What is minimally invasive cardiac surgery?

Most patient concerns and demands for less invasive surgery are focused on comfort, cosmesis, and rehabilitation that are all related to the degree of invasiveness. The degree of invasiveness of cardiac surgery depends on two factors: the surgical approach-the length of the skin incision, the degree of retraction and aggression to the tissue, and the loss of blood--and the use of cardiopulmonary bypass. Regarding the surgical strategy, four categories of less invasive cardiac surgery can be distinguished: (1) direct coronary artery surgery via sternotomy on the beating heart (without extracorporeal circulation); (2) limited or modified approaches using conventional techniques and instruments with either conventional cardiopulmonary bypass or the EndoCPB(R) endovascular cardiopulmonary bypass system; (3) minimally invasive direct coronary artery bypass on the beating heart via a parasternal or left anterior small thoracotomy; and (4) true port-Access(TM) surgery in which all surgical acts are performed through ports and the heart is arrested with the Endoaortic Clamp(TM) catheter. These categories offer different advantages in terms of reducing invasiveness and may have different learning curves. Minimally invasive cardiac surgery is undergoing an explosive evolution, and although the indications and best strategies for the different categories are yet to be determined, the trend cannot be stopped. We try to distinguish between "fashionable" strategies and those that are truly revolutionary and investments in the future.