During the recent EACTS congress in Lisbon (October 10-12, 2024), a multicenter study on minimally invasive pediatric cardiac surgery involving over 3000 patients was presented. The study includes data from 10 European centers and one American center (USA) from 1999 to January 2024, focusing on lateral accesses (submammary, horizontal, and vertical axillary incisions, predominantly). The authors emphasized the gradual increase in alternative approaches to the conventional median sternotomy, along with the inclusion of more complex pathologies. As expected, simple defects such as atrial septal defects (ASD), ventricular septal defects (VSD), partial anomalous pulmonary venous connections (PAPVC), and intermediate atrioventricular canal defects like ostium primum ASD predominate. All these defects share a common approach via the right atrium. Groups with greater expertise have expanded their repertoire to include aortic root pathology (valvular and subvalvular) in addition to right-sided conditions (outflow tract anomalies and tetralogy of Fallot). No patient required conversion to median sternotomy. Complications, all minor, were infrequent. The results gain significance when benchmarked against the European Congenital Heart Surgeons Association (ECHSA) database, showing favorable outcomes compared to similar pathologies treated with median sternotomy during the same period. A draft of the study is under review by the European Journal of Cardiothoracic Surgery, and we look forward to its publication soon.
Interventional cardiology is advancing rapidly, driven by the efforts of our colleagues and industry support. The appeal of avoiding a surgical procedure and a sternotomy scar is an undeniable argument for patients (or their parents, in this case). I will not delve into long-term comparative results, a topic for other forums and more specialized voices. Beyond progress in valvular and coronary pathology in adults, children are also candidates for minimally invasive approaches. I recommend a recent review by the Toronto group on the subject, which provides a comprehensive overview of the English-language literature (including a very extensive appendix) and a detailed description of various alternatives to sternotomy. Central cannulation and repair through the same incision stand out in all these approaches. The review is complemented by the use of thoracoscopy and peripheral cannulation, adapted from minimally invasive mitral surgery in adults, pointing toward the future with endoscopic and robotic surgery. The support of peripheral cannulation in these advanced techniques varies according to weight criteria (15-50 kg, depending on the authors) and femoral arteries >5 mm in diameter. Several pioneering centers in minimally invasive access for congenital heart disease exist, primarily in Europe and, more recently, in the United States. Most describe a trajectory through various anterior and posterior-lateral approaches, with a clear trend toward vertical axillary incision.
Our group has been performing minimally invasive surgery for 25 years, with the program at Gregorio Marañón Hospital (Madrid) starting in 2013. Patience is essential when beginning a minimally invasive surgery program. While simple cases (such as ASD) are appropriate to start, it is difficult to justify a complication or poor outcome for the same reason. Gaining the support of anesthesiologists, perfusionists, surgical assistants, etc., (just within the operating room) is crucial to get off to a good start. Hence, the first patients are carefully selected until some experience is gained, and all those involved in the operating room feel comfortable (or “relatively uncomfortable,” at least). In less than 12 years, we have reached 500 extracorporeal circulation (ECC) procedures for congenital heart disease, as presented at the recent SECCE congress in Madrid (June 5-7, 2024).
As guidance, we use a lower mini-sternotomy approach for cases under 10-15 kg, axillary access for patients between 15-30 kg, and submammary incisions for adolescent girls with developed breasts. As noted in the studies reviewed, ASD, VSD, PAPVC, and ostium primum ASD are the most common defects, with a gradual inclusion of less frequent conditions (complete atrioventricular canal, aortic valvuloplasty, subaortic membrane, mitral, tricuspid, or pulmonary valve disease, etc.). Although less common, we incorporate peripheral cannulation combined with thoracoscopy to minimize submammary incision in females and use the periareolar route in males. It is essential to highlight the peculiarities of the size and vasoreactivity of femoral arteries in children. After 12 years and with all service members familiarized, 98% of ASDs and 70% of VSDs are treated in our center through a minimally invasive approach (personalized according to patient weight and height). The experience gained (while maintaining caution) encourages us to push boundaries. Our smallest patient, a neonate with a VSD corrected through a lower mini-sternotomy, and a pulmonary prosthesis in an adolescent via left axillary access, serve as examples.
Every team initiating a minimally invasive surgery program must ensure a minimum number of procedures for surgeons, anesthesiologists, perfusionists, and others to gain experience. Similarly, families seeking such procedures will turn to centers proven in this regard. The growing competition from percutaneous procedures compels us to explore less invasive accesses that reduce the impact of cardiac surgery on quality of life. For children with no anticipated future interventions (e.g., ASD, VSD), a minimally invasive access allows their scar to remain hidden for life. Without compromising surgical outcomes, minimally invasive surgery offers a cosmetic advantage appreciated by patients and, in our case, their parents. Think mini.
REFERENCES:
Dodge-Khatami A, Gil-Jaurena JM, Hörer J, Heinisch PP, Arrigoni SC, Cesnjevar RA et al. >3’000 Mini Thoracotomies from ECHSA for Quality Repairs of common Congenital Heart Defects: Safe, Routine, and Mature Enough for the New Training Curriculum? The EACTS 38th Annual Meeting. 9-12 October 2024, Lisbon (Portugal).
Gupta S, McEwen C, Eqbal A, Haller C. Minimally Invasive Surgery for Congenital Heart Disease. Ann Thorac Surg. 2024 Oct;118(4):953-962. doi: 10.1016/j.athoracsur.2023.11.032.
Prêtre R, Kadner A, Dave H, Dodge-Khatami A, Bettex D, Berger F. Right axillary incision: a cosmetically superior approach to repair a wide range of congenital cardiac defects. J Thorac Cardiovasc Surg. 2005 Aug;130(2):277-81. doi: 10.1016/j.jtcvs.2005.03.023
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Gil-Jaurena JM, Pérez-Caballero R, Pita-Fernández A, González-López MT, Sánchez J, De Agustín JC. How to set-up a program of minimally-invasive surgery for congenital heart defects. Transl Pediatr. 2016 Jul;5(3):125-133. doi: 10.21037/tp.2016.06.01.
Gil-Jaurena JM, De Agustín JC, Valda C, Pita A, Pardo C, Pérez-Caballero R. Developing new skills for smaller and hidden incisions. J Surg Transplant Sci 2023:10(1):1088-91.
Gil-Jaurena J-M, Pardo C, Pita A, Fajardo E, Pérez-Caballero R. Neonatal Closure of Apical Ventricular Septal Defect. February 2021. doi:10.25373/ctsnet.13913369
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