Minimally Invasive Cardiac Surgery

What is minimally invasive cardiac surgery?

Minimally invasive cardiac surgery (MICS) refers to a group of heart operations performed through small incisions in the chest, rather than opening the breastbone (sternotomy) as in traditional open-heart surgery.

Sometimes described as keyhole heart surgery or small-incision heart surgery, MICS allows surgeons to treat certain heart conditions while reducing trauma to the chest wall.

MICS achieves the same surgical objectives as conventional open-heart surgery, but with potential benefits such as less pain, smaller scars, shorter hospital stays and faster recovery, where clinically appropriate.

How it works

In minimally invasive cardiac surgery, surgeons access the heart through small incisions between the ribs, instead of cutting through the breastbone. Specialised surgical instruments and camera guidance are used to visualise and operate on the heart.

Depending on the type of procedure, the heart-lung bypass machine may still be used, even though the chest is not fully opened. The exact approach depends on the heart condition being treated, the patient’s anatomy, and the complexity of surgery.

Minimally invasive cardiac surgery vs open-heart surgery

Both minimally invasive and traditional open-heart surgery aim to correct the same underlying heart conditions. The main difference lies in how the heart is accessed.

Compared with open-heart surgery, minimally invasive cardiac surgery is performed through smaller chest incisions, avoiding the need to open the breastbone. This approach may offer several advantages, including:

• Faster recovery, with most patients able to resume usual daily activities within 2 – 4 weeks
• Less postoperative pain and scarring
• Reduced physical and psychological trauma associated with surgery
• Shorter hospital stay, with earlier discharge typically within 3 – 4 days
• Better early lung function after surgery
• Lower risk of infection and bleeding

In some cases, open-heart surgery may still be the safest or most effective option for patients with complex or extensive heart conditions. The most appropriate surgical approach will be carefully assessed and recommended by your surgeon based on your individual condition and overall health.

Why do you need minimally invasive cardiac surgery?

Minimally invasive cardiac surgery may be recommended to treat certain heart conditions that require surgical correction, including:

• Heart valve diseases such as mitral or aortic valve disorders
• Coronary artery disease requiring bypass surgery
• Congenital heart defects such as atrial septal defects (ASD) and ventricular septal defects (VSD)
• Selected heart rhythm conditions requiring surgical intervention

MICS may be considered when catheter-based treatments are not suitable, or when minimally invasive surgery offers better long-term outcomes. The decision to proceed with minimally invasive surgery depends on your condition, anatomy, overall health and surgical complexity.

What are the types of minimally invasive cardiac surgery?

At our hospitals, MICS may be used to treat selected heart conditions using small chest incisions instead of opening the breastbone. The specific approach depends on the condition being treated, anatomical considerations, and overall suitability for minimally invasive techniques. Types include:

Minimally invasive mitral valve repair or replacement

Minimally invasive mitral valve surgery is commonly performed to treat mitral regurgitation (leakage of the valve) or mitral stenosis (narrowing of the valve). Through a small incision on the side of the chest (mini-thoracotomy), surgeons can access the mitral valve without opening the breastbone.

Depending on the condition of the valve, the procedure may involve repairing the native valve or replacing it with a prosthetic valve. Camera-assisted (endoscopic) techniques are often used to enhance visualisation during surgery.

Compared with open-heart surgery, this approach may result in less pain, smaller scars and faster recovery in suitable patients.

Minimally invasive aortic valve replacement

Minimally invasive aortic valve replacement is used to treat aortic valve narrowing (aortic stenosis) or aortic valve leakage (aortic regurgitation) when surgical intervention is required.

In qualifying patients, the valve can be replaced through a small incision on the chest, sometimes with the aid of a specialised camera, avoiding a full sternotomy. This surgical approach aims to relieve symptoms, improve blood flow from the heart, and preserve heart muscle function, while offering the potential benefits of reduced surgical trauma and earlier recovery.

Minimally invasive coronary artery bypass surgery

Minimally invasive coronary artery bypass surgery (CABG) may be used to treat coronary artery disease in selected patients, including those requiring single- or multi-vessel grafting.

Through a small incision on the side of the chest, surgeons can bypass blocked coronary arteries to restore blood flow to the heart muscle without opening the breastbone.

In some cases, this may form part of a hybrid approach, where bypass surgery is combined with stent placement (angioplasty) to treat other narrowed arteries. This allows patients to benefit from both surgical and catheter-based techniques, where clinically appropriate.

Minimally invasive repair of congenital heart defects (ASD and VSD)

Certain congenital heart defects, such as atrial septal defects (ASD) and ventricular septal defects (VSD), can be repaired using minimally invasive surgical techniques.

These procedures are performed through small incisions on the side of the chest, avoiding the need for a traditional sternal split. Minimally invasive repair allows surgeons to correct abnormal blood flow between heart chambers while potentially reducing recovery time and postoperative discomfort.

Minimally invasive removal of heart tumours

Selected heart tumours, such as atrial myxomas, fibroelastomas, and other benign growths within the heart, can be removed using minimally invasive techniques.

Through a small chest incision, with or without camera assistance, surgeons can safely access and remove these tumours. This approach allows for effective treatment while minimising surgical trauma and supporting a smoother recovery.

Minimally invasive surgery for selected redo cases

In certain patients who have undergone previous heart surgery, repeat (redo) procedures may still be possible using a minimally invasive approach.

By avoiding reopening the breastbone, minimally invasive techniques may reduce surgical risk in carefully selected redo cases. Suitability depends on multiple factors, including the type of previous surgery, scar tissue, and the current heart condition.

In selected patients, minimally invasive techniques may also be applied to other valve, bypass, congenital or rhythm-related heart conditions, depending on clinical suitability and surgical assessment. Not all minimally invasive approaches are appropriate for every patient, and the most suitable technique will be advised by the treating surgeon.

Who should not undergo minimally invasive cardiac surgery?

Most patients assessed in Mount Elizabeth’s heart programme are considered suitable candidates for minimally invasive heart surgery.

Drawing on the expertise of Prof Theodoros Kofidis and our broader team of cardiac specialists, we offer a wide range of procedures across the heart-surgery spectrum with proven outcomes.

Some patients may not be suitable for minimally invasive or endoscopic approaches due to anatomical or clinical considerations. In selected cases, certain procedures can also be performed on a beating heart, depending on what is safest and most appropriate for the individual.

To determine whether you are a candidate for minimally invasive heart surgery, your doctor is likely to:

• Review your medical history
• Conduct a physical examination
• Perform tests (such as imaging tests, laboratory tests, pulmonary function tests and cardiac evaluation)

Your doctor and treatment team will work with you to determine the best option to treat your condition.

What are the risks and complications of minimally invasive cardiac surgery?

As with all heart surgeries, minimally invasive cardiac surgery may carry potential risks and complications, which vary depending on the procedure and individual health factors. These may include:

• Bleeding
• Infection
• Irregular heart rhythms (arrhythmias)

However, minimally invasive heart surgery generally carries advantages over open-heart surgery. These include:

• Less risk for bleeding
• Less risk for infection
• Less risk for irregular heart rhythms (arrhythmias)*
• Same risk for stroke
• Same risk for death

If your surgeon thinks it is not safe to continue with the minimally invasive heart surgery approach, your procedure may need to be changed to open-heart surgery.

How do you prepare for minimally invasive cardiac surgery?

Before your surgery, your doctor will:

• Bring you through the surgical procedures of minimally invasive heart surgery
• Explain the potential risks
• Discuss any concerns you may have
• Talk about any advance directives or other information to consider prior to your surgery

In general, you may feel free to ask for your doctor’s experience and outcomes in any field of interest. Your preoperative preparation may involve some cleaning and shaving of the areas to be addressed. Your skin may be washed with special soap to reduce the risk of infection.

Before admission for your surgery, talk to your family about your hospital stay and discuss the help you might need when you return home. Your doctor and treatment team will give you instructions to follow during your recovery when you return home.

Food and medications

Talk to your doctor about:

• When you should stop eating or drinking the night before the surgery
• When you can take your regular medications and whether you can take them before your surgery
• Medications you have brought to the hospital and when you should take medications on the day of the procedure
• Allergies or reactions you have had to medications

Clothing and personal items

You may want to pack the following items for your hospital stay:

• A list of your medications
• Spectacles, hearing aids or dentures
• Personal care items, such as a brush, comb, shaving equipment and toothbrush
• Loose-fitting, comfortable clothing
• A copy of your advance medical directive
• Items that might help you relax, such as a portable music player or books

During surgery, avoid wearing:

• Contact lenses
• Dentures
• Jewellery
• Nail polish
• Spectacles

What can you expect in minimally invasive cardiac surgery?

In all types of minimally invasive cardiac procedures, your surgeon will reach your heart through small incisions. These incisions can be located at various sites, such as between the ribs of your chest, groin or armpit.

Your surgeon will insert a tool with a small video camera through one of the incisions to provide a magnified, three-dimensional image of the operating site.

Most minimally invasive procedures use a heart-lung bypass machine (same as in open heart surgery), but the access is different, in that we would not be touching the chest bone. The machine keeps blood moving through your body during the procedure.

Robot-assisted heart surgery

In robot-assisted heart surgery, your surgeon uses robotic arms to perform the manoeuvres used in traditional open-heart surgery.

During this procedure, your surgeon works at a remote console and views your heart in a magnified high-definition 3D view on a video monitor. From the console, your surgeon's hand movements translate precisely to the robotic arms at the operating table, which moves similarly to the human wrist.

A second surgeon and surgical team will assist at the operating table, changing surgical instruments attached to the robotic arms.

Thoracoscopic surgery

In thoracoscopic surgery (sometimes referred to as a mini-thoracotomy), your surgeon inserts a long, thin tube (thoracoscope) containing a tiny high-definition video camera into a small incision in your chest.

Your surgeon repairs your heart using long instruments inserted through small incisions between your ribs.

Hybrid approach

If you have:

• Ischaemic heart disease, some coronary arteries may be more suitably dealt with by angioplasty and stenting.
• Cardiac valvular disease coupled with coronary artery disease, you may have to undergo a full sternotomy using standard methods to fix both the valve and coronary artery stenosis.
• Multiple coronary artery disease can be treated in a minimally invasive or hybrid fashion in our programme. Our minimally invasive heart surgeon and his team will explore – together with you- an option that suits your needs.

Your doctor will assess and develop a treatment plan customised to your cardiac condition.

After the procedure

You will generally spend a day or so in the intensive care unit (ICU). You will be given fluids and medications through intravenous (IV) lines. Other tubes placed during surgery will drain urine from your bladder and fluid and blood from your chest. You might be given oxygen through a face mask or prongs in your nose.

Usually, MICS leads to shorter ventilation times and shorter stay in the ICU, as well as faster mobilisation in the hospital.

After the ICU, you will be moved to a regular hospital room for several days. The time you spend in the ICU and hospital will depend on your condition and surgery.

Your treatment team will:

• Monitor your condition and watch for signs of infection at your incision sites
• Monitor your blood pressure, breathing and heart rate
• Work with you to manage any pain
• Encourage you to get up and walk, and demonstrate how to gradually increase your activity
• Show you how to do deep-breathing exercises, including how to cough to clear your lungs

Care and recovery after minimally invasive cardiac surgery

Your doctor will give you instructions to follow during your recovery, such as:

• Watching for signs of infection in your incisions
• Caring for your incisions
• Taking medications
• Managing pain

Your doctor will let you know when you can return to daily activities, such as working, driving and exercise.

Do attend regular follow-up appointments with your doctor. You may be asked to do several tests to evaluate and monitor your condition.

As part of your recovery, your doctor may advise you to incorporate healthy lifestyle changes into your life — such as physical activity, a healthy diet, stress management and avoiding tobacco use.

Your doctor may also recommend that you participate in cardiac rehabilitation to help you improve your health and recovery after heart surgery.