Book Review

Minimally Invasive Cardiac Surgery

N Engl J Med 1999; 341:926-927September 16, 1999

Article

Minimally Invasive Cardiac Surgery
Edited by Robbin G. Cohen, Michael J. Mack, James D. Fonger, and Rodney J. Landreneau. 359 pp., illustrated. St. Louis, Quality Medical, 1999. $245. ISBN: 0-942219-79-1

Coronary bypass is the most exhaustively studied operation in the history of surgery, and it has achieved widespread use because its benefits have been so thoroughly documented. Yet the dominance of coronary bypass is being threatened by the success of interventional cardiology. The need to reduce the discomfort, morbidity, and costs associated with conventional cardiac surgery has led surgeons to explore various “minimally invasive” approaches, such as minimally invasive direct coronary-artery bypass (MIDCAB), in which coronary bypass (usually with a single graft) is performed on the beating heart without the heart–lung machine and through a small incision; off-pump coronary-artery bypass (OPCAB), in which cardiopulmonary bypass is eliminated and the heart continues to beat, as in MIDCAB, but in which a full median sternotomy is usually performed to expose the entire heart for multiple bypasses to more than one coronary artery; minimally invasive valve surgery, a general term for valve repair or replacement accomplished with limited exposure through small incisions and with cardiopulmonary bypass by any of a variety of modified approaches; and port-access coronary or valve surgery, in which a proprietary system of catheters is introduced from peripheral vessels in the groin and neck, both to establish cardiopulmonary bypass and to isolate the heart by inflating a balloon in the ascending aorta.

For such radically new techniques, comprehensive, authoritative, and timely textbooks are crucial, and Minimally Invasive Cardiac Surgery admirably satisfies those criteria. The four editors, all widely recognized pioneers in this new and rapidly evolving field, assembled a “who's who” of contributors and somehow managed to publish this book so rapidly that it is remarkably up to date. It thus stands as the authoritative and comprehensive description of the state of the art in minimally invasive cardiac surgery. The 38 chapters are organized into an informative and cohesive manual that covers every aspect of the subject. In addition to chapters providing detailed and profusely illustrated descriptions of techniques, there are comprehensive chapters on the historical evolution of minimally invasive cardiac surgery, on patient selection, on anesthetic techniques, on patient education and clinical pathways, and on future directions. The book focuses on practical details of preoperative, intraoperative, and postoperative management, so it will be of greatest interest to cardiac surgeons, all of whom will want to own a copy. But there is also material that will be useful to primary physicians and cardiologists, who must help patients requiring cardiac care to select the approach that best suits their needs. I particularly recommend two chapters to nonsurgeons. Chapter 4, “Principles of Minimally Invasive Cardiac Surgery,” clearly explains the rationale for attempting minimally invasive approaches and identifies the morbidity associated with conventional surgery that these new strategies seek to mitigate or eliminate, and chapter 9, “Training, Credentials, and Ethical Issues,” contains an insightful discussion of the ethical questions posed by the need for surgeons to practice these new techniques. In the early days of cardiac surgery, when no other treatments were available, experimentation was unavoidable, and patients who died after their operation could hardly have lived longer without it. Now, the decision to use new approaches is more complex, since conventional cardiac surgery is remarkably safe and effective.

The book has few weaknesses. It is no surprise that chapters 37 and 38, which deal with future directions — in particular, robotic heart surgery — are somewhat outdated. In this rapidly moving field, speculations about the future can become reality before the predictions can be published. The too brief chapter entitled “Economic Impact of Minimally Invasive Surgery” is disappointing; it presents few hard data to bolster the claim of purported cost savings. The authors of this chapter should have addressed the counterarguments that hospitalization and postoperative disability after conventional cardiac surgery have decreased dramatically and that the patient's expectation of rapid recovery may be more important than the length of the incision. Furthermore, the high cost of the specialized equipment used for some of these approaches can nullify cost savings.

Although the techniques described in this book may augur a revolution in cardiac surgery, they have not been accepted unhesitatingly by all surgeons. Even this excellent book cannot yet provide a definitive answer to the most important question: since these techniques can offer only short-term benefits, will the long-term results be as good as those of proven conventional techniques?

Lawrence I. Bonchek, M.D.
Lancaster General Hospital, Lancaster, PA 17604-3555