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22 t m c » p u l s e | o c t o b e r 2 0 1 8 Ali Dodge-Khatami, M.D., Ph.D., an Iranian-born surgeon who was raised and trained in Switzerland, arrived in Houston in July—right after the Nations Baseball World Series and just before fall tryouts. Dodge-Khatami is director of pediatric heart surgery at McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth) and an attending pediatric cardiovascular surgeon at the Children's Heart Center at Children's Memorial Hermann Hospital. "We were presented with three options that would have been possibili- ties to repair the hole," Julie said. "One would have been to have a heart catheter through the groin, which is an overnight procedure—done and done. The second was a method through the armpit—the right axillary thoracotomy. Or, the third, through the chest." Ethan did not have the proper amount of tissue to qualify for the heart catheter through the groin. Ultimately, the Page family chose the right axillary thoracotomy. A window to the heart A right axillary thoracotomy for transa- trial repair of congenital heart defects is a highly uncommon approach in pediatric cardiology in the United States today. Dodge-Khatami is one of a hand- ful of doctors in the country doing this surgery, according to administrators at Children's Memorial Hermann. "What will happen over time is, peo- ple will train on this, expand it and then people will be in a fellowship program for congenital heart surgery and they will learn how to do it," said Kevin P. Lally, M.D., surgeon-in-chief, Children's Memorial Hermann Hospital, and chair of the department of pediatric surgery at McGovern Medical School at UTHealth. "I am confident that for certain opera- tions, this will clearly be the approach, but it will take a while." Dodge-Khatami begins by making a roughly four-inch incision (depending on the size of the patient) down the right side of the chest, underneath the armpit. Once the incision is made, he separates two ribs—the third and fourth or the fourth and fifth—with a chest-spreader. "Entering on the right side places you at a bit of a distance away from the heart," Dodge-Khatami said. "It gives you less room to operate in, so there is definitely a learning curve to this." Once he separates the patient's ribs, Dodge-Khatami pushes through layers of muscle and tissue, passing the lungs to eventually reach the heart. "What everybody has in between two ribs is muscles," he explained. "You do have to cut one muscle, which you put back together at the end … You don't actually cut the middle of the muscle. Whenever you cut perpendicularly through a muscle, even when you suture it up at the end, that muscle doesn't have the same function or strength as it otherwise would, so what we try to do are muscle-sparing incisions." Keeping cuts to a minimum—spread- ing muscles as opposed to clipping muscles on the way to the heart—offers huge benefits for his patients. "To get to the heart, there are various layers of muscles that all of us have in