Less invasive heart surgery.

gical techniques in the last three years has been one of the most dramatic changes in the field of cardiology in some time. It is fair to say that although improvements and results are being published almost monthly in the cardiac surgery literature, these approaches are still in their infancy. Access to the heart through small incisions (8–10 cm) has received a lot of attention and many patients as well as surgeons have learned about these operations from the lay press. In the past, surgeons tended to embrace new procedures as a group; in this case, there has been a significant level of resistance among some in the cardiac surgical community. The question raised over and over again is: Why should one change perfectly good and safe procedures? The trend in other surgical specialties over recent years has been to minimize surgical trauma. The prevailing opinion seems to be that smaller is better. This concept contradicts the classical teaching of the French schools that believe that petit incision, petit chirurgien. Cardiac surgeons as a group have been slower than other specialists to adopt these techniques. The reason perhaps is that we are dealing with a moving target. A discrepancy exists in the cardiac surgical world as to what constitutes a “less invasive” procedure. While some believe that this is determined by the size of the incision, others think that it is a function of eliminating cardiopulmonary bypass as part of the procedure. Patients are motivated to have smaller incisions for aesthetic reasons, but also because their ability to return to conventional daily activities is unquestionably accelerated. The complete median sternotomy produces discomfort of the entire thoracic cage as the ribs are stretched laterally, affecting joints, costal cartilages, and occasionally the brachial plexus. In addition, although rare (1–2%), conventional median sternotomy exposes the anterior mediastinum to infection. Although the limited anterior thoracotomy is also painful, it affects patients in a more localized manner and, in general, for no more than 24–48 hours. The pain then settles without residual thoracic cage problems. In order to understand the terminology of less invasive cardiac surgery, it is important to note that this term — as well as the term minimally invasive — has been rather loosely applied to a diverse variety of cardiac surgical procedures. These include: 1) coronary bypass surgery through conventional median sternotomy without the use of cardiopulmonary bypass (CPB); 2) coronary bypass surgery through small and even “keyhole” incisions on a beating heart without CPB and using direct vision, which is also known as minimally invasive direct coronary artery bypass (MIDCAB); 3) port-access coronary artery bypass utilizing a proprietary system that allows for conventional CPB with aortic cross-clamping and optimal myocardial protection while affording the opportunity of operating through a relatively small incision; and Less Invasive Heart Surgery