Tremendous technological advances in cardiac surgery have

allowed a significant decrease in the morbidity and mortality once

common in neonates and in young infants with congenital heart

disease. With many centers now experiencing excellent immediate

surgical results, should we not concentrate on improving the

long-term outcomes utilizing novel surgical approaches?

Perhaps a surprise to some, congenital heart disease remains

common, affecting nearly one percent of all newborns. It has

been estimated thatapproximately 32,000 children will be born

in this country with heart defects,a large proportion of these

requiring intervention. Currently, more than half of the children

undergoing cardiopulmonary bypass (CPB) in North America

are younger than 1 year of age.

For the neonate, infant or child undergoing cardiac surgery,

smaller incisions mean less tissue disruption and discomfort,

faster recovery and better cosmetic results. In addition, our data

would support a lower incidence of significnat infections in all

ages using these newer techniques. For the surgeon, however,

this smaller workspace presents several challenges: decreased

vision, less room for hands and instruments to work, and no

room for an assistant's hand. In addition, many of the currently

used instruments are simply too large to work within the confined

space. Despite these current limitations in equipment and the

increased demands it places on the surgeon, minimally invasive

cardiac surgery is rapidly becoming the future of cardiovascular

surgery. The external pressures for change remain diverse and

strong, and thus procedures such as ours, that potentially reduce

hospital resources while maintaining cosmetics and patient safety

will be supported on multiple levels. Parents for example,

remain ecstatic that their children can undergo complex open-heart

procedures safely while staying only 1-3 days in hospital. A well

placed 2-inch incision is all that remains of their brief hospitalization.

There are some that remain skeptical of change, stating that

minimally invasive techniques of surgery are no more than

a publicity stunt without scientific merit. Legitimate concerns

over children's safety, the length of the procedure

including the cardiopulmonary bypass and x-clamp times),

and the duration of hospitalization has been

addressed in our initial and/or intermediate experience

demonstrating no untoward mortality or significant morbidity.

Initial experience with the correction of simple defects has

enabled the repair of more complicated defects utilizing the

mini-sternotomy. Working with a Californian company,

our first generation robot has modified to correct both simple

and complex types of congenital heart defects through

incisions no larger than 2 inches. Original developments

and designs (a virtual port avoiding thoracoscopic ports)

have enable improved robotic function via the mini sternotomy

reducing the multitude of potentially disfiguring thoracic

ports regardless of age and body stature and thus

should standardize the procedures allowing widespread

acceptance into the medical community.

That is, all patients should benefit!

It is important to note: that the innovative techniques

described above, can now be successfully used

in the repair of adults with congenital heart disease.

Adults too can have the BENEFITS of a

MINIMALLY INVASIVE surgical repair - a

cosmetic repair, early extubation and discharge.

For the mother who asked about subaortic fibromuscular obstruction (August. 03),

here is a brief video of a minimally invasive surgical resection.

Below is a young boy staus post extra-cardiac Fontan

operation who just gave me this great photo.

In summary, congenital defects can be repaired via the mini hemi-sternotomy

in a safe and reproducible manner as compared to a traditional full

sternotomy approach. The introduction of intra-cardiac imaging has permitted

the repair of more complex congenital lesions both as an aid to

surgical visualization and as a teaching tool. Robotic video assistance

with a virtual port has allowed for the evolution of the trans-sternal

approach without limiting robotic video assistance as a trans-thoracic

procedure. As experience accumulates and as instrumentation and

imaging technology improve, it will be possible to repair most forms

of congenital heart disease utilizing a minimally invasive approach

while reducing the utilization of hospital resources and possibly

avoiding cardiopulmonary bypass. Telemanipulation without the need

for cardiopulmonary bypass and fetal surgery may soon be achievable goals.

Manuscript references supplied upon request.

Here are a few examples of children that underwent minimally invasive

heart surgery. Since the sternum in not fully "broken" children often

resume their normal activites faster. In fact several children have

excelled in competitive sports.