Editorial
Minimally invasive cardiac surgery, a fleeting fancy or a lasting prospect?

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Introduction

The past few months have witnessed the birth of an entirely new form of cardiac surgery. Minimally invasive cardiac surgery is a previously unknown concept which is based, in addition to established principles of cardiac surgery, on ideas and facts acquired from the experience in video-assisted thoracic surgery in the past few years. Two main aims currently drive the development of minimally invasive cardiac surgery; minimizing the surgical incision and eliminating the need to use cardiopulmonary bypass.

There is no doubt that median sternotomy does entail significant morbidity, including a notable incidence of brachial plexus traction injury [1]. Alternative incisions proposed recently include a range of parasternal incisions, partial sternotomies, or anterior mini-thoracotomies 2, 3, 4. Not surprisingly, this has provoked immediate arguments from conservative surgeons who debate that smaller size incisions do not necessarily correlate with lower morbidity, particularly when the need for cardiopulmonary bypass cannot be waived. Nevertheless, recent experience in valve replacement or atrial septal defect closure through limited incisions has bared the significant morbidity related to median sternotomy per se 2, 3. In our own series of patients undergoing atrial septal defect closure through right parasternal incisions, we found considerably less postoperative pain and expeditious postoperative recovery compared to patients operated on through median sternotomy. All patients were discharged home on the third postoperative day and were back to work 2 weeks after surgery.

Realizing this, some workers concentrated great efforts on developing new minimally invasive surgical approaches to coronary artery surgery. An example is `port-access' coronary artery surgery, using femoral cardiopulmonary bypass support with the addition of complete cardioplegic arrest using a novel intravascular system [5]. In this method, anastomoses are performed entirely endoscopically with video assistance.

This approach remains largely experimental, although advances in instrumentation and technique pledge to deliver it into clinical practice in the near future.

Taking the less invasive concept into another context, numerous attempts have been made to avoid the need for cardiopulmonary bypass and its associated morbidity. Yet, such efforts in coronary artery surgery have been going on since the early days of cardiac surgery. Indeed, large clinical series of cases performed through median sternotomy on a beating heart (so called `off-pump' surgery) were reported recently with excellent long-term results 6, 7. These reports formed the first impulse to attempt off-pump coronary revascularisation through minimal incisions; also known as Minimally Invasive Direct Coronary Artery Bypass (MIDCAB).

The majority of reported cases involved an anterior mini-thoracotomy, partial or complete mobilisation of the internal mammary artery (occasionally performed with the help of the thoracoscope), followed by an anastomosis between the internal mammary artery and the left anterior descending or right coronary artery under direct vision. To date, significant experience exists with MIDCAB, mainly involving patients with predominantly single vessel disease 4, 8, and it is hard not to be impressed by the mean hospital stay of 2 days and 95% early patency presented in the largest published series [4].

While this relatively simple approach is feasible, effective performance of more complex operations have been reported. One approach is to use the percutaneous `Hemopump' axial flow system for circulatory support together with the `Octopus' wall immobilization device to maintain coronary artery stability [9]. This method may open new vistas for multiple vessel revascularisation. Another alternative created by these new concepts is an integrated approach utilising staged or synchronised angioplasty and MIDCAB to achieve complete revascularisation in multiple vessel disease [10]. We have adopted this strategy in our institution for the management of patients with multiple vessel disease who have poor left ventricular function or suffer from an associated medical condition that increases considerably the risk of cardiopulmonary bypass (such as severe chronic renal failure). Patients undergo left internal mammary artery graft to the left anterior descending coronary artery, followed by angioplasty to the other coronary vessels within the same hospital admission. In a recent group of 8 patients, we have not encountered any in-hospital mortality or morbidity, and all patients were discharged home on the third postoperative day. Follow-up to 3 months confirms all patients to be in NYHA angina class I, and on no medical treatment. We now consider this approach to be the treatment of choice for this high risk group of patients.

Section snippets

Where do we currently stand?

The need to minimise the surgical incision has become widely accepted. This can be quickly appreciated by the notable number of recent publications describing a range of surgical approaches to a variety of cardiac surgical operations. Another driving factor behind the popularity of this form of minimally invasive cardiac surgery is the massive publicity which has accompanied the realisation that the `mutilation' of sternotomy is no longer an essential part of cardiac operations. The `public

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