Left axillary approach for pulmonary valve replacement

A 14-year-old girl was scheduled for pulmonary valve replacement. A computed tomography scan showed an enlarged cardiac silhouette with an aneurysmal pulmonary artery. A less-invasive approach through the left axilla with peripheral cannulation was selected. The patient was draped in the decubitus position, with a roll under the left shoulder and the left arm over the head. The anatomical landmarks were the left nipple and the tip of the scapula. A 5-cm vertical incision in the mid-axillary line was performed, and the thorax was entered through the fourth intercostal space. Peripheral cannulation for cardiopulmonary bypass was achieved by a right groin dissection. Partial bypass was instituted and, on an unloaded heart, the ascending aorta plus the right appendage and the pulmonary artery were further cannulated. With the heart beating, the pulmonary artery was opened, and a 25-mm biological Carpentier Perimount-Magna valve was chosen. A second stitch was used to close the arteriotomy with large bites in a double row to reduce the perimeter of the trunk. Cardiopulmonary bypass was discontinued (after 64 minutes), and the cannulas were removed sequentially. Echocardiography showed a good result, with proper valve function and a reduced pulmonary artery. The patient was discharged on postoperative day 12 on antiplatelet therapy.

Minimally-invasive approach via percutaneous femoral cannulation for the resection of intra-cardiac masses: a single center experience in the Middle-East

BACKGROUND

Intra-cardiac masses are rare and challenging lesions with an overall incidence ranging of 0.02-0.2%. Minimally invasive approaches have been recently introduced for surgical resection of these lesions. Here, we evaluated our early experience using minimally invasive techniques in addressing intra-cardiac lesions.

METHODOLOGY

This is a retrospective descriptive study conducted between April 2018 to December 2020. All patients were diagnosed with cardiac tumors and treated via a right mini-thoracotomy with cardiopulmonary bypass through femoral cannulation at King Faisal Specialist Hospital and Research Centre, Jeddah.

RESULTS

Myxoma was the most common pathology representing 46% of cases followed by thrombus (27%), leiomyoma (9%), lipoma (9%) and angiosarcoma (9%). All tumors were resected with negative margins. One patient was converted to open sternotomy. Tumor locations were in the right atrium, left atrium, and left ventricle in 5, 3, and 3 patients, respectively. The median ICU stay was 1.33 days. The median length of hospitalization was 5.7 days. There was no 30-days hospital mortality recorded in this cohort.

CONCLUSION

Our early experience shows that minimally invasive resection can be performed safely and effectively for intra-cardiac masses. The minimally invasive approach using a mini-thoracotomy with percutaneous femoral cannulation can be an effective alternative in resecting intra-cardiac masses that achieves clear margin resection, quick post-operative recovery, and low rates of recurrence for benign lesions.

Minithoracotomy versus sternotomy in mitral valve surgery: meta-analysis from recent matched and randomized studies

BACKGROUND

There is still ongoing debate about the benefits of mini-thoracotomy (MTH) approach in mitral valve surgery in comparison with complete sternotomy (STER). This study aims to update the current evidence with mortality as primary end point.

METHODS

The MEDLINE and EMBASE databases were searched through June 2022. Two randomized studies and 16 propensity score matched studies published from 2011 to 2022 were included with a total of 12,997 patients operated on from 2005 (MTH: 6467, STER: 6530). Data regarding early mortality, stroke, reoperation for bleeding, new renal failure, new onset of atrial fibrillation, need of blood transfusion, prolonged ventilation, wound infection, time-related outcomes (cross clamp time, cardiopulmonary bypass time, ventilation time, length of intensive care unit stay, length of hospital stay), midterm mortality and reoperation, and costs were extracted and submitted to a meta-analysis using weighted random effects modeling.

RESULTS

The incidence of early mortality, stroke, reoperation for bleeding and prolonged ventilation were similar, all in the absence of heterogeneity. However, the sub-group analysis showed a significant OR in favor of MTH when robotic enhancement was used. New renal failure (OR 1.67, 95% CI 1.06-2.62, p = 0.03), new onset of atrial fibrillation (OR 1.31, 95% CI 1.15-1.51, p = 0.001) and the need of blood transfusion (OR 1.77, 95% CI 1.39-2.27, p = 0.001) were significantly lower in MTH group. Regarding time-related outcomes, there was evidence for important heterogeneity of treatment effect among the studies. Operative times were longer in MTH: differences in means were 20.7 min for cross clamp time (95% CI 14.9-26.4, p = 0.001), 36.8 min for CPB time (95% CI 29.8-43.9, p = 0.001) and 37.7 min for total operative time (95% CI 19.6-55.8, p < 0.001). There was no significant difference in ventilation duration; however, the differences in means showed significantly shorter ICU stay and hospital stay after MTH compared to STER: - 0.6 days (95% CI - 1.1/- 0.21, p = 0.001) and - 1.88 days (95% CI - 2.72/- 1.05, p = 0.001) respectively, leading to a significant lower hospital cost after MTH compared to STER with difference in means - 4528 US$ (95% CI - 8725/- 326, p = 0.03). The mid-term mortality was significantly higher after STER compared to MTH: OR = 1.50, 1.09-2.308 (95% CI), p = 0.01; the rate of mid-term reoperation was reported similar in MTH and STER: OR = 0.76, 0.50-1.15 (95% CI), p = 0.19.

CONCLUSIONS

The present meta-analysis confirms that the MTH approach for mitral valve disease remains associated with prolonged operative times, but it is beneficial in terms of reduced postoperative complications (renal failure, atrial fibrillation, blood transfusion, wound infection), length of stay in ICU and in hospitalization, with finally a reduction in global cost. MTH approach appears associated with a significant reduction of postoperative mortality that must be confirmed by large randomized study.

Coronary artery bypass grafting and mitral valve replacement via a left anterior minithoracotomy

We present a technique for multivessel minimally invasive coronary revascularization combined with mitral valve replacement through a left anterior minithoracotomy. This newly developed technique is unique because it allows us to intervene and repair or replacement the mitral valve with a conventional surgical technique through a limited left anterior approach. The minimally invasive approaches for combined cardiac surgical procedures are being increasingly investigated and are of special interest to cardiac surgeons.

Measurement of health-related quality of life post aortic valve replacement via minimally invasive incisions

Background

Minimally invasive aortic surgery is growing in popularity among surgeons. Although many clinical reports have proven both the safety and efficacy from a surgical point of view, there are few data regarding its impact on patients’ quality of life and whether there is a difference between ministernotomy and minithoracotomy from the patient perspective.

Methods

This prospective, questionnaire-based, nonrandomized study included 189 patients who underwent aortic valve replacement via a minimally invasive incision between May 2014 and December 2020 and completed at least 1 year of follow-up. The study uses the RAND SF 36-Item Health Survey 1.0 to assess and compare health-related quality of life between ministernotomy and minithoracotomy.

Results

There was a statistically significant improvement in the minithoracotomy group with regard to physical functioning, role limitation due to a physical problem, and social functioning (79.69 ± 20.72, 75.28 ± 26.52, 87.91 ± 16.98) compared to the ministernotomy group (70.31 ± 22.88, 58.59 ± 31.17, 66.15 ± 27.32) with p values (0.0036, 0.0001, < 0.0001), respectively.

Conclusions

Both minimally invasive aortic valve incisions positively impacted patient quality of life. The minithoracotomy incision showed significant improvements in physical capacity and successful patient re-engagement in daily physical and social activities. This, in turn, positively improved their general health status compared to the 1-year preoperative status.

Trial registration: This study was approved by the Research Ethics Committee (REC) at the Faculty of Medicine, Ain Shams University, under the number code (FWA 000017585, FAMSU R 91 /2021).

Mitral valve perforation after left lateral accessory pathway ablation: a case report

Background

Radiofrequency catheter ablation is considered to be a relatively safe procedure. This is an unusual case report in which severe mitral regurgitation was occurred after left lateral accessory pathway radiofrequency catheter ablation.

Case presentation

A 15-year-old man without structural heart disease was referred for ablation of a left lateral accessory pathway. He was a rugby player who had lived with Wolff–Parkinson–White syndrome since 2017. In 2017, two failed extensive radiofrequency catheter ablations of a left lateral accessory pathway had been performed in another center. In June 2018, he underwent a third radiofrequency catheter ablation of a left lateral accessory pathway using an anterograde transseptal approach with an early recurrence one month later. A successful fourth procedure was performed in August 2018 using a retrograde aortic approach. Three months later, the patient presented to the hospital with atypical chest pain and dyspnea on exertion. Transthoracic echocardiography revealed severe mitral regurgitation caused by a perforation of the posterior leaflet. Given the symptoms and the severity of the mitral valve regurgitation, the decision was taken to proceed with surgical intervention. Posterior mitral leaflet perforation was confirmed intraoperatively. The patient underwent video-assisted mitral valve repair via Minithoracotomy approach.

Conclusion

This case demonstrates a very rare complication of Wolff–Parkinson–White radiofrequency ablation.

Minimally invasive and full sternotomy in aortic valve replacement: a comparative early operative outcomes

Introduction

aortic valve replacement is usually performed through a median full sternotomy (MFS) in our department. Minimally invasive aortic valve replacement (MIAVR) has been recently adopted as a new approach. According to the literature, the superiority of MIAVR is controversial. In this study we report early post-operative outcomes in MIAVR compared with MFS access with reference to blood Loss, wound infections, post-operative recovery, morbidity and mortality.

Methods

this study was a prospective data collection from 36 consecutive patients undergoing isolated valve replacement. Two population study was identified, MIAVR group (group I n=18) and MFS group (group II n=18). Patients´ data were collected and analyzed using IBM SPSS statistics 21 software and Khi2 test has been used to compare the variables. The study variables are presented as numbers, percentage, median with interquartile range. Pre-operative planning was performed so that to obtain similar characteristics.

Results

in group I, upper mini-sternotomy was used in 12 patients and right mini-thoracotomy in 6 patients. There was no difference in term of mortality and morbidity. MIAVR was associated with longer CPB time (93.25 (58-161) vs 131 (75-215) mins, P=0.047) with no significant difference in term of ACC time (81 (33-162) vs 58.8 (59-102) mins P=0.158). MIAVR´ Patients had likely lower incidence of red blood cells transfusion (16.7 vs 52.3%) without significant difference about post-operative haemoglobin (P = 0,330). Patients in group I had shorter ventilation time (2.35 (1-12) vs 9.3 (1-48) hours P < 0.01), shorter ICU stay (2.44 (1-8) vs 4.25 (1-9) days, P = 0,024). The length of hospital stay was shorter, 6.5 (5-9) days in group I vs 7.4 (6-11), P=0.0274. Length of chest tube stay was shorter in group I (mean 1.53 vs 2.4 days, P=0,033). Wound infections were not found in both groups.

Conclusion

minimally invasive aortic valve replacement is associated with less blood loss, faster post-operative recovery faster post-operative recovery but increase operation time.

The feasibility and safety of same-day surgery for diaphragmatic eventration by minithoracotomy in children

PURPOSE

The diaphragmatic plication procedure by thoracoscopy has gradually become standard treatment for diaphragmatic eventration (DE). However, thoracoscopic diaphragmatic plication is difficult to manipulate and the surgical learning curve is long. This study aimed to demonstrate the feasibility and safety of same-day surgery for DE by minithoracotomy in children.

METHODS

From December 2017 to December 2019, we included 22 patients who underwent diaphragmatic plication of DE in the Department of Pediatric Thoracic Surgery at the Guangzhou Women and Children's Medical Center. A total of 10 patients underwent diaphragmatic plication by minithoracotomy and 12 patients underwent thoracoscopic plication. The perioperative condition and postoperative follow-up were evaluated, respectively.

RESULTS

The age, sex, and weight were no different in the minithoracotomy group versus the thoracoscopy group (P > 0.05). The intraoperative time, blood loss volume, and postoperative hospital stay of the minithoracotomy group were significantly less than that of the thoracoscopy group (31.10 ± 4.70 min vs. 72.08 ± 22.8 min; 1.20 ± 0.42 ml vs. 2.58 ± 1.67 ml; and 1.00 ± 0.00 days vs. 6.00 ± 2.95 days, respectively, all P < 0.05). The eventration levels in these two groups were significantly different in the perioperative and postoperative periods as detected by chest X-ray. No chest tubes were inserted and no recurrence of DE occurred in the thoracoscopy group through the postoperative follow-up of at least 6 months.

CONCLUSION

Same-day surgery by minithoracotomy as a treatment for DE was feasible and safe with less operative time, less blood loss, and low recurrence. Same-day surgery for DE was attributed to a quick recovery. More prospective studies are necessary to further explore the consequences of same-day surgery for DE by minithoracotomy.

Minimally invasive or sternotomy approach in mitral valve surgery: a propensity-matched comparison

Objectives

Conventional mitral valve surgery through median sternotomy improves long-term survival with acceptable morbidity and mortality. However, less-invasive approaches to mitral valve surgery are now increasingly employed. Whether minimally invasive mitral valve surgery is superior to conventional surgery is uncertain.

Methods

A retrospective analysis of patients who underwent mitral valve surgery via minithoracotomy or median sternotomy between 2012 and 2018. A propensity score-matched analysis was generated to eliminate differences in relevant preoperative risk factors between the two groups.

Results

Data from 525 patients were evaluated, 189 underwent minithoracotomy and 336 underwent median sternotomy. The 30 day mortality was similar between the minithoracotomy and conventional surgery groups (1 and 3%, respectively; p = 0.25). No differences were seen in the incidence of stroke (p = 1.00), surgical site infections (p = 0.09), or myocardial infarction (p = 0.23), or in total hospital cost (p = 0.48). However, the minimally invasive approach was associated with fewer patients receiving transfusions (59% versus 76% in the conventional group; p = 0.001) or requiring reoperation for bleeding (3% versus 9%, respectively; p = 0.03). There were no significant differences in 5 year survival between the minithoracotomy and conventional surgery groups (93% versus 86%, respectively; p = 0.21) and freedom from mitral valve reoperation (95% versus 94%, respectively; p = 0.79).

Conclusions

In patients undergoing mitral valve surgery, a minimally invasive approach is feasible, safe, and reproducible with excellent short-term outcomes; mid-term outcomes and efficacy were also seen to be comparable to conventional sternotomy.

Use of porcine acellular dermal matrix to repair lung Hernia after minithoracotomy: A case report with 6-Year follow-up

Lung hernia following minimally invasive cardiac surgery is rare with few reported cases in the literature. Surgical repair is debated, and several methods have been described including a variety of synthetic and biological materials. We report a case of a 36-year-old woman who developed lung hernia and a strong retraction of the pectoralis major muscle after minithoracotomy that was performed for mitral valve surgery. The herniated lung was reduced and the chest wall defect was repaired with a non-cross linked acellular dermal matrix (ADM) anchored to the thoracic wall. At a 6-year follow-up, she was asymptomatic and without recurrence of the hernia. Our experience suggests that ADMs are a safe and reliable surgical technique for lung hernia repair due to their biological and mechanical properties, even in those secondary hernias to minithoracotomy where a complete muscle coverage of the matrix could not be provided.

Excellent long-term results with minimally invasive edge-to-edge repair in myxomatous degenerative mitral valve regurgitation

OBJECTIVES

Previous series of minimally invasive mitral valve repairs showed excellent results at up to 10 years of follow-up. The goal of this study was to assess the long-term durability beyond 10 years of the edge-to-edge repair for myxomatous degeneration performed through a minimally invasive approach.

METHODS

Ninety-seven consecutive patients (mean age 35 ± 9 years; left ventricular ejection fraction 63 ± 6%) with severe myxomatous mitral regurgitation (MR) underwent mitral valve repair through a right minithoracotomy between 1999 and 2006. MR was due to lesions involving the posterior leaflet (7.2% of patients), anterior leaflet (12.4%) and both leaflets (80.4%).

RESULTS

No hospital deaths occurred. At hospital discharge all patients had no or trivial MR. Follow-up was 100% complete (median 15.5 years; interquartile range 13.6-17.0, max 19.3 years). The 16-year overall survival rate was 95.9 ± 2.02% [95% confidence interval (CI) 89.39-98.43]. At 16 years, the cumulative incidence function of cardiac death, with non-cardiac death as a competing risk, was 3.1 ± 1.75 (95% CI 0.83-8.02). Only 3 patients (4.1%) had redo operations for recurrent severe MR. At 16 years, the cumulative incidence functions of reoperation for and recurrence of MR ≥3+, with death as a competing risk, were 3.1 ± 1.76% (95% CI 0.83-8.02) and 5.6 ± 2.47% (95% CI 2.06-11.83), respectively. No predictors of recurrence of MR ≥3+ were identified. At the last follow-up, moderate MR (2+/4+) was detected in 17 patients (17.5%); most of the patients were in New York Heart Association functional class I-II (97%) and in sinus rhythm (90%).

CONCLUSIONS

Minimally invasive mitral valve edge-to-edge repair through a right minithoracotomy for myxomatous degeneration appears to be an effective and durable approach even in the long-term follow-up (up to 19 years).

Effectiveness of wound infusion of 0.2% ropivacaine by patient control analgesia pump after minithoracotomy aortic valve replacement: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Local anesthetic wound infusion has become an invaluable technique in multimodal analgesia. The effectiveness of wound infusion of 0.2% ropivacaine delivered by patient controlled analgesia (PCA) pump has not been evaluated in minimally invasive cardiac surgery. We tested the hypothesis that 0.2% ropivacaine wound infusion by PCA pump reduces the cumulative dose of opioid needed in the first 48 h after minithoracothomy aortic valve replacement (AVR).

METHODS

In this prospective, randomized, double-blind, placebo-controlled study, 70 adult patients (31 female and 39 male) were analyzed. Patients were randomized to receive 0.2% ropivacaine or 0.9% saline wound infusion by PCA pump for 48 h postoperatively. PCA pump was programmed at 5 ml h^- 1 continuously and 5 ml of bolus with 60 min lockout. Pain levels were assessed and recorded hourly by Numeric Rating Scale (NRS). If NRS score was higher than three the patient was administered 3 mg of opioid piritramide repeated and titrated as needed until pain relief was achieved. The primary outcome was the cumulative dose of the opioid piritramide in the first 48 h after surgery. Secondary outcomes were frequency of NRS scores higher than three, patient's satisfaction with pain relief, hospital length of stay, side effects related to the local anesthetic and complications related to the wound catheter.

RESULTS

The cumulative dose of the opioid piritramide in the first 48 h after minithoracotomy AVR was significantly lower (p < 0.001) in the ropivacaine (R) group median 3 mg (IQR 6 mg) vs. 9 mg (IQR 9 mg). The number of episodes of pain where NRS score was greater than three median 2 (IQR 2), vs 3 (IQR 3), (p = 0.002) in the first 48 h after surgery were significantly lower in the ropivacaine group, compared to control. Patient satisfaction with pain relief in our study was high. There were no wound infections and no side-effects from the local anesthetic.

CONCLUSIONS

Wound infusion of local anesthetic by PCA pump significantly reduced opioid dose needed and improves pain control postoperatively. We have also shown that it is a feasible method of analgesia and it should be considered in the multimodal pain control strategy following minimally invasive cardiac surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03079830 , date of registration: March 15, 2017. Retrospecitvely registered.

Total arterial multivessels minimal invasive direct coronary artery bypass grafting via left minithoracotomy

BACKGROUND

Minimal Invasive Direct Coronary Artery Bypass Surgery (MIDCAB) is becoming popular and an important armamentarium for cardiac surgeons. We aimed to evaluate the result of MIDCAB total arterial revascularization.

METHODS

We have evaluated 216 patients who underwent MIDCAB multivessel total arterial revascularization through a left anterolateral mini thoracotomy. LIMA harvested in every patient, RIMA or radial artery used as second conduit. LIMA-RIMA Y or LIMA-RADIAL Y was made to accomplish multivessels total arterial revascularization. Post-operative graft patency was evaluated in all patients by CT coronary angiography at 6 months following discharge.

RESULTS

Mean age of patients was 52.5 ± 9.8 years. Average number of anastomosis performed were 2.34 ± 0.75. Multivessels total arterial CABG was accomplished in all individuals. There was no mortality or deep wound infection. Re-exploration was done in two patients for bleeding. In one patient emergency CPB was required. Average ICU and hospital stay was 1.52 ± 0.77 and 4.92 ± 1.46 days, respectively. Patients were mobilized earlier due to less pain. Wound healing of anterolateral thoracotomy was faster. In the follow up CT angiography 100% of the LIMA grafts were patent.

CONCLUSIONS

Multivessels total arterial MIDCAB can be accomplished safely in selected individuals. RIMA can be harvested in long standing diabetic patients with no concern for sternal wound healing. MIDCAB patients experience better cosmetics and early return to daily activities.

Rapid Deployment Aortic Valve Replacement via Right Lateral Mini-Thoracotomy - First Clinical Experience in Japan

BACKGROUND

Rapid deployment aortic valve replacement has been developed to shorten procedural times and to facilitate minimally invasive cardiovascular surgery. Methods and Results: As a representative rapid-deployment valve, the balloon-expanding INTUITY Elite (the 2nd-generation Edwards INTUITY Valve System) was uneventfully implanted via a right lateral mini-thoracotomy in 2 patients with severe aortic valve stenosis. Both of them recovered quickly and were discharged from hospital without significant adverse events.

CONCLUSIONS

Implantation of the INTUITY Elite valve via right mini-thoracotomy is feasible and safe.

Minimally Invasive Surgical Mitral Valve Repair: State of the Art Review

Minimally invasive surgical mitral valve repair (MVRepair) has become routine for the treatment of mitral valve regurgitation, and indications have been expanded to include reoperations. Current European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines for the management of valvular heart disease recommended standards in terms of mitral valve disease differentiation, timing of intervention and surgical techniques to improve patient care. Numerous minimally invasive techniques to lessen the invasiveness have been described, such as the minimal-access J-sternotomy (ministernotomy), the parasternal incision, the port-access technique and the right minithoracotomy. Despite the development of catheter-based techniques, surgical repair remains the gold standard today for nearly all patients with degenerative valvular diseases and the majority of patients with other types of valvular diseases. Techniques include resection of the prolapsed segment, neo-chordae implantation and ring annuloplasty. In this review, the current indications for mitral valve surgery are summarised and state-of-the-art MVRepair techniques are highlighted.

Minimally invasive endoscopic repair of atrial septal defects via right minithoracotomy

Atrial septal defect (ASD) repair has been conventionally performed via midline sternotomy with very low operative risk and excellent early and late outcomes. Recently, many of these patients with suitable anatomy are being treated with percutaneous catheter-based closure of their ASD, but issues of prosthetic device implantation, long-term antiplatelet therapy and late device complications persist. Minimally invasive repair of ASD via a 3-cm right minithoracotomy provides patients with a much less invasive surgical repair with all the durable benefits of autologous pericardial patch closure. However, widespread adoption of the minithoracotomy approach to ASD closure remains slow. This study describes the simple steps to ASD repair via a right minithoracotomy.

Atrial septal defect closure: comparison of vertical axillary minithoracotomy and median sternotomy

BACKGROUND

This study aims to evaluate whether or not the method of right vertical axillary minithoracotomy (RVAM) is preferable to and as reliable as conventional sternotomy surgery, and also assesses its cosmetic results.

METHODS

Thirty-three patients (7 males, 26 females) with atrial septal defect were admitted to the Cardiovascular Surgery Clinic of Cukurova University from December 2005 until January 2010. The patients' ages ranged from 3 to 22. Patients who underwent vertical axillary minithracotomy were assigned to group I, and those undergoing conventional sternotomy, to group II. Group I and group II were compared with regard to the preoperative, perioperative and postoperative variables. Group I included 12 females and 4 males with an average age of 16.5±9.7. Group II comprised 14 female and 3 male patients with an average age of 18.5±9.8 showing similar features and pathologies. The cases were in Class I-II according to the New York Heart Association (NYHA) Classification, and patients with other cardiac and systemic problems were not included in the study. The ratio of the systemic blood flow to the pulmonary blood flow (Qp/Qs) was 1.8±0.2. The average pulmonary artery pressure was 35±10 mmHg. Following the diagnosis, performing elective surgery was planned.

RESULTS

No significant difference was detected in the average time of the patients' extraportal circulation, cross-clamp and surgery (p>0.05). In the early postoperative period of the cases, the duration of mechanical ventilator support, the drainage volume in the first 24 hours, and the hospitalization time in the intensive care unit were similar (p>0.05). Postoperative pains were evaluated together with narcotic analgesics taken intravenously or orally. While 7 cases (43.7%) in group I needed postoperative analgesics, 12 cases (70.6%) in group II needed them. No mortality or major morbidity has occurred in the patients. The incision style and sizes in all of the patients undergoing RVAM were preserved as they were at the beginning. Furthermore, the patients of group I were mobilized more quickly than the patients of group II. The patients of group I were quite pleased with the psychological and cosmetic results. No residual defects have been found in the early postoperative period and after the end of the follow-up periods. All of the patients achieved functional capacity per NYHA. No deformation of breast growth has been detected during 18 months of follow-up for the group I patients, who underwent RVAM.

CONCLUSION

To conclude, the repair of atrial septal defect by RVAM, apart from the limited working zone for the surgeon in these pathologies as compared to sternotomymay be considered in terms of the outcomes, and early and late complications. And this has accounted for less need of analgesics and better cosmetic results in recent years.