Minimal Access Cardiac Surgery: State of the Art and Future Perspectives

A special issue of Journal of Cardiovascular Development and Disease (ISSN 2308-3425). This special issue belongs to the section "Cardiac Surgery".

Deadline for manuscript submissions: 30 November 2024 | Viewed by 20700

Special Issue Editor

Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge CB2 0AY, UK
Interests: minimal-access cardiac surgery; risk scoring; EuroSCORE; postoperative outcomes; heart and lung transplantation
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Special Issue Information

Dear Colleagues,

As with all areas of surgical practice, there has been a move in recent years towards minimally invasive approaches to many operations. For example, VATS lobectomy is becoming the standard of care. In cardiac surgery, I think it fair to term these approaches minimal access, rather than minimally invasive, since the invasiveness of the surgery, in terms of cardiopulmonary bypass, cardioplegic arrest, the opening of cardiac chambers, and other aspects, is much the same.

There are an increasing number of centres offering minimal-access cardiac surgery and the range of procedures offered is expanding. Patients like the idea of minimal-access procedures for a range of reasons: improved cosmesis, the perception of faster recovery, and reduced pain. Interestingly though, there remains some scepticism among the cardiac surgical community as to the true benefit of minimal-access cardiac surgery. Indeed, very few randomised controlled trials which compare outcomes to standard cardiac surgery remain.

In some ways, it is this scepticism that prompts this timely Special Issue, where the current status of minimal access cardiac surgery will be explored together with consideration of future advances and directions, in order to provide the cardiac surgical community with a robust review of the current literature.

Dr. Jason Ali
Guest Editor

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Keywords

  • minimal access
  • minimally invasive
  • robotic
  • robot-assisted
  • cardiac surgery

Published Papers (12 papers)

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Research

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13 pages, 2195 KiB  
Article
Transferring Surgical Expertise: Analyzing the Learning Curve of Robotic Cardiac Surgery Operative Time Reduction When Surgeon Moves from One Experienced Center to Another
by Sherif M. Khairallah, Mohamed Rahouma and Stephanie L. Mick
J. Cardiovasc. Dev. Dis. 2024, 11(3), 81; https://doi.org/10.3390/jcdd11030081 - 29 Feb 2024
Viewed by 916
Abstract
Background: Robotically assisted cardiac surgery is performed in a team setting and is well known to be associated with learning curves. Surgeon and operative team learning curves are distinct entities, with total operative time representing the entire operative team (surgery, anesthesia, nursing, and [...] Read more.
Background: Robotically assisted cardiac surgery is performed in a team setting and is well known to be associated with learning curves. Surgeon and operative team learning curves are distinct entities, with total operative time representing the entire operative team (surgery, anesthesia, nursing, and perfusion) and cross-clamp time representing mainly the surgical team. Little is known about how a team learning curve evolves when an experienced surgeon transitions from one surgical center to another. This study investigates the dynamics of the team learning curve expressed as total operative time in the case of a surgeon with previous experience transitioning to a new team. Methods: A retrospective analysis was conducted on robotic cardiac surgeries performed by a surgeon who transitioned from one experienced surgical center to another. Operative time data were collected and categorized to assess the evolution of the learning curve. Statistical analysis, including learning curve modeling and linear regression analysis, was used to evaluate changes in total time in the operating room per case. Results: 103 cases were included in Weill Cornell Medicine (2019–2023). The median patient age was 63 years, 68% were males, 90.3% of cases were repaired for degenerative mitral valve disease, and the median body mass index was 23.87. Operative time (ORT) decreased from a median of 5.00 h [95%CI: 4.76, 6.00] in the first 30 cases to 4.83 [95%CI: 4.10, 5.27] thereafter, with the apparent curve plateauing indicative of the adaptation period to the new surgical environment (p = 0.01). Subgroup analysis among mitral cases (n = 93) showed a decrease in ORT from 5.00 [95%CI: 4.71, 5.98] in the first 26 cases to 4.83 [95%CI: 4.14, 5.30] (p = 0.045). There was no difference between the initial 30 cases and subsequent cases regarding cardiopulmonary bypass time, myocardial ischemia time, reoperation for bleeding, prolonged ventilation, reintubation, renal failure, need for an intra-aortic balloon pump, readmission to the ICU, reoperation for valvular dysfunction within 30 days, pneumonia, and deep venous thrombosis. Multivariate significant predictors of longer operative time were the first 30 cases, resection-based repairs, and MAZE as a concomitant procedure. Conclusions: Total operative time can be expected to decrease after about 30 cases when an experienced robotic surgeon moves between centers. Complications and cross-clamp times are less susceptible to a learning curve phenomenon in such a circumstance, as these depend primarily on the operating surgeon’s level of experience. Understanding these dynamics can inform the planning and management of surgical transitions, ensuring optimal patient care and continued improvement in surgical outcomes. Full article
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10 pages, 1370 KiB  
Article
Minimally Invasive Surgery for Simple Congenital Heart Defects: Preserving Aesthetics without Jeopardizing Patient Safety
by Mauro Lo Rito, Ylenia Claudia Maria Brindicci, Mario Moscatiello, Alessandro Varrica, Matteo Reali, Antonio Saracino, Massimo Chessa, Tommaso Aloisio, Giuseppe Isgrò and Alessandro Giamberti
J. Cardiovasc. Dev. Dis. 2023, 10(11), 452; https://doi.org/10.3390/jcdd10110452 - 06 Nov 2023
Viewed by 1587
Abstract
Minimally invasive surgeries for pediatric patients have been proposed for decades, with different approaches in mind. Minimal right axillary thoracotomy (MRAT), proposed two decades ago, allows the preservation of patients’ safety alongside faster aesthetic and functional recovery. The MRAT did not become widely [...] Read more.
Minimally invasive surgeries for pediatric patients have been proposed for decades, with different approaches in mind. Minimal right axillary thoracotomy (MRAT), proposed two decades ago, allows the preservation of patients’ safety alongside faster aesthetic and functional recovery. The MRAT did not become widely adopted due to the prejudice that to follow a minimally invasive approach, safety and efficacy must be compromised. With this study, we aim to compare MRAT to the standard median sternotomy approach with a focus on safety and clinical outcomes. Between January 2017 and April 2021, 216 patients diagnosed with ASD, pAVSD, or PAPVD underwent surgical repair with different approaches in the same period. MRAT was used for 78 patients, and median sternotomy was used for 138 patients. In this last group, standard median sternotomy (SMS) was used for 116 patients, while a minimal skin incision (SMS mini) was used for 22 patients. There were no major complications overall nor in each specific approach. MRAT enabled the successful repair of simple heart defects, providing similar post-operative and cardiological recovery. MRAT does not compromise patients’ safety and does not prolong the duration of surgery once the learning curve is overcome, which is generally after 15–20 consecutive operations. Full article
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12 pages, 627 KiB  
Article
Less (Transfusion) Is More—Enhancing Recovery through Implementation of Patient Blood Management in Cardiac Surgery: A Retrospective, Single-Centre Study of 1174 Patients
by Mihai Ștefan, Dana Tomescu, Cornelia Predoi, Raluca Goicea, Mihai Perescu, Mihai Popescu, Dan Dorobanțu, Gabriela Droc, Ștefan Andrei, Ovidiu Știru, Șerban-Ion Bubenek Turconi and Daniela Filipescu
J. Cardiovasc. Dev. Dis. 2023, 10(7), 266; https://doi.org/10.3390/jcdd10070266 - 22 Jun 2023
Viewed by 1413
Abstract
Introduction: The implementation of Patient Blood Management (PBM) in cardiac surgery has been shown to be effective in reducing blood transfusions and associated complications, as well as improving patient outcomes. Despite the potential benefits of PBM in cardiac surgery, there are several barriers [...] Read more.
Introduction: The implementation of Patient Blood Management (PBM) in cardiac surgery has been shown to be effective in reducing blood transfusions and associated complications, as well as improving patient outcomes. Despite the potential benefits of PBM in cardiac surgery, there are several barriers to its successful implementation. Objectives: The main objectives of this study were to ascertain the impact of the national Romanian PBM recommendations on allogeneic blood product transfusion in cardiac surgery and identify predictors of perioperative packed red blood cell transfusion. Methods: As part of the Romanian national pilot programme of PBM, we performed a single-centre, retrospective study in a tertiary centre of cardiovascular surgery, including patients from two time periods, before and after the implementation of the national recommendations. Using coarsened exact matching, from a total of 1174 patients, 157 patients from the before group were matched to 169 patients in the after group. Finally, we built a multivariate regression model from the entire cohort to analyse independent predictors of PRBC transfusion in the perioperative period. Results: Although there was a trend towards a lower proportion of patients requiring PRBC transfusion in the “after” group compared to the “before” group (44.9%vs. 50.3%), it was not statistically significant. There was a significant difference between the “after” group and the “before” group in terms of fresh-frozen plasma (FFP) transfusion rates, with a lower percentage of patients requiring FFP transfusion in the “after” group compared to “before” (14.2%, vs. 22.9%, p = 0.04). This difference was also seen in the total perioperative FFP transfusion (mean transfusion 0.7 units in the “before” group, SD 1.73 vs. 0.38 units in the “after” group, SD 1.05, p = 0.04). In the multivariate regression analysis, age > 64 years (OR 1.652, 95% CI 1.17–2.331, p = 0.004), female sex (OR 2.404, 95% CI 1.655–3.492, p < 0.001), surgery time (OR 1.295, 95% CI 1.126–1.488, p < 0.001), Hb < 13 g/dl (OR 3.611, 95% CI 2.528–5.158, p < 0.001), re-exploration for bleeding (OR 3.988, 95% CI 1.248–12.738, p = 0.020), viscoelastic test use (OR 2.18, 95% CI 1.34–3.544, p < 0.001), FFP transfusion (OR 4.023, 95% CI 2.426–6.671, p < 0.001), and use of a standardized pretransfusion checklist (OR 8.875, 95% CI 5.496–14.332, p < 0.001) remained significantly associated with PRBC transfusion. The use of a preoperative standardized haemostasis questionnaire was independently associated with a decreased risk of perioperative PRBC transfusion (0.565, 95% CI 0.371–0.861, p = 0.008). Conclusions: Implementation of national PBM recommendations led to a reduction in FFP transfusion in a cardiac surgery centre. The use of a preoperative standardized haemostasis questionnaire is an independent predictor of a lower risk for PRBC transfusion in this setting. Full article
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15 pages, 2787 KiB  
Article
Postoperative Weight Gain within Enhanced Recovery after Cardiac Surgery
by Alexandra Krüger, Anna Flo Forner, Jörg Ender, Aniruddha Janai, Youssef Roufail, Wolfgang Otto, Massimiliano Meineri and Waseem Z. A. Zakhary
J. Cardiovasc. Dev. Dis. 2023, 10(6), 263; https://doi.org/10.3390/jcdd10060263 - 16 Jun 2023
Viewed by 1496
Abstract
Optimal fluid therapy during perioperative care as part of enhanced recovery after cardiac surgery (ERACS) should improve the outcome. Our objective was finding out the effects of fluid overload on outcome and mortality within a well-established ERACS program. All consecutive patients undergoing cardiac [...] Read more.
Optimal fluid therapy during perioperative care as part of enhanced recovery after cardiac surgery (ERACS) should improve the outcome. Our objective was finding out the effects of fluid overload on outcome and mortality within a well-established ERACS program. All consecutive patients undergoing cardiac surgery between January 2020 and December 2021 were enrolled. According to ROC curve analysis, a cut-off of ≥7 kg (group M, n = 1198) and <7 kg (group L, n = 1015) was defined. A moderate correlation was shown between weight gain and fluid balance r = 0.4, and a simple linear regression was significant p < 0.0001, R2 = 0.16. Propensity score matching showed that increased weight gain was associated with a longer hospital length of stay (LOS) (L 8 [3] d vs. M 9 [6] d, p < 0.0001), an increased number of patients who received pRBCs (L 311 (36%) vs. M 429 (50%), p < 0.0001), and a higher incidence of postoperative acute kidney injury (AKI) (L 84 (9.8%) vs. M 165 (19.2%), p < 0.0001). Weight gain can easily represent fluid overload. Fluid overload after cardiac surgery is common and is associated with prolonged hospital LOS and increases the incidence of AKI. Full article
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13 pages, 1036 KiB  
Article
An Individualized, Less-Invasive Surgical Approach Algorithm Improves Outcome in Elderly Patients Undergoing Mitral Valve Surgery
by Ulvi Cenk Oezpeker, Fabian Barbieri, Daniel Höfer, Can Gollmann-Tepeköylü, Johannes Holfeld, Florian Sommerauer, Julian Wagner, Sasa Rajsic, Suat Ersahin, Nikolaos Bonaros, Michael Grimm and Müller Ludwig
J. Cardiovasc. Dev. Dis. 2023, 10(1), 28; https://doi.org/10.3390/jcdd10010028 - 11 Jan 2023
Cited by 1 | Viewed by 1435
Abstract
Background: For mitral valve surgery (MVS) in elderly, frail patients with increasing life expectancy, finding the least harmful means of access is a challenge. In the complexity of MVS approach evolution, using three different approaches (mini-thoracotomy (MT), partial upper-sternotomy (PS), full-sternotomy (FS), we [...] Read more.
Background: For mitral valve surgery (MVS) in elderly, frail patients with increasing life expectancy, finding the least harmful means of access is a challenge. In the complexity of MVS approach evolution, using three different approaches (mini-thoracotomy (MT), partial upper-sternotomy (PS), full-sternotomy (FS), we developed a personalized, minimized-invasiveness algorithm for MVS. Methods: In this retrospective analysis, 517 elderly patients (≥70 years) were identified who had undergone MVS ± TV repair. MVS was performed via MT (n = 274), FS (n = 128) and PS (n = 115). The appropriate access type was defined according to several clinical patient conditions. Using uni- and multivariate regression models, we analyzed combined operative success (residual MV regurgitation, conversion to MV replacement or larger thoracic incisions); perioperative success (30-days mortality, thoracotomy, ECMO, pacemaker implantation, dialysis, longer ventilation); and reoperation-free long-term survival. An additional EuroSCORE2 adjustment was performed to reduce the bias of clinical conditions between all access types. Results: The EuroSCORE2-adjusted Cox regression analysis showed significantly increased reoperation-free survival in the MT cohort compared to FS (HR 0.640; 95% CI 0.442–0.926; p = 0.018). Mortality was additionally reduced after the implementation of PS (p = 0.023). Combined operative success was comparable between the three access types. The perioperative success was higher in the MT cohort compared to FS (OR 2.19, 95% CI 1.32–3.63; p = 0.002). Conclusion: Less-invasive approaches in elderly patients improve perioperative success and reoperation-free survival in those undergoing MVS procedures. Full article
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Review

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12 pages, 254 KiB  
Review
Anaesthesia for Minimally Invasive Cardiac Surgery
by Daniel Aston, Daniel Zeloof and Florian Falter
J. Cardiovasc. Dev. Dis. 2023, 10(11), 462; https://doi.org/10.3390/jcdd10110462 - 15 Nov 2023
Cited by 1 | Viewed by 1775
Abstract
Minimally invasive cardiac surgery (MICS) has been used since the 1990s and encompasses a wide range of techniques that lack full sternotomy, including valve and coronary artery graft surgery as well as transcatheter procedures. Due to the potential benefits offered to patients by [...] Read more.
Minimally invasive cardiac surgery (MICS) has been used since the 1990s and encompasses a wide range of techniques that lack full sternotomy, including valve and coronary artery graft surgery as well as transcatheter procedures. Due to the potential benefits offered to patients by MICS, these procedures are becoming more common. Unique anaesthetic knowledge and skills are required to overcome the specific challenges presented by MICS, including mastery of transoesophageal echocardiography (TOE) and the provision of thoracic regional analgesia. This review evaluates the relevance of MICS to the anaesthetist and discusses pre-operative assessment, the relevant adjustments to intra-operative conduct that are necessary for these techniques, as well as post-operative care and what is known about outcomes. Full article
11 pages, 1739 KiB  
Review
Is There a Future for Minimal Access and Robots in Cardiac Surgery?
by Gloria Faerber, Murat Mukharyamov and Torsten Doenst
J. Cardiovasc. Dev. Dis. 2023, 10(9), 380; https://doi.org/10.3390/jcdd10090380 - 04 Sep 2023
Viewed by 1157
Abstract
Minimally invasive techniques in cardiac surgery have found increasing use in recent years. Both patients and physicians often associate smaller incisions with improved outcomes (i.e., less risk, shorter hospital stay, and a faster recovery). Videoscopic and robotic assistance has been introduced, but their [...] Read more.
Minimally invasive techniques in cardiac surgery have found increasing use in recent years. Both patients and physicians often associate smaller incisions with improved outcomes (i.e., less risk, shorter hospital stay, and a faster recovery). Videoscopic and robotic assistance has been introduced, but their routine use requires specialized training and is associated with potentially longer operating times and higher costs. Randomized evidence is scarce and transcatheter treatment alternatives are increasing rapidly. As a result, the concept of minimally invasive cardiac surgery may be viewed with skepticism. In this review, we examine the current status and potential future perspectives of minimally invasive and robotic cardiac surgery. Full article
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17 pages, 1167 KiB  
Review
Minimal-Access Coronary Revascularization: Past, Present, and Future
by Rushmi Purmessur, Tharushi Wijesena and Jason Ali
J. Cardiovasc. Dev. Dis. 2023, 10(8), 326; https://doi.org/10.3390/jcdd10080326 - 31 Jul 2023
Cited by 1 | Viewed by 1022
Abstract
Minimal-access cardiac surgery appears to be the future. It is increasingly desired by cardiologists and demanded by patients who perceive superiority. Minimal-access coronary artery revascularisation has been increasingly adopted throughout the world. Here, we review the history of minimal-access coronary revascularization and see [...] Read more.
Minimal-access cardiac surgery appears to be the future. It is increasingly desired by cardiologists and demanded by patients who perceive superiority. Minimal-access coronary artery revascularisation has been increasingly adopted throughout the world. Here, we review the history of minimal-access coronary revascularization and see that it is almost as old as the history of cardiac surgery. Modern minimal-access coronary revascularization takes a variety of forms—namely minimal-access direct coronary artery bypass grafting (MIDCAB), hybrid coronary revascularisation (HCR), and totally endoscopic coronary artery bypass grafting (TECAB). It is noteworthy that there is significant variation in the nomenclature and approaches for minimal-access coronary surgery, and this truly presents a challenge for comparing the different methods. However, these approaches are increasing in frequency, and proponents demonstrate clear advantages for their patients. The challenge that remains, as for all areas of surgery, is demonstrating the superiority of these techniques over tried and tested open techniques, which is very difficult. There is a paucity of randomised controlled trials to help answer this question, and the future of minimal-access coronary revascularisation, to some extent, is dependent on such trials. Thankfully, some are underway, and the results are eagerly anticipated. Full article
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15 pages, 2090 KiB  
Review
Minimal Access Aortic Valve Surgery
by Bilal H. Kirmani and Enoch Akowuah
J. Cardiovasc. Dev. Dis. 2023, 10(7), 281; https://doi.org/10.3390/jcdd10070281 - 30 Jun 2023
Cited by 1 | Viewed by 1251
Abstract
Minimally invasive approaches to the aortic valve have been described since 1993, with great hopes that they would become universal and facilitate day-case cardiac surgery. The literature has shown that these procedures can be undertaken with equivalent mortality rates, similar operative times, comparable [...] Read more.
Minimally invasive approaches to the aortic valve have been described since 1993, with great hopes that they would become universal and facilitate day-case cardiac surgery. The literature has shown that these procedures can be undertaken with equivalent mortality rates, similar operative times, comparable costs, and some benefits regarding hospital length of stay. The competing efforts of transcatheter aortic valve implantation for these same outcomes have provided an excellent range of treatment options for patients from cardiology teams. We describe the current state of the art, including technical considerations, caveats, and complications of minimal access aortic surgery and predict future directions in this space. Full article
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13 pages, 850 KiB  
Review
Minimal-Access Atrial Septal Defect (ASD) Closure
by Gillian Hardman and Joseph Zacharias
J. Cardiovasc. Dev. Dis. 2023, 10(5), 206; https://doi.org/10.3390/jcdd10050206 - 10 May 2023
Cited by 1 | Viewed by 3637
Abstract
Progress towards the development and adoption of minimally invasive techniques in cardiac surgery has been slower than that seen in other surgical specialties. Congenital heart disease (CHD) patients represent an important population within cardiac disease, of which atrial septal defect (ASD) is one [...] Read more.
Progress towards the development and adoption of minimally invasive techniques in cardiac surgery has been slower than that seen in other surgical specialties. Congenital heart disease (CHD) patients represent an important population within cardiac disease, of which atrial septal defect (ASD) is one of the most common diagnoses. Management of ASD encompasses a range of minimal-access and minimally invasive approaches, including transcatheter device closure, mini-sternotomy, thoracotomy, video-assisted, endoscopic, and robotic approaches. In this article, we will discuss the pathophysiology of ASD, along with diagnosis, management, and indications for intervention. We will review the current evidence supporting minimally invasive and minimal-access surgical ASD closure in the adult and paediatric patient, highlighting peri-operative considerations and areas for further research. Full article
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10 pages, 1369 KiB  
Review
Minimal Access Tricuspid Valve Surgery
by Jean-Alexandre Sauvé, Yung-Szu Wu, Ravi Ghatanatti and Joseph Zacharias
J. Cardiovasc. Dev. Dis. 2023, 10(3), 118; https://doi.org/10.3390/jcdd10030118 - 13 Mar 2023
Viewed by 1805
Abstract
Tricuspid valve diseases are a heterogeneous group of pathologies that typically have poor prognoses when treated medically and are associated with significant morbidity and mortality with traditional surgical techniques. Minimal access tricuspid valve surgery may mitigate some of the surgical risks associated with [...] Read more.
Tricuspid valve diseases are a heterogeneous group of pathologies that typically have poor prognoses when treated medically and are associated with significant morbidity and mortality with traditional surgical techniques. Minimal access tricuspid valve surgery may mitigate some of the surgical risks associated with the standard sternotomy approach by limiting pain, reducing blood loss, lowering the risk of wound infections, and shortening hospital stays. In certain patient populations, this may allow for a prompt intervention that could limit the pathologic effects of these diseases. Herein, we review the literature on minimal access tricuspid valve surgery focusing on perioperative planning, technique, and outcomes of minimal access endoscopic and robotic surgery for isolated tricuspid valve disease. Full article
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Other

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11 pages, 1347 KiB  
Opinion
Reduced Invasiveness of Cardiopulmonary Bypass: The Mini-Circuit and the Micro-Cardioplegia
by Thierry Carrel
J. Cardiovasc. Dev. Dis. 2023, 10(7), 290; https://doi.org/10.3390/jcdd10070290 - 07 Jul 2023
Viewed by 1735
Abstract
The aim of cardiopulmonary bypass is the maintenance of a sufficient whole body perfusion and gas exchange during open or closed heart surgery procedure (coronary artery bypass grafting, valve repair and replacement, surgical intervention on the ascending aorta and/or aortic arch, repair of [...] Read more.
The aim of cardiopulmonary bypass is the maintenance of a sufficient whole body perfusion and gas exchange during open or closed heart surgery procedure (coronary artery bypass grafting, valve repair and replacement, surgical intervention on the ascending aorta and/or aortic arch, repair of congenital malformations, and finally implantation of ventricular assist devices or cardiac transplantation). The main components of cardiopulmonary bypass are the pump that supplies the circulation and the oxygenator that regulates gas exchange. However, even though this technology has been extensively developed and improved over the last decades, one of the major drawbacks—which is the fact that blood has to flow through tubing systems with foreign surfaces—persists so far. Nevertheless, interesting innovations have been made more recently in order to better control the side-effects that culminate into a major activation of the coagulation and inflammatory systems: among them, miniaturization of the circuits, together with reduction of the priming volume and a simplified cardioplegia concept. All of these lead to a significant decrease of hemodilution and thereby a significant reduction of volume overload during surgery. In this brief review we will present some of these most interesting topics around minimized circuits and the simplified low-volume cardioplegia and discuss their potential benefits on the clinical outcome. Full article
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