DEFINITIONS AND RATIONAL
There is currently no clear definition of minimally
invasive cardiac surgery (MICS). While the Society
of Thoracic Surgeons (STS) defines MICS as "any procedure not performed with full sternotomy and
cardiopulmonary bypass (CPB) support", the American
Heart Association (AHA) defined it in 2008 as "a
small chest wall incision that does not include the
conventional full sternotomy".[8] Chitwood et al.[1]
proposed, however, that the definition of MICS should
not be limited to a specific surgical procedure, but
rather be defined as a "philosophy" toward cardiac
procedures, entailing specific strategies to different
operations. We agree with that philosophical definition
of MICS and view it as a set of continually changing
and adapting techniques and approaches to cardiac
surgery, designed to evermore reduce the invasiveness
of cardiac surgical procedures compared to what
is contemporarily considered as conventional. Thus,
MICS, and more specifically µICS, are constantly
evolving with the advent of each new technique or
technological advancement which adds to the arsenal
of the cardiac surgeon.
This definition is not limited to a specific surgical access used in a procedure, but rather encompasses a multitude of standards of care at different levels of the surgery and in-hospital care designed with the goal of reducing the operative morbidity associated with cardiac surgery, as well as promoting an early mobilization, rehabilitation, and re-assimilation into society. They include the operative access and technique, the instruments used, the technological advancements enabling this micro-invasiveness, as well as standards of postoperative care. These standards are applied in a wide spectrum of cardiac surgeries, include coronary revascularization, valve surgery, and other cardiac operations.
First described in 1994, minimally invasive direct coronary artery bypass (MIDCAB) on a beating heart (off-pump) has been shown to be a safe and feasible approach for select patients, offering a short intensive care unit (ICU) stay and lower blood transfusion requirements with good postoperative outcomes and low mortality.[10] Minimally invasive approaches to valve surgeries were also introduced into the medical literature in the early 1990s; they are safely applied today in an extensive spectrum of valve-related operations via video-assisted access or totally endoscopically through a mini-thoracotomy, including single valve surgery such as aortic or mitral valve surgery,[3,4] as well as more complex operations along the lines of redo valve surgeries and valve surgery with concomitant complex procedures.[11,12] These approaches to valve surgeries have been consistently shown to be associated with several advantages over the traditional sternotomy such as, amongst others, similar surgical success and postoperative mortality rates, shortened hospital and ICU stays, decreased blood product requirements, better cosmesis, and postoperative respiratory and pain parameters.[2,4,11]
In addition to the inherent cosmetic advantages of µICS, the potential reduction in morbidity as well the shorter length of stay (LOS) both in the ICU and in-hospital complements a Cardiac Enhanced Recovery After Surgery (ERAS), promoting a reduction in perioperative physical and psychological stress to the patient and early optimal recovery.[13] Taking advantage of the recent boom in technological advancements, computational power, and computer software development, the aim of µICS remains in providing the patients with excellence; that of both safety and outcomes, compared to the traditional invasive approaches.
OPERATIVE PLANNING
Surgical access
With regards to the surgical access, our preferred
approach to micro-invasive cardiac surgery is a right
anterior mini-thoracotomy (RAMT) at the level of the
third intercostal space (ICS) for aortic valve, aortic
root surgery and for multiple valve surgery and the
level of the fourth ICS for single mitral or tricuspid
valve surgery with the possibility of concomitant maze
procedure and/or LAA closure, as well as cardiac
tumor surgery. For MIDCAB procedures, our standard
surgical access is a left anterior mini-thoracotomy
(LAMT) at the level of the fourth ICS. A RAMT
can also be employed for MIDCAB involving the
right coronary system.[14,15] The exact approach used,
namely the location of the mini-thoracotomy, naturally
differs from one patient to another due to inherent
anatomical variations or anomalies.[6,16] A careful
preoperative planning and patient assessment based on
the preoperative computed tomography (CT) is, thus,
mandatory for all patients selected to undergo a µICS,
ensuring an optimal exposure of the surgical field on
an individual basis.
Preoperative computed tomography
Computed tomography is the mainstay of
preoperative planning. A CT scan of the chest as well
as CT angiography of the aorta and arterial system
can help to identify those inter-patient variations,
particularly with regards to the position of the aorta
in relation to the sternum and chest wall, the distance
between skin and the ascending aorta, its angle in
relation to the midline, a laterally displaced heart,
and the distance between the sternum and the right ventricle. This information is crucial in deciding
where the operative access should be performed. The
surgeon can also obtain valuable information about
other conditions that should be taken into consideration
prior to the operation, such as chest wall deformities,
emphysematous lungs, severe intra-thoracic adhesions
and central and/or peripheral arterial calcifications, as
well as severe valvular annuli calcifications.[2]
3MENSIO SOFTWARE
The increasingly small incisions employed in
µICS present another challenge in endoscopic
valve replacement surgery: sometimes-impractical
intraoperative valvular sizing. With the help of recent
advancements in computer software, CT can also
be used in combination with specialized programs
in a tomography-based valve sizing and prosthesis
simulation, which is already a standard approach in
the field of interventional cardiology for transcatheter
aortic valve replacements.[17] Developed in the
Netherlands, 3mensio (3mensio Medical Imaging B.V.,
Utrecht, Netherlands) offers software for preoperative
sizing and planning enabling the simulation of a
digital phantom and aortic valve prosthesis using
company-given details of the prosthesis, which is,
then, superimposed on the aortic annulus using
the CT images avoiding potential prosthesis-patient
mismatch (Figure 1).[18] This software also enables
the precise measurement of the anterior mitral leaflet,
mitral valve annulus and its distance from the
circumflex coronary branch, which helps the surgeon to safely plan the mitral valve surgery. The 3mensio
additionally gives detailed information about the
anatomy, size, and the pattern of calcification of the
abdominal aorta, iliac, and femoral arteries for a
safe cannulation for CPB at the groin for retrograde
perfusion.
MIXED-REALITY
With the advent of virtual reality, mixed
and augmented reality, three-dimensional (3D)
reconstructions of CT images can now be visualized
intraoperatively, projected as a hologram on the
operating table in real space, manipulated and
interacted with in a sterile way by the surgeon
(Figure 2). This holographic visualization of the
patient's imaging data can be achieved through
the CarnaLife Holo System (MedApp, Krakow,
Poland) and an augmented reality headset (Microsoft
HoloLens 2, USA). Using hand gestures in a sterile
fashion, the surgeon can manipulate and customize
the hologram in real time and space, plan the course
of the surgery, including the peripheral cannulation
for CPB, the surgical access, prosthetic valve size
and type.[18] The hologram can also be adjusted
during the operation according to the surgeon's
preferences and the present surgical step.
Transesophageal echocardiography with 3D
reconstruction
In cases of mitral valve surgery, transesophageal
echocardiography with 3D reconstruction offers crucial information about the exact pathology of
the mitral valve, as well as the size of the anterior
mitral leaflet, thereby allowing the surgeon to choose
preoperatively the right ring for the underlying
pathology of the mitral valve.
Cannulation for cardiopulmonary bypass
Micro-invasive cardiac surgery, particularly
valve surgeries, often requires cardiac arrest and
extracorporeal circulation (ECC). While a central
access for CPB is traditionally employed in surgery
via sternotomy, peripheral cannulation of the common
femoral vessels to achieve a retrograde ECC can be
used in µICS. There has been concerns, however,
about the potentially increased risk of cerebrovascular
complications associated with this technique.[19]
As aforementioned, the crucial preoperative CT
imaging can help, however, to identify a difficult
femoral cannulation, such as extensive femoral or iliac artery calcification, kinking, or stenoses, which
may theoretically lead to retrograde dissection and/or
retrograde embolism. Imaging can additionally enable
a precise measure of the artery's size and shape,
thereby aiding in the choice of the most suitable
size of arterial cannula. In cases where both femoral
arteries cannot be used for cannulation, the right
axillary artery offers a safe and effective alternative
for establishing CPB, with an added benefit of
providing an antegrade circulatory perfusion as well
as an antegrade cerebral perfusion, if needed.[20,21]
Femoral cannulation can be achieved in a minimally invasive manner percutaneously, in contrast to the traditional open surgical approach, where the femoral artery is cannulated under direct vision. Under intraoperative ultrasonographic control, the artery is accessed using the Seldinger technique and can be later decannulated and closed using a vascular closure device such as the MANTA device (Teleflex, Wayne, PA, USA). The MANTA device is collagen-plug-based solution dedicated to achieve arterial decannulation and hemostasis safely and effectively. Percutaneous access in combination with the MANTA device has been shown to be associated with fewer access-site complications such as wound healing disorders, lymph-related complications, and vacuum therapy, as well as a shorter procedural duration.[22-24]
Totally endoscopic approach
A totally endoscopic approach to µICS can
currently be applied in a wide spectrum of
procedures, including single or multiple valve
surgeries, redo surgeries, aortic root and ascending
aorta surgery, maze procedure and LAA closure,
cardiac tumors surgery, radial artery and vein
harvesting or thoracoscopic internal thoracic artery
preparation/harvesting for MIDCAB, as well as
coronary malformations surgery, or procedures in
patients with anatomical anomalies such as situs
inversus totalis.[3,10,16,25-29]
In combination with long instruments, it enables the undertaking of the µICS without the need for direct vision and/or a rib retractor and using only a soft tissue retractor (ValveGate™ Soft Tissue Retractor, Geister, Germany), thereby promoting the smallest incisions feasible and the least trauma to the chest and ribs without injuring the internal thoracic vessels.[3,30]
The smaller incisions and narrowing working space present however some challenges and steepen the learning curve of µICS. The latter can nonetheless be managed with the help of several specialized tools and instruments, standardization of the minimally invasive cardiac procedures, in addition to elaborate computer training and simulation technologies:[2,31]
3D camera
A 3D high resolution stereoscopic camera
(B. Braun Aesculap® EinsteinVision®, Tuttlingen,
Germany) offers an overview of the operative field
with a high degree of spatial perception. It enables the
secure placement of the Chitwood aortic cross-clamp,
as well as an excellent visualization of the smallest
details of cardiac structures (Figure 3).[2]
Automated suturing technologies
During valve replacement surgeries, obstacles due
to the limited remote working space and reduced
direct visualization can also be overcome using
automated suture technologies, including the RAM®
device, the SEW-EASY® device, as well as the
COR-KNOT MINI® device from LSI SOLUTIONS®
(Victor, NY, USA) (Figure 4). Such customized
solutions aim at providing task specific functions,
which are originally developed to enable the concise
and precise resolution of specific and repetitive
steps through tiny surgical access incisions. Detailed
descriptions and steps using those devices were
previously published.[25,30] In short, the RAM®
device is an automated annular suturing device,
simultaneously driving two curved needles in the
valvular annulus, thus placing the initial bites of
a horizontal mattress suture (Figure 5). Using two
RAM® devices simultaneously in each of both hands facilitates the suturing of some difficult to reach
parts of the valvular annulus, if the latter is angled
or deeply recessed outwards. By engaging the first
device on a portion of the ring adjacent to the
problematic region without releasing the lever, this
"Bonn's maneuver" allows the surgeon to use the first
RAM® device as a forceps, and with a simultaneously
light pulling centripetal and rotating motion, exposes
the adjacent receded part of the annulus (Figure 6).
The latter can, then, be placed in the jaw of the second
RAM® device for suture placement. Using the latter as
a starting step of the Bonn's maneuver permits it to
be performed continuously in a daisy-chain fashion.
The SEW-EASY® device drives the ends of the annular suture through the sewing cuff of the prosthetic valve using straight needles, completing the horizontal mattress suture. The COR-KNOT MINI® device is used after the placement of the prosthetic in its position above the valvular annulus to crimp a titanium fastener securing the suture and trim the suture tails in a single motion. Also aiming at reducing suture times, and subsequently ischemic times, this more automated approach to annular suturing facilitates the adoption of MICS in a wider population of surgeons by flattening some of the learning curve, offering the advantages of a less traumatic valvular replacement surgery to more patients.
AVR-Navigator™ aortic root retractor system
In addition to the technologies mentioned
above, developed with the goal of flattening the
learning curve of endoscopic µICS by automating
surgical steps and shortening the procedural times
of endoscopic µICS, other specialized instruments
aim at improving the exposure of the surgical field,
particularly the intracardial structures operated on.
The AVR-Navigator™ (LSI Solutions Inc., NY, USA) is a novel aortic root retraction system designed
to optimize the visualization and stabilization of
the aortic annulus during endoscopic aortic valve
replacement surgery.[32] This flexible aortic root
retractor comes with a delivery device and consists
of a three-lobed plastic frame fixed by expansion and
three sutures that are placed in the aortic root below
the sinotubular junction (Figure 7). Its positioning and
deployment can easily be performed by fixating three
sutures in the aortic wall at the sinotubular junction
after the total excision of the aortic valve prior to the annular suture placement (Figure 8). The sutures are,
then, passed through each flexible conduit with the
help of a looped wire before parachuting the retractor
in using the delivery device and guided by the
fixating sutures, in a similar fashion to parachuting
a valvular prosthesis. It can be, then, used to adjust
the angulation of the aortic annulus in relation of the
surgical access and 3D-camera, thus providing an
excellent exposure of the aortic root while ensuring
its stability. The design of the AVR-Navigator™
system allows it to be used in combination with the RAM® device without hindering the access to the
aortic root its visibility (Figure 8).
SOMOHA
The SOMOHA retractor developed by Fehling
Instruments GmbH (Karlstein, Germany) is a
novel and simple self-expanding retractor which
can substantially improve the visualization of the
aortic valve during endoscopic aortic valve repair or
replacement. Consisting of a flexible metallic sheet
with guiding tabs and a guiding bar at each end, its
assembled very easily by bringing both ends on top
of each other and inserting the guiding tabs into the
insertion opening, due to the springy nature of the
metallic retractor, releasing the pressure on both ends
of the retractor allows it to try to expand, guiding
the tabs into the bar and locking the retractor in a
rolled state. Deploying the retractor in situ starts
with reversing the lock by pushing the guiding
tabs back toward the insertion opening and passing
them back through. While the retractor held in a
"rolled" state with a forceps, it is, then, introduced
in the ascending aorta above the sinotubular junction
and let to self-expand (Figure 9). It allows for an
increased stability of the ascending aorta and aortic
root, while the increased diameter of the valvular
annulus maintains an increased field of view of the
left ventricular outflow tract and intraventricular
structures (Figure 9). Although its design and
practical application are markedly uncomplicated, the
SOMOHA retractor offers an invaluable way to avoid
some of the technical challenges of the narrow work
field of micro-invasive valve surgery.
Remote suturing system
The C1® device (LSI Solutions Inc., NY, USA) for
automated suture placement is optimized to facilitate
minimally invasive surgery providing precise
remote suture placement with features to enhance
visualization and reduce needle exposure.
It is available with an angled shaft for optimized remote suture delivery and incorporates a viewing window for maximal tissue visualization. Moreover, this device features a rotational knob with integrated indicator fin for enhanced suturing ergonomics. All these features enable an automated closure of the left atrium in endoscopic mitral valve surgery and presents a potential solution for aortotomy closure in endoscopic aortic valve surgery, as well as for prosthetic tube graft suturing in endoscopic ascending aorta replacement.
Left atrial appendage closure
Epicardial LAA clip occlusion using the
AtriClip® (AtriCure, OH, USA) in patients with atrial fibrillation is a simple and quick procedure
providing a safe, effective, and durable left appendage
isolation for patients with atrial fibrillation.[33] The
AtriClip® provides an epicardial exclusion, thereby
avoiding an implant in the blood stream, while
maintaining a dynamic closing force maintaining the
LAA exclusion even after the atrial tissue ischemic
changes. Furthermore, the two parallel legs of the
clip minimize the occurrence of tissue folds ensuring
a durable and effective closure of the LAA ostia,
while still being atraumatic without any incisions.
With the AtriClip® PRO.V model, which offers a port
compatibility for endoscopic surgery and a tip-first
closure design, LAA clip closure can be easily
performed either concomitantly with other surgeries
or as a solo procedure totally endoscopically.
Cryoablation
The Cox-maze procedure (CMP) is an established
effective treatment of atrial fibrillation. It has,
nonetheless, originally been technically challenging
and time-consuming due the nature of the
"cut-and-sew" maze, which hindered its adoption.[34]
The development of cryoablation devices such as the
ATS Medtronic Cryo probe and clamp has, however,
reintroduced the CMP (CMP-IV) as a time efficient
and simple procedure. Using argon to reach minimum
temperatures of -185.7ºC, the CMP has the goal of
terminating atrial fibrillation and isolating foci of
arrhythmogenicity by creating a pattern of lesions on
both atria.[35] In µICS, the CMP-IV procedure can be
done endoscopically through RAMT, which allows
both epicardial and endocardial cryoablation of both
atria.
In combination with LAA exclusion via AtriClip®, cryoablation therapy is the mainstay of atrial fibrillation surgery that can be achieved in a microinvasive manner totally endoscopically.
TOTALLY ENDOSCOPIC CORONARY
ARTERY BYPASS (TE CAB )
The advantages of micro-invasive surgery also
apply to coronary artery revascularization surgery. The
MIDCAB has already been established as a safe and
effective approach to bypass surgery, while offering
the benefits of the lesser trauma, including fewer
transfusions, shorter LOS, and lower hospital costs
in contrast to the traditional coronary artery bypass
grafting (CABG) via sternotomy.[10,36,37]
Although MIDCAB was initially more commonly employed in cases of single vessel coronary artery disease of the left anterior descending artery (LAD) or in combination with interventional cardiology as part of a hybrid revascularization approach, current advances and techniques in endoscopic µICS allow for the surgical treatment of patients with multiple vessels disease with several bypasses on both the right and the left coronary artery systems.[14,38-40] A TECAB can, thus, be achieved with the help of stabilization systems such as the Octopus® Nuvo tissue stabilizer (Medtronic Inc., MN, USA), which are introduced in the chest cavity through a stab incision and used to safely perform the anastomosis on the target coronary artery during endoscopic off-pump CABG. Endoscopic right coronary artery bypass can also be safely performed through a RAMT, while multiple bypasses can be achieved with multiple grafts using a T-graft or a Y-graft, which can be prepared endoscopically intra-thoracically. When extreme manipulation and luxation of the heart is needed to reach the posterior wall for example, cardioplegia and CPB can be achieved using a transthoracicallyplaced Chitwood aortic cross clamp and peripheral percutaneous cannulation for ECC, which is used in combination with the MANTA system for arterial closure, as is standard in micro-invasive valve surgery. Peripheral cannulation and ECC without cardioplegia can also be performed to achieve partial CPB, helping to decompress the heart while performing on-pump beating heart TECAB.
Endoscopic graft harvesting
A totally endoscopic approach to coronary
revascularization surgery should also be applied
to other aspects of the procedure, including grafts
harvesting. Both right and left internal thoracic
arteries (RIMA and LITA, respectively) can be safely
prepared endoscopically, sparing the patient the need
for spreading the ribs for better exposure of the needed
length for the bypass conduit responsible for some of the postoperative pain associated with MIDCAB
surgery (Figure 10). The most favorable positioning of
the camera port and instrument ports can be guided by
the preoperative CT based tools such as 3mensio and
intraoperatively using the CarnaLife Holo System by
helping in visualizing the exact location of the internal
thoracic arteries and the optimal location of the graftcoronary
anastomosis.
Figure 10: Endoscopic harvesting of the RIMA.
RIMA: Right internal mammary artery.
Furthermore, endoscopic vessel harvesting (EVH) of the radial artery, as well as the great saphenous vein significantly reduces woundrelated complications, postoperative LOS, and outpatient wound management while improving patient satisfaction.[41] It can be performed using the Hemopro family of closed tunnel EVH devices (Maquet GmbH, Rastatt, Germany).
Robotic surgery
The recent popularity and acceptance of a
minimally invasive approach in cardiac surgery
has also revived the interest in robotics. Stemming
in the late 80s, in part from development and
funding from DARPA, a research and development
agency of the United States Department of Defense,
robotic cardiac surgery culminates currently with
the daVinci XI surgical system (Intuitive Surgical
Inc., Sunnyvale, CA, USA). The daVinci XI features
many advances such as a laser targeting system, seven
degrees of ergonomic freedom, tremor-free dexterity
for both hands, a 3D endoscope and "wrist-like"
instrument movements and articulations.[1] These
state-of-the-art technological advances enable trained
surgeons to perform a variety of cardiac surgical
procedures ranging from isolated internal mammary
artery dissection to complete valvular surgeries
with improved outcomes compared to conventional
approaches, although they are associated with a greatly
steep learning curve and a prohibiting increased
financial burden.[42,43] A 2023 propensity-matched
retrospective review of the STS adult cardiac surgery
database compared the outcomes of robotic totally
endoscopic mitral valve repair to both sternotomy and
mini-thoracotomy over a period of seven years across
103 hospitals found that, despite similar mortality
and morbidity, patients undergoing robotic surgery
had a shorter LOS and fewer 30-day readmissions,
while mortality and mortality were lower in high
volume centers.[44] Furthermore, a retrospective study
of 720 patients undergoing robotic TECAB surgery
included 93 patients selected for a postoperative
Day 1 discharge in combination with the ERAS
protocols and showed lower readmission rates and
a trend toward earlier return to work, albeit not statistically significant.[45] The major hindrance to the
adoption of robotics in cardiac surgery remains the
costs associated with the purchasing, implementation,
and maintenance of the daVinci System, as well as
the per case costs incurred to both the healthcare
provider and to the patient.
Criticisms and resolutions
Despite the several advantages of minimally
invasive techniques in cardiac surgeries, which extent
beyond the better cosmetic results, µICS, and more
extensively MICS, have yet to achieve a widespread
adoption. Its perceived difficulty and steep learning
curve, which in association with potentially longer
operative and ischemic times, represent the core
of the obstacle to its general acceptance. In our
experience, however, it has not been associated with
longer procedural durations compared to sternotomy,
and in some cases, endoscopic valve surgery was
indeed shown to take less time overall when used
with some of the technologies presented in this paper,
such as the RAM® device, COR-KNOT® device, and
the MANTA® device used for femoral artery closure
following peripheral decannulation.[4,24] Some of the
devices and solutions presented in this review have
been specifically developed with time effectiveness
in mind, automating repetitive and difficult routines,
which may also help to oppose some of the time
challenges of MICS. We believe that after overcoming
the initial learning curve, which can be considerably
flattened with the appropriate technologies and
instruments, µICS can be safely and punctually
performed in most patients.
Although these innovative technologies and instruments are invaluable tools for the cardiac surgeon facing the steep learning curve of µICS, the latter remains a significant challenge to overcome. An appropriate simulation-based training is an effective way to ease this challenge while remaining safe. During the 36th European Association of Cardiothoracic Surgery annual meeting, a 2-h simulation-based training in placing an annular suture at the posterior mitral valve annulus endoscopically was set up.[31] Forty-six participants were included in a study measuring the accuracy and time gains following the simulation, showing a significant improvement in both time and accuracy of the suture. Such simulation-based training programs can be of great value, not only in workshops during conferences and meetings, but also in cardiac surgery centers, where residents and surgeons can undergo a regular continued training, and experienced surgeons can keep developing their skills and techniques to further advance their respective fields.
Other concerns about the cost-effectiveness of MICS have also been raised.[46] The decreased trauma rates, morbidity, blood requirements, and LOS both in-hospital and in the ICU, in combination with the ERAS philosophy of early enhanced recovery, offset the operative costs associated with MICS, at least on the short and middle term.[13]
In conclusion, the recent trend toward minimal invasiveness and technological advances represents a significant turn of events for cardiac surgery, ushering the era of micro-invasive heart surgery. The latest advancements and techniques discussed in this review are a defining step in defining the future of this field. In combination with the philosophy of enhanced recovery after surgery, micro-invasive cardiac surgery is a way to provide patients a high standard of care with satisfying results and early return to normal life and to work.
Data Sharing Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.
Author Contributions: Idea/concept, controlle/supervision: F.B.; Data collection and/or processing; writting the article: S.S.; Litterature review; critical review: K.E.; Design, analysis and or Interpretation: A.E.S.A.
Conflict of Interest: Farhad Bakhtiary reports a relationship with Edwards Lifesciences, Medtronic and LSI that includes consulting or advisory and speaking and lecture fees. All other authors have nothing to disclose with regard to commercial support.
Funding: The authors received no financial support for the research and/or authorship of this article.
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