Right Vertical Infra-Axillary Minithoracotomy Versus Median Sternotomy for Doubly Committed Subarterial Ventricular Septal Defect: A Retrospective Cohort Study of 689 Patients
This retrospective cohort study of 689 patients demonstrates that right vertical infra-axillary minithoracotomy is a safe and feasible alternative to median sternotomy for repairing doubly committed subarterial ventricular septal defects, offering comparable perioperative safety and clinical outcomes while significantly reducing hospital stay, mechanical ventilation duration, and improving incision-related satisfaction.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
Heart surgery has long been defined by a single, unavoidable truth: to fix a broken heart, surgeons must open the chest. For decades, the standard way to reach the heart has been to cut straight down the middle of the breastbone, a method that offers a clear view but leaves a permanent, vertical scar. This approach is reliable, but for children and teenagers, the physical and emotional cost of such a large wound is significant. It can lead to longer recovery times and a visible mark that follows a person for life. In recent years, surgeons have sought a gentler path, one that avoids the breastbone entirely. They have turned to a technique that enters the chest through a small opening on the side, tucked away under the arm. This approach promises the same life-saving repair with less trauma and a much better cosmetic result, but for a specific, complex type of heart defect, the evidence needed to prove it was safe and effective on a large scale was missing.
The defect in question is known as a doubly committed subarterial ventricular septal defect. In plain terms, this is a hole in the wall that separates the two lower pumping chambers of the heart. What makes this particular hole tricky is its location: it sits right beneath the valves that control blood flow to the lungs and the rest of the body. Because the hole is so close to these delicate valves, fixing it requires extreme precision; a surgeon must close the gap without damaging the valves or leaving a leak. For years, the standard solution was the traditional midline incision, which gives the surgeon the widest possible view of the heart. However, a team of surgeons at the Shanghai Children's Medical Center wanted to know if the newer, side-approach method could achieve the same perfect results without the heavy toll of the traditional cut.
To find the answer, the researchers looked back at the records of 689 children and young adults who had undergone surgery for this specific heart defect between January 2021 and October 2025. They divided these patients into two groups based on the surgery they received. One group, consisting of 222 patients, had the traditional surgery where the breastbone was split down the middle. The other, larger group of 467 patients, had the minimally invasive procedure. In this second approach, the patient is turned onto their side, and the surgeon makes a small vertical cut in the right armpit area, entering the chest between the ribs rather than through the bone. The heart is then stopped temporarily, and the hole is patched closed using a piece of tissue or synthetic material, all while the surgeon works through that small side opening.
The study found that the side-approach method was not only safe but offered clear advantages in how quickly patients recovered. Children who had the side surgery left the hospital sooner and spent less time on a breathing machine compared to those who had the traditional breastbone surgery. The time it took to run the heart-lung machine and the time spent in the intensive care unit were roughly the same for both groups, suggesting that the side approach did not make the surgery itself more difficult or dangerous. Crucially, the quality of the repair was identical. When the doctors checked the hearts after surgery and again six months later, the rate of leaks or remaining holes was extremely low and equal in both groups. The function of the heart valves remained just as good, and no one needed a second surgery to fix a problem caused by the first operation. There were no deaths in either group during the hospital stay.
Perhaps the most striking difference was not in the medical numbers, but in how the patients felt about their scars. Six months after the operation, the researchers asked the families to rate their satisfaction with the appearance of the surgical mark. In the group that had the traditional breastbone surgery, only about 36 percent of families rated the scar as very good or excellent. In contrast, 84 percent of families in the side-approach group gave the same high ratings. The scar from the side approach is hidden in the natural folds of the armpit and is barely visible when a person is wearing normal clothes, whereas the traditional scar runs straight down the center of the chest. The researchers noted that this difference in satisfaction was significant, offering a major psychological benefit for children who will live with the scar for the rest of their lives.
The study confirms that for this specific, complex heart defect, the side-approach surgery is a viable and effective alternative to the traditional method. It suggests that surgeons can achieve the same life-saving repair with a smaller incision, a faster recovery, and a much more favorable cosmetic outcome. While the researchers acknowledged that their study was a look back at past cases rather than a new experiment, the large number of patients and the careful comparison of results provide strong evidence that this technique is ready for wider use. It offers a path forward where the cure for a serious heart condition does not require a child to carry a heavy, visible reminder of the trauma they endured.
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