FEATURE
( continued from page 15 )
ed long-term outcome . This process is often shadowed by the ever decreasing but certain upfront surgical risk and the early recovery process . Others ( patients and referrals alike ) perception of surgery oftentimes is very different than ours and they are ambiguous about the risk-benefits , durability or best procedure choice and recommendations are often made based on procedural risk and expectations , sometimes unrealistic .
Despite these facts , many surgeons and centers around the world ( 6,8 ) have persisted and continued to evolve the LICS field . Many of us , as true believers , and others likely for marketing purposes to capture some of those interested patients , many of them disoriented , that shop in different centers for a small incision , pain and complication free , sort of magic procedure . The truth is probably in between , as usual . Fortunately , in the last few years , the perception of a need for less invasiveness has grown in patients and referrals alike . Furthermore , the cardiac surgical community , maybe with reluctance , is slowly accepting the obvious and the positive changes as I describe in this note .
After 20 years of involvement with most of these techniques , I will give my opinion as a true believer in their benefits , and also , I will emphasize the importance of a versatile surgical training and the selective use of multiple different techniques in those embarking in this direction . The learning curve is steep , and the initial setbacks are usually not well received by patients and referrals alike . Furthermore , criticism will be unavoidable even from our own colleagues . But there is strong data suggesting that in centers where surgeons have the interest ( 1-3 ), dedication and experienced surgical teams , the results are similar or even better to open traditional surgery in those selected groups of patients , such as cases of isolated valve disease , selected coronary disease , cardiac masses and few others . ( Table 1 )
Table 1
Ideal indications for small incision LICS procedures 1 . Valve repair or replacement
· Mitral
· Aortic
· Tricuspid
· Combined ( M-A or M-T ) 2 . Cardiac masses ( tumors , thrombus ) 3 . Coronary bypass ( selected anatomy ) 4 . Atrial arrhythmias 5 . Congenital defects ( ASD and other ) 6 . Mediastinal masses
Careful patient selection , explanation of the procedures and its limitations , explaining the pros and cons , and establishing realistic expectations for patients seeking LICS procedures are of utmost importance . I explain to my patients that the most important goal of surgery is to survive it , the next most important but yet not always possible , is to give the patient a high chance of completing the anticipated operation ( i . e . valve repair ) and finally to do a procedure resulting in low complications , less pain and the most acceptable cosmetic ( small incisions ) result possible . Therefore , the first two cannot be jeopardized because of a desire of having the third as main interest . Fortunately , most patients understand this concept and are willing to take the advice and the procedure offered . If the patient is not willing to accept the recommendation , then another surgeon or center may be able to fulfill his / her extreme and / or probably unrealistic expectations . As Mark Twain said , “ It is never wrong to do the right thing ,” even if things don ’ t go as planned . This is real life , and I can live with my decision .
On the other hand , it is the patient ’ s right when he / she is well informed and has a realistic inquire for a less invasive procedure . If the procedure is not offered because of the surgeon ’ s unwillingness to do it or the lack of training / interest and when the answers are not convincing , more likely than not , that patient will seek another opinion or an out-of-town second opinion and possibly , “ destination ” surgery . All these situations illustrate the many variables involved in cardiac surgery referrals patterns and cardiology team “ trust ” of their surgeons . Honest reporting of surgical outcomes by surgeons and the setting of realistic expectations to referrals and patients alike are crucial to a successful LICS program .
In our Center for Less Invasive Cardiac Surgery , at Baptist Cardiac Surgery , we apply to all patients our concept of cardiac surgery with “ less impact ” as I described . We tailor the many available procedures to the particular patient and needs ( Tables 2-3 ). The surgical options considered should be standard open procedures
Table 2
Other LICS or trans-catheter procedures available 1 . Hybrid coronary bypass ( MICS-CABG , PCI )
2 . TAVR ( percutaneous aortic valve implants for higher risk or old and frail patients )
3 . Valve in valve TAVR or Mitral 4 . TEVAR ( thoracic aortic stenting-grafting )
5 . PARACHUTE device ( left ventricular exclusion for aneurysms )
6 . ASD closure 7 . Others
16 LOUISVILLE MEDICINE