Minimally Invasive Approach in Surgery for Congenital Heart Disease

*Massimo A. Padalino, Demetrio G. Pittarello, Vladimiro L. Vida and Giovanni Stellin*

## **Abstract**

Surgery for congenital heart disease (CHD) has changed considerably during the last decade. Improved surgical results in patients with simple CHD and new interventional cardiology procedures have stimulated the surgeon to adopt minimally invasive techniques to reduce the patient's surgical insult and obtain good functional and cosmetic results. As a consequence, new surgical techniques and specialized equipment for minimally invasive cardiac surgery (MICS) procedures have been developed and refined in recent years. 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 patient's surgical trauma and improve functional and cosmetic results while maintaining a high standard of clinical outcomes and possibly shortening hospitalization times. This article reports on our updated full experience and institutional protocols with MICS in children and adults with CHD.

**Keywords:** congenital heart defects, minimally invasive, surgery, long-term outcomes, cost-effective

## **1. Introduction**

Ever since the first intracardiac repair of an atrial septal defect (ASD) by Lewis and Varco in 1954 [1], congenital heart surgery has continued to evolve, to become a widely available treatment modality with excellent results. Simple defects like an ASD can now be repaired with almost no mortality and morbidity. In the meantime, interventional cardiology has developed significantly effective transcatheter procedures to perform therapeutic closure of simple defects as well as relieving valvar and vascular obstructions. These catheter-based repairs as an alternative to the surgical gold standard have become popular thanks to its minimally invasive appeal and excellent cosmetic outcome. However, sometimes results may be suboptimal [2, 3], and they may also have severe postoperative complications leading to death [4]. However, these procedures are equally well accepted because they are claimed to be "noninvasive. "Despite the current advancement of surgical and catheter-based techniques having been pursued for the patient's benefit, as physicians and surgeon,

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 psychological.

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 possibly shortening hospitalization times.

We present our current experience with MICS in patients with CHD, according to our institutional policy.
