Perspectives on minimally invasive coronary artery surgery. Current assessment and future directions

Excellent long-term results have been obtained with conventional coronary artery bypass surgery. However, significant mortality and morbidity still exists due to the use of cardiopulmonary bypass for circulatory support and the traditional method of access by median sternotomy. Minimally invasive concepts have been adopted in cardiac surgery in an attempt to make these procedures less invasive. Minimally invasive alternatives include the minimally invasive direct coronary artery bypass procedure in which cardiopulmonary bypass is eliminated and the operation is performed through minimal access incisions; the Port Access approach in which the procedure is done through minimal access incisions and cardiopulmonary support is instituted through an extra thoracic approach. The third alternative is the "off pump" sternotomy approach which allows greater access for more extensive revascularization, but the procedure is still performed on a beating heart. All procedures have their limitations, but offer the potential for a less invasive approach for coronary revascularization. Current results are only short to immediate term, but are promising. Current efforts to extend the procedure include improved methods for facilitating beating heart coronary artery surgery, better visualization for endoscopic approaches and finding alternatives to cardiopulmonary bypass for circulatory support and alternatives to suturing for performance of vascular anastomoses. Additional alternatives to extend the procedure include hybrid operations in which minimally invasive coronary bypass is combined with transcatheter procedures (stents) for the treatment of multivessel disease.