Minimally Invasive Cardiac Surgery

A Practical Guide

Theo Kofidis

• Publisher: CRC Press
• Year: 2021
• Print ISBN: 9780367641740
• eBook ISBN: 9781498736497
• Edition: 1
• Topic: Medicine
• Subtopic: Cardiology

Minimally invasive cardiac surgery(MICS) is an integral component of every future cardiac surgeon's training. There continues to be a growing global demand towards less invasive surgical techniques. Both cardiologist and cardiac surgeon form "heart teams" to provide patients with novel, minimally invasive procedures, with all their benefits.

Less invasive techniques are often complex and require special knowhow and skills. This book offers an innovative approach to learning, utilizing QR code technology, which refers the reader to essential audio-visual material, which, along with the didactic text, focuses on practical aspects of minimally invasive cardiac surgery. In modern Heart Teams, and with the advent of the hybrid era, surgeons will only be able to survive if they have state-of-the-art skills in less invasive technologies, which can be incorporated in the hybrid theatre and/or trans-catheter arena. This text accompanies the surgeon along this path, and provides clinical advice and practical solutions, beyond the necessary basic knowledge. Which courses to visit, which videos to watch, which centres to join for serious training? How best to exploit public and multimedia? How to consent a patient into a MICS procedure? How to set up a MICS program or practice? In the era of value driven outcomes, and a shift towards shorter and better patient journeys, MICS is a skill that no heart surgeon can be without.

Minimally Invasive Cardiac Surgery: A Practical Guide

is a teaching resource, reference book and manual written by surgeons who both operate and teach the procedures described within.

• Provides access to online resources via QR codes

• Includes links to videos and the e-version of the text

• Acts as a gateway to a huge choice of minimally invasive cardiac surgery materials

1
Foreword/Introduction

Theo Kofidis

Mantra: “We went bankrupt slowly…slowly…slowly…, then suddenly.”

Ernest Hemingway

“We can’t reach somewhere we haven’t been before, without doing things we haven’t done before.”

Unknown

Cardiac surgeons don’t read anymore. At least not as they used to do a generation ago, when Kirklin and Cohn’s book was devoured by all of us as the “Cardiac Surgery Bible”. The multimedia pluralism in 2021 offers much better, and certainly more impregnable educational material to train the cardiac surgeon of the modern era. Heart surgeons are presently spoiled by choice: CTSNet offers a domain-specific content, reasonably and sensibly structured, and constitutes a go-to page for surgical content, industry ads, colleague search, the latest news and event calendar. VuMedi and webinars have revolutionized surgical education, and hence virtualized lectures, so that the surgeon can watch their subject of choice, by their speakers of choice, without moving an inch. The majority of our annual cardiothoracic surgery conferences offer off-line digital material for purchase. An impressive example: the AATS, EACTS, or Mitral Conclave, which I wouldn’t miss, no matter the cost. The content is THAT substantial. Furthermore, journals offer online submission, and PubMed is a universal link to all available literature, particularly for the corporate or university audience. Next, many surgeons post their own material on their own webpages; see for instance an amazing and rich page created and regularly refreshed by Prof. Joe Lamelas on minimally invasive heart valve techniques.

Last but not least: where do we all turn for advice … the day before a demanding or controversial procedure for reference? We ask “Professor GOOGLE”; we watch how it’s done on YouTube! The content there in the meantime is very rich and spans from basic procedural steps (EVH, minimally invasive mammary harvest, robotic setup, and more) all the way to full, complex procedures, which feature both minimally invasive tool setup techniques, as well as core procedures, such as mitral valve repair techniques, or MICS CABG anastomoses. Having shared the above, nothing can replace the hands-on training and regular exposure, and also, increasingly, surgical simulation. There is a visible trend away from in-patient hands-on training for the young surgeon, more towards in-silico training, hence simulations and workshops, aiming at reducing the learning curve on the actual patient and teaching both surgical skill as well as – recently – troubleshooting.

• As a matter of fact, why would you need another hardcopy book in the modern era?

Let me start by referring to the needs of the “market”, that is to say, the patients’ and surgeons’ needs in this relatively new, yet rapidly expanding, field of surgery, minimally invasive cardiac surgery.

Minimally invasive cardiac surgery is not just another feat of surgical bravado nor is it a fashion trend to abate soon. Is it here to stay? While started by a number of surgeons, on a number of occasions around the globe, we don’t profess to claim who was the “first” in each case, as this would spark controversy, and certain first-time achievements often cannot be attributed to one single surgeon; it has now reached the main stage, as a well-accepted methodology that can provide the same efficacy and safety as the so-called “Gold Standard” – allow me a neologism, or a small teaser here: sometimes indeed the “Comfort Standard” – particularly for the older-generation surgeon who, by force of habit, and for lack of competition, sticks to the old habits. This is not to denigrate median sternotomy, which is still the traditional and well-proven approach for the majority of cardiac cases.

Hence, MICS surgery is not only a subspecialty niche, but started co-defining the cardiac surgeon’s training, as more cardiac surgeons incorporate MICS techniques in their specialty training. Furthermore, at times of aggressive cardiology pursuit and evolving patient demands, MICS surgery is not only in compliance with those needs and the most primary Hippocratic principles; it is a breadwinner, and a crucial remaining platform for the continuation and expansion of the cardiac surgery métier. Cardiac surgeons recognize this, and there is now a huge wave towards MICS, with developing countries showing greatest interest. A growing number of cardiac surgeons train in MICS surgery. It is a mode of survival, and it’s also in compliance with evolving patient demands. There is a huge and pressing trajectory around the globe towards less invasive techniques. The cardiologist and cardiac surgeon nowadays form “heart teams” to provide patients with novel, minimally invasive procedures. Those aim at less trauma, better safety, less risk, faster recovery and better cosmesis.

There is a great demand to learn and apply less invasive techniques. These are often complex and require special knowhow and skills. There is no dedicated and comprehensive book to teach this knowhow with an up-to-date methodology and modern materials. The last systematic work was edited by Dr. Mehmet Oz in 2001, and is now totally outdated. The demand is high. The training colleagues around the world are well-saturated with the basic knowledge “Bibles”, such as Kirklin, Edmunds, Sabiston, etc. But, beyond that, they do care about acquiring knowledge that will help them earn a living, and find a niche in our fields’ competitive environment. MICS is a MUST-do and -learn issue for another reason. In modern heart teams and with the advent of the hybrid era, a surgeon will only be able to survive if he has state-of-the-art skills in less invasive technologies, which can be incorporated in the hybrid theatre and/or trans-catheter arena. The hybrid portfolio has not been exploited fully yet. There is a long way to go, including anecdotal combinations of procedures which will soon be undergoing systematic study, such as mitral valve repair and stenting, aortic valve TAVI plus minimally invasive bypass procedure, etc., in all kinds of combinations. The field of cardiac surgery as we know it will change for ever. We need a book to accompany the surgeon along this path, and provide true hints and solutions, beyond the necessary basic knowledge. Which courses to visit, which videos to watch, which centers to join for serious training? How to exploit public and multimedia best? How to consent a patient into a MICS procedure? How to set up a MICS program/practice?

Finally, the patient demand is huge, particularly in developing countries, which pursue development and innovation at great speed and with great investment. SE Asia, India, and China expand their health services aggressively, with a clear domination of less invasive procedures.

As a MICS surgeon and tutor/proctor, I have been setting up a few MICS courses and programs around Asia and Europe; I am astounded by the volume and intensity of the demand. I often wish for an accompanying book to use as teaching foundation, reference and handout at those courses. In conclusion, it is time for a dedicated MICS book, written by embedded surgeons, who routinely do it and teach it. A practical guide.

So, what makes the present book special? It’s the newly adopted concept of using Quick Response (QR) codes to link the text with multimedia material on the Internet. The QR code has infiltrated both the market as well as the educational community, as a gateway to richer large-volume or audiovisual material on the Internet. Medical journals have long adopted it to link to such material, lectures or how-to-do-it videos. Societies employ QR codes for various functions, mainly for the purpose of one-action step transfer to relevant pages. The utilization of QR codes has in fact just started, and their potential will only expand as an educational tool, to append material on a secured Internet space. There is a plethora of apps out there, which anyone can download onto his smartphone, and exploit the full potential of QR codes. Last, any amateur can now easily generate QR codes from any http//: link, hence any Internet address, and refer to that respective link (Figure 1.1).

FIGURE 1.1 Scan the QR code to go to the ISMICS webpage.

Cardiac surgeons nowadays learn from CTSNet, Heart Surgery Forum, online PubMed access, YouTube videos, webinars, conferences, etc. Today’s cardiac surgeons (and today’s young generation altogether) are more visual, and more practically oriented. They appreciate live media, they want pictures, sounds and links. Here, we offer them a novel concept, namely all the above elements in an unprecedented book, which “comes alive” with meaningful tips, videos, checklists, instrument lists, YouTube videos and app references, and automatic updates, a fully loaded educational script, which brings it to the point, using audiovisual content.

The book has a new, practice-oriented layout of the chapters, updated content (since a dedicated book on MICS is missing in the market), and new moda...

Table of contents

• Cover
• Half-Title
• Title
• Copyright
• Dedication
• Contents
• Prologue
• Acknowledgments
• Our Editorial Team
• Contributors
• 1 Foreword/Introduction
• 2 History of Minimally Invasive Cardiac Surgery
• 3 How to Set up a Minimally Invasive Program
• 4 Instrumentation and Operating Theater Set up in Minimally Invasive Cardiac Surgery
• 5 Anesthesia for Minimally Invasive Cardiac Surgery
• 6 Surgical Approaches in Minimally Invasive Cardiac Surgery
• 7.1 The Aortic Valve: Minimally Invasive Aortic Valve Replacement. The Right Anterior Minithoracotomy
• 7.2 Minimally Invasive Aortic Valve Replacement: Upper “J” Sternotomy
• 7.3 The Aortic Valve: Sutureless Valves in the Setting of MICS AVR
• 7.4 The Aortic Valve: Endoscopic Aortic Valve Surgery
• 8.1 Transcatheter Aortic Valve Implantation (TAVI): Transapical Transcatheter Aortic Valve Replacement
• 8.2 Transfemoral Transcatheter Aortic Valve Implantation
• 8.3 Transcatheter Aortic Valve Implantation (TAVI): Alternative Approaches for Transcatheter Aortic Valve Implantation
• 9.1 The Mitral Valve: Minimally Invasive Mitral Valve Surgery
• 9.2 The Mitral Valve: Alternative Approaches to Minimally Invasive Mitral Valve Surgery
• 9.3 The Mitral Valve: Robotic Mitral Valve Surgery
• 9.4 The Mitral Valve: Percutaneous Mitral Valve Repair: MitraClip®
• 10 Minimally Invasive Tricuspid Valve Surgery
• 11 Minimally Invasive Combined Heart Valve Surgery
• 12.1 The Coronaries: Minimally Invasive Coronary Artery Bypass Grafting Surgery
• 12.2 The Coronaries: Robot Facilitated Coronary Artery Bypass Grafting
• 12.3 Anaortic, Off-Pump, Total-Arterial Coronary Artery Bypass Grafting Surgery: The Coronaries
• 12.4 The Coronaries: Hybrid Coronary Artery Bypass Grafting Surgery
• 13 Minimally Invasive Atrial Ablation Surgery
• 14.1 Aortic Surgery: Minimally Invasive Ascending Aortic Surgery
• 14.2 Aortic Surgery: Endovascular and Hybrid Approaches for Distal Arch and Descending Thoracic Aorta
• 15 Minimally Invasive Heart Failure Surgery
• 16 Epilogue
• Annex
• Index