Establishing Minimally Invasive Cardiac Surgery in a Developing Country: A Five-Year Experience at Hayatabad Medical Complex, Pakistan

Abstract

Background The adoption of minimally invasive cardiac surgery (MICS) has increased over the past 25 to 30 years, driven by advancements in technology and a growing understanding of its benefits. This study evaluates the outcomes of 144 elective MICS procedures performed between January 2019 and September 2024. Methods Patients underwent various surgical approaches, including upper mini-sternotomy, mini-thoracotomy, and sub-xiphoid access. Patient demographics, preoperative characteristics, and surgical outcomes were analyzed. A total of 144 MICS procedures were performed. Results The cohort had a mean age of 30.72 years, with a nearly equal gender distribution, indicating that MICS can be performed safely in Pakistani patients. The mean ejection fraction was 53.58%, with hypertension being the most common comorbidity (22.2%). Aortic cannulation was primarily utilized, and aortic valve replacement (AVR) was the most common procedure (44.4%). The mean cardiopulmonary bypass (CPB) time was 95.9 ± 56.3 minutes and the mean aortic cross-clamp time was 62.22 ± 57.004 minutes, demonstrating efficient procedural times. The overall incidence of complications was low, supporting the safety and efficacy of MICS. Conclusion Our findings suggest that MICS is a viable and effective approach for a diverse patient population, with favorable clinical outcomes. The results underscore the potential for MICS to become standard practice in cardiothoracic surgery. Future research should focus on long-term outcomes and the influence of comorbidities to further enhance MICS methodologies.

Keywords: mini-sternotomy; minimal invasive cardiac surgery; minimal invasive direct coronary artery bypass; surgical outcomes; thoracotomy.

Figure 1. Upper mini-sternotomy

A: Shows upper mini-sternotomy for aortic valve replacement and aortic root enlargement. B: Shows upper mini-sternotomy for modified central shunt (Aasim’s shunt) in adult congenital heart disease with hypoplastic pulmonary valve severe stenosis and pulmonary vessels. C1 and C2: Shows upper mini-sternotomy for modified Bentall aortic valve replacement surgery as standard treatment for type A aortic dissection.

Figure 2. Left thoracotomy approach for MIDCAB

MIDCAB, minimally invasive direct coronary artery bypass.

Figure 3. Right mini-thoracotomy MICS for ASD-II closure, showing arrangements of the cardiopulmonary bypass cannulae and use of Cosgrove aortic cross-clamp

MICS, minimally invasive cardiac surgery; ASD-II, secundum atrial septal defect.

Figure 4. Illustration of distribution of cases

LAD, left anterior descending; PPM, permanent pacemaker; ASD, atrial septal defect; PDA, patent ductus arteriosus; AVR, aortic valve replacement; MIDCAB, minimally invasive direct coronary artery bypass; MVR: mitral valve replacement.

Figure 5. Types of incisions and their percentages

Figure 6. The distribution of cannulation techniques, highlighting that aortic cannulation (53.7%) was the most frequently employed, followed by femoral cannulation (2.7%)

The cases labeled as "no cannulation" (43.75%) in the graph represent procedures performed off bypass.