Is minimal skin incision and partial sternotomy approach for congenital heart defects less invasive?; evaluation of SIRS on ventricular septal defect

OBJECTIVES: Minimally invasive cardiac surgery (MICS) has been developed to offer patients the benefits of open heart operations with limited skin incision. But it is unclear whether this procedure is less invasive. We evaluate postoperative duration of systemic inflammatory response syndrome (SIRS) on ventricular septal defect (VSD). METHODS: From August 1997 to March 2000, 47 patients VSD underwent total repair by the minimal skin incision and lower partial median sternotomy (MICS group). We compared duration of SIRS between MICS and conventional method group (n = 14) and between early MICS and recent MICS group. We also evaluated the relationship between MICS and postoperative clinical course. RESULTS: Duration of SIRS of MICS group were obviously shorter than that of conventional method group (p < 0.05). That of recent MICS group is also significantly shorter than that of early MICS group (p < 0.05). Operative time, bypass time, postoperative intubation time and length of skin incision were related duration of SIRS. CONCLUSIONS: The results of this study indicate that MICS for VSD may be less invasive method.     

Minimally Invasive Cardiac Surgery in the Adult: Surgical Instruments, Equipment, and Techniques

To clarify the special instruments and equipment used for minimally invasive cardiac surgery (MICS), we examined the initial experiences with MICS operations with ministernotomy or minithoracotomy at our institution. Fifty adult patients with congenital, valvular, and/or ischemic heart diseases underwent MICS operations, and all surgical procedures were completed without conversion to full sternotomy. The length of the skin incision was about 10 cm or less in all patients. Postoperative recovery was favorable, and the majority of the patients were discharged from the hospital around the end of the second postoperative week. In this series of patients, an oscillating bone saw, lifting type retractor, 2 blade spreader, cannula with a balloon, and right-angled aortic clamp among other items, were very useful for successfully performing various operations with MICS approaches and techniques. The associated results suggest that MICS with ministernotomy or minithoracotomy was feasible using special instruments and equipment and could be encouraged for adult patients with various cardiovascular diseases.     

Advantages and limitations in minimally invasive cardiac surgery

The introduction of endoscopic technology to cardiovascular surgery was significantly delayed compared to abdominal and lung surgery, although it has been gradually introduced in this field during the past decade in closure of patent ductus arteriosus, repair of the vascular ring, implantation of pacemaker leads or AICD, and pericardectomy. Endoscopic technology also started to be used in harvesting saphenous vein grafts (SVG) and the left internal thoracic artery for coronary artery bypass grafting(CABG) from the mid-1990s. Although complete endoscopic surgery has not yet been established in the major field of standard cardiovascular surgery, many cardiac surgeons attempt to minimize the size of chest wounds with 6- to 8-cm skin incisions, which is called minimally invasive cardiac surgery (MICS) or minimally invasive direct coronary artery bypass (MIDCAB). Complete endoscopic cardiac surgeries were performed utilizing the Zeus system and Da Vinci system at the end of the 20th century. Another method to minimize the invasiveness of CABG is to perform it without cardiopulmonary bypass, so-called off-pump coronary artery bypass (OPCAB). Currently, less-invasive procedures are mainly applied for relatively simple cardiac surgeries, although these procedures are also potentially effective to avoid postoperative cerebral or respiratory complications in high-risk patients. MICS is effective in reducing the size of surgical wounds and in decreasing intraoperative blood loss. On the other hand, the duration of anesthesia and surgery can be prolonged due to technical difficulty, and the risk of unsatisfactory anastomosis or incomplete revascularization can also be increased. The cardiopulmonary bypass circuit utilized for MICS requires a more complicated system including negative pressure venous drainage. The detection of accidental trouble during surgery, which is related to the extracorporeal circulation or the MICS procedure itself, can be delayed due to the limited surgical view. MICS procedures carry additional risks related to the more complicated cardiopulmonary bypass system and small surgical wound. We must be deliberate in determining the indications for MICS and obtain complete informed consent from patients when we perform MICS, including informing them of the additional risks related to the MICS procedure itself and the possibility of conversion to standard open-heart surgery.     

Minimally invasive cardiac surgery--the efficacy of right parasterna approach

The recent concepts of minimally invasive surgery have affected even cardiovascular surgery. Especially, the desire to lessen incisional pain and hospital stay has made minimally invasive cardiac surgery (MICS) desirable. However, its efficacy is still controversial. To investigate this goal, we assessed the efficacy of avoidance of median sternotomy through right parasternal approach in view of the postoperative bleeding, % transfusion, postoperative intubation period, degree of incisional pain and serum level of cytokines. Patients with mitral valve disease or atrial septal defects were divided into the MICS (M) group and the control (C) group. In the M group, operations were performed through right parasternal incision under cardiopulmonary bypass (CPB) instituted by placing a venous cannula directly into superior vena cava and arterial and the other venous cannulae into femoral artery and vein. On the other hand, in the C group, operations were performed through median sternotomy under conventional CPB. There were no significant differences in CPB and AXC time between two groups. The M group showed significantly lower value in the postoperative bleeding volume, % transfusion, postoperative intubation time. Patients in the M group showed higher satisfaction of small incision as compared with those in the C group. Serum level of IL-8 after CPB was significantly lower in the M group than in the C group. These results suggested that MICS for mitral disease or ASD appears to be less invasive when median sternotomy is avoided. This suggest that MICS is a promising and contributed approach for open heart surgery to improve the QOL of the patients.     

Intensive imaging assessment for successful minimally invasive cardiac surgery

To clarify special imaging assessment that is useful for minimally invasive cardiac surgery (MICS), we examined 141 cases of MICS operations with ministernotomy or minithoracotomy. In the 141 patients, 62 valve, 42 coronary, 37 congenital heart, and 2 other procedures were successfully completed without conversion to full sternotomy. Preoperative chest x-ray, computed tomography, and/or magnetic resonance imaging were necessary for determining the level of ministernotomy, especially in aortic valve operations. Transthoracic echocardiography was useful for selecting procedures of mitral valve or intracardiac repair through the MICS approach. Intraoperative transesophageal echocardiography was essential for continuous monitoring of cardiac function, intracardiac flow, air bubbles, and so forth. The above results suggest that intensive imaging assessment might be very important for successful MICS operations with ministernotomy or minithoracotomy and that extensive indications for this technique exist for various cardiovascular diseases.     

Semi-automatic suturing device for minimally invasive cardiac surgery

Semi-automatic suturing device for minimally invasive cardiac surgery (MICS) was developed. Exchange of the needle is attained by an automatic grasping action and the needle shift parallel to the long axis of the device. This device (5 mm in diameter) can be inserted through a 5 mm trocar. This new device facilitates not only operative procedure such as mitral valve replacement and patch closure during MICS but conventional cardiac surgery.     

Eight-Year Experience with Minimally Invasive Cardiothoracic Surgery

Background  

Over the past decade, minimally invasive cardiac surgery (MICS) has emerged as an accepted approach for the management of cardiac disease that requires a surgical solution. We report the results of an 8-year, single-institution experience with MICS.     

Minimally invasive cardiac surgery in Japan: history and current status

This review examines the historical and current status of minimally invasive cardiac surgery (MICS) in Japan, based on reports that have been published in English. Although enthusiasm for MICS in Japan increased during the 1990s, it waned during the early 2000s because of various limitations. However, the introduction of minimally invasive mitral valve surgery, aortic valve replacement, atrial septal defect closure, and coronary artery bypass has led to the resurgence of MICS in Japan during recent years. Academic societies and a national registry system will play an important role in ensuring that this new wave of MICS is implemented safely and effectively. Off-the-job training and team building are also key factors for implementing a successful MICS program.     

A successful surgical case of incomplete atrioventricular septal defect with pulmonary dysfunction

A 58-year-old female with incomplete atrioventricular septal defect was treated successfully with surgery. We repaired the defect by closure of atrioventricular septal defect, suture of cleft and tricuspid valve annuloplasty. We adopted method of minimally invasive cardiac surgery (MICS) expecting to preserve pulmonary function and to perform tracheostomy on early stage. After the operation she recovered with no major complications. It is suggested that MICS is effective method for patients with pulmonary dysfunction.     

Aortic valve repair with minimal access "J" sternotomy

Recently many cardiovascular operations have been performed with minimally invasive cardiac surgery (MICS). It is reported that MICS is superior to standard full sternotomy in regard to cosmetic and post-operative recovery. In our institution, aortic valve repair operations have been performed to aortic valve insufficiency. This time, we performed aortic valve repair by minimal access "J" sternotomy. A 63-year-old male with degenerative aortic regurgitation underwent aortic valve repair by MICS. He had experienced dyspnea on exertion 7 days before admission. Preoperative transthoracic echocardiogram showed the grade of aortic regurgitation (AR) was severe. Surgery was successful and the grade of AR became trivial. This combined procedure have merits for patients because of freedom from anticoagulation and small incision. Such combined surgery may be indicated in the treatment in a subset of patients with degenerative AR.     

Stress Caused by Minimally Invasive Cardiac Surgery versus Conventional Cardiac Surgery: Incidence of Systemic Inflammatory Response Syndrome

The present study was conducted to evaluate the degree of stress in patients induced by minimally invasive cardiac surgery (MICS) in comparison with that caused by conventional cardiac surgery. We did this by assessing the incidence of systemic inflammatory response syndrome (SIRS). A total of 48 adult patients who underwent surgery for single valve disease were included in this study, 27 of whom underwent conventional surgery and 21 MICS. We evaluated the stress inflicted on the patients in these two groups by analyzing the duration and degree of SIRS and the level of C-reactive protein (CRP). SIRS was assessed by measuring body temperature, heart rate, respiratory rate, and white blood cell counts. There were no significant differences in the operating times, perfusion times, or aorta clamp times between the two groups; and the mean volume of blood transfusion did not differ significantly either. There was no significant difference in the incidence of SIRS or the mean duration of SIRS between the two groups. The CRP levels did not differ significantly between the two groups. Thus although MICS is superior to conventional cardiac surgery in that only a small skin incision is required, the stress experienced by the patient may be the same as that experienced by the patient undergoing conventional cardiac surgery.     

Repair of traumatic tricuspid insufficiency via minimally invasive port access

We report on a successful tricuspid valve plasty using port-access minimally invasive cardiac surgery (MICS) for severe traumatic tricuspid insufficiency caused by blunt chest trauma suffered 15 years previously. A combination repair procedure, consisting of cleft closures, plication of the anteroseptal commissure, and ring annuloplasty, was necessary to achieve valve competence and proved possible via port access without difficulty. Port-access MICS is an alternative approach for tricuspid valve surgery.     

Surgical closure of atrial septal defect

Background: Closure of ostium secundum atrial septal defect (ASD) vis median sternotomy (MS) is a simple procedure for most cardiac surgeons. Minimally invasive cardiac surgery (MICS) has recently been applied in the management of intracardiac lesions. Methods: We report our experience in surgical closure of isolated ASD via MICS in 60 patients and via MS in 58 patients. There was no difference between these two groups in gender, age, body weight, ratio of systemic to pulmonary blood flow, and pulmonary arterial pressure. Results: The duration of cardiopulmonary bypass was significantly longer in the MICS group than in the MS group [27 to 126 min (42 ± 12) and 14 to 158 min (27 ± 11), respectively; (p < 0.001]. However, the length of incision, incidence of temporary pacemaker wire insertion rate, duration of endotracheal intubation, timing of oral intake, postoperative day drainage amount, incidence of parenteral analgesic injection, postoperative length of stay, and return to normal activity interval were significant shorter and lower in patients of the MICS group than in those of the MS group. All the patients recovered rapidly from the surgery. Follow-up was complete in all patients, with no late complications and no residual shunt. Conclusion: Our results suggest that MICS is a good option for surgical closure of ASD. Received: 4 June 1997/Accepted: 29 October 1997     

微创心脏手术中排气研究

目的探讨微创心脏手术中的排气技术，并评价排气效果。方法选取复旦大学附属中山医院2011年6月至2013年6月收治的56例行微创心脏手术患者为微创组，男31例、女25例，年龄33～7l（57-3±7．2）岁；同期56例行常规胸骨正中切口心脏二尖瓣成形术患者为对照组，男27例、女29例，年龄51～69（53．7±6,8）岁。比较两组患者术后心腔内残留气泡量、心电图异常发生率、术后清醒时间、术后思维能力及脑部并发症发生率等指标。结果微创组心腔内残留气泡量少量占69．6％、中量占30．4％，对照组少量占73．2％、中量占26．8％，两组差异无统计学意义（P〉0．05）。微创组心电图异常发生率与对照组差异无统计学意义（32．1％VS．26．8％，P〉0．05）。微创组术后思维能力评价好85．7％、中12．5％、差1．8％，对照组好78．6％、中19．6％、差1．8％，两组差异无统计学意义（P〉0．05）。两组脑部并发症发生率差异无统计学意义（1．8％vs．1．8％，P〉0．05）。结论采取一系列心脏排气措施可使微创心脏手术的空气栓塞发生率与胸骨正中切口手术相似，在空气栓塞并发症方面无需承担更高的风险。     

Vacuum assisted cardiopulmonary bypass in minimally invasive cardiac surgery: its feasibility and effects on hemolysis

The present study describes a cardiopulmonary bypass (CPB) technique that incorporates vacuum assisted venous drainage and arterial return using a centrifugal pump in minimally invasive cardiac surgery (MICS). The technique was performed on 40 patients scheduled to undergo MICS. The proposed CPB technique enables a good operative field to be obtained even through a limited incision through the use of peripheral cannulation using small cannulae. Vacuum pressure was applied to the venous reservoir (-43 +/- 14 mm Hg) to maintain adequate CPB flow (>2.4 L x min-1 x M-2). The effects of CPB on hemolysis were subsequently compared between patients who underwent the proposed procedure (MICS group; n = 6) and a control group who underwent coronary arterial bypass grafting (CABG group; n = 6) with conventional CPB. Plasma free hemoglobin (FHb) increased and plasma haptoglobin (Hp) decreased during CPB in both groups, with no significant difference between the groups. By the next day, FHb had returned to pre-CPB levels whereas Hp remained lower in both groups. Again, these values did not differ significantly between groups. Thus, we conclude that the proposed CPB technique is useful in MICS with acceptable effects on hemolysis.     

Risk management of minimally invasive cardiac surgery

Since the initiation of port-access minimally invasive cardiac surgery (MICS) in 1998, 350 patients have undergone the operations in our institute. With development of new instruments, the operation of mitral valve diseases and simple congenital defect has become easier. At present, it is the procedure of choice in operation of these lesions. Its weakness, however, is the limitation of visual field and working space. In order to maintain the same operative quality as median sternotomy and avoid any perioperative risk, cooperation of the anesthesiologist and the medical engineering technologist is indispensable. This paper reports on latest surgical procedure and risk management of the port-access MICS.     

Comparison of early postoperative quality of life in minimally invasive versus conventional valve surgery

Purpose.Minimally invasive cardiac surgery (MICS), an approach in which full sternotomy is avoided and the surgical incision is minimal, has been shown to produce less postoperative discomfort and to enable earlier mobilization and discharge than conventional cardiac surgery (CCS). This study was performed to retrospectively evaluate quality of life following MICS in comparison with CCS valve surgery.Methods.Sixty-six patients scheduled for MICS and 50 patients scheduled for CCS for isolated aortic or mitral valve surgery from January 1999 to June 2001 were enrolled in the study. The clinical records for the two groups were compared across intraoperative parameters and those associated with postoperative quality of life.Results.The aortic clamp and cardiopulmonary bypass times in the MICS group were longer than those in the CCS group (144 ± 42 and 224 ± 58min vs 112 ± 21 and 179 ± 27min, P 0.001). Postoperative pain medication (rectal buprenorphine and intramuscular pethidine) was administered to 18 of the 66 MICS patients (27%), as compared with 26 of the 50 CCS patients (52%, P = 0.007). Postoperative delirium was less frequent in the MICS group than the CCS group (26% vs 44%, P = 0.039). Initial postoperative food intake and urine catheter removal were possible earlier in the MICS than in the CCS group. MICS patients had shorter stays in the intensive care unit than CCS patients (37.4 ± 7.3 vs 45.9 ± 8.7h, P 0.001).Conclusion.Although longer aortic clamp and cardiopulmonary bypass times remain a problem in MICS procedures, our results suggest that MICS, as compared with CCS, facilitates earlier recovery of daily activities and provides improved quality of life in the early postoperative period.     

Anesthetic management of MICS with Port-Access system

Port-Access system (P-A) is a catheter-based system for minimally invasive cardiac surgery (MICS) characterized by avoidance of full sternotomy with the aid of Endoaortic Clamp Catheter (EAC) for intra-aortic occlusion instead of the conventional external aortic crossclamping. In our hospital, eleven patients underwent MICS using P-A from August in 1998 to the present time. We compared the intra- and post-operative anesthetic management of these patients with that of fifteen patients done by using our conventional MICS method, Saitama Medical School system (SMS). Anesthetic management of these MICS patients is directed toward early extubation, and therefore all patients receive intravenous anesthesia with a small dose of fentanyl combined with inhalational agent or propofol. Without increasing the time of the cardiopulmonary bypass (CPB) and the amount of the intraoperative bleeding, MICS with P-A needs more time to begin CPB than that with SMS because it takes more time to insert these catheters, especially EAC into the suitable position using transesophageal echocardiography (TEE) and fluoroscopy. The time to start CPB must be shortened by skilled cannulation. There is no difference in the postoperative length of ICU and hospital stays between P-A and SMS. In MICS, TEE is the window to the heart for both surgeon and anesthesiologist and used to guide for the placing of the catheters and weaning from CPB, and anesthesiologist should be skillful in using TEE to evaluate the de-airing procedure and assess volume load and contractility of the left ventricle.     

Treatment of ischemic heart disease by minimally invasive coronary surgery with the "Octopus" system]

Results of 30 operations performed for combined lesions of coronary and peripheral arteries are analyzed. All the operations were performed as off-pump minimally invasive coronary surgery (MICS) on beating heart with "Octopus" system Medtromic. There were no lethal outcomes. Number of complications was minimal. MICS is high-effective procedure in selected patients with coronary heart disease. It is necessary to use differential policy of surgical treatment of coronary heart disease.     

Minimally invasive coronary artery bypass grafting

Minimally invasive cardiac surgery (MICS)-CABG is a technique that at its core has patient comfort, early return to routine activities, meeting patient expectations for less invasive options, and maintaining the highest possible standards of care and outcomes. The technique requires not only surgical dexterity but also integration of significant technological advancements in patient care. At a time when percutaneous interventions are often prescribed on the pretext of increased patient comfort and demand, minimally invasive myocardial revascularization becomes even more relevant. Minimally invasive myocardial revascularization is ever evolving and encompasses both small-incision open techniques as well as endoscopic-assisted procedures. The success of the procedure depends not only on the learning curve and familiarity with the technology but also on appropriate patient selection. Mere feasibility of the technique is not sufficient, and the results have to be comparable with the long-established techniques of conventional coronary artery bypass grafting both in terms of early morbidity and mortality as well as long-term outcomes. In this review, we discuss patient selection and technical aspects of minimally invasive coronary artery bypass grafting. We also provide an evidence-based comparison to early and long-term outcomes with conventional coronary artery bypass grafting. Finally, we review the uptake and outcomes of minimally invasive revascularization in the Indian subcontinent.