A 22-year-old man, weighing 65 kg, was admitted to our hospital to evaluate a murmur in the routine examination. He had complained of mild shortness of breath on physical exertion for one month. Physical examination on admission revealed a systolic murmur in the left para-sternum, trans-thoracic echocardiography showed a subarterial VSD with a diameter of 8 mm, left to right shunting, pressure gradient via the defect was 70 mmHg. The left ventricle dilated mildly with left ventricle end-diastolic diameter was 57 mm and left ventricular ejection fraction was normal range. Pulmonary artery systolic pressure was 33 mmHg at rest. Mild aortic regurgitation was present. The patient was conducted under general anesthesia with a single-lumen endotracheal tube and placed in supine position as for standard median sternotomy with two arms along the body. Defibrillation pads were placed on the right and left chest before sterile draping. The femoral artery and vein were dissected in preparation for cannulation with a 2–3 cm oblique right groin incision. A 4 cm left parasternal thoracotomy was used to enter the thorax via the third intercostal space (ICS). The left internal thoracic artery was preserved carefully. The third costal cartilage was divided close to the sternum, without resection, to increase exposure. The ribs were slowly spread with a mini-thoracic retractor. The pericardium was opened longitudinally and suspended with stay sutures. The femoral artery cannula was inserted directly into the common femoral artery. A multi-stage venous cannula was inserted using the Seldinger technique with the tip of cannula advanced to the superior vein cava under transesophageal echocardiography guidance. After femoral arterial and venous cannulation, cannulas were secured, and cardiopulmonary bypass (CPB) initiated. CPB was initiated with vacuum-assisted venous drainage and body temperature maintained at approximately 34 °C A long cardioplegia needle (Livanova, London United Kingdom) was utilized to deliver warm blood cardioplegia directly into the aortic root and repeated every 15–20 minutes. An aortic clamp was introduced through the thoracotomy incision as a standard median sternotomy. The aorta was cross-clamped after dissecting the main pulmonary artery from ascending aorta. The VSD was exposed through a transverse right ventriculotomy. A left vent was inserted via the VSD to evaluated the edge of the defect. The subarterial VSD was closed with a patch (Bovine pericardial patch, Edwards Lifesciences) by a continuous suture. The left heart was filled with saline to exclude air before tying the suture. Any remaining air was then vented through the original cardioplegia site. Ventriculotomy was closed, and two ventricular temporary epicardial pacing electrodes were placed before releasing the aortic clamp. The cardioplegia needle was removed after the de-airing maneuver was completed, and the patient might be weaned from CPB and decannulated. CPB and cross-clamp times were 58 and 42 min, respectively. The patient was ventilated postoperatively in the intensive care unit and extubated within 4 h without any complications. Echocardiography prior to discharge showed completely closed VSD, mild aortic regurgitation. The patient was discharged from the hospital on the fifth postoperative day. There were no complications after 3 months and 6 months of follow-up (,, ).