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 Email : jwlee@amc.seoul.kr J Korean Med Assoc 2008; 51(4): 335-346 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
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
Minimally Invasive Cardiac Surgery Figure 1. The da Vinci TM surgical system. 337
Lee JW Jung SH Je HG Figure 2. A postoperative scar after minimally invasive mitral valve surgery. 338
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%) < 0.001 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
Lee JW Jung SH Je HG Figure 3. Transapical aortic valve implantation via a limited left anterior thoracotomy. 340
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
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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Lee JW Jung SH Je HG Peer Reviewers Commentary 346