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Minimally Invasive Cardiac Surgery

Minimally Invasive Cardiac Surgery

1. History

A. Beating heart anastomosis
1) Alexsis Carrell on dog
2) Kolessov 1967 first LIMA to LAD (6 pts)
3) Banned/ Buffalo 1990/1991
4) Subramanian/Acuff/Mack/Calafiore - MIDCAB

2. Port Access Cardiac Surgery

A. CABG -- Stevens 1996 (Stanford)
B. MVR -- Schwartz, Ribakove (NYU)
C. MIDCAB --
D. Exposure thru 4th ICS
E. 1 or 2 vessel bypass
F. 5-20% stenosis rate
G. Anterior wall revascularization only
H. Less use of resources
I. Eliminates CPB and sternotomy

3. OPCAB

A. Exposure median sternotomy
B. Bypass multiple targets
C. Patency unknown
D. No CPB
E. Port access
F. 4th ICS
G. Femoral cannulation CPB
H. Still heart
I. Total revascularization
J. Can use SVG for proximals
K. Over 2000 cases done similar results as open

4. Endoscopic CABG

A. LIMA taken down with scope only
B. Then conventional MIDCAB or Port Access

5. MIDCAB or OPCAB

A. Use in patients you might not want to use CPB
B. Calcified aorta, poor LVEF, severe PVD
C. Severe COPD, CRF, coagulopathy
D. Transfusion issues, i.e., Jehovahs witness
E. Good target vessels not diffuse disease
F. Anterior/lateral wall revascularzation
G. Target revascularzation in older sicker patients

6. Port Access

A. More universal use
B. Multi-vessel revascularization
C. Redo cases
D. Where sternum healing is problem
E. Obese, DM, steroids

7. Aortic Valve surgery

A. Approach
1) Right parasternal first used by Cosgrove 2nd and 3rd costal cartilages
removed try to preserve RIMA
2) Mini sternotomy (Gundry) upper sternotomy T off to the right 3rd or 4th
ICS better for homograft root replacement
3) Transected sternum (Cosgrove) transect at 3rd ICS level both RIMA and LIMA divided

8. Mitral Valve Surgery

A. Approach
B. Right parasternal
C. Lower mini sternotomy
D. Right anterior lateral thoracotomy
E. CPB has been accomplished with Heartport system
F. Fem-fem CPB
G. Direct cannulation of aorta and atrium

9. Advantages

A. Decreased length of stay (average 4 days)
B. Decreased blood transfusions (Cohn, et al)
C. Return to activity sooner
D. Less atrial fibrillation (5-10% incidence vs 20-30% open CPB)

10. Pediatric Cardiac Surgery

A. Ligation of PDA and division of vascular rings via thorascopic technique (Burke)
B. Open procedures VSD, Tetralogy via mini-sternotomy (Gundry)
C. ASD closure with Heartport port access
D. Graphs

11. Future robotics

A. 3-D imaging
B. Total closed chest still experimental
C. What to do?
D. All will become tools to be used
E. Each will find a niche
F. How to define role for each tool
G. Balance co-morbidities with complete revascularization