Minimally Invasive Cardiac Surgery (MICS) | Procedure & Cost

MICS comprises a broad range of surgical techniques designed to reduce tissue trauma while achieving the same therapeutic goals as conventional open-heart surgery. These techniques involve keyhole (smaller incisions), specialised equipment, and video- or robotic-assisted technologies, and these surgeries are selected depending on the patient's pathology, anatomy, and overall risk profile. The major types of MICS include:

Core Categories by Indication

• Minimally invasive coronary artery bypass surgery
• Minimally invasive valve surgery
• Minimally invasive atrial septal defect (ASD) repair
• Minimally invasive arrhythmia Surgery
  
  

Enabling Technologies and Advanced Applications

• Robotic-assisted cardiac surgery
• Minimally Invasive Heart Failure Interventions
  
  

Minimally invasive coronary artery bypass surgery

This technique repairs blocked coronary arteries through small chest incisions (partial sternotomy or mini-thoracotomy) without fully opening the chest. Hybrid coronary revascularisation combines minimally invasive bypass surgery with coronary stenting to treat blockages. Surgeons perform a small-incision bypass to the most critical artery (usually the LAD), and interventional cardiologists place stents in the other blocked arteries.

Minimally invasive valve surgery

This surgery repairs or replaces diseased mitral or aortic valves through mini-thoracotomy or partial sternotomy, using small incisions and specialised tools. The heart is accessed through narrow spaces, allowing the valve to be corrected without a whole chest opening. Tricuspid valve repair/replacement (TVR) surgery is performed through a right mini-thoracotomy or keyhole incisions instead of opening the whole chest. Surgeons repair or replace the tricuspid valve using long, slender instruments and endoscopic vision. This approach is increasingly preferred for tricuspid regurgitation and combined valve disease.

Minimally invasive atrial septal defect (ASD) repair

This surgery uses small thoracic incisions with endoscopic or robotic assistance to close the defect in the atrial septum. This approach avoids the larger sternotomy and offers faster recovery with similar safety and efficacy.

Minimally invasive Arrhythmia Surgery

The minimally invasive Maze procedure treats atrial fibrillation by creating precise lines of scar tissue in the atria using radiofrequency or cryotherapy delivered through small incisions. These lines block abnormal electrical signals that cause irregular heart rhythm.

Robotic-Assisted Cardiac Surgery

This surgery uses a robotic system to perform heart procedures through very small keyhole incisions. This technique is commonly used for mitral valve repair, tricuspid valve surgery, coronary artery bypass (in selected cases), and atrial septal defect repair.

Minimally Invasive Heart Failure Interventions

A minimally invasive VAD implantation involves placing a mechanical pump that helps a weak heart pump blood, but through small thoracic incisions instead of a full sternotomy. Surgeons insert the device using limited-access approaches on the left side of the chest.

Minimally Invasive Cardiac Surgery Indications

Minimally invasive cardiac surgery is recommended for patients who require cardiac procedures but are suitable for smaller incisions instead of a full sternotomy. Common indications include:

• Coronary artery disease (CAD)
• Valvular heart disease
• Rhythm surgery
• Atrial septal defects (ASD)
• Anatomical factors favouring MICS
• Additional procedures
  
  

Coronary artery disease (CAD)

It is indicated for patients with coronary artery disease when bypass grafting can be safely performed through small chest incisions. It is beneficial for blockages in the left anterior descending (LAD) artery or other vessels accessible through a mini-thoracotomy.

Valvular heart disease

Conditions such as severe mitral regurgitation, aortic stenosis, or significant tricuspid regurgitation are commonly treated using this approach. Minimally invasive valve surgery is chosen when it can provide the same surgical benefit as conventional surgery with less trauma and a faster recovery.

Rhythm surgery 

Patients with atrial fibrillation (AF) may qualify for MICS if their irregular heart rhythm does not improve with medications or catheter ablation. Using these small thoracoscopic openings, surgeons can create accurate scar patterns that prevent incorrect electrical signals. This method is recommended because it effectively restores rhythm without requiring a full sternotomy.

Atrial septal defects (ASD)

Patients with an ASD that requires surgical closure are strong candidates for minimally invasive repair. The procedure can be performed through small right-sided chest incisions using long instruments and endoscopic visualisation. It is most suitable for simple secundum ASDs and patients with favorable chest anatomy.

Anatomical factors favouring MICS

MICS is indicated when the patient’s physical anatomy supports a safe small-incision approach. Ideal anatomical factors include a normal chest structure, minimal scar tissue from past surgeries, and good peripheral vessels for cannulation. Patients at high risk for sternum healing problems (such as those who are obese, diabetic, or elderly) also benefit.

Additional procedures

Many other heart procedures can be done effectively with minimal incisions, making them indications for MICS. These include left atrial appendage closure, removal of small tumours, pericardial procedures, and selected congenital repairs.

Minimally Invasive Cardiac Surgery Contraindications

MICS is usually safe and effective for many patients; certain medical conditions, anatomical, or technical factors may make the approach unsuitable. In such situations, a standard open heart surgery may offer better exposure, safer cannulation, and more reliable operative control to the surgeon. The major contraindications to minimally invasive cardiac surgery include the following:

• Emergency or unstable situations
• Complex anatomical issues 
• Severe lung disease
• Higher age
• Severe pectus excavatum
• Previous cardiac surgeries
• Patient preference
  
  

Emergency or unstable situations

Hemodynamic instability or emergency surgery that requires immediate intervention makes minimally invasive cardiac surgery contraindicated. This is because there is limited access for quick resuscitation, longer setup times, and a greater chance of having to switch to sternotomy. These factors can lead to worse outcomes than those seen with direct open access.

Complex anatomical issues

Patients with complex heart or chest anatomy often cannot undergo minimally invasive cardiac surgery. Severe aortic calcification, unusual heart position, enlarged chambers, or complex valve anatomy can limit visibility and instrument movement through small incisions.

Severe lung disease

Severe lung diseases such as advanced chronic obstructive pulmonary disease (COPD) or restrictive lung conditions make minimally invasive surgery risky because the procedure usually requires one-lung ventilation. Patients with poor lung function cannot tolerate collapsing one lung, which may cause dangerously low oxygen levels or respiratory failure.

Higher age

Old age by itself is not a strict barrier. However, it combines with frailty, a high EuroSCORE, or other health issues to discourage minimally invasive cardiac surgery (MICS). This combination raises the risks during and after surgery, as the benefits of less access may not make up for longer procedure times in at-risk patients.

Severe pectus excavatum

Severe pectus excavatum alters the shape and position of the chest cavity, making it difficult to access the heart through small side incisions. This causes limited working space and poor visibility during minimally invasive surgeries.

Previous cardiac surgeries

Patients who have undergone previous heart surgeries often develop scar tissue inside the chest. These adhesions increase the risk of injury to the heart, grafts, or lungs when entering through small incisions. Minimally invasive access becomes unsafe because the surgeon cannot predict the exact location of the scarred structures.

Patient preference

If a patient refuses or prefers minimally invasive heart surgery, it is a clear reason not to proceed. Surgery cannot happen without informed consent, and ethical guidelines require full patient agreement. Patients may refuse for various reasons, such as fear, misunderstanding, cultural beliefs, or a preference for a different method.

Minimal invasive cardiac surgery offers several advantages compared with traditional open-heart surgery. Instead of using the traditional surgical method, surgeons operate through small keyhole-sized openings, which reduces physical stress on the body. The benefits listed below highlight why this method is increasingly preferred for eligible patients:

• No opening of the chest or cutting of bones
• Faster recovery
• Minimal pain
• Decreased blood loss and no need for blood transfusion
• Minimal scarring
• Shorter hospital stay
• Lower risk of complications
  
  

No opening of the chest 

In MICS, the surgeon uses small keyhole cuts instead of splitting the breastbone (sternotomy). Because the chest is not fully opened, the body experiences less trauma. This makes the surgery gentler compared to traditional open-heart surgery.

Faster recovery

In MICS, the bones are not cut, and there is less tissue damage, allowing the body to heal more quickly. Patients can return to normal activities weeks earlier than with traditional open-heart surgery.

Minimal pain

Less disruption of muscles, bones, and soft tissue leads to significantly reduced postoperative pain. Many patients require fewer pain medications and report greater comfort during recovery.

Decreased blood loss and no need for blood transfusion

Because the incisions are smaller and no major bones are cut, surgical bleeding is minimised. This also makes surgery safer for patients who have bleeding risks. Reduced blood loss often eliminates the need for transfusions, lowering the risk of transfusion-related reactions and infections. It is helpful for patients who prefer to avoid transfusions.

Minimal scarring

Small incisions (often only a few centimetres long) result in tiny, less noticeable scars compared to the long midline scar from a traditional sternotomy.

Shorter hospital stay

Faster healing, fewer complications, and reduced pain allow patients to leave the hospital sooner—sometimes within a few days—compared to a week or more with open-heart surgery.

Lower risk of complications

Preserving the sternum lowers the risk of mediastinitis, dehiscence, and deep sternal wound infection. This is especially advantageous for high-risk individuals like those with diabetes, obesity, osteoporosis, or chronic lung disease.

It includes the following steps:

Before minimally invasive cardiac surgery 

• Before MICS, patients undergo a comprehensive pre-operative evaluation to ensure the heart, lungs, and overall body condition are safe for surgery. Surgeons evaluate patients' medical history, existing heart conditions, previous surgeries, and risk factors.
• The surgical team suggest a set of diagnostic tests be performed, which includes blood tests, electrocardiogram (ECG), chest X-ray, echocardiography, and, sometimes, computed tomography (CT) angiography, to determine chest anatomy. These tests help detect any structural challenges that could affect port placement or surgical access.
• Medication management is also optimised. Blood thinners, diabetes medications, and certain heart medications may need adjustment to reduce bleeding risk and maintain stable heart function. Smoking cessation is strongly advised several weeks before surgery to minimise respiratory problems. 
• Patients are counselled on the procedure, risks, benefits, and expectations for recovery. They are instructed to maintain good nutrition, prevent infections, and follow fasting restrictions the night before the surgery. This careful pre-operative preparation increases surgical safety, minimises complications, and enhances postoperative recovery.
  
  

During Minimally Invasive Cardiac Surgery (MICS)

Anaesthesia and monitoring

This procedure is performed under general anaesthesia, with endotracheal intubation and controlled mechanical ventilation. A transesophageal echocardiogram (TEE) is inserted to guide the surgery and monitor heart function throughout the procedure.

Patient positioning and incision

The patient is placed in a supine position, sometimes with the right chest slightly elevated. A mini-thoracotomy (4–6 cm) or small keyhole ports are created, depending on the procedure. CO₂ is insufflated to reduce the risk of air embolism.

Cannulation and cardiopulmonary bypass (CPB)

In this surgery, circulation is often supported through peripheral cannulation, most commonly involving the femoral artery and vein. Once the extracorporeal circuit is functioning, the surgeon uses cardioplegia to arrest cardiac activity, which creates a motionless, blood-depleted environment that facilitates targeted intracardiac repair. 

Surgical technique

The choice of technique depends on the cardiac condition. For cardiac surgeries, such as mitral valve repair or replacement, atrial septal defect closure, minimally invasive coronary bypass, or tricuspid valve surgery, surgeons use small thoracic access points, long-shafted instruments, and endoscopic visualization. Through these small incisions, the surgeon repairs or replaces the mitral valve, and atrial septal defects can be closed with suturing or patching techniques. Coronary grafting can be done using the left internal mammary artery (LIMA) to revascularize the LAD on a beating heart, and tricuspid valve pathology can be addressed through focused right-sided access. 

Intraoperative care and haemostasis

This step focuses on careful haemostasis and precise repair using absorbable materials. It requires constant attention to avoid kind of injury to nearby nerves and vessels. The team reassesses transesophageal echocardiography (TEE) to confirm proper valve function, check patch integrity, and ensure there are no remaining defects.

Weaning from cardiopulmonary bypass and closure

After the repair is completed, the heart gradually returns to normal function. The patient is smoothly taken off cardiopulmonary bypass, with TEE used to confirm that the cardiac function is satisfactory, the valves are moving properly, and there is no residual air. The small incisions are then closed, chest drains are placed, and the patient is transferred to the cardiac intensive care unit (ICU) for further monitoring.

After minimally invasive cardiac surgery

Recovery room monitoring

Patients are observed for vital signs stability, bleeding, and pain control in the post-anaesthesia care unit. The breathing tube remains in place initially and is removed once the patient is stable and breathing adequately on their own.

Pain management and respiratory care

Pain is usually less than that of open-heart surgery, and can be managed with IV or oral medicines. Breathing exercises, incentive spirometry, and early chest physiotherapy all help to prevent lung infections and improve expansion. 

Chest tube and wound care

Chest drains remove excess fluid or air from the heart and lungs and are normally removed within 24 to 48 hours. Surgical sites are examined daily for bleeding, redness, and infection. The dressings are kept clean and dry. 

Early mobilisation

Patients are encouraged to sit, stand, and walk within 24 hours. Early movement reduces the risk of blood clot formation, improves lung functioning, and speeds recovery. 

Medication management

The doctor prescribes postoperative drugs that may include anticoagulants, antiplatelets, beta-blockers, diuretics, and pain relievers. Medication adjustments are done based on heart rhythm, blood pressure, fluid balance, and valve type (if valve surgery was done).

Hospital stay duration

Most patients stay 3–5 days, shorter than traditional open-heart surgery, because there is no sternotomy to heal.

Follow-ups

Patients were advised that follow-up is usually scheduled within 1–2 weeks after discharge to assess wound healing, heart rhythm, medications, and rehabilitation progress. Sutures or staples may be removed during this visit.

Minimally invasive cardiac surgery generally has a lower rate of complications than traditional open-heart surgery. However, it still carries inherent risks common to all surgeries and some specific to the technique. Below are the common MICS complications:

• Bleeding and need for re-exploration
• Conversion to full sternotomy
• Wound complications and infection
• Stroke
• Renal (kidney) dysfunction
• Respiratory complications
• Valve-related complications

Bleeding and need for re-exploration

Bleeding can still occur in MICS because even though the cuts are small, the surgery is performed on major blood vessels and the heart. Small thoracotomy wounds may hide internal bleeding, and sometimes a blood vessel or stitch may leak. If bleeding does not stop on its own or causes a drop in blood pressure, the surgeon may need to return to the operating room to control it.

Conversion to full sternotomy

During MICS, the chest is not fully opened, which limits visibility and access. If the surgeon experiences uncontrolled bleeding, unexpected anatomy, or technical difficulty, they may switch to an open sternotomy to protect the patient and finish the surgery safely.

Wound complications and infection

Wound infections can occur even in less invasive incisions, generally in patients with risk factors such as obesity.
 

Stroke

It can occur due to embolism or hypoperfusion during surgery and is a serious postoperative risk with potential for long-term disability.

Renal (kidney) dysfunction

The patient may develop kidney problems after MICS due to temporary low blood pressure, inflammation from the heart–lung bypass machine, or reduced blood flow during surgery. Patients with diabetes, older age, or pre-existing kidney disease are more at risk.

Respiratory complications

This surgery requires working through the side of the chest, sometimes using one-lung ventilation. This can temporarily reduce lung capacity and lead to problems such as prolonged mechanical ventilation, re-expansion pulmonary edema (a rare complication of MICS), atelectasis (lung collapse), pneumonia, or breathing difficulty, especially in older adults or smokers.
 

Valve-related complications

In valve surgeries done minimally invasively, complications can include arrhythmias, heart block, and valve malfunction, which sometimes necessitate further interventions.

Minimally invasive cardiac surgery generally offers a much shorter recovery time than open-heart surgery. Individuals often recover in 2 to 4 weeks after MICS, compared to 6 to 12 weeks after open-heart surgery. Hospital stays are shorter, lasting 2 to 5 days for MICS. Patients usually start cardiac rehabilitation within 1 to 2 weeks after surgery to safely regain heart fitness and overall strength. Most people can return to routine activities, including work and exercise, within 2-4 weeks, although heavy lifting is avoided for several weeks longer. Recovery speed varies based on individual factors such as age, pre-operative health, and adherence to rehabilitation plans.

What questions can patients ask the healthcare team about minimally invasive cardiac surgery?

• What type of minimally invasive approach will be used (mini-thoracotomy, mini-sternotomy, robotic)?
• Am I a suitable candidate for minimally invasive cardiac surgery?
• What are the benefits of this approach compared with open-heart surgery?
• What is the success rate of this procedure?
• How long is the hospital stay after MICS?
• Will I need cardiac rehabilitation?
• How much postoperative pain should I expect?
• What precautions should I follow after surgery?
• Will I need to continue the same heart medications after surgery?
• What signs or symptoms after discharge should make me seek urgent care?

Minimally invasive cardiac surgery vs Open-heart surgery

Minimally Invasive Cardiac Surgery (MICS) Cost in Hyderabad, India

The cost of Minimally Invasive Cardiac Surgery (MICS) in Hyderabad generally ranges from ₹2,50,000 to ₹5,20,000 (approx. US $3,010 – US $6,265).

The exact cost of Minimally Invasive Cardiac Surgery (MICS) varies depending on factors such as the type of heart condition treated (valve repair or replacement, ASD closure, or CABG), the minimally invasive or thoracoscopic surgery approach used (mini-thoracotomy, mini-sternotomy, thoracoscopic, or keyhole techniques), the use of advanced surgical instruments, the patient’s risk profile, surgeon expertise, ICU and postoperative care requirements, and the hospital facilities chosen including cashless treatment options, TPA corporate tie-ups, and assistance with medical insurance wherever applicable.

Cost Breakdown According to Type of Minimally Invasive Cardiac Surgery

• Minimally Invasive Mitral Valve Repair / Replacement – ₹2,80,000 – ₹4,80,000 (US $3,375 – US $5,780)
• Transcatheter Aortic Valve Replacement (TAVR) – ₹3,00,000 – ₹5,20,000 (US $3,615 – US $6,265)
• Minimally Invasive Direct Coronary Artery Bypass (MIDCAB / Keyhole Bypass) – ₹2,70,000 – ₹4,60,000 (US $3,255 – US $5,540)
• Minimally Invasive ASD / VSD Closure – ₹2,50,000 – ₹3,90,000 (US $3,010 – US $4,700)
• Redo Cardiac Surgery Using Minimally Invasive Approach – ₹3,40,000 – ₹5,20,000 (US $4,090 – US $6,265)
  

What is a minimally invasive heart surgery?

MICS is a type of heart surgery performed via small incisions rather than the large cut used in traditional open-heart surgery. This approach includes procedures such as coronary artery bypass, valve repair or replacement, and congenital defect correction. Benefits generally include reduced blood loss, less pain, a quick recovery, and a lower risk of infection.

What conditions does MICS treat?

MICS is used to treat many heart problems that traditionally required open-heart surgery. It is effective in managing valve diseases (mitral, aortic, and tricuspid), coronary artery disease in selected patients, atrial septal defects, certain arrhythmias, and tumors inside the heart. It is also used for repairing or replacing damaged heart structures.

What are the disadvantages of minimally invasive heart surgery?

MICS procedures may take longer due to small cuts, which limit visibility and tool access, increasing the risk of needing to switch to open surgery. It requires highly trained surgeons and specialised instruments, which may not be available everywhere and may raise treatment costs. Not all patients qualify, particularly those with abnormal heart shapes, weak heart muscle, or prior chest infections.

Does MICS use a heart-lung machine?

Most MICS do use a heart-lung machine, especially for valve repair, valve replacement, and certain congenital heart procedures. Many studies show that using the machine allows the surgeon to work on a still, blood-free heart through small incisions, which improves precision and safety. However, some minimally invasive cardiac bypass surgeries can be performed without the machine. The decision depends on the patient’s heart condition and the type of surgery planned.

What is the size of the incision in MICS?

The incision size in MICS is generally small, about 3-4 inches (approximately 7-10 cm) for partial sternotomy or mini-thoracotomy. For mitral valve surgery, about 7 cm long incision is done on the right side of the chest is used. These incisions avoid cutting through the breastbone and result in less trauma and quicker healing compared to traditional open surgery.

Can elderly patients undergo minimally invasive cardiac surgery?

Yes, elderly individuals can undergo this surgery; but, the eligibility is determined by the patient's overall health, disease severity, and surgical risk evaluation.MICS may benefit elderly patients by reducing trauma and speeding recovery, but careful evaluation is important to ensure safety.

How long is the hospital stay after minimally invasive cardiac surgery (MICS)?

Most patients need to stay in the hospital for 3-5 days after minimally invasive cardiac surgery. The stay is often shorter than traditional open-heart surgery because smaller incisions lead to quicker mobility, better breathing comfort, and fewer complications.

Can a mitral valve be replaced without open-heart surgery?

Yes, mitral valve replacement or repair can be performed using minimally invasive procedures rather than complete open-heart surgery. Surgeons use advanced instruments and cardiopulmonary bypass support to access the valve through small incisions (such as a mini-thoracotomy), avoiding large chest cuts.

What is life expectancy after MICS?

Life expectancy after the surgery is generally comparable to that of open-heart surgery, according to many studies. Long-term survival mainly depends on the previous heart disease, overall health, age, and how well the heart responds after treatment, not on the incision size.

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