Repair of Partial Atrioventricular Septal Defect via Vertical Right Axillary Thoracotomy (VRAT) in Eleven-Year-Old

The patient is an eleven-year-old, 38.8 kg boy who was diagnosed with partial atrioventricular septal defect and has been followed clinically with minimal symptoms. Past medical and surgical history included ADHD and need for surgery for club feet. A chest X-ray showed cardiomegaly with increased pulmonary vascularity. A preoperative ECG showed sinus bradycardia with left axis deviation and a nonspecific intraventricular conduction delay. Of note: this article will refer to the left and right atrioventricular valves as the mitral and the tricuspid valves, respectively, and will refer to the zone of apposition of the left atrioventricular valve as the cleft in the anterior mitral valve leaflet. This is for simplicity, as we know there are differences between these anatomic structures. An echocardiogram showed a large ostium primum atrial septal defect with a large left-to-right shunt. The defect measured about 2 cm in diameter. There was a cleft in the anterior leaflet of the mitral valve with a mild to moderate degree of mitral valve regurgitation. The septal leaflet of the tricuspid valve appeared to be tethered with mild tricuspid valve regurgitation. There was no ventricular level shunt and no additional atrial level shunting. There was a moderate degree of right atrial and right ventricular chambers enlargement with normal systolic function. The decision was made to proceed with surgical repair via a vertical right axillary thoracotomy. The Surgery In this case, the patient was positioned in the modified left lateral decubitus position with the right side up. In addition to routine monitoring lines, an erector spinae block catheter was placed for postoperative pain management. A 6 cm vertical skin incision was made in the right midaxillary line extending from the second to the fifth ribs. Generous skin and subcutaneous flaps were then created with electrocautery. The anterior border of the latissimus dorsi muscle was slightly mobilized, and the fibers of the serratus anterior muscle were separated to expose the underlying intercostal spaces. The right chest was entered through the right fourth intercostal space, and the right lung was retracted to expose the pericardium. Next, the pericardium was longitudinally opened 2 cm anterior to the right phrenic nerve, and stay sutures were placed. Heparin was then administered systemically. The ascending aorta was cannulated with an 18 French arterial cannula. The inferior and superior venae cavae were cannulat