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| Guest Commentary |
by Didier de Canniere, M.D., Ph.D.
Hôpital Erasme - U.L.B., Brussels, Belgium |
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What is Minimally Invasive Cardiac Surgery?
Over more than 50 years of evolution and refinement, cardiac surgery became a mature discipline. Operations like coronary artery bypass grafting (CABG) or valvular replacement became some of the commonest surgical procedures, being performed over 1 000 000 times a year worldwide. Those operations provide excellent long term results in various clear-cut indications with a major favorable impact on patient’s outcome and adverse cardiac events recurrence.
However, they still represent major physiological insult leading to significant complication rates, major morbidity such as CVA, or sometimes even mortality in the high risk group of patients. The cost of cardiac surgery and its complications represent an enormous financial burden for the western societies. For instance, the direct cost of heart disease is about 190 billion dollars per year in the U.S.
In order to decrease the above-mentioned physiological insult, hence the complications and, on the longer run, control the costs associated with a long post-operative recovery and with the complications themselves, the surgical community developed new surgical strategies known as a group under the name of minimally invasive cardiac surgery (MICS). This has eventually become a “subspecialty” in cardiac surgery.
The simple rationale underlying MICS is to perform “classical” operations, whose results are well-known and reproducible, (e.g. mammary grafting, mitral valve repair, aortic replacement, conduit harvesting). The notion is to avoid one, or more, of the 3 maneuvers that generate most of the “invasiveness” and therefore, complications for the patient, i.e. sternotomy (and/or eventually leg incision), cardiopulmonary bypass (CPB) and aortic manipulations.
Byzantine debates occurred in the early days of MICS to determine what is more, what is less, what is more or less invasive: “Do we have to get rid of the cardiopulmonary bypass or do we have to get rid of the sternotomy?” I believe this kind of presentation misses (at least) the opportunity for clarification. Even further, the answer to the above-mentioned question led most of the industrial research toward developing enabling platforms for beating heart surgery, eventually avoiding the need for other approaches. In fact, every step in the reduction of the invasiveness, even small, even cosmetic, that can be measured in an objective way, which does not compromise the long-term result of the operation as compared to the gold standard of surgical care, is a step in the right direction.
One could maybe voice provocatively that MICS is state of mind in heart surgery. The benefit of cardiac interventions has been demonstrated widely; an optimization of the risk/benefit ratio goes through a decrease of the surgical aggression. In some case, this leads to minor adaptation in the strategy, such as the avoidance of repeated aortic clamping, sometimes to major paradigm changes such as in robotic surgery. The point is to enlarge the array of the surgical armamentarium directed against heart disease.
More specifically, in the field of coronary artery surgery different “less invasive” operative strategies could be integrated into a therapeutic armamentarium: MIDCAB, OPCAB, small access arrested heart CABG or totally endoscopic coronary artery bypass (TECAB). These approaches enhance each other and are not mutually exclusive. Their existence enables the surgeon to “Taylor the operation to the patient and not the patient to the operation” as we have heard many times.
The “Holy Grail” of heart surgery is not difficult to define: it is a fully endoscopic operation without aortic manipulations, performed on the beating heart that provides even or better long-term results when compared to open chest interventions. This is where the border between cardiac surgery and invasive cardiology fades away. In some instances, such as single mammary-to-LAD graft, this goal has been achieved already, in other cases we are far from this end point.
It is noteworthy that, beside those classical operations, performed through alternative minimally invasive techniques; unexpected developments take place with increasing experience in using technologies that have been developed to enable MICS. New operations such as closed chest beating heart operations for atrial fibrillation may be feasible in the very near future.
This future is exciting!
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