Minimally invasive cardiac operation: adapting cardioprotective strategies.
BACKGROUND
Minimally invasive heart operation differs from traditional cardiac operations through the omission of a sternotomy, cardiopulmonary bypass, or both. Current concerns with minimally invasive operation include: operative 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 operations, the safe applications of minimally invasive operations require unique techniques of myocardial protection.


RESULTS
Omission of extracorporeal perfusion may benefit patients through attenuation of systemic inflammatory response, decrement in neurologic insults, and reduced bleeding complications. As a counterbalance, surgeons must consider long-term operative quality and level of myocardial protection provided during beating heart coronary operation. Current issues that must be addressed include: pharmacologic management, coronary collateralization and ischemic preconditioning, the utility of intraluminal coronary shunts, and technical adequacy of the anastomosis. Nonsternotomy cardiopulmonary bypass methods utilize alternative incisions and "port-access" technology, and may render more rapid patient recovery including: decreased pain, shortened hospital stay, and more rapid return to work. Altered strategies of myocardial protection in a closed chest environment must address: method 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 included limitations in operative exposure, inadequate perfusion technology, and inability to provide myocardial protection. Recent advances in videoscopic visualization and evolving mechanisms of myocardial protection may justify the expanding application of minimally invasive techniques.
Chitwood
W R
WR
Department of Surgery, East Carolina University School of Medicine, Greenville, North Carolina 27858, USA. chitwood@brody.med.ecu.edu
Wixon
C L
CL
Elbeery
J R
JR
Francalancia
N A
NA
Lust
R M
RM
D005240:Feasibility Studies; D006324:Heart Arrest, Induced / Q000295:instrumentation; D006801:Humans; D019157:Ischemic Preconditioning, Myocardial; D019060:Minimally Invasive Surgical Procedures; D015428:Myocardial Reperfusion Injury / Q000209:etiology / Q000517:prevention & control*; D009204:Myocardial Revascularization / Q000295:instrumentation; D013525:Surgical Instruments