Right vertical infra-axillary thoracotomy for surgical repair of paediatric ventricular septal defect: a propensity score matched cohort study.

Objectives: The goal of this study was to evaluate the feasibility and learning curve of a right vertical infra-axillary thoracotomy (RVIAT) in the surgical closure of a ventricular septal defect (VSD).

Methods: Clinical outcomes in paediatric patients (<18 years) undergoing VSD operations between 2018 and 2021 in 2 tertiary hospitals were reviewed retrospectively. After 1:1 propensity score matching, patients undergoing an RVIAT were compared with those undergoing a median sternotomy (MS). The learning curve that reflected the number of cases needed to achieve technical proficiency was measured using total operating time as a metric and was evaluated using a risk-adjusted cumulative sum analysis.

Results: Of the 3515 eligible patients, 2183 (62%) underwent an MS and 1332 (38%) underwent an RVIAT. After matching, 797 cases in the RVIAT and MS groups were recorded, respectively. Propensity weighting produced an excellent balance in patient baseline characteristics including age, weight, and VSD subtypes. There was no between-group difference in postoperative rhythm disturbances (0.6% vs 1.1%; P = 0.83), significant residual VSD (0.1% vs 0.4%, P = 0.62), and reoperation within 60 days postoperatively (0.1% vs 0.9%, P = 0.07). The RVIAT provided better cosmesis (satisfactory score: 9.21 ± 0.06 points vs 6.98 ± 1.17 points; P < 0.001), shorter median length of hospital stay (5.5 days vs 8.0 days, P < 0.001), and lower cost (8513.3 ± 3193.2 USD vs 9222.3 ± 2504.9 USD; P < 0.001). The surgeons could conquer the early learning phase of the RVIAT after performing a mean of 41 operations.

Conclusions: A RVIAT can combine good outcomes with favourable cosmesis in VSD repair, and sufficient exposure to RVIAT procedures is crucial for proficiency.