**2.1 Transesophageal echocardiography**

Routine TEE imaging is helpful in the surgical repair of CHD in children. Performance of TEE in these patients submitted to MICS represents a great contributor to the overall excellence in outcome for CHD. The TEE that has been used intraoperatively since the 1980s [17, 18] is a mainstay of monitoring during simple and complex pediatric cardiovascular surgery [19, 20], especially in MICS, since it provides dynamic control and intraoperative anatomical information but also:


It has been especially valuable in the operating room where it is used preoperatively to confirm or modify anatomical diagnoses which have been established by TTE and angiography and also identifies possible additional pathologic conditions to delineate anatomy and structural details that may have remained ill-defined by transthoracic imaging [23–25]. The technological advancements, particularly the use of small probe sizes, have significantly improved patient safety and success of cardiac surgery in infants and children [26–33].

The probe is usually inserted by the anesthesiologist, after induction of general anesthesia, and it is used for all the time of operation with a Philips Sonos IE33 echocardiography machines (Philips, Andover, MA) equipped with pulsed, continuous wave, color Doppler, and 3D capabilities. In patients >20 kg, we have been using an adult probe (xMatrix probe: X7-2t; 3D matrix array probe; 2–7 MHz; Philips, Andover, MA) with 2500 elements per transducer and, on the contrary, in pediatric patients (whose weight is between 4.0 and 20.0 kg), a pediatric probe (Mini Multi probe: S7-3t; 3–7 MHz; Philips, Andover, MA) with 64 elements per transducer and dimensions of 10.7 mm (tip width) and 8.0 mm (tip height).

These clinical benefits, a growing number of highly skilled operators, and improvements in technology have led to the rapid adoption of TEE monitoring in pediatric cardiac surgery with remarkable advances in the management of patients with congenital heart disease in this particular setting.

### **2.2 Anesthesia care**

In recent years, "FastTrack" management (FTM), in the perioperative care of patients with CHD, with early tracheal extubation after cardiac surgery, has become increasingly popular [34–37] especially in MICS, with the delivery of cost-efficient care considered as an additional variable when measuring and comparing surgical outcomes [37, 38].

Potential advantages were previously described [38]:


In this context, anesthesia should not be managed by a strict protocol. A general institutional approach for children who are candidates to FastTrack extubation consisted of induction of anesthesia with thiopental 5 mg/kg, fentanyl 3 mcg/ kg, and rocuronium 0.9 mg/kg. During surgery and cardiopulmonary bypass (CPB), anesthesia is maintained with remifentanil 0.5–1 mcg/kg/min and propofol 3–5 mg/kg. Muscle relaxants are given again before CPB at 0.15 mg/kg. The patient is monitored as routine (ECG, pulse oximetry, invasive arterial pressure, central venous pressure, diuresis, temperature, and somatic and cerebral near-infrared spectroscopy (NIRS)). Shortly before the end of the surgery, remifentanil is discontinued, and intravenous morphine (0.1–0.2 mg/kg) or fentanyl (1–2 mcg/ kg) is administered. When surgery is over, according to FTM protocol, the neuromuscular block is reversed by the intravenous administration of atropine, 0.01 mg/ kg, and neostigmine, 0.05 mg/kg. Immediate post-extubation analgesia or sedation in children includes a single administration of rectal paracetamol (40–50 mg/kg),

**73**

*Minimally Invasive Approach in Surgery for Congenital Heart Disease*

a bolus of morphine 0.05 mg/kg iv or fentanyl 0.5–1 mcg/kg iv, and/or midazolam

For the first 24 postoperative hours, morphine is given by continuous iv in most patients. Pain scores and vital signs are recorded by the bedside nurse, on an hourly basis throughout the day, or, when appropriate, by the parents or even by the child, if it is old enough to report his/her pain scores on a 0–10 pain scale. Supplemental analgesia is administrated if required, according to the recorded pain scores. Despite this program, extubation in the OR after pediatric cardiac surgery is to be meditated. In order to migrate to a routine practice of early extubation, it is necessary that surgeons, anesthesiologists, intensivists, perfusionists, and nurses have the same mindset and cooperate to achieve this goal and the final decision. Extubation, either in the operating room or in the ICU, is usually decided based on clinical evaluation and also considering some operative parameters such as bypass and aortic cross-clamp times, the complexity of surgery, requirement of high dosage inotropic support, hemodynamic stability, and occurrence of persistent bleeding. Operating room extubation is usually not performed if there are signs of airway compromise, hemodynamic instability requiring bolus delivery of vasopressors, cardiac rhythm instability, excessive bleeding, or core temperature < 35°C.

In patients submitted to VATS, postoperative pain is significant, especially early after surgery [39, 40], and higher than sternotomy. For these reasons, there has been an increased interest in the use of paravertebral block (PVB). The intercostal nerves are relatively devoid of covering fascia as they traverse the paravertebral space, making it an ideal location for local anesthetic blockade [41]. The PVB technique includes the use of ultrasound [42] with a linear probe at high frequency in pediatric patient with weight > 15 kg, alternatively, which can be performed by a single injection at the level of paravertebral space intraoperatively under direct vision by the surgeon [43] or anesthesiologists prior to chest closure [44]. The single-shot multilevel PVB with ropivacaine 0.5% has a place in these procedures (max 0.4 ml/kg at the fifth intercostal space), with analgesic benefits seen in the

In this kind of patients, a change in the attitude of surgeons, anesthesiologists, perfusionists, and nurses, combined with appropriate anesthetic and surgical

According to our minimally invasive surgical protocol [45], a direct aortic and bicaval cannulation is usually employed in patients with a body weight of less than 10 kg. Since 2006, in larger patients, we have routinely used a peripheral arterial and venous cannulation [46–48] for establishing the cardiopulmonary bypass (CPB). This is achieved by percutaneous cannulation of the superior vena cava (SVC) followed by surgical isolation and cannulation of the

The SVC peripheral cannulation is usually performed by a trained anesthesiologist with experience with patients with CHD, using 2D transesophageal echo (TEE) guidance (**Figure 2**), after 100 U/kg of heparin has been systemically administered [46]. The internal jugular vein is punctured and dilated, and then an SVC (Medtronic Biomedicus 96,570 Next Gen, MN, USA) is inserted and positioned under TEE monitoring, about 1 cm above the SVC-right atrial junction. Currently, we reserve this approach to DVAPP, in which the presence of pulmonary veins in the SVC may complicate the traditional SVC cannulation through a small incision. In all other cases, as experience has increased, we have recently moved to a direct SVC cannulation with a right angle metal tipped venous cannula (Medtronic DLP single

first few hours, and can reduce long-term adverse pain outcomes.

techniques, permitted better results and outcomes.

femoral vessels (**Figure 1**).

**2.3 Cardiopulmonary bypass and operative strategies**

*DOI: http://dx.doi.org/10.5772/intechopen.87136*

0.05–1 mg/kg iv, with repeated boluses as needed.

#### *Minimally Invasive Approach in Surgery for Congenital Heart Disease DOI: http://dx.doi.org/10.5772/intechopen.87136*

*Cardiac Surgery Procedures*

**2.2 Anesthesia care**

outcomes [37, 38].

2.Reduced parental stress

5.Earlier ICU discharge

4.More rapid patient mobilization

6.Decreased length of hospital stay

compromise

continuous wave, color Doppler, and 3D capabilities. In patients >20 kg, we have been using an adult probe (xMatrix probe: X7-2t; 3D matrix array probe; 2–7 MHz; Philips, Andover, MA) with 2500 elements per transducer and, on the contrary, in pediatric patients (whose weight is between 4.0 and 20.0 kg), a pediatric probe (Mini Multi probe: S7-3t; 3–7 MHz; Philips, Andover, MA) with 64 elements per transducer and dimensions of 10.7 mm (tip width) and 8.0 mm (tip height). These clinical benefits, a growing number of highly skilled operators, and improvements in technology have led to the rapid adoption of TEE monitoring in pediatric cardiac surgery with remarkable advances in the management of patients

In recent years, "FastTrack" management (FTM), in the perioperative care of patients with CHD, with early tracheal extubation after cardiac surgery, has become increasingly popular [34–37] especially in MICS, with the delivery of cost-efficient care considered as an additional variable when measuring and comparing surgical

1.Reduced incidence of airway irritation and ventilator-associated complications (i.e., accidental extubation, laryngotracheal trauma, pulmonary hypertensive crisis during endotracheal tube suctioning, mucous plugging of endotracheal tubes, barotraumas secondary to positive airway pressure ventilation, and ventilator-associated pulmonary infections and atelectasis)

3.Reduced requirements of sedation and potential associated hemodynamic

7.Reduced costs (ventilator-associated and length of ICU/hospital stay)

institutional approach for children who are candidates to FastTrack extubation consisted of induction of anesthesia with thiopental 5 mg/kg, fentanyl 3 mcg/ kg, and rocuronium 0.9 mg/kg. During surgery and cardiopulmonary bypass (CPB), anesthesia is maintained with remifentanil 0.5–1 mcg/kg/min and propofol 3–5 mg/kg. Muscle relaxants are given again before CPB at 0.15 mg/kg. The patient is monitored as routine (ECG, pulse oximetry, invasive arterial pressure, central venous pressure, diuresis, temperature, and somatic and cerebral near-infrared spectroscopy (NIRS)). Shortly before the end of the surgery, remifentanil is discontinued, and intravenous morphine (0.1–0.2 mg/kg) or fentanyl (1–2 mcg/ kg) is administered. When surgery is over, according to FTM protocol, the neuromuscular block is reversed by the intravenous administration of atropine, 0.01 mg/ kg, and neostigmine, 0.05 mg/kg. Immediate post-extubation analgesia or sedation in children includes a single administration of rectal paracetamol (40–50 mg/kg),

In this context, anesthesia should not be managed by a strict protocol. A general

with congenital heart disease in this particular setting.

Potential advantages were previously described [38]:

**72**

a bolus of morphine 0.05 mg/kg iv or fentanyl 0.5–1 mcg/kg iv, and/or midazolam 0.05–1 mg/kg iv, with repeated boluses as needed.

For the first 24 postoperative hours, morphine is given by continuous iv in most patients. Pain scores and vital signs are recorded by the bedside nurse, on an hourly basis throughout the day, or, when appropriate, by the parents or even by the child, if it is old enough to report his/her pain scores on a 0–10 pain scale. Supplemental analgesia is administrated if required, according to the recorded pain scores.

Despite this program, extubation in the OR after pediatric cardiac surgery is to be meditated. In order to migrate to a routine practice of early extubation, it is necessary that surgeons, anesthesiologists, intensivists, perfusionists, and nurses have the same mindset and cooperate to achieve this goal and the final decision. Extubation, either in the operating room or in the ICU, is usually decided based on clinical evaluation and also considering some operative parameters such as bypass and aortic cross-clamp times, the complexity of surgery, requirement of high dosage inotropic support, hemodynamic stability, and occurrence of persistent bleeding. Operating room extubation is usually not performed if there are signs of airway compromise, hemodynamic instability requiring bolus delivery of vasopressors, cardiac rhythm instability, excessive bleeding, or core temperature < 35°C.

In patients submitted to VATS, postoperative pain is significant, especially early after surgery [39, 40], and higher than sternotomy. For these reasons, there has been an increased interest in the use of paravertebral block (PVB). The intercostal nerves are relatively devoid of covering fascia as they traverse the paravertebral space, making it an ideal location for local anesthetic blockade [41]. The PVB technique includes the use of ultrasound [42] with a linear probe at high frequency in pediatric patient with weight > 15 kg, alternatively, which can be performed by a single injection at the level of paravertebral space intraoperatively under direct vision by the surgeon [43] or anesthesiologists prior to chest closure [44]. The single-shot multilevel PVB with ropivacaine 0.5% has a place in these procedures (max 0.4 ml/kg at the fifth intercostal space), with analgesic benefits seen in the first few hours, and can reduce long-term adverse pain outcomes.

In this kind of patients, a change in the attitude of surgeons, anesthesiologists, perfusionists, and nurses, combined with appropriate anesthetic and surgical techniques, permitted better results and outcomes.

#### **2.3 Cardiopulmonary bypass and operative strategies**

According to our minimally invasive surgical protocol [45], a direct aortic and bicaval cannulation is usually employed in patients with a body weight of less than 10 kg. Since 2006, in larger patients, we have routinely used a peripheral arterial and venous cannulation [46–48] for establishing the cardiopulmonary bypass (CPB). This is achieved by percutaneous cannulation of the superior vena cava (SVC) followed by surgical isolation and cannulation of the femoral vessels (**Figure 1**).

The SVC peripheral cannulation is usually performed by a trained anesthesiologist with experience with patients with CHD, using 2D transesophageal echo (TEE) guidance (**Figure 2**), after 100 U/kg of heparin has been systemically administered [46]. The internal jugular vein is punctured and dilated, and then an SVC (Medtronic Biomedicus 96,570 Next Gen, MN, USA) is inserted and positioned under TEE monitoring, about 1 cm above the SVC-right atrial junction. Currently, we reserve this approach to DVAPP, in which the presence of pulmonary veins in the SVC may complicate the traditional SVC cannulation through a small incision. In all other cases, as experience has increased, we have recently moved to a direct SVC cannulation with a right angle metal tipped venous cannula (Medtronic DLP single

#### **Figure 1.**

*Exposure of the femoral artery and vein is obtained by means of a transversal skin incision (2 cm in length) along with the groin folder (bikini incision).*

#### **Figure 2.**

*Percutaneous cannulation of the internal jugular vein utilizing a venous cannula (bio-Medicus Medtronic, USA), inserted using standard echo-guided modified Seldinger technique.*

stage venous) through a usual 5.0 Prolene purse string on the right atrium or in the SVC when approach is through an ALT, where SVC is very well exposed (**Figure 3**).

A 2 cm incision is employed at the inguinal fold (**Figure 1**) for exposing the femoral artery and vein. After full systemic heparinization has been achieved (with activated clotting time (ACT) > 400 s), direct arterial cannulation is usually accomplished with a femoral arterial cannula with introducer (Medtronic Biomedicus 96,570 NextGen MN, USA). Venous cannulation (Medtronic Biomedicus 96,670 NextGen MN, USA femoral venous cannula) is then performed using the Seldinger technique under TEE guidance that can clearly show the guide in the right atrium.

In children weighing less than 15 kg, the femoral artery may be too small for safe cannulation; for this reason, we prefer central cannulation in the ascending aorta, utilizing a FEM FLEX arterial cannula, fixed with double 4.0 Ticron purse string. This mixed cannulation approach has allowed us to extend MICS to children as small as 10 kg.

When femoral arterial cannulation is performed, we routinously monitor both lower extremities by NIRS, with sensors positioned on the anterior side of the thigh,

**75**

*Minimally Invasive Approach in Surgery for Congenital Heart Disease*

so as to check for any oxygen saturation variations in the cannulated leg during the

*Diagram showing direct superior vena cava cannulation through the RALMT, with a right angle metal tipped* 

Assisted venous drainage (with a maximum vacuum of 50 mmHg) is adopted to minimize the size of tubing and venous cannulas (that are usually one to two under the estimated size for a patient's body surface area [BSA]). Once the cardiopulmonary bypass is started, mild hypothermia (rectal temperature of 34–35°C) is

At full flow, once the venae cavae are snared, ventricular fibrillation is induced by an epicardial electrode and cable connected to a fibrillator (Fi 20 M, Stockert, Livanova Group, Munich, Germany) in all patients requiring a RAMT. On the contrary, when a MS or RPMT is used, a conventional aortic cross-clamping with

At the end of the intracardiac repair, an accurate de-airing of the left cardiac sections is performed under transesophageal 2D-echocardiographic monitoring, on Trendelenburg position. The de-airing is obtained by filling the left cardiac chambers with saline solution before declamping or defibrillating. Sustained blow ventilation is always performed by the anesthesiologist to clear the left atrial chamber from residual air bubbles. During induced ventricular fibrillation time, it

After surgical repair is completed and the intracardiac de-airing is completed, the induced fibrillation is discontinued. An intravenous lidocaine bolus of 1 mg/ kg is given, and the heart is promptly defibrillated by external direct current shock (3–5 J/kg) when sinus rhythm is not naturally restored. In patients requiring aortic cross-clamping, a further de-bubbling is achieved through the cardioplegia needle

cold hematic cardioplegia may be employed as an alternative.

is essential to avoid blood suction inside the left cardiac sections.

by continuous suction, before and after clamp removal.

*DOI: http://dx.doi.org/10.5772/intechopen.87136*

extracorporeal perfusion [48].

reached [45].

**Figure 3.**

*venous cannula.*

*Minimally Invasive Approach in Surgery for Congenital Heart Disease DOI: http://dx.doi.org/10.5772/intechopen.87136*

#### **Figure 3.**

*Cardiac Surgery Procedures*

**74**

small as 10 kg.

**Figure 2.**

**Figure 1.**

*along with the groin folder (bikini incision).*

stage venous) through a usual 5.0 Prolene purse string on the right atrium or in the SVC when approach is through an ALT, where SVC is very well exposed (**Figure 3**). A 2 cm incision is employed at the inguinal fold (**Figure 1**) for exposing the femoral artery and vein. After full systemic heparinization has been achieved (with activated clotting time (ACT) > 400 s), direct arterial cannulation is usually accomplished with a femoral arterial cannula with introducer (Medtronic Biomedicus 96,570 NextGen MN, USA). Venous cannulation (Medtronic Biomedicus 96,670 NextGen MN, USA femoral venous cannula) is then performed using the Seldinger technique under TEE guidance that can clearly show the guide in the right atrium. In children weighing less than 15 kg, the femoral artery may be too small for safe cannulation; for this reason, we prefer central cannulation in the ascending aorta, utilizing a FEM FLEX arterial cannula, fixed with double 4.0 Ticron purse string. This mixed cannulation approach has allowed us to extend MICS to children as

*Percutaneous cannulation of the internal jugular vein utilizing a venous cannula (bio-Medicus Medtronic,* 

*Exposure of the femoral artery and vein is obtained by means of a transversal skin incision (2 cm in length)* 

*USA), inserted using standard echo-guided modified Seldinger technique.*

When femoral arterial cannulation is performed, we routinously monitor both lower extremities by NIRS, with sensors positioned on the anterior side of the thigh, *Diagram showing direct superior vena cava cannulation through the RALMT, with a right angle metal tipped venous cannula.*

so as to check for any oxygen saturation variations in the cannulated leg during the extracorporeal perfusion [48].

Assisted venous drainage (with a maximum vacuum of 50 mmHg) is adopted to minimize the size of tubing and venous cannulas (that are usually one to two under the estimated size for a patient's body surface area [BSA]). Once the cardiopulmonary bypass is started, mild hypothermia (rectal temperature of 34–35°C) is reached [45].

At full flow, once the venae cavae are snared, ventricular fibrillation is induced by an epicardial electrode and cable connected to a fibrillator (Fi 20 M, Stockert, Livanova Group, Munich, Germany) in all patients requiring a RAMT. On the contrary, when a MS or RPMT is used, a conventional aortic cross-clamping with cold hematic cardioplegia may be employed as an alternative.

At the end of the intracardiac repair, an accurate de-airing of the left cardiac sections is performed under transesophageal 2D-echocardiographic monitoring, on Trendelenburg position. The de-airing is obtained by filling the left cardiac chambers with saline solution before declamping or defibrillating. Sustained blow ventilation is always performed by the anesthesiologist to clear the left atrial chamber from residual air bubbles. During induced ventricular fibrillation time, it is essential to avoid blood suction inside the left cardiac sections.

After surgical repair is completed and the intracardiac de-airing is completed, the induced fibrillation is discontinued. An intravenous lidocaine bolus of 1 mg/ kg is given, and the heart is promptly defibrillated by external direct current shock (3–5 J/kg) when sinus rhythm is not naturally restored. In patients requiring aortic cross-clamping, a further de-bubbling is achieved through the cardioplegia needle by continuous suction, before and after clamp removal.

At the end of CPB, systemic heparinization is reverted, and the femoral cannulas are then removed. After chest closure, the SVC cannula is removed by the anesthesiologist. As a routine, the femoral vessel patency is checked by 2D-echo and Doppler, before discharge.

After completion of the procedure, decannulation and hemostasis are performed. The opened pericardium is partially approximated with interrupted stitches; this is suggested to avoid rare but potentially lethal complications such as cardiac herniation [49]. A subperiosteal epidural catheter is placed in the posterior intercostal groove created extrapleurally for bupivacaine infusion. A thorax drain is inserted and the thorax closed in layers.
