The Golden Age of Minimally Invasive Cardiothoracic Surgery: Current and Future Perspectives

Abstract

Over the past decade, minimally invasive cardiothoracic surgery (MICS) has grown in popularity. This growth has been driven, in part, by a desire to translate many of the observed benefits of minimal access surgery, such as decreased pain and reduced surgical trauma, to the cardiac surgical arena. Initial enthusiasm for MICS was tempered by concerns over reduced surgical exposure in highly complex operations and the potential for prolonged operative times and patient safety. With innovations in perfusion techniques, refinement of transthoracic echocardiography and the development of specialized surgical instruments and robotic technology, cardiac surgery was provided with the necessary tools to progress to less invasive approaches. However, much of the early literature on MICS focused on technical reports or small case series. The safety and feasibility of MICS have been demonstrated, yet questions remain regarding the relative efficacy of MICS over traditional sternotomy approaches. Recently, there has been a growth in the body of published literature on MICS long-term outcomes, with most reports suggesting that major cardiac operations that have traditionally been performed through a median sternotomy can be performed through a variety of minimally invasive approaches with equivalent safety and durability. In this article, we examine the technological advancements that have made MICS possible and provide an update on the major areas of cardiac surgery where MICS has demonstrated the most growth, with consideration of current and future directions.

Cardiac surgery using a single thoracic port—current status and future directions

“…Minimally invasive aortic valve surgery has traditionally been done by a upper mini-sternotomy or a right anterior mini thoracotomy (2,10).…”

“…Of these, upper and lower mini-sternotomies and left and right thoracotomies represent attempts to diminish cardiac surgery invasiveness. Unfortunately, these approaches have not been completely successful in their objective-pain and infections still happen with mini-sternotomies, albeit less, and pain is still a very significant component of thoracotomies (2).…”

TAVI Patient Selection and Multidisciplinary Evaluation

“…Aortic valve replacement (AVR) is the only effective treatment for symptomatic AS, being surgery the preferred AVR option for patients across all age groups. Although surgical AVR has an overall low operative mortality [1], elderly and frail patients are at a much higher risk, presumably owing to the presence of multiple coexisting conditions [2]. Cribier et al [3] performed the first human transcatheter aortic valve implantation (TAVI) in 2002, a procedure typically targeted at patients with severe AS who were unfit for conventional surgery [4][5][6].…”

Fibrin sealants: surgical hemostat, sealant and adhesive

“…A product with multiple roles will have added versatility due to the decreased need to stock multiple agents. Additionally, increase in laparoscopic, endoscopic and robotic procedures may push surgeons to look for agents to aid in hemostasis or tissue adherence when pressure or suturing may be difficult [5][6][7]. Increasing evidence of the negative effects of blood transfusion may also drive a market for agents that reduce bleeding or surgical wound breakdown [8][9][10].…”