Randolph Chitwood MD

Cardiothoracic Surgeon Professor and Chairman, Department of Surgery East Carolina University School of Medicine Greenville, North Carolina

IN THE LAST SEVERAL years, the public has become entranced by the idea of reducing both the psychological and the physical effects of heart surgery. Minimally invasive techniques have recently emerged as one way to speed patient recovery, reduce discomfort, and reduce the economic impact of these expensive operations. Unfortunately, despite rapid, multiple advances in other surgical specialties and interventional cardiology, heart surgery has lagged behind in the development of less invasive methods.

Cardiac surgeons have been afraid of accepting the added risk of performing major heart operations through tiny incisions and obtaining less-than-excellent results. In fact, our surgical teachers, many of whom are featured in this book, taught that exposure of the entire heart and great vessels was central to performing safe, technically excellent surgery.

In the early 1960s, it was a feat to have patients survive even simple heart valve operations.

Most patients were at the end stages of their cardiac disease, the heart-lung machines were crude, and heart valve prostheses were in early evolution. Moreover, these were uncharted waters for surgeons regarding technique and postoperative care. In spite of these impediments, pioneers in heart surgery took the necessary first steps.

Years later, minimally invasive cardiac surgery is emerging with no less skepticism and criticism. However, simultaneous near-meteoric advances have been made in both Europe and the United States. After just three years, we are beginning to see improvements in our specialty and what may be a renaissance in cardiac care. Evolving technology has afforded us opportunities to make these changes safely.

Many of us think it is time to make bold steps in cardiac care. Advances in heart-lung perfusion, surgical mini-cameras (endoscopes), "smart" instruments and robotics, and cardiac cellular protection have catapulted us to a better position. Moreover, standard heart operations are safer than ever. For example, both coronary bypass and heart valve operations in uncomplicated cases can be performed with only a 1 percent to 2 percent operative mortality, even in the elderly.

Why should we try to improve on these outstanding results? Technology has allowed some surgeons to envision ways to improve heart operations. Still, most heart surgeons perform operations through large breastbone incisions. Patient recovery is slow because of muscular and skeletal tissue trauma rather than the operation on the heart itself. Thus, surgeons are now asking themselves: Can quality coronary bypass and valve operations be done through tiny access ports using endoscopes and miniaturized instruments, and even robotic assistance?

Minimally Invasive Valve Surgery — The Beginnings

The trek to a completely closed chest heart operation may be compared to a Mt. Everest ascent. There are multiple levels of accomplishment established before reaching the summit. This surgical trek began at a "base camp" that was the conventional valve operation with a breastbone incision. All new procedures are being compared to this gold standard.

Although widespread adoption has been slow, many cardiac surgeons already have learned to use less invasive techniques to replace and repair valves and place coronary artery grafts. They can do this safely, with demonstrated expertise and improved outcomes.

The first minimally invasive valve operations were done in 1996 through smaller incisions yet under direct vision. Clinical results in the last three years have been excellent. Dr. Delos Cosgrove of the Cleveland Clinic Foundation and Dr. Lawrence Cohn of Brigham and Women's Hospital pioneered much of this early work.

Operative results have been excellent in hundreds of patients who had both aortic and mitral valves repaired and replaced through smaller chest incisions

(four to five inches) with a 1 percent operative mortality.

Others have followed and shown that these results can be reproduced in many local hospitals. Using more expensive aortic balloon occlusion devices, namely the Port-Access™ device (Heartport, Inc., Redwood City, California), the Stanford University and New York University groups have operated through even smaller chest incisions (3 inches to 3.5 inches) to repair and replace mitral valves effectively with a 2 percent mortality.

Video-Assisted Minimally Invasive

Mitral Valve Surgery: Trekking to Robotic Heart Surgery

Once these valve operations, performed under direct vision through a smaller incision, were accomplished, the door was opened to the use of tiny cameras for secondary vision. This allowed surgeons to operate through even smaller incisions. Ultimately and hopefully, physicians will be able to perform true closed-chest cardiac surgery by using a monitor or head-mounted visual display to see the inside of the chest. The use of computer-assistance and robotic techniques may one day allow a completely endoscopic heart valve operation. These devices continue to evolve at a very rapid pace.

Dr. Alain Carpentier in Paris performed the first video-assisted mitral valve operation in February 1996. Three months later, our group at East Carolina University performed the first videoscopic mitral valve replacement in North America. Since then, more than ninety minimally invasive videoassisted mitral valve replace s-_j. j- ■

Using robotic technology, surgeons are able to perform heart operations through much smaller incisions in the side of the chest.

ments or repairs have been done at our center. Details of the results In the first thirty-one patients were published, as was the technique.

To perform these operations, an even smaller (2.5-inch) chest incision was used, and intracar-diac instrument manipulation was performed using videoscop-ic vision. There were no operative deaths, and midterm results were excellent. Both transfusion and ICU requirements were markedly less than with the breastbone incision, and the length of stay averaged 3.5 days. There have been few major complications. Each videoscopic operation is now performed with an effort similar to that in a conventional operation. Overseas doctors have also pioneered videoscopic mitral valve surgery, working through tiny, two-inch incisions, and have had excellent results in more than two hundred patients.

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