**6. Conclusions**

*Cardiac Surgery Procedures*

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

*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,* 

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

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

conventional Chitwood clamps in children.

*right lateral mini-thoracotomy (modified from Vida et al. [16]).*

safety strategy to prevent a cerebral air embolism.

**84**

**Figure 11.**

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 for transcatheter repair.
