Comparison Of Perioperative Results Between Right Vertical Infra-axillary Thoracotomy And Conventional Standard Sternotomy For Repair Of Ventricular Septal Defect In Adults

Objective:The purpose of this study was to compare the perioperative effects of right vertical infra-axillary thoracotomy(RVIAT)and conventional standard sternotomy(CSS)in adult patients with congenital ventricular septal defect(VSD).Methods:Retrospective analysis was performed on 768 patients with ventricular septal defect repair of congenital heart disease in the Department of Cardiothoracic Surgery of Nanjing Drum Tower Hospital from December 2002 to December 2019.The clinical data was collected,and 268 adult patients with congenital VSD were screened.Between the two groups(RVIAT 152 vs CSS 116),we performed comparison of perioperative outcomes of them and propensity score matching to get 97 pairs of patients for comparison.Furthermore,Eighty-nine adult patients with simple VSD from 268 patients were screened by inclusion and exclusion criteria,and the perioperative effect of the two groups of patients was compared(RVIAT 56 vs CSS 33)so as the two groups after propensity score matching(RVIAT 24 vs CSS 24).Results:It was shown that compared with CSS(n=116).adult patients with RVIAT(n=152)had less time of aortic occlusion time(min)[(52.44.39)vs(60,55,35)](P=0.021),less time of ventilator use(h)[(6.5,5.8,4.0)vs(9.0.6.5.7.0)](P<0.01),less ICU stay(d)[(2.9,2.0,2.0)vs(3.1,2.0,1.0)](P=0.029),less blood transfusion volume(ml)[(531.4.450.0,350.0)vs(671.4,600.0.500.0)](P=0.089),less postoperative 24h drainage volume(ml)[(805,355,1365)vs(832,445,1193)](P=0.044);less hospital stays(d)[(13,13,4)vs(16,13,6)](P=0.03)and inpatient deaths were not statistically significant[0(0%)vs 1(0.9%)](P=0.434).The results showed that RVIAT had the same safety and better.minimally invasive performance as CSS for adult simple ventricular defect repair.However,between two groups,the ages[(28.8,26.0,11.0)vs(35.8,32.5,21.0)],the heights[(163.8,162.0,12.0)vs(166.1,167.0,1 1.0)],the weights[(57.2,55.0,14.0)vs(62.8,63.0,17.0)],EF[(62.6±4.8)vs(60.5±5.3)],the gender composition(male)[40(26.3%)vs 63(54.3%)]had significant differences(P<0.01).On the one hand,the 268 adult VSD patients were matched with age and weight to obtain 97 pairs of patients with both incisions.The preoperative basic condition of RVIAT in the groups had more female patients and more membranous ventricular deficiency patients(P<0.01).There was not shown statistically significant difference in the primary postoperative end point.In terms of secondary endpoints,the RVIAT group had shorter mechanical ventilation time(h)[RVIAT(6.4,5.5,4.0)vs CSS(9.5,7.0,7.0)]with statistically significant differences(P<0.01).The RVIAT group had shorter ICU stay(d)[RVIAT(2.6,2.0,2.0)vs CSS(3.2,2.0,1.0)]and the difference was statistically significant(P=0.003).The RVIAT group had less postoperative one-day drainage volume(ml)[RVIAT(810,370,1350)vs CSS(930,550,1353)]and the difference was statistically significant(P=0.03).The Cardiopulmonary bypass time(min)[RVIAT(83,76,48)vs CSS(89,85,48)]was not significantly different between the two groups(P=0.370).The Aorta occlusion time(min)[RVIAT(52.43,39)vs CSS(57,53,36)]was not statistically significant(P=0.150).There was no significant difference in blood transfusion volume(ml)[RVIAT(612.2±473.4)vs CSS(683.3±333.0)](P=0.694)nor hospital stays(d)[RVIAT(13,13,4)vs CSS(15,13,5)].On the other hand,a total of 48 patients from 89 patients with both types of incisions matched by the propensity scores of more matching variables after the inclusion and exclusion criteria were further compared.There was no statistical difference in preoperative conditions between the 24 pairs of patients(P>0.05).Postoperative primary end points were not statistically significant(P>0.05).As for the secondary end point,RVIAT group had a shorter mechanical ventilation time(h)than CSS group[(5.7,5.6,3.0)vs(8.8,6.0,6.8)]and the difference was statistically significant(P=0.019).Cardiopulmonary bypass time(min)[RVIAT(79,73,50)vs CSS(82,76.42)]had no statistically significant difference(P=0.837).Aorta occlusion time(min)[RVIAT(48,39,38)vs CSS(51,47,36)]had no statistically significant difference(P=0.606).ICU stay time(d)[RVIAT(2.0,2.0,2.0)vs CSS(2.3,2.0,1.0)]had no statistically significant difference(P=0.228).The postoperative drainage volume(ml)during 24 hours after surgery[RVIAT(1023,1033,1766)vs CSS(948,665,1286)]had no statistically significant difference(P=0.902).Neither RBC transfusion volume(ml)[RVIAT(65.0,0.0,0.0)vs CSS(116.7,0.0,150.0)](P=0.256)nor hospital stays(d)[RVIAT(14,14,5)vs CSS(15,13,6)](P=0.780)had statistically significant.Conclusion:For adult patients with congenital ventricular septal defect repair,RVIAT,without increasing the operation time and extracorporeal circulation time,did not increase the adverse prognostic events.RVIAT had a shorter time of mechanical ventilation,being a safe and economic effective minimally invasive alternative to CSS.