Evolving strategies in cardiac surgery: a word of caution

The introduction of minimally invasive coronary artery bypass surgery has e xpanded the technical armementarium for operative treatment of coronary art ery disease. Minimal access surgery using partial sternotomy or anterior in tercostal minimal thoracotomy can be combined with video-scopic techniques or port-access-methods. Either atrio-aortal cannulation, femoro-femoral or jugular-femoral connections to the pump are possible for extracorporal circ ulation (ECC). Even endoluminar occlusion of the aorta and application of c ardioplegia into the aortic root can be considered and applied, Extracorpor al circulation has developed into a safe standardized method. As far as pat hophysiology is concerned, the decision to use ECC or not is of much more i mportance than the grade of invasiveness. Fundamentally we therefore need t o distinguish between minimally invasive methods with and without ECC. Vide o-assisted coronary surgery in hearts under hypothermia and fibrillation wi th ECC is also recommended occasionally. Minimally invasive coronary artery procedures on beating hearts without ECC have to be done in a stabilized a nd bloodless operative field to allow the construction of high standard ana stomoses between bypass grafts and coronary arteries. In practice, silicon occluders, epicardial and myocardial suture occlusion and fixation, mechani cal stabilization devices, and pharmacologic induction of bradycardia are u sed. In principle a skilled surgeon should be familiar with all these metho ds to select the most suitable solution for the special clinical problem. A final judgement about each method is not possible up to now. High patient numbers have to be recruited in the groups and subgroups due to low mortali ty (1%) and morbidity (5%), otherwise statistical significance of the resul ts cannot be gained.