Right Vertical Infra-Axillary Minithoracotomy Versus Median Sternotomy for Doubly Committed Subarterial Ventricular Septal Defect: A Retrospective Cohort Study of 689 Patients

Background: Minimally invasive approaches are increasingly used for surgical repair of congenital heart defects. However, evidence for right vertical infra-axillary minithoracotomy (RVIAT) in doubly committed subarterial ventricular septal defect (dcVSD) remains limited. This study compared the perioperative outcomes of median sternotomy and RVIAT in patients with dcVSD and evaluated the safety, feasibility, and overall incision-related satisfaction of RVIAT. Methods: This single-center retrospective study included 689 consecutive patients with dcVSD who underwent primary surgical repair between January 2021 and October 2025. Patients were classified into two groups according to the incision type: the median sternotomy group (Mid group, n = 222) and the right thoracic incision group (Right group, n = 467). Perioperative outcomes, postoperative complications, follow-up findings, and a five-level overall incision-related satisfaction rating were compared between groups. Age-stratified analyses and propensity score matching (PSM) were performed to reduce the impact of baseline differences. Results: Compared with the Mid group, patients in the Right group had significantly shorter hospital stay and mechanical ventilation duration (both P < 0.001). Cardiopulmonary bypass (CPB) time and cardiac intensive care unit (CICU) stay were comparable between groups. Age-stratified analyses showed subgroup-specific differences, whereas PSM confirmed shorter hospital stay and mechanical ventilation duration in the Right group. The incidence of residual shunt remained low and comparable both postoperatively and at 6-month follow-up (all P > 0.05). Similarly, no significant differences were observed in the progression of aortic regurgitation or reoperation rates. No in-hospital mortality occurred. Overall incision-related satisfaction was significantly higher in the Right group than in the Mid group (84.3% vs. 36.0%, P < 0.001). Conclusions: In patients with dcVSD, the RVIAT approach provides perioperative safety and clinical outcomes comparable to those of median sternotomy, and higher reported overall incision-related satisfaction at six months. It provides a feasible alternative to median sternotomy. Trial registration Clinical trial number: Not applicable.