The reconfiguration of the surgery is about a process through which this medical specialty incorporated the technical advances and became a practice over the past few years1. These advances were important in making surgical procedures safer for patients. In this context, such said Minimally Invasive procedures (MI) has been introduced alternatively in heart surgery2.

With the purpose of making universal the access in cardiovascular surgical procedures, from the beginning of 19603, surgeons have adopted the total median sternotomy as the preferred incision, at the expense of initial thoracotomy4. With sternotomy it was enabled the access to all surfaces, compartments and great vessels of the heart, with central cannulations. This access, which communicates widely the middle mediastinum with the operative environment, brought comfort to the surgeon. However, possibly due to the wide opening and also due to the inherent bone division, it has been considered a stigma for the patients to be operated.

In 1997, with incentives from previously published work by Laborde et al5, it was clear the necessity for a technical involvement for the development of an initial experience in video-assisted surgical procedures6. Continuing, in 1999 a project was developed with a focus on experimental laparoscopic surgery, which due to structural problems, has not moved on. Only since 2006 is that the team started to develop strong actions oriented to MI surgery, based on the initial experience of other authors7 ^, 8. At this stage, it took intensive training and additional training of capabilities, the first procedures were performed from the end of 2007. The fact is that the process to achieve the method used nowadays was progressive and graduated.

This paper had the purpose of describing the methodology used and the immediate results obtained over 5 years experience in a total of 102 patients undergoing MI cardiovascular surgeries.

In the period between December 2007 and December 2012, 102 patients underwent, after informed consent form was obtained, MI procedures. This single-center, prospective, descriptive, quantitative approach study evaluated the clinical and operative variables, in addition to the immediate evolution during hospitalization of the patients, and was approved by the ethics committee of the University of Fortaleza.

The procedures of patients undergoing therapeutic MI D included aortic valve replacement (n = 11), valve repair (n = 1), valve replacement with annular enlargement (n = 1) and septoplasty with pulmonary flow redirection (n = 1).

The procedures of 88 patients undergoing therapeutic MI VA included valve repair (n = 17), valve replacement (n = 26), septorraphy (n = 22), septoplasty with pericardium (n = 19), tumor resection (n = 4).

In the group of patients with MI VA, it is noteworthy that the mitral repair consisted of five commissurotomy (associated with papillectomy in three cases), 11 partial resections of the leaflet with annuloplasty (semi-rigid ring in seven cases and pericardial strip in four) and in one case commissuroplasty with neochord. In addition to the mitral valve procedures, four ultrasonic isolation of the pulmonary veins were carried out.

Mean aortic clamping time was 91.6 ± 21.8 minutes in the MI D group and 71.6 ± 29 min in the MI VA group. The mean cardiopulmonary bypass time was 112.7 ± 27.9 minutes in the MI D group and 99.7 ± 32.6 minutes in the MI VA group. These and other temporal variables are described in Table 2.

There was one death (0.98%) in the MI D group. There were two new episodes of atrial fibrillation that was pharmacologically reversed. There was one post-operative pericardial drainage in the MI D group and two revisions of hemostasis in the MI VA group. One patient in MI VA group reported transient numbness in the thigh, this being one of the first patients in the series. One patient developed pneumothorax requiring redrainage. One female patient undergoing septoplasty presented reversed pulmonary hypertension with vasodilator. Among the patients submitted to VA MI, 15 (17%) has tubes removed at the room. The final aspect of portals in one patient in MI VA group is shown in Figure 3.

One of the foundations of the MI procedures, regardless of the form of access, consists of a well balanced and skilled team. Supporting this team, the following are important: Detailed knowledge of the inner and surface anatomy of the chest, careful selection of patients, use of proper equipment, development of skills and expertise in laparoscopic surgery; in addition, philosophical and conceptual change, and sheer determination are also necessary .

In fact, the Brazilian cardiac surgery, after an initial experience, is another of the surgical specialties to incorporate, in a more definitive manner, the MI surgical procedures. Nowadays, mitral valve surgery and correction of atrial septal defects surgery are performed with the same safety for the patient, as previously demonstrated11 ^- 15. This benefit could be extended to other procedures: removal of cardiac tumors, surgical ablation, arrhythmia, pericardial procedures and dissection of grafts. This has boosted our experience, so that these video-assisted surgical procedures represent 24% of our surgical movement.

The process of incorporation of this methodology allowed our team to outline some priorities, such as heart surgery, clinical cardiology and pre-anesthetic consultation, this added to the assessment and guidance of physiotherapy and nursing. In addition to the usual tests needed - blood count, coagulation, biochemistry, urinalysis, electrocardiogram and chest radiograph in posteroanterior and profile views - we specifically ask for arterial ultrasound with doppler of the aortc, iliac and femoral arteries with quantification of the internal diameter of these vessels. The pre-operative evaluation of the coronary circulation is carried out in fairly stratified manner. In patients without major risk factors for myocardial ischemic disease, we prefer an assessment of the anatomy of the coronary arteries with CT angiography, associated with an ischemic provocative testing with myocardial scintigraphy and ergometric testing. Any changes, questions or greater risk recommended an invasive coronary angiography via the left femoral or upper limb.

Some authors reported extensive experience with this procedure16 ^- 19. This has shown that, in specialized centers, certain diseases can be preferentially addressed by MI accesses. All this accumulated experience has shown that the benefits include greater protection of the operated area, lower incidence of bleeding, less use of blood products, better pain control, less infection, better healing, shorter hospital stay, faster recovery and rehabilitation of the patient to its daily activities. The benefits can be extended to the members of the team: less contamination, better sharing of the operative field and better quality of life for the surgeon, with fewer visits and sharing of responsibilities. Moreover, some disavantages can be indicated: access to two spaces in the chest, peripheral cannulation, increased surgical time in the adjustment curve of the method, higher cost for formatting the software and adaptation to specific instruments.

Among surgical patients, there was a predominance of females. In women undergoing MI VA procedure, the portal to work is very similar to the incision for breast augmentation. In this situation, the advantage is the subpectoral access without muscle division. On the other hand, Poffo et al10 introduce the periareolar access, which maximizes the cosmetic appearance, however implying in division of mammary glands and muscle division.

In MI D procedures, aortic valve heart disease has prevailed. A MI approach is already widely employed by others, in which the aortic valve replacement is performed by anterior right minithoracotomy20. So there is an observation to be made, in those cases, about the impossibility of compression of the heart during reperfusion phase, sometimes necessary in cases of significant myocardial hypertrophy. Therefore, I see just one limitation of this method, which may have contributed to the single death in the series.

Regarding MI VA procedures, mitral procedures and procedures for closure of atrial septal defect were predominant.

Among the mitral, valve replacement was the most common. However, 17 valves were repaired, which represents 40% of video-assisted surgical mitral procedures. This percentage can be considered low if we analyze the indexes for mitral valve repair in severe impairment of degenerative etiology21. However, considering that the valve injury was an isolated failure in only 17 patients and the inflammatory-rheumatic etiology was very common, this video-assisted surgical valve repair procedures index can be acceptable and comparable to the one reported in the literature for transternal access22.

Considering the septal procedures, there was a balance between the closure by suture and closure with pericardium. In closure by suture, we have modified our initial technique, which consisted of double continuous suture to suture with stitches separated in U, anchored in a Teflon cushion. Other authors have also shown good results, with video-assisted surgical procedure for the closure of septal defect23.

Finally, four tumors were removed with MI VA access. The histopathological result was myxoma in all of them. We believe this is an excellent access to treat this disease, including verifying in details the interior of the left ventricle. This impression is also supported by other authors20. It is here recorded the necessary attention to sessile tumors of the right atrium regarding the positioning of the cannula from the inferior vena cava and the use of vacuum, as well as the myxomas of papillary or villous type, which tend to be extremely friable in the left atrium and of high emboligenic risk.

Considering the temporal variables, we have noticed that, although long clamping time and cardiopulmonary bypass, this did not influence the patients' evolution. Rather, there was a rapid recovery in the Intensive Care Unit (ICU) and post-operative hospitalization. These findings confirm those already published in the literature that compared MI access and access by sternotomy2 ^, 15 ^, 24.

Our impression is that cardiovascular surgeons today live a time of transformation in the specialty. Innovations and technical modifications may progressively be incorporated into surgical practice, should they make the procedure more precise and safe.

Minimally invasive procedures have been employed in two forms - Direct and Video-Assisted - safely in the treatment of valvular heart diseases, septum defect and heart neoplasia. We evidended longer times of operative variables in these procedures. However, the recovery in hospital was fast, regardless of access and disease treated. In selected cases, such forms of access may become the preferred method of surgical approach.