[Changes in heart surgical strategies: a word of caution]

The introduction of minimally invasive coronary artery bypass surgery has expanded the technical armementarium for operative treatment of coronary artery disease. Minimal access surgery using partial sternotomy or anterior intercostal minimal thoracotomy can be combined with videoscopic techniques or port-access-methods. Either atrio-aortal cannulation, femoro-femoral or jugular-femoral connections to the pump are possible for extracorporal circulation (ECC). Even endoluminar occlusion of the aorta and application of cardioplegia into the aortic root can be considered and applied. Extracorporal circulation has developed into a safe standardized method. As far as pathophysiology is concerned, the decision to use ECC or not is of much more importance than the grade of invasiveness. Fundamentally we therefore need to distinguish between minimally invasive methods with and without ECC. Video-assisted coronary surgery in hearts under hypothermia and fibrillation with ECC is also recommended occasionally. Minimally invasive coronary artery procedures on beating hearts without ECC have to be done in a stabilized and bloodless operative field to allow the construction of high standard anastomoses between bypass grafts and coronary arteries. In practice, silicon occluders, epicardial and myocardial suture occlusion and fixation, mechanical stabilization devices, and pharmacologic induction of bradycardia are used. In principle a skilled surgeon should be familiar with all these methods to select the most suitable solution for the special clinical problem. A final judgement about each method is not possible up to now. High patients numbers have to be recruited in the groups and subgroups due to low mortality (1%) and morbidity (5%), otherwise statistical significance of the results cannot be gained.