TY - JOUR
AU - D’Onofrio, Augusto
AB - Micro-invasive surgery, Cardiac surgery, Evolving technologies, Heart valve disease ‘Science is a ‘trial and error’ learning process, and one of the virtues of an open society is its ability to learn from experience. Closed societies resist novelty and therefore pass up the chance to learn from experience.’ —Karl Popper, The Open Society and Its Enemies On 6 May 1953, John Heysham Gibbon, a surgeon at Pennsylvania University in Philadelphia, Pennsylvania, USA, first repaired an atrial septal defect (ASD) in 18-year-old Cecilia Bavolek using a heart-lung machine [1]. Dr. Gibbon achieved his goal, our goal, of correcting structural heart defects by believing in his theories, pursuing his objectives and finally developing on his own an extracorporeal machine to keep a patient alive while stopping and replacing her heart and lung function during an intervention. The surgical closure of the ASD in young Cecilia Bavolek was the first ‘Big Bang’ for cardiac surgery. Since then, Gibbon’s heart-lung machine has allowed surgeons to perform open-heart surgical procedures that were previously unthinkable. In the following decades, the heart-lung machine has improved dramatically, allowing today’s surgeons to not only repair congenital defects but also to perform a multitude of other complex operations including those to treat valvular defects and coronary artery disease. Full sternotomy, cardiopulmonary bypass (CPB) and cardioplegic arrest (CA) have been considered essential requirements to overcome procedural limits and reduce intra- and postoperative complications. We can name this era the era of ‘conventional’ or ‘standard’ cardiac surgery, which remains prevalent today. Nevertheless, techniques continue to evolve, and technology supports this evolution. Cardiac surgeons have moved forward to minimally invasive approaches, which imply that structural heart defects can be treated through minimal surgical entry access (i.e. ministernotomy and small thoracotomy techniques) but still require the use of CPB and CA. As a result, the surgical philosophy and perspective have changed dramatically. Compared to before, external and intracavitary cardiac defects do not need to be examined and repaired under the surgeon’s direct vision through a full sternotomy but rather using magnified fields, for example obtained using video-assisted tools. Despite the evolution of technology allowing for progressively smaller access and enhanced 3-dimensional views using cameras and monitors for intrathoracic surgical visualization, minimally invasive cardiac surgery (including robotic surgery) still requires CPB and CA when applied to treating heart valve disease. CPB and CA operative times are often longer in minimally invasive procedures than in conventional surgery, thus challenging the concept of reduced invasiveness. We had to wait almost 70 years to witness the second Big Bang in structural heart surgery. CPB is no longer needed when one is implanting a cardiac valve: The era of the transcatheter aortic valve implant came like an asteroid onto the dinosaurs [2]. Through the transcatheter aortic valve implant lens, we acquired a vision of what was to come: evolving technologies would require the rapid, parallel evolution of surgical techniques. As we anticipated in previous editorials on this topic [3, 4], we need to shift the paradigm of conventional and minimally invasive cardiac surgery towards a different goal: we need to realize the impact exerted by evolving techniques and technologies and the inalienable (r)evolution of cardiac surgery. This realization will result in a professional journey from the more cautious approaches of classical surgery to the embracement of new technologies and interventions. At the same time, we clearly must refine our etymological approach: in other words, we are surgeons and, as surgeons, we have multiple opportunities to correct heart defects. Now a question arises. How should we define a surgical procedure that allows us to replace or repair a heart valve on the beating heart, with no need for CPB, with the chest closed, in a transcatheter fashion and that can also be performed under local anaesthesia in selected cases? It is reasonable to say that such procedures are definitely less invasive than those we traditionally term ‘minimally invasive’ cardiac procedures. In other fields, electronics for example, when a device becomes progressively smaller and smaller, it becomes first ‘mini’ and then ‘micro’. Similarly, the definition of ‘microinvasive’ cardiac surgery is the natural evolution of the journey towards the least invasive possibility of surgical heart valve therapy. Using a very common and relevant example, a patient with severe aortic stenosis is a surgical patient regardless of the way the defect is corrected. It does not really matter how we choose to replace the valve: standard invasive approaches (mostly implying full sternotomy), minimally invasive ones to implant conventional or rapid-deployment prosthetic valves or microinvasive approaches to implant transcatheter aortic and mitral valves. All of these methods deserve to be considered purely different strategies that can be applied by surgeons. There are other examples in completely different areas: the ability to remove thrombotic material from cardiac cavities with the Angiovac system [5]. Likewise, mechanical circulatory support is moving quickly away from the standard left ventricular assist device implants using a full sternotomy approach, to a less-invasive approach tending towards the minimally invasive or even microinvasive scenario: small incisions, off-pump, beating heart [6]. And, in the very near future, when percutaneous ventricular assist device systems become a reality, surgeons will be able to implant them using transcatheter techniques. Therefore, we propose the term ‘microinvasive’ cardiac surgery with the following caveats in mind: The term ‘surgery’ used alone would be diminutive. According to the Cambridge Dictionary, surgery is defined as the activity in which a doctor cuts people's bodies open and repairs or removes something. When it comes to heart surgery, opening bodies for some circumstances is unnecessary because technology allows surgeons to repair defects without opening the heart cavities. The term ‘microsurgery’ alone would be also incorrect. According to the Cambridge Dictionary, microsurgery implies the use of a surgical microscope because operations are carried out on very small areas of the body. It is true that microsurgical techniques can be facilitated by robotic aids, especially where the surgeon does not have clear access to the site. However, in cardiac surgery, invasiveness is not wholly dependent on the length and site of the surgical incision but also on whether or not CPB and CA are required. The term ‘minimally invasive’ surgery, as mentioned above, mostly takes into account the location and length of the surgical scar, the use of CPB and CA notwithstanding. Therefore, one can understand why the term ‘minimal access surgery’ would be better suited to these techniques. Despite the fact that the access is minimal, the procedure itself has a degree of invasiveness similar to that of conventional surgery [7]. Avoiding the term ‘transcatheter technique’. The term ‘transcatheter’ should be reserved for those procedures that are performed without any incision. Recently, 2 valuable technologies have been developed that allow mitral valve repair on a beating heart under off-pump, physiological conditions, therefore in a microinvasive fashion [8, 9]. These 2 technologies are not catheter-based; rather they are device-based; therefore, using the term ‘transcatheter’ in cases like these would be inappropriate. We are obliged to use the word surgery regardless of the types of instruments the technology provides. In other words, a scalpel, forceps, or a catheter should, in our opinion, all be defined as crucial ‘tools’ for correcting heart structural defects. It does not really matter how one performs the surgical repair—with maximal or minimal or even microinvasive access to the body. These are technical and technological evolving aspects of surgery. The emerging clinical need and the abruptly expanding interest of industry will lead microinvasive mitral and tricuspid solutions to become the next structural heart focus. Nowadays, up to one-third of patients with severe mitral regurgitation are never referred and nearly half are denied for conventional cardiac surgery because of prohibitive risk or patient preference. Moreover, by 2030, the increasing population age will translate into an estimated increase of 50% in the prevalence of heart failure, resulting in a significantly higher rate of accompanying mitral and tricuspid regurgitation [10]. Therefore, new less-invasive therapies are needed to further expand the proportion of patients treated, and the possibility of microinvasive surgery has generated significant interest in recent years. Industry interest is expanding rapidly, and the global market is estimated to grow significantly from $2 billion in 2021 to $3 billion in 2025 with a compound annual growth rate of 11% [11]. The variety of different pathological mechanisms causing mitral regurgitation and the complex anatomy of the mitral valve itself have led to the development of different percutaneous technologies, each of them focused on the treatment of a specific anatomical lesion or component of the mitral apparatus. These technologies can often target just a single component of the mitral apparatus (chordae or leaflets or annulus), in contrast to conventional surgical repair, which allows for combined multitarget procedures (chordae and leaflets and annulus) [12]. In reality, it has already been demonstrated that ‘combo-procedures’ that combine different microinvasive technologies can be safely used in selected patients. Transapical neochord implants combined with percutaneous mitral annuloplasty may allow the replication of what is normally performed in conventional and in minimally invasive surgery, using a microinvasive approach. THE MULTIDISCIPLINARY APPROACH The importance of patient selection leads us to stress the importance of a multidisciplinary and multistep evaluation to achieve the optimal results, including different specialists throughout different stages of the patient’s journey. Cardiac surgeons, cardiologists and anaesthesiologists are the main medical specialists to be involved, not just during the preoperative evaluation but also during the entire perioperative and follow-up period. In the operating room, strong collaboration among the surgical team, the cardiologists and the anaesthesiologist is critical to obtain the optimal results. THE ROLE OF THE SURGEON To offer the patient the greatest range of therapeutic options available, we strongly believe that the surgeon should be an integral component of the valve team. Because the surgeon has the in-depth knowledge and the skills to perform all possible repairs, ranging from a full sternotomy to mini-invasive to microinvasive procedures and from single-targeted solutions to combo-procedures, we believe that all patients should be seen by a trained hybrid cardiac surgeon. In summary, we as surgeons should shift the paradigm from standard or conventional to minimally invasive and then to microinvasive cardiac surgery, regardless of the type of prosthesis, device or catheter that we use to repair the cardiac defects. With this in mind, we should redefine cardiac surgery to include the broadest aspect of therapies including all future technological advancements in heart valve therapy and we should serve as key members for these important developments. We already made a grave mistake not thinking that the second ‘Big Bang’ was for surgeons. Let us amend it. REFERENCES 1 Theruvath TP , Ikonomidis JS. 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Eur J Cardiothorac Surg 2018 ; 53 : 871 – 3 . Google Scholar Crossref Search ADS PubMed WorldCat 10 Udelson JE , Stevenson LW. The future of heart failure diagnosis, therapy, and management . Circulation 2016 ; 133 : 2671 – 86 . Google Scholar Crossref Search ADS PubMed WorldCat 11 Abbott ZR. Edwards focus on mitral valve as market projected to rival TAVR . Medtechdive 2021 . Google Scholar OpenURL Placeholder Text WorldCat 12 D'Onofrio A , Fiocco A, Nadali M, Gerosa G. Transapical mitral valve repair procedures: primetime for microinvasive mitral valve surgery . J Card Surg 2021 ;1–9. Google Scholar OpenURL Placeholder Text WorldCat © The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
TI - Microinvasive cardiac surgery: when less is more—‘render to Caesar the things that are Caesar’s; and to the surgeon the things that are the surgeons’’
JF - European Journal of Cardio-Thoracic Surgery
DO - 10.1093/ejcts/ezac084
DA - 2022-02-14
UR - https://www.deepdyve.com/lp/oxford-university-press/microinvasive-cardiac-surgery-when-less-is-more-render-to-caesar-the-3IKI56Wrrd
VL - 62
IS - 1
DP - DeepDyve
ER -