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[Translate to Englisch:] Schläuche Minimal-invasive Eingriffe - Immanuel Herzzentrum Brandenburg in Bernau bei Berlin

Minimally-invasive procedures

Minimally-invasive cardiac surgery can be less disruptive and traumatic for the human body, reducing recovery time and improving cosmetic results. Minimally-invasive techniques may be suitable for certain procedures involving the heart valves and certain types of routine bypass surgery.

Minimally-invasive cardiac surgery - what does it really mean?

Minimally-invasive means that the degree of invasiveness of the procedure is minimal, which is why this type of surgery is often referred to as keyhole surgery. The terms minimally-invasive and keyhole surgery both became established as part of developments in endoscopic surgery, i.e. surgery that uses special instruments and optical probes, which are introduced into the body using sharp-pointed medical instruments (trocars) and cannulas.

Minimally-invasive cardiac surgery can be less disruptive and traumatic for the human body, making it particularly beneficial in elderly patients who are at an increased risk of surgical complications.

The term "minimally-invasive", when applied to cardiac surgery, generally refers to a variety of techniques aimed at making surgery simpler, quicker and less invasive. A particular focus is placed on avoiding the use of cardiopulmonary bypass (a heart-lung machine), and on reducing the size of the access site in the chest as much as possible. 



The term "minimally-invasive" has almost become a catchphrase, and judging by the information commonly disseminated in magazine articles, radio shows and television programs, one might be tempted into thinking that minimally-invasive treatment options are already widely available for a whole range of heart conditions. This sort of information should be treated with caution, as it almost exclusively refers to very new procedures which are, at best, at the clinical trial stage, and have only been used in a select number of patients. This also means that no long-term results exist, making it impossible for the outcomes of such new procedures to be compared with those of similar yet established treatments.

Purely endoscopy-based (keyhole) procedures, such as those used for gall bladder removal, have not proved viable in the field of cardiac surgery. Similarly, the use of minimally-invasive procedures is very much limited to certain heart conditions.

And, while established treatment methods have been tried and tested thousands of times with clearly-established long-term outcomes, the same cannot be said for many of the newer treatment options.

It is important to note that when the term "minimally-invasive" is used, this refers to a whole range of very different methods and techniques whose common aim is to reduce the degree of invasiveness of the procedure(s) involved, thereby reducing the amount of trauma caused to the patient. It should be noted, however, that no purely endoscopic techniques exist within cardiac surgery. Despite attempts at introducing such purely endoscopic techniques having been unsuccessful, endoscopic techniques are being used in combination with some of the other surgical procedures involved (optical probes to assist with intraoperative visualization; long endoscopic instruments).



However, even these minimally-invasive procedures, which have become established in clinical practice and produce good long-term results, are only suitable for use in certain, specific patients. Each patient will be assessed by the heart surgeon responsible for their care, and a decision will be made as to whether it is possible use minimally-invasive techniques as part of bypass surgery, heart valve reconstruction or heart valve replacement. To a large degree, this decision will depend on anatomical factors and technical considerations, but may also be influenced by how complex the surgical procedure is likely to be.

What conditions are treated with this type of procedure?

Minimally-invasive procedures can be considered in conjunction with the following conditions:

Minimally-invasive procedures in our clinic

At the Brandenburg Heart Center, we offer all minimally-invasive procedures currently established in routine clinical practice. After an initial assessment, we will discuss the options that are available in your case. Instead of pursuing minimally-invasive procedures at all costs, we prefer to focus on likely long-term results and the quality of life that is likely to be achieved with a certain procedure. We will only ever advise patients to choose a minimally-invasive option if we are certain that it is likely to produce the same long-term results as conventional surgery.

The following section provides a brief overview of different minimally-invasive procedures and how these are currently ranked in terms of their potential benefits.

Minimally-invasive direct coronary artery bypass (MIDCAB):

These procedures are well-established in clinical practice, and are indicated in very specific situations. Should your coronary artery disease affect only the left coronary artery, bypass grafting can be performed using the left internal mammary artery. This procedure, which is performed without the use of cardiopulmonary bypass (a heart-lung machine), involves only a small incision being made in the chest, below the left nipple.



Off-pump coronary artery bypass (OPCAB):

Depending on the specifics of your case, coronary artery bypass surgery may be able to be performed without the use of cardiopulmonary bypass, i.e. without a heart-lung machine. This procedure is only suitable in cases involving very specific changes to the coronary arteries. Consequently, it is not suitable for use in all patients, nor does it necessarily constitute a benefit when compared to conventional bypass surgery.



Mini extracorporeal circuit (MECC):

Depending on the specifics of your case, coronary artery surgery may be possible using a minimally-invasive type of cardiopulmonary bypass, or mini extracorporeal circuit (MECC) cardiopulmonary bypass. This special mini-circuit cardiopulmonary bypass system reduces the adverse effects of cardiopulmonary bypass on blood components. Unfortunately, it is not suitable for use in all patients.



Minimally-invasive mitral valve replacement/repair:
Instead of conventional open chest surgery involving a midline sternotomy, this procedure only requires a small incision to be made in the side of the chest, while connection to the cardiopulmonary bypass (heart-lung) machine is established via the blood vessels in the groin. This procedure can only be performed in patients with isolated mitral valve defects who also meet additional anatomical requirements. While data from large-scale research into the procedure's long-term results are still outstanding, the procedure should be regarded as well-established in clinical practice.



Minimally-invasive aortic valve replacement:

Although this particular procedure initially became established as a result of its reduced invasiveness, with access being achieved via a partial sternotomy in the middle of the chest, the procedure itself is only marginally effective.

More recent developments have resulted in the procedure now allowing endovascular valve replacement via the apex (tip) of the heart or via the femoral artery, i.e. without the need for open chest surgery (TAVI). While this new procedure has become established over the past few years, long term results remain outstanding. Its use remains limited to older and seriously ill patients, for whom conventional surgery would pose an unacceptably high risk.

Hybrid procedures:

In some patients, the degree of invasiveness of a surgical procedure can be reduced through a combination of procedures that are performed one after the other, such as the minimally-invasive, catheter-based implantation of an endovascular stent (PTCA), performed by an interventional cardiologist, followed by heart valve replacement or repair by a cardiac surgeon. This combined procedure is not only well-established in clinical practice in general, but forms part of our routine interdisciplinary approach to treatment. More recently, our Heart Center has also started to offer hybrid procedures involving both TAVI and PTCA.

In spite of these developments, it is not usually possible to perform a hybrid bypass graft surgery with heart valve replacement using a purely minimally-invasive approach.

Benefits associated with minimally-invasive procedures

Reduced level of trauma caused to the body

Minimally-invasive procedures usually cause significantly less trauma to patients when compared to conventional heart surgery. In particular older, high-risk patients in whom conventional surgery is contraindicated can often be treated successfully using minimally-invasive procedures.
Physicians tend to use the term "minimally-invasive" to describe a variety of techniques aimed at making surgery simpler, quicker and less invasive. A particular focus is placed on avoiding the use of cardiopulmonary bypass (a heart-lung machine) which, during conventional heart surgery, is used to replace the functions normally executed by the patient's heart and lungs. This allows the heart to be stopped, which makes heart surgery much easier for the surgeon. However, this method also results in the patient's blood coming into prolonged contact with artificial surfaces, something that has been shown to be potentially harmful. Surgery performed without cardiopulmonary bypass can therefore lead to a considerable reduction in these harmful effects, reducing the impact on both the patient's blood and immune system.

Reduction in chest wall trauma
One further objective of minimally-invasive procedures is to reduce surgical trauma by minimizing the damage caused to the chest wall. While conventional surgery requires the entire sternum (breastbone) to be cut in half, minimally-invasive procedures do not often require more than an incision five to six centimeters in length, which is made between the ribs. In addition to reducing blood loss and the patient's risk of infection, this also improves cosmetic results, as well as reducing post-operative pain and allowing a faster recovery.

Treatment of certain isolated heart valve defects

Minimally-invasive procedures have become firmly established in the treatment of isolated heart valve defects. For instance, a surgeon treating a defective mitral valve - the valve between the left atrium and the left ventricle - can perform a left anterior thoracotomy (also known as a mini-thoracotomy) - a small incision in the side of the chest - in order to gain access to the heart and replace or repair the heart valve. While this procedure requires the patient to be connected to a cardiopulmonary bypass (heart-lung) machine via the blood vessels in the groin, a catheter-based procedure to treat a narrowed aortic valve (aortic valve stenosis) can be performed without cardiopulmonary bypass. This procedure involves the surgeon making a small incision below the left nipple and using a catheter to advance a prosthetic aortic valve through the wall of the heart. Once the catheter has reached the defective valve, the surgeon uses x-ray guidance technology to expand and implant the prosthetic valve. This catheter-based technique, which is carried out by an interdisciplinary team of cardiac surgeons and cardiologists, can also be performed using a different approach route, which is accessed via a blood vessel in the groin (i.e. without the need for an incision in the chest wall).

Certain bypass surgery procedures do not require cardiopulmonary bypass (a heart-lung machine)

Minimally-invasive techniques have also proven effective in certain types of bypass surgery, where the need for cardiopulmonary bypass (a heart-lung machine) has been eliminated, allowing the procedure to be performed on a beating heart (known as off-pump technique). Surgery on a beating heart involves the use of suction cups in the area of the diseased coronary arteries in order to minimize the motion of the heart, thus making it possible for the bypass grafts to be implanted.
The degree of trauma caused by this procedure is particularly small when only the left coronary artery is affected by stenosis, and thus only one bypass graft is required. In this case (which is anything but common), the procedure can be performed without cardiopulmonary bypass (a heart-lung machine), and will only require an incision a few centimeters in length to be made in the chest wall.

Limitations of minimally-invasive procedures


Purely endoscopy-based (keyhole) procedures

Purely endoscopy-based (keyhole) procedures, such as those used for gall bladder removal, have not shown to be viable in the field of cardiac surgery. These procedures have so far proved impractical mainly due to the heart's complex anatomy and the fact that the thoracic cavity is a crowded space to work in. So far, surgeons have only ventured as far as using camera systems, endoscopic light sources and long endoscopic instruments to assist with certain procedures.
Not feasible or advisable for the treatment of all types of heart disease.

Not feasible or advisable for the treatment of all types of heart disease

Not all types of heart disease can be - or should be - treated using minimally-invasive procedures. The benefits of procedures that are simpler, quicker and less invasive must be weighed against the potential of these procedures having an adverse effect on long-term outcomes. It is not usually possible for more complex heart surgery and combined procedures to be performed using minimally-invasive techniques.




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