Minimally invasive cardiac operation: Adapting cardioprotective strategies

Background. Minimally invasive heart operation differs from traditional car diac operations through the omission of a sternotomy, cardiopulmonary bypas s, or both. Current concerns with minimally invasive operation include: ope rative safety, learning curve, operative times, arrest times, and adequacy of myocardial protection. While many of the protective strategies used for traditional procedures may be applied to minimally invasive cardiac operati ons, the safe applications of minimally invasive operations require unique techniques of myocardial protection. Methods and Results. Omission of extracorporeal perfusion may benefit patie nts through attenuation of systemic inflammatory response, decrement in neu rologic insults, and reduced bleeding complications. As a counterbalance, s urgeons must consider long-term operative quality and level of myocardial p rotection provided during beating heart coronary operation. Current issues that must be addressed include: pharmacologic management, coronary collater alization and ischemic preconditioning, the utility of intraluminal coronar y shunts, and technical adequacy of the anastomosis. Nonsternotomy cardiopu lmonary bypass methods utilize alternative incisions and "port-access" tech nology, and may render more rapid patient recovery including: decreased pai n, shortened hospital stay, and more rapid return to work. Altered strategi es of myocardial protection in a closed chest environment must address: met hod of cannulation, technique of aortic occlusion, rapidity and maintenance of cardiac arrest, and cardiac de-airing techniques. Conclusions. Previous obstacles to minimally invasive cardiac operations in cluded limitations in operative exposure, inadequate perfusion technology, and inability to provide myocardial protection. Recent advances in videosco pic visualization and evolving mechanisms of myocardial protection may just ify the expanding application of minimally invasive techniques. (C) 1999 by The Society of Thoracic Surgeons.