Choosing Minimally Invasive vs Open Cardiac Surgery: How Patients Are Selected

Every surgery has a different cost, but as an approximate range, minimally invasive procedures, depending on the valve involved and the complexity of the case, generally run from $6,500 to $18,000, depending on the consumables used.

Valve replacement is done the same way as conventional surgery, except through a robotic-assisted approach: instead of a large incision, four ports are used, and robotic arms carry out the same cross-clamping, cautery, scissors, needle holders and sutures used in open surgery. The only real difference is the approach, long instruments are operated through the robotic arms rather than by hand, giving the surgeon four arms instead of two, with the ability to switch between them.

For valve repairs such as tricuspid valve surgery, cardiopulmonary bypass is established through peripheral cannulation, one line into the aorta feeding the heart, and the SVC and IVC snugged with cannulas for venous return, so blood bypasses the heart via the bypass machine while the heart itself keeps beating. The body is cooled to around 30 degrees so the heart beats at a slower rate, allowing precise stitching while it is still beating, which is generally better for outcomes than arresting the heart, since some hearts do not come off bypass well after being arrested. Aortic and mitral valve work, heart transplants and acute dissections still require arresting the heart, but tricuspid repair is done on a beating heart specifically because the results are better that way.

There is no absolute contraindication as such, complex cases including acute dissections and acute coronary syndromes have been safely transported, and some patients are shifted on ECMO. The determining factor is haemodynamic stability: patients on high inotropic support, requiring more than 5 litres of oxygen per minute, or with an unstable rhythm need to be stabilised where they are rather than shifted immediately. It is a dynamic, case-by-case decision made jointly by the shifting team and the receiving hospital based on a video call reviewing the patient's arterial blood gas and clinical parameters.

This reflects a training distinction rather than a hard rule: cardiac surgeons handle coronary and aortic work, while vascular surgeons handle the thoracic and abdominal aorta and peripheral vascular disease, with some grey zones between the two. These are micro-specialisations within cardiothoracic and vascular surgery training rather than entirely separate fields, and which areas a given surgeon focuses on often comes down to personal interest, coronary, valvular and aortic work in one case, or peripheral and femoral vascular work in another, both trained under the same cardiothoracic and vascular surgery programme.

Around 40% are minimally invasive; the remaining 60% are traditional open surgery, chosen through a structured, case-by-case checklist rather than a general preference for one approach.

Pre-operative habits, CT aortogram findings, echocardiography, and international society guidelines. A finding such as a calcified pleura from prior tuberculosis can redirect a patient toward open surgery even when minimally invasive surgery was initially planned.