Results
During the study period, 67 patients underwent minimally invasive VSD repair at our institution, of whom 36 (females 27, males 9; mean age, 29.08 ± 9.52 years) underwent total thoracoscopic VSD repair and 31 (females 12, males 19; mean age, 28.39 ± 8.67 years) underwent mini-sternotomy VSD repair. There was no significant difference in basic preoperative data between the groups, except for the higher proportion of women in the total thoracoscope group (75% vs 38.7%;p =0.003). Preoperative echocardiography showed 33 perimembranous VSDs and three inlet VSDs in total thoracoscopic group, while four perimembranous VSDs and 27 doubly committed and juxta-arterial VSD. See Table 1 for details.
All patients underwent surgery on an elective basis. The mean CPB and ACC time in the total thoracoscopy group was significantly longer than that of the mini-sternotomy group (CPB time: 111.78 ± 23.16 min vs 77.58 ± 37.90 min, respectively, p < 0.001; ACC time: 111.78 ± 23.16 min vs 77.58 ± 37.90 min, respectively, p < 0.001). Five patients in the total thoracoscopy group underwent tricuspid valvuloplasty with Edward ring followed by VSD repair. They suffered from tricuspid regurgitation due to annular or right ventricular dilatation as a result of left-to-right shunt. In 24 patients, for whom exposure of VSD was difficult due to septal leaflets attached to the rim of the VSD to form an aneurysm or abnormal chordal attached to the septum, underwent tricuspid valve detachment in the total thoracoscopy group. They were all free from atrioventricular conduction block and tricuspid regurgitation during the follow-up period. See Table 2 for the relevant data.
There were no inpatient deaths in either group (Table 3); however, one patient in the mini-sternotomy group underwent tracheotomy due to pulmonary infection and could not be taken off the ventilator. Finally, the patient was discharged from the hospital and transferred to a local hospital for further treatment. The patient did not die during follow-up. Only one patient in the TT group was found to have residual shunt immediately after coming off bypass, measured at 1.5 mm using transesophageal echocardiography. It disappeared spontaneously by the time of discharge. No patients underwent reoperation for bleeding in the TT group; however, one patient did so in the mini-sternotomy group. This patient had bleeding because of the sternotomy. Tracheal intubation time (6.42 ± 3.85 hours vs 28.55 ± 123.18 hours, p = 0.325), ICU time (20.47 ± 9.52 hours vs 49.65 ± 163.72 hours, p = 0.330) and postoperative hospital stay time (5.11 ± 2.48 days vs 5.90 ± 6.27 days, p = 0.488) tended to be shorter in the thoracoscopy group than in the mini-sternotomy group, suggesting faster recovery in the thoracoscopy group. In addition, the chest drainage was less in the thoracoscopy group than in the mini-sternotomy group (139.86 ± 111.71 ml vs 196.13 ± 147.34 ml, p = 0.081). One patient in the mini-sternotomy group had wound infection, which recovered after wound debridement and vacuum sealing drainage. There were no low cardiac output syndromes, strokes, complete atrioventricular conduction blocks, myocardial infarction, or tricuspid regurgitation in either group. Follow-up duration ranged from 12 months to 96 months. No patient died, and echocardiography showed no residual shunts or tricuspid regurgitation at follow-up.