FEATURE
about the size of the incision? Well …, the small incision is part
of it but in the overall picture is probably not the most important
factor. But from both the patient’s perception point and marketing
view, undoubtedly it is the selling point as we see how the surgical
websites, TV or even highway billboard advertising obsess with it!
Since the inception over two decades ago, LICS procedures have
been the subject of intense scrutiny and controversy by the surgical
community, as reflected in national and international meetings.
Even now, cardiac surgeons are divided in two distinct camps, and
their antagonistic positions on the subject are maintained fiercely.
Furthermore, probably more effort has been placed in trying to
prove the advancements wrong rather than in cautiously promoting
and improving these new options. This “all or none” approach to
new procedures is not unusual in the cardiac surgery community,
with other clear examples of “developmental arrest” lately being the
lack of acceptance and advancement of coronary bypass surgery
without the use of the heart lung machine, the so called “off pump”
or OPCAB operations. Nobody can deny the deleterious effects of
the use of the “heart-lung” machine in patients with renal and liver
dysfunction, poor lungs, hematologic disease, post transplantation,
aortic calcification or in the Jehovah’s Witness population. It is clear
to most surgeons that OPCAB is a more technically demanding,
stressful procedure and therefore, requires a motivated, interested
and skillful surgeon to do them. But most surgeons with the adequate
training and interest could do them. It makes sense to me that the
subgroups of patients I mentioned will do better without the use of
CPB, and many studies have shown that (4,5). Other studies, however
some of them with a questionable design, patient selection and/or
surgeon experience have shown otherwise (6), again feeding the
“all or none” mentality and minimizing the value of OPCAB as an
alternative option. In the USA, sadly enough, less than 15 percent
of coronaries are performed without the pump.
Looking at the LICS acceptance argument from the other side, I
can point to some of the factors I see as supporting the reluctance to
change, or at least, slowing the acceptance of the “MICS” or “LICS”
approaches. The dogma in our specialty has always been to simplify
the techniques and to improve outcomes. So, why make a cardiac
operation more complicated than it is? Without doubt, small incision
procedures (Pictures # 1-2) have more steps and allows for more
room for mistakes, especially during the learning curve. Moreover,
cardiac surgeons develop confidence and acquire experience at a low
pace compared to other specialties. For example, it will take many
years for the average CV surgeon to acquire the adequate volume
of cases and experience to be comfortable performing complex
mitral valve repairs or aortic surgery. To expect the average surgeon
to perform complex repairs through alternative LICS approaches
early in his/her career may not be realistic, or even safe, except for
Standard approach for LICS mitral valve repair
( image with permission of Edwards, Inc, Irvine, CA)
few exceptions. The price to be paid, for both patient and surgeon,
could be steep. Other factors related to adoption could be the av-
erage age of heart surgeons in the U.S., which is well over 50 years.
Acceptance to practice change may not be well received, distinctly
if more training is required with an inherent risky learning curve,
longer procedures, more stress, jeopardy of referrals and of course,
all … for the same pay! Therefore, the incentive is not there.
It is contradicting and very surprising to me that cardiac surgeons
are willing to accept and promote the extremes of care; i.e. the most
accepted modalities for the treatment of symptomatic severe aortic
stenosis (AS) are both the proven (more than 50 years) yet most
invasive full open sternotomy aortic valve replacement (SAVR)
and the minimalistic but promising and now frequently used per-
cutaneous valve implants (TAVR) for higher risk patients, yet most
surgeons still debate and argue against the use and try to fight off
mini AVR operations, which are less invasive, easily reproducible
and provide great results and patient satisfaction.
The modern trend is that all procedures and operations are be-
coming less invasive. Even many operations have now become per-
cutaneous procedures in riskier patients, such as TAVR (trans-aortic
valve replacement), Angio-Vac (tumors and clots suctioned through
catheters) and others. It is obvious that patients are looking at other
options to avoid open surgery. Even if those options are less than
perfect, some with a poorer overall outcome and potentially requir-
ing multiple other procedures in the future at a higher cumulative
risk, patients may consider them if offered. The perfectionist view,
our cardiac surgery view, is based on offering the best possible
procedure available, a good technical result as well as a document-
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