Minimally invasive cardiac surgery

Other names| MICS CABG, MIMVS
Specialty| cardiology

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Minimally invasive cardiac surgery, encompasses various aspects of cardiac surgical procedures (aortic valve replacement, mitral valve repair, coronary artery bypass surgery, ascending aorta or aortic root surgery) that can be performed with minimally invasive approach either via mini-thoracotomy or mini-sternotomy.[1][2] MICS CABG (Minimally Invasive Cardiac Surgery/Coronary Artery Bypass Grafting) or the McGinn technique is heart surgery performed through several small incisions instead of the traditional open-heart surgery that requires a median sternotomy approach, and can be performed in patients with multivessel coronary artery disease.[3] MICS CABG is a beating-heart multi-vessel procedure performed under direct vision through an anterolateral mini-thoracotomy.[4]

Advantages of minimally invasive heart surgery are less blood loss, reduced post-operative discomfort, faster postoperative recovery and lower risk of infections, reduced duration of mechanical ventilation as well as eliminating the possibility for sternal non-union. This procedure makes heart surgery possible for patients who were previously considered too high risk for traditional surgery due to age or medical history.[5][6] Patients referred for this procedure may have coronary artery disease (CAD); aortic, mitral or tricuspid valve diseases; or previous unsuccessful stenting.

A recent meta-analysis of randomized controlled trials by Amin et al (2024) showed that minimally invasive mitral valve surgery (MIMVS) reduced the number of days spent in the hospital and demonstrated a trend towards lower postoperative pain scores, but it did not decrease the risk of all-cause mortality or the number of patients needing blood product transfusions.[7]

## Contents

* 1 The procedure
* 2 The McGinn Technique (Proximal Anastomoses)
* 3 Pump-assisted beating heart bypass
* 4 Hybrid coronary revascularization
* 5 After surgery
* 6 Benefits of MICS CABG/ The McGinn Technique
* 7 MICS CABG Study Results
* 7.1 2014
* 7.2 2013
* 7.3 2012
* 7.4 2010
* 7.5 2009
* 8 History
* 9 References
* 10 Further reading
* 11 External links

## The procedure

MICS CABG is performed through one 5–7 cm incision in the 4th intercostal space (ICS). In some cases the thoracotomy may be necessary in the 5th ICS instead. A soft tissue refractor is used to allow for greater visibility and access. MICS CABG may be completed in an "anaortic" or no-touch off-pump technique, which has demonstrated reduced postoperative stroke and mortality compared to traditional CABG.[8]

Two access incisions are also made at the 6th intercostal space and xiphoid process to allow for instruments to position and stabilize the heart.[4][9]

## The McGinn Technique (Proximal Anastomoses)

Minimally invasive heart surgery has been used as an alternative to traditional surgery for the following procedures:

* Coronary artery bypass
* Mitral valve repair
* Mitral valve replacement
* Aortic valve replacement
* Atrial septal defects
* Hybrid coronary revascularization

## Pump-assisted beating heart bypass

## Hybrid coronary revascularization

Hybrid coronary revascularization is a common procedure that takes advantage of coronary stenting in combination with CABG. Hybrid coronary bypass is a relatively new procedure and alternative to traditional bypass surgery that is defined by the performance of coronary bypass surgery and coronary stenting of different areas of a patient's heart. MICS CABG allows utilization of the left internal mammary artery (IMA; aka left internal thoracic artery, left ITA) to bypass the left anterior descending artery (LAD), which is termed as left IMA-LAD, as a preferable anastomosis whenever indicated and technically feasible (Loop et al.) and has been proven to benefit in event free survival (Acinapura et al.). The other one or two arteries will be stented, when appropriate, allowing cardiologists and cardiothoracic surgeons to work together.[10][11]

## After surgery

After a minimally invasive procedure, patients recover more quickly than from sternotomy and develop fewer complications. Most patients can expect to resume everyday activities within a few weeks of their operation. After surgery, patients are administered an anaesthetic pain pump and drains that will be removed prior to discharge. Patients are encouraged to move around as much as possible after their operation to recover quickly. Once discharged from hospital, patients require no further post-operative assistance.[12]

Minimally invasive heart surgery is a safe and broadly applicable technique for performing a wide range of complex heart procedures, including single or multiple heart valve procedures, bypass surgery, and congenital heart repairs.

## Benefits of MICS CABG/ The McGinn Technique

Eliminating the need for median sternotomy greatly reduces the trauma and pain associated with open-chest surgery and improves quality of life for patients. In the hospital, reduced post-operative discomfort enables patients to quickly begin a shorter recovery process. Most patients ambulate more easily and participate more actively in their personal care. Additionally, this approach lowers risk of complications such as bleeding, infection and eliminates the risk of sternal non-union.[13]

Minimally invasive heart surgery improves cosmetic results. Rather than a prominent 10-inch scar down the middle of the chest, patients are left with smaller marks to the side of the ribs. For women, in many cases, this scar is completely unnoticeable as it sits below the breast.[13]

Benefits Include:

* No splitting of the breastbone
* Reduction in pain
* Lower risk of infection
* Lower risk of bleeding
* Reduced ICU and hospital stay
* Improved postoperative pulmonary function
* Accelerated recovery/return to activity
* Improved quality of life
* Greatly improved cosmetic result

## MICS CABG Study Results

### 2014

At the 2014 International Society for Minimally Invasive Cardiothoracic Surgery Annual Meeting in Boston, Dr. Joseph T McGinn presented a study titled "Minimally Invasive CABG is Safe and Reproducible: Report on the First Thousand Cases," which found a low rate of conversion to sternotomy and low rate of complications. Assessing survival and adverse cardiac events up to 8.0 years (average 2.9±2.0 years), MICS CABG is a safe, reproducible operation that yields survival (96.1±0.9%) and durability comparable to conventional CABG.[14][15]

### 2013

The Journal of Thoracic and Cardiovascular Surgery published a study on November 1, 2013, that confirmed MICS CABG as safe, feasible, and associated with excellent graft patency rates at 6 months post surgery, with graft patency of 92% for all grafts and 100% for left internal thoracic artery grafts. Coronary artery bypass graft patency was studied through computed tomography angiography. 92% of patients were free from angina and none of the participants experienced any aortic complications, repeat revascularizations, cerebrovascular accidents, myocardial infarctions or death. The two-year study included 91 participants between the ages 48 and 79, averaging a hospital stay of 4 days (range, 3–9 days). Clinical Trial Registration Unique identifier: NCT01334866.[10][16]

### 2012

At 2012 American Heart Association's Scientific Sessions and Resuscitation Science Symposium, a study titled "Minimally Invasive CABG: Results to 6 Years" was presented, demonstrating MICS CABG feasibility and established alternative for multivessel sternotomy CABG. It was also noted that the procedure is associated with a short hospital length of stay, no deep wound infections and is safe. The study also proved survival and durability on par with sternotomy.[17]

### 2010

At the 2010 International Society for Minimally Invasive Cardiothoracic Surgery Annual Meeting in Berlin, Germany, duel center data was presented the standardization of MICS CABG in performance and reproducibility of its results. Its safety and effective alternative for performing surgical myocardial revascularization on the beating heart (OPCAB) is emphasized. "Shortened hospital stay is starting to be realized and its application to high risk and complex patients is now being done."[18]

### 2009

A 2009 publication in Circulation, titled "Minimally Invasive Coronary Artery Bypass Grafting: Dual-Center Experience in 450 Consecutive Patients" concluded MICS CABG as a feasible procedure with excellent short-term outcomes. At that time the study noted, "this operation could potentially make multivessel MICS CABG safe, effective and more widely available."[9]

## History

Minimally invasive cardiac surgery was pioneered by Dr Joseph T McGinn, Jr. The first minimally invasive heart cardiac surgery was performed in the United States on January 21, 2005, at The Heart Institute at Staten Island University Hospital in Staten Island, New York by a team led by Dr. Joseph T. McGinn. This technique is an off-pump coronary artery bypass surgery. The procedure is much less invasive than traditional bypass surgery because it is performed through three small incisions rather than the traditional sternotomy. Since its first procedure, over 1000 MICS CABG procedures have been performed at The Heart Institute and elsewhere around the world.[6] Other centers that utilize the MICS CABG technique for coronary heart disease are the University of Ottawa Heart Center (ON, Canada), Houston Methodist DeBakey Heart Center (Houston, TX), and Vanderbilt University Medical Center (Nashville, TN).[19][20][21]

## References

1. ↑ Mihaljevic, T; Cohn, LH; Unic, D; Aranki, SF; Couper, GS; Byrne, JG (September 2004). "One thousand minimally invasive valve operations: early and late results.". Annals of Surgery 240 (3): 529-34; discussion 534. doi:10.1097/01.sla.0000137141.55267.47. PMID 15319724.
2. ↑ Sef, D; Bahrami, T; Raja, SG; Klokocovnik, T (June 2022). "Current trends in minimally invasive valve-sparing aortic root replacement-Best available evidence.". Journal of Cardiac Surgery 37 (6): 1684–1690. doi:10.1111/jocs.16453. PMID 35348237.
3. ↑ Sef, D; Thet, MS; Hashim, SA; Kikuchi, K (12 September 2024). "Minimally Invasive Coronary Artery Bypass Grafting for Multivessel Coronary Artery Disease: A Systematic Review.". Innovations (Philadelphia, Pa.) 19 (4): 351–359. doi:10.1177/15569845241265867. PMID 39267397.
4. ↑ 4.0 4.1 "MICS CABG Technique Overview: Minimally Invasive CABG (MICS CABG) Procedure", "[1]", 2010, p. 1
5. ↑ "NYU Langone Medical Center", "[2]", December 29, 2009
6. ↑ 6.0 6.1 "The Heart Institute","[3] ", March 25, 2011
7. ↑ "Frontiers - Minimally invasive vs. conventional mitral valve surgery: a meta-analysis of randomised controlled trials", "[4]", August, 2024
8. ↑ Zhao, Dong Fang (February 28, 2017). "Coronary Artery Bypass Grafting With and Without Manipulation of the Ascending Aorta: A Network Meta-Analysis". Journal of the American College of Cardiology 69 (8): 924–936. doi:10.1016/j.jacc.2016.11.071. PMID 28231944. http://www.onlinejacc.org/content/69/8/924.
9. ↑ 9.0 9.1 "Minimally invasive coronary artery bypass grafting: dual-center experience in 450 consecutive patients". Circulation 120 (11 Suppl): S78–84. September 2009. doi:10.1161/CIRCULATIONAHA.108.840041. PMID 19752390.
10. ↑ "Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events". The New England Journal of Medicine 314 (1): 1–6. January 1986. doi:10.1056/NEJM198601023140101. PMID 3484393.
11. ↑ "Internal mammary artery bypass grafting: influence on recurrent angina and survival in 2,100 patients". The Annals of Thoracic Surgery 48 (2): 186–91. August 1989. doi:10.1016/0003-4975(89)90065-9. PMID 2788393.
12. ↑ "Medtronic", "[5]", 2009
13. ↑ 13.0 13.1 McGinn JT Jr, Usman S, Lapierre H, Pothula VR, Mesana TG, Ruel M (2009). "Minimally invasive coronary artery bypass grafting: dual-center experience in 450 consecutive patients". Circulation 120 (11 Suppl): S78–84. doi:10.1161/CIRCULATIONAHA.108.840041. PMID 19752390.
14. ↑ 2014 International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS) Annual Scientific Meeting- Boston,[6], May 2014
15. ↑ McGinn JT, Shariff MA, Nabagiez JP, Sadel S, Sharma R, Abogato P, Daniele E, Fazio L, Lapierre H, Sohmer B, Ruel M. (May 2014) Minimally Invasive CABG is Safe and Reproducible: Report on the First Thousand Cases. Presentation at International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS) 2014 in Boston,[7], 2014
16. ↑ "Results of the Minimally Invasive Coronary Artery Bypass Grafting Angiographic Patency Study". The Journal of Thoracic and Cardiovascular Surgery 147 (1): 203–8. January 2014. doi:10.1016/j.jtcvs.2013.09.016. PMID 24183338.
17. ↑ 2012 American Heart Association's Scientific Sessions and Resuscitation Science Symposium, [8], 2012.
18. ↑ De C, Laffery J, Lakhani M, Shariff M, Ramchandani M, McGinn J. Minimally Invasive Coronary Artery Bypass Grafting: An Alternative Approach to Perform Coronary Artery Bypass Grafting on the Beating Heart. Poster presented at: International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS) June 2010, Berlin, Germany, [9], 2010
19. ↑ http://www.ottawaheart.ca/misc/marc-ruel_research- linical-interests.h tm
20. ↑ Houston Methodist DeBakey Heart Center, http://www.houstonmethodist.org/DrMaheshRamchandani
21. ↑ Vanderbilt University Medical Center, "Department of Cardiac Surgery - Steven J. Hoff, M.D.". http://www.mc.vanderbilt.edu/root/vumc.php?site=section&doc=28786.

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[2]

## Further reading

* "Results of the Minimally Invasive Coronary Artery Bypass Grafting Angiographic Patency Study". The Journal of Thoracic and Cardiovascular Surgery 147 (1): 203–8. January 2014. doi:10.1016/j.jtcvs.2013.09.016. PMID 24183338.
* "Experience with a minimally invasive approach to combined valve surgery and coronary artery bypass grafting through bilateral thoracotomies". The Heart Surgery Forum 16 (3): E125–31. June 2013. doi:10.1532/HSF98.20121126. PMID 23803234.
* "Elevated preoperative neutrophil/lymphocyte ratio as a predictor of increased long-term survival in minimal invasive coronary artery bypass surgery compared to sternotomy". Journal of Cardiothoracic Surgery 8. 2013. doi:10.1186/1749-8090-8-193. PMID 24070055.
* "Minimally invasive coronary artery bypass grafting: is it time for the robot?". Current Opinion in Cardiology 28 (6): 639–45. November 2013. doi:10.1097/HCO.0b013e3283653fd1. PMID 24077608.
* "Off-pump coronary surgery through mini-incisions: is it reasonable?". Current Opinion in Cardiology 21 (6): 578–83. November 2006. doi:10.1097/01.hco.0000245737.62959.e3. PMID 17053407.
* "Minimally invasive coronary artery bypass grafting via a small thoracotomy versus off-pump: a case-matched study". European Journal of Cardio-Thoracic Surgery 40 (4): 804–10. October 2011. doi:10.1016/j.ejcts.2011.01.066. PMID 21393011.
* "Long-term mortality in minimally invasive compared with sternotomy coronary artery bypass surgery in the geriatric population (75 years and older patients)†". European Journal of Cardio-Thoracic Surgery 47 (5): 862–7. July 2014. doi:10.1093/ejcts/ezu267. PMID 24994756.
* Ruel M, Shariff M, Lapierre H, Goyal N, Sohmer B, McGinn J. Final Results of the Minimally Invasive Coronary Artery Bypass Angiographic Graft Patency Study. 93rd American Association for Thoracic Surgery (AATS) Annual Meeting, Minneapolis, MN. (https://web.archive.org/web/20140624073145/http://aats.org/annualmeeting/Program-Books/2013/T6.cgi).
* "Results of completion arteriography after minimally invasive off-pump coronary artery bypass". The Annals of Thoracic Surgery 91 (1): 31–6; discussion 36–7. January 2011. doi:10.1016/j.athoracsur.2010.09.057. PMID 21172481.
* Hoff SJ (2009). "Off-pump coronary artery bypass: techniques, pitfalls, and results". Seminars in Thoracic and Cardiovascular Surgery 21 (3): 213–23. doi:10.1053/j.semtcvs.2009.09.002. PMID 19942119.

## External links

* Bypass technique is less taxing for patients- St. Louis Today

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1. ↑ "Heart & Vascular Disease | Houston Methodist". 2017-07-31. https://web.archive.org/web/20160731192503/http://www.houstonmethodist.org/heart-vascular/.
2. ↑ PubMed, Pubmed (2024-08-12). "Frontiers | Minimally invasive vs. conventional mitral valve surgery: a meta-analysis of randomised controlled trials". doi:10.3389/fcvm.2024.1437524.

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