Introduction

The history of cardiac surgery reflects a constant search by cardiac surgeons for safer and less-invasive ways to treat their patients. Since Dr. F. John Lewis's pioneering operation in 1952, followed by Dr. C. Walton Lillehei's first successful series of intracardiac defect repairs in the mid-1950s, cardiac surgery as a surgical subspecialty has expanded dramatically. Notably, one of the most important technological innovations in cardiac surgery was the development and modification of a cardiopulmonary bypass machine. For years, this machine has been used extensively by cardiac surgeons. Its use has enabled cardiac surgery to become a safe and reproducible daily routine in many hospitals across the country. Now, although most cardiac operations are considered somewhat standardized, continued improvements as well as recognition of the importance of postoperative recovery and quality of life remain significant concerns for patients as well as physicians.

In recent years, there has been a major push to develop and provide "less-invasive cardiac surgery" as standard care. All four of the major steps used in conventional cardiac surgery need to be considered when attempting to develop less-invasive modifications: (1) gaining access to the heart through a full sternotomy or posterolateral thoracotomy; (2) supporting the vital organs through a cardiopulmonary bypass machine; (3) arresting the heart by administering cardioplegia; and/or

(4) manipulating the ascending aorta during aortic cannulation, during cross-clamping and side-clamping, and during proximal anastomosis in coronary artery bypass grafting. Unfortunately, any of these steps can impose significant risks or adverse effects. More specifically, a large incision typically corresponds to greater pain, a noticeable scar, more complications, and/or a longer recovery time. Similarly, cardiopulmonary bypass has been known to trigger adverse inflammatory reactions or subsequent multiple organ dysfunction. Finally, manipulating the aorta can lead to strokes (e.g., from plaque dislodge-ment) or other neurological deficits. Importantly, less-invasive approaches or minimally invasive cardiac surgery can minimize or eliminate complications that may occur relative to each of the four steps commonly used in conventional cardiac surgery. This chapter focuses on less-invasive methodologies commonly employed in adult cardiac surgical procedures.

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