IntroductionThe aim of this study was to report clinical and hemodynamic results from a real-world registry of aortic valve replacement (AVR) with the Perceval sutureless bioprosthesis, comparing mini-sternotomy (MS) versus mini-thoracotomy (MT) approach.MethodsThis prospective international registry enrolled 1,652 patients across 55 institutions between 2011 and 2021. Patients undergoing isolated AVR by minimally invasive cardiac surgery approaches were analyzed. Preoperative covariates were adjusted using 1:1 propensity score matching, reaching a final cohort of 261 patients for each approach.ResultsIsolated AVR via minimally invasive approaches was performed in 710 patients—406 in MS and 304 in MT. After matching, the baseline characteristics were similar between the two groups, except for the preoperative NYHA class distribution. MT was associated with shorter intensive care unit and hospital stays (p = <0.001 and p = 0.050, respectively), but with higher cross-clamp and cardiopulmonary bypass times compared to MS (<0.001). Within 30 days, one cardiovascular death occurred in the MS group, while 4 (1.5%) reinterventions were reported in the MT group. Pacemaker implantation was required in 5 (1.9%) patients in the MS group and 14 (5.4%) patients in the MT group, with no statistically significant difference. In the matched cohort, survival probability for late events showed no difference between surgical approaches. Mean pressure gradients remained stable during follow-up, with no difference between the groups.DiscussionOur propensity-matched analysis demonstrates that the use of Perceval in minimally invasive approaches is associated with low perioperative complication rates. Sutureless implanted in MT has lower intensive care and in-hospital stay without significant differences in long-term clinical and echocardiographic outcomes.

Hypoxia conditioned adipose-derived stem cell-derived extracellular vesicle therapy improves cardiac function in a rat model of ischemic cardiomyopathy

ObjectivesWe conducted a study comparing full sternotomy (FS) and minithoracotomy (MT) for aortic valve replacement (AVR). The primary end-point was determining all-cause mortality and other variables according to the VARC 3 Consortium.MethodsRetrospective investigation from January 2017 to December 2024 in 2 referral centres in Peru. We selected 142 patients who were submitted to isolated AVR through MT and 772 through FS. We used unmatched analysis and a propensity score matching (PSM) for matched analysis.ResultsIn the unmatched analysis, operative mortality for MT was similar (MT: 2.1% vs FS: 1.6%, P: .391), stroke rate in the MT group was 2.1% and in the FS group 1% (P: .278), pacemaker insertion was more common in the MT group (MT: 3.5% vs FS: 0.5%, P < .001) as well as post-operative atrial fibrillation (POAF) (19% vs 9.2%, P < .001). After a PMS, operative mortality was similar (MT: 1/108, 0.9% vs FS: 3/108, 2.8%, P: .314); as well as, pacemaker insertion (MT: 2.8% vs FS: 0%, P: .081), stroke (MT: 1.9% vs FS: 0%, P: .162) or POAF (MT: 15.7%, FS: 8.33%, P: .086). At follow-up, PMS analysis showed a similar 5-year survival estimates (MT: 97.6%, IC 95%: 90.7%-99.4% and for FS: 94%, IC 95%: 85.2%-97.6%, P: .103).ConclusionsIsolated AVR through MT or FS has similar operative and follow-up mortality rates. It is possible to implement a minimally invasive cardiac surgery (MICS) program with good results in middle-income countries.

Right anterior mini-thoracotomy for isolated aortic valve replacement: An international and multicenter study.

Objective Minimally invasive techniques represent an emerging standard of care for the surgical treatment of myxomatous mitral valve disease. Due to the limited availability of the daVinci surgical system at our center, a robotic‐assisted (RA) approach is generally reserved for patients with complex leaflet pathology. Consequently, in order to accurately evaluate any possible outcome difference between the minimally invasive right thoracotomy and RA surgical approach, we selected patients with myxomatous mitral valve disease for evaluation. Methods From 2012 to 2021, 300 patients with degenerative mitral valve disease and myxomatous pathology underwent isolated mitral repair surgery through either a mini‐thoracotomy (MT) (229 patients) or a RA (71 patients) approach. Propensity score matching yielded 71 patients in each group for which outcomes were evaluated. Results After propensity score matching, there was no difference between groups with respect to the preoperative baseline characteristics. There was no difference in cross‐clamp time between the two groups. The RA patients were more likely to receive a partial annuloplasty band, a titanium knot fastener, and a triangular resection compared to the MT group. Residual mitral regurgitation greater than mild was similar between groups (RA = 1.4%, MT = 0%, NS). There was no difference in the postoperative outcomes between groups. Conclusions Based on our experience, both RA and MT surgical approaches yield excellent results for patients with myxomatous mitral valve disease. While there were differences in mitral repair technique between the two groups, there was no significant difference in outcomes. Expansion of this evidence base through prospective and multicenter studies may be warranted. Central Message In our single institution experience, both RA and MT mitral valve repair yield excellent results for patients with myxomatous mitral valve disease.

Background/Objectives: Postoperative pneumonia (PP) is a significant complication following thoracic surgery, increasing morbidity, mortality, and hospital length of stay. Identifying risk factors is crucial for optimizing perioperative management. This study analyses predictors for PP in patients undergoing anatomical lung resections in a single center setting. Methods: A prospective cohort study was conducted using data from the German Thoracic Registry (GTR). Patients who underwent anatomical lung resection were included in the study, while non-anatomical resections and cases with missing data were excluded. The primary outcome measure was the incidence of PP, which was analyzed using chi-square tests and Fisher’s exact test. Results: PP was observed in 15.2% of the 381 patients. Significant preoperative predictors included American Society of Anesthesiologists (ASA) classification ≥ 3 (p = 0.021), C-reactive protein (CRP) ≥ 20 mg/L (p = 0.004), white blood cell count (WBC) ≥ 15,000/µL (p = 0.003) and forced expiratory volume in 1 s (FEV1) < 50% (p = 0.004). Intraoperative risk factors included thoracotomy (THT) (p = 0.001) and duration of operation > 180 min (p = 0.002). Postoperative predictors included Intensive Care Unit (ICU) admission (p < 0.001) and mechanical ventilation > 24 h (p < 0.001). PP was associated with a higher perioperative mortality rate (10.3% vs. 1.2%, p = 0.01) and prolonged hospital stay. Conclusions: A number of risk factors for the development of PP have been identified, which may help to reduce the incidence of the condition. For further validation, multicenter studies are required.

Background: Innovations in left ventricular assist device (LVAD) technology have led to improved survival with less complications, however external outflow graft obstruction (EOGO) has been recognized as a new complication. EOGO occurs when fibrinous materials collect between the LVAD outflow graft, due to its porous nature, and bend relief cover. This collection compresses the graft and can cause low flow alarms and worsening heart failure. Consensus on management of EOGO has not been established. For patients with suspected EOGO, what diagnostic modalities should be utilized and what interventions should be considered? Description of case: A 54-year-old man with an LVAD was admitted for recurrent low flow alarms. Transthoracic echocardiogram (TTE) demonstrated a dilated left ventricle (LV) at 6cm, and ejection fraction of 21%. Computed tomography angiogram (CTA) showed stenosis in the proximal outflow graft near the pump housing. Endovascular approach, LVAD exchange, and graft repair were all considered, however he was listed for heart transplant. Prior to transplant, he developed cardiogenic shock with persistent low flow alarms. Repeat CTA showed extension of the outflow obstruction. He underwent mini thoracotomy, the space between the outflow graft and bend relief was fenestrated, and a yellow proteinaceous material gushed out. The outflow graft immediately expanded with improvement of LVAD flows. Discussion: EOGO should be considered in LVAD patients with recurrent low flow alarms. Multimodality imaging is vital to determine etiology and location of obstruction. On TTE, obstruction should be suspected if there is worsening LV dilation and mitral regurgitation. CTA is recommended as it allows visualization and localization of outflow graft obstruction. If obstruction is distal to the LVAD pump (near the aorta) endovascular approaches (stenting or balloon angioplasty) can be considered. If proximal to the pump housing, endovascular approaches may pose higher risk and surgery should be considered. Surgical interventions include relief of the obstruction by fenestrations in the bend relief, pump exchange, or even heart transplant. Given our patient's EOGO was proximal to the pump housing, endovascular approaches were not attempted. In summary, EOGO can be thoroughly evaluated with multimodality imaging including echocardiogram and CTA. CTA is imperative to evaluate severity and location of obstruction, guiding appropriate treatments strategies.

Abstract Background Aortic valve disease is the most common valvular heart disease in developed countries and its incidence is likely to increase with age and rheumatic heart disease. Aortic valve replacement (AVR) through a full sternotomy (FS) is the conventional approach for the treatment of aortic valve disease yet minimally invasive techniques provide a safe and more efficient alternative. Aim This study aimed to compare between two approaches for minimally invasive Aortic valve replacement surgery (MICS AVR) which are upper mini sternotomy and right anterior thoracotomy. Patients and Methods This prospective observational study was conducted on 40 patients who were divided into 2 groups; 20 patients underwent MICS AVR through upper mini sternotomy (Group I) and 20 patients underwent MICS AVR through right anterior mini thoracotomy (Group II). Results Among this study patients there was statistically significant longer total CPB time and total operative time in group II compared to group I. However, group II had insignificantly longer total cross clamp time. The current study showed that there was statistically significant longer total ICU stay in group I. No ICU mortality was reported in any patient of both groups. In this study there was a statistically insignificant difference between both groups in terms of postoperative complications. There was statistically significant increase in total hospital stay in group I [10.7±1.34 days] than group II [8.35±1.18 days]. Also, there was statistically significant more pain score in group II [5(4 − 6)] than group I [3(2 − 3)]. Also, there was statistically significant increase in percentage of patients with pain in group II [5 (25.0%)] than group I [0 (0.0%)]. There was statistically significant increase in time to full recovery and mobility in group I [60 days] than group II [14 days], while no statistically significant difference between both groups regarding dyspnea class. There was statistically significant higher overall satisfaction score and cosmetic satisfaction score in group II than group I. Conclusion In patients undergoing isolated AVR, CPB and total operative time are significantly decreased in the upper ministemotomy approach, which also lowers postoperative pain. On the other side, a right anterior minithoracotomy had a shorter incision length and shorter mechanical ventilation time and ICU stay, hospital stay and time to full recovery and mobility and increases overall and patients satisfaction.

Background: The standard approach for mitral valve surgery was a sternotomy, but with the new trends, mitral valve surgery can now be performed with right mini thoracotomy incision. Minimally invasive mitral valve surgery has demonstrated superior cosmetic outcomes, less surgical trauma, shortened intensive care unit and hospital stays, cost effectiveness, and faster recovery, while the efficacy is comparable to conventional sternotomy. Objective: The aim of this research is to investigate the short-term outcomes of thoracoscopic minimally invasive mitral valve replacement in comparison with the conventional technique. Subjects and Methods: This study included 100 patients with isolated mitral valve disease, who were randomly divided into two equal groups. Group A underwent a right anterolateral video-assisted mini-thoracotomy, while Group B was approached via a conventional median sternotomy. Results: The minimally invasive group had significantly longer total operative time (291.3±48.89 min vs. 227.68±49.18 min, p = 0.001). However, Group A demonstrated better post-operative outcomes, including shorter ICU stay (2.1±1.07 vs. 3.82±1.49 days, p = 0.002), shorter extubation time (4.24±1.12 vs. 8.45±4.55 hours, p = 0.0001), reduced post-operative blood loss (271.7±107.09 ml vs. 449.2±230.93 ml, p &lt; 0.0001). Post-operative pain scores were significantly lower in Group A (VAS 3.84±1.53 vs. 7.58±1.62, p &lt; 0.0001), and hospital stay was shorter (7.22±1.37 vs. 11.21±3.53 days, p &lt; 0.0001). Conclusions: Minimally invasive mitral valve surgery can be a safe and effective alternative to traditional MVS in patients with mitral valve disease.

Abstract Objective We present a case of a 18 years old girl with Marfan syndrome presented with severe mitral regurgitation (MR) in a degenerative Barlow disease with prolapse of both leaflets. Methods Chest X–rays showed a severe kyphoscoliosis combined with a pectus excavatum (Figure 1). The patient refused full sternotomy for psychological and cosmetic reasons. Pulmonary function test showed a restrictive syndrome with hypercapnia and normal oximetry at rest. A 3D rendering CT–scan assessed the feasibility of a minithoracotomy (MT) approach: by rotating the 3D scan surgeons and radiologists realized that the only available option was the access of the 3rd intercostal (IC) space, inserting the 3D endoscope in the 2nd one. An accurate valve analysis was obtained with transoesophageal echocardiography (TEE) that revealed a Barlow valve with multi–scallops prolapse more evident at the level of A2 and P2 segments. A 3D mixed and augmented reality (AR) software was used to examine further chest and mitral valve anatomy before surgery (Figure 2). A percutaneous clip was excluded because of the young age and the complexity of lesions, whereas the surgical treatment was suggested as the best solution due to the necessity to preserve and repair the valve, in spite of a difficult surgical access. Results A single endotracheal intubation and a femoral cannulation with single venous cannula were performed. A MT was performed in the 3rd IC space and a 10 mm 3D endoscope was inserted in the 2nd IC space port; the aorta was directly cross clamped and the anterograde cardioplegia was delivered. The left atrium was hidden by the vertebrae and its opening was possible with the help of two stay sutures above the right atrium. After positioning the left atrial retractor, we realized that a direct mitral valve (MV) vision was impossible: we could analyze and correct the multi scallop prolapse only through the endoscopic visualization. MV repair was performed by the insertion of 2 pairs or PTFE artificial chords on anterior and posterior leaflets and a complete prosthetic ring (Figure 3). TEE showed a good coaptation and no MR. Conclusions Due to anatomical complex chest deformity and a Barlow MV, a multi–specialist team approach was fundamental to assess the appropriate surgical access with a dedicated 3D CT scan and AR analysis. A specific endoscopic expertise and a 3D full HD platform were mandatory to achieve a MV repair via small right MT with inadequate direct vision in a minimally invasive approach.Figure 1:CT-Scan showing and Chest X-Rays showing severe kiphoscoliosis and pectus excavatum.Figure 2:A 3D and mixed reality software was used to examine chest anatomy and mitral valve defect.Figure 3:Minimally invasive surgical approach allowed totally endoscopic successful mitral repair.

Abstract Background Acquired diseases in the adult congenital heart disease (ACHD) population are rarely encountered and their management is challenging due to limited data. Improved survival rates in this subgroup will likely lead to more cases in the future. History A 72–year–old male patient with repaired Tetralogy of Fallot (ToF) was admitted with mild dyspnea (NYHA class II). He had undergone palliative surgery at age 6 with a systemic–pulmonary shunt, followed by complete repair at 26 years old. His medical history also included arterial hypertension and atrial flutter treated with ablation. Trans–thoracic echocardiography (TTE) revealed severe mitral regurgitation due to a flail posterior leaflet from chordal rupture, moderate–to–severe tricuspid regurgitation, mild aortic regurgitation, severe left ventricular hypertrophy, EF 60%, mild right ventricular dilation and PAPs of 48 mmHg. ECG showed sinus bradycardia, LAFB, and RBBB. Trans–esophageal echocardiography (TEE) confirmed severe mitral regurgitation (EROA 0.4 cm²) with flail of posterior leaflet. Characteristics of the valve included MV area › 4 cm², posterior leaflet length › 10 mm, flail gap ‹ 10 mm and mean gradient 1 mmHg. Despite favorable parameters for mitral transcatheter edge–to–edge repair (TEER), the Heart Team decided to proceed with a minimally invasive surgical approach, considering the optimal conditions and the pre–operative angioCT findings. The surgical procedure was performed via a right axillary mini–thoracotomy with cardiopulmonary bypass and intra–aortic balloon clamping (Intraclude – Edwards) with cardioplegic arrest. After an initial attempt to repair the valve, a biological prosthesis (CE Magna Ease n° 31) was implanted since the water test was unsatisfactory due to extensive fibro–elastic deficiency of the valve. The post–operative course was uneventful. TTE showed good bioprosthesis function and moderate tricuspid regurgitation with PAPs of 35 mmHg. The patient was discharged home on the seventh post–operative day, without need forrehabilitation. Discussion Managing acquired degenerative diseases in ACHD patients is difficult due to the absence of standardized risk scores and limited data. The evaluation of the best choice for each patient is based on clinical–instrumental history and the experience of the Centers. Despite the emerging role of TEER, a minimally invasive approach with mitral valve replacement permitted optimal results and fast recovery for this patient.

Thymectomy is indicated in the presence of primary thymic diseases such as thymoma. However, there is no clear conclusion which is the best surgical approach for thymectomy. We performed this network meta-analysis (NMA) to compare the outcomes of different surgical approaches for thymectomy. An exhaustive search of PubMed, Excerpt Medica Database (EMBASE), Web of Science and the Cochrane Central Register of Controlled Trials (CENTRAL) was conducted to identify relevant studies from inception to May 1, 2024. Direct and indirect evidence was combined to calculate the odds ratios (ORs) or standardized mean differences (SMDs), along with their 95% confidence intervals (CIs). Cluster analyses were adopted to compare the outcomes of different surgical approaches according to the similarity of two variables. Publication bias was detected by comparison-adjusted funnel plots. Fifty-eight studies were enrolled in this NMA, involving four surgical approaches: thoracotomy (TORA), robot-assisted thoracoscopic surgery (RATS), video-assisted thoracoscopic surgery (VATS) and subxiphoid video-assisted thoracoscopic surgery (SPT). The results indicated that in terms of blood loss, RATS was the least, and TORA had more blood loss than VATS and SPT. As for pleural drainage volume, TORA had more pleural drainage volume than VATS and SPT. In terms of visual analogue scale (VAS) score, VATS and TORA had higher VAS scores than SPT. The complete stable remission (CSR) of RATS was superior to that of VATS and TORA. SPT has faster postoperative recovery and less postoperative pain, and other perioperative outcomes are not inferior to other surgical approaches. RATS is safer and has certain clinical advantages in CSR. We look forward to more large-sample, high-quality randomized controlled studies published in the future.

Abstract INTRODUCTION: Robotic-assisted bronchoscopy (RAB) uses shape sensing navigational technology and provides a safe alternative for biopsies of peripheral lung nodules and can also be used to mark lesions so they may be more easily localized during surgical resection. Performing RAB with/without biopsy, with nodule localization for surgical resection in a single-anesthetic procedure may reduce delays time between diagnosis and intervention for suspicious pulmonary nodules. METHODS: We retrospectively reviewed the first 32 patients undergoing Assisted Single Anesthetic Procedure (ASAP) for RAB and surgical resection at a tertiary care center. RESULTS: From April 2022 to February 2024, 33 patients underwent robotic-assisted bronchoscopy (RAB) with nodule localization followed by immediate surgical resection. The median age was 71 years of age (+/- 9). Median procedure time was 4 hours and 22 minutes. The average lesion size was 1.5cm and 75% of lesions were less than or equal to 2cm. Additional lesion characteristics are noted in Table 1. Navigation was successful with at least a fair view of the lesion on radial endobronchial ultrasound in 74% of cases. In 20 of these cases, RAB was utilized for localization of the lesion for planned immediate resection during the same anesthesia event. In 12 cases, the patients were planned for RAB with biopsy for diagnostic purposes immediately followed by surgical resection if intra-procedural pathology was suspicious for malignancy. If RAB was used for localization only, the average procedure time was 267 minutes; when resection was dependent on ROSE pathology evaluation, the average procedure time was 294 minutes. This difference did not reach statistical significance in our cohort. Most patients underwent video-assisted thorascopic surgery (VATS) for wedge excision, segmentectomy, and/or lobectomy, while eight patients were converted to open or mini thoracotomy. Observed complications are noted in Table 1; patients generally recovered well with a median hospital stay of 3 days. 27 of 32 cases were ultimately confirmed to be malignant on pathology of the surgical specimens. Of these, 24 (88.9%) were Stage I cancer and 81.5% were ultimately diagnosed as adenocarcinoma on pathology. DISCUSSION: Robotic-assisted bronchoscopy with biopsy, dye marking, or both combined followed by surgical resection in a single anesthetic procedure was safe and effective. Combining diagnostic evaluation and therapeutic resection continues to be a promising option and may decrease procedural burden and time to definitive treatment for patients with suspected Stage I or II lung cancer.

Atrial septal defect (ASD) is a hole in the wall that divides the upper chambers of the heart. It may close spontaneously or require closure. Historical approach was operative closure by a full sternotomy. Currently, the gold standard approach is the device closure. When this approach is not available or is not indicated, the alternative is the minimally invasive approaches. In Burkina Faso, West Africa, ASD closure has been performed since 2021 by sternotomy. The authors report the first experience ever of minimally invasive cardiac surgery. A right mini thoracotomy was successfully used as an approach to close secundum atrial septal defect in a four-year old boy. Thoracic wall muscles were spared. The team did not face any technical issue during the procedure and so did not convert to a full sternotomy. Cross clamping time was 23 minutes and CPB lasted 40 minutes. Postoperative course was uneventful, and the patient discharged on day five.

Robotic-assisted mitral valve repair surgery has a steep learning curve, and it is not clear whether previous experience in minimally invasive mitral valve surgery (MIMVS) facilitates this process. We aimed to investigate the initial experience of 2 cardiac centres starting their robotic programmes, evaluating the impact of previous MIMVS experience. Retrospective analysis was performed for the 1st consecutive cases operated due to severe degenerative mitral valve regurgitation using the robotic surgical platform in 2 European centres, 1 transitioning from conventional surgery (centre 1) and the other from mini thoracotomy MIMVS (centre 2). Cumulative sum analysis was used to evaluate the learning process using both surgical times and a combined primary outcome including relevant intra- and postoperative results. First 62 patients in each centre were included. All median surgical times were shorter in centre 2: cardiopulmonary bypass: 238 vs 115 min, P < 0.001; cross-clamp: 143 vs 82 min, P < 0.001; and total intervention: 313 vs 228 min, P < 0.001. The combined primary outcome showed no significant differences (9.7% vs 8%; P = 1). However, the turning point making the end of the learning phase was detected at the 60th case in centre 1 and at the 50th in centre 2. Regarding surgical time, the learning curve was steeper in centre 1 with both cardiopulmonary bypass and cross-clamp overcoming the learning phase after 32 cases, as compared to 16 cases in centre 2. A successful robotic-assisted mitral repair programme can be safely started coming from either conventional open approach or mini thoracotomy MIMVS. However, previous mini thoracotomy MIMVS experience had positive impact on the initial learning curve.

Midterm Outcomes of Right Anterior Mini Thoracotomy Aortic Valve Replacement

BackgroundAortic regurgitation with dilated annulus presents a technical challenge for conventional transcatheter aortic valve implantation (TAVI) procedures.Case presentationWe report a case of an 84-year-old frail patient with a history of breathlessness found to have severe aortic regurgitation and moderately impaired left ventricular systolic function. The patient underwent a successful TAVI procedure using the XL-Myval 32 mm transcatheter heart valve (THV) via an anterior right mini-thoracotomy with a direct aortic approach. The patient recovered well post-operatively with good hemodynamic resolution.ConclusionsThis first in human case highlights the efficacy and potential of applying innovative approaches, such as the new sizes of Myval THV and direct aortic access via anterior right mini thoracotomy, in addressing challenging anatomical variations in TAVI procedures with good outcome.

Outflow Graft Tamponade: An Underrecognized Cause of Obstruction

Abstract Introduction Traditional guidelines for the primary treatment of pneumothorax differ and include simple aspiration, small-bore catheter or chest tube drainage. Treatment via conventional chest tube drainage connected to a suction system is usually associated with hospitalization for approximately 6 days, immobilization, and discomfort. However, reliable patients who do not want to be hospitalized can safely be treated as outpatients with a small-bore catheter attached to a Heimlich valve, True-Close Thoracic Vent (TV). We started using TV at Capio S:t Görans hospital (CStG) in 1999 in cooperation with dr Leif Dernevik, Department of Thoracic Surgery, Sahlgrenska University Hospital. Method TV is a minimally invasive, immediate salvage device for the treatment of pneumothorax. Indications are primary &amp; secondary spontaneous and iatrogenic pneumothorax. The exclusion criteria: hydro/hemopneumothorax, patient refusal, dementia or psychologically unstable, and underlying pulmonary disease requiring supplemental oxygen. Patients are identified and operated on in the ward or postop area. Operation technique: 2nd intercostal-space (IC2) in the midclavicular line (MCL), local anesthetics together with light iv sedation, mini thoracotomy (no-bore safe ATLS-technique), aspiration of air and fixation of TV. Post drain x-ray is conducted and most of the patients are sent home the next day with a 5+2-day ambulatory treatment plan. Result 2016-2023: Cases n 445 Male/female 75/25% Success rate 93% AVLOS 2,3 days Mortality 0% Morbidity grade 3b, one patient (erroneous placement in IC1 MCL). Discussion TV is a safe, cost-effective ambulatory method for treatment of pneumothorax. By using this technique, CStG has saved approximately 2800 beds since 1999 compared to non-ambulatory pneumothorax care.

Ostium secundum atrial septal defect (ASD II) is one of the most common congenital heart defects (CHDs), occurring in 5% to 10% of children (1) and in 30% of adult patients with CHD (2,3). Surgical closure has been considered for many years the gold standard treatment for patients with an ASD II. Operative mortality is low (0% to 3%) (4–6) and long-term survival is high (25-year survival of 92%) (7). Here, we describe our initial experience with minimally invasive approach using total peripheral cannulation (TPC) and an axillary minithoracotomy (AMT) 4-5 cm long incision for surgical closure of an ASD. In our knowledge ASD closure with axillary mini-thoiracotomy is for the first time in the country.