Innovations in minimally invasive cardiac surgery procedures

Cardiac surgery is a field in which technological innovation is also changing the way operations are carried out. Alongside traditional surgery, minimally invasive techniques have been developed which, in selected patients, allow access to the heart via small incisions, thereby minimising tissue trauma.
Among the most advanced applications is minimally invasive endoscopic surgery, used in particular for the treatment of heart valve disorders. To understand how it works and what prospects this development in cardiac surgery opens up, we asked Dr Daniele Maselli, a cardiac surgeon at the Cardiac Surgery Unit at the IRCCS Policlinico San Donato.

From traditional surgery to minimally invasive approaches
In traditional cardiac surgery, access to the heart is generally gained by opening the sternum. Minimally invasive techniques, on the other hand, follow a different approach, using very small incisions between the ribs that allow the heart to be reached without fully opening the chest. The sole purpose of this small incision is, in fact, to allow surgical instruments and prostheses to pass through. It is through the endoscope, however, that the operation is then performed and visualised.
‘The real innovation,’ explains Maselli, ‘lies not merely in reducing the size of the incision, but in the ability to work through a much smaller access point whilst maintaining a high level of surgical precision. This is made possible by specialised instruments and, above all, by high-definition three-dimensional endoscopic vision.”
A camera inserted through a small incision provides a magnified, three-dimensional view of the anatomical structures, whilst slender instruments allow the operation to be performed with great precision. It is precisely this high-definition endoscopic view that guides, step by step, every detail of the surgical procedure: the surgeon does not operate ‘freehand’, but relies on the magnified endoscopic image to precisely define every technical manoeuvre.

3D technology in the service of precision
‘3D technology allows us to perceive depth, distances and the relationships between different anatomical structures with very high image quality,’ emphasises Maselli. This facilitates the surgeon’s work, particularly when operating in a confined space such as the thoracic cavity.”
A minimally invasive approach does not mean compromising on the complexity of the procedure. During the operation, cardiopulmonary bypass may be used, which maintains cardiac and circulatory functions whilst the surgeon operates on the heart under controlled conditions.
The combination of 3D visualisation and miniaturised instruments thus makes it possible to perform complex procedures via a minimally invasive approach.

What procedures can be performed
One of the main applications is mitral valve surgery, which may involve repairing or replacing the valve. Using the same endoscopic technique, it is also possible to operate on the aortic and tricuspid valves, treat certain cardiac tumours and correct interatrial septal defects.
“There is no single minimally invasive technique that is suitable for everyone without exception,” explains the cardiac surgeon. “The choice depends on the patient’s anatomical and clinical characteristics, the type of condition and the complexity of the procedure.”
A thorough diagnostic assessment is therefore necessary before proceeding. Echocardiography, CT scans and, where indicated, coronary angiography allow for a detailed examination of the heart and blood vessels and help determine the most appropriate surgical strategy.

Less invasiveness, a quicker recovery
Reducing the extent of the surgical incision means minimising tissue trauma, with potential benefits for post-operative recovery.
“‘In appropriately selected patients,’ notes Maselli, ‘the minimally invasive approach can be associated with reduced post-operative pain, smaller scars and a faster recovery. The length of hospital stay may also be reduced, depending on the patient’s condition and the type of procedure.’

Innovation also depends on training
Technology alone is not enough to apply these techniques safely. Minimally invasive surgery requires a specific learning curve and a team accustomed to working in ways that differ from those of traditional surgery. “Training is essential,” concludes Dr Maselli. “The use of advanced technologies must be accompanied by experience, training and teamwork. The future of minimally invasive cardiac surgery will depend on the ability to integrate technological innovation, specialist skills and careful patient selection.”
The evolution of minimally invasive cardiac surgery is therefore not measured solely in terms of technology, but in the ability to devise, on a case-by-case basis, the surgical approach best suited to the individual patient. It is this combination of innovation and personalisation that defines the direction of the discipline today.