**2. The Padova minimally invasive congenital cardiac surgery protocol**

Since the early 1990s, we have continuously adopted a minimally invasive approach to the surgical closure of simple CHD which has evolved through the years to a systematic protocol of MICS for all patients with simple and moderately severe CHD, which includes:


The surgical approach has always been chosen according to the patient's age, gender, and specific patient's request, balancing safety and effectiveness of the operation and patient's satisfaction after the operation (according to the "genderdifferentiated minimally invasive surgery" protocol [7]). For example, a right anterior mini-thoracotomy (RAMT) is less visible in adult females when the incision is within the submammary sulcus. An axillary lateral mini-thoracotomy (RALMT) is

**71**

*Minimally Invasive Approach in Surgery for Congenital Heart Disease*

patients with simple CHD and a bodyweight superior to 15 kg.

**2.1 Transesophageal echocardiography**

• Can diagnose myocardial performance.

cardiac surgery in infants and children [26–33].

currently offered to both male and females whose weight is higher than 10 kg, for repair of simple CHD such as ASD, partial anomalous pulmonary venous drainage (PAPVD), discrete subaortic stenosis (SAS), membranous ventricular septal defect (VSD), and partial atrioventricular septal defects (p-AVSD). On the contrary, some kind of a mini-sternotomy (MS), meant as limited to the body of the sternum, is offered mostly to infants and children, weighing less than 10 kg, in order to repair lesions other than ASD, such as large VSD with significant left to right shunt in 3–6-month-old infants. In fact, according to our experience, this approach with the help of an appropriate retractor (Bookwalker retractor, Codman Surgical instruments, GS Medical Ltd., Dublin) can guarantee an excellent exposure of the great vessels when other maneuvers are required (i.e., aortic cross-clamping, pulmonary valvotomy, closure of patent ductus arteriosus (PDA)). In addition to these approaches, a right posterior mini-thoracotomy (RPMT) has occasionally been offered as a surgical option in older children and young females, to approach the aortic valve, SAS repair, and VSD closure. Also, from June 2006, as a refinement of our minimally invasive protocol, we have routinely employed peripheral cannulation (usually through right groin vessels) for the cardiopulmonary bypass in

Last, as part of our minimally invasive armamentarium, a video-assisted thoracoscopic surgery (VATS) has also been widely utilized since 1994, for the correction of simple CHD as PDA and vascular rings. However, after the introduction of percutaneous closure of restrictive PDA, we have drastically reduced this practice.

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:

• Allows the surgeon to review the anatomical findings preoperatively.

(avoiding repeat surgery and its associated costs [21, 22]).

patient's safety in regard to air embolism-related problems.

• Provides an evaluation of postsurgical results and can show residual shunts or other surgical problems that can be addressed during the same operative time

• Allows evaluation of effective de-airing after MICS procedure, enhancing

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

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,

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

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

*Cardiac Surgery Procedures*

possibly shortening hospitalization times.

to our institutional policy.

CHD, which includes:

ventilation).

• Postoperative pain control.

psychological.

we have to remember that our goal is to accomplish the optimal repair that ensures a healthy survival, a safe technique, and the best quality of life, either physical or

There are several surgical approaches that have been proposed as an alternative to the standard sternotomy [5] which have been introduced to reduce the invasiveness of surgery while ensuring the perfect repair. In addition, since a sternal scar, however small, continues to be at a disadvantage because of it attracting a stigma of being a cardiac patient or because of sociocultural issues, other alternatives must be explored. These have included a small incision with a full sternotomy [6], a partial sternotomy or mini-sternotomy [7, 8], a right axillary [9] or anterolateral [10, 11], as well as a posterior thoracotomy [12–14]. However, as more experience was gained, the complete anterolateral thoracotomy (in spite of being once considered superior to a sternotomy) has been less utilized because of reports of thoracic cage deformity (caused by rib deformation and atrophy of severed pectoral muscles) and asymmetric development of breasts when used prepubescently [15]. Utilization of a mini-anterolateral thoracotomy and an appropriate location of the incision away from the nipple area have been reported by our group to avoid these complications in the long term [16, 17]. Thus, the improving surgical outcomes in patients with CHD, the significant advances in surgical instrumentation and perfusion technology, and the broad utilization of new catheter-based interventional procedures to repair simple CHD have triggered surgeons' interest to adopt and innovate minimally invasive approaches for CHD repair, so as to reduce the patient's surgical trauma and improve functional and cosmetic results while maintaining a high standard of clinical outcomes and

We present our current experience with MICS in patients with CHD, according

**2. The Padova minimally invasive congenital cardiac surgery protocol**

Since the early 1990s, we have continuously adopted a minimally invasive approach to the surgical closure of simple CHD which has evolved through the years to a systematic protocol of MICS for all patients with simple and moderately severe

• Routine perioperative transesophageal 2D-echo monitoring (TEE); in small infants weighing less than 4 kg, we have used epicardial 2D echocardiography.

• "FastTrack" management (extubation within 3 hours of mechanical

• Early discharge home (within 4–5 days from the operation) [16].

The surgical approach has always been chosen according to the patient's age, gender, and specific patient's request, balancing safety and effectiveness of the operation and patient's satisfaction after the operation (according to the "genderdifferentiated minimally invasive surgery" protocol [7]). For example, a right anterior mini-thoracotomy (RAMT) is less visible in adult females when the incision is within the submammary sulcus. An axillary lateral mini-thoracotomy (RALMT) is

• Early discharge from the intensive care unit (ICU).

**70**

currently offered to both male and females whose weight is higher than 10 kg, for repair of simple CHD such as ASD, partial anomalous pulmonary venous drainage (PAPVD), discrete subaortic stenosis (SAS), membranous ventricular septal defect (VSD), and partial atrioventricular septal defects (p-AVSD). On the contrary, some kind of a mini-sternotomy (MS), meant as limited to the body of the sternum, is offered mostly to infants and children, weighing less than 10 kg, in order to repair lesions other than ASD, such as large VSD with significant left to right shunt in 3–6-month-old infants. In fact, according to our experience, this approach with the help of an appropriate retractor (Bookwalker retractor, Codman Surgical instruments, GS Medical Ltd., Dublin) can guarantee an excellent exposure of the great vessels when other maneuvers are required (i.e., aortic cross-clamping, pulmonary valvotomy, closure of patent ductus arteriosus (PDA)). In addition to these approaches, a right posterior mini-thoracotomy (RPMT) has occasionally been offered as a surgical option in older children and young females, to approach the aortic valve, SAS repair, and VSD closure. Also, from June 2006, as a refinement of our minimally invasive protocol, we have routinely employed peripheral cannulation (usually through right groin vessels) for the cardiopulmonary bypass in patients with simple CHD and a bodyweight superior to 15 kg.

Last, as part of our minimally invasive armamentarium, a video-assisted thoracoscopic surgery (VATS) has also been widely utilized since 1994, for the correction of simple CHD as PDA and vascular rings. However, after the introduction of percutaneous closure of restrictive PDA, we have drastically reduced this practice.
