Minimally Invasive Coronary Artery Surgery

The MI (Minimally Invasive) prefix to cardiac procedures now extends to coronary artery surgery. There are a variety of names suggested –

MICS – Minimally Invasive Coronary Surgery

MICABG – Minimally Invasive Coronary Artery Bypass Graft surgery

ThoraCAB – Thoracotomy Coronary Artery Bypass

This concept started off the MIDCAB (Minimally Invasive Direct Coronary Artery Bypass), a technique that created a buzz in the mid to late 1990s as a part of the off-pump coronary surgery wave. Unfortunately, the size of the thoracotomy incision and the associated pain caused some early enthusiasts to question this technique. The limited number of grafts that could be performed through this incision and the fact that enabling technologies were very rudimentary effectively led to the demise of the MIDCAB. When the Da Vinci robot came on the scene, the hope was of a resurrection of this concept. The adoption and utilization of the Da Vinci robot in cardiac surgery has been slow. However, the learning curve required to achieve some degree of control with the robot, has allowed few surgeons to use this for coronary artery surgery procedures.

Minimally invasive approaches in cardiothoracic surgery have to weighed in balance – safety is paramount when dealing with the major blood vessels, heart and lungs within the chest. This explains the reluctance of many practicing and experienced surgeons in adopting smaller incisions in cardiac surgery. The video-assisted thoracic surgery (VATS) revolution transformed many aspects of esophageal and lung surgery in the 1990s and has recently expanded to include lung resection.

Over the next 15 years, the principles of the approach were modified and used to provide access to the mitral and tricuspid valves, while cardiopulmonary bypass support was provided by peripheral cannulation. Which brings us to the present – increasing numbers of minimally invasive cardiac procedures are being carried out to a great degree of success with the same safety profile as standard open procedures in selected centers by groups and teams that have built experience.

In the realm of coronary artery surgery, the resurgence of the left mini-thoracotomy for bypass surgery has been slow to expand and take off. There are about one hundred institutions in the US and a handful in Europe that offer this procedure. Essentially, this calls for specialized equipment in the form of special retractors, long-shafted instruments, endoscopic stabilizers, etc. In addition, the surgeons need to be comfortable in performing these procedures through smaller incisions on a beating heart. The decline of off-pump surgery has translated to fewer surgeons who are confident of performing off-pump bypass surgery. At The University of Chicago, we had an 18 month experience with the Da Vinci robot in performing robot assisted CABG. This allowed us to get familiar with MI CABG procedures. We initially reserved for the high risk patients where a conventional sternotomy would be fraught with complications. Over the past 6 months, we have performed close to 30 of these procedures with very encouraging results.

So, while the marketing imperative of being able to perform these procedures with less morbidity exists, there are some centers that have excellent results with these techniques. It is important that you find the right center for your procedure and be comfortable with them.