Short-term Outcomes of Atrial Septal Defect Repair via Right Axillary Incision: A Single-center Propensity-matched Analysis

Short-term Outcomes of Atrial Septal Defect Repair via Right Axillary Incision: A Single-center Propensity-matched Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Short-term Outcomes of Atrial Septal Defect Repair via Right Axillary Incision: A Single-center Propensity-matched Analysis Jingyu Liu, Zhuheng Wu, Lin Xie, Xingyu Zheng, Ke Lin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7427189/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Dec, 2025 Read the published version in BMC Surgery → Version 1 posted 18 You are reading this latest preprint version Abstract Background To compare the short-term outcomes of atrial septal defect (ASD) repair via right axillary incision (RAI) versus median sternotomy (MS). Methods This single-center, retrospective, controlled study aimed to compare the short-term outcomes of ASD repair performed via right axillary incision versus median sternotomy. The primary endpoint was the incidence of postoperative residual shunt. Results A total of 210 patients were included in this study, with 67 patients in the RAI group and 143 patients in the MS group. The overall mean age of enrolled patients was 22.4 years, and 72 (34.3%) patients of them were male. The RAI group had less intraoperative bleeding ( P < 0.001), shorter ventilation time ( P < 0.001), and shorter drainage time ( P = 0.004). The overall median follow-up time was 6.0 (3.0–11.0) months. During the last follow-up, residual shunt was observed in one patient in each group [1 (1.5%) vs. 1 (0.7%); P = 0.544]. During propensity score matching, 20 patients from the RAI group and 23 from the MS group were successfully matched. After match, the RAI group exhibited longer cardiopulmonary bypass time ( P = 0.027), less drainage time ( P = 0.013) and less drainage in 24 hours ( P < 0.001). No patient from either group still had residual shunt during the last follow-up. Weight, age, height, and chest depth were identified as potential predictors in assisting the decision-making between RAI and MS approaches. Conclusion The RAI approach is a safe option for ASD repair with satisfactory outcomes. The RAI approach demonstrates comparable perioperative and short-term surgical outcomes to the conventional MS approach. Atrial septal defect Right axillary incision Median sternotomy Short-term outcome Figures Figure 1 Figure 2 1 Introduction Atrial septal defect (ASD) is currently the third most common congenital cardiac anomaly, with an estimated incidence of 100 cases per 100,000 live births[ 1 ]. While transcatheter device closure has become the preferred treatment modality for the majority of patients, surgical repair remains essential in cases involving large defects, inadequate rim morphology, or associated intracardiac anomalies. Median sternotomy (MS) continues to be the standard surgical approach for ASD repair; however, it is associated with significant surgical trauma, prolonged postoperative recovery, and less favorable cosmetic outcomes[ 2 – 6 ]. In recent years, the right axillary incision (RAI) approach has emerged as a minimally invasive alternative for ASD repair. By avoiding median sternotomy, the RAI approach offers adequate surgical exposure while reducing recovery time, minimizing postoperative complications, and improving cosmetic satisfaction and overall quality of life[ 7 – 13 ]. The choice between MS and RAI for ASD repair is based on patient-related anatomical and clinical factors, surgeon preference, and parental expectations. According to previous studies, MS is preferred in: [a]Patients with complex or multiple intracardiac anomalies requiring wide exposure; [b]Cases with anticipated difficult exposure; [c]Emergency surgeries or reoperations; [d]Patients with significant tricuspid regurgitation requiring extensive repair. RAI is selected in: [a]Patients with isolated or simple secundum-type ASD; [b]Elective, hemodynamically stable patients; [c]Strong parental preference for minimally invasive cosmetic outcomes. This decision-making process has been refined over time based on surgical experience and outcomes and is not fixed by a single algorithm.[ 14 ] The clinical application of the RAI approach remains limited to select centers. Most published studies to date are single-center analyses with small to moderate sample sizes and frequently lack appropriate control groups. Additionally, the reported outcomes across studies have been variable, limiting the generalizability and widespread adoption of this technique[ 15 ]. In this study, we conducted a retrospective analysis of over one year of institutional experience with ASD repair via the RAI approach. We compared the short-term outcomes of RAI and MS approaches and summarized the surgical experience to contribute further evidence supporting the clinical utility of RAI in ASD repair. 2 Methods 2.1 Selection Criteria This was a single-center, retrospective, controlled study. Patients who underwent ASD repair under cardiopulmonary bypass at our institution between January 2023 and September 2024 were retrospectively enrolled and divided into either the MS group or the RAI group according to the surgical approach employed. There were four experienced pediatric cardiac surgeons performed the procedures. The exclusion criteria included: (a) the presence of concomitant intracardiac anomalies requiring concurrent surgical correction—excluding partial anomalous pulmonary venous return and functional tricuspid regurgitation; and (b) a history of prior cardiac surgery. 2.2 Surgical Strategy The surgical strategy for ASD repair via the MS approach is not elaborated here. At our center, the RAI technique is performed as follows: The patient is positioned in the right lateral decubitus position with the shoulder and back elevated approximately 60–90°, and the right upper limb is flexed and secured. A vertical skin incision is made through the third to fifth intercostal spaces, and the thoracic cavity is entered via the fourth intercostal space. The pericardium is opened longitudinally, approximately 1.5–2 cm anterior to the right phrenic nerve, extending superiorly to the pericardial reflection over the ascending aorta and inferiorly to the dome of the diaphragm. A transverse incision is then made anteriorly along the diaphragm to optimize exposure. Cardiopulmonary bypass is established via cannulation of the ascending aorta and both the superior and inferior vena cava. Peripheral cannulation was selectively performed in patients with a body weight above 25 kg or in those with difficult central access. The ascending aorta is cross-clamped, and cardioplegic solution is administered through the aortic root to induce cardiac arrest. After occlusion of the vena cavae, a right atriotomy is performed to expose the atrial septal defect. The defect is then repaired using an appropriately sized bovine pericardial patch. Upon completion, a chest drain is placed through the seventh intercostal space at the right midaxillary line and connected to a closed drainage system. 2.3 Research outcomes The primary outcome of this study was the incidence of residual atrial septal shunt at the time of the last follow-up. Secondary outcomes included: (a) the incidence of perioperative adverse events; (b) the severity of tricuspid regurgitation at the final follow-up; (c) potential predictors and their cut-off values for the decision between MS and RAI ASD repair. 2.4 Statistical Analysis The normality of continuous variables was assessed using the Shapiro–Wilk test. Depending on data distribution, continuous variables were expressed as either mean ± standard deviation (Mean ± SD) or median with interquartile range [M (IQR)]. Group comparisons of continuous variables were performed using the student’s t-test for normally distributed data or the Wilcoxon rank-sum test for non-normally distributed data. Categorical variables were presented as counts and percentages [n (%)], and intergroup differences were evaluated using the Chi-square test or Fisher’s exact test, as appropriate. We used a random forest model to explore the surgical indications for RAI atrial septal defect (ASD) repair. The surgical approach—either MS or RAI—was designated as the outcome variable, while weight, height, age, sex, ASD size, and chest depth were selected as potential predictive variables. Missing data were handled using multiple imputation (n = 3), and a random forest model was constructed for each imputed dataset (number of decision trees = 500). Variable importance was assessed using the Mean Decrease in Gini index (MDG), and Partial Dependence Plots (PDP) were used to determine the threshold values of relevant predictors. To adjust for potential confounders, propensity score matching (PSM) was conducted in a 1:2 ratio between the RAI and MS groups. Covariates included in the matching model were age, body weight, ASD size, and the presence of associated anomalies. A caliper width of 0.2 was applied, and standardized differences of less than 0.2 were considered indicative of successful matching. All statistical analyses were two-tailed, with a significance level set at α = 0.05. Analyses were performed using R software (version 4.3.1). This study was approved by the Ethics Committee of West China Hospital [2024(2454)], and due to the retrospective nature of this study, patients’ consents were waived. 3 Results 3.1 Baseline Characteristics A total of 210 patients were included in this study, comprising 67 patients in the RAI group and 143 in the MS group. Baseline characteristics are summarized in Table 1 . The overall mean age of the cohort was 22.4 years. Patients in the RAI group were significantly younger than those in the MS group [2.0 (2.0–4.0) years vs. 32.0 (17.5–50.0) years; P < 0.001]. A total of 72 (34.3%) patients were male, with no significant difference in sex distribution between groups [22 (32.8%) vs. 50 (35.0%); P = 0.762]. The RAI group had significantly lower body weight [13.0 (12.0–16.0) kg vs. 53.0 (45.0–62.5) kg; P < 0.001] and smaller ASD size [19.0 (15.8–22.0) mm vs. 26.5 (19.0–33.0) mm; P < 0.001]. Congenital cardiac anomalies other than ASD were present in 11(16.4%) patients in the RAI group and 38 (26.6%) patients in the MS group ( P = 0.105), with partial anomalous pulmonary venous return being the most commonly associated lesion. Regarding preoperative tricuspid regurgitation (TR), no patients in the RAI group had moderate or greater TR, whereas 10 (7.0%) patients in the MS group had moderate-to-severe TR, including 6 (4.2%) patients with severe TR ( P = 0.021). After propensity score matching, 20 patients in the RAI group were successfully matched with 23 patients in the MS group. Love plot is presented in Fig. 1 . Post-matching baseline characteristics are also presented in Table 1 . There were no statistically significant differences between the two groups with respect to age, body weight, echocardiographic ASD size, presence of associated anomalies, or severity of valvular regurgitation. Table 1 Baseline Characteristics Characteristics Before Match After Match Right Axillary Incision(n = 67) Median Sternotomy(n = 143) T Value/ χ2 Value/ Z Value P Value Right Axillary Incision(n = 20) Median Sternotomy (n = 23) T Value/ χ2 Value/ Z Value P Value Height, cm 92.0(88.0, 105.0) 158.0(152.0, 164.5) -14.852 < 0.001 106.4 ± 28.1 112.9 ± 22.7 0.823 0.416 Weight, kg 13.0(12.0, 16.0) 53.0(45.0, 62.5.0) -14.847 < 0.001 17.8(10.8, 20.3) 21.0(14.0, 22.8) -5.284 0.150 BMI 15.1(13.8, 16.0) 20.4(18.0, 23.5) -15.872 < 0.001 14.5(13.4, 16.0) 15.2(13.5, 17.0) -5.600 0.263 Gender (Male) 22(32.8) 50(35.0) 0.022 0.762 7(35.0) 7(30.4) 0.102 0.750 Age, yrs 2.0(2.0, 4.0) 32.0(17.5, 50.0) -14.608 < 0.001 4.5(1.8, 7.0) 6.0(3.0, 7.5) -5.345 0.167 ASD Size, mm 19.0(15.8, 22.0) 26.5(19.0, 33.0) -20.734 < 0.001 19.1 ± 8.4 21.2 ± 8.2 0.836 0.408 Multiple Defects 11(16.4) 16(11.2) 0.696 0.291 2(10.0) 4(17.4) - 0.669 LV, mm 27.5(25.8, 31.0) 39.0(36.0, 42.0) -16.710 < 0.001 29.5 ± 5.3 29.2 ± 4.1 -0.160 0.874 LA, mm 19.0(17.0, 21.0) 32.0(29.0, 36.0) -16.265 < 0.001 19.0(17.8, 22.3) 22.0(18.5, 25.5) -4.992 0.083 LVEF, % 67.8 ± 5.0 66.1 ± 6.5 -2.103 0.037 67.4 ± 5.3 66.0 ± 5.5 -0.821 0.417 TR Severity a - 0.021 - 0.117 None 29(43.3) 42(29.4) 5(25.0) 12(52.2) Mild 25(37.3) 53(37.1) 10(50.0) 5(21.7) Moderate 10(14.9) 30(21.0) 5(25.0) 4(14.4) Moderate to Severe 0(0.0) 10(7.0) 0 1(4.3) Severe 0(0.0) 6(4.2) 0 1(4.3) Comorbidity 11(16.4) 38(26.6) 2.630 0.105 2(10.0) 3(13.0) - > 0.999 Arrhythmia 2(3.0) 15(10.5) 3.405 0.065 1(5.0) 0(0.0) - 0.463 Chest depth, mm 9.6 (8.4, 10.8) 17.5(15.4, 19.1) < 0.001 10.5 (8.2, 11.7) 10.9 (10.2, 12.1) 0.257 BMI : body mass index; ASD : atrial septal defect; LA : left atrium; LV : left ventricle; LVEF : left ventricle ejection fraction; TR : tricuspid regurgitation. a : The total rate didn’t add up to 100.0% because there were missing values. 3.2 Surgical Results Surgical results are presented in Table 2 . The RAI group demonstrated significantly shorter total surgical time, cardiopulmonary bypass time, and clamp time compared to the MS group ( P < 0.001, P = 0.004, and P < 0.001, respectively). Intraoperative bleeding was also significantly lower in the RAI group [30.0 (20.0–50.0) ml vs. 175.0 (100.0–200.0) ml; P < 0.001]. There were no statistically significant differences between the two groups in the incidence of immediate residual shunt [1 (1.5%) vs. 1 (0.7%); P = 0.537] or in the occurrence of postoperative tricuspid regurgitation [6 (9.0%) vs. 15 (10.5%); P = 0.730]. However, the proportion of patients undergoing concomitant tricuspid valvuloplasty was significantly higher in the MS group [7 (10.4%) vs. 99 (69.2%); P < 0.001]. There was no significant difference in ICU stay between the two groups ( P = 0.257). Nonetheless, the use of inotropic agents during ICU stay was lower in the RAI group [32.8% vs. 51.0%; P = 0.031], and ventilation time also was shorter [4.0 (3.0–4.8) h vs. 5.0 (4.0–8.0) h; P < 0.001]. The RAI group also exhibited significantly lower postoperative 24-hour chest drainage volume ( P 0.999] or postoperative blood transfusion [11 (16.4%) vs. 17 (11.9%); P = 0.368]. One patient in the MS group required reoperation due to anterior mitral leaflet prolapse with regurgitation. No cases of chylothorax or in-hospital mortality were observed in either group. Following propensity score matching, cardiopulmonary bypass time was longer in the RAI group than in the MS group [64.0 (51.0–68.0) min vs. 45.5 (38.8–56.3) min; P = 0.027]. Immediate postoperative outcomes were deemed satisfactory in 15 (75%) patients in the RAI group and in 20 (87%) patients in the MS group. The drainage volume in 24-hour remained significantly lower in the RAI group [42.5 (30.0–97.8) mL vs. 157.5 (126.3–225.0) mL; P < 0.001]. One patient (4.3%) in the MS group required chest tube insertion after matching. Table 2 Surgical Results Characteristics Before Match After Match Right Axillary Incision(n = 67) Median Sternotomy(n = 143) T Value/ χ2 Value/ Z Value P Value Right Axillary Incision(n = 20) Median Sternotomy (n = 23) T Value/ χ2 Value/ Z Value P Value Surgical Time, min 155.0(131.0, 177.5) 183.0(155.5, 240.5) -20.096 < 0.001 156.0(138.8, 195.8) 138.0(121.5, 168.0) -8.206 0.137 CPB, min 58.0(48.0, 67.5) 68.0(53.0, 93.8) -25.287 0.004 64.0(51.0, 68.0) 45.5(38.8, 56.3) -9.776 0.027 Clamp Time, min 29.0(20.3, 36.0) 39.0(30.0, 49.0) -24.263 < 0.001 31.0(20.0, 38.0) 24.5(19.8, 31.3) -9.070 0.265 Intraoperative Bleeding, ml 30.0(20.0, 50.0) 175.0(100.0, 200.0) -22.384 0.999 Immediate Residual Shunt 1(1.5) 1(0.7) - 0.537 0(0.0) 0(0.0) - > 0.999 Tricuspid Valve Repair 7(10.4) 99(69.2) 63.066 0.999 ICU Stay, d 2.0(1.0, 3.0) 2.0(1.1, 3.0) -23.963 0.257 2.0(1.4, 4.0) 2.0(1.0, 2.3) -8.023 0.187 Inotropes 22(32.8) 73(51.0) 6.109 0.013 11(55.0) 7(30.4) 2.652 0.103 Ventilation Time, h 4.0(3.0, 4.8) 5.0(4.0, 8.0) -21.378 0.999 0(0.0) 0(0.0) - > 0.999 ECMO 0(0.0) 0(0.0) - > 0.999 0(0.0) 0(0.0) - > 0.999 Drainage in 24h, ml 63.0(32.0, 121.5) 270.0(190.0, 380.0) -16.076 < 0.001 42.5(30.0, 97.8) 157.5(126.3, 225.0) -3.725 0.999 0(0.0) 1(4.3) - > 0.999 In Hospital Reoperation 0(0.0) 1(0.7) - > 0.999 0(0.0) 0(0.0) - > 0.999 Transfusion 11(16.4) 17(11.9) 0.810 0.368 2(10.0) 5(21.7) - 0.420 Chylothorax 0(0.0) 0(0.0) - > 0.999 0(0.0) 0(0.0) - > 0.999 CPB : cardiopulmonary bypass; TR : tricuspid regurgitation; ICU : intensive care unit; ECMO : Extracorporeal Membrane Oxygenation. 3.3 Follow-up Outcomes Follow-up Outcomes are presented in Table 3 . Before propensity score matching, the median follow-up time was comparable between the two groups [8.0 (3.0–12.0) months vs. 6.0 (3.0–11.0) months; P = 0.767]. One patient in each group still had residual shunting during the last follow-up ( P = 0.544). The incidence of postoperative arrhythmia was significantly higher in the MS group [2 (3.0%) vs. 18 (12.6%); P = 0.024]. Readmission occurred in 4 (6.0%) patients in the RAI group (all due to delayed wound healing) and in 9 (6.3%) patients in the MS group (due to delayed wound healing, low cardiac output syndrome, and pulmonary hypertension) ( P > 0.999). After matching, median follow-up time remained similar between groups [7.0 (3.0–10.0) months vs. 6.0 (3.0–10.0) months; P = 0.453]. No residual shunt was observed in either group. Mild tricuspid regurgitation was observed in 4 (20.0%) patients in the RAI group and in 5 (21.7%) patients in the MS group ( P > 0.999). Two (10.0%) patients in the RAI group and one (4.3%) patient in the MS group were readmitted due to delayed wound healing. Table 3 Follow-up Outcomes Characteristics Before Match After Match Right Axillary Incision(n = 67) Median Sternotomy (n = 143) T Value/ χ2 Value/ Z Value P Value Right Axillary Incision(n = 20) Median Sternotomy(n = 23) T Value/ χ2 Value/ Z Value P Value Residual Shunt 1(1.5) 1(0.7) - 0.544 0(0.0) 0(0.0) - > 0.999 LV, mm 31.0(28.5, 34.5) 44(40.8, 47.0) -15.751 < 0.001 34.0(28.8, 37.0) 33.0(30.5, 36.0) -6.733 0.990 LA, mm 20.0(18.0, 23.0) 33.0(28.0, 36.0) -19.031 0.999 - > 0.999 None 57(85.1) 118(82.5) 16(80.0) 18(78.3) Mild 10(14.9) 21(14.7) 4(20.0) 5(21.7) Moderate 0 1(0.7) 0(0.0) 0(0.0) Moderate to Severe 0 0 0(0.0) 0(0.0) Severe 0 0 0(0.0) 0(0.0) Arrhythmia 2(3.0) 18(12.6) 5.068 0.024 1(5.0) 2(8.7) - > 0.999 Readmission 4(6.0) 9(6.3) - > 0.999 2(10.0) 1(4.3) - 0.590 Follow-up Time, months 8.0(3.0, 12.0) 6.0(3.0, 11.0) -23.562 0.767 7.0(3.0, 10.0) 6.0(3.0, 10.0) -7.451 0.453 LA : left atrium; LV : left ventricle; LVEF : left ventricle ejection fraction; TR : tricuspid regurgitation. a : The total rate didn’t add up to 100.0% because there were missing values. 3.4 Prediction Outcomes In the random forest analysis, the importance of potential predictive variables for determining the surgical approach was assessed using MDG, as illustrated in Fig. 2 . The results indicated that the importance order of the included variables is: weight > age > height > chest depth. To further elucidate the clinical utility of these predictors, PDPs were generated for each variable to approximate optimal thresholds that may provide guidance for surgical decision-making. Based on these analyses, favorable conditions for selecting RAI included: weight < 20 kg, age < 8 years, height < 105 cm, and chest depth < 12 cm. 4 Discussion Atrial septal defect (ASD) is the third most common congenital cardiac anomaly and remains one of the most frequently surgical treated congenital heart diseases[ 16 ]. Both transcatheter device closure and surgical patch repair under cardiopulmonary bypass are established first-line treatment strategies. However, due to anatomical limitations, transcatheter closure is not suitable for all patients, making surgical repair the only viable option in select cases[ 17 ]. Since the first surgical repair of ASD by Lewis and Varco in 1952, techniques have undergone substantial evolution and refinement[ 18 , 19 ]. Although median sternotomy (MS) provides excellent exposure, it is associated with increased surgical trauma, less favorable cosmetic outcomes, and potential psychological impact [ 4 , 7 – 9 , 20 ]. In recent years, various minimally invasive alternatives have been introduced to minimize invasiveness and improve cosmetic satisfaction, including lower partial sternotomy[ 21 ], anterior thoracotomy[ 22 ], posterolateral thoracotomy [ 23 ], and right axillary incision (RAI) [ 8 , 9 , 13 ]. Due to its adequate exposure, low complication rate, and aesthetic benefits, RAI has gained increasing attention. While MS remains the primary approach at most institutions, our center adopts a selective strategy. MS is the default technique; however, RAI is preferred in pediatric patients and young females, aiming to maintain surgical efficacy while optimizing postoperative cosmesis. Cardiopulmonary bypass is typically established via ascending aortic and bicaval cannulation, although femoral cannulation has also been described[ 12 ]. In selected patients, we externalize the inferior vena cava cannula through a small chest wall stab incision to enhance exposure and facilitate drainage. Interestingly, although the CPB time was shorter in the RAI group before matching, it became significantly longer after matching. This reversal may be attributed to the inherent technical challenges and steep learning curve associated with the right axillary approach. In our early experience, the RAI procedure required more time for peripheral cannulation, atrial exposure, and intracardiac repair due to the limited working space and altered anatomical orientation. These factors were particularly evident in operations performed by less experienced surgeons during the initial implementation phase. Importantly, the longer CPB time did not correlate with increased complication rates or prolonged recovery, supporting the overall safety of the minimally invasive approach despite its technical demands. Although off-pump ASD repair has been reported, limited visualization, increased intraoperative bleeding, and technical challenges have hindered its widespread adoption. Therefore, our institution continues to perform repair on an arrested heart. In a previous study by Martin-Garcia et al. [ 24 ], 18 of 162 patients (11.1%) underwent tricuspid valvuloplasty, primarily using annuloplasty or direct suture repair, consistent with our approach. Given the younger patient population in the RAI group, suture techniques are typically favored. Regarding baseline characteristics, we included patients with ASD sizes of 10 mm or greater, whereas smaller defects are generally treated with device closure. This inclusion threshold aligns with earlier studies[ 7 , 8 , 13 ]. Unlike most prior research that focused on children under 12 years of age, our study enrolled patients across a broader age range, enabling comprehensive evaluation of short-term outcomes and cosmetic satisfaction in a more diverse population. As age increases, valvular regurgitation becomes more prevalent, leading to a higher likelihood of concomitant tricuspid repair. To minimize bias, propensity score matching (PSM) was applied to balance baseline variables and mitigate confounding effects. In a study by Dave et al.[ 2 ], only 2 of 123 patients (0.02%) exhibited trace or greater residual shunting postoperatively, a finding consistent with our results. Among 210 patients in our cohort, two exhibited immediate postoperative residual shunts—one in each group. In the RAI group, a 1-mm shunt was noted on TEE and resolved by 3-month TTE follow-up. In the MS group, a 4-mm residual shunt was observed, which also resolved on follow-up. Among 35 RAI patients with mild or greater tricuspid regurgitation, only 7 (20%) patients underwent tricuspid repair, whereas all 99 MS patients with similar findings received surgical correction. Intraoperative TEE revealed residual tricuspid regurgitation in 6 RAI patients who did not receive repair, with spontaneous resolution observed in 78.6% (22/28) of cases. Conversely, 15 MS patients had residual regurgitation intraoperatively, likely reflecting more advanced valvular pathology due to older age. Notably, although the tricuspid valve repair rate was significantly higher in the MS group compared to the RAI group, the postoperative residual TR rate was similar between the two. This finding may reflect baseline differences in the severity of valvular involvement. Patients in the MS group were generally older and had longer-standing ASDs, which likely resulted in more prolonged right ventricular volume overload and annular dilation[ 25 ]. These pathophysiological changes may have led surgeons to adopt a lower threshold for performing tricuspid valve repair during MS procedures. Therefore, the higher rate of intervention in the MS group likely reflects more advanced disease rather than overcorrection, whereas the lower intervention rate in the RAI group may be due to earlier intervention and less severe valvular changes. This interpretation aligns with existing evidence that the duration of volume overload plays a critical role in the progression of TR severity[ 26 ]. During follow-up, persistent tricuspid regurgitation was observed in 32 patients: 10 in the RAI group and 22 in the MS group. All 10 RAI patients had preoperative regurgitation and did not undergo tricuspid repair; none developed new-onset regurgitation. In the MS group, 22 patients had postoperative regurgitation, including 2 with residual regurgitation post-repair, 8 with no residual regurgitation post-repair, 1 who developed regurgitation without repair, and 11 who neither underwent repair nor exhibited intraoperative regurgitation. Excluding patients with persistent intraoperative regurgitation, the de novo regurgitation rate in the MS group was 19.2% (19/99). In both groups, only one case of postoperative residual shunt was observed, and no reoperations were required, consistent with the findings of Yang et al. [ 8 ]. However, in Yang’s study, none of the 17 RAI patients required readmission for wound-related complications, whereas 7 of 29 MS patients did (P = 0.047), indicating a higher infection risk with MS. In contrast, our study noted 4 readmissions in each group for wound-related issues. This discrepancy may be attributed to the RAI incision's proximity to the axilla and increased subcutaneous fat in pediatric patients, making wound care more challenging[ 8 , 27 ]. The increased incidence of postoperative arrhythmias in the MS group is likely multifactorial[ 28 ]. One contributing factor is the surgical technique itself: median sternotomy provides broader exposure of the atria and generally requires more extensive atrial manipulation, which may increase the likelihood of transient or sustained conduction disturbances. Additionally, patients in the MS group were significantly older compared to those in the RAI group. Age is a well-recognized risk factor for arrhythmogenesis due to progressive atrial fibrosis and electrophysiological remodeling[ 29 ]. Moreover, the average ASD diameter was larger in the MS group, suggesting a longer duration of left-to-right shunting and more pronounced atrial volume overload, both of which may predispose to structural atrial remodeling and subsequent arrhythmia[ 30 ]. These combined anatomical and clinical factors likely explain the higher arrhythmia rate observed following the MS approach. In exploring potential predictors for selecting between RAI and MS approaches, we employed a random forest model and assessed variable importance using MDG. This analysis identified four key predictors and ranked them in order of importance, with approximate threshold values determined via partial dependence plots. Based on these findings, we propose that patients meeting specific criteria may be better suited for the RAI approach, providing a potential reference for tailoring surgical strategy. However, given the single-center, retrospective nature of this study and the variability in surgical approach preference among different surgeons, we recommend interpreting these predictor rankings and thresholds as preliminary guidance rather than definitive criteria. The cosmetic advantages of the RAI approach have been well documented. Schreiber et al.[ 31 ] noted that avoiding disruption of major muscle groups and breast tissue contributes to improved cosmetic outcomes, and a small axillary incision is effective in achieving these goals. Yang et al. [ 8 ] utilized the Vancouver Scar Scale to quantify cosmetic outcomes, reporting a 100% satisfaction rate (17/17) in the RAI group versus 66.7% (18/27) in the MS group (P = 0.018). Although we did not employ formal scar assessment tools, patients in the RAI group reported high levels of subjective satisfaction with postoperative wound appearance during the follow-up times. This study has several limitations: a. As a single-center cohort study, the overall sample size, though larger than in previous studies, remains relatively limited after propensity score matching, with a smaller number of matched pairs and relatively short follow-up duration. Therefore, the findings require validation in studies with larger sample sizes and longer follow-up periods; b. Aesthetic outcomes were not formally assessed using standardized questionnaires or rating scales. As such, the cosmetic advantages of the right axillary incision compared to the median sternotomy remain to be further investigated; c. Given that the choice of surgical approach and technical nuances may vary among surgeons, the findings of this study primarily reflect the operative idea and decision-making patterns at our institution, which may limit the generalizability of the conclusions. 5 Conclusion Based on the findings of this study, we draw the following conclusions: a. The RAI approach for ASD repair demonstrates favorable safety, efficacy, and satisfactory short-term outcomes; b. The RAI is superior to MS in reducing surgical trauma, but there is no difference in the main outcomes; c. Weight, age, height, and chest depth are potential predictors in assisting the decision-making between RAI and MS approaches for ASD repair. Abbreviations ASD Atrial Septal Defect RAI Right Axillary Incision MS Median Sternotomy MDG Mean Decrease in Gini PDP Partial Dependence Plots PSM Propensity Score Matching BMI Body Mass Index LV Left Ventricle LA Left Atrium LVEF Left Ventricle Ejection Fraction TR Tricuspid Regurgitation CPB Cardiopulmonary Bypass ICU Intensive Care Unit ECMO Extracorporeal Membrane Oxygenation mm Millimeter cm Centimeter min Minute h Hour d Day yrs years TEE Transesophageal Echocardiography TTE Transthoracic Echocardiography Declarations Ethics approval and consent to participate: This study was approved by the Ethics Committee of West China Hospital [2024(2454)], and due to the retrospective nature of this study, The requirement for individual informed consent was waived by the Institutional Review Board of the Ethics Committee of West China Hospital, in accordance with national regulations. This study was conducted in accordance with the principles of the Declaration of Helsinki. Consent for publication: Not applicable Clinical trial number : not applicable. Availability of Data and Materials: The data that support the findings of this study are available from the Corresponding Author, Ke Lin, upon reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: The authors received no specific funding for this study. Author Contributions: Jingyu Liu, Zhuheng Wu, Lin Xie contributed in study design, data collection, investigation, data analysis, visualization and manuscript drafting; Xingyu Zheng contributed in data collection, visualization and manuscript drafting; Ke Lin contributed in study design, investigation, supervision, validation and manuscript review. Acknowledgement: Not applicable. References Bradley EA, Zaidi AN. Atrial Septal Defect. Cardiology clinics. 2020;38(3):317-24. Dave HH, Comber M, Solinger T, Bettex D, Dodge-Khatami A, Prêtre R. Mid-term results of right axillary incision for the repair of a wide range of congenital cardiac defects. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. 2009;35(5):864-9; discussion 9-70. An G, Zhang H, Zheng S, Wang W, Wu Q, Xing Q. Minimally invasive surgical closure for doubly committed subarterial ventricular septal defects through a right subaxillary thoracotomy. Interactive cardiovascular and thoracic surgery. 2016;23(6):924-8. Bleiziffer S, Schreiber C, Burgkart R, Regenfelder F, Kostolny M, Libera P, et al. The influence of right anterolateral thoracotomy in prepubescent female patients on late breast development and on the incidence of scoliosis. The Journal of thoracic and cardiovascular surgery. 2004;127(5):1474-80. Cherup LL, Siewers RD, Futrell JW. Breast and pectoral muscle maldevelopment after anterolateral and posterolateral thoracotomies in children. The Annals of thoracic surgery. 1986;41(5):492-7. An K, Li S, Yan J, Wang X, Hua Z. Minimal Right Vertical Infra-axillary Incision for Repair of Congenital Heart Defects. The Annals of thoracic surgery. 2022;113(3):896-902. 王文杰, 雷雨, 陶杰, 白向锋, 梅松, 李斌. 右腋下小切口及正中开胸在房间隔缺损修补术中的效果对比 %J 云南医药. 2023;44(01):17-20. Yang X, Hu Y, Dong J, Huang P, Luo J, Yang G, et al. Rightvertical axillary incision for atrial septal defect: a propensity score matched study. Journal of cardiothoracic surgery. 2022;17(1):256. Liu H, Wang Z, Xia J, Hu R, Wu Z, Hu X, et al. Evaluation of Different Minimally Invasive Techniques in Surgical Treatment for Ventricular Septal Defect. Heart, lung & circulation. 2018;27(3):365-70. Yan L, Zhou ZC, Li HP, Lin M, Wang HT, Zhao ZW, et al. Right vertical infra-axillary mini-incision for repair of simple congenital heart defects: a matched-pair analysis. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. 2013;43(1):136-41. Wang Q, Li Q, Zhang J, Wu Z, Zhou Q, Wang DJ. Ventricular septal defects closure using a minimal right vertical infraaxillary thoracotomy: seven-year experience in 274 patients. The Annals of thoracic surgery. 2010;89(2):552-5. Prêtre R, Kadner A, Dave H, Dodge-Khatami A, Bettex D, Berger F. Right axillary incision: a cosmetically superior approach to repair a wide range of congenital cardiac defects. The Journal of thoracic and cardiovascular surgery. 2005;130(2):277-81. Silva Lda F, Silva JP, Turquetto AL, Franchi SM, Cascudo CM, Castro RM, et al. Horizontal right axillary minithoracotomy: aesthetic and effective option for atrial and ventricular septal defect repair in infants and toddlers. Revista brasileira de cirurgia cardiovascular : orgao oficial da Sociedade Brasileira de Cirurgia Cardiovascular. 2014;29(2):123-30. Watanabe N, Hapak A, Nasirov T. "Invisible" Incision: Modified Horizontal Right Axillary Mini-Thoracotomy for Pediatric Cardiac Surgery. Annals of thoracic surgery short reports. 2023;1(1):99-101. Luo ZR, Chen Q, Yu LL, Chen LW, Huang ZY. Comparative Study between Surgical Repair of Atrial Septal Defect via Median Sternotomy, Right Submammary Thoracotomy, and Right Vertical Infra-Axillary Thoracotomy. Brazilian journal of cardiovascular surgery. 2020;35(3):285-90. Botto LD, Correa A, Erickson JD. Racial and temporal variations in the prevalence of heart defects. Pediatrics. 2001;107(3):E32. Thomson JD, Aburawi EH, Watterson KG, Van Doorn C, Gibbs JL. Surgical and transcatheter (Amplatzer) closure of atrial septal defects: a prospective comparison of results and cost. Heart (British Cardiac Society). 2002;87(5):466-9. Murray G. Closure of defects in cardiac septa. Annals of surgery. 1948;128(4):843-53. Lewis FJ, Taufic M. Closure of atrial septal defects with the aid of hypothermia; experimental accomplishments and the report of one successful case. Surgery. 1953;33(1):52-9. Lee T, Weiss AJ, Williams EE, Kiblawi F, Dong J, Nguyen KH. The Right Axillary Incision: A Potential New Standard of Care for Selected Congenital Heart Surgery. Seminars in thoracic and cardiovascular surgery. 2018;30(3):310-6. Seipelt RG, Popov A, Danner B, Paul T, Tirilomis T, Schoendube FA, et al. Minimally invasive partial inferior sternotomy for congenital heart defects in children. The Journal of cardiovascular surgery. 2010;51(6):929-33. Mishaly D, Ghosh P, Preisman S. Minimally invasive congenital cardiac surgery through right anterior minithoracotomy approach. The Annals of thoracic surgery. 2008;85(3):831-5. Yoshimura N, Yamaguchi M, Oshima Y, Oka S, Ootaki Y, Yoshida M. Repair of atrial septal defect through a right posterolateral thoracotomy: a cosmetic approach for female patients. The Annals of thoracic surgery. 2001;72(6):2103-5. Martin-Garcia AC, Dimopoulos K, Boutsikou M, Martin-Garcia A, Kempny A, Alonso-Gonzalez R, et al. Tricuspid regurgitation severity after atrial septal defect closure or pulmonic valve replacement. Heart (British Cardiac Society). 2020;106(6):455-61. Donal E, Yamada H. Do not underestimate the impact of load and of remodelling capabilities of the right heart. Heart (British Cardiac Society). 2022;108(24):1926-7. Guler S, Reyhancan A, Kubat E, Onan IS, Kadirogullari E, Onan B. Impact of additional annuloplasty on tricuspid valve and cardiac functions after atrial septal defect closure in adults. Journal of cardiac surgery. 2020;35(11):2895-901. Tran DM, Tran VQ, Nguyen MT, Mai DD, Doan AV, Hoang ST, et al. Minimally Invasive Surgical Repair of Simple Congenital Heart Defects Using the Right Vertical Infra-Axillary Thoracotomy Approach. Innovations (Philadelphia, Pa). 2024;19(5):520-5. Jacquemart E, Bessière F, Combes N, Ladouceur M, Iserin L, Gardey K, et al. Incidence, Risk Factors, and Outcomes of Atrial Arrhythmias in Adult Patients With Atrioventricular Septal Defect. JACC Clinical electrophysiology. 2022;8(3):331-40. Krause U. Age Matters: Atrial Arrhythmias in Adult Patients With Atrioventricular Septal Defect. JACC Clinical electrophysiology. 2022;8(3):341-2. Deaconu S, Deaconu A, Marascu G, Stanculescu MO, Cozma D, Cinteza E, et al. Arrhythmic Risk and Treatment after Transcatheter Atrial Septal Defect Closure. Diagnostics (Basel, Switzerland). 2023;14(1). Schreiber C, Bleiziffer S, Lange R. Midaxillary lateral thoracotomy for closure of atrial septal defects in pre-pubescent female children: reappraisal of an "old technique". Cardiology in the young. 2003;13(6):565-7. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7427189","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":512127172,"identity":"1954a71d-c454-4573-a44d-c95354656006","order_by":0,"name":"Jingyu Liu","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Jingyu","middleName":"","lastName":"Liu","suffix":""},{"id":512127173,"identity":"cd05cac0-464c-4142-88dc-43039ce987e1","order_by":1,"name":"Zhuheng Wu","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Zhuheng","middleName":"","lastName":"Wu","suffix":""},{"id":512127174,"identity":"c8f4e1f1-133b-483e-af42-f780faa035c3","order_by":2,"name":"Lin Xie","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Lin","middleName":"","lastName":"Xie","suffix":""},{"id":512127175,"identity":"69a1aaba-3843-4e34-b3e1-43d90a45515b","order_by":3,"name":"Xingyu Zheng","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Xingyu","middleName":"","lastName":"Zheng","suffix":""},{"id":512127177,"identity":"a9f70472-288b-447d-87f4-804334940ac4","order_by":4,"name":"Ke Lin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAsklEQVRIiWNgGAWjYFCCxAaJBAYGOTb29gOkaTHm4zmTQKyWBAYJkMZ5Eg4GxGngZ09uvPGg5k56mwRQ84+KbYS1SPY8bLZIOPYst0268QBjz5nbhLUY3Ehsk0hgO5zbJnMggZmxjQgt9mAt/w6ns0kkGBCnxUACqCWx7XAC8VokzgD9kth32LANGMgHifILf3v6w5s/vh2Wl29vP/jgRwURWlDAARLVj4JRMApGwSjABQAOFj9Q6+yDZAAAAABJRU5ErkJggg==","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":true,"prefix":"","firstName":"Ke","middleName":"","lastName":"Lin","suffix":""}],"badges":[],"createdAt":"2025-08-21 14:38:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7427189/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7427189/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12893-025-03400-y","type":"published","date":"2025-12-04T15:57:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":91193746,"identity":"ae69b9e7-afdd-44ce-bd52-9a65fedaef07","added_by":"auto","created_at":"2025-09-12 14:46:03","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":43829,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eLove plot for propensity score matching. Pre-match (blue dots) and post-match (purple dots) standardized mean difference of the included covariates are exhibited.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7427189/v1/f305eb738cec33ab1cd69df9.jpg"},{"id":91193747,"identity":"552bc20f-3850-482b-a5ca-04591d210238","added_by":"auto","created_at":"2025-09-12 14:46:03","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":84034,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eImportance of predictors and Partial Dependence Plots for each predictor. \u003c/em\u003e\u003cem\u003e\u003cstrong\u003eA:\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e the importance order of the potential predictive variables, ranked based on its mean decrease in Gini in the random forest model (a larger mean decrease in Gini indicates greater importance of the corresponding variable). \u003c/em\u003e\u003cem\u003e\u003cstrong\u003eB:\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e The partial dependence plots of Weight in random forest models. \u003c/em\u003e\u003cem\u003e\u003cstrong\u003eC: \u003c/strong\u003e\u003c/em\u003e\u003cem\u003eThe partial dependence plots of Age in random forest models. \u003c/em\u003e\u003cem\u003e\u003cstrong\u003eD:\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e The partial dependence plots of Height in random forest models. \u003c/em\u003e\u003cem\u003e\u003cstrong\u003eE:\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e The partial dependence plots of Chest Depth in random forest models.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7427189/v1/1215d31ff4a7affb257a0973.jpg"},{"id":97723956,"identity":"33274cf6-3edc-40ae-8873-2f57104fc874","added_by":"auto","created_at":"2025-12-08 16:10:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1258281,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7427189/v1/bf98a054-a978-4200-8d06-38199723e781.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Short-term Outcomes of Atrial Septal Defect Repair via Right Axillary Incision: A Single-center Propensity-matched Analysis","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eAtrial septal defect (ASD) is currently the third most common congenital cardiac anomaly, with an estimated incidence of 100 cases per 100,000 live births[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. While transcatheter device closure has become the preferred treatment modality for the majority of patients, surgical repair remains essential in cases involving large defects, inadequate rim morphology, or associated intracardiac anomalies. Median sternotomy (MS) continues to be the standard surgical approach for ASD repair; however, it is associated with significant surgical trauma, prolonged postoperative recovery, and less favorable cosmetic outcomes[\u003cspan additionalcitationids=\"CR3 CR4 CR5\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn recent years, the right axillary incision (RAI) approach has emerged as a minimally invasive alternative for ASD repair. By avoiding median sternotomy, the RAI approach offers adequate surgical exposure while reducing recovery time, minimizing postoperative complications, and improving cosmetic satisfaction and overall quality of life[\u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11 CR12\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe choice between MS and RAI for ASD repair is based on patient-related anatomical and clinical factors, surgeon preference, and parental expectations. According to previous studies, MS is preferred in: [a]Patients with complex or multiple intracardiac anomalies requiring wide exposure; [b]Cases with anticipated difficult exposure; [c]Emergency surgeries or reoperations; [d]Patients with significant tricuspid regurgitation requiring extensive repair. RAI is selected in: [a]Patients with isolated or simple secundum-type ASD; [b]Elective, hemodynamically stable patients; [c]Strong parental preference for minimally invasive cosmetic outcomes. This decision-making process has been refined over time based on surgical experience and outcomes and is not fixed by a single algorithm.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe clinical application of the RAI approach remains limited to select centers. Most published studies to date are single-center analyses with small to moderate sample sizes and frequently lack appropriate control groups. Additionally, the reported outcomes across studies have been variable, limiting the generalizability and widespread adoption of this technique[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this study, we conducted a retrospective analysis of over one year of institutional experience with ASD repair via the RAI approach. We compared the short-term outcomes of RAI and MS approaches and summarized the surgical experience to contribute further evidence supporting the clinical utility of RAI in ASD repair.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Selection Criteria\u003c/h2\u003e\u003cp\u003eThis was a single-center, retrospective, controlled study. Patients who underwent ASD repair under cardiopulmonary bypass at our institution between January 2023 and September 2024 were retrospectively enrolled and divided into either the MS group or the RAI group according to the surgical approach employed. There were four experienced pediatric cardiac surgeons performed the procedures. The exclusion criteria included: (a) the presence of concomitant intracardiac anomalies requiring concurrent surgical correction\u0026mdash;excluding partial anomalous pulmonary venous return and functional tricuspid regurgitation; and (b) a history of prior cardiac surgery.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Surgical Strategy\u003c/h2\u003e\u003cp\u003eThe surgical strategy for ASD repair via the MS approach is not elaborated here. At our center, the RAI technique is performed as follows: The patient is positioned in the right lateral decubitus position with the shoulder and back elevated approximately 60\u0026ndash;90\u0026deg;, and the right upper limb is flexed and secured. A vertical skin incision is made through the third to fifth intercostal spaces, and the thoracic cavity is entered via the fourth intercostal space. The pericardium is opened longitudinally, approximately 1.5\u0026ndash;2 cm anterior to the right phrenic nerve, extending superiorly to the pericardial reflection over the ascending aorta and inferiorly to the dome of the diaphragm. A transverse incision is then made anteriorly along the diaphragm to optimize exposure.\u003c/p\u003e\u003cp\u003eCardiopulmonary bypass is established via cannulation of the ascending aorta and both the superior and inferior vena cava. Peripheral cannulation was selectively performed in patients with a body weight above 25 kg or in those with difficult central access. The ascending aorta is cross-clamped, and cardioplegic solution is administered through the aortic root to induce cardiac arrest. After occlusion of the vena cavae, a right atriotomy is performed to expose the atrial septal defect. The defect is then repaired using an appropriately sized bovine pericardial patch. Upon completion, a chest drain is placed through the seventh intercostal space at the right midaxillary line and connected to a closed drainage system.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Research outcomes\u003c/h2\u003e\u003cp\u003eThe primary outcome of this study was the incidence of residual atrial septal shunt at the time of the last follow-up. Secondary outcomes included: (a) the incidence of perioperative adverse events; (b) the severity of tricuspid regurgitation at the final follow-up; (c) potential predictors and their cut-off values for the decision between MS and RAI ASD repair.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Statistical Analysis\u003c/h2\u003e\u003cp\u003eThe normality of continuous variables was assessed using the Shapiro\u0026ndash;Wilk test. Depending on data distribution, continuous variables were expressed as either mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD) or median with interquartile range [M (IQR)]. Group comparisons of continuous variables were performed using the student\u0026rsquo;s t-test for normally distributed data or the Wilcoxon rank-sum test for non-normally distributed data. Categorical variables were presented as counts and percentages [n (%)], and intergroup differences were evaluated using the Chi-square test or Fisher\u0026rsquo;s exact test, as appropriate.\u003c/p\u003e\u003cp\u003eWe used a random forest model to explore the surgical indications for RAI atrial septal defect (ASD) repair. The surgical approach\u0026mdash;either MS or RAI\u0026mdash;was designated as the outcome variable, while weight, height, age, sex, ASD size, and chest depth were selected as potential predictive variables. Missing data were handled using multiple imputation (n\u0026thinsp;=\u0026thinsp;3), and a random forest model was constructed for each imputed dataset (number of decision trees\u0026thinsp;=\u0026thinsp;500). Variable importance was assessed using the Mean Decrease in Gini index (MDG), and Partial Dependence Plots (PDP) were used to determine the threshold values of relevant predictors.\u003c/p\u003e\u003cp\u003eTo adjust for potential confounders, propensity score matching (PSM) was conducted in a 1:2 ratio between the RAI and MS groups. Covariates included in the matching model were age, body weight, ASD size, and the presence of associated anomalies. A caliper width of 0.2 was applied, and standardized differences of less than 0.2 were considered indicative of successful matching.\u003c/p\u003e\u003cp\u003eAll statistical analyses were two-tailed, with a significance level set at α\u0026thinsp;=\u0026thinsp;0.05. Analyses were performed using R software (version 4.3.1).\u003c/p\u003e\u003cp\u003e This study was approved by the Ethics Committee of West China Hospital [2024(2454)], and due to the retrospective nature of this study, patients\u0026rsquo; consents were waived.\u003c/p\u003e\u003c/div\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Baseline Characteristics\u003c/h2\u003e\u003cp\u003eA total of 210 patients were included in this study, comprising 67 patients in the RAI group and 143 in the MS group. Baseline characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The overall mean age of the cohort was 22.4 years. Patients in the RAI group were significantly younger than those in the MS group [2.0 (2.0\u0026ndash;4.0) years vs. 32.0 (17.5\u0026ndash;50.0) years; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. A total of 72 (34.3%) patients were male, with no significant difference in sex distribution between groups [22 (32.8%) vs. 50 (35.0%); \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.762]. The RAI group had significantly lower body weight [13.0 (12.0\u0026ndash;16.0) kg vs. 53.0 (45.0\u0026ndash;62.5) kg; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001] and smaller ASD size [19.0 (15.8\u0026ndash;22.0) mm vs. 26.5 (19.0\u0026ndash;33.0) mm; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001].\u003c/p\u003e\u003cp\u003eCongenital cardiac anomalies other than ASD were present in 11(16.4%) patients in the RAI group and 38 (26.6%) patients in the MS group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.105), with partial anomalous pulmonary venous return being the most commonly associated lesion. Regarding preoperative tricuspid regurgitation (TR), no patients in the RAI group had moderate or greater TR, whereas 10 (7.0%) patients in the MS group had moderate-to-severe TR, including 6 (4.2%) patients with severe TR (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.021).\u003c/p\u003e\u003cp\u003eAfter propensity score matching, 20 patients in the RAI group were successfully matched with 23 patients in the MS group. Love plot is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003ePost-matching baseline characteristics are also presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. There were no statistically significant differences between the two groups with respect to age, body weight, echocardiographic ASD size, presence of associated anomalies, or severity of valvular regurgitation.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline Characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003eBefore Match\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e\u003cp\u003eAfter Match\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRight Axillary Incision(n\u0026thinsp;=\u0026thinsp;67)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMedian Sternotomy(n\u0026thinsp;=\u0026thinsp;143)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eT Value/\u003c/p\u003e\u003cp\u003eχ2 Value/\u003c/p\u003e\u003cp\u003eZ Value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP Value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eRight Axillary Incision(n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eMedian Sternotomy\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eT Value/\u003c/p\u003e\u003cp\u003eχ2 Value/\u003c/p\u003e\u003cp\u003eZ Value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eP Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeight, cm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e92.0(88.0, 105.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e158.0(152.0, 164.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-14.852\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e106.4\u0026thinsp;\u0026plusmn;\u0026thinsp;28.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e112.9\u0026thinsp;\u0026plusmn;\u0026thinsp;22.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.823\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.416\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeight, kg\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13.0(12.0, 16.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53.0(45.0, 62.5.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-14.847\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e17.8(10.8, 20.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e21.0(14.0, 22.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-5.284\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.150\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15.1(13.8, 16.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.4(18.0, 23.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-15.872\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e14.5(13.4, 16.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e15.2(13.5, 17.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-5.600\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.263\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender (Male)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22(32.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50(35.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.762\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7(35.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e7(30.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.102\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.750\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, yrs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.0(2.0, 4.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32.0(17.5, 50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-14.608\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4.5(1.8, 7.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e6.0(3.0, 7.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-5.345\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.167\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eASD Size, mm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19.0(15.8, 22.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.5(19.0, 33.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-20.734\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e19.1\u0026thinsp;\u0026plusmn;\u0026thinsp;8.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e21.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.836\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.408\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMultiple Defects\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11(16.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16(11.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.696\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.291\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2(10.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4(17.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.669\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLV, mm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27.5(25.8, 31.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39.0(36.0, 42.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-16.710\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e29.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e29.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.160\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.874\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLA, mm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19.0(17.0, 21.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32.0(29.0, 36.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-16.265\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e19.0(17.8, 22.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e22.0(18.5, 25.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-4.992\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.083\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLVEF, %\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e67.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66.1\u0026thinsp;\u0026plusmn;\u0026thinsp;6.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-2.103\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.037\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e67.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e66.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.821\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.417\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTR Severity\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.117\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29(43.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42(29.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5(25.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e12(52.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMild\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25(37.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53(37.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10(50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5(21.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10(14.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30(21.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5(25.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4(14.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate to Severe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10(7.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1(4.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6(4.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1(4.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComorbidity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11(16.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38(26.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.630\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.105\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2(10.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3(13.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eArrhythmia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15(10.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.405\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.065\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1(5.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.463\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChest depth, mm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.6 (8.4, 10.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17.5(15.4, 19.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10.5 (8.2, 11.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e10.9 (10.2, 12.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.257\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e: body mass index; \u003cb\u003eASD\u003c/b\u003e: atrial septal defect; \u003cb\u003eLA\u003c/b\u003e: left atrium; \u003cb\u003eLV\u003c/b\u003e: left ventricle; \u003cb\u003eLVEF\u003c/b\u003e: left ventricle ejection fraction; \u003cb\u003eTR\u003c/b\u003e: tricuspid regurgitation. \u003cb\u003ea\u003c/b\u003e: The total rate didn\u0026rsquo;t add up to 100.0% because there were missing values.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Surgical Results\u003c/h2\u003e\u003cp\u003eSurgical results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The RAI group demonstrated significantly shorter total surgical time, cardiopulmonary bypass time, and clamp time compared to the MS group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004, and \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively). Intraoperative bleeding was also significantly lower in the RAI group [30.0 (20.0\u0026ndash;50.0) ml vs. 175.0 (100.0\u0026ndash;200.0) ml; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. There were no statistically significant differences between the two groups in the incidence of immediate residual shunt [1 (1.5%) vs. 1 (0.7%); \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.537] or in the occurrence of postoperative tricuspid regurgitation [6 (9.0%) vs. 15 (10.5%); \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.730]. However, the proportion of patients undergoing concomitant tricuspid valvuloplasty was significantly higher in the MS group [7 (10.4%) vs. 99 (69.2%); \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001].\u003c/p\u003e\u003cp\u003eThere was no significant difference in ICU stay between the two groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.257). Nonetheless, the use of inotropic agents during ICU stay was lower in the RAI group [32.8% vs. 51.0%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.031], and ventilation time also was shorter [4.0 (3.0\u0026ndash;4.8) h vs. 5.0 (4.0\u0026ndash;8.0) h; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. The RAI group also exhibited significantly lower postoperative 24-hour chest drainage volume (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and shorter drainage time (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004).\u003c/p\u003e\u003cp\u003eA small number of patients in both groups required chest tube insertion [1 (1.5%) vs. 4 (2.8%); \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.999] or postoperative blood transfusion [11 (16.4%) vs. 17 (11.9%); \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.368]. One patient in the MS group required reoperation due to anterior mitral leaflet prolapse with regurgitation. No cases of chylothorax or in-hospital mortality were observed in either group.\u003c/p\u003e\u003cp\u003eFollowing propensity score matching, cardiopulmonary bypass time was longer in the RAI group than in the MS group [64.0 (51.0\u0026ndash;68.0) min vs. 45.5 (38.8\u0026ndash;56.3) min; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.027]. Immediate postoperative outcomes were deemed satisfactory in 15 (75%) patients in the RAI group and in 20 (87%) patients in the MS group. The drainage volume in 24-hour remained significantly lower in the RAI group [42.5 (30.0\u0026ndash;97.8) mL vs. 157.5 (126.3\u0026ndash;225.0) mL; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. One patient (4.3%) in the MS group required chest tube insertion after matching.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSurgical Results\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003eBefore Match\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e\u003cp\u003eAfter Match\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRight Axillary Incision(n\u0026thinsp;=\u0026thinsp;67)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMedian Sternotomy(n\u0026thinsp;=\u0026thinsp;143)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eT Value/\u003c/p\u003e\u003cp\u003eχ2 Value/\u003c/p\u003e\u003cp\u003eZ Value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP Value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eRight Axillary Incision(n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eMedian Sternotomy\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eT Value/\u003c/p\u003e\u003cp\u003eχ2 Value/\u003c/p\u003e\u003cp\u003eZ Value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eP Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgical Time, min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e155.0(131.0, 177.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e183.0(155.5, 240.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-20.096\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e156.0(138.8, 195.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e138.0(121.5, 168.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-8.206\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.137\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCPB, min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e58.0(48.0, 67.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e68.0(53.0, 93.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-25.287\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e64.0(51.0, 68.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e45.5(38.8, 56.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-9.776\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.027\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClamp Time, min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29.0(20.3, 36.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39.0(30.0, 49.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-24.263\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e31.0(20.0, 38.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e24.5(19.8, 31.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-9.070\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.265\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntraoperative Bleeding, ml\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30.0(20.0, 50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e175.0(100.0, 200.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-22.384\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e40.0(17.5, 100.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e50.0(30.0, 90.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-8.668\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.228\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImmediate TR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6(9.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15(10.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.119\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.730\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3(15.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3(13.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImmediate Residual Shunt\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1(1.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1(0.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.537\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTricuspid Valve Repair\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7(10.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e99(69.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e63.066\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4(20.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5(21.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICU Stay, d\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.0(1.0, 3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.0(1.1, 3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-23.963\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.257\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2.0(1.4, 4.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.0(1.0, 2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-8.023\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.187\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInotropes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22(32.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e73(51.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.109\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.013\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e11(55.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e7(30.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2.652\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.103\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVentilation Time, h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.0(3.0, 4.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.0(4.0, 8.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-21.378\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4.0(3.0, 4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4.0(3.3, 5.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-6.635\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.479\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRe-Intubation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1(0.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eECMO\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDrainage in 24h, ml\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e63.0(32.0, 121.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e270.0(190.0, 380.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-16.076\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e42.5(30.0, 97.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e157.5(126.3, 225.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-3.725\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDrainage Time, d\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.0(2.5, 4.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.0(3.5, 5.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-22.189\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-2.681\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.013\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChest Tube Insertion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1(1.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4(2.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1(4.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIn Hospital Reoperation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1(0.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTransfusion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11(16.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17(11.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.810\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.368\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2(10.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5(21.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.420\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChylothorax\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCPB\u003c/b\u003e: cardiopulmonary bypass; \u003cb\u003eTR\u003c/b\u003e: tricuspid regurgitation; \u003cb\u003eICU\u003c/b\u003e: intensive care unit; \u003cb\u003eECMO\u003c/b\u003e: Extracorporeal Membrane Oxygenation.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Follow-up Outcomes\u003c/h2\u003e\u003cp\u003eFollow-up Outcomes are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Before propensity score matching, the median follow-up time was comparable between the two groups [8.0 (3.0\u0026ndash;12.0) months vs. 6.0 (3.0\u0026ndash;11.0) months; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.767]. One patient in each group still had residual shunting during the last follow-up (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.544). The incidence of postoperative arrhythmia was significantly higher in the MS group [2 (3.0%) vs. 18 (12.6%); \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.024]. Readmission occurred in 4 (6.0%) patients in the RAI group (all due to delayed wound healing) and in 9 (6.3%) patients in the MS group (due to delayed wound healing, low cardiac output syndrome, and pulmonary hypertension) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.999).\u003c/p\u003e\u003cp\u003eAfter matching, median follow-up time remained similar between groups [7.0 (3.0\u0026ndash;10.0) months vs. 6.0 (3.0\u0026ndash;10.0) months; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.453]. No residual shunt was observed in either group. Mild tricuspid regurgitation was observed in 4 (20.0%) patients in the RAI group and in 5 (21.7%) patients in the MS group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.999). Two (10.0%) patients in the RAI group and one (4.3%) patient in the MS group were readmitted due to delayed wound healing.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFollow-up Outcomes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003eBefore Match\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e\u003cp\u003eAfter Match\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRight Axillary Incision(n\u0026thinsp;=\u0026thinsp;67)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMedian Sternotomy\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;143)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eT Value/\u003c/p\u003e\u003cp\u003eχ2 Value/\u003c/p\u003e\u003cp\u003eZ Value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP Value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eRight Axillary Incision(n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eMedian Sternotomy(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eT Value/\u003c/p\u003e\u003cp\u003eχ2 Value/\u003c/p\u003e\u003cp\u003eZ Value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eP Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResidual Shunt\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1(1.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1(0.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.544\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLV, mm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31.0(28.5, 34.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e44(40.8, 47.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-15.751\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e34.0(28.8, 37.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e33.0(30.5, 36.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-6.733\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.990\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLA, mm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20.0(18.0, 23.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33.0(28.0, 36.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-19.031\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e21.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e23.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1.420\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.165\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLVEF, %\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e68.0(63.0, 72.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67.5(63.0, 70.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-25.678\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.723\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e66.1\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e68.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1.164\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.253\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTR Severity\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57(85.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e118(82.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e16(80.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e18(78.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMild\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10(14.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21(14.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4(20.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5(21.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1(0.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate to Severe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eArrhythmia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18(12.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.068\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1(5.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2(8.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReadmission\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4(6.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9(6.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2(10.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1(4.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.590\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFollow-up Time, months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.0(3.0, 12.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.0(3.0, 11.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-23.562\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.767\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7.0(3.0, 10.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e6.0(3.0, 10.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-7.451\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.453\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLA\u003c/b\u003e: left atrium; \u003cb\u003eLV\u003c/b\u003e: left ventricle; \u003cb\u003eLVEF\u003c/b\u003e: left ventricle ejection fraction; \u003cb\u003eTR\u003c/b\u003e: tricuspid regurgitation. \u003cb\u003ea\u003c/b\u003e: The total rate didn\u0026rsquo;t add up to 100.0% because there were missing values.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Prediction Outcomes\u003c/h2\u003e\u003cp\u003eIn the random forest analysis, the importance of potential predictive variables for determining the surgical approach was assessed using MDG, as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The results indicated that the importance order of the included variables is: weight\u0026thinsp;\u0026gt;\u0026thinsp;age\u0026thinsp;\u0026gt;\u0026thinsp;height\u0026thinsp;\u0026gt;\u0026thinsp;chest depth. To further elucidate the clinical utility of these predictors, PDPs were generated for each variable to approximate optimal thresholds that may provide guidance for surgical decision-making. Based on these analyses, favorable conditions for selecting RAI included: weight\u0026thinsp;\u0026lt;\u0026thinsp;20 kg, age\u0026thinsp;\u0026lt;\u0026thinsp;8 years, height\u0026thinsp;\u0026lt;\u0026thinsp;105 cm, and chest depth\u0026thinsp;\u0026lt;\u0026thinsp;12 cm.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eAtrial septal defect (ASD) is the third most common congenital cardiac anomaly and remains one of the most frequently surgical treated congenital heart diseases[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Both transcatheter device closure and surgical patch repair under cardiopulmonary bypass are established first-line treatment strategies. However, due to anatomical limitations, transcatheter closure is not suitable for all patients, making surgical repair the only viable option in select cases[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Since the first surgical repair of ASD by Lewis and Varco in 1952, techniques have undergone substantial evolution and refinement[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Although median sternotomy (MS) provides excellent exposure, it is associated with increased surgical trauma, less favorable cosmetic outcomes, and potential psychological impact [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In recent years, various minimally invasive alternatives have been introduced to minimize invasiveness and improve cosmetic satisfaction, including lower partial sternotomy[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], anterior thoracotomy[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], posterolateral thoracotomy [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], and right axillary incision (RAI) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Due to its adequate exposure, low complication rate, and aesthetic benefits, RAI has gained increasing attention.\u003c/p\u003e\u003cp\u003eWhile MS remains the primary approach at most institutions, our center adopts a selective strategy. MS is the default technique; however, RAI is preferred in pediatric patients and young females, aiming to maintain surgical efficacy while optimizing postoperative cosmesis. Cardiopulmonary bypass is typically established via ascending aortic and bicaval cannulation, although femoral cannulation has also been described[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In selected patients, we externalize the inferior vena cava cannula through a small chest wall stab incision to enhance exposure and facilitate drainage. Interestingly, although the CPB time was shorter in the RAI group before matching, it became significantly longer after matching. This reversal may be attributed to the inherent technical challenges and steep learning curve associated with the right axillary approach. In our early experience, the RAI procedure required more time for peripheral cannulation, atrial exposure, and intracardiac repair due to the limited working space and altered anatomical orientation. These factors were particularly evident in operations performed by less experienced surgeons during the initial implementation phase. Importantly, the longer CPB time did not correlate with increased complication rates or prolonged recovery, supporting the overall safety of the minimally invasive approach despite its technical demands.\u003c/p\u003e\u003cp\u003eAlthough off-pump ASD repair has been reported, limited visualization, increased intraoperative bleeding, and technical challenges have hindered its widespread adoption. Therefore, our institution continues to perform repair on an arrested heart. In a previous study by Martin-Garcia et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], 18 of 162 patients (11.1%) underwent tricuspid valvuloplasty, primarily using annuloplasty or direct suture repair, consistent with our approach. Given the younger patient population in the RAI group, suture techniques are typically favored.\u003c/p\u003e\u003cp\u003eRegarding baseline characteristics, we included patients with ASD sizes of 10 mm or greater, whereas smaller defects are generally treated with device closure. This inclusion threshold aligns with earlier studies[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Unlike most prior research that focused on children under 12 years of age, our study enrolled patients across a broader age range, enabling comprehensive evaluation of short-term outcomes and cosmetic satisfaction in a more diverse population. As age increases, valvular regurgitation becomes more prevalent, leading to a higher likelihood of concomitant tricuspid repair. To minimize bias, propensity score matching (PSM) was applied to balance baseline variables and mitigate confounding effects.\u003c/p\u003e\u003cp\u003eIn a study by Dave et al.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], only 2 of 123 patients (0.02%) exhibited trace or greater residual shunting postoperatively, a finding consistent with our results. Among 210 patients in our cohort, two exhibited immediate postoperative residual shunts\u0026mdash;one in each group. In the RAI group, a 1-mm shunt was noted on TEE and resolved by 3-month TTE follow-up. In the MS group, a 4-mm residual shunt was observed, which also resolved on follow-up.\u003c/p\u003e\u003cp\u003eAmong 35 RAI patients with mild or greater tricuspid regurgitation, only 7 (20%) patients underwent tricuspid repair, whereas all 99 MS patients with similar findings received surgical correction. Intraoperative TEE revealed residual tricuspid regurgitation in 6 RAI patients who did not receive repair, with spontaneous resolution observed in 78.6% (22/28) of cases. Conversely, 15 MS patients had residual regurgitation intraoperatively, likely reflecting more advanced valvular pathology due to older age. Notably, although the tricuspid valve repair rate was significantly higher in the MS group compared to the RAI group, the postoperative residual TR rate was similar between the two. This finding may reflect baseline differences in the severity of valvular involvement. Patients in the MS group were generally older and had longer-standing ASDs, which likely resulted in more prolonged right ventricular volume overload and annular dilation[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. These pathophysiological changes may have led surgeons to adopt a lower threshold for performing tricuspid valve repair during MS procedures. Therefore, the higher rate of intervention in the MS group likely reflects more advanced disease rather than overcorrection, whereas the lower intervention rate in the RAI group may be due to earlier intervention and less severe valvular changes. This interpretation aligns with existing evidence that the duration of volume overload plays a critical role in the progression of TR severity[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDuring follow-up, persistent tricuspid regurgitation was observed in 32 patients: 10 in the RAI group and 22 in the MS group. All 10 RAI patients had preoperative regurgitation and did not undergo tricuspid repair; none developed new-onset regurgitation. In the MS group, 22 patients had postoperative regurgitation, including 2 with residual regurgitation post-repair, 8 with no residual regurgitation post-repair, 1 who developed regurgitation without repair, and 11 who neither underwent repair nor exhibited intraoperative regurgitation. Excluding patients with persistent intraoperative regurgitation, the de novo regurgitation rate in the MS group was 19.2% (19/99).\u003c/p\u003e\u003cp\u003eIn both groups, only one case of postoperative residual shunt was observed, and no reoperations were required, consistent with the findings of Yang et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, in Yang\u0026rsquo;s study, none of the 17 RAI patients required readmission for wound-related complications, whereas 7 of 29 MS patients did (P\u0026thinsp;=\u0026thinsp;0.047), indicating a higher infection risk with MS. In contrast, our study noted 4 readmissions in each group for wound-related issues. This discrepancy may be attributed to the RAI incision's proximity to the axilla and increased subcutaneous fat in pediatric patients, making wound care more challenging[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe increased incidence of postoperative arrhythmias in the MS group is likely multifactorial[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. One contributing factor is the surgical technique itself: median sternotomy provides broader exposure of the atria and generally requires more extensive atrial manipulation, which may increase the likelihood of transient or sustained conduction disturbances. Additionally, patients in the MS group were significantly older compared to those in the RAI group. Age is a well-recognized risk factor for arrhythmogenesis due to progressive atrial fibrosis and electrophysiological remodeling[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Moreover, the average ASD diameter was larger in the MS group, suggesting a longer duration of left-to-right shunting and more pronounced atrial volume overload, both of which may predispose to structural atrial remodeling and subsequent arrhythmia[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. These combined anatomical and clinical factors likely explain the higher arrhythmia rate observed following the MS approach.\u003c/p\u003e\u003cp\u003eIn exploring potential predictors for selecting between RAI and MS approaches, we employed a random forest model and assessed variable importance using MDG. This analysis identified four key predictors and ranked them in order of importance, with approximate threshold values determined via partial dependence plots. Based on these findings, we propose that patients meeting specific criteria may be better suited for the RAI approach, providing a potential reference for tailoring surgical strategy. However, given the single-center, retrospective nature of this study and the variability in surgical approach preference among different surgeons, we recommend interpreting these predictor rankings and thresholds as preliminary guidance rather than definitive criteria.\u003c/p\u003e\u003cp\u003eThe cosmetic advantages of the RAI approach have been well documented. Schreiber et al.[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] noted that avoiding disruption of major muscle groups and breast tissue contributes to improved cosmetic outcomes, and a small axillary incision is effective in achieving these goals. Yang et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] utilized the Vancouver Scar Scale to quantify cosmetic outcomes, reporting a 100% satisfaction rate (17/17) in the RAI group versus 66.7% (18/27) in the MS group (P\u0026thinsp;=\u0026thinsp;0.018). Although we did not employ formal scar assessment tools, patients in the RAI group reported high levels of subjective satisfaction with postoperative wound appearance during the follow-up times.\u003c/p\u003e\u003cp\u003eThis study has several limitations: \u003cb\u003ea.\u003c/b\u003e As a single-center cohort study, the overall sample size, though larger than in previous studies, remains relatively limited after propensity score matching, with a smaller number of matched pairs and relatively short follow-up duration. Therefore, the findings require validation in studies with larger sample sizes and longer follow-up periods; \u003cb\u003eb.\u003c/b\u003e Aesthetic outcomes were not formally assessed using standardized questionnaires or rating scales. As such, the cosmetic advantages of the right axillary incision compared to the median sternotomy remain to be further investigated; \u003cb\u003ec.\u003c/b\u003e Given that the choice of surgical approach and technical nuances may vary among surgeons, the findings of this study primarily reflect the operative idea and decision-making patterns at our institution, which may limit the generalizability of the conclusions.\u003c/p\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eBased on the findings of this study, we draw the following conclusions: \u003cb\u003ea.\u003c/b\u003e The RAI approach for ASD repair demonstrates favorable safety, efficacy, and satisfactory short-term outcomes; \u003cb\u003eb.\u003c/b\u003e The RAI is superior to MS in reducing surgical trauma, but there is no difference in the main outcomes; \u003cb\u003ec.\u003c/b\u003e Weight, age, height, and chest depth are potential predictors in assisting the decision-making between RAI and MS approaches for ASD repair.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eASD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 558px;\"\u003e\n \u003cp\u003eAtrial Septal Defect\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eRAI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 558px;\"\u003e\n \u003cp\u003eRight Axillary Incision\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eMS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 558px;\"\u003e\n \u003cp\u003eMedian Sternotomy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eMDG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 558px;\"\u003e\n \u003cp\u003eMean Decrease in Gini\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003ePDP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 558px;\"\u003e\n \u003cp\u003ePartial Dependence Plots\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003ePSM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 558px;\"\u003e\n \u003cp\u003ePropensity Score Matching\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 558px;\"\u003e\n \u003cp\u003eBody Mass Index\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eLV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 558px;\"\u003e\n \u003cp\u003eLeft Ventricle\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eLA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 558px;\"\u003e\n \u003cp\u003eLeft Atrium\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eLVEF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 558px;\"\u003e\n \u003cp\u003eLeft Ventricle Ejection Fraction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eTR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 558px;\"\u003e\n \u003cp\u003eTricuspid Regurgitation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eCPB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 558px;\"\u003e\n \u003cp\u003eCardiopulmonary Bypass\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 558px;\"\u003e\n \u003cp\u003eIntensive Care Unit\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eECMO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 558px;\"\u003e\n \u003cp\u003eExtracorporeal Membrane Oxygenation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003emm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 558px;\"\u003e\n \u003cp\u003eMillimeter\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003ecm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 558px;\"\u003e\n \u003cp\u003eCentimeter\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003emin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 558px;\"\u003e\n \u003cp\u003eMinute\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 558px;\"\u003e\n \u003cp\u003eHour\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003ed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 558px;\"\u003e\n \u003cp\u003eDay\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eyrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 558px;\"\u003e\n \u003cp\u003eyears\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eTEE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 558px;\"\u003e\n \u003cp\u003eTransesophageal Echocardiography\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eTTE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 558px;\"\u003e\n \u003cp\u003eTransthoracic Echocardiography\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThis study was approved by the Ethics Committee of West China Hospital [2024(2454)], and due to the retrospective nature of this study, The requirement for individual informed consent was waived by the Institutional Review Board of the Ethics Committee of West China Hospital, in accordance with national regulations. This study was conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials:\u0026nbsp;\u003c/strong\u003eThe data that support the findings of this study are available from the Corresponding Author, Ke Lin, upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThe authors received no specific funding for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u0026nbsp;\u003c/strong\u003eJingyu Liu, Zhuheng Wu, Lin Xie contributed in study design, data collection, investigation, data analysis, visualization and manuscript drafting;\u0026nbsp;Xingyu Zheng contributed in\u0026nbsp;data collection,\u0026nbsp;visualization and manuscript drafting; Ke Lin contributed in study design, investigation, supervision, validation and manuscript review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement:\u003c/strong\u003e Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBradley EA, Zaidi AN. Atrial Septal Defect. Cardiology clinics. 2020;38(3):317-24.\u003c/li\u003e\n\u003cli\u003eDave HH, Comber M, Solinger T, Bettex D, Dodge-Khatami A, Pr\u0026ecirc;tre R. Mid-term results of right axillary incision for the repair of a wide range of congenital cardiac defects. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. 2009;35(5):864-9; discussion 9-70.\u003c/li\u003e\n\u003cli\u003eAn G, Zhang H, Zheng S, Wang W, Wu Q, Xing Q. Minimally invasive surgical closure for doubly committed subarterial ventricular septal defects through a right subaxillary thoracotomy. Interactive cardiovascular and thoracic surgery. 2016;23(6):924-8.\u003c/li\u003e\n\u003cli\u003eBleiziffer S, Schreiber C, Burgkart R, Regenfelder F, Kostolny M, Libera P, et al. The influence of right anterolateral thoracotomy in prepubescent female patients on late breast development and on the incidence of scoliosis. The Journal of thoracic and cardiovascular surgery. 2004;127(5):1474-80.\u003c/li\u003e\n\u003cli\u003eCherup LL, Siewers RD, Futrell JW. Breast and pectoral muscle maldevelopment after anterolateral and posterolateral thoracotomies in children. The Annals of thoracic surgery. 1986;41(5):492-7.\u003c/li\u003e\n\u003cli\u003eAn K, Li S, Yan J, Wang X, Hua Z. Minimal Right Vertical Infra-axillary Incision for Repair of Congenital Heart Defects. The Annals of thoracic surgery. 2022;113(3):896-902.\u003c/li\u003e\n\u003cli\u003e王文杰, 雷雨, 陶杰, 白向锋, 梅松, 李斌. 右腋下小切口及正中开胸在房间隔缺损修补术中的效果对比 %J 云南医药. 2023;44(01):17-20.\u003c/li\u003e\n\u003cli\u003eYang X, Hu Y, Dong J, Huang P, Luo J, Yang G, et al. Rightvertical axillary incision for atrial septal defect: a propensity score matched study. Journal of cardiothoracic surgery. 2022;17(1):256.\u003c/li\u003e\n\u003cli\u003eLiu H, Wang Z, Xia J, Hu R, Wu Z, Hu X, et al. Evaluation of Different Minimally Invasive Techniques in Surgical Treatment for Ventricular Septal Defect. Heart, lung \u0026amp; circulation. 2018;27(3):365-70.\u003c/li\u003e\n\u003cli\u003eYan L, Zhou ZC, Li HP, Lin M, Wang HT, Zhao ZW, et al. Right vertical infra-axillary mini-incision for repair of simple congenital heart defects: a matched-pair analysis. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. 2013;43(1):136-41.\u003c/li\u003e\n\u003cli\u003eWang Q, Li Q, Zhang J, Wu Z, Zhou Q, Wang DJ. Ventricular septal defects closure using a minimal right vertical infraaxillary thoracotomy: seven-year experience in 274 patients. The Annals of thoracic surgery. 2010;89(2):552-5.\u003c/li\u003e\n\u003cli\u003ePr\u0026ecirc;tre R, Kadner A, Dave H, Dodge-Khatami A, Bettex D, Berger F. Right axillary incision: a cosmetically superior approach to repair a wide range of congenital cardiac defects. The Journal of thoracic and cardiovascular surgery. 2005;130(2):277-81.\u003c/li\u003e\n\u003cli\u003eSilva Lda F, Silva JP, Turquetto AL, Franchi SM, Cascudo CM, Castro RM, et al. Horizontal right axillary minithoracotomy: aesthetic and effective option for atrial and ventricular septal defect repair in infants and toddlers. Revista brasileira de cirurgia cardiovascular : orgao oficial da Sociedade Brasileira de Cirurgia Cardiovascular. 2014;29(2):123-30.\u003c/li\u003e\n\u003cli\u003eWatanabe N, Hapak A, Nasirov T. \u0026quot;Invisible\u0026quot; Incision: Modified Horizontal Right Axillary Mini-Thoracotomy for Pediatric Cardiac Surgery. Annals of thoracic surgery short reports. 2023;1(1):99-101.\u003c/li\u003e\n\u003cli\u003eLuo ZR, Chen Q, Yu LL, Chen LW, Huang ZY. Comparative Study between Surgical Repair of Atrial Septal Defect via Median Sternotomy, Right Submammary Thoracotomy, and Right Vertical Infra-Axillary Thoracotomy. Brazilian journal of cardiovascular surgery. 2020;35(3):285-90.\u003c/li\u003e\n\u003cli\u003eBotto LD, Correa A, Erickson JD. Racial and temporal variations in the prevalence of heart defects. Pediatrics. 2001;107(3):E32.\u003c/li\u003e\n\u003cli\u003eThomson JD, Aburawi EH, Watterson KG, Van Doorn C, Gibbs JL. Surgical and transcatheter (Amplatzer) closure of atrial septal defects: a prospective comparison of results and cost. Heart (British Cardiac Society). 2002;87(5):466-9.\u003c/li\u003e\n\u003cli\u003eMurray G. Closure of defects in cardiac septa. Annals of surgery. 1948;128(4):843-53.\u003c/li\u003e\n\u003cli\u003eLewis FJ, Taufic M. Closure of atrial septal defects with the aid of hypothermia; experimental accomplishments and the report of one successful case. Surgery. 1953;33(1):52-9.\u003c/li\u003e\n\u003cli\u003eLee T, Weiss AJ, Williams EE, Kiblawi F, Dong J, Nguyen KH. The Right Axillary Incision: A Potential New Standard of Care for Selected Congenital Heart Surgery. Seminars in thoracic and cardiovascular surgery. 2018;30(3):310-6.\u003c/li\u003e\n\u003cli\u003eSeipelt RG, Popov A, Danner B, Paul T, Tirilomis T, Schoendube FA, et al. Minimally invasive partial inferior sternotomy for congenital heart defects in children. The Journal of cardiovascular surgery. 2010;51(6):929-33.\u003c/li\u003e\n\u003cli\u003eMishaly D, Ghosh P, Preisman S. Minimally invasive congenital cardiac surgery through right anterior minithoracotomy approach. The Annals of thoracic surgery. 2008;85(3):831-5.\u003c/li\u003e\n\u003cli\u003eYoshimura N, Yamaguchi M, Oshima Y, Oka S, Ootaki Y, Yoshida M. Repair of atrial septal defect through a right posterolateral thoracotomy: a cosmetic approach for female patients. The Annals of thoracic surgery. 2001;72(6):2103-5.\u003c/li\u003e\n\u003cli\u003eMartin-Garcia AC, Dimopoulos K, Boutsikou M, Martin-Garcia A, Kempny A, Alonso-Gonzalez R, et al. Tricuspid regurgitation severity after atrial septal defect closure or pulmonic valve replacement. Heart (British Cardiac Society). 2020;106(6):455-61.\u003c/li\u003e\n\u003cli\u003eDonal E, Yamada H. Do not underestimate the impact of load and of remodelling capabilities of the right heart. Heart (British Cardiac Society). 2022;108(24):1926-7.\u003c/li\u003e\n\u003cli\u003eGuler S, Reyhancan A, Kubat E, Onan IS, Kadirogullari E, Onan B. Impact of additional annuloplasty on tricuspid valve and cardiac functions after atrial septal defect closure in adults. Journal of cardiac surgery. 2020;35(11):2895-901.\u003c/li\u003e\n\u003cli\u003eTran DM, Tran VQ, Nguyen MT, Mai DD, Doan AV, Hoang ST, et al. Minimally Invasive Surgical Repair of Simple Congenital Heart Defects Using the Right Vertical Infra-Axillary Thoracotomy Approach. Innovations (Philadelphia, Pa). 2024;19(5):520-5.\u003c/li\u003e\n\u003cli\u003eJacquemart E, Bessi\u0026egrave;re F, Combes N, Ladouceur M, Iserin L, Gardey K, et al. Incidence, Risk Factors, and Outcomes of Atrial Arrhythmias in Adult Patients With Atrioventricular Septal Defect. JACC Clinical electrophysiology. 2022;8(3):331-40.\u003c/li\u003e\n\u003cli\u003eKrause U. Age Matters: Atrial Arrhythmias in Adult Patients With Atrioventricular Septal Defect. JACC Clinical electrophysiology. 2022;8(3):341-2.\u003c/li\u003e\n\u003cli\u003eDeaconu S, Deaconu A, Marascu G, Stanculescu MO, Cozma D, Cinteza E, et al. Arrhythmic Risk and Treatment after Transcatheter Atrial Septal Defect Closure. Diagnostics (Basel, Switzerland). 2023;14(1).\u003c/li\u003e\n\u003cli\u003eSchreiber C, Bleiziffer S, Lange R. Midaxillary lateral thoracotomy for closure of atrial septal defects in pre-pubescent female children: reappraisal of an \u0026quot;old technique\u0026quot;. Cardiology in the young. 2003;13(6):565-7.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Atrial septal defect, Right axillary incision, Median sternotomy, Short-term outcome","lastPublishedDoi":"10.21203/rs.3.rs-7427189/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7427189/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eTo compare the short-term outcomes of atrial septal defect (ASD) repair via right axillary incision (RAI) versus median sternotomy (MS).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis single-center, retrospective, controlled study aimed to compare the short-term outcomes of ASD repair performed via right axillary incision versus median sternotomy. The primary endpoint was the incidence of postoperative residual shunt.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 210 patients were included in this study, with 67 patients in the RAI group and 143 patients in the MS group. The overall mean age of enrolled patients was 22.4 years, and 72 (34.3%) patients of them were male. The RAI group had less intraoperative bleeding (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), shorter ventilation time (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and shorter drainage time (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004). The overall median follow-up time was 6.0 (3.0\u0026ndash;11.0) months. During the last follow-up, residual shunt was observed in one patient in each group [1 (1.5%) vs. 1 (0.7%); \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.544]. During propensity score matching, 20 patients from the RAI group and 23 from the MS group were successfully matched. After match, the RAI group exhibited longer cardiopulmonary bypass time (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.027), less drainage time (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.013) and less drainage in 24 hours (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No patient from either group still had residual shunt during the last follow-up. Weight, age, height, and chest depth were identified as potential predictors in assisting the decision-making between RAI and MS approaches.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe RAI approach is a safe option for ASD repair with satisfactory outcomes. 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