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1255Ann Thorac Surg IRIBARNE ET AL2010;90:1251–6 MINIMALLY INVASIVE CARDIAC MASS RESECTION

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his series must take into account our institutional expe-ience with MICS and may not be generalized to low-olume centers. The results of this study with regard toariables such as cross-clamp and cardiopulmonary by-ass times do not highlight the potential effect of learningurves for this technique.

onclusions and Implicationsn this series, which is relatively large considering theow incidence of cardiac neoplasms, we demonstrate thatn MI approach for the resection of cardiac masses isoth safe and effective. In addition to the aforementioned

imitations of this analysis, patients in the MI group werelightly younger and the majority of masses in this groupere located in the left atrium. Despite the limitations of

his analysis and potentially unmeasured confounders,here was no associated increase in operative times orompromise of tumor resection margins with an MIpproach. Importantly, the MI approach is associatedith a significant reduction in length of stay. Thus, given

he potential for improvements in patient satisfactionnd decreased resource utilization, the MI approach maye an effective approach for tumor resections when

echnically feasible.

his work was supported in part by NIH Training Grant 5T32-L007854-13 (A.I.).

eferences

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assisted thoracoscope. Ann Thorac Surg 1997;63:221–3.

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2010 by The Society of Thoracic Surgeonsublished by Elsevier Inc

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7. Greco E, Mestres CA, Cartañá R, Pomar JL. Video-assistedcardioscopy for removal of primary left ventricular myxoma.Eur J Cardiothorac Surg 1999;16:677–8.

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0. Galloway AC, Schwartz CF, Ribakove GH, et al. A decade ofminimally invasive mitral repair: long-term outcomes. AnnThorac Surg 2009;88:1180–4.

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NVITED COMMENTARY

s the largest reported experience of cardiac tumor resec-ion using minimally invasive techniques, this report [1]rovides valuable insight into the advantages of mini-ally invasive surgery used in the appropriate patient

nd context. The sternotomy approach remains the stan-ard of care, but the authors demonstrate that minimally

nvasive techniques in selected patients provide similar

hen added to the other studies cited by the authors, theseata help document a reproducible benefit of nonsterno-

omy approaches on patient recovery. This finding ismportant because all surgeons are under pressure toischarge patients early regardless of the techniques theyrefer. Management decisions that affect length of stay

eg, when to extubate, discharge from the intensive care

nit or the hospital) are susceptible to patient and pro-

0003-4975/$36.00doi:10.1016/j.athoracsur.2010.05.065

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1256 IRIBARNE ET AL Ann Thorac SurgMINIMALLY INVASIVE CARDIAC MASS RESECTION 2010;90:1251–6

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ider biases. The authors should confirm this benefit in aollow-up study by measuring other surrogates of recov-ry time such as the Duke Activity Status Index or byocumenting the time required to return to work.Their suggestion that stroke rates may be improved by

ess invasive surgery is more problematic because of theoor power of the study and the presence of multipleonfounders, measured and unmeasured. The minimallynvasive cohort was younger and had smaller tumorssolated to the left atrium. Postoperative strokes in theternotomy cohort occurred in those at high risk fortroke, such as complex atrial reconstructions with dif-use attachments of tumor or thrombus, chronic atrialbrillation, and a history of stroke. Because both groupsvoided the risk of complications associated with femoralnd endoaortic approaches, the biologic rationale thatmplicates the choice of surgical incision on postopera-ive stroke is weak.

Success with surgical innovation starts by building aultidisciplinary team. Because learning comes from

oing, it is unrealistic to expect to build a team around aare operation like the atrial tumor resection. The authorsf this study benefitted from extensive experience withinimally invasive mitral valve surgery that was readily

ransferrable to atrial tumor resection. Although notpecifically outlined in this report, it is highly likely that

he fundamentals of team training were still relevant

espite the benefit of the “halo effect.” Successful adop-ion of change centers on regular team meetings toeview the goals of the cardiac tumor program androvide regular feedback of outcomes after minimally

nvasive resection. Adverse trends are coupled with anction plan for improvement, and favorable outcomes areromoted to reinforce the extra efforts required of front-

ine staff. Their final step, a peer-reviewed publication,elps to establish an infrastructure in which all thelements needed for future innovations become inte-rated, creating an environment where seamless changeecomes second nature.

obert Poston, MDranjal Desai, MD

ivision of Cardiac Surgeryoston University8 E Newton, Robinson 402oston, MA 02118-mail: robert.poston@bmc.org

eference

. Iribarne A, Easterwood R, Russo MJ, et al. Long-term out-comes with a minimally invasive approach for resection of

cardiac masses. Ann Thorac Surg 2010;90:1251–6.