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EDITORIAL |
| The John Nasseff Heart Hospital Minneapolis, Minnesota, USA |
Because minimally invasive cardiac surgery (MICS) requires enabling technology, the medical industry and device companies readily participated in the development of equipment to improve the performance of MICS. The excitement generated by the rapid introduction of new techniques and technology, cost benefit of eliminating cardiopulmonary bypass in patients with significant comorbid risk factors, and the decrease in tissue trauma of minimally invasive surgery even with the use of cardiopulmonary bypass, generated the scheduling of multiple international meetings. These meetings, often supported by funds contributed by the medical industry, were unsupervised and the core curriculum was not audited. Additionally, individual companies held their own symposia in an effort to popularize devices as well as market their own products. Data were scarce and prospective trials relating to the scientific evaluation of the minimally invasive processes were limited, casting pallor over the development of MICS.
In June 1996, Robert W Emery and colleagues in Minnesota organized the first meeting on MICS in Minneapolis, Minnesota, USA. There was a high level of interest and a great deal of enthusiasm among cardiac surgeons. Nearly 1,000 surgeons, cardiologists, and paramedical personnel wanted to attend this meeting, but space was limited and many were turned away. The aim of the meeting was to have a well-organized and supervised meeting allowing attendees to share ideas and evaluate aspects of new innovations. After listening to the experts at this meeting, many of the surgeons took home the idea that MICS was a rather simple innovation and could be carried out by everyone with potentially excellent results.
In May 1997, the idea was circulated that a society dedicated to the evaluation and promotion of MICS should be formed. The International Society for Minimally Invasive Cardiac Surgery (ISMICS) was named and incorporated in the state of Minnesota in 1997. Just about the same time, the second annual meeting on MICS was held again in Minneapolis. The level of enthusiasm continued and excellent abstracts were submitted, representing short-term results of minimally invasive direct coronary artery bypass (MIDCAB). Some general concerns were voiced by surgeons about taking down the left internal mammary artery without thorascopic visualization, which could compromise the quality of the internal mammary artery at the caudal area to the thoracotomy site. Others felt that the commercially available stabilizing devices were not adequate to facilitate a perfect anastomosis. The ability to visualize the entire length of left anterior descending coronary artery (LAD) through a small thoracotomy incision was also a concern, causing some surgeons to evaluate the use of a lower partial sternotomy.
The first annual meeting of ISMICS was also held in Minneapolis in June 1998 (third consecutive meeting on MICS in Minneapolis) with only 200 attendees. The level of enthusiasm had waned and many surgeons had found out that MICS was not for everyone. Midterm results were not as positive as initially reported. There were various thoracotomy approaches suggested in order to reach the high diagonal arteries and circumflex system. Regardless of the disappointing outcomes, the international venue allowed an exchange of experience and further developed MICS on a global basis. These meetings provided an educational forum for groundbreaking techniques and information to an informed active audience, allowing a broadening of the horizon of thought in the performance of open-heart surgery.
The second annual meeting of ISMICS was held in Paris, France, in May 1999. There were 200 attendees and over 100 abstracts submitted. There were more papers on thorascopic and robotic approaches. There were numerous papers on off-pump coronary artery bypass (OPCAB) and the audience began to speculate that the elimination of cardiopulmonary bypass might be more important than elimination of the sternotomy approach. There was a general agreement that OPCAB could provide better visualization and a more precise anastomosis, but this was laden with hesitation regarding the ability to ensure complete revascularization.
The third annual ISMICS meeting was held in Atlanta, Georgia, in June 2000. With peaking interest in OPCAB procedures, attendance grew. There were more information on robotic surgeries from the European countries and North America. There were short-term angiographic studies, financial outcomes, and midterm longitudinal results on MIDCAB.
The next ISMICS meeting is scheduled for Munich, Germany, in 2001. While minimally invasive surgery has been difficult to define in the year 2000, four aspects of coronary bypass surgery will continue to be considered minimally invasive. These include MIDCAB, OPCAB, port-access, and robotic approaches. The future of these approaches varies from the lessons learned from the limitation of each approach, the comfort level of the surgeon, and the long-term results.
MIDCAB
Currently, patency rates from the large experienced centers are excellent. In spite of this, the operation has become used less frequently and its application currently serves less than 3% of the cardiac surgical population. Indeed, even the cooperative effort of utilizing MIDCAB with internal mammary artery anastomosis to the LAD and stenting one or more other vessels to avoid a major operative procedure has not been popularized.
OPCAB
This form of surgery has become the most user-friendly of all approaches. Currently, it is estimated that approximately 25% of coronary bypass surgery carried out in the United States is performed without the use of cardiopulmonary bypass. This is a dramatic increase from the approximately 5% of coronary bypass cases completed in 1996–1997. It is theorized that with appropriate training and broad acceptance of this procedure, we may hear in Munich that 40% to 50% of all bypass surgery will be performed with OPCAB, making complete revascular-ization undoubtedly feasible.
Port-Access
A third form of MICS is utilizing Heartport technology with peripheral cannulation and multivessel bypass surgery through a left anterior thoracotomy approach. The procedure is time-consuming and technically difficult. Therefore, it has not been widely applied to coronary artery bypass.
Robotic Coronary Artery Bypass
The use of Heartport technology has served as a platform for the newest form of minimally invasive surgery: computer-assisted or robotic coronary endoscopic surgery. While the current Food and Drug Administration (FDA) device exemption protocol requires the use of open chest cardiopulmonary bypass in the United States, true robotic beating heart port-access coronary artery bypass has been performed in Europe and Canada. The application of anastomotic coupling devices will have a dramatic effect on this approach in the near future. The process of complete multivessel endoscopic coronary bypass surgery is indeed on the horizon.
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