R. China;

Corresponding?author：

LIANG Weijie, Email: lwj3781@126.com

Keywords：

Congenital heart disease; minimally invasive cardiac surgery; modified right vertical infra-axillary thoracotomy; doubly committed subarterial ventricular septal defect; all age groups; cardiopulmonary bypass

DOI：

10.7507/1007-4848.202601034

Video：

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Objective To evaluate the safety, feasibility, and short-term surgical outcomes of a modified right vertical infra-axillary thoracotomy (MRVIAT, single 2-5 cm incision without peripheral cannulation) for the treatment of doubly committed subarterial ventricular septal defect in patients of all ages, and to summarize relevant surgical techniques. Methods This study retrospectively included patients of all ages with doubly committed subarterial ventricular septal defect who underwent surgical repair via MRVIAT from January 2022 to June 2025, all receiving a single 2-5 cm incision without peripheral cardiopulmonary bypass. The perioperative and follow-up data were analyzed. Results A total of 241 patients were enrolled, comprising 92 males and 149 females with a median age of 1.2 (0.5, 3.5) years [including 11 (4.6%) patients aged ≥18 years] and a median weight of 10.5 (7.0, 16.4) kg. Preoperative left ventricular ejection fraction was 66.9%±4.2%, and the mean defect size was (7.6±2.8) mm. All surgeries were successfully completed without conversion to median sternotomy or in-hospital mortality. Cardiopulmonary bypass time was (55.4±13.3) min, aortic cross-clamping time was (34.8±10.1) min, postoperative hospital stay was (6.5±1.9) d, ventilation time was (6.5±6.1) h, intensive care unit stay was (39.7±24.1) h, and postoperative left ventricular ejection fraction was 67.8%±7.6%. Postoperative complications included mild residual shunt in 3 (1.2%) patients, incision infection in 2 (0.8%) patients, and pulmonary infection in 1 (0.4%) patient. The median follow-up time was 1.7 years (range, 0.3-3.5 years), during which no surgery-related chest deformities or moderate-to-severe valvular regurgitation were observed. Conclusion The MRVIAT is safe and feasible for treating doubly committed subarterial ventricular septal defect in patients of all ages, offering a smaller and more concealed incision without the need for peripheral cardiopulmonary cannulation, and may be considered an alternative to median sternotomy.

1.	Rao PS. Diagnosis and management of ventricular septal defects. Rev Cardiovasc Med, 2024, 25(11): 411.
2.	Fan C, Pan Z, Wu C, et al. Progress in the treatment of subarterial ventricular septal defect. Pediatr Discov, 2025, 3(1): e2519.
3.	Zhang H, Cao H, Liang W, et al. Modified right vertical infra-axillary thoracotomy: 2-5 cm incision approach for repair of doubly committed subarterial ventricular septal defect in all age groups. Heart Lung Circ, 2026, 35(3): 392-399.
4.	Grant VR, Crerand CE, Jackson JL. Implications of cardiac scarring on body image disturbance among young adults with congenital heart defects. J Cardiovasc Nurs, 2024, 39(6): E212-E217.
5.	Konstantinov IE, Kotani Y, Buratto E, et al. Minimally invasive approaches to atrial septal defect closure. JTCVS Tech, 2022, 14: 184-190.
6.	Dodge-Khatami A, Dodge-Khatami J, Nguyen TD, et al. Minimal invasive approaches for pediatric and congenital heart surgery: safe, reproducible, more cosmetic than through sternotomy, and here to stay. Transl Pediatr, 2023, 12(9): 1744-1752.
7.	Gupta S, McEwen C, Eqbal A, et al. Minimally invasive surgery for congenital heart disease. Ann Thorac Surg, 2024, 118(4): 953-962.
8.	Lo Rito M, Brindicci YCM, Moscatiello M, et al. Minimally invasive surgery for simple congenital heart defects: preserving aesthetics without jeopardizing patient safety. J Cardiovasc Dev Dis, 2023, 10(11): 452.
9.	Dodge-Khatami A, Gil-Jaure?a JM, H?rer J, et al. Over 3, 000 minimally invasive thoracotomies from the European Congenital Heart Surgeons Association for quality repairs of the most common congenital heart defects: safe and routine for selected repairs. World J Pediatr Congenit Heart Surg, 2025, 16(5): 578-584.
10.	Ullah A, Khan A, Iqbal M, et al. Comparison of short-term outcomes: minimally invasive thoracotomy versus median sternotomy for atrial septal defect closure. Cureus, 2025, 17(2): e78972.
11.	Rodriguez E, Velez DA. Time to rethink congenital heart surgery: minimally invasive surgery or better yet minimal impact surgery. Ann Thorac Surg, 2024, 118(4): 962-963.
12.	An K, Li S, Yan J, et al. Minimal right vertical infra-axillary incision for repair of congenital heart defects. Ann Thorac Surg, 2022, 113(3): 896-902.
13.	Zhu J, Zhang Y, Bao C, et al. Individualized strategy of minimally invasive cardiac surgery in congenital cardiac septal defects. J Cardiothorac Surg, 2022, 17(1): 5.
14.	Atalay A, ?etin ??, Demir ?H, et al. Can right infra-axillary vertical thoracotomy make a big difference in congenital heart surgery? Heart Lung Circ, 2022, 31(12): 1704-1711.
15.	Liu L, Wang J, Dong J, et al. Right vertical axillary incision vs. median sternotomy for congenital ventricular septal defect repair in children: a propensity score-matched study. Front Cardiovasc Med, 2025, 11: 1527042.
16.	Luo H, Zhou Q, Wu H, et al. Right vertical infra-axillary thoracotomy for surgical repair of paediatric ventricular septal defect: a propensity score matched cohort study. Interdiscip Cardiovasc Thorac Surg, 2025, 40(8): ivaf153.
17.	Li C, Gong X, Huang J, et al. Effects of repairing ventricular septal defects with right vertical infra-axillary mini-incision on lung function and postoperative analgosedation. Exp Ther Med, 2021, 21(4): 302.
18.	Bayya PR, Naik GD, Murthy KS, et al. Transaxillary approach for surgical repair of simple congenital cardiac lesions: pitfalls and complications. World J Pediatr Congenit Heart Surg, 2021, 12(3): 337-343.
19.	Heinisch PP, Bartkevics M, Beck MJ, et al. Right axillary thoracotomy in congenital cardiac surgery. Ann Thorac Surg, 2021, 112(6): 2047-2053.
20.	Tang C, Zhou K, Shao S, et al. Transfemoral occlusion of doubly committed subarterial ventricular septal defect using the Amplatzer duct occluder-Ⅱ in children. Front Cardiovasc Med, 2022, 9: 837847.
21.	Lin HC, Lin MT, Chen CA, et al. Safety and efficacy of transcatheter closure of outlet-type ventricular septal defects in children and adults with Amplatzer duct occluderⅡ. J Formos Med Assoc, 2021, 120(1 Pt 1): 180-188.
22.	Tan B, Li M, Zhang K, et al. Comparison of ADO-Ⅱ percutaneous occlusion and traditional surgery in the treatment of doubly committed subarterial ventricular septal defects in children. Front Cardiovasc Med, 2025, 12: 1541796.
23.	Wu Z, Zhang S, Xie L, et al. Device closure versus surgical repair for doubly committed subarterial ventricular septal defect. J Thorac Cardiovasc Surg, 2025, 170(3): 815-826. e10.
24.	Pan S, Zhang H, Wang C. Left anterior mini-thoracotomy for adult complicated subarterial ventricular septal defect. Ann Thorac Surg Short Rep, 2024, 3(1): 102-105.
25.	梁維杰, 張合琪, 曹華, 等. 改良右腋下直小切口治療全年齡段多種先天性心臟病的單中心近期臨床效果分析. 中華胸心血管外科雜志, 2025, 41(10): 610-615.Liang WJ, Zhang HQ, Cao H, et al. Single-center analysis of the early clinical outcomes of modified right vertical infra-axillary thoracotomy for various congenital heart diseases across all age groups. Chin J Thorac Cardiovasc Surg, 2025, 41(10): 610-615.
26.	Werner P, Winter M, Coti I, et al. State-of-the-art review: advantages and disadvantages of femoral versus central cannulation. Innovations (Phila), 2025, 20(2): 148-157.
27.	Nishijima T, Ushijima T, Fuke Y, et al. Cannula to femoral artery diameter ratio predicts potential lower-limb ischemia in minimally invasive cardiac surgery with femoral cannulation. Innovations (Phila), 2024, 19(2): 161-168.
28.	Ismail M, Aydin DMB, Lee JS, et al. Femoral vessel cannulation strategies in minimally invasive cardiac surgery: single Perclose ProGlide versus open cut-down. Eur J Cardiothorac Surg, 2025, 67(4): ezaf118.
29.	Moisa SM, Popa E, Gheorghe L, et al. An up-to-date narrative review on congenital heart interventions and imaging modalities in children. Medicina (Kaunas), 2022, 58(6): 742.
30.	El-Andari R, Watkins AR, Fialka NM, et al. A systematic review of minimally invasive approaches to atrial septal defect repair. Heart Lung Cir, 2025, 34(8): 764-776.
31.	Zhang H, Cao H, Liang W, et al. Recent efficacy of modified right vertical infra-axillary thoracotomy for ventricular septal defects in pediatric patients with younger age and low body weight. Front Pediatr, 2026, 13: 1683641.

1. Rao PS. Diagnosis and management of ventricular septal defects. Rev Cardiovasc Med, 2024, 25(11): 411.
2. Fan C, Pan Z, Wu C, et al. Progress in the treatment of subarterial ventricular septal defect. Pediatr Discov, 2025, 3(1): e2519.
3. Zhang H, Cao H, Liang W, et al. Modified right vertical infra-axillary thoracotomy: 2-5 cm incision approach for repair of doubly committed subarterial ventricular septal defect in all age groups. Heart Lung Circ, 2026, 35(3): 392-399.
4. Grant VR, Crerand CE, Jackson JL. Implications of cardiac scarring on body image disturbance among young adults with congenital heart defects. J Cardiovasc Nurs, 2024, 39(6): E212-E217.
5. Konstantinov IE, Kotani Y, Buratto E, et al. Minimally invasive approaches to atrial septal defect closure. JTCVS Tech, 2022, 14: 184-190.
6. Dodge-Khatami A, Dodge-Khatami J, Nguyen TD, et al. Minimal invasive approaches for pediatric and congenital heart surgery: safe, reproducible, more cosmetic than through sternotomy, and here to stay. Transl Pediatr, 2023, 12(9): 1744-1752.
7. Gupta S, McEwen C, Eqbal A, et al. Minimally invasive surgery for congenital heart disease. Ann Thorac Surg, 2024, 118(4): 953-962.
8. Lo Rito M, Brindicci YCM, Moscatiello M, et al. Minimally invasive surgery for simple congenital heart defects: preserving aesthetics without jeopardizing patient safety. J Cardiovasc Dev Dis, 2023, 10(11): 452.
9. Dodge-Khatami A, Gil-Jaure?a JM, H?rer J, et al. Over 3, 000 minimally invasive thoracotomies from the European Congenital Heart Surgeons Association for quality repairs of the most common congenital heart defects: safe and routine for selected repairs. World J Pediatr Congenit Heart Surg, 2025, 16(5): 578-584.
10. Ullah A, Khan A, Iqbal M, et al. Comparison of short-term outcomes: minimally invasive thoracotomy versus median sternotomy for atrial septal defect closure. Cureus, 2025, 17(2): e78972.
11. Rodriguez E, Velez DA. Time to rethink congenital heart surgery: minimally invasive surgery or better yet minimal impact surgery. Ann Thorac Surg, 2024, 118(4): 962-963.
12. An K, Li S, Yan J, et al. Minimal right vertical infra-axillary incision for repair of congenital heart defects. Ann Thorac Surg, 2022, 113(3): 896-902.
13. Zhu J, Zhang Y, Bao C, et al. Individualized strategy of minimally invasive cardiac surgery in congenital cardiac septal defects. J Cardiothorac Surg, 2022, 17(1): 5.
14. Atalay A, ?etin ??, Demir ?H, et al. Can right infra-axillary vertical thoracotomy make a big difference in congenital heart surgery? Heart Lung Circ, 2022, 31(12): 1704-1711.
15. Liu L, Wang J, Dong J, et al. Right vertical axillary incision vs. median sternotomy for congenital ventricular septal defect repair in children: a propensity score-matched study. Front Cardiovasc Med, 2025, 11: 1527042.
16. Luo H, Zhou Q, Wu H, et al. Right vertical infra-axillary thoracotomy for surgical repair of paediatric ventricular septal defect: a propensity score matched cohort study. Interdiscip Cardiovasc Thorac Surg, 2025, 40(8): ivaf153.
17. Li C, Gong X, Huang J, et al. Effects of repairing ventricular septal defects with right vertical infra-axillary mini-incision on lung function and postoperative analgosedation. Exp Ther Med, 2021, 21(4): 302.
18. Bayya PR, Naik GD, Murthy KS, et al. Transaxillary approach for surgical repair of simple congenital cardiac lesions: pitfalls and complications. World J Pediatr Congenit Heart Surg, 2021, 12(3): 337-343.
19. Heinisch PP, Bartkevics M, Beck MJ, et al. Right axillary thoracotomy in congenital cardiac surgery. Ann Thorac Surg, 2021, 112(6): 2047-2053.
20. Tang C, Zhou K, Shao S, et al. Transfemoral occlusion of doubly committed subarterial ventricular septal defect using the Amplatzer duct occluder-Ⅱ in children. Front Cardiovasc Med, 2022, 9: 837847.
21. Lin HC, Lin MT, Chen CA, et al. Safety and efficacy of transcatheter closure of outlet-type ventricular septal defects in children and adults with Amplatzer duct occluderⅡ. J Formos Med Assoc, 2021, 120(1 Pt 1): 180-188.
22. Tan B, Li M, Zhang K, et al. Comparison of ADO-Ⅱ percutaneous occlusion and traditional surgery in the treatment of doubly committed subarterial ventricular septal defects in children. Front Cardiovasc Med, 2025, 12: 1541796.
23. Wu Z, Zhang S, Xie L, et al. Device closure versus surgical repair for doubly committed subarterial ventricular septal defect. J Thorac Cardiovasc Surg, 2025, 170(3): 815-826. e10.
24. Pan S, Zhang H, Wang C. Left anterior mini-thoracotomy for adult complicated subarterial ventricular septal defect. Ann Thorac Surg Short Rep, 2024, 3(1): 102-105.
25. 梁維杰, 張合琪, 曹華, 等. 改良右腋下直小切口治療全年齡段多種先天性心臟病的單中心近期臨床效果分析. 中華胸心血管外科雜志, 2025, 41(10): 610-615.Liang WJ, Zhang HQ, Cao H, et al. Single-center analysis of the early clinical outcomes of modified right vertical infra-axillary thoracotomy for various congenital heart diseases across all age groups. Chin J Thorac Cardiovasc Surg, 2025, 41(10): 610-615.
26. Werner P, Winter M, Coti I, et al. State-of-the-art review: advantages and disadvantages of femoral versus central cannulation. Innovations (Phila), 2025, 20(2): 148-157.
27. Nishijima T, Ushijima T, Fuke Y, et al. Cannula to femoral artery diameter ratio predicts potential lower-limb ischemia in minimally invasive cardiac surgery with femoral cannulation. Innovations (Phila), 2024, 19(2): 161-168.
28. Ismail M, Aydin DMB, Lee JS, et al. Femoral vessel cannulation strategies in minimally invasive cardiac surgery: single Perclose ProGlide versus open cut-down. Eur J Cardiothorac Surg, 2025, 67(4): ezaf118.
29. Moisa SM, Popa E, Gheorghe L, et al. An up-to-date narrative review on congenital heart interventions and imaging modalities in children. Medicina (Kaunas), 2022, 58(6): 742.
30. El-Andari R, Watkins AR, Fialka NM, et al. A systematic review of minimally invasive approaches to atrial septal defect repair. Heart Lung Cir, 2025, 34(8): 764-776.
31. Zhang H, Cao H, Liang W, et al. Recent efficacy of modified right vertical infra-axillary thoracotomy for ventricular septal defects in pediatric patients with younger age and low body weight. Front Pediatr, 2026, 13: 1683641.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Latest ArticlesShort-term outcomes of modified right vertical infra-axillary thoracotomy for doubly committed subarterial ventricular septal defect repair

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