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1 Focused Issue of This Month Minimally Invasive Cardiac Surgery JaeWon Lee, MDSung Ho Jung, MDHyung Gon Je, MD Department of Cardiovascular Surgery, University of Ulsan College of Medicine jwlee@amc.seoul.kr J Korean Med Assoc 2008; 51(4): Abstract Traditional cardiac surgery has been performed via a big median sternotomy incision by significant complexity and invasiveness. The traditional big incision has presented with many problems, and at the same time, has given opportunity to make the procedures less invasive. During the past decade, improvement in endoscopic equipments and operative techniques has resulted in development of minimal invasive cardiac operations using small incisions with or without robotics. A number of cardiac procedures are currently performed by minimal invasive approaches and for many surgeons a minimal invasive cardiac surgery has become a standard practice. Herein, we reviewed the minimal invasive cardiac surgery in the aortic valve, mitral valve, tricuspid valve, atrial septal defect, and coronary artery disease. Keywords : Minimal invasive; Robotic; Cardiac surgery 335

2 Lee JW Jung SH Je HG Table 1. Potential benefits of minimally invasive mitral valve surgery Avoidance of sternotomy Very small incision Less surgical trauma Better visualization of intracardiac structures Reduced bleeding Less blood product utilization Lower infection risk Less pain Shorter hospitalization Faster recovery Better cosmesis Greater patient satisfaction 336

3 Minimally Invasive Cardiac Surgery Figure 1. The da Vinci TM surgical system. 337

4 Lee JW Jung SH Je HG Figure 2. A postoperative scar after minimally invasive mitral valve surgery. 338

5 Minimally Invasive Cardiac Surgery Table 2. Residual mitral regurgitation between sternotomy and minimally invasive surgery (MIS) patients MR > Mild Sternotomy MIS P value after 1 week 5(1.2%) / n=432 2 (2.3%) / n=88 NS after 6 months 17 (4.8%) / n=349 2 (2.5%) / n=80 NS after 12 months 20 (9.6%) / n=209 2 (5.8%) / n=34 NS MR: mitral regurgitation, NS: not significant Table 3. Mitral valve repair techniques Technique Sternotomy (n=432) MIS (n=88) P value Annuloplasty 366 (84%) 86 (97%) < 0.01 New chordae formation 73 (17%) 45 (51%) < Leaflet resection (Q* or T**) 97 (22%) 24 (27%) NS Alfieri stitch 2 (0.4%) 2 (2.2%) NS Chordae transfer/shortening 29 (7%) 3 (3%) NS * Q; quadrangular resection ** T; triangular resection MIS: minimally invasive surgery, NS: not significant 339

6 Lee JW Jung SH Je HG Figure 3. Transapical aortic valve implantation via a limited left anterior thoracotomy. 340

7 Minimally Invasive Cardiac Surgery Table 4. Current Recommendations for OPCAB Pathology Indications Contraindications Cardiac Multivessel disease Intramyocardial LAD Diffusely calcified coronaries RCA stenosis <80% Severe LV dysfunction LVEDP Moderate MR Calcified ascending aorta Neurologic history COPD Renal dysfunction Bleeding diathesis OPCAB: Offpump coronary artery bypass grafting, LAD: Left anterior descending coronary artery, RCA: Right coronary artery, LV: Left ventricle, LVEDP: Left ventricular end diastolic pressure, MR: Mitral regurgitation, COPD: Chronic obstructive pulmonary disease Ventricular arrhythmias Noncardiac Elderly age Dilated ascending aorta 341

8 Lee JW Jung SH Je HG Table 5. Current Recommendations for MIDCAB Pathology Indications Contraindications Isolated highgrade (>80%) LAD stenosis Intramyocardial LAD Redo LAD bypass (if LIMA not previously used) Diffuse calcified LAD Cardiac RCA stenosis( right MIDCAB or subxiphoid) LAD <1.5mm Multivesel disease(hybrid procedure) Ventricular arrhythmias Severe LV dysfunction Young, active patients Severe COPD (FEV1 <1.0L) Noncardiac Same indicationas as OPCAB in highrisk patients Severe obesity (BMI >35) Previous laparotomy (subxiphoid procedure only) MIDCAB: Minimal invasive direct coronary artery bypass, LAD: Left anterior descending coronary artery, RCA: Right coronary artery, LIMA: Left internal mammary artery, LV: Left ventricle, LVEDP: Left ventricular enddiastolic pressure, OPCAB: Offpump coronary artery bypass grafting, COPD; Chronic obstructive pulmonary disease 342

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11 Minimally Invasive Cardiac Surgery 11. Cosgrove DM, Sabik JF. Minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996; 62: Cohn LH, Adams DH, Couper GS, Bichell DP, Rosborough DM, Sears SP, Aranki SF. Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of valve replacement and repair. Ann Surg 1997; 226: Navia JL, Cosgrove DM. Minimally invasive mitral valve operations. Ann Thorac Surg 1996; 62: Argenziano M, Oz MC, Kohmoto T, Morgan J, Dimitui J, Mongero L, Beck J, Smith CR. Totally endoscopic atrial septal defect repair with robotic assistance. Circulation 2003; 108 (S1): II191- II Bonatti J, Schachner T, Bernecker O, Chevtchik O, Bonaros N, Ott H, Friedrich G, Weidinger F, Laufer G. Robotic totally endoscopic coronary artery bypass: program development and learning curve issues. J Thorac Cardiovasc Surg 2004; 127: Wimmer Greinecker G, Dogan S, Aybek T, Khan MF, Mierdl S, Byhahn C, Moritz A. Totally endoscopic atrial septal repair in adults with computer enhanced telemanipulation. J Thorac Cardiovasc Surg 2003; 126: Cho SW, Chung CH, Kim KS, Choo SJ, Song H, Song MG, Lee JW. Initial experience of robotic cardiac surgery. Korean J Thorac Cardiovasc Surg 2005; 38: Grossi EA, Galloway AC, LaPietra A, Ribakove GH, Ursomanno P, Delianides J, Culliford AT, Bizekis C, Esposito RA, Baumann FG, Kanchuger MS, Colvin SB. Minimally invasive mitral valve surgery: a 6year experience with 714 patients. Ann Thorac Surg 2002; 74: Casselman FP, Van Slycke S, Dom H, Lambrechts DL, Vermeulen Y, Vanermen H. Endoscopic mitral valve repair: feasible, reproducible, and durable. J Thorac Cardiovasc Surg 2003; 125: Dogan S, Aybek T, Risteski PS, Detho F, Rapp A, Wimmer Greinecker G. Minimally invasive port access versus conventional mitral valve surgery: prospective randomized study. Ann Thorac Surg 2005; 79: Kim BS, Soltesz EG, Cohn LH. Minimally invasive approaches to aortic valve surgery: brigham experience. Semin Thorac Cardiovasc Surg 2006; 18: Lee JW, Lee SK, Choo SJ, Song H, Song MG. Routine minimally invasive aortic valve procedures. Cardiovasc Surg 2000; 8: Cribier A, Eltchaninoff H, Bash A, Borenstein N, Tron C, Bauer F, Derumeaux G, Anselme F, Laborde F, Leon MB. Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis: first human case description. Circulation 2002; 106: Cribier A, Eltchaninoff H, Tron C, Bauer F, Agatiello C, Nercolini D, Tapiero S, Litzler PY, Bessou JP, Babaliaros V. Treatment of calcific aortic stenosis with the percutaneous heart valve: midterm followup from the initial feasibility studies: the French experience. J Am Coll Cardiol 2006; 47: Lichtenstein SV, Cheung A, Ye J, Thompson CR, Carere RG, Pasupati S, Webb JG. Transapical transcatheter aortic valve implantation in humans: initial clinical experience. Circulation 2006; 114: Puskas JD, Williams WH, Duke PG, Staples JR, Glas KE, Marshall JJ, Leimbach M, Huber P, Garas S, Sammons BH, McCall SA, Petersen RJ, Bailey DE, Chu H, Mahoney EM, Weintraub WS, Guyton RA. Offpump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements and length of stay: A prospective, randomized comparison. SMART study. J Thora Cardiovasc Surgery 2003; 125: Puskas J, Cheng D, Knight J, Angelini G, DeCannier A, Dullum M, Martin J, Ochi M, Patel N, Sim E, Trehan N, Zamvar V. Off pump versus conventional coronary artery bypass grafting: a metaanalysis and consensus statement from the 2004 ISMICS consensus conference. Innovations 2005; 1: Holzhey DM, Jacobs S, Mochalski M, Walther T, Thiele H, Mohr FW, Falk V. Sevenyear followup after minimally invasive direct coronary artery bypass: experience with more than 1300 patients. Ann Thorac Surg 2007; 83: Diegeler A, Thiele H, Falk V, Hambrecht R, Spyrantis N, Sick P, Diederich KW, Mohr FW, Schuler G. Comparison of stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery. N Engl J Med. 2002; 347: Hannan EL, Wu C, Walford G, Culliford AT, Gold JP, Smith CR, Higgins RS, Carlson RE, Jones RH. Drugeluting stents vs. coronaryartery bypass grafting in multivessel coronary disease. N Engl J Med 2008; 358: Nathoe HM, van Dijk D, Jansen EW, Suyker WJ, Diephuis JC, van Boven WJ, de la Rivie re AB, Borst C, Kalkman CJ, Grobbee DE, Buskens E, de Jaegere PP; Octopus Study Group. A comparison of onpump and offpump coronary bypass surgery in lowrisk patients. N Engl J Med 2003; 348: Falk V, Fann JI, Grünenfelder J, Daunt D, Burdon TA. Endoscopic computer enhanced beating heart coronary artery bypass grafting. Ann Thorac Surg 2000; 70:

12 Lee JW Jung SH Je HG Peer Reviewers Commentary 346

황지웅

황지웅 Comparison of Laparoscopy and Exploration in the Distal Pancreatectomy BACKGROUND: To determine the benefits of laparoscopic surgery compared with exploration, the clinical outcomes of open and laparoscopic