Anaesthesia for minimally invasive cardiac surgery

Minimally invasive cardiac surgery is used for both extracardiac and intracardiac procedures. Extracardiac procedures, such as coronary artery bypass grafting, are often performed on a beating heart. Intracardiac procedures are done with the aid of cardiopulmonary bypass. The surgery is performed via a minithoracotomy or a ministernotomy. Thoracoscopic video-assisted surgery, often with robotic assistance, necessitates prolonged one-lung ventilation to optimize exposure. Port-access surgery will require appropriate positioning of various catheters to establish cardiopulmonary bypass. Adequate flow during cardiopulmonary bypass may require suction augmentation of venous return and may increase the risk of air emboli. Limited exposure of the heart during surgery poses challenges with management of arrhythmia, haemostasis, myocardial protection and de-airing at the end of surgery. Patient selection is important to avoid intra-operative and post-operative complications. Prolonged single-lung ventilation, incomplete revascularization in hybrid procedures, and limited access for rapid intervention pose challenges with patient management. Conversion to sternotomy that may be required occasionally and extension of portals over several dermatomal segments mandate a versatile analgesic technique.