When heart-lung machines made extracorporeal circulation possible in the fifties, cardiac surgeons gained virtually unrestricted access to the resting, motionless heart. Valve repair and reconstruction, in particular, made great progress as a result of extracorporeal circulation. While the distinct advantages of extracorporeal circulation for cardiosurgery remain undisputed, awareness of the significant perioperative risks of extracorporeal circulation for the patient has been increasing in recent years. This has lead to an interest in alternative cardiosurgical techniques avoiding extracorporeal circulation. Inspired by minimally-invasive procedures in abdominal surgery, cardiosurgical instruments as well as surgical techniques of access to the heart and large thoracic vessels were systematically modified leading to today's minimally-invasive cardiosurgical procedures such as off-pump coronary artery bypass grafting on the beating heart. Similarly, in the field of cardiac valve repair, new cannulation techniques for instituting extracorporeal circulation make median sternotomy unnecessary. The developments described above have lead to the recent introduction of robot-assisted techniques with or without extracorporeal circulation, which are expected to make possible in the near future the performance of the whole range of cardiosurgical procedures with minimal surgical trauma. The introduction of the new techniques has changed the intraoperative responsibilities of the anesthesiologist. The present article will therefore describe both the new surgical techniques as well as the new tasks required of the anesthesiologist, in particular with regard to cannulation and monitoring. Since a number of terms in minimally-invasive cardiosurgery are not precisely defined, a clear description of the various surgical techniques is also provided.
