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Key Concepts

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  • Innovations in alternative methods for cannulation and cardiopulmonary bypass (CPB), new visualization systems, retractors and stabilizers, and robotic platforms have facilitated the development of minimally invasive cardiac surgery.

  • Minimally invasive direct coronary artery bypass (MIDCAB) and totally endoscopic coronary artery bypass grafting (TECAB) remain hindered by inherent technical complexities.

  • Minimally invasive approaches for mitral valve surgery include mini-right thoracotomy, partial sternotomy, parasternal approach, and robotic port access.

  • Complications associated with the endoclamp include balloon migration/rupture and retrograde aortic dissection.

  • Elevated atherosclerotic plaques greater than 2 mm in height in the descending thoracic aorta or arch may increase the risk of retrograde cerebral and other systemic embolization and constitutes a contraindication to femoral artery-perfused minimally invasive mitral valve surgery.

  • Relative contraindications for a mini-right thoracotomy mitral approach include previous right thoracotomy with dense pleural adhesions, significant obesity, severe chest deformity (e.g., pectus excavatum), scoliosis, and prior breast implant or reconstruction.

  • Other operations that can be performed through a small right thoracotomy include tricuspid valve surgery, atrial septal defect closure, atrial myxoma resection, and septal myectomy.

  • Minimally invasive approaches for aortic valve surgery generally consist of limited sternotomies.

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The midline sternotomy incision offers excellent access to all cardiac structures and has been the traditional route for the performance of most cardiac operations. However, the growth and advancement of percutaneous interventional techniques such as coronary artery stenting have been accompanied by a growing patient willingness to undergo procedures with less favorable mid- and long-term outcomes compared with coronary artery bypass grafting (CABG), largely to enjoy lower periprocedural risks and less invasiveness. In response to this, cardiac surgeons have progressively developed less invasive operations to provide the benefits of standard cardiac procedures with less morbidity. Through the use of innovative surgical approaches combined with new technology, cardiac surgeons have introduced a spectrum of novel, minimally invasive operations. The avoidance of cardiopulmonary bypass (CPB) and/or the full median sternotomy incision are the main features common to this new generation of procedures. This chapter describes and discusses the evolution and results of minimally invasive cardiac surgery, with an emphasis on minimally invasive mitral valve operations.

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Minimally Invasive Coronary Artery Bypass Grafting

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Although the first attempts to revascularize ischemic myocardium were accomplished on a beating heart, the advent of CPB with cardioplegic arrest offered a reliable and highly reproducible means to perform CABG. During the mid-1990s, in an attempt to circumvent the need for sternotomy, surgeons developed a procedure to create a left internal mammary artery (LIMA)-to-left anterior descending coronary artery (LAD) anastomosis through a small left anterior thoracotomy. In this procedure, termed minimally invasive direct coronary artery bypass (MIDCAB), the LIMA is harvested through a left anterior thoracotomy or limited sternal split incision with the assistance of a variety of chest retractors. A stabilizer is subsequently applied on the beating heart, thus facilitating the performance of the coronary anastomosis (Fig. 54-1). Coronary occlusion is obtained ...

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