Table 3.

Surgical approaches in frail patients.

Disease	Surgical principles in frail patients	Available techniques
Coronary artery disease	Reduce aortic manipulation Minimize surgical incision Consider LITA-LAD + PCI of other vessels	Anaortic coronary artery bypass: off-pump + no touch Left thoracotomy: MIDCAB, MICS CABG Robotic surgery: TECAB Hybrid revascularization
Aortic valve disease	Minimize surgical incision Reduce CPB time	Mini-sternotomy / Mini-thoracotomy /Right Mini-thoracotomy Sutureless and rapid deployment valves
Mitral valve disease	Minimize surgical incision Consider trans-apical off-pump approaches	Right Mini-thoracotomy NeoChord Trans-catheter valves
Tricuspid valve disease	Minimize surgical incision Reduce CPB time	Right Mini-thoracotomy Beating heart right heart surgery
Ascending aorta and aortic arch	Minimize surgical incision Reduce cardiac ischemic time Consider debranching of supra-aortic vessels + EVAR Consider total endoscopic approach	Mini-sternotomy Beating heart aortic surgery Hybrid arch repair Fenestrated/branched arch endografts
Heart failure	Minimize surgical incision	LVAD implantation with right thoracotomy + mini-sternotomy

CABG, coronary artery bypass graft; CPB, cardiopulmonary bypass time; EVAR, endovascular aneurysm repair; LAD, left anterior descending artery; LITA, left internal thoracic artery; LVAD, left ventricular assist device; MICS, minimally invasive cardiac surgery; MIDCAB, minimally invasive direct coronary artery bypass; PCI, percutaneous coronary intervention; TECAB, total endoscopic coronary artery bypass.