Minimally invasive surgeries for pediatric patients have been proposed for decades, with different approaches in mind. Minimal right axillary thoracotomy (MRAT), proposed two decades ago, allows the preservation of patients’ safety alongside faster aesthetic and functional recovery. The MRAT did not become widely adopted due to the prejudice that to follow a minimally invasive approach, safety and efficacy must be compromised. With this study, we aim to compare MRAT to the standard median sternotomy approach with a focus on safety and clinical outcomes. Between January 2017 and April 2021, 216 patients diagnosed with ASD, pAVSD, or PAPVD underwent surgical repair with different approaches in the same period. MRAT was used for 78 patients, and median sternotomy was used for 138 patients. In this last group, standard median sternotomy (SMS) was used for 116 patients, while a minimal skin incision (SMS mini) was used for 22 patients. There were no major complications overall nor in each specific approach. MRAT enabled the successful repair of simple heart defects, providing similar post-operative and cardiological recovery. MRAT does not compromise patients’ safety and does not prolong the duration of surgery once the learning curve is overcome, which is generally after 15–20 consecutive operations.

Background: Infants < 10 kg undergoing cardiac surgery with cardiopulmonary bypass (CPB) may receive either fresh frozen plasma (FFP) or other solutions in the CPB priming volume. The existing comparative studies are controversial. No study addressed the possibility of total avoidance of FFP throughout the whole perioperative course in this patient population. This retrospective, non-inferiority, propensity-matched study investigates an FFP-free strategy compared to an FFP-based strategy. Methods: Among patients <10 kg with available viscoelastic measurements, 18 patients who received a total FFP-free strategy were compared to 27 patients (1:1.5 propensity matching) receiving an FFP-based strategy. The primary endpoint was chest drain blood loss in the first 24 postoperative hours. The level of non-inferiority was settled at a difference of 5 mL/kg. Results: The 24-h chest drain blood loss difference between groups was −7.7 mL (95% confidence interval −20.8 to 5.3) in favor of the FFP-based group, and the non-inferiority hypothesis was rejected. The main difference in coagulation profile was a lower level of fibrinogen concentration and FIBTEM maximum clot firmness in the FFP-free group immediately after protamine, at the admission in the ICU and for 48 postoperative hours. No differences in transfusion of red blood cells or platelet concentrate were observed; patients in the FFP-free group did not receive FFP but required a larger dose of fibrinogen concentrate and prothrombin complex concentrate. Conclusions: An FFP-free strategy in infants < 10 kg operated with CPB is technically feasible but results in an early post-CPB coagulopathy that was not completely compensated with our bleeding management protocol.

Neonates undergoing surgery for congenital heart disease (CHD) are at high risk for brain function impairment. Reliable early predictors of postoperative neurological complications are lacking. We examined a retrospective cohort of 55 surgically treated CHD neonates systematically monitored by concomitant conventional electroencephalography (cEEG) and amplitude-integrated EEG (aEEG). Neonates underwent cEEG/aEEG at three time points: T0 (preoperative, duration: 90–120 min); T1 (24–48 h after cardiac surgery, duration: ≥11 h); and T2 (7–10 days post-surgery, duration: 90–120 min). For each patient, aEEG background activity was evaluated and scored, and clinical and surgical data were retrieved to establish short-term post-surgical outcomes. Patients with normal T0 monitoring had significantly higher aEEG bandwidths in T1. A lower Aristotle basic score was associated with an improvement in aEEG at T1. Inversely, a narrower aEEG bandwidth in T1 was associated with post-surgical neurological deterioration. The aEEG bandwidth accurately predicted short-term neurological outcome; in particular, a minimal aEEG amplitude above 17.5 µV excluded poor neurological outcome with a negative predictive value of 81.48%. Our results demonstrated that aEEG bandwidth and trend dynamics may be associated with surgical complexity and neurological outcomes. aEEG background trend monitoring may provide relevant prognostic information on neurological outcomes in surgically treated CHD neonates.