DOI: 10.1177/21501351261458304 ISSN: 2150-1351

Minimally Invasive Right Thoracotomy Versus Median Sternotomy for Atrial and Ventricular Septal Defect Closure: A Propensity-Matched Analysis

Dhivan Naidu, Nor Athirah Azeman, Khairul Anuar Abdul Aziz, Sivakumar Sivalingam, Ahmad Bin Sallehuddin
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Background

Minimally invasive cardiac surgery aims to reduce surgical trauma while maintaining excellent outcomes. Evidence comparing minimally invasive right thoracotomy with conventional median sternotomy for septal defect closure remains limited in large contemporary cohorts. We compared perioperative and short-term outcomes between these approaches for atrial septal defect (ASD) and ventricular septal defect (VSD) repair.

Methods

We retrospectively analyzed 527 consecutive patients undergoing surgical ASD or VSD closure between January 2024 and October 2025 at the National Heart Institute, Kuala Lumpur. Patients were stratified by surgical approach: minimally invasive right thoracotomy (MIS, n  = 81) and median sternotomy (MS, n  = 446). Propensity score matching (1:1) was performed using logistic regression incorporating age, body surface area, defect type, and relevant comorbidities, yielding 79 well-balanced matched pairs (standardized mean difference <0.1). Primary endpoints included perioperative mortality, major morbidity, intensive care unit (ICU) length of stay, and duration of mechanical ventilation.

Results

After propensity score matching, baseline characteristics and operative times were comparable between groups. No perioperative mortality occurred in either group. MIS was associated with significantly shorter ICU stay (median 2.0 vs 3.0 days, P  < .001) and reduced duration of mechanical ventilation (7.5 vs 11.4 h, P  = .007). Total hospital length of stay did not differ significantly (8.2 vs 8.8 days, P  = .367). Complication profiles differed: thoracotomy patients experienced higher rates of diaphragm paralysis (6.3% [5/79] vs 2.5% [2/79]) and pneumothorax (10.1% [8/79]vs 6.2% [5/79]), whereas sternotomy patients had higher incidences of pleural effusion (1.3% [1/79] vs 0%), chylothorax (1.3% [1/79] vs 0%), pericardial effusion (5.1% [4/79] vs 0%), and ventilation >48 h duration (5.1% [4/79] vs 0%). Reintervention was required in 1 of 79 thoracotomy patients (1.3%) for ASD closure revision. At median follow-up of 0.1 to 0.3 years, 100% of patients were alive with no significant difference in reintervention-free survival (log-rank P  = .249).

Conclusions

Minimally invasive right thoracotomy for ASD and VSD closure shortens ICU stay and ventilatory support without compromising operative or short-term outcomes compared with median sternotomy. However, the higher observed rates of phrenic nerve injury and pneumothorax in the thoracotomy cohort represent clinically important safety considerations that warrant transparent informed consent and meticulous surgical technique. In carefully selected patients at experienced centres, this approach remains a sound and reproducible alternative to conventional sternotomy.

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