Introduction
Ventricular septal defect (VSD) is a common congenital heart disease in children, and most VSDs are perimembranous ventricular septal defects (PmVSDs).
Traditionally, PmVSDs are surgically repaired under direct visualization with cardiopulmonary bypass. Although this surgery is effective, it is associated with significant trauma and slow postoperative recovery.Blood transfusion is necessary in the cardiopulmonary bypass approach.
Alternatively, the percutaneous closure of a PmVSD has the advantages of no blood transfusion, minimal trauma and rapid recovery[1,2] . But it is associated with exposure of radiation and allergy to contrast agent[3,4]. Another disadvantage of the percutaneous closure technique is that it is a complicated approach requiring an arteriovenous guidewire loop; this procedure cannot be performed in patients with vascular access problems.
In recent years, PmVSDs closure via transthoracic minimally invasive incision under transesophageal echocardiography(TEE) guidance has attracted the attention of many scholars[5-10].This approach does not require cardiopulmonary bypass and radiation; it has the advantages of a short delivery path and no restriction on weight or vascular access. It is particularly advantageous for children patients who cannot be treated with percutaneous catheter closure or patients who cannot tolerate surgery and cardiopulmonary bypass. However, this surgical method requires the sternum to be transected, which easily causes postoperative bleeding, pain, and pectus excavatum[11]. Moreover, the incision length can reach approximately 2-3 cm, which affects appearance. Therefore, the procedure cannot be considered as ideal in terms of minimally invasive surgery.
Based on the minimally invasive transthoracic closures of nearly 1000 patients, our team modified this surgical incision as follows: a less than 1cm trans intercostal incision in the left sternal margin. Via an ultra-minimal trans intercostal incision and a pericardium hanging technique, PmVSDs had been successfully occluded using the concentric occluder devices under TEE guidance. In this study, we aimed to investigate the safety, feasibility and availability of this new surgical approach in children.