FEATURE
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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
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