Subaxillary thoracotomy pulmonary valve-sparing repair of tetralogy of Fallot using the transatrial approach: a retrospective cohort study.

Abstract

Background: Preserving the pulmonary valve during tetralogy of Fallot (TOF) repair via a right subaxillary approach is important as it reduces pulmonary regurgitation, maintains right ventricular function, and minimizes long-term complications, thereby improving patient outcomes. It is also innovative as it combines minimally invasive techniques with advanced surgical precision, offering better cosmetic results and expanding surgical options for complex congenital heart defects. This study aimed to evaluate the clinical outcomes of right subaxillary mini-incision procedures for TOF transatrial repair with pulmonary valve preservation.

Methods: The cases of 20 pediatric patients diagnosed with TOF who underwent right subaxillary mini-incision transatrial repair with pulmonary valve preservation at the Sixth Medical Center of the Chinese People's Liberation Army General Hospital from August 2020 to February 2022 were reviewed. The patients included 14 males and six females, with a mean age of 41.8±34.9 months, body weight of 14.6±6.2 kg, body surface area of 0.67±0.24 m², McGoon ratio (echocardiography) of 1.9±0.4, and McGoon ratio [cardiac computerized tomography (CT)] of 1.9±0.3. T-tests were used, with a one-tailed P value of <0.05 considered statistically significant. The primary outcome measures included pressure gradients across the pulmonary valve and right ventricular outflow tract (RVOT), assessed immediately postoperatively and at 1 week, 3, 6, and 12 months. The secondary outcome measures included mortality rate and the degree of pulmonary valve regurgitation. Postoperative follow-up includes regular telephone calls and outpatient visits at 3, 6, and 12 months thereafter to monitor cardiac function, pulmonary valve performance, and overall recovery.

Results: All 20 patients survived the procedure and were discharged uneventfully, with no severe complications during hospitalization. Median cardiopulmonary bypass (CPB) time is 139 minutes (range, 77-334 minutes), and median aortic clamp time is 105 minutes (range, 44-242 minutes). The significant decreases were observed postoperatively in mean pressure gradients across the RVOT (6.1±3.2 vs. 45.6±33.4 mmHg, P<0.05) and the pulmonary valve (19.0±12.3 vs. 59.4±27.7 mmHg, P<0.05). The mean pulmonary subvalvular diameter was significantly wider (13.0±2.7 vs. 5.5±3.6 mm, P<0.05), and all the pulmonary and tricuspid valves demonstrated mild insufficiency. The median follow-up was 11.6 months (range, 3.1-20.8 months), and the follow-up rate was 100% (20/20). No major complications occurred during this period, and all patients recovered well.

Conclusions: The right subaxillary mini-incision procedure is technically feasible for TOF transatrial repair with pulmonary valve preservation. This technique may offer advantages including reduced trauma, faster recovery, shorter hospitalization, lower costs, and improved cosmetic outcomes, potentially lessening the psychological impact compared to traditional approaches.