Is the right vertical axillary incision an alternative technique to the submammarian incision for the repair of simple congenital heart defects in female patients

We read with interest the surgical approach of Yan et al. [1] to simple congenital heart defects. The right vertical axillary incision (RVAI) procedure decreased neither cardiopulmonary bypass time nor aortic cross-clamp and hospital stay. The authors claim that they had excellent results, achieving cosmetically satisfactory outcomes in young female patients. Although an objective multiple-choice questionnaire that focused attention on the autoevaluation of the aesthetic result and its psychological influences has been reported previously [2], we could not understand how Yan et al. evaluated patient satisfaction. Meanwhile, it is not stated whether the subgroup analysis was made in terms of age and gender. This approach is recommended for its cosmetic advantages in young female patients, but adult patients in particular, might be dissatisfied regarding the incision of lateral breast tissue. Minithoracotomy with a submammarian incision can be specifically considered a more favourable approach. Contrary to the authors’ comment, breast deformity or asymmetry or any cage deformity will not develop when a careful tissue approximation is performed by the elevation of the breast tissue in young or adult female patients [3, 4]. As stated by the authors, due to poor exposure of the operating field with the RVAI approach, the learning period of this technique will take longer than the other minimally invasive techniques. The conversion of the process into another approach such as an additional surgical incision, can be very difficult, may cause the sacrifice of the internal mammarian artery and may pulmonary complications and increase the magnitude of pain in the postoperative period as well. We fully agree with the authors’ concern about femoral artery stenosis in the future, however, vascular complications such as dissection or stenosis after femoral cannulation is still a debateable topic. Femoral access [5] has been shown to be a safe and preferable option in selected patients and allows limited surgical chest incisions thereby reducing the patient’s surgical trauma. In the preoperative period, Doppler examination of the femoral artery (diameter and quality) can minimize the possible vascular problems and assist in determining the surgical strategy in the young or adult patient. In conclusion, this is a valuable study, and we are grateful to the authors for sharing their experiences. This surgical technique, specialized according to gender, might be performed in male adolescent patients in particular. It might be an alternative to the submammarian incision in female and adult patients.