**3.4 Right axillary lateral mini-thoracotomy**

The right axillary lateral mini-thoracotomy is currently out the approach of choice since it can be safely and efficiently employed for repair of various types of moderately severe CHD, similar to standard surgical procedures, either in adults or in children as small as 10 kg. A right axillary incision provides the best direct plane of vision to the atrial septum, AV valves, and the membranous ventricular septum (**Figure 8**). On the contrary, we do not suggest this approach for conal septal defects or pulmonary valve procedures, since the right ventricular outflow tract is not accessible to expose, and there is the potential risk of a suboptimal repair and postoperative residual defects or complications. Also, the axillary area is one of the least muscularly covered parts of the thoracic cage, allowing for less invasive transthoracic access to the heart. Last, the subaxillary location of the scar, being far away from the breast and being naturally covered by a resting arm, provides an excellent cosmetic result, either in female or in male patients. At the beginning of our experience, we primarily employed this approach to close ostium secundum type ASD. As

**79**

**Figure 8.**

*Minimally Invasive Approach in Surgery for Congenital Heart Disease*

we gained experience and confidence about exposure of various parts of the heart, application of this approach has been extended to the correction of other CHD, such as PAPVC of right-sided pulmonary veins (including performance of the Warden procedure—SVC reinsertion onto the RA appendage), the scimitar vein syndrome (off pump relocation of the anomalous vein to the left atrium), partial AVSD, SAS,

*Minimal invasive approaches and cardiac structure exposure. Angio-CT scan 3D reconstruction in a control patient (right oblique anterior view) showing different minimally invasive surgical chest approaches and their relationship with the cardiac structures and their related capability of exposing them adequately: (A) mini-sternotomy (light blue) shows atrial and ventricular septa and the great vessels. (B) Right anterior mini-thoracotomy (yellow) shows atrial septum; (C) right axillary lateral mini-thoracotomy to perform various procedures on the superior vena cava and aorta through III intercostal space (black) and on the atrial* 

The patient is placed in a left lateral decubitus, with slightly backward reclining position. The lower torso and pelvic region are placed in a 45-degree position to allow access to the inguinal region (**Figure 9**). Marked anterior and median axillary lines and the appropriate intercostal space are used as guiding parameters for the proper axillary incision. In fact, a third intercostal space may be better for DVAPP repair, since it allows a perfect exposure of the entire SVC area to the innominate vein, while a fourth or fifth intercostal space is better indicated for ASD or VSD or mitral valve exposure. An oblique incision is performed in the right axilla from the median to the anterior line, not extending the latter one. The skin is undermined to be able to slide to the desired operative field. The latissimus dorsi is mobilized free of its fascial attachments, and the digitations of serratus anterior overlying the intercostal space are identified and split. The thoracothomy is performed with a subperiosteal entry through the superior margin of the rib. The pericardium is opened 2 cm anterior to the phrenic nerve. Placing stay sutures along both the margins of the pericardium should be placed so as to expose the field as much as possible. Sometimes, the institution of CPB through inguinal cannulation and deflation of the lungs are necessary to achieve adequate exposure of the heart. In patients older than 15 years or weighing more than 25 kg, a selective bronchial intubation is feasible and highly recommended so as to deflate the right lung and keep the left lung inflated during the procedure (whose inflated volume can push

and restrictive peri-membranous/subaortic VSD.

*or membranous ventricular septa through the IV intercostal space (green).*

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

**Figure 7.** *Right axillary lateral mini-thoracotomy approach.*

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

#### **Figure 8.**

*Cardiac Surgery Procedures*

than the skin incision at each side. A video-assisted optical technology using a 5 mm 0° optical scope, which is inserted through a separate 5 mm incision, in the fourth intercostal space, may be helpful to implement the surgical vision [45], but with increased experience we have realized that this aid is rarely necessary for infants and children. In patients >15 kg who undergo peripheral cannulation, the SVC is usually occluded with a cross-clamp that is inserted through a separate lateral 5-mm

In our hands, this approach has been ideal for treating discrete SAS, PAPVD, and sinus venosus ASD. This technique was introduced for simple CHD since 2001. After the original description by Metras and Kreitmann in 1999 [14] for repairing simple CHD, we have modified it from a classic wide right posterior thoracotomy to a mini-thoracotomy, the RPMT (**Figure 7**). Currently, a 4-cm subscapular incision is employed for entering the chest in the fourth intercostal space [45]. This technique has been mainly used in female patients (under specific patient's request). Through this surgical approach, the aorta can be easily visualized and cross-

The right axillary lateral mini-thoracotomy is currently out the approach of choice since it can be safely and efficiently employed for repair of various types of moderately severe CHD, similar to standard surgical procedures, either in adults or in children as small as 10 kg. A right axillary incision provides the best direct plane of vision to the atrial septum, AV valves, and the membranous ventricular septum (**Figure 8**). On the contrary, we do not suggest this approach for conal septal defects or pulmonary valve procedures, since the right ventricular outflow tract is not accessible to expose, and there is the potential risk of a suboptimal repair and postoperative residual defects or complications. Also, the axillary area is one of the least muscularly covered parts of the thoracic cage, allowing for less invasive transthoracic access to the heart. Last, the subaxillary location of the scar, being far away from the breast and being naturally covered by a resting arm, provides an excellent cosmetic result, either in female or in male patients. At the beginning of our experience, we primarily employed this approach to close ostium secundum type ASD. As

incision that is later utilized for inserting chest drainage.

**3.3 Right posterior mini-thoracotomy**

clamped, and aortic valve area can be exposed.

**3.4 Right axillary lateral mini-thoracotomy**

**78**

**Figure 7.**

*Right axillary lateral mini-thoracotomy approach.*

*Minimal invasive approaches and cardiac structure exposure. Angio-CT scan 3D reconstruction in a control patient (right oblique anterior view) showing different minimally invasive surgical chest approaches and their relationship with the cardiac structures and their related capability of exposing them adequately: (A) mini-sternotomy (light blue) shows atrial and ventricular septa and the great vessels. (B) Right anterior mini-thoracotomy (yellow) shows atrial septum; (C) right axillary lateral mini-thoracotomy to perform various procedures on the superior vena cava and aorta through III intercostal space (black) and on the atrial or membranous ventricular septa through the IV intercostal space (green).*

we gained experience and confidence about exposure of various parts of the heart, application of this approach has been extended to the correction of other CHD, such as PAPVC of right-sided pulmonary veins (including performance of the Warden procedure—SVC reinsertion onto the RA appendage), the scimitar vein syndrome (off pump relocation of the anomalous vein to the left atrium), partial AVSD, SAS, and restrictive peri-membranous/subaortic VSD.

The patient is placed in a left lateral decubitus, with slightly backward reclining position. The lower torso and pelvic region are placed in a 45-degree position to allow access to the inguinal region (**Figure 9**). Marked anterior and median axillary lines and the appropriate intercostal space are used as guiding parameters for the proper axillary incision. In fact, a third intercostal space may be better for DVAPP repair, since it allows a perfect exposure of the entire SVC area to the innominate vein, while a fourth or fifth intercostal space is better indicated for ASD or VSD or mitral valve exposure. An oblique incision is performed in the right axilla from the median to the anterior line, not extending the latter one. The skin is undermined to be able to slide to the desired operative field. The latissimus dorsi is mobilized free of its fascial attachments, and the digitations of serratus anterior overlying the intercostal space are identified and split. The thoracothomy is performed with a subperiosteal entry through the superior margin of the rib. The pericardium is opened 2 cm anterior to the phrenic nerve. Placing stay sutures along both the margins of the pericardium should be placed so as to expose the field as much as possible. Sometimes, the institution of CPB through inguinal cannulation and deflation of the lungs are necessary to achieve adequate exposure of the heart. In patients older than 15 years or weighing more than 25 kg, a selective bronchial intubation is feasible and highly recommended so as to deflate the right lung and keep the left lung inflated during the procedure (whose inflated volume can push

#### **Figure 9.**

*Operative position of the patient undergoing a RALMT; the patient is rotated in left lateral decubitus, and the proposed incision lines are shown.*

up the heart and allow for a better exposure of the surgical field). This is especially true in adults with big chest or overweight patients.

#### **3.5 Left posterior extrapleural mini-thoracotomy (LPEMT)**

As we have previously reported [45], a left posterior extrapleural minithoracotomy may be used for PDA closure [50] as an alternative to VATS closure, according to surgeon's preferences and especially in children with a body weight greater than 3 kg. On a right lateral decubitus position and through a limited left subscapular skin incision (usually 2–3 cm) and total muscle-sparing technique, the superficial thoracic fascia muscularis is incised [50]. The parietal pleura is carefully detached from the thoracic wall with blunt dissection. A triple ligation closes the PDA. The left lung then is re-expanded for preventing air entrapment within the extrapleural space, and the chest is usually closed without the use of chest drainage. This is a straightforward technique that is preferred in patients with a bodyweight of less than 20 kg carrying low postoperative complications when compared with the transpleural approach [50]. This LPEMT procedure with no need for intensive care and hospitalization of only 24 hours has been reported to be cost-effective [50] when compared to traditional transpleural approach, which requires a more extended hospitalization, or to percutaneous procedures, in which the costs of a single or multiple coils, or an Amplatzer device, make costs increase stellarly. In conclusion, the minimally invasive skin and muscle splitting LPEMT technique is a safe and effective procedure, more cosmetic and significantly less expensive than other standard procedures (surgical or percutaneous, respectively).

#### **3.6 Video-assisted thoracoscopy**

Video-assisted thoracoscopy has been widely utilized in over 200 patients for PDA closure, before the broad application of percutaneous PDA occlusion. Nowadays, its application is drastically reduced but may be an alternative for infants and children less than 10 kg (or under specific patient's request) [51] and for relieving respiratory/digestive compression caused by vascular rings. Technically, we have described previously this procedure [45]: the patient is put on the right

**81**

considerations.

**Figure 10.**

6–14 years).

**4. Our 22 years of surgical experience**

a median cross-clamping time of 16 min (IQR 9–25).

are described in detail in **Table 1**.

*Minimally Invasive Approach in Surgery for Congenital Heart Disease*

lateral decubitus position; three incisions are made around the left scapula (2 of 5 mm and 1 of 10 mm, **Figure 10**). After lung retraction and dissection of the surrounding anatomical structures, a single titanium clip 10 mm long is squeezed tight on the aortic junction of the duct. The complete closure of the duct is routinely assessed in the operating room through cross-sectional and color Doppler echocardiographic imaging, which can be performed with transesophageal or transthoracic echocardiography. In the case of residual shunting, a second clip may be applied. Patients are usually extubated in the operating room and discharged the following day. However, VATS equipment is not everywhere available because of cost

*and one 10-mm incision below the tip of the scapula, for the optical camera probe.*

*Patent ductus arteriosus VATS closure. On right decubitus, three mini-incisions are done along with the fourth intercostal space: Two 5-mm long incisions (1 and 3) for the introduction of the surgical instruments in the chest* 

From 1996 to 2018, we have treated with MICS techniques 976 patients affected by CHD (M/F 387/589). Overall, the median age at repair was 5 years (interquartile range 1.7–11 years). The most common CHD was ASD secundum type in 557 patients (57%), while the remaining were affected by other anomalies (VSD, p-AVSD, PAPVD, SAS). In particular, a large VSD patch closure was performed by MS in 145 infants <1 year of age (14.8%). Minimally invasive access was a midline MS in 452 patients (median age 2, IQR 0.5–5 years), RAMT in 356 (median age 9, IQR 4–20 years), and a RALMT in 168 (median age 9, IQR

All patients required CPB, and peripheral cannulation was used in 191 patients

There were no early and late deaths at operation. Minor postoperative complications occurred in 110 patients (11.2%), being 39 (35.6%) post-pericardiotomy syndrome. Median intensive care unit stay was 1 day (IQR 1–2), and all patients were discharged home after a median stay of 5 days (IQR 4–6). All clinical preoperative, operative, and postoperative data divided by minimally invasive approach

(19.5%); it is of note that almost all patients undergoing RALMT underwent peripheral cannulation (96%). Induced ventricular fibrillation was used in 598 patients (61.3%), while aortic cross-clamping was employed in the remaining, with

*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*

#### **Figure 10.**

*Cardiac Surgery Procedures*

**Figure 9.**

*proposed incision lines are shown.*

up the heart and allow for a better exposure of the surgical field). This is especially

*Operative position of the patient undergoing a RALMT; the patient is rotated in left lateral decubitus, and the* 

As we have previously reported [45], a left posterior extrapleural minithoracotomy may be used for PDA closure [50] as an alternative to VATS closure, according to surgeon's preferences and especially in children with a body weight greater than 3 kg. On a right lateral decubitus position and through a limited left subscapular skin incision (usually 2–3 cm) and total muscle-sparing technique, the superficial thoracic fascia muscularis is incised [50]. The parietal pleura is carefully detached from the thoracic wall with blunt dissection. A triple ligation closes the PDA. The left lung then is re-expanded for preventing air entrapment within the extrapleural space, and the chest is usually closed without the use of chest drainage. This is a straightforward technique that is preferred in patients with a bodyweight of less than 20 kg carrying low postoperative complications when compared with the transpleural approach [50]. This LPEMT procedure with no need for intensive care and hospitalization of only 24 hours has been reported to be cost-effective [50] when compared to traditional transpleural approach, which requires a more extended hospitalization, or to percutaneous procedures, in which the costs of a single or multiple coils, or an Amplatzer device, make costs increase stellarly. In conclusion, the minimally invasive skin and muscle splitting LPEMT technique is a safe and effective procedure, more cosmetic and significantly less expensive than other standard procedures (surgi-

Video-assisted thoracoscopy has been widely utilized in over 200 patients for PDA closure, before the broad application of percutaneous PDA occlusion. Nowadays, its application is drastically reduced but may be an alternative for infants and children less than 10 kg (or under specific patient's request) [51] and for relieving respiratory/digestive compression caused by vascular rings. Technically, we have described previously this procedure [45]: the patient is put on the right

true in adults with big chest or overweight patients.

cal or percutaneous, respectively).

**3.6 Video-assisted thoracoscopy**

**3.5 Left posterior extrapleural mini-thoracotomy (LPEMT)**

**80**

*Patent ductus arteriosus VATS closure. On right decubitus, three mini-incisions are done along with the fourth intercostal space: Two 5-mm long incisions (1 and 3) for the introduction of the surgical instruments in the chest and one 10-mm incision below the tip of the scapula, for the optical camera probe.*

lateral decubitus position; three incisions are made around the left scapula (2 of 5 mm and 1 of 10 mm, **Figure 10**). After lung retraction and dissection of the surrounding anatomical structures, a single titanium clip 10 mm long is squeezed tight on the aortic junction of the duct. The complete closure of the duct is routinely assessed in the operating room through cross-sectional and color Doppler echocardiographic imaging, which can be performed with transesophageal or transthoracic echocardiography. In the case of residual shunting, a second clip may be applied. Patients are usually extubated in the operating room and discharged the following day. However, VATS equipment is not everywhere available because of cost considerations.

#### **4. Our 22 years of surgical experience**

From 1996 to 2018, we have treated with MICS techniques 976 patients affected by CHD (M/F 387/589). Overall, the median age at repair was 5 years (interquartile range 1.7–11 years). The most common CHD was ASD secundum type in 557 patients (57%), while the remaining were affected by other anomalies (VSD, p-AVSD, PAPVD, SAS). In particular, a large VSD patch closure was performed by MS in 145 infants <1 year of age (14.8%). Minimally invasive access was a midline MS in 452 patients (median age 2, IQR 0.5–5 years), RAMT in 356 (median age 9, IQR 4–20 years), and a RALMT in 168 (median age 9, IQR 6–14 years).

All patients required CPB, and peripheral cannulation was used in 191 patients (19.5%); it is of note that almost all patients undergoing RALMT underwent peripheral cannulation (96%). Induced ventricular fibrillation was used in 598 patients (61.3%), while aortic cross-clamping was employed in the remaining, with a median cross-clamping time of 16 min (IQR 9–25).

There were no early and late deaths at operation. Minor postoperative complications occurred in 110 patients (11.2%), being 39 (35.6%) post-pericardiotomy syndrome. Median intensive care unit stay was 1 day (IQR 1–2), and all patients were discharged home after a median stay of 5 days (IQR 4–6). All clinical preoperative, operative, and postoperative data divided by minimally invasive approach are described in detail in **Table 1**.


#### **Table 1.**

*Clinical preoperative, operative and postoperative data by minimally invasive approach (n = 976) since 1996.*

## **5. Discussion**

Recent technological advances have enabled treatment for a wide range of CHD, with excellent early and late results. As a consequence, both children and adults with CHD can now expect better outcomes. In the last decade, however, surgical techniques have also centered around the reduction of trauma and postoperative recovery time and even improvement of cosmetic results. A standard median sternotomy has been the conventional approach for correction of congenital cardiac defects for many years, but it often yields to unsatisfactory esthetic results [6, 7, 52]. Unsightly midline scars arouse displeasure and psychological distress, especially in young female patients. Minimally invasive cardiac surgery can offer real value to the patients, be it cosmetic, psychological (no scar in the front), biological (less bleeding, less pain, less sternum deformity without division of the manubrium), or even sociocultural (as in some Middle Eastern countries, in which a frontal scar in female patients is considered as a doom). However, these techniques have had particular application in congenital cardiac surgery when compared with adults.

**83**

breast development.

the aortic valve or sub-valvar area).

*Minimally Invasive Approach in Surgery for Congenital Heart Disease*

It is true that MICS in this context is mostly about minimally invasive incisions, while real minimally invasive procedures which avoid utilization of cardiopulmonary bypass are under evaluation nowadays. For the surgical approach, CPBassisted operations with minimal thoracotomies or "hybrid procedures" have been

Nowadays, ASD can usually be closed by an interventional cardiologist, unless morphological features are unfavorable. This can be called a true minimally invasive method since no incision and, mostly, no CPB is involved in the procedure. It is, in fact, CPB that is more invasive since it can trigger the so-called systemic inflammatory syndrome, which is proportional to the CPB time and inversely proportional to BSA [50]. Any other attempt is rather "minimal access" surgery. However, surgery does not require X-ray exposure and allows complete repair using biological or physiological materials such as autologous or heterologous pericardium. On the contrary, current transcatheter procedures require prolonged X-ray exposure [51], and septal defect closure devices are made of a rigid metal material that is bound to stay inside the heart forever: is this going to be safe forever? Some authors have reported late device dislocation and higher risk late

On the other side, Butera et al. [2] reported that ASD closure by percutaneous approach has a significantly lower rate of either total or major early post-procedural complications than surgery. However, costs remain high, and financial issues are a matter of concern in many countries with public health system. During the last few years, with increasing experience, we have observed a significant reduction in the operative times without increased risk, when compared with conventional surgery [16]. The median cost for treatment of ASDS was 7275 euros (IQR 6975-7515 euros). According to scatterplot analysis, we showed a progressive reduction of hospital

In the light of our results, we are now extending our minimally invasive approaches to CHD which are more complex than ASD. Besides, the safety of the peripheral CPB convinced us to employ it progressively to lower body weight patients. We believe that soon, due to the miniaturization of surgical instruments, cannulas, and tubing systems, we will spread the use of minimally invasive surgery

Since many years, it has been our institutional policy to promote a genderdifferentiated minimally invasive approach for patients with CHD [52]. This has proven to be safe, and it offers excellent clinical results comparable to classic more invasive methods. In addition, in our experience, we have demonstrated a 95% patient satisfaction after RAMT, with no evidence of scoliosis, restriction to shoulder movement, breast development, or lactation problems at follow-up [15]. The only complication we could outline in our female patients with mini-thoracotomy (MT) was a temporary trivial neuro-sensorial deficit at the mammary area that disappeared in all within 6 months after surgery. In addition to the benefit of a limited cutaneous incision, a careful and gentle muscle plane dissection and reconstruction is certainly related to the high quality of our results. It is highly advisable that the MT incision be located very low in the submammary area, usually at least 4–5 cm under the right nipple and away from any possibility of future

The RALMT has been added relatively recently in our minimally invasive surgical armamentarium [45], and it has rapidly gained affidability as it has proven to be an effective and safe approach to correct patients with PAPVD from the right lung (which is even easier to identify from this approach). Also, it allows excellent visualization of the aortic root when needed (i.e., aortic cross-clamping or access to

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

reoperation [5]: is this acceptable for ASD?

costs over time (P = 0.009) (**Figure 11**).

with peripheral CPB in even smaller children.

described.

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

*Cardiac Surgery Procedures*

**82**

**5. Discussion**

**Table 1.**

Recent technological advances have enabled treatment for a wide range of CHD, with excellent early and late results. As a consequence, both children and adults with CHD can now expect better outcomes. In the last decade, however, surgical techniques have also centered around the reduction of trauma and postoperative recovery time and even improvement of cosmetic results. A standard median sternotomy has been the conventional approach for correction of congenital cardiac defects for many years, but it often yields to unsatisfactory esthetic results [6, 7, 52]. Unsightly midline scars arouse displeasure and psychological distress, especially in young female patients. Minimally invasive cardiac surgery can offer real value to the patients, be it cosmetic, psychological (no scar in the front), biological (less bleeding, less pain, less sternum deformity without division of the manubrium), or even sociocultural (as in some Middle Eastern countries, in which a frontal scar in female patients is considered as a doom). However, these techniques have had particular application in congenital cardiac surgery when compared with adults.

*Clinical preoperative, operative and postoperative data by minimally invasive approach (n = 976) since 1996.*

It is true that MICS in this context is mostly about minimally invasive incisions, while real minimally invasive procedures which avoid utilization of cardiopulmonary bypass are under evaluation nowadays. For the surgical approach, CPBassisted operations with minimal thoracotomies or "hybrid procedures" have been described.

Nowadays, ASD can usually be closed by an interventional cardiologist, unless morphological features are unfavorable. This can be called a true minimally invasive method since no incision and, mostly, no CPB is involved in the procedure. It is, in fact, CPB that is more invasive since it can trigger the so-called systemic inflammatory syndrome, which is proportional to the CPB time and inversely proportional to BSA [50]. Any other attempt is rather "minimal access" surgery. However, surgery does not require X-ray exposure and allows complete repair using biological or physiological materials such as autologous or heterologous pericardium. On the contrary, current transcatheter procedures require prolonged X-ray exposure [51], and septal defect closure devices are made of a rigid metal material that is bound to stay inside the heart forever: is this going to be safe forever? Some authors have reported late device dislocation and higher risk late reoperation [5]: is this acceptable for ASD?

On the other side, Butera et al. [2] reported that ASD closure by percutaneous approach has a significantly lower rate of either total or major early post-procedural complications than surgery. However, costs remain high, and financial issues are a matter of concern in many countries with public health system. During the last few years, with increasing experience, we have observed a significant reduction in the operative times without increased risk, when compared with conventional surgery [16]. The median cost for treatment of ASDS was 7275 euros (IQR 6975-7515 euros). According to scatterplot analysis, we showed a progressive reduction of hospital costs over time (P = 0.009) (**Figure 11**).

In the light of our results, we are now extending our minimally invasive approaches to CHD which are more complex than ASD. Besides, the safety of the peripheral CPB convinced us to employ it progressively to lower body weight patients. We believe that soon, due to the miniaturization of surgical instruments, cannulas, and tubing systems, we will spread the use of minimally invasive surgery with peripheral CPB in even smaller children.

Since many years, it has been our institutional policy to promote a genderdifferentiated minimally invasive approach for patients with CHD [52]. This has proven to be safe, and it offers excellent clinical results comparable to classic more invasive methods. In addition, in our experience, we have demonstrated a 95% patient satisfaction after RAMT, with no evidence of scoliosis, restriction to shoulder movement, breast development, or lactation problems at follow-up [15]. The only complication we could outline in our female patients with mini-thoracotomy (MT) was a temporary trivial neuro-sensorial deficit at the mammary area that disappeared in all within 6 months after surgery. In addition to the benefit of a limited cutaneous incision, a careful and gentle muscle plane dissection and reconstruction is certainly related to the high quality of our results. It is highly advisable that the MT incision be located very low in the submammary area, usually at least 4–5 cm under the right nipple and away from any possibility of future breast development.

The RALMT has been added relatively recently in our minimally invasive surgical armamentarium [45], and it has rapidly gained affidability as it has proven to be an effective and safe approach to correct patients with PAPVD from the right lung (which is even easier to identify from this approach). Also, it allows excellent visualization of the aortic root when needed (i.e., aortic cross-clamping or access to the aortic valve or sub-valvar area).

#### **Figure 11.**

*Scatterplot showing the variation of the overall cost of treatment for surgical ostium secundum atrial septal defect closure, by year of surgery. MS, mini-sternotomy; RAMT, right anterior mini-thoracotomy; RALMT, right lateral mini-thoracotomy (modified from Vida et al. [16]).*

In our two decades of experience, induced ventricular fibrillation has been a safe and reproducible technique, which we have always associated with mild systemic protective hypothermia [7, 25, 26]. It avoids cumbersome cross-clamping and consequently allows smaller access especially in RAMT or RALMT approaches. Nonetheless, we are also aware that a cross-clamping through RAMT can also be used when needed [28]. With the recent introduction of the RALMT, which exposes the ascending aorta much better, aortic cross-clamping can be quickly done employing a Novare Straight Cygnus Aortic Cross Clamp in adults or even with conventional Chitwood clamps in children.

Intraoperative TEE echocardiographic monitoring is of paramount importance in such limited surgical exposure since it can ensure a total de-airing of the left chambers together with a complete assessment of the surgical correction and detection of possible residual lesions. Furthermore, the utilization of Trendelenburg position as a default position during open heart surgery on induced FV is a new safety strategy to prevent a cerebral air embolism.

The use of a peripheral CPB has been shown to be a safe and excellent option in selected patients [18, 19], since it permits minimal surgical incisions, consequently reducing the patient's surgical trauma. As mentioned above, the NIRS monitoring of the blood perfusion to the lower extremities in patients with peripheral CPB is a useful tool to control blood flow perfusion variations to the lower extremities during CPB time. It is of notice that we were never required to convert peripheral to central CPB because of issues with lower limb blood flow. However, critical NIRS levels (<30%) has been reached in patients with a bodyweight of less than 15 kg for a maximum period of 30 min, which has entirely normalized after arterial

**85**

*Minimally Invasive Approach in Surgery for Congenital Heart Disease*

borderline femoral arteries (in children < than 15 kg).

decannulation as did the postoperative myoglobin and creatine phosphokinase levels (within 12 hours). Last, we needed to patch repair the femoral artery only in five patients among all. However, as we shifted to the subaxillary (muscle sparse) approach, we have switched to central aortic cannulation utilizing the same arterial cannula (Medtronic Bio-Medicus NextGen MN, USA), to avoid residual stenosis in

Minimally invasive cardiac surgery for CHD consists in the minimization of surgical access with consequent reduction of surgical trauma, reduced postoperative pain, and a more prompt recovery that can permit a decrease in hospital stays and costs. Despite minimal incisions, in our hands, these techniques have allowed optimal repair which is comparable to the conventional surgery ones in terms of safety, with an additional better cosmetic result and a better-perceived quality of the treatment by the patients, especially female, with less psychological discomfort caused by the more traditional sternal scars. The technological advancement (such as vacuum-assisted venous drainage, new retracting systems, and the use of peripheral cannulation for CPB) has permitted further miniaturization of our incisions without increasing patients' morbidity and, on the contrary, improving results and patients' satisfaction. The recent lateralization of surgical access has added another benefit contributing to an increase in the types of CHD we can treat, with no additional risk. Nowadays, MICS for CHD continues to evolve and expand with growing technology and surgeon experience. It is safe and effective for various types of CHD, and it does not appear to result in significant differences in short-term and long-term survival and freedom from adverse events when compared with the more traditional midline sternotomy approaches. It seems to result in faster recovery to healthy routine life, reducing the length of hospital stay and better satisfaction among patents. As this compares favorably with percutaneous techniques, MICS for CHD is now to be considered the gold standard for surgical repair of simple and moderately severe CHD which are not amenable or borderline

We acknowledge Mr. Nicola Paccagnella (Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Italy)

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

**6. Conclusions**

for transcatheter repair.

**Acknowledgements**

**Conflict of interest**

**Acronyms**

for the artwork. We had no fundings.

The authors declare no conflict of interest.

MICS minimally invasive cardiac surgery

LPEMT left posterior extrapleuric mini-thoracotomy

CHD congenital heart disease

MS midline mini-sternotomy

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

decannulation as did the postoperative myoglobin and creatine phosphokinase levels (within 12 hours). Last, we needed to patch repair the femoral artery only in five patients among all. However, as we shifted to the subaxillary (muscle sparse) approach, we have switched to central aortic cannulation utilizing the same arterial cannula (Medtronic Bio-Medicus NextGen MN, USA), to avoid residual stenosis in borderline femoral arteries (in children < than 15 kg).
